No need for CRNA bashing... but, do we honestly think this is a good idea?

[DrOwnage]

Anesthesiologists need to stop training SRNAs. Problem solved

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[TaoistDoc]

Wakeupdoc.org

 

[emergentmd]

an anesthesiologist on staff who works collaboratively with the CRNAs.

This is the most profoundly sad statement about where medicine is heading. Instead of an MD running the show, they will just be support for the real providers - CRNA/NPs.

Hospitals like any other business only care about $$$. They only care about patient care when it lines up with maximizing profit.

Just like car companies. They know their cars have issues and has calculated the cost of lawsuits vs fixing the issues. If 100 will dies because of fixable defect and will lose 100 Mil in lawsuits, then they will take that risk if it will costs them 200 Mil to fix/recall the product.

Same here. They know care will be substandard with increased morbidity/mortality but better path to pay the lawsuits knowing they will be more profitable.

Anesthesiology just like EM, you are just a widget and unless you own something no matter what you are still a widget. You can be the best widget at your job, but if another widget can do something similar and make more $$$$, they will replace you with a cheaper widget.

 

[ProRealDoc]

Incidents like this should serve as a reminder to all that your path to financial independence should not rely on practicing medicine until you are 65 but rather on being smart with your money and diversifying away from medicine as soon as possible.

 

[Twiggidy]

Incidents like this should serve as a reminder to all that your path to financial independence should not rely on practicing medicine until you are 65 but rather on being smart with your money and diversifying away from medicine as soon as possible.

Can’t disagree at all

 

[dtrack22]

Surgeon has no idea that he is liable for any anesthesia complication.

Are there a lot of cases where the surgeon has been held liable for a medical error related entirely to the administration of anesthesia?

Luckily I haven't had any anesthesia or surgical complication issues so far in my career (so I'm clueless here), but that seems no different than holding the anesthesiologist liable for surgical error on my end.

 

[dannyboy1]

So....if the CRNAs are so safe, why do they still need an anesthesiologist around to “collaborate” with them?
Saying one thing, but actions demonstrate another.
But those of us who have supervised CRNAs know their limitations, and aren’t surprised they have elected to keep a physician around “just in case”

This doesn’t exactly help us. Sure they may keep a few MD’s around for when $hit hits the fan. It won’t be any 4:1 ratio though, just some general “oversight”. You can guess what that does to the job market.

 

[DokterMom]

I've reach the point of realization that we cannot change the healthcare system in America and that midlevels are out of the bag. (The tragic thing in this particular case is that there were physicians willing to work in this rural setting but they were fired.) MBAs control healthcare. But call midlevels for what they are. Less trained, less educated, and arguably worse outcomes.

The public can choose safe and less safe options. They can drive a Volvo or they can drive a motorcycle without a helmet. But don't lie by saying the motorcycle is just as safe as the Volvo when you've never been involved in a crash. And don't go around calling the motorcycle a Volvo.

Incidents like this should serve as a reminder to all that your path to financial independence should not rely on practicing medicine until you are 65 but rather on being smart with your money and diversifying away from medicine as soon as possible.

You CAN change the healthcare business -- but not by sitting on your high horses complaining about the MBAs and CRNAs.

You want to call the shots? Own the business.

Own the business and hire the MBAs,
or let them own the businesses and hire the MDs -- or CRNAs.

 

[anbuitachi]

You CAN change the healthcare business -- but not by sitting on your high horses complaining about the MBAs and CRNAs.

You want to call the shots? Own the business.

Own the business and hire the MBAs,
or let them own the businesses and hire the MDs -- or CRNAs.

i agree but at teh same time, the small guys and girls are competing against big private firms worth billions. it's a very uphill battle. also a lot of doctors simply do not have the capital to start a business. even with NO gap years, you are graduating at age 30, with hundreds of thousands of debt. it's way easier said than done for most of us. way more likely to take the 300k job than to continue the 10 year grind and debt by starting a business

 

[coffeebythelake]

You CAN change the healthcare business -- but not by sitting on your high horses complaining about the MBAs and CRNAs.

You want to call the shots? Own the business.

Own the business and hire the MBAs,
or let them own the businesses and hire the MDs -- or CRNAs.

Isn't there a law preventing physicians from owning hospitals?

 

[Zekchar]

Incidents like this should serve as a reminder to all that your path to financial independence should not rely on practicing medicine until you are 65 but rather on being smart with your money and diversifying away from medicine as soon as possible.

Biggest takeaway from this post. Diversify diversify diversify

 

[WholeLottaGame7]

Are there a lot of cases where the surgeon has been held liable for a medical error related entirely to the administration of anesthesia?

Luckily I haven't had any anesthesia or surgical complication issues so far in my career (so I'm clueless here), but that seems no different than holding the anesthesiologist liable for surgical error on my end.

Outside of a lost airway, there aren't a ton of "clean" anesthesia kills. But what happens if you run into unexpected surgical bleeding and they didn't spend the extra 5 minutes to get an a-line or set up blood? What if they miss the subtle EKG changes and the patient has an MI? The list is endless. There's a lot of stuff that a good anesthesiologist will do to prevent something bad from happening that would otherwise get chalked up to the surgeon.

 

[BLADEMDA]

The AMCs want you all to be happy with any job they give you. The pay will be low and the call frequent but the alternative is unemployment. Combine the crna issue with the soon to be glut of new grads from community programs this field will become saturated. Again, this is good for the AMCs as it lowers wages. The AMC is paying in 2021 what it paid in 2014 to many of their employed Anesthesiologists. Fast forward 10 years and the salary Gap between “providers” will be less than 25 percent.

I honestly could see myself working for crna pay in 6-7 years if I could get their cushy work load to go with it. The irony is that even if I offered to work for crna pay the AMC would expect 2-3 x the amount of work.

 

[ProRealDoc]

Outside of a lost airway, there aren't a ton of "clean" anesthesia kills. But what happens if you run into unexpected surgical bleeding and they didn't spend the extra 5 minutes to get an a-line or set up blood? What if they miss the subtle EKG changes and the patient has an MI? The list is endless. There's a lot of stuff that a good anesthesiologist will do to prevent something bad from happening that would otherwise get chalked up to the surgeon.

Spinal anesthetic in an undiagnosed severe AS patient.

 

[GeneralVeers]

We've been discussing this on the EM forum. They are doing the same thing to you guys as they are doing to us. The plan from Envision is entire high-volume EDs staffed with MLPS and maybe one supervising physician......or none. It just depends what they can get away with.

The sad thing is that admin has calculated the body count, and has determined that the cost of lawsuits is less than the cost of safe staffing.

 

[nimbus]

We actually have a CRNA only hospital in our big “desirable” coastal city. They used to have anesthesiologists on staff but I think they all ended up leaving because the payor mix was so bad.

 

[anbuitachi]

Outside of a lost airway, there aren't a ton of "clean" anesthesia kills. But what happens if you run into unexpected surgical bleeding and they didn't spend the extra 5 minutes to get an a-line or set up blood? What if they miss the subtle EKG changes and the patient has an MI? The list is endless. There's a lot of stuff that a good anesthesiologist will do to prevent something bad from happening that would otherwise get chalked up to the surgeon.

i say this all the time, however i also believe a lot of these more subtle errors are difficult to be blamed on the anesthesiology team directly. i believe it's harder to sue and get a easy win for these.

the example i give often is a good anesthesiologist imo focuses more than just intraop events, but optimizes the patient in ways that improves overall care. 99.99% of the time, you can get thru a surgery with the patients glucose in the 400s. but i would argue fixing it benefits wound healing and outcome. however if a poor outcome occurs later that may be attributable to hyperglycemia, it'd probably be difficult to place the blame on the anesthesiologist.

a lot of good care the anesthesiologists provide are difficult to capture

 

[anbuitachi]

We actually have a CRNA only hospital in our big “desirable” coastal city. They used to have anesthesiologists on staff but I think they all ended up leaving because the payor mix was so bad.

i thought per hour wise, crnas arent much cheaper than anesthesiologists?

 

[patriot6]

If their crnas are anything like ours, I sure hope they can get all the cases done before 3pm.

 

[BLADEMDA]

https://www.aana.com/home/aana-updates/2021/03/24/patients-in-arkansas-now-have-increased-access-to-affordable-quality-anesthesia-care

another opt out.

Patients in Arkansas Now Have Increased Access to Affordable, Quality Anesthesia Care​

• Mar 24, 2021

 

[chocomorsel]

We actually have a CRNA only hospital in our big “desirable” coastal city. They used to have anesthesiologists on staff but I think they all ended up leaving because the payor mix was so bad.

Are patients dying or being maimed left and right? Because if not, then there you have it. We are our wind worst enemy.

 

[deleted941485]

Did my own little Gaswork search on the CRNA side vs MD side in the opt out states. Looks like there are plenty of CRNA practices out there offering what alot of MD specialists would make 400 was the highest I saw. But if you look at a state like Idaho or Iowa. Total Dearth of MD jobs but a good number of CRNA ones.

Honestly, the future is more opt out states and less MD jobs being swallowed whole by CRNAs. Seriously I got chills. I mean at this point they are pretty much making what alot of newly graduated hospitalists and IM docs would get there first year out.

If that doesn't make a new grad step back and go wtf am I doing here, then Im not sure what will.

 

[2.0%]

I don’t think that physician is even in-house. I think he’s like operating from another state in the C suite. Just to make things legal.

I bet this is correct. The anesthesia departments of a few "CRNA only" rural hospitals in our region are overseen by an anesthesiologist in another state. The only influence they really exert is with credentialing standards. Their position only blurs the line about physician involvement within the organization.

 

[dannyboy1]

i say this all the time, however i also believe a lot of these more subtle errors are difficult to be blamed on the anesthesiology team directly. i believe it's harder to sue and get a easy win for these.

the example i give often is a good anesthesiologist imo focuses more than just intraop events, but optimizes the patient in ways that improves overall care. 99.99% of the time, you can get thru a surgery with the patients glucose in the 400s. but i would argue fixing it benefits wound healing and outcome. however if a poor outcome occurs later that may be attributable to hyperglycemia, it'd probably be difficult to place the blame on the anesthesiologist.

a lot of good care the anesthesiologists provide are difficult to capture

This. All you have to do is just not kill anybody in the OR (or not do something completely bonkers, like the guy I know who gave 12 L of crystalloid intraop) and you have done a good job in the minds of the people who count (surgeons and admin). With the bar set so low it should be no surprise that this field is ripe for takeover...

 

[dannyboy1]

Spinal anesthetic in an undiagnosed severe AS patient.

Meh. With isobaric you will probably be just fine. The spinal/AS thing is mostly overblown academic dogma. It’s not like the pressure doesn’t drop when you induce GA...

 

[GassYous]

Meh. With isobaric you will probably be just fine. The spinal/AS thing is mostly overblown academic dogma. It’s not like the pressure doesn’t drop when you induce GA...

It's amazing how much bull**** they shovel at you in academia that you have to unlearn in practice. I'm glad I found this site because the education I got here was much better than most of the garbage I was fed in residency.

 

[nimbus]

Are patients dying or being maimed left and right? Because if not, then there you have it. We are our wind worst enemy.

No. According to a surgeon (Ortho/spine) who works there, they are excellent. That said, they are not new grads. They are mostly former Navy.

 

[nimbus]

i thought per hour wise, crnas arent much cheaper than anesthesiologists?

I’m pretty sure they bill their own cases. Hospital is owned by a notoriously cheap outfit (Prime healthcare/Prem Reddy). Bad payor mix+low (if any) stipend=low pay.

 

[deleted162650]

We actually have a CRNA only hospital in our big “desirable” coastal city.

Which shop is that?

 

[vector2]

No. According to a surgeon (Ortho/spine) who works there, they are excellent. That said, they are not new grads. They are mostly former Navy.

One of my buddies from high school is a general surgeon at a critical access hospital. CRNAs only. Says it's fine working with them because the patient acuity is pretty low and when something like a sick perforated viscous comes in he just dictates some of the critical cafe management across the drape.

SMH...

 

[ProRealDoc]

Meh. With isobaric you will probably be just fine. The spinal/AS thing is mostly overblown academic dogma. It’s not like the pressure doesn’t drop when you induce.

Great! I'll line a up a bunch 70 and 80 somethings and want you to just do the spinal in all of them without any questions.

 

[coffeebythelake]

Meh. With isobaric you will probably be just fine. The spinal/AS thing is mostly overblown academic dogma. It’s not like the pressure doesn’t drop when you induce GA...

Blahahhahaha ok buddy..
I hope you aren't takingnabout using full dose propofol when you induce

 

[secretasianman]

Ha ha buddy. I am loving the Volvo analogy because guess what I drive?
But yes totally agree that this is a losing battle in this country.
On a positive note, my COO cousin out in California says he prefers dealing with physicians much more so than dealing with unionized nurses. He is so tired of those nurses. He says they are just way too damn needy and demanding compared to Physcians. This after I sort of heated conversation from my end about how we can’t stand the C suite and how they treat us.

Because they actually have power, and we don’t. It is an impossible war to fight when you have a three front battle against hospital administration, insurance, and private equity. Doctors join these shady groups often because of a lack of choice. With the first two, it’s like fighting with both hands tied behind your back when you have no leverage. It wouldn’t be the case if doctors could own hospitals. Ok for others to profit off us though..

 

[GassYous]

There are currently 37k EM physicians: can the market support 20k more?

I did some number crunching based on AAMC's data...

forums.studentdoctor.net

5 years ago and look at them now. Our market can collapse anytime. Make hay while the sun shines.

 

[patriot6]

I had been kicking around the idea of going back to do a peds fellowship here in town...

This might be the straw.

 

[Shouldawouldacouldas]

I'm surprised the surgeons at that hospital are so willing to take on the added liability of supervising CRNAs

Wisconsin allows independent practice so the surgeons do not need to be on the record as supervising or directing.

 

[deleted126335]

...It wouldn’t be the case if doctors could own hospitals. Ok for others to profit off us though..

So you can be exploited by your fellow physicians.

 

[chocomorsel]

So you can be exploited by your fellow physicians.

We are all ****ed. Honestly, before I got into medicine I thought people were noble and fair and in the process ALSO made a good living.
The greed in medicine from all affronts is astounding. Healthcare in this country is a ****ing racket. The crap I have seen people do for money, and the crap I have heard insurances deny or payout, the lack of access to healthcare in the “greatest country in the world” is beyond anything I ever imagined. Frankly I never imagined it at all.

 

[TaoistDoc]

Don't worry, nothing is meant to last forever. Everything in this world is transient, including our life.. Enjoy what you have today. Take care of the present and the future will take care of itself.

 

[GassYous]

Don't worry, nothing is meant to last forever. Everything in this world is transient, including our life.. Enjoy what you have today. Take care of the present and the future will take care of itself.

wtf...

 

[deleted126335]

Don't worry, nothing is meant to last forever. Everything in this world is transient, including our life.. Enjoy what you have today. Take care of the present and the future will take care of itself.

Just curious, Do you have children?

 

[nimbus]

wtf...

Name fits

 

[deleted162650]

Don't worry, nothing is meant to last forever. Everything in this world is transient, including our life.. Enjoy what you have today. Take care of the present and the future will take care of itself.

Username checks out.

Edit: Arg. Beat me to it @nimbus. Touché.

 

[nimbus]

In before @SaltyDog

 

[TaoistDoc]

Lol yeah I have 2 kids. I'm just saying, all this fear and anger I hear serves no real purpose other than making yourself suffer. Holding on to anger is like drinking a poison and hoping the other person dies.

 

[deleted126335]

We are all ****ed. Honestly, before I got into medicine I thought people were noble and fair and in the process ALSO made a good living.
The greed in medicine from all affronts is astounding. Healthcare in this country is a ****ing racket. The crap I have seen people do for money, and the crap I have heard insurances deny or payout, the lack of access to healthcare in the “greatest country in the world” is beyond anything I ever imagined. Frankly I never imagined it at all.

Today's NY times:

A Single Ohio Hospital Reveals All That’s Wrong With American Health Care (Published 2021)

In Brian Alexander’s “The Hospital,” an intimate portrait of a small hospital in Bryan, Ohio.

www.nytimes.com

 

[Lecithin5]

Don't worry, nothing is meant to last forever. Everything in this world is transient, including our life.. Enjoy what you have today. Take care of the present and the future will take care of itself.

There’s some truth to this statement

 

[vm26]

Lol yeah I have 2 kids. I'm just saying, all this fear and anger I hear serves no real purpose other than making yourself suffer. Holding on to anger is like drinking a poison and hoping the other person dies.

Pema Chodron?

Below is one of my favorite quotes:
“We are not disturbed by what happens to us, but by our thoughts about what happens to us.”
― Epictetus

 

[vm26]

Wisconsin allows independent practice so the surgeons do not need to be on the record as supervising or directing.

So who is ultimately liable when CNRAs are acting independently?

Also can MDs testify against non-MDs in trial?

 

[deleted126335]

So who is ultimately liable when CNRAs are acting independently?

Also can MDs testify against non-MDs in trial?

Not a lawyer, but...

1. The CRNA....But, the question is are they truly acting independently? State Law is but one element of making that determination. Hospital bylaws, Employer contracts, Department Policy manual, "Informed" Consent all come into play in making that determination.

2. Depends on state law. Anesthesia is recognized as a practice of Medicine and a practice of Nursing. Regulated by different governing boards. Depending on the state, Anesthesiologists may or may not be able to give expert witness testimony against or for CRNAs. Likewise a CRNA may or may not be able to give expert witness testimony against or for an anesthesiologist.