Scope Creep

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Arch Guillotti said:
Interesting that they would cede their turf so readily. Going to do central lines in the ICU is a huge pain but no way I would ever cede to anyone but a physician. No way either I would do a CVL on a floor patient. U/S guided IV or PICC by radiology.
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The human animal responds to incentives. If CMS decreases the reimbursement for a procedure, it goes to a healthcare worker who's paid less on an hourly basis, not to the most qualified person.

In this case, that's midlevel/resident/ specialized RN, unless the attending doesn't have anything better to do.
 
FFP said:
The human animal responds to incentives. If CMS decreases the reimbursement for a procedure, it goes to the healthcare worker who's paid less on an hourly basis.

Welcome to America!
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Maybe in your world. Not in mine. I have no idea what the reimbursement is for a central line. I do know that is a service that my group provides that seems to be valued somewhat and that my group is intent on keeping our contract with the hospital and doing our best to maintain homeostasis.
 
Arch Guillotti said:
Maybe in your world. Not in mine. I have no idea what the reimbursement is for a central line. I do know that is a service that my group provides that seems to be valued somewhat and that my group is intent on keeping our contract with the hospital and doing our best to maintain homeostasis.
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Yep. Part of the package. You win some, you lose some. And, for you, it's occasional not habitual.

For me, when I wear my intensivist hat, it's habitual, because it's part of my job, and I have a ton of more important things to do than procedures. So, if a less-qualified person can do them safely, more power to them.

Being able to do line/tube placements does NOT define a good intensivist. So we are not losing any turf.

AFAIK, a central line placement (CPT 36556) reimburses somewhere in the vicinity of $90 (2.45 RVU).
 
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It's amazing how people will fight for scope of practice battles and then give it away to midlevels. Like ir vs vascular for procedures, only to train pas. Or em vs fm/im/gen surg etc in the ed but then they let themselves get replaced by nps and pas.
 
GassYous said:
It's amazing how people will fight for scope of practice battles and then give it away to midlevels. Like ir vs vascular for procedures, only to train pas. Or em vs fm/im/gen surg etc in the ed but then they let themselves get replaced by nps and pas.
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In an overworked corporate environment? You bet. The salary stays the same, regardless who's doing those procedures. Would I allow a midlevel to do a procedure on a loved one? Absolutely not!

Humans are very predictable. All it takes is the right (dis)incentive. In this case, destruction of the physician independent practice by Obamacare.
 
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FFP said:
In an overworked corporate environment? You bet. The salary stays the same, regardless who's doing those procedures. Would I allow a midlevel to do a procedure on a loved one? Absolutely not!

Humans are very predictable. All it takes is the right (dis)incentive. In this case, destruction of the physician independent practice by Obamacare.
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Come on. Physicians were selling out even before Obamacare.
How long have AMCs been around? Just 10 years?
 
chocomorsel said:
Come on. Physicians were selling out even before Obamacare.
How long have AMCs been around? Just 10 years?
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Even before Obamacare, CMS was screwing doctors left and right, but Obamacare dumped a lot of gasoline on that smoldering fire.

I live close to a university hospital system that's been expanding in my state like a cancer. In the last 10 years, they have acquired 5 other hospitals, and countless practices, while virtually doubling the cost.

Patients are getting worse care for more money than ever.
 
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FFP said:
Even before Obamacare, CMS was screwing doctors left and right, but Obamacare dumped a lot of gasoline on that smoldering fire.

I live close to a university hospital system that's been expanding in my state like a cancer. In the last 10 years, they have acquired 5 other hospitals, and countless practices, while virtually doubling the cost.

Patients are getting worse care for more money than ever.
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Even though I trained there, it irks me to support the local university hospital with my tax dollars while simultaneously competing with them for patients and staff.
 
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Where I have worked I have seen:

- Anesthesia Techs (trained and credentialled) to do Alines
- RTs doing Aline AND Central lines
- Paramedics and transport RNs (air and ground) doing both

That is about it outside an APP or Physician.
 
AnesTDL said:
Where I have worked I have seen:

- Anesthesia Techs (trained and credentialled) to do Alines
- RTs doing Aline AND Central lines
- Paramedics and transport RNs (air and ground) doing both

That is about it outside an APP or Physician.
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Who are responsible for their **** ups?
 
I'm sure I'll piss everyone off here, but I'm an AA and I routinely place central lines in neonates (IJ and femoral) as well as A-lines (radial/femoral/whatever you can get). The attendings I work with have taught me these skills and seem quite happy to let me do them. We save time when I do the neck line and the attending does the a-line. I've never claimed to have the knowledge base of a peds cardiac attending, but I've never thought of placing a line as something that was only an attending skill. Everyone gets done earlier, seems like a win win.

To the guy comparing a vein harvest to suturing in a valve, you know as well as anyone that those are not similar, and also comparing apples to oranges with anesthesia staff placing lines.
 
btbam said:
I'm sure I'll piss everyone off here, but I'm an AA and I routinely place central lines in neonates (IJ and femoral) as well as A-lines (radial/femoral/whatever you can get). The attendings I work with have taught me these skills and seem quite happy to let me do them. We save time when I do the neck line and the attending does the a-line. I've never claimed to have the knowledge base of a peds cardiac attending, but I've never thought of placing a line as something that was only an attending skill. Everyone gets done earlier, seems like a win win.

To the guy comparing a vein harvest to suturing in a valve, you know as well as anyone that those are not similar, and also comparing apples to oranges with anesthesia staff placing lines.
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Not saying anything against you at all, cause obviously you can do the job, but that's pretty bold your attendings. I'd be hard pressed to find a place willing to let me place a central line on a neonate even as a graduating anesthesia resident.
 
MirrorTodd said:
Not saying anything against you at all, but that's pretty bold your attendings. I'd be hard pressed to find a place willing to let me place a central line on a neonate even as a graduating anesthesia resident.
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If that’s all you do, for the next five years, I am sure someone will let you.
The breadth and depth of your knowledge is very different than crna and aa’s.

Don’t ever compare yourself to midlevels.

btbam said:
I'm sure I'll piss everyone off here, but I'm an AA and I routinely place central lines in neonates (IJ and femoral) as well as A-lines (radial/femoral/whatever you can get). The attendings I work with have taught me these skills and seem quite happy to let me do them. We save time when I do the neck line and the attending does the a-line. I've never claimed to have the knowledge base of a peds cardiac attending, but I've never thought of placing a line as something that was only an attending skill. Everyone gets done earlier, seems like a win win.

To the guy comparing a vein harvest to suturing in a valve, you know as well as anyone that those are not similar, and also comparing apples to oranges with anesthesia staff placing lines.
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The thread started with RN placing a central line. You my friend is a “mid-level”.

It’s also very different if you’re attending was in the room.

Are you not comparing oranges to apples too?

Ultimately to me, is WHO is responsible? Secondly, who makes the money? If I am responsible for any **** ups, I better get paid for it.

If midlevel want to be independent, go ahead. You better be vetted and perform at the same standards that I am being judged at.
 
IMGASMD said:
If that’s all you do, for the next five years, I am sure someone will let you.
The breadth and depth of your knowledge is very different than crna and aa’s.

Don’t ever compare yourself to midlevels.



The thread started with RN placing a central line. You my friend is a “mid-level”.

It’s also very different if you’re attending was in the room.

Are you not comparing oranges to apples too?

Ultimately to me, is WHO is responsible? Secondly, who makes the money? If I am responsible for any **** ups, I better get paid for it.

If midlevel want to be independent, go ahead. You better be vetted and perform at the same standards that I am being judged at.
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I don’t want to be independent, nor did I say as much in my post. Attending is in the room also trying to get access. Somehow these types of discussions always progress to “you’re just trying to say you’re better than anesthesiologists!” Which again, I am not saying at all. I do not think an RN should be placing central access in anyone. We have a Picc team of nurses in our hospital, but that’s all they do.
 
btbam said:
I don’t want to be independent, nor did I say as much in my post. Attending is in the room also trying to get access. Somehow these types of discussions always progress to “you’re just trying to say you’re better than anesthesiologists!” Which again, I am not saying at all. I do not think an RN should be placing central access in anyone. We have a Picc team of nurses in our hospital, but that’s all they do.
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And I thank you for your perspective.
 
btbam said:
I'm sure I'll piss everyone off here, but I'm an AA and I routinely place central lines in neonates (IJ and femoral) as well as A-lines (radial/femoral/whatever you can get). The attendings I work with have taught me these skills and seem quite happy to let me do them. We save time when I do the neck line and the attending does the a-line. I've never claimed to have the knowledge base of a peds cardiac attending, but I've never thought of placing a line as something that was only an attending skill. Everyone gets done earlier, seems like a win win.

To the guy comparing a vein harvest to suturing in a valve, you know as well as anyone that those are not similar, and also comparing apples to oranges with anesthesia staff placing lines.
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I mean our neonatal icus are just chock full of undertrained "neonatal nps" doing things they shouldn't and for some reason the pediatricians are busy trying to get their trainees to do a 3 year "hospitalist fellowship".
 
What exactly is keeping intensivists busy that they can't do procedures? If the answer is seeing 20 - 25 patients then that is no different then being a procedure monkey. That would be called a rounding monkey. Some would say that's what Pain Anesthesia is ESI after ESI after ESI - but hey its what the prevailing perception regarding "physician work".

There is no perfect system that financially compensates "Thinking - Doctoring" and "Action - Doctoring" but in the end we must do both. Because that is what separates Physicians from midlevels. We have CRNAs that can intubate but couldn't care less that perhaps that 3rd dose of XYZ opioid isn't necessary and maybe an alternative agent might be useful, and likewise we have ICU NPs who point to a RV which in fact is a LV and state the patient is volume up "lets diurese!
 
btbam said:
I don’t want to be independent, nor did I say as much in my post. Attending is in the room also trying to get access. Somehow these types of discussions always progress to “you’re just trying to say you’re better than anesthesiologists!” Which again, I am not saying at all. I do not think an RN should be placing central access in anyone. We have a Picc team of nurses in our hospital, but that’s all they do.
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CAAs have been getting training in CVLs (and Swans) and a-lines for 50 years. Not all of us do them though. In GA, those skills are in the basic job description for AAs. However - my practice and hospital specifically prohibit us from doing those as well as neuraxial anesthesia. And that's fine. The position of the AAAA is that the best person to determine individual scope of practice is the attending anesthesiologist at the local level. They are in the best position to assess someone's level of competence, as well as determine whether they have a need for non-physicians to practice those skills. In some practices (heavy CV private practices) it is quite common for CAAs to do lines. I learned how to do Swans 40 years ago by anesthesiologists whose names you would all recognize, back in the day where we had to retrieve each individual piece of equipment and open them on a sterile field - no pre-made kits back then because it was very new technology. But - I'm not the one who determines my ultimate scope of practice - my group and my hospital do.
 
MirrorTodd said:
Not saying anything against you at all, cause obviously you can do the job, but that's pretty bold your attendings. I'd be hard pressed to find a place willing to let me place a central line on a neonate even as a graduating anesthesia resident.
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As a peds cardiac attending, can confirm, that is...bold. I let fellows, obviously, and some senior residents who are skilled and motivated, but that's about it.
 
WholeLottaGame7 said:
As a peds cardiac attending, can confirm, that is...bold. I let fellows, obviously, and some senior residents who are skilled and motivated, but that's about it.
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I bet @btbam is skilled and motivated and can run circles around me when putting in baby lines.
 
I hate that procedures have been downgraded and are acceptable to be done by mid levels or nurses. I do think it’s inappropriate many times, but obviously depends who your working with. If a physician is in the room immediately supervising it’s ok, but at that point why not just do it yourself?
 
As medicine and technology progress, a number of procedures physicians used to do get handed down to less educated providers, to save time and money, or just out of physician comfort (as it should - we should be the top of that food chain, because it wouldn't exist without us). E.g. no physician should have to measure or empty urine (but anesthesiologists are not "physicians", at least not according to a number of Epic installations, right?).

It's not an issue when it's something monkey see monkey do, with low rate of complications. I'm sure peripheral IVs used to be placed only by doctors, in the beginning. ICU procedures don't make the intensivist (kind of different story in anesthesia, which is mostly a theatrical specialty).
 
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dipriMAN said:
If a physician is in the room immediately supervising it’s ok, but at that point why not just do it yourself?
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Doesn’t appear to be the anesthesiology way. If there’s a midlevel to be found in a 50 sq mile radius the anesthesiologist should ‘supervise’ them doing procedures. Right? I mean isn’t there a chance at any point somewhere in the hospital the expertise of the anesthesiologist will be needed (tongue firmly in cheek)?
 
Southpaw said:
Doesn’t appear to be the anesthesiology way. If there’s a midlevel to be found in a 50 sq mile radius the anesthesiologist should ‘supervise’ them doing procedures. Right? I mean isn’t there a chance at any point somewhere in the hospital the expertise of the anesthesiologist will be needed (tongue firmly in cheek)?
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That only applies during business hours. 😉

This is a service specialty. As in "servant". Anesthesiologists are "needed" mostly when other physicians/midlevels are not interested in stealing our jobs (e.g. at night). Like nurses, whom this specialty is exactly for. What other type of physician pushes carts or stretchers, or is treated as equal to a nurse/midlevel?
 
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FFP said:
That only applies during business hours. 😉

This is a service specialty. As in "servant". Anesthesiologists are "needed" mostly when other physicians/midlevels are not interested in stealing our jobs (e.g. at night). Like nurses, whom this specialty is exactly for. What other type of physician pushes carts or stretchers, or is treated as equal to a nurse/midlevel?
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This crap right here is hilarious. Especially the comment about this being a theatrical specialty? What does that even mean?
A @dhb, who pushes the stretchers in Europe?
I do have to agree with everything you say tho.
When I am in the ICU, I totally am the queen bee. I just ask the nurses what I would like and it gets done. Somehow I don’t get the pushback that I sometimes get with CRNAs
It’s so different than the OR. And I push no stretchers. And see outside through the window next to my office or in the patients‘ rooms.
 
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chocomorsel said:
This crap right here is hilarious. Especially the comment about this being a theatrical specialty? What does that even mean?
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It means that anesthesiologists are judged mostly on artistic impression. Smoke and mirrors. It's very hard for non-anesthesiologists (including patients) to figure out the quality of an anesthetic (no, it's not about PONV, sore throat or mouth injury).

Plus anesthesia is so easy "even a CRNA can do it". It ain't rocket science, at least not in the eyes of other healthcare staff.
 
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chocomorsel said:
This crap right here is hilarious. Especially the comment about this being a theatrical specialty? What does that even mean?
A @dhb, who pushes the stretchers in Europe?
I do have to agree with everything you say tho.
When I am in the ICU, I totally am the queen bee. I just ask the nurses what I would like and it gets done. Somehow I don’t get the pushback that I sometimes get with CRNAs
It’s so different than the OR. And I push no stretchers. And see outside through the window next to my office or in the patients‘ rooms.
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This field would be different, be viewed different, and be treated different, if however many years ago when we started this supervision nonsense we said 'no thanks', and anesthesiologists supported by the ASA decided the anesthesia should be delivered by either a physician or a midlevel, but not both. The decision to supervise was a decision to empower CRNAs and 'give' the OR to them. It's been downhill since, and the ship won't right itself until anesthesiologists make the hard decisions necessary to do it themselves. That's not to say we won't have jobs in supervision. I imagine we will, but they'll continue to be lackluster jobs and professionally unfilling jobs (primarily, and especially, in private practice). I guess I should say here that this is all my opinion?

There's a stark difference between a group of MD only anesthesiologists and a group of supervising anesthesiologists. In skill, in pride, in joy, and in respect through the ORs and the hospital. Does that mean it's so for every single anesthesiologist everywhere? No, of course not, but broad general strokes can be made.

Medical students and residents can and should learn that the ASA has done itself, and especially anesthesiologists, no favor by embracing supervision, terms like physician anesthesiologist, and anesthesiologist as leader of a 'team'. Team implies groupwork, roles, and acceptance of those roles. That's not the case in an anesthesia team, despite how many times we tell ourselves it's the case. Sorry, but no.
 
chocomorsel said:
So you were joking? I totally missed it.
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No they are called resident registered nurse anesthetist, just the same as their resident physician cohorts ya know. This is in an academic place as well, one that has docs doing mixed supervision with residents and CRNAs, and own cases as well. I can't imagine how and why the docs accepted that the srna program would use this moniker instead... Horrible
 
2Fast2Des said:
No they are called resident registered nurse anesthetist, just the same as their resident physician cohorts ya know. This is in an academic place as well, one that has docs doing mixed supervision with residents and CRNAs, and own cases as well. I can't imagine how and why the docs accepted that the srna program would use this moniker instead... Horrible
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If I were a resident in that program I’d start immediately calling myself ‘student physician’ the minute the department signed off on the change. Or push to transfer programs. We are not equal regardless of how desperately nurses want us to be. Any attending who approved of the change did so not because it was right (they knew it wasn’t....) but because it didn’t affect their paycheck and they didn’t want to make waves.
 
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2Fast2Des said:
No they are called resident registered nurse anesthetist, just the same as their resident physician cohorts ya know. This is in an academic place as well, one that has docs doing mixed supervision with residents and CRNAs, and own cases as well. I can't imagine how and why the docs accepted that the srna program would use this moniker instead... Horrible
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Wow. Just wow.
 
jwk said:
Oh yeah - this is all the rage in nursing circles, and not just nurse anesthesia students. At our place, we have "OR nurse residents". That used to be called "orientation".
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I won’t be here much longer to deal w all this craziness.
Thank God.
 
jwk said:
Oh yeah - this is all the rage in nursing circles, and not just nurse anesthesia students. At our place, we have "OR nurse residents". That used to be called "orientation".
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Oh yeah, even one of the GI nurses who I guess just finished his nursing school, is in a nurse residency program in the GI suite, apparently working the job is the residency. It's ridiculous
 
nimbus said:
I bet @btbam is skilled and motivated and can run circles around me when putting in baby lines.
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Ah yes the internet, where people feel emboldened to say things they’d never say in real life.
 
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