Right to practice: CRNA vs Anesthesiologist in a Medical Direction model
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You are supervising…you have some measure of responsibility…even if you are not at fault….even if the CRNA makes a very bad clinical decision that is 100% of the cause of a bad outcome. Cost of doing business. On the positive side, in such a circumstance you are unlikely to take a hit in peer review or state board action…just the NPDB.
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It's a weak medically directed practice if the CRNAs don't take direction.
Let’s be honest. Most “medically directed practices” typically devolve into independent practice with some docs name on the chart. Less and less meaningful “direction” happens as time goes on and the CRNA becomes comfortable and experienced. Yes you will be sued if something goes wrong. You will also be paid well to sit in a hospital and do essentially nothing. It is what it is….
I don’t think that’s universally true. If a place is committed to 4:1 direction and the anesthesiologists get off their asses and go see patients, do blocks, lines, go for induction all the time, handle pacu issues etc… I think there can be an effective care team practice where the dr really directs care. That’s how it is (for now) at my hospital.
However I have seen lazy ass anesthesiologist who watch tv, trade stocks, etc and not confident anesthesiologist that hide when the **** it’s the fan, who undermine the profession and empower the crnas.
Most of the drs in my old practice were like this.
If we all claim we are better and make a difference (which I believe most of us do) then we have to BE better…. Direct! Not idly supervise from afar. Some anesthesiologists are partly to blame for the crnas thinking the way some do.
One of the crnas from my old hospital said she was sick of being up all night on call and the doc saying call me if you really need a hand and he would head off to sleep all night. He wouldn’t come for induction, meet the patient - nothing.
We have to be better - too bad half of us have sold the rest down the river with laziness or ineptitude - and just cash the checks and ride the gravy train while it lasts
However I have seen lazy ass anesthesiologist who watch tv, trade stocks, etc and not confident anesthesiologist that hide when the **** it’s the fan, who undermine the profession and empower the crnas.
Most of the drs in my old practice were like this.
If we all claim we are better and make a difference (which I believe most of us do) then we have to BE better…. Direct! Not idly supervise from afar. Some anesthesiologists are partly to blame for the crnas thinking the way some do.
One of the crnas from my old hospital said she was sick of being up all night on call and the doc saying call me if you really need a hand and he would head off to sleep all night. He wouldn’t come for induction, meet the patient - nothing.
We have to be better - too bad half of us have sold the rest down the river with laziness or ineptitude - and just cash the checks and ride the gravy train while it lasts
So you agree it’s kind of true. Even if you start out with good intentions the laziness will creep in. Human nature.
It is illegal to practice like this.
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deleted87051
Some people on this board brag about sitting at home all weekend for 30k while a CRNA is doing cases by themself at the hospital. “The money is in the calls” and it’s important not to do “solo call”. Must have CRNA.
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You can call out @aneftp it's ok.
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deleted643396
It’s why I fully support independent practice of CRNAs (among other reasons). The fat farters sitting in the lounge would be the first to go.
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deleted87051
I’m more than happy to let them have all the bunions, eyeballs, and outpatient cystos. We were replaced at a surgicenter that had this case mix. The independent CRNAs will be more than fine.
If you ever read some Reddit CRNA posts, they totally disrespect the "ologist" (as that's what they call the anesthesiologist. They don't call us doctors but ologist). These Reddit posts from the CRNAs that are care team or collaborative or whatever BS name is given, these Reddit CRNA posts rant about how they practice at the top of their licenses and but have no liabilities because the "ologist" takes the fall. Some Reddit CRNA posts say the ologist takes first call and they never get called in because the ologist does. I have seen practices different practices and also done locums and I have seen how many CRNAs get upset if an anesthesiologists comes in the OR, follows the computer vitals, or makes comments about the care. It happens because of the many many sell-out "leadership" anesthesiologists who work for private equity or private practices who just cared about money. If you look at many of the Gaswork CRNA jobs they will advertise "practice at the top of your license". That's fine as long as the attending anesthesiologists doesn't have to sign their charts but most collaborative models just want the ologist to be the fall guy/gal.
What is practicing at the top of your license mean?
If AA practice at the top of their license =crnas? The crnas would go crazy
If docs practice at the top of their license >>crna/AA.
We might as well let AA practice independently also. Crnas will fight it all the way
Ironic right?
Top of their license—garbage bag term. For CRNAs it could mean practicing in a medical direction practice, it could mean 1:8, it could mean supervised by surgeon. For me it could mean practicing neurosurgery.
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Not if you’re not a lazy piece of **** with some integrity - don’t you feel some obligation to make sure YOUR patient is okay. when I’m on call and we have a case going I stalk the chart on epic and check in frequently in person and via text with my crna. I’m directing his/her actions - I’m responsible for that patient - also face time with surgeons and OR teams is important. If the anesthesiologist presence and direction is not needed then you’ve made the case for the CRNAs and we are superfluous
The biggest joke is that we are against Crna independent practice but our organizations support “non anesthesiologist or dentist” supervision. Dare I say we need to grow some cojones, tell the greedy proceduralists, no, you do not know **** about anesthesia, you are not qualified to supervise anything anesthesia related. Lobby for ANESTHESIOLOGIST involvement in every anesthetic not some cocky dentist/plastics/murse combo. Yea yea yea cats out the bag I know
Yup. Who is the bigger problem? You work with what you have. You look at each situation one at a time. Did you know that in some opt out states the medical boards actually supported CRNA opt out because that is what the proceduralists wanted? better a non-anesthesiologist physician or dentist be required to supervise CRNAs than full independence.
The biggest sellouts were act models.
No md only practice ever got 4-7 million per doc partner from private equity. Only the act models got huge paydays
The app are coming right back to bite corporate medicine with higher demands for pay
Crna per hour and rate adjusted for off peak hours working and weekends and availability on beeper likely make 90% of what docs make on a w2 model.
That’s why it’s all come full circle and docs under value their beeper time on call and crnas laugh all the way to the bank refusing to do beeper
No md only practice ever got 4-7 million per doc partner from private equity. Only the act models got huge paydays
The app are coming right back to bite corporate medicine with higher demands for pay
Crna per hour and rate adjusted for off peak hours working and weekends and availability on beeper likely make 90% of what docs make on a w2 model.
That’s why it’s all come full circle and docs under value their beeper time on call and crnas laugh all the way to the bank refusing to do beeper
Call me jaded due to surgeons and proceduralists often times not supporting us and our expertise. I would argue that we can counter the CRNA Indy argument of “Dr Jones the orthopod hasn’t intubated anyone in his life. He didn’t even do an anesthesia rotation in medical school. Why would he be qualified to supervise me doing anesthesia?” With “you’re absolutely right, he’s not. That’s why you must have an anesthesiogist if you want to do anesthesia at your facility as that is the standard patient deserve.” And if that’s not “realistic” then at least we went down fighting knowing we did what was right.
Just refuse to do calls or nights or weekends
Let the crnas have those cases independent
Their independent model goes out the window with 2am bs elective cases they are only getting $300-hr
Soon they will demand $400/hr. Let them have it.
Sit back and chill at home.
Cause the costs will start to sky rocket for admin
But it won’t be your problem.
10% of the independent crnas are the most vocal. Let them have all the junk hours and weekends.
In an ideal world, I would agree with your approach. Unfortunately we don't live in that world. I had rather have a partial win by compromising my values (on this issue with this argument) than lose while being simon pure to my ideals.
I respect that and understand the politics. I give a lot of money to asapac because that’s how life works in America. I’d respectfully say we need to shake up the battle lines and stop playing defense with AANA and complicit MDs for the sake of patients and our own self respect. I wouldn’t supervise a surgical PA because there’s a shortage of surgeons. The culture of AANA is having real impact downstream on “the youth” whether it’s title misappropriation, over estimation of abilities, or passive aggressive subordination. You want to “push drugs” on your own ACT patient, according to online Crnas which are rapidly becoming the leadership of state organizations, you, and the complicit crnas, are desecrating the memory of Alice Magaw herself. Any crna against the group think gets shouted down. Lets be real, a two tier system is already taking shape. Let’s not be complicit.
Reading this thread it becomes apparent to me what the answer to all these problems is. Just introduce Anesthesiologist Assistants to your state and start incorporating them into your practice en masse if you are currently in an ACT model. For those of us who sit our own cases day in and day out hopefully we can eek out another 10 years of practice at a respectable physician salary until the system won;t want to support us anymore. What then? Go to CRNA wages? Not sustainable. Would shutter anesthesia residencies.
If you are a long term strategist: , 20-30 years I'm talking, you want to preserve medical integrity of anesthesia by Start vociferouly advocating for AAs to replace CRNAs. Abandon the care team model with CRNAs and replace them with AAs. ASA can't keep fighting with CRNA on a legislative level for the next 20-50 years. Just isn't a smart way to spend your time. I would spend less time responding to the CRNA legislative onslaught and more time spending a crap ton of resources opening up AA schools in all 50 states and opening up schools at every academic institution. Will there be bad outcomes with independent CRNAs. Oh ***t yea' there will be, but this is what America wants. Will there be growing pains, oh my yes. Displaced MDs, absolutely. BUt this is all for the long term good of patients and patient saftey.
If you are a long term strategist: , 20-30 years I'm talking, you want to preserve medical integrity of anesthesia by Start vociferouly advocating for AAs to replace CRNAs. Abandon the care team model with CRNAs and replace them with AAs. ASA can't keep fighting with CRNA on a legislative level for the next 20-50 years. Just isn't a smart way to spend your time. I would spend less time responding to the CRNA legislative onslaught and more time spending a crap ton of resources opening up AA schools in all 50 states and opening up schools at every academic institution. Will there be bad outcomes with independent CRNAs. Oh ***t yea' there will be, but this is what America wants. Will there be growing pains, oh my yes. Displaced MDs, absolutely. BUt this is all for the long term good of patients and patient saftey.
But private insurance and fast turnovers?
Phacos in PP are fast with rapid back to back cases if you cluster preoping them. So 20 easy cases done by 1pm, at a base of 4 units each is something you want to give away? (And yes, that is a real number of cases and duration that my friend in MD solo PP did last week; I witnessed it in person.)
Don’t get me wrong, I question if any anesthesia is needed for the vast majority of these cases. But you are literally shooting yourself and your group/employer in the economic foot by saying no thanks.
Instead you want to only cover the 2hr lap appy on the ASA 3-4? Doesn’t make economic sense. It is like saying no GI with decent scope docs. Again, look at the units currently set for the cases. That is where you can stack up a bunch of units to help the $ bottom line for the lower unit cases.
What hospital / health systems see is numbers - money and complications. As long as the money column is doing better than the complications column they will squeeze for more. Not being involved with high unit days will only hurt you in the end. The bean counters don’t know & don’t really care about the clinical care implications - their job is just to care about the numbers.
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deleted87051
We did up to 20 cataracts at that surgicenter. It made for a very busy low paid day with a lot of old awake patients that can’t hear anything. Cataracts are almost all Medicare. The average unit value at this surgicenter was $35 (this was brought up by the cystos and bunions). Mean unit value for cataracts was in the low 20s. Doesn’t matter how many cases you do with that unit value. That’s why we were trying to negotiate a stipend. The surgicenter decided to go with independent CRNAs. The CRNA group that replaced us advertises positions for $350k. That’s the income that one could make at that surgicenter without stipends or subsidies. A day at that surgicenter was a money loser for us. We left another eye only office surgery center a few years ago for the same reason. Happy to give that up. There are more interesting and much better paid ways to spend a workday.
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deleted87051
Yes on fast turnovers. Some private insurance. See above. We were losing money when we went there compared to the hospital. We were trying to bring it closer to a day of hospital work.
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Fair enough
It’s only a stop gap solution for the surgery center with crna only for 350k 1099.
Once you factor in vacation coverage. It’s still not profitable for anesthesia even crna only independent and no subsidies.
Surgery center will be asked to give subsidies within 2 year or less. Or switch to another company to provide services
Margins are razor thin with independent billing even crna independent billing
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I have no idea why they need anesthesia for cataracts. Typically give a homeopathic dose of fentanyl amd the patient is completely awake
U don’t need propofol
anesthesia for most GI cases either
It was all about the money.
The real GI docs knew how to do their own sedation and some still do it on weekends without anesthesia services
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deleted87051
it’s human nature
path of least resistance
i do solo md for this reason and i haven’t looked back. i also think amc culture is to blame because for them both md and crna are employees. sometimes credentials of physicians and authority becomes less important in that scenario to maintain peace and be a “team player”.
it truly is humiliating for a physician who wants to do the right thing and be the dr and leader that they’re supposed to be.
also crnas aren’t the most upstanding and forth coming individuals in my opinion. they have a gang mentality and will undercut a physician given an opportunity
it’s a knowledge issue with them
just my humble opinion based on experience
sometimes i do medical direction (less than 5% of my practice) but i’ve known those crnas for a very long time - no issues - the group has done a very good job of maintaining a good culture - but it’s an md owned, run and operated group
The ASA should consider putting more of their time, energy and money into getting more states to approve AA schools and training programs, getting the word out to the college kids that there is such a track as AA for them to have a career in. Plus having AAs have equal salaries as CRNAs as there are practices that pay AAs less vs CRNAs in the same practice; I've heard of them. If CRNAs want to be independent, let them be independent. Who wants to be a liability sponge for these CRNAs, I certainly don't want to. If current anesthesia leadership were smart and wanted to preserve and promote our specialty, they should focus on promoting AA care team more instead of harping on CRNA independent practice at the VA. Guess what, cat's out of the bag Bro! CRNAs are already practicing independently at many sites already and/or the "ologists" are paid to be the fall guy/gal in a lot of these collaborative, care team, private equity models or hospital employed models. ASA should be promoting something that will uplift the profession and move away from fighting the CRNA political group
Curious… do they push prop or the ‘ol midaz/fent (🤮)
Sorry- I disagree.
CRNAs like ICU RN’s/PA/APRNs, shouldn't be practicing independently.
I agree with AA advocacy. We used to be a training site for them.
Personally, I am not ok with having a location/region that is solely staffed by CRNAs. The clinical depth is lacking.- Sure they will learn…. eventually, at the cost of morbidity and mortality. I’m not ok with that. It also devalues what seasoned anesthesia group can add to a hospital system.
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deleted87051
Midaz/Fent for upper and lower GI scopes is analogous to the Winnie technique to BP blocks in my mind (i know you get that reference 😉).
or transarterial approach 😆😆
There are just better ways to do it with faster discharge and patient experiences.
There are just better ways to do it with faster discharge and patient experiences.
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deleted87051
And there are old school anesthesiologists (and old school surgeons) who can place central lines faster than u can do with ultrasound and just as successful.
There is zero proof Propofol is better than regular conscious sedation. Yet the mass media is sold on idiotic “studies” that Propofol sedation lead to faster recovery , more patient satisfaction
The reality is Propofol sedation does not improve the quality of the colonoscopy. It just adds to the cost of it.
Money is the driving force of American medicine. And we will do anything to justify more fees collected.
One of our GI
Haha! Touché.!
It’s a conspiracy! LMAO. 😆
@aneftp we disagree here once again.
Propofol is faster acting and faster recovering. It’s an antiemetic. It doesn’t linger for long and you can give boat loads of it to resistant patient populations with little worries of long apnea times. It has potent amnestic properties compared to midaz and fent which lingers around and makes patients nauseous. Propofol is a unicorn dream waking up.
Midaz/prop also get’s slippery after 2 of midaz and 250 of fent on an opiod naive patient that has their p450 reved up. Prop is light years more titratable at higher doses compared to fent/midaz. Also… i’d rather deep sedation with prop vs midaz/fent “conscious sedation” after a bowel prep. I want no recollection of what happens with a scope up the chocolate star fish.
Propofol provides efficient and fast room turnovers for not only the procedure room but also pacu. GI centers owned by GI docs love that level of efficiency as do I.
Geesh man…. you push midaz/fent for your colons? How about your egd’s?
Bro- they are not equal. Gimme a break.
Propofol is faster acting and faster recovering. It’s an antiemetic. It doesn’t linger for long and you can give boat loads of it to resistant patient populations with little worries of long apnea times. It has potent amnestic properties compared to midaz and fent which lingers around and makes patients nauseous. Propofol is a unicorn dream waking up.
Midaz/prop also get’s slippery after 2 of midaz and 250 of fent on an opiod naive patient that has their p450 reved up. Prop is light years more titratable at higher doses compared to fent/midaz. Also… i’d rather deep sedation with prop vs midaz/fent “conscious sedation” after a bowel prep. I want no recollection of what happens with a scope up the chocolate star fish.
Propofol provides efficient and fast room turnovers for not only the procedure room but also pacu. GI centers owned by GI docs love that level of efficiency as do I.
Geesh man…. you push midaz/fent for your colons? How about your egd’s?
Bro- they are not equal. Gimme a break.
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so the solution to mid level creep is to train more of them?? I don’t buy it. These folks will be clamoring for independence one day as well (just like PA’s). And no, we should not be promoting CRNA independence in any way shape or form.
Dude, you have lost the battle. Admit defeat and pivot. You need a competitor to the CRNA. We all know AAs are better trained and have a better education. Lets train them. and push for a lot of them.
Again, you are NOT going to win the argument that physicians are better than CRNAs with the legislature. They dont see it because they dont wanna see it. If you are waiting for them, youll be waiting a long time. They WILL put you out of a job while youre scremin' " But Im better,than these mid levels"
We hire AAs and CRNAs. We train students of both. I am going to disagree with you. A new hire AA (in general) has a steeper learning curve than a new hire CRNA.
Let’s play this out. Suppose we train up a whole bunch of AA’s overnight. What do you think will happen to the CRNA’s. They will just vanish into thin air?? Nope. What will happen is the ones who are currently happy in ACT models will push harder for independence to keep their jobs. Right now the rank and file don’t care. They are happy to work with our name on the chart and get paid well. Take that ability away they will all be chomping at the bit to practice at “the top of their license”. Hospital administrators will be very happy as salaries for MD’s and CRNA’s become a race to the bottom…,
There is an insatiable desire for surgery in this country. No one is going to call out patients for morbid obesity or uncontrolled DM, etc. so the knee replacements and amputations and AV fistulas will continue. The fact is there just aren’t enough of us anesthesiologists to go around. We have to pick the lesser of two evils here.
I’ve been in several practices where they would like to hire AAs but cannot find enough of them (especially if the crnas all threaten to quit. Funny how the AA practices never threaten to quit if they add crnas. I don’t know how crnas can justify not ever wanting AAs - makes them look petty - but they get away with it.) More better trained AAs is the answer. So what if you have to pay a little more attention to a new grad? Some of the new grad crnas are scary too and have to be watched. The standards for crna schools have loosened - minimal icu experience required these days.
Midlevels should never practice independently. Period. If you want to practice medicine go to med school.
I’ve been in several practices where they would like to hire AAs but cannot find enough of them (especially if the crnas all threaten to quit. Funny how the AA practices never threaten to quit if they add crnas. I don’t know how crnas can justify not ever wanting AAs - makes them look petty - but they get away with it.) More better trained AAs is the answer. So what if you have to pay a little more attention to a new grad? Some of the new grad crnas are scary too and have to be watched. The standards for crna schools have loosened - minimal icu experience required these days.
Midlevels should never practice independently. Period. If you want to practice medicine go to med school.
