New TEE Requirement

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Ignatius J said:
If you tell someone that you need something long enough, they will begin to believe you. I have no doubt we are a few years away from people with regional and OB fellowships talking about how much more qualified they are to perform in these areas.
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Few years away? This was talked about during my residency, and I'll admit, that's probably why I'm a bit more "turf-y" regarding anesthesia specialties. Won't lie, my residency screwed with my outlook on things
 
I'm actually impressed by the variety of opinions this thread has sparked, good on us. This clearly is something that deeply effects us in private practice. The issue for me, and I feel that for many of us in PP, isn't that, as Twiggidy puts it, we are non cardiac guys trying to make cardiac money. Those in the group that opted out of doing hearts get paid the same as the rest of us. It's that for a lower volume center, the certification will be next to impossible to get and double that to maintain. We're looking into if testamur status will be kosher with the powers that be and it appears that they will. Also I don't buy the argument that if the clipboard dudes make rules we should just fall in line. If the admins show up tomorrow and say - "Hey, we hired 10 new CRNAs and they are gonna start running the show down here, just pop out of your office now and then and walk around. End of discussion." I should just fall in line, right? No, I'm gonna ask questions. If it makes a difference to my practice, I should question things. We all should.

My goal is not to avoid enhancing my skills, it's not because I'm lazy, it's not because I think this is a bad idea even. My argument is that for centers such as mine this isn't even a practical request. To put the honus on me of reading TEEs in a competent, advanced fashion for the cases that I will do when I really won't be doing them that often is probably not safe. Isn't one of the mantras of this message board "know your own limits?" I have good basic echo skills but maintaining advanced TEE skills would be a limit of mine. Maybe this doesn't make any sense, but I actually feel that my patients will do better with someone else reading the echo. Because if I miss something critical out of a lack of experience - that would devastate me.
 
One thing to consider if these smaller volume places are going to have fellowship-trained, TEE-certified anesthesiologists doing hearts is recertification. For Advanced PTEE recent, you have to do 50 TEEs per year for 2 of the last 3 years prior to recert. At small volume hospitals, these could be tough to get. At a place with 200-300 hearts/year, are you really gonna have less than 4-5 guys doing hearts? That makes for a crummy call schedule, not even considering vacations. If they can't get the numbers, do you tell your CV trained, formerly TEE-certified doc "sorry bro, you're out. we gotta hire a newly certified guy until his 10 years are up"?
 
Way to go, let us continue to restrict patients' access to anesthesiologists and further fragment the care we provide. Beyond the fact that plenty of non-fellowship trained anesthesiologists provide excellent care to heart patients every single day (I'm not even going to go into further detail since everyone in PP knows this is the case), REQUIRING a cardiac fellowship and/or other certifications (OB, regional, etc) is beyond *****ic and will cause us to dig our profession further into the pit that it is already in. Meanwhile the CRNAs in town will be content taking a weekend class on echocardiography or regional anesthesia and will happily take your job when you are off training for another couple years (since, of course, 12 years of schooling/training was not enough). And guess what? Studies will show NO OUTCOME difference between the weekend-trained CRNA and you with your fancy echo skills for run-of-the-mill CABGs/valves, so the hospital will gladly keep them around and dump your sorry ass to the curb.

You guys need to pull your heads out of the sand, climb down from your ivory towers, and view our specialty for what it is today. It isn't about who knows more anymore or who can score higher on standardized tests. The CRNAs have made "access to care" their mantra for decades, and only now it is slowly morphing into "we are better than them." Further restricting patients' access to anesthesiologists will only help their cause. We are fighting a war, and the guerrilla warfare tactics of the nurses are winning. Pulling your highly-trained soldiers out of the front lines to put them back into military academy for a couple more years is beyond the stupidest idea I have ever heard.

I suppose it is worth mentioning, if it made one iota of difference in day-to-day practice, perhaps I could support it. But, the reality is, it won't.
 
PoorInvestment said:
I'm actually impressed by the variety of opinions this thread has sparked, good on us. This clearly is something that deeply effects us in private practice. The issue for me, and I feel that for many of us in PP, isn't that, as Twiggidy puts it, we are non cardiac guys trying to make cardiac money. Those in the group that opted out of doing hearts get paid the same as the rest of us. It's that for a lower volume center, the certification will be next to impossible to get and double that to maintain. We're looking into if testamur status will be kosher with the powers that be and it appears that they will. Also I don't buy the argument that if the clipboard dudes make rules we should just fall in line. If the admins show up tomorrow and say - "Hey, we hired 10 new CRNAs and they are gonna start running the show down here, just pop out of your office now and then and walk around. End of discussion." I should just fall in line, right? No, I'm gonna ask questions. If it makes a difference to my practice, I should question things. We all should.

My goal is not to avoid enhancing my skills, it's not because I'm lazy, it's not because I think this is a bad idea even. My argument is that for centers such as mine this isn't even a practical request. To put the honus on me of reading TEEs in a competent, advanced fashion for the cases that I will do when I really won't be doing them that often is probably not safe. Isn't one of the mantras of this message board "know your own limits?" I have good basic echo skills but maintaining advanced TEE skills would be a limit of mine. Maybe this doesn't make any sense, but I actually feel that my patients will do better with someone else reading the echo. Because if I miss something critical out of a lack of experience - that would devastate me.
Click to expand...

So are you covering all the heart call plus OR call for the same money as the docs who aren't messing with hearts at all? My old group tried to pull that on those of us who were taking more call...when it came time to vote, the non heart people outnumbered the heart people, it was bogus.
And yes, unfortunately if the admin makes a decision they expect you to fall in line. You can try to negotiate with them and hope that works.
 
In small groups like mine (5 docs) we all make the same amount of money. There is no bonus for heart call, since we are all on heart call. We all take the same amount of call days, weekends, and backup call days (give or take 1). There is no practical way to divy that up into any smaller bunches.
 
While I don't think a fellowship and/or certification should be required, if someone is doing hearts consistently I think they owe it to themselves and the patients to pass the advanced PTeXAM
 
Urzuz said:
Way to go, let us continue to restrict patients' access to anesthesiologists and further fragment the care we provide. Beyond the fact that plenty of non-fellowship trained anesthesiologists provide excellent care to heart patients every single day (I'm not even going to go into further detail since everyone in PP knows this is the case), REQUIRING a cardiac fellowship and/or other certifications (OB, regional, etc) is beyond *****ic and will cause us to dig our profession further into the pit that it is already in. Meanwhile the CRNAs in town will be content taking a weekend class on echocardiography or regional anesthesia and will happily take your job when you are off training for another couple years (since, of course, 12 years of schooling/training was not enough). And guess what? Studies will show NO OUTCOME difference between the weekend-trained CRNA and you with your fancy echo skills for run-of-the-mill CABGs/valves, so the hospital will gladly keep them around and dump your sorry ass to the curb.

You guys need to pull your heads out of the sand, climb down from your ivory towers, and view our specialty for what it is today. It isn't about who knows more anymore or who can score higher on standardized tests. The CRNAs have made "access to care" their mantra for decades, and only now it is slowly morphing into "we are better than them." Further restricting patients' access to anesthesiologists will only help their cause. We are fighting a war, and the guerrilla warfare tactics of the nurses are winning. Pulling your highly-trained soldiers out of the front lines to put them back into military academy for a couple more years is beyond the stupidest idea I have ever heard.

I suppose it is worth mentioning, if it made one iota of difference in day-to-day practice, perhaps I could support it. But, the reality is, it won't.
Click to expand...
This is going on in academics now. There are completely destroying the specialty. Rather than request a well rounded anesthesiologist they put in job ads fellowship required. So I called one of those ass holes and I actually got the chairman on the phone. He said I only hire fellowship trained. I replied surely you must have run Of the mill Kmart blue light special cases such as appy chokes ortho etc that a well rounded generalist can take care of. He said those guys have fellowships too. I said you know what you are sir? He said what? I said a mass hole .and hung up.
 
We only hire fellowship trained people, but it's a children's hospital...
Chairmen/presidents can hire anyone they want. If they want a cardiac guy, they get a cardiac guy, if they want a regional guru, they get one. If they want everyone in a research track, that's who they hire, and you will publish or perish. It makes sense for academic centers to have sub specialists as they teach, do research, etc. It's hard to believe anyone would hire only fellowship trained people though, as there aren't fellowships in all the specialty fields and there aren't enough fellowship trained people to fill a big university department. The large adult hospital down the street definitely hires generalists.
 
My residency program went through a ten year period where they didn't hire any non-fellowshipped people (except high end basic science PhD folks). They ended up with way too many people taking subspecialty call (CV, critical care, pain, peds, transplant, etc-all from home), and way too few people taking general OR call (in house). The only people hired during that period who were in the general pool were regional or neuro. The majority of OR cases don't fall into a special fellowship area. Not to say you don't need specialists, but a good program/group should recognize the need to have quality general anesthesiologists around as well.
 
diceksox said:
While I don't think a fellowship and/or certification should be required, if someone is doing hearts consistently I think they owe it to themselves and the patients to pass the advanced PTeXAM
Click to expand...

Exactly. Mandating certification versus leaving it up to one's professional judgment are very, VERY different. The former is dangerous, ill-conceived, and is an example in a list of ways organizations have found to gouge physicians for thousands of dollars, for pieces of paper apparently validating our competence and worth.
 
criticalelement said:
This is going on in academics now. There are completely destroying the specialty. Rather than request a well rounded anesthesiologist they put in job ads fellowship required. So I called one of those ass holes and I actually got the chairman on the phone. He said I only hire fellowship trained. I replied surely you must have run Of the mill Kmart blue light special cases such as appy chokes ortho etc that a well rounded generalist can take care of. He said those guys have fellowships too. I said you know what you are sir? He said what? I said a mass hole .and hung up.
Click to expand...
So ... you made a crank call? What are you, 14 years old?
 
Urzuz said:
Way to go, let us continue to restrict patients' access to anesthesiologists and further fragment the care we provide. Beyond the fact that plenty of non-fellowship trained anesthesiologists provide excellent care to heart patients every single day (I'm not even going to go into further detail since everyone in PP knows this is the case), REQUIRING a cardiac fellowship and/or other certifications (OB, regional, etc) is beyond *****ic and will cause us to dig our profession further into the pit that it is already in. Meanwhile the CRNAs in town will be content taking a weekend class on echocardiography or regional anesthesia and will happily take your job when you are off training for another couple years (since, of course, 12 years of schooling/training was not enough). And guess what? Studies will show NO OUTCOME difference between the weekend-trained CRNA and you with your fancy echo skills for run-of-the-mill CABGs/valves, so the hospital will gladly keep them around and dump your sorry ass to the curb.

You guys need to pull your heads out of the sand, climb down from your ivory towers, and view our specialty for what it is today. It isn't about who knows more anymore or who can score higher on standardized tests. The CRNAs have made "access to care" their mantra for decades, and only now it is slowly morphing into "we are better than them." Further restricting patients' access to anesthesiologists will only help their cause. We are fighting a war, and the guerrilla warfare tactics of the nurses are winning. Pulling your highly-trained soldiers out of the front lines to put them back into military academy for a couple more years is beyond the stupidest idea I have ever heard.

I suppose it is worth mentioning, if it made one iota of difference in day-to-day practice, perhaps I could support it. But, the reality is, it won't.
Click to expand...

I agree with a lot of the sentiment here...... We are attempting to restrict the practice of our fellow anesthesiologists with all of this stuff. Meantime, you think the CRNA's care about that?

Again, I'll never suggest a fellowship is bad or unnecessary (Peds, Cardiac, CCM). I know better than this. But not all cardiac is created equal. Nor are all peds cases. Do you guys realize how many Peds ENT are done out of ASC's?? LOTS. But, they are ASA 1's.

This is different than poor EF for dual valve surgery, complicated redo's etc. etc. OR from sick neonates or sick kids. I get it. I don't want to do those cases.

I would feel more comfortable doing more advanced cardiac IF my TEE skills were also more advanced (working on it).

But, we need to be careful how we attempt to "limit" cases. The fellowship issue is NOT the solution to our mid-level encroachment problems, IMHO.

Oh, and the folks in our group that don't do cardiac call in a cardiac guy from home when a heart comes in during the off hours. This is very infrequent. Some of the guys that are comfortable doing hearts but don't do a lot of them will do the case themselves. ***We don't get a premium or stipend or make any more money to do hearts at my gig..... FYI
 
criticalelement said:
This is going on in academics now. There are completely destroying the specialty. Rather than request a well rounded anesthesiologist they put in job ads fellowship required. So I called one of those ass holes and I actually got the chairman on the phone. He said I only hire fellowship trained. I replied surely you must have run Of the mill Kmart blue light special cases such as appy chokes ortho etc that a well rounded generalist can take care of. He said those guys have fellowships too. I said you know what you are sir? He said what? I said a mass hole .and hung up.
Click to expand...

This is the exact reason I would not take a job at my training program, which I could have in spite of no fellowship. The skill attrition that occurs in this type of setting was unacceptable to me.

When I realized that for my CURRENT gig, I was more competitive than some of the best cardiac or peds guys at my former place, I realized the power of a good general anesthesiologist. Their numbers of cardiac and peds WARRANTED fellowship only for those specialties. Also the complexity. But, my gig needs a good generalist that can do a wide array of cases. Some of my attendings could not do what I do every day. Not without a substantial bump in the road as they redeveloped those lost skills.
 
An argument in favor of subspecialty training and certification is that it further distinguishes us from the CRNAs.
They are starting to do the same as far as subspecialization. There are at least a few CRNA "fellowships" or "advanced subspecialty training" out there for them.
 
I think the days of just being a generalist and getting hired are getting slimmer. This is in Canada, but the vast majority of my surgical colleagues finishing residency have to pursue a fellowship +/- masters to get a job in the city. Our specialty is likely no different.
 
GA8314 said:
I agree with a lot of the sentiment here...... We are attempting to restrict the practice of our fellow anesthesiologists with all of this stuff. Meantime, you think the CRNA's care about that?

Again, I'll never suggest a fellowship is bad or unnecessary (Peds, Cardiac, CCM). I know better than this. But not all cardiac is created equal. Nor are all peds cases. Do you guys realize how many Peds ENT are done out of ASC's?? LOTS. But, they are ASA 1's.

This is different than poor EF for dual valve surgery, complicated redo's etc. etc. OR from sick neonates or sick kids. I get it. I don't want to do those cases.

I would feel more comfortable doing more advanced cardiac IF my TEE skills were also more advanced (working on it).

But, we need to be careful how we attempt to "limit" cases. The fellowship issue is NOT the solution to our mid-level encroachment problems, IMHO.

Oh, and the folks in our group that don't do cardiac call in a cardiac guy from home when a heart comes in during the off hours. This is very infrequent. Some of the guys that are comfortable doing hearts but don't do a lot of them will do the case themselves. ***We don't get a premium or stipend or make any more money to do hearts at my gig..... FYI
Click to expand...

Agree. However at my shop the cardiac group gets no stipend or added pay, except if called in while first call is not a heart guy. In that case they get a per hour from the partner that has chosen to no longer care of cardiac cases. Makes a 2 AM call in for a bring back more palatable.
 
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Gosh I thought nowadays it was only kids being tested to death. They think there's a difference between 3x5 and 5x3. Like the OB specialist who can't intubate or regional specialist who can't do GI.
 
2-4 person cardiac teams are possible, even with vacation. it's not like you'd actually be q2 call. more than likely you'd be 1 week or 2 weeks on and then 1-2 weeks off call. that kind of discussion should be in private forums so our cardiac surgeon colleagues who actually do that schedule don't see it.

i will at this point agree that those of us that did cardiac, the money was on the list but not the top reason. Most of us WANTED to have the ability to read and interpret echos and for me, i like the quote-by the book-unquote aspect of the cardiac room. we do things the same way everyday because that's the right way to do it (however it may be that you decide is your right way). that's why keeps the hearts alive barring true disaster. it's generally what I hate about some other aspects of general anesthesia or ob anesthesia where there can be this "fly by your wings" attitude.

"oh, make this epidural light." "oh the dad in this C/S wants to dance around the room but don't call him out because we don't want to lose patients" "oh don't do a block" "oh do a block"

you generalist can have that. give me a CABG or a valve so i can put an A-line in them, put them to sleep, slip in a echo, throw in a CVP/Swan and get on with my life.

that's just me...

so in essence, i guess it just baffles me that someone would want to do hearts but not want to read and interpret their on TEEs
 
Twiggidy said:
2-4 person cardiac teams are possible, even with vacation. it's not like you'd actually be q2 call. more than likely you'd be 1 week or 2 weeks on and then 1-2 weeks off call. that kind of discussion should be in private forums so our cardiac surgeon colleagues who actually do that schedule don't see it.

i will at this point agree that those of us that did cardiac, the money was on the list but not the top reason. Most of us WANTED to have the ability to read and interpret echos and for me, i like the quote-by the book-unquote aspect of the cardiac room. we do things the same way everyday because that's the right way to do it (however it may be that you decide is your right way). that's why keeps the hearts alive barring true disaster. it's generally what I hate about some other aspects of general anesthesia or ob anesthesia where there can be this "fly by your wings" attitude.

"oh, make this epidural light." "oh the dad in this C/S wants to dance around the room but don't call him out because we don't want to lose patients" "oh don't do a block" "oh do a block"

you generalist can have that. give me a CABG or a valve so i can put an A-line in them, put them to sleep, slip in a echo, throw in a CVP/Swan and get on with my life.

that's just me...

so in essence, i guess it just baffles me that someone would want to do hearts but not want to read and interpret their on TEEs
Click to expand...

I've seen dad's take their shirt off for immediate skin-to-skin for the baby. I have yet to see the dancing dad though!
 
jope said:
I've seen dad's take their shirt off for immediate skin-to-skin for the baby. I have yet to see the dancing dad though!
Click to expand...

i may have turned in my wings after that one. i'm starting to lose the edge like Cougar anyway...
 
jope said:
I've seen dad's take their shirt off for immediate skin-to-skin for the baby. I have yet to see the dancing dad though!
Click to expand...

Not sure I could tolerate that...sounds like a special miracle you got to be involved in.
 
I think OB gets a bad wrap because a lot of docs like to pretend they don't like OB soley based upon the social issues. My true feeling is that a LOT of anesthesiologists dump on OB because they don't like (or can't handle) the stress involved in OB anesthesia. I've personally seen docs hem and haw over positioning for minutes.... You know what? They're not ever going to be perfectly positioned! Just get it done! I've seen docs yelling at the patient because of the stress of a laboring patient in pain. Suck it up, talk calmly, and get the epidural in.

This is my personal feeling towards OB. Lots of docs shy away from it because it CAN be very stressful. You need to be fluid. You need to be very flexible and adaptive. And, yes, the acuity CAN become very high in a hurry. It's not for everyone, I suppose.... O.k., flame away......
 
GA8314 said:
I think OB gets a bad wrap because a lot of docs like to pretend they don't like OB soley based upon the social issues. My true feeling is that a LOT of anesthesiologists dump on OB because they don't like (or can't handle) the stress involved in OB anesthesia. I've personally seen docs hem and haw over positioning for minutes.... You know what? They're not ever going to be perfectly positioned! Just get it done! I've seen docs yelling at the patient because of the stress of a laboring patient in pain. Suck it up, talk calmly, and get the epidural in.

This is my personal feeling towards OB. Lots of docs shy away from it because it CAN be very stressful. You need to be fluid. You need to be very flexible and adaptive. And, yes, the acuity CAN become very high in a hurry. It's not for everyone, I suppose.... O.k., flame away......
Click to expand...

Nah.....

honestly, i find OB to be rewarding. it's one of the few instances in medicine where you see immediate results. patients go from screaming to smiling and they have you to thank for it

I hate
1) OB Nurses
2) C-sections
3) Being woken up all night

#3 is the main reason I want to rid OB from my life. Even the Obstetricians are usually at home while we're in the hospital dealing with BS. I want to be home at night with my family like the next man.
 
OB can be one of the most lucrative subspecialties of anesthesia.

10-25 epidurals + 5 or more one hour c/sections per shift = hard work with great compensation.

Add to that a good payor mix and continuous billing for neuraxial anesthesia.

I never understood why groups give it up to CRNAs.
 
sevoflurane said:
OB can be one of the most lucrative subspecialties of anesthesia.

10-25 epidurals + 5 or more one hour c/sections per shift = hard work with great compensation.

Add to that a good payor mix and continuous billing for neuraxial anesthesia.

I never understood why groups give it up to CRNAs.
Click to expand...

Unless you're like the places I've worked and the majority are indigent and you're lucky if they speak English....baby after baby born addicted to something and very sick as a result. That tore me up to see day after day. I would be happy to do OB in a nice suburban hospital, don't get me wrong🙂
 
sevoflurane said:
10-25 epidurals + 5 or more one hour c/sections per shift = hard work with great compensation.
Click to expand...

that sounds like a nightmare shift..... but maybe that's because i cover OB like 6-8 times a month and 6-8 shifts like that would make me want to burn "something"

sevoflurane said:
I never understood why groups give it up to CRNAs.
Click to expand...

see reason #3
 
Man o War said:
Unless you're like the places I've worked and the majority are indigent and you're lucky if they speak English....baby after baby born addicted to something and very sick as a result. That tore me up to see day after day. I would be happy to do OB in a nice suburban hospital, don't get me wrong🙂
Click to expand...

Careful of that.....those suburbanites can be some of the worst patients
 
Twiggidy said:
Careful of that.....those suburbanites can be some of the worst patients
Click to expand...

Yeah they come with their own issues, but I could deal for private insurance reimbursement and no caseworkers waiting to take away drug addicted baby number 8!
 
I've worked at a hospital that had 4000 deliveries a year. It was a rough shift for sure.

But average Doc compensation was 750K+

Look at ACI OB division in Vegas.

They do pretty well.... but work hard for it.

I couldn't do OB 100%.

I like my current set up which is 1-2 OB shifts a month. 15-20 procedures a shift. Sometimes more (sometimes less). I had one hour of sleep last time I did OB. Def. busiest shift at my current gig as we have a huge OB population.
 
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You're right. OB is very lucrative and we deal with all types of insurance.

We do about 6000 deliveries a year. The reason its not my favorite is having to deal with mutiple OB's who all think that their section needs to go first. Having said that, i'll take the indigent patient any day over the uppity patient with the 12 point labor plan.
 
dr doze said:
An argument in favor of subspecialty training and certification is that it further distinguishes us from the CRNAs.
They are starting to do the same as far as subspecialization. There are at least a few CRNA "fellowships" or "advanced subspecialty training" out there for them.
Click to expand...

I am not interested in smoke and mirrors ploys to try and get support. If the already large discrepancy in training cannot convince the powers that be of our superiority, why the heck would one more year of fluff convince them?
 
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