Nurse Practitioner for Pre-Op and Post-Op Evals?

[OKenM]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

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[Hamhock]

HH

Edit: just saw it was his first post ever. Just close it now!

 

[IMGASMD]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

I personally don’t think it works, but may work well enough for your shop.
Do you have the volume or the resources to really train a NP well enough? The second part of that equation, how much faith do you have in someone who doesn’t know what we do every day, a NP, an internist or even a cardiologist..... how many medical clearance, cardiology clearance letters we laugh out loud on a daily basis?

I’ve seen this work out at two pervious places that I worked at..... one at an ivory tower, maybe four NPs with one Anesthesiologist. They present every single patient to the attending, basically a medical clinic. They see maybe 10-15 patients 1/2 day at the clinic. They would really gather as much information as possible for the anesthesiologists, and MD would ask for more info as needed, labs, ekg, echo. Etc.

The other was at a smaller hospital. They have one full time NP and residents see patients as needed, but no full time anesthesiologist to really talk through these patients. That NP struggled, because there was no real direction.

The other part of this discussion (i will preface this by, I worked as an internist before anesthesia). Internist/NP/cards have no clue what we do. When I was doing IM eval, a lot of times, I wouldn’t even know what to write or why I am even writing the information down. We had a form that would say the patient is low, intermediate, high risk for the procedure. What does that really mean? I had no clue. You and I and any literate person can read the guidelines, but is that assessment worth the paper they’re printed on? Our EMR recently started to have a pre-populated H&P for hospitalist for our IP patients. They started to assign ASA classification..... GTFOH

 

[urge]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

Will most likely help being compliant with all the paperwork. And way cheaper than getting an anesthesiologist to do the work.

The patients will probably not like it specially at the beginning while this person learns to fake all the answers to anesthesia questions of which he/she has no idea.

Overall don't think it is a great idea. Patient satisfaction might be low. It will likely not improve quality. And even though it seems like a cheaper option I really wonder if it is. Factor in a full time salary for an NP plus benefits. We might be talking of around 200k/year for about 220 days of work. Maybe could toss that to the post call person and have them earn some extra cash. Or maybe you could create one assignment where the person takes care of the pacu, preops, post ops, and the occasional fire in the OR. That will likely improve quality.

 

[nimbus]

We have a preop screening clinic staffed by regular RNs. Whenever they have questions, they stop by the lounge to catch one of us between cases. 99% of the questions are about EKG’s. It works well for us.

 

[Hamhock]

I personally don’t think it works, but may work well enough for your shop.
Do you have the volume or the resources to really train a NP well enough? The second part of that equation, how much faith do you have in someone who doesn’t know what we do every day, a NP, an internist or even a cardiologist..... how many medical clearance, cardiology clearance letters we laugh out loud on a daily basis?

I’ve seen this work out at two pervious places that I worked at..... one at an ivory tower, maybe four NPs with one Anesthesiologist. They present every single patient to the attending, basically a medical clinic. They see maybe 10-15 patients 1/2 day at the clinic. They would really gather as much information as possible for the anesthesiologists, and MD would ask for more info as needed, labs, ekg, echo. Etc.

The other was at a smaller hospital. They have one full time NP and residents see patients as needed, but no full time anesthesiologist to really talk through these patients. That NP struggled, because there was no real direction.

The other part of this discussion (i will preface this by, I worked as an internist before anesthesia). Internist/NP/cards have no clue what we do. When I was doing IM eval, a lot of times, I wouldn’t even know what to write or why I am even writing the information down. We had a form that would say the patient is low, intermediate, high risk for the procedure. What does that really mean? I had no clue. You and I and any literate person can read the guidelines, but is that assessment worth the paper they’re printed on? Our EMR recently started to have a pre-populated H&P for hospitalist for our IP patients. They started to assign ASA classification..... GTFOH

This just amazes me, for two primary reasons:

1. Anesthesiologists -- yes the original midlevel pushers and current midlevel complainers -- CHOOSING to not evaluate patients as physicians so that more money and less work can be done; thereby abdicating one more physician responsibility that distinguishes us from nurses.

2. In the same post, IMGASMD complains -- no, mocks/laughs at -- physicians who are completing the pre-ops and going on about how they are unqualified to make these designations. Anyone guess why they do this (I used to have to do this and sometimes I am still asked to do it in the ICU!)? ...because anesthesiologists won't. The hospitals and surgeons want "medical clearance" but the anesthesiologists won't do it. I understand the concept of medical optimization, which can be a cardiologist's or internist's job once an anesthesiologist requests it for some reason. However, we are talking about medical clearance for the operating room, which anesthesiologists here constantly state they are the only ones qualified (probably true)for, yet they won't do it...even when there is a clinic set for this to be completed.

HH

 

[IMGASMD]

This just amazes me, for two primary reasons:

1. Anesthesiologists -- yes the original midlevel pushers and current midlevel complainers -- CHOOSING to not evaluate patients as physicians so that more money and less work can be done; thereby abdicating one more physician responsibility that distinguishes us from nurses.

2. In the same post, IMGASMD complains -- no mocks/laughs at -- physicians who are completing the pre-ops and going on about how they are unqualified to make these designations. Anyone guess why they do this (I used to have to do this and sometimes I am still asked to do it in the ICU!)? ...because anesthesiologists won't. The hospitals and surgeons want "medical clearance" but the anesthesiologists won't do it. I understand the concept of medical optimization, which can be a cardiologist's or internist's job once an anesthesiologist requests it for some reason. However, we are talking about medical clearance for the operating room, which anesthesiologists here constantly state they are the only ones qualified (probably true) yet they won't do it...even when there is a clinic set for this to be completed.

HH

I just want to respond to the second point. I have to assign every patient’s asa status, I have to do a pre-op for every single patient. Regardless whether they have a pre-op H&P from a internist or intensivist or not.

I’ve canceled enough cases to know that it don’t matter what that cardiologist/internist letter says.... a lot of things can and do happen between that medical evaluation and the day of surgery.

 

[Shimmy8]

Don’t need an NP.

An RN can do the same thing much cheaper. We have one currently for all our inpatients. It’s great. She’s an information gatherer, communicates with us about upcoming issues, and knows what is important to us. Invaluable.

 

[Hamhock]

I just want to respond to the second point. I have to assign every patient’s asa status, I have to do a pre-op for every single patient. Regardless whether they have a pre-op H&P from a internist or intensivist or not.

I’ve canceled enough cases to know that it don’t matter what that cardiologist/internist letter says.... a lot of things can and do happen between that medical evaluation and the day of surgery.

I gotcha, but then why are they requested?

Why does the intensivist or cardiologist get asked to write the letter/note in the computer?

You may say it is because the surgeon wants it, but: (1) why does the surgeon want it? (rhetorical); (2) I have been personally ask multiple times this year to "medically clear" a patient (who is in the ICU!) by the anesthesiologist; and (3) throughout my internship we (the interns with attending later signing the note after barely reading it) were required to write a note on every IM patient going to the OR or anesthesiology would cancel.

Perhaps you will see patients in your pre-op clinic and make this assessment. Perhaps there are more anesthesiology pre-op clinics and "homes" these days. Perhaps. ...but in my career working in three specialties in five states on both coasts, I have never seen it. Not once. OTOH, I constantly hear from internists and cardiologists that they are writing "clearance" notes. All the time. They don't want to do it. I suspect this is because the responsibility -- indeed, the duty -- has been forfeited by the anesthesiologists. (and this attitude is again being expressed in the OP's post and your response)

If I am just unaware or in a bubble, please let me know. I not trying to be argumentative. I am sharing my experience and kinda hoping I am way off.

HH

 

[nimbus]

I gotcha, but then why are they requested?

Why does the intensivist or cardiologist get asked to write the letter/note in the computer?

You may say it is because the surgeon wants it, but: (1) why does the surgeon want it? (rhetorical); (2) I have been personally ask multiple times this year to "medically clear" a patient (who is in the ICU!) by the anesthesiologist; and (3) throughout my internship we (the interns with attending later signing the note after barely reading it) were required to write a note on every IM patient going to the OR or anesthesiology would cancel.

Perhaps you will see patients in your pre-op clinic and make this assessment. Perhaps there are more anesthesiology pre-op clinics and "homes" these days. Perhaps. ...but in my career working in three specialties in five states on both coasts, I have never seen it. Not once. OTOH, I constantly hear from internists and cardiologists that they are writing "clearance" notes. All the time. They don't want to do it. I suspect this is because the responsibility -- indeed, the duty -- has been forfeited by the anesthesiologists. (and this attitude is again being expressed in the OP's post and your response)

If I am just unaware or in a bubble, please let me know. I not trying to be argumentative. I am sharing my experience and kinda hoping I am way off.

HH

Surgeons request that cardiologists and internist “clear” their patients because they believe it will reduce the chances that their case will be delayed for further workup. Some anesthesiologists are obstructionist and will use that as an excuse, often at 4pm when they would rather go home. We are actually more interested in echos, stress echos, and myocardial perfusion scans because they tell us what we are dealing with. I have on rare occasions requested cardiac clearance if I feel there may be unaddressed unstable ischemic heart disease or if they have a fresh stent. Much more frequently I will delay a case get an echo which could change my anesthetic management in a patient with known ischemic heart disease. I’ve never asked for intensivist clearance. I do almost 1000 cases a year and cancel maybe 1 or 2. Most of those 1000 patients have no “clearance”. The IM note requirement may be an attempt to make sure that all caregiving services are on the same page and agree that the patient will be going to surgery. All our 95 yo hip fractures are admitted to medicine. It has never stopped me from proceeding if an admitting note was missing but most of them do have notes. It may be our practice style too. We are MD only, in the room with the surgeons all day, every day. We talk directly to each other about patients coming down the pike. That prevents a lot of unnecessary testing, consults, and delays.

 

[deleted50478]

I’ve yet to send anyone for medical clearance. I didn’t think any anesthesiologists did. I assume it’s a way for surgeons to spread the liability around.

I agree with you that it undermines our specialty to act like we need medicine or family medicine to tell us the patient is ready for surgery. I mean some patients scheduled for elective surgery need to be optimized by medicine, but that isn’t the same thing as medical ‘clearance’. That’s when there is a specific issue that needs management that can’t be done in a few hours. It’s not the same as just sending everyone for medical clearance to avoid thinking.

 

[Hamhock]

Surgeons request that cardiologists and internist “clear” their patients because they believe it will reduce the chances that their case will be delayed for further workup. Some anesthesiologists are obstructionist and will use that as an excuse, often at 4pm when they would rather go home. We are actually more interested in echos, stress echos, and myocardial perfusion scans because they tell us what we are dealing with. I have on rare occasions requested cardiac clearance if I feel there may be unaddressed unstable ischemic heart disease or if they have a fresh stent. Much more frequently I will delay a case get an echo which could change my anesthetic management in a patient with known ischemic heart disease. I’ve never asked for intensivist clearance. I do almost 1000 cases a year and cancel maybe 1 or 2. Most of those 1000 patients have no “clearance”. The IM note requirement may be an attempt to make sure that all caregiving services are on the same page and agree that the patient will be going to surgery. All our 95 yo hip fractures are admitted to medicine. It has never stopped me from proceeding if an admitting note was missing but most of them do have notes. It may be our practice style too. We are MD only, in the room with the surgeons all day, every day. We talk directly to each other about patients coming down the pike. That prevents a lot of unnecessary testing, consults, and delays.

Fair enough. This practice environment seems desirable...but, in your experience is it common?

Also, if surgeons are feeling that a case may not be delayed if they get "pre-op" clearance by an internist or cardiologist, there must be a reason. Perhaps it's tradition, but I doubt that. Perhaps it is so everyone knows the patient is going to get surgery; but then a quick call or email from the surgeon or anesthesiologist would do. I suspect because there is a role for this pre-operative visit (or whatever name it should have) that is not filled by anesthesiologists (although it probably should be). This leaves me with two questions:

1. Is this "need" non-existent? That is, would there be no detriment to not having these "clearances" (I know you dislike that name, but I don't know what else to call it)? Would there be no increased delays or cancelled cases (in your case from 1-2/1000 to say 20/1000)?

2. And if there is a need or a benefit to the patient's being seen by internists or cardiologists first, and if the internists and cardiologists are unqualified to fill that need (as is claimed here frequently), shouldn't it be performed by an anesthesiologist (and not a nurse)?

HH

 

[deleted50478]

Fair enough. This practice environment seems desirable...but, in your experience is it common?

Also, if surgeons are feeling that a case may not be delayed if they get "pre-op" clearance by an internist or cardiologist, there must be a reason. Perhaps it's tradition, but I doubt that. Perhaps it is so everyone knows the patient is going to get surgery; but then a quick call or email from the surgeon or anesthesiologist would do. I suspect because there is a role for this pre-operative visit (or whatever name it should have) that is not filled by anesthesiologists (although it probably should be). This leaves me with two questions:

1. Is this "need" non-existent? That is, would there be no detriment to not having these "clearances" (I know you dislike that name, but I don't know what else to call it)? Would there be no increased delays or cancelled cases (in your case from 1-2/1000 to say 20/1000)?

2. And if there is a need or a benefit to the patient's being seen by internists or cardiologists first, and if the internists and cardiologists are unqualified to fill that need (as is claimed here frequently), shouldn't it be performed by an anesthesiologist (and not a nurse)?

HH

Medical clearance is unnecessary and its supposed role can be filled in anesthesia preop clinic.
Cardiac clearance is valuable but mostly to say that the patient doesn’t need cardiac intervention before surgery and just to get the cardiac records. If we had access to everyone’s medical records at various facilities I think most cardiac clearances would also be unnecessary.
My 2 cents.

 

[Hamhock]

I agree with you that it undermines our specialty to act like we need medicine or family medicine to tell us the patient is ready for surgery. .

Exactly!
This further undermines anesthesiology and contributes to the idea that nurses are equivalent. Hell, the OP is looking for his patient's to be seen by an internist/cardiologist and then a nurse!
It seems almost embarrassing. Physicians evaluate patients, develop a diagnostic and therapeutic treatment plan, and then carry it out. Nurses don't. If any field verbalizes this but chooses repeatedly to act not in accordance with stated beliefs to their own detriment, this field must be called anesthesiology.
You folks are my people, and it hurts me to read about this over and over again.
HH

 

[nimbus]

Fair enough. This practice environment seems desirable...but, in your experience is it common?

Also, if surgeons are feeling that a case may not be delayed if they get "pre-op" clearance by an internist or cardiologist, there must be a reason. Perhaps it's tradition, but I doubt that. Perhaps it is so everyone knows the patient is going to get surgery; but then a quick call or email from the surgeon or anesthesiologist would do. I suspect because there is a role for this pre-operative visit (or whatever name it should have) that is not filled by anesthesiologists (although it probably should be). This leaves me with two questions:

1. Is this "need" non-existent? That is, would there be no detriment to not having these "clearances" (I know you dislike that name, but I don't know what else to call it)? Would there be no increased delays or cancelled cases (in your case from 1-2/1000 to say 20/1000)?

2. And if there is a need or a benefit to the patient's being seen by internists or cardiologists first, and if the internists and cardiologists are unqualified to fill that need (as is claimed here frequently), shouldn't it be performed by an anesthesiologist (and not a nurse)?

HH

I think much of it is indeed tradition. We are moving away from generic clearance and consult only for specific questions.

 

[Hamhock]

I think much of it is indeed tradition. We are moving away from generic clearance and consult only for specific questions.

Maybe so. That seems to be the impression I get reading here, in general. I would welcome that change everywhere to benefit patients and anesthesiologists.

Of my two hospitals, the "weaker" anesthesiology group that is dependent on "clearance" and outsourcing a lot of peri-operative management is at the more traditional institution.

Assuming this is true, and consistent with this spirit, would you not agree that the OP's group should have a physician seeing every patient pre-operatively? (with a midlevel collecting data, at most)
Please re-read the original post before responding.

HH

 

[nimbus]

We do exactly as you say suggest above.

I perform a preoperative evaluation on every single patient before I administer their anesthetic, whether they’ve been through our screening clinic or not. I’m certain the OPs group also does their own preops. I see what you mean regarding his wording. It may not be the best choice in words. But I think what he is suggesting is no different than what many surgeons and ER docs do. Many of them now use NP’s or PA’s during preliminary work ups, data collection, and also for postop rounds. Then when all the information is collected, the physician reviews the information and makes a plan. Just as an ER doc wouldn’t discharge a patient that was worked up by a PA before he layed his own eyes on them, anesthesiologists don’t put patients to sleep before they make their own assessments.


The screening clinic that sees the patient days before surgery is exactly that, a screening clinic. Not every patient is seen there or needs to be. The nurses collect data and flag patients that might need more data. It’s purpose is primarily for efficiency, to reduce delays and cancellations, and to make sure all relevant data is available to the anesthesiologist on the day of surgery so the anesthesiologist can do a complete preoperative assessment at that time.

The nurses do an excellent job of screening and bringing patients who may need more testing and evaluation to our attention. In addition, our surgeons also do an excellent job of flagging patients for us. That doesn’t mean the nurses or the surgeons are doing the preoperative evaluation for us. (That said, many of us have been working together for years. We know their drill and they know ours.)

As an aside, I occasionally get an outpatient or morning admission who hands me a prescription form from their outside primary or a consultant that reads “cleared for surgery”. That is truly worthless...the only useful information on that sheet of paper is their phone number.

 

[vector2]

When I send a preop patient to a specialist, it's not for a clearance, but rather because I want that patient optimized. For instance, a pt with CHF who is in their usual state of health, compliant with meds, and capable of their baseline activity level doesn't need a cards clearance. If they come to clinic and they're short of breath and their preop BNP is 600, I send them to cards not to get cleared for surgery, but rather so someone who actually chronically follows them can take a look at their lasix regimen or add a nitrate or do whatever intervention is necessary. If someone has IHD and <6 mo stents, then I'm of the opinion that I am not the most qualified person to be saying that they should go ahead and stop their plavix 5 days before.

There is a time and place for sending pts to medicine or specialists, but unfortunately I think of lot of us have gotten into a bad habit of thinking that a referral clearance note for someone with stable disease somehow lessens our risk.

 

[Mman]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

back to the original topic...there are definitely models for RNs and NPs providing assistance with preoperative evaluations. As for postop evaluations, CMS requires those to be completed by someone credentialed to administer anesthesia so they must be done by a physician, CRNA, or AA.

 

[Southpaw]

Just as an ER doc wouldn’t discharge a patient that was worked up by a PA before he layed his own eyes on them, anesthesiologists don’t put patients to sleep before they make their own assessments.

Not sure if I understood you correctly here, but this is where the fields of anesthesia and EM differ. I think it’s common for PAs and NPs to see patients in the ED independently and discharge them with no involvement of the ED physician at all.

As for ‘medical clearance’, that practice is outdated and worthless. Optimization however, by certain specialists especially the cardiologist, can be useful and necessary.

 

[nimbus]

Not sure if I understood you correctly here, but this is where the fields of anesthesia and EM differ. I think it’s common for PAs and NPs to see patients in the ED independently and discharge them with no involvement of the ED physician at all.

I did not know that is common. The few times I or my family went to the ER, we always eventually saw and talked to a doctor.

 

[jwk]

back to the original topic...there are definitely models for RNs and NPs providing assistance with preoperative evaluations. As for postop evaluations, CMS requires those to be completed by someone credentialed to administer anesthesia so they must be done by a physician, CRNA, or AA.

We have several NP's working with our group. We love them.

They see scheduled inpatients pre-op, as well as add-ons during the day. They consult with the anesthesiologists on every one of these that they see if there are problems that need to be addressed pre-operatively. They can order additional labs/testing as needed, and are great at checking/following up/ordering additional consults as needed (cards, pulm, etc).

They also manage and do pain rounds on acute and chronic pain patients in-house. Those rounds are followed up the same day with an anesthesiologist.

Regardless, every patient is seen by an anesthesiologist prior to surgery.

 

[AdmiralChz]

I think it’s common for PAs and NPs to see patients in the ED independently and discharge them with no involvement of the ED physician at all.

Doesn’t some EM physician have to sign off on the chart? I’d be hacked off if I went in with what I think is a concern worthy of the ED (yes I know that’s not always the case) and I didn’t see a physician.

 

[Southpaw]

Doesn’t some EM physician have to sign off on the chart? I’d be hacked off if I went in with what I think is a concern worthy of the ED (yes I know that’s not always the case) and I didn’t see a physician.

If you read the EM forum it appears it’s not abnormal for them to be asked to sign midlevel charts having not seen the patients. Pretty uncomforting situation if you ask me.

 

[Hamhock]

If you read the EM forum it appears it’s not abnormal for them to be asked to sign midlevel charts having not seen the patients. Pretty uncomforting situation if you ask me.

It is very common in EM, especially in EDs run by CMGs -- for midlevels to see patients independently and then discharge them without the doc ever seeing the patient. These charts are often co-signed at the end of the doc's shift.

Sometimes the midlevel "presents" cases to the ED doc.

HH

 

[AdmiralChz]

It is very common in EM, especially in EDs run by CMGs -- for midlevels to see patients independently and then discharge them without the doc ever seeing the patient. These charts are often co-signed at the end of the doc's shift.

Sometimes the midlevel "presents" cases to the ED doc.

HH

This is why midlevels are eyeing EM as the next frontier for independent practice. Not just nurses, they have PAs to fight as well. Couple that with burnout and declining/rejected reimbursements for freestanding EDs........

 

[Modanq]

Agree with above. Bro is ED doc and it’s already there to stay. He is supervising 4 PAs but interviewed at places where he only signs charts. Actually asked me how the contracts and supervision looks like in Anesthesia so he stays protected. At least we have precedent.

It’s a dangerous world in medicine. Because deep down we all know it’s here in all specialities. Heck I just read an article called nurse driven pocus. Point of care ultrasound. What the world!!!

 

[LeroyJenkinsMD]

Serious question.

Why not hire an NP to insert the laryngoscope, another to insert the tube, another to turn the vent on, and another to watch the monitor during the surgery? Would probably need an NP to turn the gas on too.

 

[Hamhock]

Serious question.

Why not hire an NP to insert the laryngoscope, another to insert the tube, another to turn the vent on, and another to watch the monitor during the surgery? Would probably need an NP to turn the gas on too.

Well, I was premature (and a bit uneducated) with my emoticon in post #2.

May I try again?



Or, alternatively: :troll:

I just can't decide.

HH

 

[IMGASMD]

Serious question.

Why not hire an NP to insert the laryngoscope, another to insert the tube, another to turn the vent on, and another to watch the monitor during the surgery? Would probably need an NP to turn the gas on too.

This coming from a FM resident who wants to do EM in rural area, so doesn’t have to compete with EM certified doctors?!
Go pick your fights somewhere else.

 

[LeroyJenkinsMD]

This coming from a FM resident who wants to do EM in rural area, so doesn’t have to compete with EM certified doctors?!
Go pick your fights somewhere else.

I’d stalk your post history and come up with some sort of incorrect witty personal attack, but that is way too much effort.

 

[deleted162650]

I’d stalk your post history and come up with some sort of incorrect witty personal attack, but that is way too much effort.

Too much effort?

Sorta like getting EM certified would be too much effort??

 

[Gastrapathy]

This ***** scope jockey is amused.

 

[dhb]

This ***** scope jockey is amused.

But nobody farted

 

[LeroyJenkinsMD]

Too much effort?

Sorta like getting EM certified would be too much effort??

Yes, actually. Too much unnecessary effort for certain doctors who don’t need to start completely over when they can build onto their current foundation and not lose several hundred thousand dollars in opportunity costs. Winning the approval of SDN is a noble pursuit, but a very expensive one for FM doctors who already do a great job. See previous arguments for details.

 

[Southpaw]

Shame on us all. I care much less about a motivated FM physician trying to work in an ED than I do about EM physicians blindly signing PA/NP charts (because of CMGs or whatever other pressures they face) or CRNAs achieving increasing independent practice (through legalese). Physician, treat thyself.

There are certainly days I wish I’d made different choices. But I worked very hard for a very long time to be able to treat patients in my setting. I provide value. I hope everyone sees it that way.

 

[NICMAN]

Part of the problem is that we have become victims of our own success. Anesthesia has become safer and therefore we are doing sicker patients. 30 day Perioperative mortality has hovered around 2% for decades not because we aren’t getting better but because that is the acceptable risk index of surgeons, patients, and anesthesiologists. As we have improved safety we are doing cases on sicker patients. Morbidly obese 90 year old with afib needs a new hip? Hold Xarelto and do it! Patient has OSA and a BMI if 55 needs a fibroid taken out? No problem.

The surgical service demands and increasing volume of all (esp. sick) patients leaves very little left over. Anesthesia services are a very scarce resource and getting an anesthesiologist out of the OR to do preops in the clinic is very expensive to anybody who is paying—Medicaid sure as hell isn’t paying for it, and I am not inclined to work for the equivalent of a third my salary in order to do preops in a clinic a week prior.

The best we can do (outside of academic centers where there is plenty of free labor in resident hours) is have a system where risk factors are flagged for our review. Sometimes that chronic CHF patient with a pro-BNP of 1,200 is as optimized as they will be for a nephrectomy or paraesophageal hernia repair. It is hard for us to judge just reading the paper so it is good to have a cardiologist who knows the patient assess if there is anything to improve the risk. Would we have done that surgery on that patient 10, 15, 20 years ago? Possibly not. We are all looking to scapegoat somebody, but there isn’t a easy solution.

 

[mmag]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

You should consider hiring a family med doc or even peds. Lots of them would be interested in a job that has no call and q10 min non-stop appointments. You'd get a much higher level of medical knowledge for not a huge difference in pay (not to mention a better attitude). Plus none of the usual nursing headaches...

 

[Hamhock]

Part of the problem is that we have become victims of our own success. Anesthesia has become safer and therefore we are doing sicker patients. 30 day Perioperative mortality has hovered around 2% for decades not because we aren’t getting better but because that is the acceptable risk index of surgeons, patients, and anesthesiologists. As we have improved safety we are doing cases on sicker patients. Morbidly obese 90 year old with afib needs a new hip? Hold Xarelto and do it! Patient has OSA and a BMI if 55 needs a fibroid taken out? No problem.

The surgical service demands and increasing volume of all (esp. sick) patients leaves very little left over. Anesthesia services are a very scarce resource and getting an anesthesiologist out of the OR to do preops in the clinic is very expensive to anybody who is paying—Medicaid sure as hell isn’t paying for it, and I am not inclined to work for the equivalent of a third my salary in order to do preops in a clinic a week prior.

The best we can do (outside of academic centers where there is plenty of free labor in resident hours) is have a system where risk factors are flagged for our review. Sometimes that chronic CHF patient with a pro-BNP of 1,200 is as optimized as they will be for a nephrectomy or paraesophageal hernia repair. It is hard for us to judge just reading the paper so it is good to have a cardiologist who knows the patient assess if there is anything to improve the risk. Would we have done that surgery on that patient 10, 15, 20 years ago? Possibly not. We are all looking to scapegoat somebody, but there isn’t a easy solution.

This is a great post on the topic; especially because it acknowledges both reality and that it is a choice (basically a money issue, which is very understandable) for why cardiologists/IM docs continue to do the pre-ops that the anesthesiologists don't care much about.

I think the only way to improve this post is to suggest that, in this reality, saying the cadiologist/IM review of the patient and their "clearance" (I know it's not true clearance) is worthless (or worse, demeaning the other physician) should stop. It has a purpose, as described in this post. Indeed, it has a purpose that anesthesiologists, in most cases, could fulfill, but they don't want to for a few reasons (probably mostly money and to avoid boredom).

HH

 

[Southpaw]

Seeing a cardiologist prior to surgery, for certain patients, CAN be valuable. Slapping a ‘cleared for surgery’ or ‘avoid hypotension, hypoxia, and fluid overload’ on the chart is both worthless and lacking understanding. Smart people can and do see the difference. Dumb people keep doing the same crap time and time again.

 

[NICMAN]

This is a great post on the topic; especially because it acknowledges both reality and that it is a choice (basically a money issue, which is very understandable) for why cardiologists/IM docs continue to do the pre-ops that the anesthesiologists don't care much about.

I think the only way to improve this post is to suggest that, in this reality, saying the cadiologist/IM review of the patient and their "clearance" (I know it's not true clearance) is worthless (or worse, demeaning the other physician) should stop. It has a purpose, as described in this post. Indeed, it has a purpose that anesthesiologists, in most cases, could fulfill, but they don't want to for a few reasons (probably mostly money and to avoid boredom).

HH

Yes there is an economic component, but I think you are also not looking at the full picture. We are already stretched very thin as it is in most cases. I actually would be happy to go to a clinic one week every so often, but who is going to be in the OR? All my call and shifts. Shire I feel comfortable managing a patient’s DAPT or AC bridging. But FACETIME with a patient prior to surgery required TIME. I wish I could see all my patients in te clinic and get control of their A1c of 10.9 over the course of repeated visits or manage their blood pressure but I don’t have time. This also ignores the economic pressure of specialization and eliminating redundancy. A patient with CHF has a cardiologists. Do we need two physicians simultaneously tinkering with a patient’s cardiac meds for optimization? Obviously this ISN’T reducible to being simply an issue of anesthesiologist being lazy.

At my residency program there were 5 full time NPs supervised by an attending anesthesiologist, another 5 or so screening RNs to comb through hundreds of charts a week, an internal medicine service to tune up diabetic/thyroid/medication management, and two Anesthesiology residents to see the complex neuro/vascular/multiple comorbid patients. There is simply no way that kind of workload can be done by the 40 or so academic group. The manhours required would purloin resources from the OR (the hospital’s main. Revenue stream). That is probably the best scenario but it involves a lot of training and trust in NPs to not miss crucial details even if the MD looks at all the EKGs and stress-tests/studies.

 

[pjl]

I'm a practicing anesthesiologist in a group. We are thinking about the concept of hiring a nurse practitioner (not a CRNA) who we can train to understand anesthesia issues who can do the pre-op evals and the post-op evals. We would sign off on all of them, but it would save us time if the NP could see all the patients for us before and after anesthesia then apprise us of any issues that need further evaluation. I'd like to hear your feedback.

We hired an internal medicine MD to do our preop clinic. The product is substantially better than what an NP or PA would deliver. To be honest, the product is better than what an anesthesiologist would deliver as well, as she actively optimizes our patients preoperatively for the OR, and will delay cases as needed/appropriate to achieve this. She also knows when cases just need to go despite a patient not being optimized.
Surgeons have been very happy with the "I decide to cut, IM MD prepares them for surgery, Anesthesia cares for them while I cut" mentality"
There was some initial resistance to having preops done by someone other than referring MD, but with some salesmanship that was overcome.