"Why we need to build bridges between primary care and anesthesiology" (Sibert)

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I appreciate a lot of her stuff. Not everything, of course. But she can be pretty good at times.

My favorite is the Great Zs.
 
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bashwell said:
I appreciate a lot of her stuff. Not everything, of course. But she can be pretty good at times.

My favorite is the Great Zs.
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Since Oz, Gupta and Gawande, I have very little respect for physicians who spew PC crap under their own name. It's all about their personal interests and careers. It's a nicely veiled form of demagoguery.

I have much more respect for people like Ioannidis, true thought changers. It's way much harder to piss against the wind.
 
FFP said:
Since Oz and Gupta, I have very little respect for physicians who publish PC crap under their own name. It's all about their personal interests.
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I'm not sure if she's become as bad as Oz and Gupta, has she? I hope not.
 
It seems to me that the writer is saying that the PCPs aren't very good at keeping their patients in optimal health, so maybe the anesthesiologists can do it (for free). I think that is a defeatist attitude. PCPs do an incredible job with many of the patients I see.
 
Impromptu said:
It seems to me that the writer is saying that the PCPs aren't very good at keeping their patients in optimal health, so maybe the anesthesiologists can do it (for free). I think that is a defeatist attitude. PCPs do an incredible job with many of the patients I see.
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Well put. I'd be surprised if the primary care physicians aren't a little bit offended by this notion that an anesthesiologist can, via a 10 or 15 min single meeting, get their uncontrolled hypertensive obese diabetic smokers to reform their wayward lives and embrace a healthy tobacco-free lifestyle of granola and yoga.
 
pgg said:
Well put. I'd be surprised if the primary care physicians aren't a little bit offended by this notion that an anesthesiologist can, via a 10 or 15 min single meeting, get their uncontrolled hypertensive obese diabetic smokers to reform their wayward lives and embrace a healthy tobacco-free lifestyle of granola and yoga.
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We are, no worries there
 
Anesthesiology is a sinking ship. It is a dead specialty for physicians and future medical students should take that warning to heart. The specialty was sold out years ago and now "leadership" is grasping at straws to maintain some relevance. While I do think the perioperative surgical home idea has some merit when caring for ACUTE patients, this article is just more evidence to me that nurses are winning the battle for this specialty.

Medical students considering anesthesiology should look at jobs being offered and compare them to primary care jobs in the same area. Starting salaries are not that much different and in some cases, primary care is paying more. Maybe this is a function of obamacare or maybe we are seeing an averaging out of anesthesia salaries as we are competing more and more with crnas.
 
Medicine is a sinking ship outside of surgical specialties. We let nurses define the practice of medicine and they are winning the PR campaigns. The AMA could care less as long as a few thousand throw them some money each year. The ASA leadership doesn't want to stand up to CRNAs because they are worried it will affect their bottom line. Remember, many anesthesia depts (even those at the big institutions) are dependent on CRNAs and love the money the nursing schools throw at them. They don't want to rock the boat.
 
Medicine is a sinking ship outside of surgical specialties. We let nurses define the practice of medicine and they are winning the PR campaigns. The AMA could care less as long as a few thousand throw them some money each year. The ASA leadership doesn't want to stand up to CRNAs because they are worried it will affect their bottom line. Remember, many anesthesia depts (even those at the big institutions) are dependent on CRNAs and love the money the nursing schools throw at them. They don't want to rock the boat.
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I completely agree.

Internal medicine also allows you to specialize that may provide some safety from nurses. I don't see them allowing nurses to do cardiac caths anytime soon...though you never know in this environment of cost cutting. Although, there has been talk about nurses doing screening colonoscopies and I believe they are already doing sigmoidoscopies in certain areas.

In terms of the topic at hand, I do think that an anesthesiologist can do a better job of preoperative work up than some silly NP that will just shotgun order tests to cover his or her bases prior to surgery. I get patients all the time that are healthy for minor surgeries who show up with echos on their chart as part of their "clearance." Almost always it's ordered by an NP. However, to me that just shows similar problems that primary care is having by having lesser trained "providers" providing care. Nothing is better than when I get a well-constructed and thought out note from a primary care physician who knows his patient well. That is not a role for anesthesiologists.
 
pgg said:
Well put. I'd be surprised if the primary care physicians aren't a little bit offended by this notion that an anesthesiologist can, via a 10 or 15 min single meeting, get their uncontrolled hypertensive obese diabetic smokers to reform their wayward lives and embrace a healthy tobacco-free lifestyle of granola and yoga.
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So I want to hit on this just a bit more.

First, show of hands from the anesthesiologists - who among you WANTS to take this added responsibility on? I grow weary of doing it sometimes and I went into FM knowing this was a big part of my day.

Second, I rotated with a vascular surgeon in residency who refused to operate on smokers. He'd even nicotine test them. These were people with significant claudication, couldn't walk to the car without pain. Want to guess how many actually quit?

Third, isn't this what pre-op optimization is supposed to be all about? I know that's what I'm doing for pre-op visits. I'd love to know how y'all are better at this than I am.
 
Third, isn't this what pre-op optimization is supposed to be all about? I know that's what I'm doing for pre-op visits. I'd love to know how y'all are better at this than I am.
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We're not better at this than you. However, we are in the final days of anesthesiology as a physician driven specialty. These are last ditch efforts to maintain some relevancy in this healthcare system. It's easier to fight physicians for their turf than to fight nurses. You must know that, right?
 
GravelRider said:
I get patients all the time that are healthy for minor surgeries who show up with echos on their chart as part of their "clearance." Almost always it's ordered by an NP. However, to me that just shows similar problems that primary care is having by having lesser trained "providers" providing care
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I think this sort of thing will self limit the expansion of advanced practice nurses. It won't take too long for the suits to realize that any up front savings from NP's are being negated by excessive testing (stemming from overall lack of understanding and experience) and increased complications/bounce backs. Factor in the complete intolerance for complications from both payers and the general public and I just don't see a complete mid level takeover as an inevitability.

We may also see more meaningful/sweeping tort reform as a byproduct of increased mid level independence.

If you look at Kaiser (in CA at least), they have largely eliminated NP's from primary care rolls. They have gone back to essentially all MD, and they are very slowly doing this in their anesthesia departments as well. I think Kaiser sort of serves as a canary in the coal mine for the healthcare system at large. At least I hope it does.
 
SaltyDog said:
If you look at Kaiser (in CA at least), they have largely eliminated NP's from primary care rolls. They have gone back to essentially all MD, and they are very slowly doing this in their anesthesia departments as well. I think Kaiser sort of serves as a canary in the coal mine for the healthcare system at large. At least I hope it does.
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What caused Kaiser to take this stance? Was it financial or based on patient demand?
 
SaltyDog said:
If you look at Kaiser (in CA at least), they have largely eliminated NP's from primary care rolls. They have gone back to essentially all MD, and they are very slowly doing this in their anesthesia departments as well. I think Kaiser sort of serves as a canary in the coal mine for the healthcare system at large. At least I hope it does.
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I used to work for a large Catholic healthcare system that did the same thing - they had around 100 PCPs across around 20-25 offices. Not a single mid-level to be had.
 
I believe it was a combination of pt dissatisfaction combined with the fact that it wasn't saving them money and costing them subscribers. They payed a lot of money to some big consulting firms and the main recommendation was to eliminate the mid levels. The phasing out of CRNAs is primarily financial. Doesn't make sense to pay 2 people for each anesthetic when you can get the MDs to work for almost the same salary.
 
GravelRider said:
We're not better at this than you. However, we are in the final days of anesthesiology as a physician driven specialty. These are last ditch efforts to maintain some relevancy in this healthcare system. It's easier to fight physicians for their turf than to fight nurses. You must know that, right?
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Why hasn't the ASA come up with a combined Family Medicine/Anesthesia residency? That's how they envision the anesthesiologist in the future. It makes no sense but that's what they are pushing for.
 
urge said:
Why hasn't the ASA come up with a combined Family Medicine/Anesthesia residency? That's how they envision the anesthesiologist in the future. It makes no sense but that's what they are pushing for.
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I'm sure they'll find a sucker to sign up for this likely 6 year residency.
 
VA Hopeful Dr said:
So I want to hit on this just a bit more.

First, show of hands from the anesthesiologists - who among you WANTS to take this added responsibility on? I grow weary of doing it sometimes and I went into FM knowing this was a big part of my day.

Second, I rotated with a vascular surgeon in residency who refused to operate on smokers. He'd even nicotine test them. These were people with significant claudication, couldn't walk to the car without pain. Want to guess how many actually quit?

Third, isn't this what pre-op optimization is supposed to be all about? I know that's what I'm doing for pre-op visits. I'd love to know how y'all are better at this than I am.
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FM/IM physicians are better suited because we know the patient.
My preops were always focused on periop optimization when I was in anesthesia.
In the PCP world, you can actively work to optimize the patient a good month or more prior to the patient having surgery. I also know to judiciously order labs, work up and am able to provide a good idea to the patients of the surgery, likely anesthetic plan with the notion that this may be anesthesiologist dependent for certain instances. I don't write silly notes about "give fluids" or other periop management issues that could potentially arise. My job is to tell about the patient's overall condition, health issues stable or otherwise, and to ensure the patient is optimized. I will discuss the patient's overall health, nutrition status, activity level, tobacco status, rheumatologic issues, etc.

This is mainly a move by the ASA to try to expand on something that is already belonging to someone else because they are on their last dying breath and need a real marketable reason to differentiate themselves from the competition when the bean counters are allocating the slices of the pie.
 
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SaltyDog said:
I believe it was a combination of pt dissatisfaction combined with the fact that it wasn't saving them money and costing them subscribers. They payed a lot of money to some big consulting firms and the main recommendation was to eliminate the mid levels. The phasing out of CRNAs is primarily financial. Doesn't make sense to pay 2 people for each anesthetic when you can get the MDs to work for almost the same salary.
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Kaiser is doing the same thing in the Emergency arena as well. I was just at one dept where they have gone from having 12 PAs on their roster to just 1 over the past few years. I was told the same thing as you, this transition is based on consulting recommendations.


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Doctor4Life1769 said:
I'm sure they'll find a sucker to sign up for this likely 6 year residency.
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It's brilliant!

I'm working on the curriculum already. On the OB months the trainee will follow the whole pregnancy making the preop evaluation at the preop clinic a breeze ( yes we will still need the patient to come to preop clinic before delivery despite you being their primary, and only, physician). The day of delivery the trainee will observe the progression of labor, administer the anesthesia as deemed necessary ( pudendal bock, epidural, CSE), carry a c section if needed, and follow her during the hospitalization. And the kicker is that we will only bill for the anesthetic, bringing immense savings to the healthcare system and more importantly, the hospital ( in which the trainee will have to live in if he is serious about his work).

And we are going to gave a couple of fellowships also. Stay tuned.

I don't know how no other idiot had thought of this before. It's just logical.
 
urge said:
It's brilliant!

I'm working on the curriculum already. On the OB months the trainee will follow the whole pregnancy making the preop evaluation at the preop clinic a breeze ( yes we will still need the patient to come to preop clinic before delivery despite you being their primary, and only, physician). The day of delivery the trainee will observe the progression of labor, administer the anesthesia as deemed necessary ( pudendal bock, epidural, CSE), carry a c section if needed, and, follow her during the hospitalization. And the kicker is that we will only bill for the anesthetic, bringing immense savings to the healthcare system and more importantly, the hospital ( in which the trainee will have to live in if he is serius about his work).

And we are going to gave a couple of fellowships also. Stay tuned.

I don't know how no other idiot had thought of this before. It's just logical.
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You'll need a fellowship to help you know how to carry out the plan on a patient who is considered "high risk" - that's gotta account for at least 1 year. Want to learn TEE for those with bad hearts? Oh that's another year! Don't forget, you'll also likely need to incorporate a patient centered pediatric medical/surgical home, too, especially for those budding pediatric anesthesiologists.
 
VA Hopeful Dr said:
So I want to hit on this just a bit more.

First, show of hands from the anesthesiologists - who among you WANTS to take this added responsibility on? I grow weary of doing it sometimes and I went into FM knowing this was a big part of my day.

Second, I rotated with a vascular surgeon in residency who refused to operate on smokers. He'd even nicotine test them. These were people with significant claudication, couldn't walk to the car without pain. Want to guess how many actually quit?

Third, isn't this what pre-op optimization is supposed to be all about? I know that's what I'm doing for pre-op visits. I'd love to know how y'all are better at this than I am.
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We are too busy following stuff that matter to us, like the Post Op Nausea and Vomiting literature.

We have heard that everyone should be on a beta blocker. So, everyone will be started on metoprolol in the preop clinic and we will say they are optimized.

Easy peasy
 
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urge said:
We are too busy following stuff that matter to us, like the Post Op Nausea and Vomiting literature.

We have heard that everyone should be on a beta blocker. So, everyone will be started on metoprolol in the prop clinic and we will say they are optimized.

Easy peasy
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Might as well throw in a statin too 😉
 
VA Hopeful Dr said:
So I want to hit on this just a bit more.

First, show of hands from the anesthesiologists - who among you WANTS to take this added responsibility on? I grow weary of doing it sometimes and I went into FM knowing this was a big part of my day.

Second, I rotated with a vascular surgeon in residency who refused to operate on smokers. He'd even nicotine test them. These were people with significant claudication, couldn't walk to the car without pain. Want to guess how many actually quit?

Third, isn't this what pre-op optimization is supposed to be all about? I know that's what I'm doing for pre-op visits. I'd love to know how y'all are better at this than I am.
Click to expand...

You might be good, but you have no idea the amount of preop "clearances" we see that include a set of labs, an echo or stress test and cxr with comments like: "cleared for surgery. Avoid hypoxemia and hypotension."

Not to mention the vast majority of PCPs who do not understand what we do or the pharmacology of the drugs we use.

Some here don't like it, but because PCPs and to some extent cardiologists do this, there is an obvious niche for the perioperative clinic. We are not trying to fix diabetes or obesity, but we are taking a look at these ASA 3+ and seeing what their periop needs will be and preparing them for that. You'd be surprised how many questions people have when they hear they won't be extubated immediately postop or need invasive lines and meds, or look like a difficult airway. Some people really need more than 5 minutes in preop holding.
 
Random Resident said:
You might be good, but you have no idea the amount of preop "clearances" we see that include a set of labs, an echo or stress test and cxr with comments like: "cleared for surgery. Avoid hypoxemia and hypotension."

Not to mention the vast majority of PCPs who do not understand what we do or the pharmacology of the drugs we use.

Some here don't like it, but because PCPs and to some extent cardiologists do this, there is an obvious niche for the perioperative clinic. We are not trying to fix diabetes or obesity, but we are taking a look at these ASA 3+ and seeing what their periop needs will be and preparing them for that. You'd be surprised how many questions people have when they hear they won't be extubated immediately postop or need invasive lines and meds, or look like a difficult airway. Some people really need more than 5 minutes in preop holding.
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And all of that is exactly what I would think your preop visit consists of because you're right I don't know much about anesthesia. The article in the OP however talks about y'all getting patients to stop smoking and eat better. That's a whole different story.
 
VA Hopeful Dr said:
And all of that is exactly what I would think your preop visit consists of because you're right I don't know much about anesthesia. The article in the OP however talks about y'all getting patients to stop smoking and eat better. That's a whole different story.
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You asked how we were better at pre-optimization. That's different from responding to Sibert.

I just want my patient prepared enough for surgery to decrease risk as best as they can for adverse outcome because of their preexisting disease.
 
What?! You must mean somewhere like Manhattan? If not, then that's just sad.
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I've recently seen starting salaries for outpatient internal medicine around 300k+. I know a couple of internists who do quite well (think 400-500k). They work hard, but no harder than us. They are not living in Podunk hills either.

It's just food for thought for med students now. Obviously, do what you enjoy doing, but the reality in anesthesia is that most med students who go into anesthesia now won't be practicing it as we think of it. You will be signing charts, doing preops, and crossing your fingers that the crna sitting in the room is semi-competent. Anesthesia will likely evolve over the next decade to include some bastardized version of this perioperative thing (again, some of it has merits and critical care is a great option). But as specialties come and go in cycles, primary care is not a bad option as long as you can put up with the paperwork and other headaches.
 
pgg said:
Yet another perioperative surgical home piece extolling the virtues of anesthesiologists talking to patients about their diabetes in clinic? Ugh.
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Retirement can't come soon enough.
 
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