Should patients get a choice of anesthesia provider?

[deleted171991]

Then your doctor dies and there are no good ones left because divas like you refused to help them train. I guess you could see the np from then on, I heard they are just as great if not better.

There will always be good doctors that take good insurance, or cash payment.

I am a strong believer that one should get what one paid for, including in healthcare. I didn't pay either for fellow-level care or for my time being wasted while educating the fellow. As long as neither happens, I don't mind if a trainee is present and watches the encounter.

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[Psai]

There will always be good doctors that take good insurance, or cash payment.

I am a strong believer that one should get what one paid for, including in healthcare. I didn't pay either for fellow-level care or for my time being wasted while educating the fellow. As long as neither happens, I don't mind if a trainee is present and watches the encounter.

And you trained solely by watching your attendings I assume

 

[anbuitachi]

Good luck with that! Those times are going away. Even teaching hospitals can't afford to lose customers anymore, especially those with commercial insurance. For example, my specialist knows that I am not there to chat with his fellow, hence he sees me alone. I think that's perfectly normal. The fellow could sit in and listen, as far as I am concerned, but I don't care about him more than I care about the furniture.

Not sure if i agree with this one. An attending working alone is an attending not covering multiple rooms. Aren't we moving to model where atttending covers multiple rooms? If that's the case then it becomes more unlikely for patients to request attendings only.

 

[deleted171991]

And you trained solely by watching your attendings I assume

No, but I don't agree to the 1:x model in such a high acuity specialty as anesthesiology. I think both the best training and care happen 1:1, but with both providers present all the time. Seconds do count.

I also believe that teaching hospitals/providers should be for the worse insurance plans. The patient gets cheaper care in exchange for allowing trainees to participate in his/her care. This is not about what's fair to the trainees; it's about the patient, aka the paying customer.

 

[Twiggidy]

Then your doctor dies and there are no good ones left because divas like you refused to help them train. I guess you could see the np from then on, I heard they are just as great if not better.

i mean im kind of on board with this response, especially as a physician to have that mindset towards in training who may actually someday take care of you, or one of your kids, or their kids

 

[Twiggidy]

No, but I don't agree to the 1:x model in such a high acuity specialty as anesthesiology. I think both the best training and care happen 1:1, but with both providers present all the time. Seconds do count.

I also believe that teaching hospitals/providers should be for the worse insurance plans. The patient gets cheaper care in exchange for allowing trainees to participate in his/her care. This is not about what's fair to the trainees; it's about the patient, aka the paying customer.

but that interesting because some of thr better “teaching cases” occur at the hospitals with the good insurance patients. im not saying a resident should be doing block when an NBA star gets knee surgery, or even you or i, but a lot if times the ‘better’ cases go where the ‘better surgeons’ are and those are sometimes at the hospitals that take good insurance

 

[Twiggidy]

And to follow up if residents are that bad to where you wouldnt want them to touch you, then maybe that training program isnt very good

 

[deleted171991]

And to follow up if residents are that bad to where you wouldnt want them to touch you, then maybe that training program isnt very good

I don't go to a place. I go to a doctor. A certain doctor. I want him, nobody else. If he needs somebody else's help, that's his call. But I couldn't care less about the big brand hospital he works for, or the training program there, unless I can't avoid "team care".

Also, I find that some of the best surgeons are not in academia. If they are really great, they tend to move to PP sooner or later.

 

[deleted171991]

Not sure if i agree with this one. An attending working alone is an attending not covering multiple rooms. Aren't we moving to model where atttending covers multiple rooms? If that's the case then it becomes more unlikely for patients to request attendings only.

Most commercial cases make good money for a PP group, so any smart group will try to accommodate solo requests made ahead of time.

 

[parcus]

Why not check with patients well in advance then if they would prefer a physician or nurse? I think we all know who'd they pick and that ultimately it would be impossible to accommodate everyone's request. Depending on demand it may even become necessary to replace all CRNAs with physicians to meet the patients' needs Who knows, maybe if it seemed like patients appreciated physician anesthesiologists at the hospital we'd even be given some, gasp, leverage?! Come to think of it, this seems like an innocuous way to tip the odds in our favor. I would even suggest politely bringing it up to the administration that you're tired of last-minute scheduling conflicts arising and that it would be good to check with patients in advance of scheduling their surgery. They will of course prefer anesthesiologist overwhelmingly and help feed the cause. Patients get to decide on their care. We show everyone anesthesiologists aren't nurses. Everyone wins.

Do you want an anesthesiologist doing your low risk procedure? That will be $100. Then you'd get very different answers. Sure I want the very best to take care of my health, but that doesn't mean I want to work until the day I die to pay for it, especially when there is a very close alternative.

 

[acidbase1]

I won't let CRNAs take care of my family members period

 

[zero0]

Do you want an anesthesiologist doing your low risk procedure? That will be $100. Then you'd get very different answers. Sure I want the very best to take care of my health, but that doesn't mean I want to work until the day I die to pay for it, especially when there is a very close alternative.

We're talking about laypeople here though. Even if the case is next to impossible to screw up, when it comes to surgery the layperson doesn't want nurses coming anywhere near them, no matter what doctor-esque letters they've managed to tack on to their names. I bet they'll go for the physician even if it's more expensive just for the peace of mind. Think of having an anesthesiologist in the room as a kind of accident insurance.

 

[nimbus]

Why not check with patients well in advance then if they would prefer a physician or nurse? I think we all know who'd they pick and that ultimately it would be impossible to accommodate everyone's request. Depending on demand it may even become necessary to replace all CRNAs with physicians to meet the patients' needs Who knows, maybe if it seemed like patients appreciated physician anesthesiologists at the hospital we'd even be given some, gasp, leverage?! Come to think of it, this seems like an innocuous way to tip the odds in our favor. I would even suggest politely bringing it up to the administration that you're tired of last-minute scheduling conflicts arising and that it would be good to check with patients in advance of scheduling their surgery. They will of course prefer anesthesiologist overwhelmingly and help feed the cause. Patients get to decide on their care. We show everyone anesthesiologists aren't nurses. Everyone wins.

Unfortunately everyone doesn’t win. Some anesthesiologists have financial incentives to say the care team model is best.

 

[nimbus]

Do you want an anesthesiologist doing your low risk procedure? That will be $100. Then you'd get very different answers. Sure I want the very best to take care of my health, but that doesn't mean I want to work until the day I die to pay for it, especially when there is a very close alternative.

That is not current reality however. As a patient you pay exactly the same whether you get a 1st month CA-1, an SRNA, a CRNA, or a triple boarded attending with 20 years and 20,000 solo cases under his belt. I’d pay the $100 for my kid. Maybe they should offer discounts to patients willing to be cared for by trainees. Like the cheap haircuts at the barber school.

 

[Painted]

Do you think the patient has the right to request attending only in a teaching hospital? The academic center consents go to great lengths explaining "will be present during key parts", medical students, training facility, etc. are all mentioned in consent. I have seen both answers from surgeons "sure" or "this is a teaching hospital"......

 

[dannyboy1]

This situation is really not complicated at all. Every patient, from those with fantastic insurance to the "self pay" population has the right to decide who participates in their care. If they want no resident/fellow then a resident or fellow cannot care for them. To do otherwise would be assault (touching without consent). That being said sometimes these requests simply cannot be accommodated due to scheduleing realities (especially if the patient springs this request on you in the holding area). It's really no different than if the patient requests a specific anesthesiologist but that doctor is not available. They will have to agree to someone else or reschedule.....

 

[Twiggidy]

How did this devolved into CRNA talk? I believe the OP was referring to a resident doing a case. We all know we'd rather have an anesthesiologist, but I believe OP said the family (or at least implied) she didn't want a resident on the case.

Edit: My bad....OP did refer to CRNA. Therefore, I agree with you guys. Carry on

 

[mwa]

Whoa. Am I the only one who thinks that a resident is still better than a CRNA...if only because the attending physician overseeing a resident is still likely to be at the top of his game, whereas the physicians "overseeing" CRNAs are often good for signing charts, and little else?

 

[nimbus]

Whoa. Am I the only one who thinks that a resident is still better than a CRNA...if only because the attending physician overseeing a resident is still likely to be at the top of his game, whereas the physicians "overseeing" CRNAs are often good for signing charts, and little else?

That’s an inaccurate assumption. There are many old academic “faculty” who couldn’t program an infusion pump or steer a bronchoscope if their life depended on it. Many are decades beyond “top of their game.”

 

[Noyac]

Whoa. Am I the only one who thinks that a resident is still better than a CRNA...if only because the attending physician overseeing a resident is still likely to be at the top of his game, whereas the physicians "overseeing" CRNAs are often good for signing charts, and little else?

Very narrow minded. A few examples doesn’t make it reality.

 

[deleted171991]

Whoa. Am I the only one who thinks that a resident is still better than a CRNA...if only because the attending physician overseeing a resident is still likely to be at the top of his game, whereas the physicians "overseeing" CRNAs are often good for signing charts, and little else?

Yes, you are. First of all, the average private practice CRNA is better than the average CA-1/CA-2. It's simply a matter of hours spent doing the same things. for 80% of the job, experience beats (lack of) knowledge; for the rest, there is the physician.

Also, the physician overseeing residents may not ever work solo (very typical at my residency program), while the one working with CRNAs may. You never know.

The right question to ask an anesthesiologist is: what percentage of your practice is solo? I wouldn't want somebody who doesn't work at least 30-40% solo.

 

[IlDestriero]

I have no issue with a patient requesting a physician anesthesiologist. I'm simply pointing out that there are logistical problems inherent in those requests in some practices. My guess would be that it's easier to accommodate in an an academic environment than private practice.

As far as pediatric anesthesia cases specifically - these types of cases by their very nature are "team" cases. I can do an adult anesthetic start to finish without the involvement of another person (illegal in my case, but just for argument's sake). That is not the case with a pediatric case, because someone else is going to have to do something with that patient. I can't manage their airway and start the IV by myself. Someone else will have to start the IV, or hold the mask (poor choice). In a care team environment, there will always be two anesthesia professionals involved. In many of our rapid fire ENT cases, there are two in the room the entire time, because it's virtually impossible for a single person to do everything (airway, IV, drugs, charting, etc.) during the actual case time. So even if it's a board-certified MD-provided pediatric anesthetic, somebody else will have to be involved - nurse, resident, anesthetist, another MD, whatever.

I sit in my own Rapid Fire ENT room all the time. The OR nurses has to be capable of placing the IV, and you have to be skilled at charting with one hand.



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Il Destriero

 

[Noyac]

I sit in my own Rapid Fire ENT room all the time. The OR nurses has to be capable of placing the IV, and you have to be skilled at charting with one hand.



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Il Destriero

That’s also the PP way. Nurses help or I will mask the kid down then have the nurse place a tourniquet and then I will place the hand over the mask and slip the IV in while maintaining mask ventilation. Then hand the arm/hand back the the nurse to connect the IV tubing. Off we go. I also do the majority of my documentation before the kid enters the room or when I hit PACU if I’m not done.

 

[chocomorsel]

Wow Noyac, the one armed IV man. Cool. Haven't mastered that. But don't do many kids.

 

[nimbus]

Or if it’s LMA case just mask them deep, insert LMA, then IV.

 

[Noyac]

Wow Noyac, the one armed IV man. Cool. Haven't mastered that. But don't do many kids.

Niven Doran taught me that one.

 

[Noyac]

Or if it’s LMA case just mask them deep, insert LMA, then IV.

Yes, but I’ve seen them Brady with that approach. It was a crna that was doing it and the kid may not have been deep enough. Or the second was left on 8% and that might have been the cause. It sure which. That’s the only kid I have done chest compressions on in the OR, if you don’t count the 16yo I did open cardiac massage on a coouple months ago.

 

[deleted162650]

Niven Doran taught me that one.

Are you sure that isn't just character on Game of Thrones?

 

[chocomorsel]

Are you sure that isn't just character on Game of Thrones?

She's real. And she's a little chili pepper. Knows her peds stuff!!

 

[Psai]

Niven Doran taught me that one.

How do you do it

 

[Noyac]

How do you do it

I’ll try to explain as best I can.
Mask the kid down.
Place the kids right hand over the mask while holding it btw thumb and index finger. The other fingers are under the hand holding the mask. Index finger under the wrist and thumb over the fingers giving the kids hand a nice bend over your mask hand.
Tourniquet is on forearm.
Slip in the catheter.
Hand over to nurse to connect.
There are many variations to this also.

 

[Noyac]

She's real. And she's a little chili pepper. Knows her peds stuff!!

Chili Pepper! Perfect description.

 

[Noyac]

Are you sure that isn't just character on Game of Thrones?

She would be a perfect character in that show from what I hear. She is a force. But the best thing I can say about her is that she never loses her cool and and is always professional. She was instrumental in my training. We sought each other out the day before and picked the nastiest Ped’s cases of the day. It was awesome.