Occasional optho coverage

[IDGARA]

I'm friends with the nurse manager of a local optho center. She's asked if I can cover a few days a month when they can't get a CRNA. They've offered to either let me do my own billing or suggest an hourly rate. This would be a 1099 deal and I would need my own malpractice coverage.

I've never worked on my own like this so I'd love some advice on how to get this going properly. Specifically, what information would I need to decide between billing myself or taking an hourly rate? I'm guessing the big things are payer mix and case volume. Additionally, does anyone have experience getting malpractice coverage for just one day at a time? I've reached out to the carrier at my current gig. I'm sure there are other things that I'm missing so I would love any advice.

Thanks!

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[Arch Guillotti]

Buy a small portable malpractice policy. Forget doing the billing yourself. Too much hassle. Go 1099 and charge them an arm and a leg. Write off the new porsche a la aneftp.

 

[IDGARA]

Thanks for the advice. What do you consider an arm and a leg? $500 an hour? I'm guessing that since they would be canceling a day of surgery without me stepping up, they can afford more than the $350-$400 an hour that is the locum market.

 

[neutro]

if it’s going to be consistent once a week or once in a while like once a month?
Buying your own malpractice may be cost prohibitive. Have them provide it for you esp if this is the only place you’ll cover

If you’re planning to work elsewhere then probably yes get your own and set up LLC/ independent contracting / prn gigs etc.

You can buy occurrence based but you have to see at what cost it comes at

Malpractice cost should not cost more than 2-3% of your yearly gross income

So it doesn’t make sense to pay 5-10 k of you’re only going to be making 50-60k per yearl with them

 

[dabears505]

They've probably been paying the crna 200 hr. They will not give you 500 hr

 

[Howard888]

If this is cataracts/glaucoma procedures only I would tell your nurse manager friend they are really wasting money on CRNAs. Go to oral sedation -Xanax or ketamine/versed melts or combo. Multiple ASCs here and now optho opening or suites in offices-no IV, patients more happy, less screening.

Optho MDs hesitant at first but once they switch they love it

 

[IDGARA]

If this is cataracts/glaucoma procedures only I would tell your nurse manager friend they are really wasting money on CRNAs. Go to oral sedation -Xanax or ketamine/versed melts or combo. Multiple ASCs here and now optho opening or suites in offices-no IV, patients more happy, less screening.

Optho MDs hesitant at first but once they switch they love it

I think there's a bunch of retain stuff as well as the cataracts/glaucoma. It seems like they have the CRNAs do retrobulbar blocks, and have asked me to do them as well.

 

[pocafx]

This is just sounding worse and worse. Babysitting cataracts, being a substitute crna and now doing eye blocks. No thanks

 

[abolt18]

I think there's a bunch of retain stuff as well as the cataracts/glaucoma. It seems like they have the CRNAs do retrobulbar blocks, and have asked me to do them as well.

Haaaaaard pass on retro-bulbar blocks. Soft pass if it was just peri-bulbar blocks.

 

[Sriddymopboi]

This is just sounding worse and worse. Babysitting cataracts, being a substitute crna and now doing eye blocks. No thanks

I think it's absolute insanity for an anesthesiologist to do a retrobulbar block for an ophthalmologist, similar to us doing an ankle block for a podiatrist

 

[DirtDocMD]

Haaaaaard pass on retro-bulbar blocks. Soft pass if it was just peri-bulbar blocks.

Yep. My training program didn’t even bother to teach them. Attendings all told me the same thing—-“That is liability you DON’T want!”.

They were right.

 

[caligas]

They want you to do the blocks for workflow and surgeon can’t bill for it

 

[UscGhost]

And when you get a retrobulbar hemorrhage, are you comfortable diagnosing and treating it?

 

[aneftp]

I think it's absolute insanity for an anesthesiologist to do a retrobulbar block for an ophthalmologist, similar to us doing an ankle block for a podiatrist

why? I personally don’t do them. But some of the friends do the eye blocks just to speed things things along. Time and money. You will get done 1 hr earlier most days

If everyone were worried about liability than do zero blocks. Period. Including peripheral nerve blocks. We are physicians. If you are trained to do something and know how to do it. There is almost no difference. The ankle block analogy is funny. Most of us know how to do ankle blocks. I’m the most “anti block” guy in my practice. By that I mean if given a choice. I’d not do it at all. But I know how to do it.

 

[Maverikk]

What do you use for the retrobulbar block?

 

[UscGhost]

What do you use for the retrobulbar block?

I use the opthalmologist

 

[PainDrain]

If this is cataracts/glaucoma procedures only I would tell your nurse manager friend they are really wasting money on CRNAs. Go to oral sedation -Xanax or ketamine/versed melts or combo. Multiple ASCs here and now optho opening or suites in offices-no IV, patients more happy, less screening.

Optho MDs hesitant at first but once they switch they love it

Ketamine/versed “melts”? Tell me more? Are opthos buying from ravers?

 

[nimbus]

Ketamine/versed “melts”? Tell me more? Are opthos buying from ravers?

Imprimis RX

www.imprimisrx.com

 

[Howard888]

Imprimis RX

www.imprimisrx.com

10+ optho around here gone to no anesthesia personnel for cataracts/glauc procedures and catching fire in other parts of country. Some use only oral Xanax, others use Xanax with these melts for higher anxiety/younger folks.

No IV, no Pat. Zero issues. Patients and facilities love it. Obviously cataracts struggle to pay for us to be involved. A very high volume day might cover our cost. In the days of shortages this is a big help-not to mention it’s the right thing to do. We are the only modern country I think who uses MD anesthesiologists for cataracts, we give less that cath lab or gi nurses, huge waste of healthcare money.

We do the occasional cataract still who can’t sit still or mental disability or something but we just squeeze them in schedule

 

[abolt18]

Imprimis RX

www.imprimisrx.com

An ENT plastics guy was talking to me about these a while back, saying he wanted to start using them in their clinic.

 

[PainDrain]

An ENT plastics guy was talking to me about these a while back, saying he wanted to start using them in their clinic.

How long before they have a “Joan Rivers” and get in over their heads here?

 

[pgg]

I think there's a bunch of retain stuff as well as the cataracts/glaucoma. It seems like they have the CRNAs do retrobulbar blocks, and have asked me to do them as well.

Years ago, I quit an ASC moonlighting gig after four whole days because an ophthalmologist wouldn't quit whining about my refusal to do his retrobulbar blocks.

Well, that was one reason, anyway.

 

[neutro]

Imprimis RX

www.imprimisrx.com

10+ optho around here gone to no anesthesia personnel for cataracts/glauc procedures and catching fire in other parts of country. Some use only oral Xanax, others use Xanax with these melts for higher anxiety/younger folks.

No IV, no Pat. Zero issues. Patients and facilities love it. Obviously cataracts struggle to pay for us to be involved. A very high volume day might cover our cost. In the days of shortages this is a big help-not to mention it’s the right thing to do. We are the only modern country I think who uses MD anesthesiologists for cataracts, we give less that cath lab or gi nurses, huge waste of healthcare money.

We do the occasional cataract still who can’t sit still or mental disability or something but we just squeeze them in schedule

they should do the same for pain management sedation.

huge waste of resources.

 

[Gern Blansten]

I did some retrobulbar blocks early in my career. Haven’t done one in about a decade. They look so simple, but don’t be fooled. There is variability in anatomy and eye length and I know some folks who had devastating complications including vision loss and code events. It can lead to lawsuits, PTSD, loss of reputation, etc. not to even mention the trauma to the patient. Avoid them if you can. Thankfully, I stopped doing them before I had any complications with them.

 

[Urzuz]

why? I personally don’t do them. But some of the friends do the eye blocks just to speed things things along. Time and money. You will get done 1 hr earlier most days

If everyone were worried about liability than do zero blocks. Period. Including peripheral nerve blocks. We are physicians. If you are trained to do something and know how to do it. There is almost no difference. The ankle block analogy is funny. Most of us know how to do ankle blocks. I’m the most “anti block” guy in my practice. By that I mean if given a choice. I’d not do it at all. But I know how to do it.

Hard disagree.

It’s not about the liability - it’s about comprising patient care. I would venture to guess that just about every ophthalmologist has more training and more comfort in doing retro- and peribulbar blocks versus any anesthesiologist. Maybe there are some exceptions, but they are extremely rare. The stakes are high - you mess up a retrobulbar block, your patient may go blind, may seize, may stop breathing, etc. So, would you rather have the best trained person doing this block, or the person who is less trained, all in the name of “saving an hour”? If the anesthesiologist is well-trained in doing them and has enough experience to feel comfortable, have at it…but again, that just isn’t the reality in 99.9% of cases (much less so from a CRNA who probably YouTubed how to do it the night before).

An ankle block is completely different for a number of different reasons, not the least of which is the stakes in “getting it wrong”…but even then, I would encourage a podiatrist to do it over me because it’s better for the patient.

The reason we do nerve blocks is because we are the best trained at doing them. The question you asked about ‘why do we do them if we’re scared of litigation’ isn’t the right one, because again, it doesn’t have to do with litigation. The more appropriate question that I want to ask is, why doesn’t an orthopedic surgeon volunteer to do the ultrasound guided interscalene block in preop while you’re waking up their previous patient? It would save an hour at the end of their lineup, AND they would be able to bill for it?

 

[aneftp]

Hard disagree.

It’s not about the liability - it’s about comprising patient care. I would venture to guess that just about every ophthalmologist has more training and more comfort in doing retro- and peribulbar blocks versus any anesthesiologist. Maybe there are some exceptions, but they are extremely rare. The stakes are high - you mess up a retrobulbar block, your patient may go blind, may seize, may stop breathing, etc. So, would you rather have the best trained person doing this block, or the person who is less trained, all in the name of “saving an hour”? If the anesthesiologist is well-trained in doing them and has enough experience to feel comfortable, have at it…but again, that just isn’t the reality in 99.9% of cases (much less so from a CRNA who probably YouTubed how to do it the night before).

An ankle block is completely different for a number of different reasons, not the least of which is the stakes in “getting it wrong”…but even then, I would encourage a podiatrist to do it over me because it’s better for the patient.

The reason we do nerve blocks is because we are the best trained at doing them. The question you asked about ‘why do we do them if we’re scared of litigation’ isn’t the right one, because again, it doesn’t have to do with litigation. The more appropriate question that I want to ask is, why doesn’t an orthopedic surgeon volunteer to do the ultrasound guided interscalene block in preop while you’re waking up their previous patient? It would save an hour at the end of their lineup, AND they would be able to bill for it?

Why do we do tee than instead of the Cardiologist.

They can read complex valve repairs most better.
Cardiologist are the best at reading tee. And many places are readily available to come in and read the tee for cardiac docs. That’s what the do in many places where it’s crna only. Patient care is at stake. Get the best train at tee. The cardiologist.

 

[Urzuz]

Why do we do tee than instead of the Cardiologist.

They can read complex valve repairs most better.
Cardiologist are the best at reading tee. And many places are readily available to come in and read the tee for cardiac docs. That’s what the do in many places where it’s crna only. Patient care is at stake. Get the best train at tee. The cardiologist.

I agree, if the cardiac anesthesiologist at the head of the bed can’t give an equivalent reading as the cardiologist around the corner in the hospital and doesn’t feeling comfortable making recommendations to the surgeon as to what to do, they should absolutely be calling the cardiologist to read the echo. Once again, high stakes. You better believe the cardiologist is getting called if I cannot make a definitive call as to whether the surgeon should replace the valve etc.

As I said, if the anesthesiologist that is blocking is confident in their ability and has enough reps to give an equivalent result as the ophthalmologist, then go for it. Unfortunately, this isn’t the reality. Ophthalmologists are far better trained and more experienced than anesthesiologists graduating from most training programs today.

Once again, why doesn’t the orthopedic surgeon block the patient in preop to save an hour?

 

[aneftp]

I agree, if the cardiac anesthesiologist at the head of the bed can’t give an equivalent reading as the cardiologist around the corner in the hospital and doesn’t feeling comfortable making recommendations to the surgeon as to what to do, they should absolutely be calling the cardiologist to read the echo. Once again, high stakes. You better believe the cardiologist is getting called if I cannot make a definitive call as to whether the surgeon should replace the valve etc.

As I said, if the anesthesiologist that is blocking is confident in their ability and has enough reps to give an equivalent result as the ophthalmologist, then go for it. Unfortunately, this isn’t the reality. Ophthalmologists are far better trained and more experienced than anesthesiologists graduating from most training programs today.

Once again, why doesn’t the orthopedic surgeon block the patient in preop to save an hour?

Some of anesthesiologists know have done 12000 or more eye blocks. And it’s more than 5 at just one practice alone.

And u think the an eye doctor who’s been out in practice has even done more than 2000 eye blocks?

There are anesthesia residency places that stil train anesthesia residents to do eye blocks. Like mass eye and ear in Boston. So your level of training matters a lot

 

[Urzuz]

Some of anesthesiologists know have done 12000 or more eye blocks. And it’s more than 5 at just one practice alone.

And u think the an eye doctor who’s been out in practice has even done more than 2000 eye blocks?

There are anesthesia residency places that stil train anesthesia residents to do eye blocks. Like mass eye and ear in Boston. So your level of training matters a lot

i feel like we are talking past each other at this point, so I will requote what you said.

“If you are trained to do something and know how to do it. There is almost no difference.”

IF you are trained to do something (like a retrobulbar block) as well as the guy you are working with, there is no problem in you performing that procedure. If you are undertrained in this area and are learning on the job just to save time, you’re doing your patients a disservice. Hopefully we can agree on that much.

Where it seems like we may disagree is in how many anesthesiologists are comfortable doing eye blocks. I can’t speak for others, but I trained at a “top program” and have never done a single one. Others who have trained at excellent programs from all around the country in my practice have also done <10 or none at all. Maybe your experience is different?

 

[nimbus]

Why do we do tee than instead of the Cardiologist.

They can read complex valve repairs most better.
Cardiologist are the best at reading tee. And many places are readily available to come in and read the tee for cardiac docs. That’s what the do in many places where it’s crna only. Patient care is at stake. Get the best train at tee. The cardiologist.

Most anesthesiologists doing intraop TEE have formal training and certification in TEE. Most cardiologists don’t have as much experience or training in intraop TEE as cardiac anesthesiologists do. They also don’t have as much experience making calls in the the immediate pre and post bypass period (which is a unique circumstance) as anesthesiologists do. They are also less familiar with provocative maneuvers that can be done under anesthesia to better assess a lesion.

I’ve been out of academics for a long time. Maybe a recent fellow can weigh in. Are cardiology fellows coming into the cardiac ORs to learn the ins and outs of intraop TEE? Our cardiologists won’t even do their own structural echo. They ask for a cardiac anesthesiologist. Over the years at our hospital we’ve had several mitral repairs cancel after induction because no matter how hard we tried, we could not get the MR to look bad enough to warrant a repair. Those patients have literally gone home with more blood pressure pills. Not all referring cardiologists are good at echo or medical management.

That said, I agree that with adequate training and supervision, I think most anesthesiologists could learn to perform retrobulbar blocks safely. The problem for most anesthesiologists is getting the requisite training and practice under supervision. RBBs are not part of the typical anesthesia curriculum. I don’t want some cowboy anesthesiologist with n=5 practicing on my eye without supervision. Like @Urzuz I’ve also done zero and don’t plan to start now. Do you do them?

 

[aneftp]

i feel like we are talking past each other at this point, so I will requote what you said.

“If you are trained to do something and know how to do it. There is almost no difference.”

IF you are trained to do something (like a retrobulbar block) as well as the guy you are working with, there is no problem in you performing that procedure. If you are undertrained in this area and are learning on the job just to save time, you’re doing your patients a disservice. Hopefully we can agree on that much.

Where it seems like we may disagree is in how many anesthesiologists are comfortable doing eye blocks. I can’t speak for others, but I trained at a “top program” and have never done a single one. Others who have trained at excellent programs from all around the country in my practice have also done <10 or none at all. Maybe your experience is different?

Well I think mass eye and ear part of Harvard program qualifies as a pretty decent program to learn eye blocks. Duke program used to produce outstanding residents who knew how to do all the blocks included eye blocks.

I’m not gonna to get into an argument what is a top program but those programs are fairly well known.

 

[Howard888]

Duke hasn’t taught eye blocks for decades. I don’t know of a single program in southeast that does or met a resident who does them in any interview over past 20 years. Not saying they’re not out there but others than Boston Eye, where?

 

[pgg]

Why do we do tee than instead of the Cardiologist.

You mean apart from the financial reason (cardiologists don't want to lose money coming to the OR)?

Have you ever watched a cardiologist hold a TEE probe? With rare exceptions, they are not very good at acquiring images. They are heavily dependent upon techs.

Sometimes it's worth getting a cardiologist's opinion intraop if there are borderline findings or an exam that's significantly different than their preop read, and the surgical plan is called into question. However this is as much because they're usually the referring doctor who called the valve good or bad in the first place, and we're now contradicting their findings, not because they cna get better images or read the guidelines better than us.

A fellowship trained and NBE boarded anesthesiologist is absolutely good for doing echo in the OR.