Northstar's latest?

[CopaceticOne]

Plus, let's be serious: a lot of surgeons like to decide everything, including what happens when coming off pump, regardless who the monkey behind the drapes is.

One of the staff at my place was a CT surgeon for quite a while before moving to the US, then did an Anesthesia residency. There are stories of this staff (on multiple occasions) dealing with CT surgeons saying what we should be doing on our side of the drape by saying "I can come over there and do your job right now, can you say the same? Then don't tell me what to do."

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[PainDrain]

One of the staff at my place was a CT surgeon for quite a while before moving to the US, then did an Anesthesia residency. There are stories of this staff (on multiple occasions) dealing with CT surgeons saying what we should be doing on our side of the drape my saying "I can come over there and do your job right now, can you say the same? Then don't tell me what to do."

I believe I know this person.

 

[VA Hopeful Dr]

It wouldn't, as long as the surgeons are still primary. We would just become the periop monkey, instead of the intraop monkey.

The way to do PSH is the Austrian model (if I remember correctly): anesthesia does everything medically pre- and postop, and scheduling-wise, the surgeons just show up to operate and do wound care postop. I am not sure many of my colleagues would like that, given their profound dislike for anything that smells remotely like internal medicine. Also, that system wouldn't work well in the US, where reimbursements for monkey skills are much higher than for real medicine (i.e. thinking, diagnosing, optimizing, first doing no harm).

As a PCP who hates doing pre-op "clearance", I fully support this idea

 

[resp228]

It wouldn't, as long as the surgeons are still primary. We would just become the periop monkey, instead of the intraop monkey.

The way to do PSH is the Austrian model (if I remember correctly): anesthesia does everything medically pre- and postop, and scheduling-wise, the surgeons just show up to operate and do wound care postop.

Can someone please explain the difference between this and the model the ASA is looking to implement?

 

[LunchMD]

I don't know, im not entirely convinced thst is what would happen. As an intern, on some surgical subspecialty rotations we had medicine "co-management" that we consulted on our +/- sicker patients. Hospitalist came, saw pt, and put in recs, but the surgery team still had to put in the orders and do all the legwork, respond to pages, discharge the pt. My residents/attendings basically never went against their recs (I guess bc have fun explaining that in court?). The hospitalists just kinda saw the patient as they felt necessary (ie maybe not every day) or if we called them with a new question. That could be one interpretation of the post-op portion. That doesn't seem very monkey-like to me, but maybe I am too naive. Or better yet we decide who we should follow based on pre-op evaluation and what happens intraop.

lI haveooked up everything I can possibly find on the internet and still don't really understand what the official vision is. I've only really been able to find one or two examples of implementation of it which didn't seem negative to me. One that I remember was for hip fractures coming into the ED. Anesthesia had the added role of seeing the patient to evaluate appropriate for OR. PT could only go to OR after Anes gave the green light. Don't remember the rest of it.

 

[GravelRider]

I don't know, im not entirely convinced thst is what would happen. As an intern, on some surgical subspecialty rotations we had medicine "co-management" that we consulted on our +/- sicker patients. Hospitalist came, saw pt, and put in recs, but the surgery team still had to put in the orders and do all the legwork, respond to pages, discharge the pt. My residents/attendings basically never went against their recs (I guess bc have fun explaining that in court?). The hospitalists just kinda saw the patient as they felt necessary (ie maybe not every day) or if we called them with a new question. That could be one interpretation of the post-op portion. That doesn't seem very monkey-like to me, but maybe I am too naive. Or better yet we decide who we should follow based on pre-op evaluation and what happens intraop.

lI haveooked up everything I can possibly find on the internet and still don't really understand what the official vision is. I've only really been able to find one or two examples of implementation of it which didn't seem negative to me. One that I remember was for hip fractures coming into the ED. Anesthesia had the added role of seeing the patient to evaluate appropriate for OR. PT could only go to OR after Anes gave the green light. Don't remember the rest of it.

I had a similar medicine consult service in my IM residency. The majority of our consults were routine medical management issues from the ortho, neurosurgery, or ENT services. Occasionally a patient would need closer watching and we would transfer to a medicine service...which most of the surgeons were more than happy to let us take over management.

I used to be a supporter of the PSH, but I have since retracted my support. First of all, I think the ASA does a poor job describing the concept of the PSH. All I ever see are flow charts and venn diagrams describing the concept. It looks like the ASA hired the Clipboard Nurse Consulting Group (CNCG for short) when they came up with the idea. I think internists would do a better job at medical management anyway. Most anesthesiologists have no desire to manage glucose or bridge back to therapeutic Coumadin doses. These are not difficult, but they are the mundane tasks that internists do every single day, so they are good at it. I just don’t see a good reason for an anesthesiologist to try to pigeonhole himself into another specialty. If the ASA wants to broaden anesthesiology’s presence in the hospital then they should focus on things we are good at...like acute pain management and critical care.

 

[hypnosMD]

This just in. Apparently Northstar lost another contract at a medium sized hospital in Kentucky. The group was somehow able to resume control as PP (likely at great legal cost).
Don’t sign any noncompetes if u work for any of these AMC outfits. (U may not wanna buy a house either but that is a different topic of discussion).

 

[PieOHmy]

Honestly this is what stresses me the most about my future. Once I am an attending with the appropriate experience, I don't think I'm going to do well being "told" what to do by colleagues in a different specialty.

This is why I'm confused when people are against the perioperative surgical home. It seems to me once we have a little more ownership of the patients pre/post-op, even if it's not you, but someone in your department, even if the services are mid-level heavy (which truthfully is how most all medicine is now anyways), if the attending is an anesthesiologist I think this would help to avoid the monkey situation?

Periop surgical home is doomed for failure because the internists are are more poised to optimize chronic conditions and follow up then we are.

 

[Mikkel]

I had a similar medicine consult service in my IM residency. The majority of our consults were routine medical management issues from the ortho, neurosurgery, or ENT services. Occasionally a patient would need closer watching and we would transfer to a medicine service...which most of the surgeons were more than happy to let us take over management.

I used to be a supporter of the PSH, but I have since retracted my support. First of all, I think the ASA does a poor job describing the concept of the PSH. All I ever see are flow charts and venn diagrams describing the concept. It looks like the ASA hired the Clipboard Nurse Consulting Group (CNCG for short) when they came up with the idea. I think internists would do a better job at medical management anyway. Most anesthesiologists have no desire to manage glucose or bridge back to therapeutic Coumadin doses. These are not difficult, but they are the mundane tasks that internists do every single day, so they are good at it. I just don’t see a good reason for an anesthesiologist to try to pigeonhole himself into another specialty. If the ASA wants to broaden anesthesiology’s presence in the hospital then they should focus on things we are good at...like acute pain management and critical care.

I think a perfect setup is having all ambulatory patients go to your clinic 2 weeks before scheduled surgery date, be seen by a Non-Physician who follows established protocols for pre-op testing, and coordinates care with the patient's specialists and surgeon office.

H&P x 100+ per day, and paying a salaried Non-Physician, could mean big bucks for you.

I'm not saying the PSH with a Non-Physician doing the legwork would be equivalent to a consulting internist, but at least the ball (and revenue) is in your group's court and you can standardize periop care.

I could see myself signing up for "supervision" if it means getting the bulk of the revenue for those visits.

Run it like a factory, and you can make money like a factory owner.

However, following patients in the hospital if admitted, is a whole separate problem that I wouldn't want to get into, and this is probably where the ASA loses their support.

 

[Mman]

Periop surgical home is doomed for failure because the internists are are more poised to optimize chronic conditions and follow up then we are.

and they know infinitely less about the surgeries patients are having

 

[deleted171991]

and they know infinitely less about the surgeries patients are having

And we know infinitely less about the diseases patients are having.

Many anesthesiologists pride themselves on "hating" internal medicine, even some of our intensivists. It's absolutely shameful. In many countries, perioperative medicine belongs to anesthesiology (as does MEDICAL critical care), and that includes preop optimization.

Only in this money-obsessed country do we allow other hyena specialties to chew at our specialty's carcass.

 

[PieOHmy]

and they know infinitely less about the surgeries patients are having

I don't need them to know about the surgeries. I need them to maximize and optimize patient's chronic diseases, tell me about their allergies and disposition socially and thats it. For people to think this is what Anesthesiologists should spend their day doing are crazy. Anesthesiologists should scan the history for holes and thats it.

 

[nimbus]

I like the narrow focus of anesthesiology. That’s the charm and challenging enough.

 

[deleted171991]

I like the narrow focus of anesthesiology. That’s the charm and challenging enough.

Narrow focus means easily replaceable. I don't give it 20 years as a physician specialty in many ORs.

 

[Noyac]

I think a perfect setup is having all ambulatory patients go to your clinic 2 weeks before scheduled surgery date, be seen by a Non-Physician who follows established protocols for pre-op testing, and coordinates care with the patient's specialists and surgeon office.

H&P x 100+ per day, and paying a salaried Non-Physician, could mean big bucks for you.

I'm not saying the PSH with a Non-Physician doing the legwork would be equivalent to a consulting internist, but at least the ball (and revenue) is in your group's court and you can standardize periop care.

I could see myself signing up for "supervision" if it means getting the bulk of the revenue for those visits.

Run it like a factory, and you can make money like a factory owner.

However, following patients in the hospital if admitted, is a whole separate problem that I wouldn't want to get into, and this is probably where the ASA loses their support.

I think a perfect setup is having all ambulatory patients go to your clinic 2 weeks before scheduled surgery date, be seen by a Non-Physician who follows established protocols for pre-op testing, and coordinates care with the patient's specialists and surgeon office.

H&P x 100+ per day, and paying a salaried Non-Physician, could mean big bucks for you.

I'm not saying the PSH with a Non-Physician doing the legwork would be equivalent to a consulting internist, but at least the ball (and revenue) is in your group's court and you can standardize periop care.

I could see myself signing up for "supervision" if it means getting the bulk of the revenue for those visits.

Run it like a factory, and you can make money like a factory owner.

However, following patients in the hospital if admitted, is a whole separate problem that I wouldn't want to get into, and this is probably where the ASA loses their support.

I have a couple questions.
What is the 100 you describe, dollars or pts?
When you are no longer viewed, by those making the decisions, as necessary because Midlevels are cheaper and are doing the work anyway then your revenue stream will come to an end. My question is, do you not see how this mentality is a disservice to our pts and to our profession?

 

[Mikkel]

I have a couple questions.
What is the 100 you describe, dollars or pts?
When you are no longer viewed, by those making the decisions, as necessary because Midlevels are cheaper and are doing the work anyway then your revenue stream will come to an end. My question is, do you not see how this mentality is a disservice to our pts and to our profession?

100 patients per day, 5 days per week.

I don't know that an H&P bills for, but if we're talking bundled payments, it's a tiny tiny part of that pie.

Trust me, I hate the idea of the PSH. But, I think it can be made to work profitably if it was forced down our throats.

 

[MoMoGesiologist]

Bad medicine rounds. During my fellowship, I used to round with the APRNs in the MICU, average of 15 minutes per patient. Done by 10 am, and that included breakfast.

I’m assuming u started at 8am, so that means only 8 pts?

 

[Noyac]

And we know infinitely less about the diseases patients are having.

Many anesthesiologists pride themselves on "hating" internal medicine, even some of our intensivists. It's absolutely shameful. In many countries, perioperative medicine belongs to anesthesiology (as does MEDICAL critical care), and that includes preop optimization.

Only in this money-obsessed country do we allow other hyena specialties to chew at our specialty's carcass.

I recently saw a pt in the preop clinic that was a mess but functionally optimized. He was not going to go away without surgery and he fully understood the risks. He no longer wanted to live in the condition he was in. So I approved the case and did it myself so as not to burden others with the drama. After surgery he was to be managed by the Hospitalists but they never saw the pt until postop. He had a slightly unsymmetrical appearance to his face with some large fat cheeks. He was prone for the entire 2:30 hrs. When I woke him up I was impressed with his alertness and condition. He looked great. It was spine surgery and his feet were numb preoperatively and a slight discrepancy was apparent in his strength btw the LE’s. When he woke up his feet were still numb but strength was good throughout and he commented on how good he felt. The next morning I checked on him and I found out that he had a complete stroke w/u for facial droop without any other symptoms. Guess what, the w/u was negative.
So he got a completely unnecessary w/u because the Hospitalists didn’t know the pt and didn’t bother to call the surgeon or myself before jumping into action.
If we were to manage the pts postop this would have been avoided. Or if they were to see the pts preop which they do sometimes.
Just think if they would have caused an iatrogenic issue on this guy after we got him through a tough surgery that many would have called reckless. We were very cautious I would like to add.

 

[Noyac]

100 patients per day, 5 days per week.

I don't know that an H&P bills for, but if we're talking bundled payments, it's a tiny tiny part of that pie.

Trust me, I hate the idea of the PSH. But, I think it can be made to work profitably if it was forced down our throats.

How are you gonna get 100 pts /day?

 

[deleted171991]

I’m assuming u started at 8am, so that means only 8 pts?

More or less. That was an associate provider team, and those were usually easier patients than on the resident teams. Still, rounding can be efficient and pleasant (that was the point I was trying to make... hyperbolically).

 

[deleted171991]

I recently saw a pt in the preop clinic that was a mess but functionally optimized. He was not going to go away without surgery and he fully understood the risks. He no longer wanted to live in the condition he was in. So I approved the case and did it myself so as not to burden others with the drama. After surgery he was to be managed by the Hospitalists but they never saw the pt until postop. He had a slightly unsymmetrical appearance to his face with some large fat cheeks. He was prone for the entire 2:30 hrs. When I woke him up I was impressed with his alertness and condition. He looked great. It was spine surgery and his feet were numb preoperatively and a slight discrepancy was apparent in his strength btw the LE’s. When he woke up his feet were still numb but strength was good throughout and he commented on how good he felt. The next morning I checked on him and I found out that he had a complete stroke w/u for facial droop without any other symptoms. Guess what, the w/u was negative.
So he got a completely unnecessary w/u because the Hospitalists didn’t know the pt and didn’t bother to call the surgeon or myself before jumping into action.
If we were to manage the pts postop this would have been avoided. Or if they were to see the pts preop which they do sometimes.
Just think if they would have caused an iatrogenic issue on this guy after we got him through a tough surgery that many would have called reckless. We were very cautious I would like to add.

One of my favorite stories is similar.

Patient post-CEA in a community hospital becomes confused and hemiplegic etc. in the PACU. The nurse calls a stroke alert (instead of an anesthesiologist). The fleas (mostly trainees) show up en masse immediately and start debating what to do next, at the bedside.

I walk by, just because I heard the stroke alert. The nurse tells me the story very briefly. I see that the SBP is around 90 (or so), so I push some phenylephrine (while they are chatting around me and messing with the patient - not mine). SBP comes up to like 140, all symptoms resolve in 30 seconds. Everybody shocked, even more chatty. I had to convince them that he didn't need any workup (thankfully the patient didn't want any either). True story.

There are TONS of stories like this, in every specialty. People should know their own limits, and first do no harm.

 

[Mikkel]

How are you gonna get 100 pts /day?

Just throwing a number out. 30, 50, 150, doesn't matter, it scales easily.

Take all the ambulatory patients from all your hospitals and ambulatory sites that your group covers, funnel them all to your Non-Physician, and get kudos from administration for "proactively finding cost effective reductions in healthcare duplication" or whatever.

 

[Mman]

And we know infinitely less about the diseases patients are having.

Many anesthesiologists pride themselves on "hating" internal medicine, even some of our intensivists. It's absolutely shameful. In many countries, perioperative medicine belongs to anesthesiology (as does MEDICAL critical care), and that includes preop optimization.

Only in this money-obsessed country do we allow other hyena specialties to chew at our specialty's carcass.

I feel confident that I know more than enough about the diseases the patient has that impact their anesthetic and surgical recovery.

 

[Mman]

I don't need them to know about the surgeries. I need them to maximize and optimize patient's chronic diseases, tell me about their allergies and disposition socially and thats it. For people to think this is what Anesthesiologists should spend their day doing are crazy. Anesthesiologists should scan the history for holes and thats it.

what exactly do you think periop surgical home means?

hint: it isn't anesthesiologists becoming internists and running outpatient clinics and rounding on everybody til they discharge. I mean there are a few people that have argued that, but that isn't really what is happening right now nor what most are arguing for.

 

[gasdoc77]

This just in. Apparently Northstar lost another contract at a medium sized hospital in Kentucky. The group was somehow able to resume control as PP (likely at great legal cost).
Don’t sign any noncompetes if u work for any of these AMC outfits. (U may not wanna buy a house either but that is a different topic of discussion).

Do you know if the sight might be in Louisville or Owensboro? Rumor had it they have been chronically short staffed at each of these places, forcing the salaried docs to cover that much more call/weekends "as team players" LOL. I highly doubt that is something the docs or Northstar pitches to interviewees.

 

[Twiggidy]

Do you know if the sight might be in Louisville or Owensboro? Rumor had it they have been chronically short staffed at each of these places, forcing the salaried docs to cover that much more call/weekends "as team players" LOL. I highly doubt that is something the docs or Northstar pitches to interviewees.

Let's just say I've kept my ear to the ground and I can say with about 85% confidence that Louisville is one of the sites. I could be wrong, but when I start putting some puzzle pieces together I feel I'm correct