New CV Surgeon wants his own strike team

[siednarb]

Thank you for all the feedback - while I am not often on this forum as I once was - I appreciate being able to come back to it from time to time and to see and hear from fellow anesthesiologists.

To try and answer some of the questions that were posed:
We have a care team model, in our state (midwest) that is the norm - mostly because insurance rates in our state, especially for BCBS suck
While many in our group would prefer to do our own cases - it's just not the norm with us purely from a fiscal perspective.
The CRNAs are under our purview in a separate entity that we own and control.
The CRNAs do not touch the TEE probe or have anything to do with it.
The central line and SG are placed by us - the only thing the CRNAs will occasionally help with is the a-line at our institutions.
We used to be a center that did over 400 hearts - some of the 8 cardiac physicians are holdover from that era and retirement on horizon.
We do have a grown structural heart lab with TAVRs and Mitral Clips, Watchman etc... we tend to also place our CV physicians there as well.
Therefore we find having 8 physicians who are cardiac enabled and known to the surgeons and cardiologists work for us - especially when you account for pre-call (our calls start at 3pm), post-call, vacation etc....
Everyone in our group is expected to do everything except for cardiac.
Having the CRNAs in our control means any pager call for a newly created heart team would have to be financed - either by us or with hospital help
I should note that there is another heart surgeon who does not take any issue with how our department staffs his heart cases.
We are lucky in that both of our regular heart surgeons are easy going and down to earth, the new guy just has these new demands.
Where I trained the CV surgeons were malignant and abusive to all the staff - so I know how lucky I am with regards to that.
We are torn between trying to propose a further compromise (ex down to 9 CRNAs) versus capitulating to the demand.
Most CRNAs in our area like getting their 40 hours in over 3-4 shifts so they have other days to work contingent jobs at ASCs in the area
This issue, along with the scheduling headache and the exclusivity this would create amongst the CRNA staff by pairing down further are our main concerns.
Again thank everyone for all your input.
Hope everyone stays safe and healthy

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[sevoflurane]

I would venture to say you do have a special situation, and that's not meant as an attack. I'm sure you have a practice that many people would enjoy and a few on here probably have similar setups. Others just may be in places where things don't align that way. I wish things were universally the way you describe but in some areas, anesthesiologist are expendable while good surgeons are a diamond in the rough. I'll admit we have a handful of surgeons that we have to bend over backwards for because they bring the patients, which in turn bring the units. There are WAY too many hospitals in the area so if we don't play the game right, they will take their patients down the road. We can change personalities and I understand it just enables bad behavior, but again, it's not like surgeons are running off an assembly line. These hospitals will fire (deny privileges) to GOOD surgeons just because they don't play well in the sandbox.

The game is just different in different places. Sure I'd be offended as an experienced CT anesthesiologist who is generally pretty affable if I weren't invited to participate with the team, but I can't get 100% mad knowing surgeon wants to have a steady team with good outcomes. At that point, I would do my best to get on the surgeon's good side.

Didn’t take it as an attack at all my dude... and I hear you.

 

[deleted126335]

And they laughed at me when I did that fellowship . . .

your posts do indicate an excess of bile.

 

[deleted162650]

your posts do indicate an excess of bile.

I think you mean vile

 

[deleted126335]

I think you mean vile

could be both.

 

[deleted697535]

Surgeon is right. You’re CRNA’s are only getting 10 cv cases a year. Anesthesiologists are only getting 30 cases a year. You‘d get improved quality by having a more dedicated heart team. Figure out what it would cost (call stipend) to go down to 6 CRNAs and 3 MDs. Present it to administration and see what they say.

Well really a shop that only does 250 pump cases a year shouldnt really be doing open hearts... Unless your 100s of miles away from the next place it doesnt make sense.

I think the surgeon has a point but there is a bigger point in that he shouldnt be operating either in those conditions

8 MDs doing 250 cases is 30 each per year! Thats not a lot being generous

 

[dchz]

Say you are a freshly graduated CT anesthesiologist and you get teamed up with a slow cabg CT surgeon who redoes every other graft meanwhile your senior partner bangs out 2 MVR’s by 1:30pm with the “valve specialist”.

How would you feel then? What if you are compensated per pump run (like my previous group)?

This pretty much sums up my experience right now, with slight exaggeration.

However, we are not compensated by pump runs. I am already salaried and I feel perfectly fine getting my footing with majority CABGs. I did my first type A the other day and several people came and checked on me just in case, which made me feel like I'd have backup just in case I needed help.

Compensation incentives can cause friction. In that case you should change the compensation model to fit better patient care. But having a new grad step up gradually rather than doing a robotic mitral valve repair on the first day is the proper way to ramp up IMO.

Demi-god personalities need to be put in check.

Yes definitely. But this is not what was said in the OP. The surgeon is simply asking for a smaller team and more consistency - a reasonable request.

 

[deleted126335]

Well really a shop that only does 250 pump cases a year shouldnt really be doing open hearts... Unless your 100s of miles away from the next place it doesnt make sense.

I think the surgeon has a point but there is a bigger point in that he shouldnt be operating either in those conditions

8 MDs doing 250 cases is 30 each per year! Thats not a lot being generous

This type of program is most likely a backstop for a more lucrative Cath lab.

Is Anybody seeing STEMIs and interventional caths being done at hospitals that don’t have onsite cardiac surgery in their corner of the world? I have heard that this is a thing now based on meta analysis of some low powered studies.

 

[Zekchar]

Unpopular opinion:
I both respect and would absolutely honor this surgeon's requests. In fact, these types of requests are what will keep us anesthesiologists employed in the future. If we are "replaceable" as per administrators (until the bad outcome lawsuit reminds them that CRNAs are vastly inferior) then surgeons asking for us specifically is what will drive our participation.

Too many on here think too highly of themselves and underestimate how replaceable they are. The patients come for the CT surgeon, OBGYN, urologist, or neurosurgeon. Not for you. Surgeons specifically trying to get their team = job security, since they bring in patients ($$$) to the hospital. I see no issue with this request and if I were coming in for heart surgery, I certainly would like to be taken care of by this "strike team" who has been working together consistently, rather than a jumbled bunch who don't like each other or know each others preferences. 98% of the time it doesn't matter which attending / CRNA pairing is doing those cases. If it's me or my family, I'd rather not find out.

 

[GassYous]

I get what you're saying but there are patients that come for the specific anesthesiologists. Patient requests are not uncommon and I have even seen patients reschedule if their anesthesiologist is not available.

 

[chocomorsel]

This type of program is most likely a backstop for a more lucrative Cath lab.

Is Anybody seeing STEMIs and interventional caths being done at hospitals that don’t have onsite cardiac surgery in their corner of the world? I have heard that this is a thing now based on meta analysis of some low powered studies.

Yes. I believe this is becoming quite common.
Problem? Call the chopper. Of course they may die en route but they will be kept “alive” for transport!

 

[btbam]

Why the hell do you have 24 crnas for 250 cases a year?? We do probably 600 pedi heart cases a year and have 8 cardiac anesthetists.

 

[sethco]

Is Anybody seeing STEMIs and interventional caths being done at hospitals that don’t have onsite cardiac surgery in their corner of the world? I have heard that this is a thing now based on meta analysis of some low powered studies.

Yes, absolutely. We have a couple sister hospitals in the area that feed into larger heart centers. At these smaller hospitals, they will do high risk Caths (I.e. Left Main stents, rotablation, STEMIs, and so). However, the higher care is available for immediate transfer and usually within 30 miles. No Cardiac surgeon/perfusion capabilities are on site, so with a crashing patient, they will put in a VAD and call for an emergent transfer

 

[Angus Avagadro]

These demands have been going on for decades. I remember when Norwood came to CHOP and wanted to bring his own anesthesia team from Boston Childrens. That went over like a fa&t in Church. Unless there is a Kaplan anesthesiologist #7, in the group , I'm not sure I would go through the gymnastics of accommodating him. Seriously, since when does the particular anesthesiologist affect the outcome? I think the best answer is yes...but. I never would say no to a proposal, but yes...but. We will try to accommodate you, but it might not always be possible. Just my 2 cents.

 

[2Fast2Des]

Unpopular opinion:
I both respect and would absolutely honor this surgeon's requests. In fact, these types of requests are what will keep us anesthesiologists employed in the future. If we are "replaceable" as per administrators (until the bad outcome lawsuit reminds them that CRNAs are vastly inferior) then surgeons asking for us specifically is what will drive our participation.

Too many on here think too highly of themselves and underestimate how replaceable they are. The patients come for the CT surgeon, OBGYN, urologist, or neurosurgeon. Not for you. Surgeons specifically trying to get their team = job security, since they bring in patients ($$$) to the hospital. I see no issue with this request and if I were coming in for heart surgery, I certainly would like to be taken care of by this "strike team" who has been working together consistently, rather than a jumbled bunch who don't like each other or know each others preferences. 98% of the time it doesn't matter which attending / CRNA pairing is doing those cases. If it's me or my family, I'd rather not find out.

Sorta taking back my original statement, one of the hospital I work at, the bariatric surgeons request our group to cover their cases because they want familiar faces who know the routine and can get cases in and out. It does lead to better collegiality and efficiency since I know what they are doing and need. They also get assigned a small group of nurses\scrubs who are known as quick and don't slow **** down.

My issue was mostly that a new guy rolls in and thinks he can change things on the fly without showing evidence of godliness and expecting anesthesiologists to roll over.

 

[Splenda88]

Are you guys/gals even physicians? Man... I know internal medicine is at the bottom of the totem pole, but I don't think I could ever be an anesthesiologist when my colleagues are treating like a tech or when my colleague can't even call me by my name and just utter the word anesthesia when referring to me.

It irritated me when I was doing my GI rotation as a PGY2 and the GI doc kept calling the anesthesiologists 'anesthesia'

 

[btbam]

These demands have been going on for decades. I remember when Norwood came to CHOP and wanted to bring his own anesthesia team from Boston Childrens. That went over like a fa&t in Church. Unless there is a Kaplan anesthesiologist #7, in the group , I'm not sure I would go through the gymnastics of accommodating him. Seriously, since when does the particular anesthesiologist affect the outcome? I think the best answer is yes...but. I never would say no to a proposal, but yes...but. We will try to accommodate you, but it might not always be possible. Just my 2 cents.

Didn't Norwood have a horrible drinking problem? Maybe he was drunk when he made this request.

 

[AdmiralChz]

Is the norm of a CT anesthesiologist to be a subservient to a CT surgeon?

Um, yes. There’s a reason I gave up most of my CV time. Enough of the “start dopamine for low urine output” crap. Even worse for many ICU docs covering the CVICU.

Sevo, your practice sounds far, far outside the normal setup for typical CV specialists. Which is great for you, but what you have is not at all generalizable.

Things are certainly better with the newer generation of surgeons but there is still a a large contingent of folks being trained under “I am the master and commander all listen to me” mentality.

 

[sevoflurane]

Um, yes. There’s a reason I gave up most of my CV time. Enough of the “start dopamine for low urine output” crap. Even worse for many ICU docs covering the CVICU.

Sevo, your practice sounds far, far outside the normal setup for typical CV specialists. Which is great for you, but what you have is not at all generalizable.

Things are certainly better with the newer generation of surgeons but there is still a a large contingent of folks being trained under “I am the master and commander all listen to me” mentality.

Sad to hear if this is how it truly is. Sounds miserable. Wasn’t like this at my previous or current cardiac gig. Interviewed at maybe 10 cardiac positions over my career. Always asked to sit for a pump run specifically to meet the CT surgeons and to observe their interactions with staff. Those personalities are out there but I think it is up to the anesthesiologist to find a practice that doesn’t harbor that kind of behavior. I remember meeting some real nice ones on the interview trail... also some a-holes where I walked out and was like:

 

[GassYous]

Um, yes. There’s a reason I gave up most of my CV time. Enough of the “start dopamine for low urine output” crap. Even worse for many ICU docs covering the CVICU.

Sevo, your practice sounds far, far outside the normal setup for typical CV specialists. Which is great for you, but what you have is not at all generalizable.

Things are certainly better with the newer generation of surgeons but there is still a a large contingent of folks being trained under “I am the master and commander all listen to me” mentality.

Didn't you just finish fellowship recently

 

[Southpaw]

Amazing how much our work environment and what we enjoy or don’t is entirely independent of us. @sevoflurane and @dchz have very nice setups.

 

[anes121508]

Probably that many people doing cardiac to spread out the call burden. You could do 250 with 1-3 guys but who wants to be on call q1-3?

highlights the real problem

 

[anes121508]

Similar sort of deal and situation went to smaller team over time at request of surgeons...can’t disagree with the fact that a smaller team is probably going to work better together. Rate limiting step seems to be the call birden


group had everyone doing hearts

Then half doing hearts

Then 6 doing hearts (800 ish cases a year).

the extra work and call is covered by a stipend. Take full call with the group and cardiac call q6 on top.

I think hospital would rather 4-5 but the call gets too much. Plus the later hours during the week add up since nobody else is around staff the rooms.

for those of you all out there with 4-8 cardiac people how to you function within the main group in terms of call and going home at end of the day?

 

[sevoflurane]

We have a ton of call positions due to all the facilities we cover. We just add cardiac stipend ontop of call. Say... I am 7th call AND cardiac at the same time.

 

[sevoflurane]

exception is OB and trauma as those can be super busy

 

[D P356]

Are you guys/gals even physicians? Man... I know internal medicine is at the bottom of the totem pole, but I don't think I could ever be an anesthesiologist when my colleagues are treating like a tech or when my colleague can't even call me by my name and just utter the word anesthesia when referring to me.

It irritated me when I was doing my GI rotation as a PGY2 and the GI doc kept calling the anesthesiologists 'anesthesia'

I’m there for the pt. Most surgeons or GI will call me by my name. I don’t mind be called anesthesia, I call them surgery/Ortho/ball busters right back.

Or just wait until they’re struggling and comment that their partners don’t have that hard of a time with the given procedure.

Putting ego in check is important.
The epitome of an excellent anesthesiologist that I witnessed was an attending I had in residency. Dude was ice cold in every emergency; he was excellent. Everyone knew it. He told me when I was a senior, “always be humble and take care of the patient.”

 

[D P356]

I heard this while in residency....

On a long flight the commercial airline pilot came overhead and stated, “if there is an anesthesiologist on board please come to the front of the plane. We need an anesthesiologist in first class immediately.”

The anesthesiologist who happened to be on the flight quickly moved to first class and then asked the nearby flight attendant if there was a passenger having a medical emergency.

Flight attendant: “We have a CT surgeon that needs his tray table raised.”

 

[anes121508]

These demands have been going on for decades. I remember when Norwood came to CHOP and wanted to bring his own anesthesia team from Boston Childrens. That went over like a fa&t in Church. Unless there is a Kaplan anesthesiologist #7, in the group , I'm not sure I would go through the gymnastics of accommodating him. Seriously, since when does the particular anesthesiologist affect the outcome? I think the best answer is yes...but. I never would say no to a proposal, but yes...but. We will try to accommodate you, but it might not always be possible. Just my 2 cents.

particular anesthesiologist and outcome - wasn’t there a popular article on this about 5 years ago?

 

[anes121508]

We have a ton of call positions due to all the facilities we cover. We just add cardiac stipend ontop of call. Say... I am 7th call AND cardiac at the same time.

Stipend a single fixed amount? Or incentive based pay in the event you come in from home to cover a dissection on the weekend?

 

[IlDestriero]

Why the hell do you have 24 crnas for 250 cases a year?? We do probably 600 pedi heart cases a year and have 8 cardiac anesthetists.

I suspect this is the problem. 8 attendings splitting cardiac call is reasonable, but with 24 CRNAs. Every time he’s in the OR he’s with a strange face looking over the drape. Our busy peds cardiac program does far more cases with 1/2 the CRNAs you have.

 

[sevoflurane]

Stipend a single fixed amount? Or incentive based pay in the event you come in from home to cover a dissection on the weekend?

Fixed stipend 100%. Carrying the CT pager for 24 hrs comes with a price.

 

[Twiggidy]

Didn’t take it as an attack at all my dude... and I hear you.

 

[Twiggidy]

Are you guys/gals even physicians? Man... I know internal medicine is at the bottom of the totem pole, but I don't think I could ever be an anesthesiologist when my colleagues are treating like a tech or when my colleague can't even call me by my name and just utter the word anesthesia when referring to me.

It irritated me when I was doing my GI rotation as a PGY2 and the GI doc kept calling the anesthesiologists 'anesthesia'

In this gig to be successful one of the first things you do is check your ego at the door

 

[deleted547339]

This is exactly why I work in a closed Micu instead of a CTICU.

 

[Angus Avagadro]

particular anesthesiologist and outcome - wasn’t there a popular article on this about 5 years ago?

Thanks for posting this. I looked it up and it was in A and A, 2015. Very interesting. Some docs had around 40% higher complication rate, although overall the total complication rate was low, like around 4% total.(Anesth Analg 2015;120:526-533). I believe this article was retracted later due to faulty design, but i may have it confused with another. It raises some good points. Personally, unless you aren't very experienced, I don't think anesthesiologists control enough parameters to be a significant risk for outcome. Most people who do cardiac cases know the goals and parameters for instituting an intervention. Success/failure is probably more related to surgical and reperfusion trauma, than anesthetic management.,IMO. I do agree its useful to look into the questions the authors put forward.

 

[drmwvr]

Have to start somewhere. Smaller, dedicated teams have better outcomes. Just because the new guy is the one asking doesn't mean his partners are not giving their silent assent. Odds are, he'll get his team sooner or later. You guys might as well be the ones but I doubt he cares who it is...

 

[itwasalladream]

He's not asking for a strike team. He's asking for a normal sized team for that kind of surgical volume.

Those who do routine hearts occasionally tend to think they can do a routine heart as well as someone who does them daily. Someone who does them daily thinks they pick up on small details, early warning signs, better management of unexpected crisis, knows the tendencies of the surgeon/team, etc etc etc. Someone's right, and someone's wrong.

But over and over it's shown that small teams with good volume and focused roles tend to deliver better outcomes. That should be the goal.

 

[deleted547339]

Thanks for posting this. I looked it up and it was in A and A, 2015. Very interesting. Some docs had around 40% higher complication rate, although overall the total complication rate was low, like around 4% total.(Anesth Analg 2015;120:526-533). I believe this article was retracted later due to faulty design, but i may have it confused with another. It raises some good points. Personally, unless you aren't very experienced, I don't think anesthesiologists control enough parameters to be a significant risk for outcome. Most people who do cardiac cases know the goals and parameters for instituting an intervention. Success/failure is probably more related to surgical and reperfusion trauma, than anesthetic management.,IMO. I do agree its useful to look into the questions the authors put forward.

I thought everything was anesthesia’s fault. Always. No matter the problem. Always. At least that’s what the surgeons told me.

 

[nimbus]

I thought everything was anesthesia’s fault. Always. No matter the problem. Always. At least that’s what the surgeons told me.

An oldie but goodie.

 

[Twiggidy]

An oldie but goodie.

View attachment 323178

#10 should've called me. He's still be Moonwalking today.....of course the DEA would also be surveilling my house

 

[OTCAwesome]

#10 should've called me. He's still be Moonwalking today.....of course the DEA would also be surveilling my house

Haha, How much was that cardiologist getting paid again? wasn't it something bonkers like >100k/month

 

[sevoflurane]

I believe it's fairly common. I am on the heart team where I work. Small group of docs and CRNA's that work together all the time.

What exactly do you do on the “heart team” ? lines, echo, valve pathology, vassopressor management? Just curious as to your roll on the heart team where you work:

 

[PikminOC]

I don’t think having crnas in heart room is a problem as long as it is 1:1 coversge and the anesthesiologist does not let them do lines or touch TEE probe. I mean, does the attending really have to be in the room during bypass?

i hope that is the set up at OP’s shop.

Really? Hospitals have one to one coverage? Then just don't have the crna

 

[PikminOC]

What's the update op? How'd you work this out?

 

[chocomorsel]

What exactly do you do on the “heart team” ? lines, echo, valve pathology, vassopressor management? Just curious as to your roll on the heart team where you work:

🧐. Oh boy.

 

[Hork Bajir]

The day that I let a CRNA start a cardiac case (or do anything to a cardiac patient) without me in the room will be a cold day in he11. Shame on the docs who allow this sort of thing to happen.

No offense intended to @CRNAinPA specifically- I just don’t think that CRNAs have any business doing the things you have described. It is not what is best for patients. Period. Any practice that allows that kind of arrangement is not a practice I want anything to do with (or one that I would let care for my family members).

Edit: lol @ realizing that a CRNA necrobumped this thread just to brag that he or she is “on the heart team” and turn the thread into yet another MD vs CRNA pissing match (and shame on me for taking the bait)

 

[chocomorsel]

The day that I let a CRNA start a cardiac case (or do anything to a cardiac patient) without me in the room will be a cold day in he11. Shame on the docs who allow this sort of thing to happen.

No offense intended to @CRNAinPA specifically- I just don’t think that CRNAs have any business doing the things you have described. It is not what is best for patients. Period. Any practice that allows that kind of arrangement is not a practice I want anything to do with (or one that I would let care for my family members).

Edit: lol @ realizing that a CRNA necrobumped this thread just to brag that he or she is “on the heart team” and turn the thread into yet another MD vs CRNA pissing match (and shame on me for taking the bait)

As much as I can’t stand working with many of them, I honestly think on this one, he or she isn’t looking to turn this into us versus them.
Why do we always act like every damn CRNA is a rogue wanna be independent one? There are plenty that are easy to work with in an ACT model. I just can’t stand having to deal with the dinguses in order to get to work with the good, non egotistical ones, so prefer to work alone.

 

[2Fast2Des]

As much as I can’t stand working with many of them, I honestly think on this one, he or she isn’t looking to turn this into us versus them.
Why do we always act like every damn CRNA is a rogue wanna be independent one? There are plenty that are easy to work with in an ACT model. I just can’t stand having to deal with the dinguses in order to get to work with the good, non egotistical ones, so prefer to work alone.

This is an issue.. a CRNA starting a cardiac case without the anesthesiologist, I mean come on... And then doing all the lines and ****. What exactly is this doc doing that they can't be bothered to be there. Especially if 1 to 1, zero excuses!!

There are good CRNAs, and the days I supervise I enjoy working with them because it makes for a pleasant day. When you have a knucklehead, then it's horrible. But no matter how nice, giving complete independence is wrong

 

[chocomorsel]

This is an issue.. a CRNA starting a cardiac case without the anesthesiologist, I mean come on... And then doing all the lines and ****. What exactly is this doc doing that they can't be bothered to be there. Especially if 1 to 1, zero excuses!!

There are good CRNAs, and the days I supervise I enjoy working with them because it makes for a pleasant day. When you have a knucklehead, then it's horrible. But no matter how nice, giving complete independence is wrong

That’s not the issue I was talking about. Was talking about an us versus them argument which is not what I see being brought on the CRNA above. He or she is just adding to the conversation.
As you said, where is the doc who let these CRNAs do these things? I mean why get pissed at them when it’s the docs who are letting them do these things. The people y’all should be having a problem with are the ones running the practice, sitting in the lounge snacking and coffeeing and letting the CRNAs do whatever. We got a bunch of lazy ass, greedy, sometimes inept docs who allow practices like these to thrive. And then defend it talking about how we need CRNAs so badly. Those DOCS are the ones we should be having a problem with.
It’s like getting pissed off at the other woman for having an affair with your man. Makes no damn sense.

 

[chocomorsel]

The cardiac docs aren't sitting in the office while the nurses start these cases. We call and say we are getting started and they either come in as we induce or get there after we get the tube in. If they aren't in the room it's likely because they are starting another cardiac case. They also might push the drugs for us and hang out and help us start. It all depends on timing and what else they have going on.

I'm gonna step back from this thread as I fear it will turn into something I didn't intend. I understand everyone's point of view and I'm not trying to say I'm some great CRNA and can do it all without help. I was just describing our model and didn't mean to cause any acrimony.

While I hear you, I don’t see why they are supervising more than one heart room. That to me is a problem. They should only have one at a time so they can focus on that.
Wlecome to the anesthesia forum! 🤣. Yeah, you gotta tread lightly around us.
I don’t agree with all that you are allowed to do, but like I said, the people in charge of you are the problematic ones.