The Surgical Home

[Planktonmd]

It's time to discuss this ASA initiative ...
It's their solution to all the problems... They want to offer your services to hospital administrators and surgeons as a cheap alternative to all the other specialists currently involved in the care of the surgical patient.
They think by doing that they will regain the territory from the anesthesia nurses.
I happen to disagree with this approach for many reasons, but it is rapidly gaining momentum.
Some AMCs and their sleazy pseudo pro anesthesiologist leaders have adopted this crap as their plan for the future and they are selling it to administrators.
What do you think?
Is the "surgical home" the future of anesthesiology or is it a scam?

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[deleted171991]

It's definitely what the bean counters want. "Let the surgeons be (just) surgeons." Meaning "let the anesthesiologists do the dirty job of pre- and post-op care".

I would not be surprised at all if hospitals will sign up for this. As anesthesiologists become cheaper, it's also cheaper to pay an anesthesiologist to babysit the surgical wards and keep the surgeons in the OR as much as possible. We will be the new surgical hospitalists, with about the same level of respect as internist hospitalists get. It might still be better than the crap awaiting us as OR firemen in a system stuffed 90% with CRNAs, many of whom are independent.

There.

Also see this: http://forums.studentdoctor.net/threads/perioperative-surgical-valet.1064499/ .

 

[IlDestriero]

I'd be happy to be the surgeon's PA for zero extra income, actually less income as we would have to devote at least one FTE to the task daily.
Sounds like a winner.
I was saddened to hear our fellowship director talking to the Chief about how to incorporate some of this into our fellows training. As it is "the future direction..."
Not for me thanks. Good luck selling it to the fellows.

 

[loveumms]

I already spoke my opinion in the other forum. I actually just attended the first periop surgical home conference this past weekend and it is not what is being portrayed above.

Anesthesiologists develop protocols that standardize care based on evidence. We oversee the planning and implementation. We help ensure patients get the best possible care. Someone is going to do this so why wouldn't we as a specialty take the lead? We are the best equipped to deal with periop problems. We need to face the fact that the days of us sitting on a chair doing ASA I cases are over. As bundled payments take over we will likely need to expand our care and develop a new niche. Many of the leaders of this conference, both academic and private practice, predict MD only groups are a thing to the past. I don't want to argue this point because I am not equipped, it's just something that was said over and over. If we don't embrace change we will get left in the dust without a job.

 

[seinfeld]

Its all crap, I asked surgeons i worked with and they all say its stupid and the want us in the OR turning cases over.

Until there is a payment that is above what I can get in the OR this will not happen on a large scale.

As far as evidenced based protocols, I am only 5 years in practice and have seen so many "EBM" protocols become non-evidenced based. Also i have learned that despite the best evidence sometimes the right and best thing to do is not what the evidence suggests. STS requires preop Beta Blocker and payers wont pay without it. The other day doing a Cabg and patient did not get preop dose, so based no our EBM protocol i gave 2.5 mg of metoprolol IV before incsion. I spent the rest of the prebypass period giving 10 mcg Epi boluses. How stupid!!!!

Look at the protocols that have been developed based upon " Early Goal Directed therapy". The recent NEJM study showed that as long as fluid and abx were given early there was no difference in mortality and when you look at trends the group that was non-protocol physician directed trended to less respiratory and renal failure.

This is why physicians need to be involved in the OR, to know when to break protocol.

 

[pgg]

Someone is going to do this so why wouldn't we as a specialty take the lead?

I don't know what the future will bring, but one of the reasons I picked anesthesiology was specifically so I wouldn't have to do all that outside-the-OR management.

I'll adapt as I have to, in order to have a job, but I just can't share the enthusiasm for this surgical home stuff.

 

[IanMcGalt]

Its all crap, I asked surgeons i worked with and they all say its stupid and the want us in the OR turning cases over.

Until there is a payment that is above what I can get in the OR this will not happen on a large scale.

As far as evidenced based protocols, I am only 5 years in practice and have seen so many "EBM" protocols become non-evidenced based. Also i have learned that despite the best evidence sometimes the right and best thing to do is not what the evidence suggests. STS requires preop Beta Blocker and payers wont pay without it. The other day doing a Cabg and patient did not get preop dose, so based no our EBM protocol i gave 2.5 mg of metoprolol IV before incsion. I spent the rest of the prebypass period giving 10 mcg Epi boluses. How stupid!!!!

Look at the protocols that have been developed based upon " Early Goal Directed therapy". The recent NEJM study showed that as long as fluid and abx were given early there was no difference in mortality and when you look at trends the group that was non-protocol physician directed trended to less respiratory and renal failure.

This is why physicians need to be involved in the OR, to know when to break protocol.

Should have gone with 2.5mg esmolol.

 

[IlDestriero]

...
Anesthesiologists develop protocols that standardize care based on evidence. We oversee the planning and implementation. We help ensure patients get the best possible care. Someone is going to do this so why wouldn't we as a specialty take the lead? We are the best equipped to deal with periop problems. We need to face the fact that the days of us sitting on a chair doing ASA I cases are over. As bundled payments take over we will likely need to expand our care and develop a new niche.
...
If we don't embrace change we will get left in the dust without a job.

This is fantasy.

Have you participated in standardizing protocols for complex surgery? I have. It takes a team approach with surgeons and anesthesiologists and critical care all working together. And they often don't agree, even within the separate groups . Many meetings, evaluations of existing studies. Weighing the data, looking at internal surgeon and institution specific data. Maybe further study is needed (always) but you make a best practice plan and get the parties involved to sign off on it. Then you try to implement it and try to figure out who is appropriate for the plan and when to deviate from it.
Guess how much that job pays everyone involved...
Zero.
That is not a job, it is an administrative responsibility for team leaders to work on after hours.
If this meeting of the minds sees this as the future vision for the specialty, they're delusional.

Any future surgical home will require us to do comprehensive pre and post op management of the patient. How many surgeons do you know, outside of ortho, who want to give up post op management. NONE. Why? Because the metrics that they track (blood product usage, infection rates, length of hospital stay, M&M, etc.) that can absolutely be affected by post op management reflect on them individually, not the "periop home team".
That is what any periop home team of the future will be doing.

This $hit gives me a headache. Those guys at the meeting are smoking some choice bud if they think that's what anesthesiologists will be doing in the future.

 

[OB1🤙]

I think this PSH stuff is well-intentioned, and in the right setting could even be accomplished effectively.

I think in the vast majority of practices out there, it's a nonstarter.

I agree that anesthesiologists can't plan on sitting the stool for ASA 1 & 2s in the future. But I think fellowship training is the answer to that, not the PSH. Just my bias.

 

[loveumms]

Yes, a

This is fantasy.

Have you participated in standardizing protocols for complex surgery? I have. It takes a team approach with surgeons and anesthesiologists and critical care all working together. And they often don't agree, even within the separate groups . Many meetings, evaluations of existing studies. Weighing the data, looking at internal surgeon and institution specific data. Maybe further study is needed (always) but you make a best practice plan and get the parties involved to sign off on it. Then you try to implement it and try to figure out who is appropriate for the plan and when to deviate from it.
Guess how much that job pays everyone involved...
Zero.
That is not a job, it is an administrative responsibility for team leaders to work on after hours.
If this meeting of the minds sees this as the future vision for the specialty, they're delusional.

Any future surgical home will require us to do comprehensive pre and post op management of the patient. How many surgeons do you know, outside of ortho, who want to give up post op management. NONE. Why? Because the metrics that they track (blood product usage, infection rates, length of hospital stay, M&M, etc.) that can absolutely be affected by post op management reflect on them individually, not the "periop home team".
That is what any periop home team of the future will be doing.

This $hit gives me a headache. Those guys at the meeting are smoking some choice bud if they think that's what anesthesiologists will be doing in the future.

Yes, actually I am involved with developing one now. You would be surprised at how many surgeons would love our help. We do NOT take over surgical management of the patient. I don't want to do that, I'm not qualified to do that and I shouldn't be doing that. We develop evidence based protocols to help GUIDE decisions. I'm not taking over the care of every patient and I'm not telling my colleagues what to do. Physicians are specially trained in that we know when and why to deviate from plans.

I'm not saying this is the perfect solution. All of you who disagree, what is your plan to stay relevant in a culture where CRNAs and other mid levels want your job and are taking it in some states? Sure, lobby your legislatures and advocate for our specialty. I'm not sure if that is going to do it for us now.

I still think we are better at managing periop problems compared to other providers (in CONJUNCTION with our surgical colleagues).

 

[loveumms]

You are r

Its all crap, I asked surgeons i worked with and they all say its stupid and the want us in the OR turning cases over.

Until there is a payment that is above what I can get in the OR this will not happen on a large scale.

As far as evidenced based protocols, I am only 5 years in practice and have seen so many "EBM" protocols become non-evidenced based. Also i have learned that despite the best evidence sometimes the right and best thing to do is not what the evidence suggests. STS requires preop Beta Blocker and payers wont pay without it. The other day doing a Cabg and patient did not get preop dose, so based no our EBM protocol i gave 2.5 mg of metoprolol IV before incsion. I spent the rest of the prebypass period giving 10 mcg Epi boluses. How stupid!!!!

Look at the protocols that have been developed based upon " Early Goal Directed therapy". The recent NEJM study showed that as long as fluid and abx were given early there was no difference in mortality and when you look at trends the group that was non-protocol physician directed trended to less respiratory and renal failure.

This is why physicians need to be involved in the OR, to know when to break protocol.

You are right - evidence changes. It constantly needs to be reevaluated and reviewed. That is true in all of medicine. It's easier to have groups of providers at looking at certain aspects and revising their protocols.

I agree some of it is crazy. The beta-blockers particularly. Giving esmolol at induction does nothing - and is ridiculous. The surgical home aims to OPTIMIZE and standardize care to some degree, the patient prior to surgery thus we get involved from the decision to perform surgery. This would have hopefully decreased the risk of the patient from neglecting to take their beta-blockers.

 

[Planktonmd]

Yes, a

All of you who disagree, what is your plan to stay relevant in a culture where CRNAs and other mid levels want your job and are taking it in some states?

The solution is for the anesthesiologist to assume the role of a real physician managing the immediate pre-op, intraop and post-op periods.
Managing patients from the time a surgery is scheduled until 30 days after discharge is way beyond the current abilities of most community based anesthesia practices and it will expand the exposure to liability and substandard patient care.
It is also going to be a free service in the world of bundled payments and value based purchase.
Sure, the concept sounds good and hospital CEOs love it since it costs them nothing... but it is simply crazy!

 

[dA pilot]

My prediction in the future is that the perioperative surgical home is going to be run by mid level providers anyway. Once the whole concept is set up, the barriers to entry to implement the protocols will be very low for mid levels to provide 95% of the care. We will just be hanging on the bag of supervising things anyway.

 

[loveumms]

dA pilot - you are correct, most major centers that have implemented 'surgical homes' have an NP who is the main point person and a faculty member to 'oversee' - generally this person has only one or two rooms during the day and is available when/if the patient falls off the pathways.

I think we all should be invested in reassuring the patient does not come back in the hospital for 30 days because this is bad medicine AND we won't get paid for it (i.e. it will come out of the bundled payment - guess where administrators are going to take that money from). A big majority of things that bring them back in the post-operative period (aside from pain) start in the pre-operative period (proper BP control, diabetes control to try and prevent wound infection, 'health' coaching, etc). All of these things we have a very heavy hand in contributing to and we can influence. The only thing that bothers me about all this (and really the insurers structuring payments this way) is it does not take into account the patients role - I can foresee one day where certain groups will refuse certain patients (morbidly obese, poorly control diabetics, etc). Either that or force the patients to comply (we will not do surgery until you have lost 50% of your body weight or you hba1c is <6.5).

At this conference they expected 150 people to register. They had to shut the doors after 350 registered (there were mostly anesthesiologists but a few surgeons). There were hundreds of small community based anesthesia providers there who think it will work for their hospital (with some tailoring) so I think you are wrong plankton - change is hard for all of us to swallow but it's already in motion and as it gains momentum, it's going to be harder and harder to not at least try. I agree with Dr. Kain - our platform is burring and unless we all provide a solution then we will be left out - (i.e. you will be left with no job or a salary that is much smaller then you have now). Make yourself marketable and helpful to the whole patient experience. Most of the smaller group anesthesia providers we talked to have significant interest from their hospital CEOs who are willing to put forth some time/resources to do this (especially with surgeon buy in and support). The one thing that really seems to hinder many small hospitals is a non-electronic medical record (which is decreasing anyway with meaningful use and government pressures - hospitals are going to be forced to do this or lose reimbursements).

I also think you are very wrong for thinking it will lead to substandard care in the 30 days post-op - I think it improves care. Some of these things are as simple as an automated phone call to the patient saying "did you get your prescriptions filled, do you know when your follow up times are and is your pain adequately treated … if you said NO to any of these, leave us a message and we will call you back within the next few hours". Then a midlevel calls the patient back and tries to sort this out. This picks up problems before either the pt calls the surgeon (and they send them to the ER) or the patient just comes back to the hospital. Having discharge planning starting from the booking of surgery - to make sure your patients are going home to a safe environment and starting the planning weeks or days before their discharge (instead of the moment they hit the door when you only have two maybe three days). You as the anesthesia provider are not doing this yourself but you are the team leader who helps make sure these departments know that we need to do it.

In the end, you act as a leader for the surgical home. You help the surgeon to operate more and make more money. You help bring more business into the hospital. You help make sure patients get excellent care. You make sure those patients don't get readmitted. Sure surgeons could be doing this but I really think we are better equipped. We know medicine and pain management better. This will all benefit you for contracts and will keep you relevant.

Again, we need to be part of the solution or come up with a better one. I like my intraoperative job but in the end we have made anesthesia for most cases incredibly safe and I don't need to be performing it (overseeing, yes but not personally performing).

 

[Consigliere]

dA pilot - you are correct, most major centers that have implemented 'surgical homes' have an NP who is the main point person and a faculty member to 'oversee' - generally this person has only one or two rooms during the day and is available when/if the patient falls off the pathways.

I think we all should be invested in reassuring the patient does not come back in the hospital for 30 days because this is bad medicine AND we won't get paid for it (i.e. it will come out of the bundled payment - guess where administrators are going to take that money from). A big majority of things that bring them back in the post-operative period (aside from pain) start in the pre-operative period (proper BP control, diabetes control to try and prevent wound infection, 'health' coaching, etc). All of these things we have a very heavy hand in contributing to and we can influence. The only thing that bothers me about all this (and really the insurers structuring payments this way) is it does not take into account the patients role - I can foresee one day where certain groups will refuse certain patients (morbidly obese, poorly control diabetics, etc). Either that or force the patients to comply (we will not do surgery until you have lost 50% of your body weight or you hba1c is <6.5).

At this conference they expected 150 people to register. They had to shut the doors after 350 registered (there were mostly anesthesiologists but a few surgeons). There were hundreds of small community based anesthesia providers there who think it will work for their hospital (with some tailoring) so I think you are wrong plankton - change is hard for all of us to swallow but it's already in motion and as it gains momentum, it's going to be harder and harder to not at least try. I agree with Dr. Kain - our platform is burring and unless we all provide a solution then we will be left out - (i.e. you will be left with no job or a salary that is much smaller then you have now). Make yourself marketable and helpful to the whole patient experience. Most of the smaller group anesthesia providers we talked to have significant interest from their hospital CEOs who are willing to put forth some time/resources to do this (especially with surgeon buy in and support). The one thing that really seems to hinder many small hospitals is a non-electronic medical record (which is decreasing anyway with meaningful use and government pressures - hospitals are going to be forced to do this or lose reimbursements).

I also think you are very wrong for thinking it will lead to substandard care in the 30 days post-op - I think it improves care. Some of these things are as simple as an automated phone call to the patient saying "did you get your prescriptions filled, do you know when your follow up times are and is your pain adequately treated … if you said NO to any of these, leave us a message and we will call you back within the next few hours". Then a midlevel calls the patient back and tries to sort this out. This picks up problems before either the pt calls the surgeon (and they send them to the ER) or the patient just comes back to the hospital. Having discharge planning starting from the booking of surgery - to make sure your patients are going home to a safe environment and starting the planning weeks or days before their discharge (instead of the moment they hit the door when you only have two maybe three days). You as the anesthesia provider are not doing this yourself but you are the team leader who helps make sure these departments know that we need to do it.

In the end, you act as a leader for the surgical home. You help the surgeon to operate more and make more money. You help bring more business into the hospital. You help make sure patients get excellent care. You make sure those patients don't get readmitted. Sure surgeons could be doing this but I really think we are better equipped. We know medicine and pain management better. This will all benefit you for contracts and will keep you relevant.

Again, we need to be part of the solution or come up with a better one. I like my intraoperative job but in the end we have made anesthesia for most cases incredibly safe and I don't need to be performing it (overseeing, yes but not personally performing).

This is the only part of your post that I agree with.

 

[sevoflurane]

Surgical home as a way to exit/expand out of the OR's? NO. Not in my life time. I didn't go into anesthesia so I could supervise or do this surgical home crap. Wanting to do so makes it sound as if we've lost this battle. We certainly have not... and my abilities are best used inside the OR environement. Furthermore, I don't need to be a surgeons pre/post hospitalist. Not even remotely intersted in that job.
MD only model still lives. Lot's of MD only practices doing ASA 1-5 cases. There are some really good ones out there that absolutely have a strong foothold w/in their territory.

 

[BuzzPhreed]

Surgical home concept is garbage. Pony-up or get out of the barn. I don't want to tag my name to and get blamed for surgical misadventures, infections, bad outcomes, etc.

 

[Planktonmd]

dA pilot - you are correct, most major centers that have implemented 'surgical homes' have an NP who is the main point person and a faculty member to 'oversee' - generally this person has only one or two rooms during the day and is available when/if the patient falls off the pathways.

I think we all should be invested in reassuring the patient does not come back in the hospital for 30 days because this is bad medicine AND we won't get paid for it (i.e. it will come out of the bundled payment - guess where administrators are going to take that money from). A big majority of things that bring them back in the post-operative period (aside from pain) start in the pre-operative period (proper BP control, diabetes control to try and prevent wound infection, 'health' coaching, etc). All of these things we have a very heavy hand in contributing to and we can influence. The only thing that bothers me about all this (and really the insurers structuring payments this way) is it does not take into account the patients role - I can foresee one day where certain groups will refuse certain patients (morbidly obese, poorly control diabetics, etc). Either that or force the patients to comply (we will not do surgery until you have lost 50% of your body weight or you hba1c is <6.5).

At this conference they expected 150 people to register. They had to shut the doors after 350 registered (there were mostly anesthesiologists but a few surgeons). There were hundreds of small community based anesthesia providers there who think it will work for their hospital (with some tailoring) so I think you are wrong plankton - change is hard for all of us to swallow but it's already in motion and as it gains momentum, it's going to be harder and harder to not at least try. I agree with Dr. Kain - our platform is burring and unless we all provide a solution then we will be left out - (i.e. you will be left with no job or a salary that is much smaller then you have now). Make yourself marketable and helpful to the whole patient experience. Most of the smaller group anesthesia providers we talked to have significant interest from their hospital CEOs who are willing to put forth some time/resources to do this (especially with surgeon buy in and support). The one thing that really seems to hinder many small hospitals is a non-electronic medical record (which is decreasing anyway with meaningful use and government pressures - hospitals are going to be forced to do this or lose reimbursements).

I also think you are very wrong for thinking it will lead to substandard care in the 30 days post-op - I think it improves care. Some of these things are as simple as an automated phone call to the patient saying "did you get your prescriptions filled, do you know when your follow up times are and is your pain adequately treated … if you said NO to any of these, leave us a message and we will call you back within the next few hours". Then a midlevel calls the patient back and tries to sort this out. This picks up problems before either the pt calls the surgeon (and they send them to the ER) or the patient just comes back to the hospital. Having discharge planning starting from the booking of surgery - to make sure your patients are going home to a safe environment and starting the planning weeks or days before their discharge (instead of the moment they hit the door when you only have two maybe three days). You as the anesthesia provider are not doing this yourself but you are the team leader who helps make sure these departments know that we need to do it.

In the end, you act as a leader for the surgical home. You help the surgeon to operate more and make more money. You help bring more business into the hospital. You help make sure patients get excellent care. You make sure those patients don't get readmitted. Sure surgeons could be doing this but I really think we are better equipped. We know medicine and pain management better. This will all benefit you for contracts and will keep you relevant.

Again, we need to be part of the solution or come up with a better one. I like my intraoperative job but in the end we have made anesthesia for most cases incredibly safe and I don't need to be performing it (overseeing, yes but not personally performing).

Your ASA has created this mutant initiative to pretend that they are doing something to fight the nurses, now they are marketing it to the hospital administrators who love it because it's free, and those administrators are going to shove it down the throat of the anesthesia groups and force them to embrace it for marketing purposes.
That's why you had so many people show up to that meeting... they are scared!

 

[IlDestriero]

And "some people" questioned my non membership in the ASA and non participation in the PAC a few years ago. I see that it may be time to return to my old position on the ASA. At least the PAC seems to be doing the right things with our money.
I'm sure the new ASA Headquarters and Wood Library are lovely though.

 

[FollowTheMoney]

Future of anesthesiology with AMCs, PSH, bundled payments, decreasing salaries, increased workload, increased responsibilities, and little to no respect. There's only one way to avoid this catastrophe... get your MBA and do something productive with it (start a group, go corporate, etc.)

 

[pgg]

If I wanted a MBA I would've had one 15 years ago. No thanks.

 

[deleted50478]

Your ASA has created this mutant initiative to pretend that they are doing something to fight the nurses, now they are marketing it to the hospital administrators who love it because it's free, and those administrators are going to shove it down the throat of the anesthesia groups and force them to embrace it for marketing purposes.
That's why you had so many people show up to that meeting... they are scared!

Don't forget they'll get an extra year of servitude out of residents!

 

[Noyac]

We opened a peri-operative clinic at my facility. It is making some what of a difference in pts care. Our clinic is mostly geared towards making sure these pts are ready for surgery. The surgeons still follow their pts post-op.

Here's how we did it.
The clinic is staffed with hospitslists who have anesthesia backup. The reason we use hospitslists is because they are cheaper, they are better at calling other specialists like cardiologist, better at navigating the EHR, and better at documenting than we are. We have a ever changing list of reasons a pt needs to also see and anesthesiologist. But in all reality the hospitslists are much cheaper to place in this role and they enjoy it more than rounding on pts on the floor. They actually fight for these clinic days. It allowed them to add more FTE's to their group and then decrease the call burden. On a typical call day I will have 2 or 3 to see in the clinic. This is much better than parking myself there all day. It allows me to run the OR at the same time and do emergent cases as needed. Much more productive and more revenue generating for all. It removes the burden on the surgeons to collect all of this material and to make sure the pts have all their instructions correct. It has decreased our cancelation rate somewhat but we were pretty low to begin with.

So in summary:
1) staffed by hospitslists with anesthesia backup
2) surgeon focuses on surgical needs
3) pts followed by hospitslists and surgeon postop with rare anesthesiologist follow up.
4) anesthesiologists remain in the OR
5) are seen pre-op and in the system
6) if cancelations are an issue this system will decrease it.
7) surgeons can spend less time with any given pt and therefore generate more cases.
8) anesthesiologist involved as consultants.

 

[deleted171991]

Very risky, lazy and bad idea. So now you have proven to the hospital that they could run a preop clinic basically without anesthesiologists. This after the AANA has been fighting to prove that one can provide anesthesia without anesthesiologists.

What's next? If we are not THE experts in periop medicine, what are we great at? Inserting some tubes and needles, supervising CRNAs, and being "consultants"? Really, how many "consults" will be needed? And how many anesthesiologists will be needed, once stupid people all around the country will allow unsupervised nurses to provide anesthesia for them?

Btw, the hospitalists might be much cheaper today, but they won't be in 10 years. Except that in 10 years, nobody there will pay an anesthesiologist for preop clinic. Why replace a hospitalist who's been doing it for years? This was your chance for a backup plan and a safety net, and you guys blew it. Instead of you learning some periop internal medicine and expanding your turf, you allowed the internists to do the same. This is exactly how we lost the battle for critical care, one of the very few countries in the world where intensivists are not anesthesiologists in an overwhelming proportion.

Of course, this is great short-term, allowing the anesthesia cats to concentrate on making more money in the OR, NOW. As Louis XV said: "Après moi, le déluge."

Just my 2 cents.

 

[Noyac]

Good point, however, that's not how I see it. We are still the final word on the pt. there truly are not that many pts that need to see anesthesiologists. The hospitslists freely admit that they can't run the clinic without our input. So we are integral in the process.

 

[deleted171991]

The hospitslists freely admit that they can't run the clinic without our input. So we are integral in the process.

For now. The same way most CRNAs "freely admit" that they want anesthesiologist supervision.

Just wait till bundled payments arrive, and everybody will be fighting for a bigger slice of that cake.

 

[Noyac]

It's definitely what the bean counters want. "Let the surgeons be (just) surgeons." Meaning "let the anesthesiologists do the dirty job of pre- and post-op care".

I would not be surprised at all if hospitals will sign up for this. As anesthesiologists become cheaper, it's also cheaper to pay an anesthesiologist to babysit the surgical wards and keep the surgeons in the OR as much as possible. We will be the new surgical hospitalists, with about the same level of respect as internist hospitalists get. It might still be better than the crap awaiting us as OR firemen in a system stuffed 90% with CRNAs, many of whom are independent.

There.

Also see this: http://forums.studentdoctor.net/threads/perioperative-surgical-valet.1064499/ .

So you prefer this?

 

[deleted171991]

So you prefer this?

Long-term, I don't think many of us will be able to avoid it, if we want to have a job. I would definitely prefer this to being an OR firefighter for 5-8 CRNAs at a time.

The anesthesia machines will only become more automated and intelligent, needing less physician involvement. Once people get used to self-driving cars, what's next? Even CRNAs might become overqualified for stool sitting. So we have to grab onto turfs that deal with sick, complicated patients and procedures. I tend to like the Austrian model the most, for our future in this country.

The genie came out of bottle first when doctors allowed the board of nursing to be independent of them, and then when we allowed the board of nursing to regulate midlevels. Or maybe when we allowed midlevels to simply exist in this country (they still don't in many countries). In many countries, if one wants to diagnose and treat, with or without supervision, one has to be a licensed physician, period. That boat has sailed in the US.

 

[Carbocation1]

Seems like Anesthesiologists are getting squeezed out by CRNAs, Hospitalists, Surgeons, and Administrators. Is there anyone who supports Anesthesiologists? Or are they more like a "necessary evil"?

 

[FollowTheMoney]

I think it is very possible the field may not exist in 10 years. Once AMCs take over completely, they will only hire CRNAs so anesthesiologists will not be needed in the OR anymore. As far as the PSH is concerned, hospitalists and/or midlevel providers will do that as well effectively leaving anesthesiologists with nothing. The future looks extremely bleak. Nobody thinks anesthesiologists are needed anymore. Plan to go corporate if you don't want a 150k salary for 50 hours a week in 5-10 years.

 

[deleted50478]

I think it is very possible the field may not exist in 10 years. Once AMCs take over completely, they will only hire CRNAs so anesthesiologists will not be needed in the OR anymore. As far as the PSH is concerned, hospitalists and/or midlevel providers will do that as well effectively leaving anesthesiologists with nothing. The future looks extremely bleak. Nobody thinks anesthesiologists are needed anymore. Plan to go corporate if you don't want a 150k salary for 50 hours a week in 5-10 years.

I'm not the most optimistic guy around here, but I think that is not at all likely. We may make closer to what crnas make per hour, and we may end up doing expanded pre- and post-op work, but we aren't going to cease to exist. We are still the best at doing our job, the only issue is cost and how much larger a percentage of what WE EARN we'll be able to keep from the AMCs vs what the nurses will get paid.

 

[FollowTheMoney]

You are trying to rationalize this situation from a physician's perspective when you need to look at it from a business perspective. Yes, you are more qualified, have better expertise, provide better patient care, and are more suitable for the job. However, when you cost on average 350k and there is someone willing, ready, and legally allowed to do it for 150k, as a businessman that's cutting 200k in overhead for the same overall outcome. If I was running an AMC, why wouldn't I do it? The AMC will rape and pillage and leave no dollar behind as they take everything. They are going to continue to pay the lowest salary they can get away with... as far as who is taking that salary they could care less.

 

[Carbocation1]

You are trying to rationalize this situation from a physician's perspective when you need to look at it from a business perspective. Yes, you are more qualified, have better expertise, provide better patient care, and are more suitable for the job. However, when you cost on average 350k and there is someone willing, ready, and legally allowed to do it for 150k, as a businessman that's cutting 200k in overhead for the same overall outcome. If I was running an AMC, why wouldn't I do it? The AMC will rape and pillage and leave no dollar behind as they take everything. They are going to continue to pay the lowest salary they can get away with... as far as who is taking that salary they could care less.[/QUOTE

Why purchase an iPhone for $999 when you can simply use the Nokia that came free with your family plan? They both can make calls and send email/text/browse the web/take photos.

 

[Carbocation1]

I don't understand why surgery centers/hospitals don't advertise their use of physician anesthesiologists, and put the CRNA-filled hospitals out of business. I've seen so many Ortho ads everywhere, it's ridiculous.

 

[BLADEMDA]

Why purchase an iPhone for $999 when you can simply use the Nokia that came free with your family plan? They both can make calls and send email/text/browse the web/take photos.

But, would you purchase the iphone for $199? if necessary, the price would be reduced to $99. My point is that the better product will sell if the price is right.

Anesthesiologists are superior to CRNAs but the bean counters will want that cost differential slashed or they will go with the free Nokia.

 

[BLADEMDA]

You are trying to rationalize this situation from a physician's perspective when you need to look at it from a business perspective. Yes, you are more qualified, have better expertise, provide better patient care, and are more suitable for the job. However, when you cost on average 350k and there is someone willing, ready, and legally allowed to do it for 150k, as a businessman that's cutting 200k in overhead for the same overall outcome. If I was running an AMC, why wouldn't I do it? The AMC will rape and pillage and leave no dollar behind as they take everything. They are going to continue to pay the lowest salary they can get away with... as far as who is taking that salary they could care less.

Your post is incorrect. Bean Counters prefer Anesthesiologists but just don't want to pay the difference in salaries. However, once that difference is just 20% or less then the choice is clear.

 

[Carbocation1]

But, would you purchase the iphone for $199? if necessary, the price would be reduced to $99. My point is that the better product will sell if the price is right.

Anesthesiologists are superior to CRNAs but the bean counters will want that cost differential slashed or they will go with the free Nokia.

That's assuming Anesthesiologists have a quality competitor like Samsung that Apple has to compete with. Apple lowers the price of the iPhone to compete with Samsung, not with Nokia.

 

[deleted50478]

You are trying to rationalize this situation from a physician's perspective when you need to look at it from a business perspective. Yes, you are more qualified, have better expertise, provide better patient care, and are more suitable for the job. However, when you cost on average 350k and there is someone willing, ready, and legally allowed to do it for 150k, as a businessman that's cutting 200k in overhead for the same overall outcome. If I was running an AMC, why wouldn't I do it? The AMC will rape and pillage and leave no dollar behind as they take everything. They are going to continue to pay the lowest salary they can get away with... as far as who is taking that salary they could care less.

I think this would be true if another AMC using a care team wouldn't step in and offer superior care (vs crna-only) for the same cost to the hospital (free).

 

[FollowTheMoney]

Your post is incorrect. Bean Counters prefer Anesthesiologists but just don't want to pay the difference in salaries. However, once that difference is just 20% or less then the choice is clear.

Yeah, that's like saying I want a Maserati, but I want to just pay 30k for it. It's pretty simple, either the Maserati stays at 120k and it holds the line or it free falls to 30k to meet the competition. Of course everyone wants an anesthesiologist, but I don't know a single one that would work for a Peds salary. I don't know about you, but I'm not working 50 hour weeks for 150-170k. That just ain't gonna happen. Sorry.

 

[FollowTheMoney]

Why purchase an iPhone for $999 when you can simply use the Nokia that came free with your family plan? They both can make calls and send email/text/browse the web/take photos.

Problem with that premise is that the iPhone is desired by everyone for its technology, abilities, entertainment, etc. and people are willing to pay for it no matter what their income level is. No one is willing to pay for an anesthesiologist because no one wants or cares about quality healthcare. More importantly, no one is willing to pay for it. When you are going against the current, the cheapest option is what's desired.

 

[nimbus]

Yeah, that's like saying I want a Maserati, but I want to just pay 30k for it. It's pretty simple, either the Maserati stays at 120k and it holds the line or it free falls to 30k to meet the competition. Of course everyone wants an anesthesiologist, but I don't know a single one that would work for a Peds salary. I don't know about you, but I'm not working 50 hour weeks for 150-170k. That just ain't gonna happen. Sorry.

Pediatricians work for peds salary and they are not dumb. Anesthesiologists would work for peds salary if that was the going rate.

 

[deleted171991]

Your post is incorrect. Bean Counters prefer Anesthesiologists but just don't want to pay the difference in salaries. However, once that difference is just 20% or less then the choice is clear.

Except that, with an overproduction of graduates, both anesthesiologists and CRNAs will become a commodity. As the market gets saturated, it's a race to the bottom (for the salaries) that will destroy both professions. It's all a matter of time.

 

[RedAnesthesia]

Except that, with an overproduction of graduates, both anesthesiologists and CRNAs will become a commodity. As the market gets saturated, it's a race to the bottom (for the salaries) that will destroy both professions. It's all a matter of time.

The majority of trends show that there will be a shortage of anesthesiologist in next 10-15 yrs with lot of older baby boomers retiring, not overproduction . They do expect a surplus of CRNAs given how many CRNAs are being pumped out. Salaries can only drop so low before nobody wants to do the field. The stress level of anesthesiologists to pediatricians isn't even compareable.

Red

 

[deleted171991]

The majority of trends show that there will be a shortage of anesthesiologist in next 10-15 yrs with lot of older baby boomers retiring, not overproduction .

Excuse me if I disagree.

There is already an overproduction of anesthesiology residency graduates (hence the crappy offers for new grads), and this while most CRNAs are still not independent. In 10-15 years, it will be worse, not better.

People are retiring all the time. The baby boomer generation is less numerous than the current generation; that's how the human population increases on this planet. The generation of physicians retiring is always smaller than the generation graduating, but since the number of patients increases, too, there are new jobs created every year. In the future, the latter component will disappear, since many anesthesiologist jobs will be taken over by independent CRNAs; hence my pessimism.

 

[Planktonmd]

Your post is incorrect. Bean Counters prefer Anesthesiologists but just don't want to pay the difference in salaries. However, once that difference is just 20% or less then the choice is clear.

Actually I think that hospital administrators prefer to deal with nurses way more than physicians because nurses are used to blindly follow policies no matter how ridiculous they might be.
Nurses don't question what they are told to do while physicians tend to be a pain in the behind and ask too many questions.

 

[Consigliere]

I'll say it again- IF any of this surgical home nonsense comes to fruition, I will immediately quit the practice of medicine. I'm an anesthesiologist, not a surgeon's personal concierge.

 

[deleted171991]

I'll say it again- IF any of this surgical home nonsense comes to fruition, I will immediately quit the practice of medicine. I'm an anesthesiologist, not a surgeon's personal concierge.

I don't see myself as the concierge, on the contrary. While in the OR the surgeon is the doctor and I am the consultant, postop (and possibly preop) I will be the attending of record and he will be... consulting for wound care. As in the ICU. Everything else will be my prerogative. He can go and do another lap appy for 3 hours for all I care.

 

[deleted171991]

Actually I think that hospital administrators prefer to deal with nurses way more than physicians because nurses are used to blindly follow policies no matter how ridiculous they might be.
Nurses don't question what they are told to do while physicians tend to be a pain in the behind and ask too many questions.

Plus many hospital administrators are nurses themselves, some of them with an itch against doctors.

 

[FollowTheMoney]

I'll say it again- IF any of this surgical home nonsense comes to fruition, I will immediately quit the practice of medicine. I'm an anesthesiologist, not a surgeon's personal concierge.

I read that Florida just had their annual conference which focused on the perioperative surgical home so in "AMC country" it's coming sir.

 

[deleted682700]

Problem with that premise is that the iPhone is desired by everyone for its technology, abilities, entertainment, etc. and people are willing to pay for it no matter what their income level is. No one is willing to pay for an anesthesiologist because no one wants or cares about quality healthcare. More importantly, no one is willing to pay for it. When you are going against the current, the cheapest option is what's desired.

How do you measure quality in anesthesia? Does experience count? what will the market pay for that experience?