CRNA vs. Anesthesiologist Surgery Help

[Noyac]

The way we are set up, MD only cannot happen. We have 265 or so anesthetizing rooms each morning at 0700. We can't spare a Doc to sit a room by themselves.

Because of financial constraints.

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[Candidate2017]

As an aside, would you guys be comfortable letting a family member have an upper GI scope at a freestanding facility? I'm not sure if the facility has an anesthesiologist. Even if they have one like at Joan Rivers' facillity, would they even have sux or ventilators if laryngospasm or something happened? I've seen scopes go bad and the GI docs just stand there looking terrified until the anesthesiologist runs in and takes over for the CRNA. My initial thought is all scopes under sedation should be in a hospital.

 

[deleted162650]

Our answer is some variation of, "People come, often long distances, to us because we are good, and the ACT is how we are rich, so if you ask us to change, it will only derail why we are rich."

There, fixed that for you .

The way we are set up, MD only cannot happen. We have 265 or so anesthetizing rooms each morning at 0700. We can't spare a Doc to sit a room by themselves.

Really, there's no one pre/post-call that can do 1 case?? No one with the day off that could do one case? I fully realize that a DOS request would be impossible to honor in an ACT practice, but if the pt makes the request when the surgery is booked weeks in advance, then it seems like poor form to not honor that. Here you have a pt that is educated and knowledgeable enough to not only know the difference between MD and CRNA, but also respects our expertise and training enough to want one of us at the head of the bed. To deny that is like giving the pt 2 big middle fingers, and telling them that they aren't worth it because you guys won't make quite as much off that one case. You're also making the profession look bad as a whole.

I believe that ACT is safe, and people like @jwk and @Mman prove that everyday (I also admit that covering 4 rooms is harder work than sitting your own case). But, you won't convince me that anything other than MD only is the best/safest. ACT is about one thing: . To deny that is being FOS.

 

[Mman]

I believe that ACT is safe, and people like @jwk and @Mman prove that everyday (I also admit that covering 4 rooms is harder work than sitting your own case). But, you won't convince me that anything other than MD only is the best/safest. ACT is about one thing: . To deny that is being FOS.

Would doing the case yourself be better than doing it 1:1 with a CRNA where you an literally not leave the room if you so desire? Is there a benefit to not having an extra pair of hands?

 

[Man o War]

Here is my personal hierarchy, safest to least safe, for choosing how I get anesthesia if I have a choice:
1) handpicked MD only (I know the doc and his/her abilities personally)
2) handpicked ACT, MD and CRNA or AA (I know both and their abilities personally)
3) random MD only (don't know doc at all)
4) random ACT, MD and CRNA or AA (don't know any of them)
5) solo CRNA- would never have any surgery or procedure with this unless emergent and comatose/unconscious

 

[nimbus]

The way we are set up, MD only cannot happen. We have 265 or so anesthetizing rooms each morning at 0700. We can't spare a Doc to sit a room by themselves.

We cover over 200 rooms without a single CRNA. Doubt Minnesota payor mix is worse than ours. It can be done and you can still make a good living.

 

[deleted162650]

Would doing the case yourself be better than doing it 1:1 with a CRNA where you an literally not leave the room if you so desire? Is there a benefit to not having an extra pair of hands?

Yes, not having a midlevel there to **** it up in the first place.

I kid, I kid.

But this situation you describe isn't based on any reality I know of. Where do they staff with an CRNA and MD both continuously in the room at all times??? Now that would be wasteful.

 

[epidural man]

Would doing the case yourself be better than doing it 1:1 with a CRNA where you an literally not leave the room if you so desire? Is there a benefit to not having an extra pair of hands?

At my hospital, a CRNA killed someone during a colonoscopy (maybe an EGD ....don't remember). Anyway, the institutional policy to fix this issue was that during road show anesthesia, we would send two people. That is a very expensive answer, but it makes the day WAY easier doing a bunch of fast turn-over colonoscopies.

 

[ZzzPlz]

At my hospital, a CRNA killed someone during a colonoscopy (maybe an EGD ....don't remember). Anyway, the institutional policy to fix this issue was that during road show anesthesia, we would send two people. That is a very expensive answer, but it makes the day WAY easier doing a bunch of fast turn-over colonoscopies.

Do they give a stipend for the extra body? That would be an expensive room to cover

 

[Urzuz]

Would doing the case yourself be better than doing it 1:1 with a CRNA where you an literally not leave the room if you so desire? Is there a benefit to not having an extra pair of hands?

Yes it is better doing it yourself. Every physician on here that works in an ACT model is always talking about how you have to tread lightly around CRNAs, let them make the plan and execute it the way they want as long as it is "safe" for the patient even if you would do things differently, let CRNAs intubate, put in arterial lines, possibly even central lines/blocks...all in the name of not hurting their feelings and "playing nice" with them. That's why having just a physician and no one else around is better. You don't have to transform from Dr. Mman to Dr. Phil, and instead of worrying about the patient, worry about the delicate CRNA's feelings and the social implications of telling them to sit the %$#& down while you do everything. That is why MD-only anesthesiology will always be superior.

 

[deleted171991]

I'm not attacking him. He repeatedly points out dislike of his job structure. Not all jobs are like that. Not all ACT practices have physicians supervising CRNAs that are not their employees. He incorrectly feels that by ever having a ratio above 2:1 that you cannot medically direct safely and appropriately and my response to that is that yes you can.

As I pointed out, my mistake was assuming the existence of a TEFRA rule that does not exist. I was not talking about my job.

 

[Noyac]

.

At my hospital, a CRNA killed someone during a colonoscopy (maybe an EGD ....don't remember). Anyway, the institutional policy to fix this issue was that during road show anesthesia, we would send two people. That is a very expensive answer, but it makes the day WAY easier doing a bunch of fast turn-over colonoscopies.

Why not just send an anesthesiologist? We consider the Endo suite to be one of the most dangerous locations in the hospital.

 

[deleted171991]

.

Why not just send an anesthesiologist? We consider the Endo suite to be one of the most dangerous locations in the hospital.

Because that would imply that the care of an anesthesiologist is better than that of a CRNA.

 

[Man o War]

.

Why not just send an anesthesiologist? We consider the Endo suite to be one of the most dangerous locations in the hospital.

I always tell residents this!! You have to be more diligent in there, not less. Especially if you're supervising.

 

[aneftp]

It feels like 70-80% of the most profitable act groups have sold out the past 6-7 years.

They see the writing on the wall. Market pressure. It just take one large group to "sell out". The dominos fall very quickly with the competing act practices locally. My area had basically zero AMC. But in late 2012. One group sold out. Bam. Domino effect. By 2016. No major practices left that were truly considered independent.

 

[deleted171991]

Remember this?

 

[Dejavu]

We cover over 200 rooms without a single CRNA. Doubt Minnesota payor mix is worse than ours. It can be done and you can still make a good living.

Could be. Just not what happens where I work.

Not directed at you, but shouldn't a forum populated by professionals be able to avoid resorting to
"That's f*cked up" and the "FOS" level of comments. Could explain why some people have trouble getting along at work. And yes, I do know this is the internet. It's just that I grew up in awe of physicians, and now that I am one, it saddens me that physicians act like this.

 

[Noyac]

Because that would imply that the care of an anesthesiologist is better than that of a CRNA.

Oh, stupid me!

 

[Noyac]

Oh

Could be. Just not what happens where I work.

Not directed at you, but shouldn't a forum populated by professionals be able to avoid resorting to
"That's f*cked up" and the "FOS" level of comments. Could explain why some people have trouble getting along at work. And yes, I do know this is the internet. It's just that I grew up in awe of physicians, and now that I am one, it saddens me that physicians act like this.

Oh, I'm sorry. Did I offend you on a site that allows physicians to interact together in a way that we can't in the overly sensitive public arena? Are you so high and mighty that the mere curse word on an internet site offends you so much? Or is it that you think physicians are not human?
Maybe you missed this: Swearing Is A Sign Of High Intelligence. Well, F*ck.

I'm just surprised physicians don't curse more since we obviously are the most intelligent folks on the planet as a whole.

This is a forum for us to express ourselves in ways that we must refrain from in public because people like yourself get too bent out of shape when they hear the slightest swearing. Get over it.

 

[Noyac]

Could be. Just not what happens where I work.

Not directed at you, but shouldn't a forum populated by professionals be able to avoid resorting to
"That's f*cked up" and the "FOS" level of comments. Could explain why some people have trouble getting along at work. And yes, I do know this is the internet. It's just that I grew up in awe of physicians, and now that I am one, it saddens me that physicians act like this.

Maybe, instead of contributing only superficially to the discussion here for 10 yrs, you could add something useful. How about you start by telling us the difference between being a nurse vs a physician, or better yet a crna vs an anesthesiologist (if that is what you really are, I'm skeptical at this point). That would be a thread that would garner an incredible amount of attention. And it could actually be useful. Actually, if you don't describe the differences then I will more than likely assume you are still a nurse.

 

[Dejavu]

Maybe, instead of contributing only superficially to the discussion here for 10 yrs, you could add something useful. How about you start by telling us the difference between being a nurse vs a physician, or better yet a crna vs an anesthesiologist (if that is what you really are, I'm skeptical at this point). That would be a thread that would garner an incredible amount of attention. And it could actually be useful. Actually, if you don't describe the differences then I will more than likely assume you are still a nurse.

I always thought it was better to not just post to hear myself talk so I can increase my post count.
I appear to have struck close to home about being civil on the forum, otherwise you wouldn't have spent the time looking at my posting history.
As to whether I am a physician, how do I know that you are who you say you are.
I got out of the Marine Corps in 1973, went to nursing school, went to CRNA school, did that for a decade, then decided I needed more to do my job the best way (see, I know there is a difference between CRNAs and MDs), so I went to Medical School in 1989, then Mayo anesthesia residency, then have been on staff for the past 20 yrs.
So, better than all of you, I know what I am talking about when I speak to the CRNA/MD controversy, however superficially.
My comments about civil discourse and unprofessional language by professionals on this forum stand. We have little enough civility in the world. As professionals, I expected better.

My sainted mother told me "I you cannot say anything good, don't say anything at all."
So I am humbly willing to let you have the last word, since you, apparently, know better than I what is right and true about this subject.
Your humble servant, Dejavu

 

[Mman]

Yes, not having a midlevel there to **** it up in the first place.

I kid, I kid.

But this situation you describe isn't based on any reality I know of. Where do they staff with an CRNA and MD both continuously in the room at all times??? Now that would be wasteful.

I didn't say for all cases. We do it for some complicated cases.

 

[Mman]

Those implying that you get better care in the 3+1 or 4+1 model are saying two things:
2) the care of the CRNA is no different than an MD--i.e. anyone can follow a template and no critical thinking goes into this process (btw, I do not believe that)
3) I am a number on a sheet for a case for you to get done that day: not much more.

I am a patient (also a physician). Someone who believes in our training and way of taking care of people. If you do not believe you bring value to treating patients from start to finish or that I am less valuable than your time, I would not want you as my Anesthesiologist (doesn't mean your a bad doctor, just not someone I would not want taking care of me).

Amongst all the monetary aspects mentioned, very few brought up the patient right in front of them. The patient... who is scared.....if they wanted their care from you... because they trust you... isn't that why we got into this profession? I know this sounds like a "preachy" and almost that soft stuff I hated in medical school. But, there is some underlying truth there.

I thought about Anesthesiology for awhile but decided on another path. My Anesthesiologist (MD only) was amazing today. He took the time to be with me through the whole case (in a busy surgery center). He also thought about some tricks to help me feel better post op I had not seen (I am currently home recovering today).

I hope this thread makes you all know---many of us in other fields see your value--- do not let others take that away from you.

Actually you are misunderstanding. The ACT model ensures you have a physician to take care of you. Interview you, examine you, review your chart, and come up with the optimal anesthetic plan for your surgery. I'll talk with you and your family before surgery. I'll be back in the OR while we induce you. I'll take care of any invasive procedures. I'll intubate you myself if I deem it necessary. I'll keep checking back throughout the case. I'll also be there when you wake up and check back on you in PACU to see how things went and treat complications as needed.

Arguing that you need the physician to click the vaporizer from 3 to 4 also argues that you don't want a surgeon that lets the PA close. I feel strongly that with ACT model we provided the highest level of care in the hospital. I mean 1 MD with 2-4 rooms depending on turnover and acuity is closer physician care than you get in the ED or in the ICU. Sitting on the stool and dumping the urine and giving the zofran is a poor use of a medical education IMHO.

But that's just me. I fully support the right of individual physicians and practices to operate that way. But you can come up with any measure you want (morbidity and mortality, turnover, patient satisfaction, etc) and MD only care is not superior to ACT model. It just isn't.

 

[Mman]

Yes it is better doing it yourself. Every physician on here that works in an ACT model is always talking about how you have to tread lightly around CRNAs, let them make the plan and execute it the way they want as long as it is "safe" for the patient even if you would do things differently, let CRNAs intubate, put in arterial lines, possibly even central lines/blocks...all in the name of not hurting their feelings and "playing nice" with them. That's why having just a physician and no one else around is better. You don't have to transform from Dr. Mman to Dr. Phil, and instead of worrying about the patient, worry about the delicate CRNA's feelings and the social implications of telling them to sit the %$#& down while you do everything. That is why MD-only anesthesiology will always be superior.

So you'd be wrong. I have never mentioned any of those things you seem to worry about. I decide on the plan for 100% of the cases. I do all the invasive procedures. I don't worry about feelings and playing nice. In my group we employ the CRNAs so we have a very good relationship with them. They like us, they like working for a private group, and they help us run it the way WE (physicians) want to.

So while you say "MD-only will always be superior", there is 0% chance of that being shown in a study. Just can't happen.


Here's a question, of the 100 largest hospitals in the country, what number do not utilize ACT model of care? I can't think of a single one within thousands of miles of the East Coast that is MD only. Are there any major ones on the West Coast?

 

[Southpaw]

Not real sure why those who supervise continually feel the need to dump on those providing MD only care. 'Dial turning, urine dumping, etc.'.... while at the same time making a monumental deal out of them dictating the exact plan in all 3-4 rooms they are supervising (presumably 3-4 times more dial turning, more urine dumping, etc.). Somehow when it's MD only care it's very simple and straightforward, yet when it's supervision it's very complex all of the sudden.

Private practices who supervise figured
out long ago that it was very profitable to do so. That simple but important financial decision is what led to widespread supervision. It had nothing whatsoever to do with putting the MD in the position to best utilize their education. First came the financial decision, then came the myriad reasons on how to defend it without being honest about the money. Are their exceptions? Sure, maybe that's Mman's practice. Maybe there are a few others. But it's certainly not the majority of supervision practices.

The simple truth is once a practice starts supervising CRNAs it's likely to never change. People all of the sudden think it's overly complex to provide MD only care, or, more likely 'the economics won't work' (meaning their lifestyle is so inflated they can't afford even the slightest paycut).

I do MD only in the community. I hope to be able to continue doing my own cases for a long time. But I'm well aware that if I move geographically I'll very likely be forced to supervise (hey, maybe I'll get a raise!). But as it sits doing MD only care can provide a very nice financial existence for myself and my family. Seriously, financially, there is nothing to complain about.

I don't care whether or not people supervise, and I certainly won't
begrudge them for the decision. But in the many years of reading this forum I've found that by and large those doing MD only care are very happy doing so, and those who supervise aren't always thrilled to the gills with many aspects of their job.

 

[deleted162650]

I didn't say for all cases. We do it for some complicated cases.

In that situation, I don't think the CRNA is offering anything that a solid anesthesia tech can't do for you.

I can't think of a single one within thousands of miles of the East Coast that is MD only. Are there any major ones on the West Coast?

The only hospitals in my area (SoCal) that use a supervision model are academic institutions where the residents outnumber CRNA's by a god margin and Kaiser where there is a mix of supervision and MD's sitting their own cases. I'm unaware of any major hospital within at least 500mi of me that run a high ratio ACT model like yours.

MD only care is not superior to ACT model. It just isn't.

ACT practices like yours and jwk's are set-up and operate the right way. I believe that you provide quality anesthesia care (as I mentioned earlier). But even in your practice, can you honestly say that you haven't had to bail out a CRNA that got themselves into a situation that they should never have gotten themselves into in the first place? Do you really believe that that isn't inferior care to not getting into near misses like that in the first place??

 

[deleted171991]

So you'd be wrong. I have never mentioned any of those things you seem to worry about. I decide on the plan for 100% of the cases. I do all the invasive procedures. I don't worry about feelings and playing nice. In my group we employ the CRNAs so we have a very good relationship with them. They like us, they like working for a private group, and they help us run it the way WE (physicians) want to.

So while you say "MD-only will always be superior", there is 0% chance of that being shown in a study. Just can't happen.


Here's a question, of the 100 largest hospitals in the country, what number do not utilize ACT model of care? I can't think of a single one within thousands of miles of the East Coast that is MD only. Are there any major ones on the West Coast?

You'd be surprised how many solo doc days are scheduled at some NYC big university hospitals. When I interviewed at one of them, I was told something around 30-50%. Many private places in the Northeast advertise around 30% solo days. Meaning that they don't have enough CRNAs, meaning that the CRNAs get to choose where they work, meaning political correctness and treating them and their feelings with gloves, meaning anything but true 100% medical direction. Especially if one is not a partner, just another employee.

Hospitals use the ACT model not because it's the best, but the cheapest.

 

[epidural man]

... we obviously are the most intelligent folks on the planet as a whole.

I doubt it. Before medical school I worked at a semi-conductor plant as an implant engineer than a reliability engineer. The place was filled with electrical engineers and other type of folks like PhD in physics and such.

Those guys where way smarter than Doctors.

I've always said - it is a sad thing in this world. Are the smartest and brightest working on curing cancer and figuring out how to fix Hashimoto thyroids? Nope. The smartest and brightest go to Microsoft and Google and Intel and Pixar and are making our phones work faster, and our video games better.

(After reading this, it may seem like I was putting myself in that category. Absolutely NOT. In fact, I mostly left because I was way out of my league. I said...these guys are way smarter than me and I can't keep up. I better go to medical school.)

 

[nimbus]

I doubt it. Before medical school I worked at a semi-conductor plant as an implant engineer than a reliability engineer. The place was filled with electrical engineers and other type of folks like PhD in physics and such.

Those guys where way smarter than Doctors.

I've always said - it is a sad thing in this world. Are the smartest and brightest working on curing cancer and figuring out how to fix Hashimoto thyroids? Nope. The smartest and brightest go to Microsoft and Google and Intel and Pixar and are making our phones work faster, and our video games better.

(After reading this, it may seem like I was putting myself in that category. Absolutely NOT. In fact, I mostly left because I was way out of my league. I said...these guys are way smarter than me and I can't keep up. I better go to medical school.)

Agree. I started out as a biomedical engineering major in college. It was way too hard. Med school was much easier than the undergrad courses required for that major. Some people can understand 6 orders of abstraction higher than the average doctor.

 

[Mman]

You'd be surprised how many solo doc days are scheduled at some NYC big university hospitals. When I interviewed at one of them, I was told something around 30-50%. Many private places in the Northeast advertise around 30% solo days. Meaning that they don't have enough CRNAs, meaning that the CRNAs get to choose where they work, meaning political correctness and treating them and their feelings with gloves, meaning anything but true 100% medical direction. Especially if one is not a partner, just another employee.

Hospitals use the ACT model not because it's the best, but the cheapest.

so all those hospitals use the ACT model except where they don't have enough staff?

 

[Mman]

The only hospitals in my area (SoCal) that use a supervision model are academic institutions where the residents outnumber CRNA's by a god margin and Kaiser where there is a mix of supervision and MD's sitting their own cases. I'm unaware of any major hospital within at least 500mi of me that run a high ratio ACT model like yours.
ACT practices like yours and jwk's are set-up and operate the right way. I believe that you provide quality anesthesia care (as I mentioned earlier). But even in your practice, can you honestly say that you haven't had to bail out a CRNA that got themselves into a situation that they should never have gotten themselves into in the first place? Do you really believe that that isn't inferior care to not getting into near misses like that in the first place??

So if you exclude academic centers and Kaiser from your analysis which both utilize an ACT model, what is left that you'd consider a major medical center? Any 1000+ bed level 1 trauma centers?

As for having to "bail out a CRNA", that depends what you mean. Most commonly I stop something before it starts. Like the oh you wanted to give that drug but let's not do that for XYZ reasons. Bailing out as I see it most commonly involves airway issues, but them not being able to intubate doesn't constitute any harm to the patient so when I come after and put the tube in there is no harm no foul.

If someone wants to argue that having the physician in the room the entire time means that maybe you have one less BP reading below whatever threshold you want during the case because you picked it up quicker and treated it faster and more appropriately, well OK make that argument (but at least tell me you've got an electronic record that is keeping the data and not a paper chart). But if you want to stretch that to say your patient is (risk adjusted) less likely to have a periop MI or stroke or will have a shorter hospital length of stay, well then you are just exaggerating because objective data disagrees with you.


edit: And because I don't want to beat a dead horse, I'll simply add this edit. For those of you in MD only care that think you are making a difference over ACT, please tell me in what way that difference can be measured. You don't have a lower 30 day mortality. You don't have a lower postop MI/MACE rate. You don't have a lower periop stroke rate. By what measure do you think you are making a difference? Because I can't find one.

 

[nimbus]

So if you exclude academic centers and Kaiser from your analysis which both utilize an ACT model, what is left that you'd consider a major medical center? Any 1000+ bed level 1 trauma centers?

As for having to "bail out a CRNA", that depends what you mean. Most commonly I stop something before it starts. Like the oh you wanted to give that drug but let's not do that for XYZ reasons. Bailing out as I see it most commonly involves airway issues, but them not being able to intubate doesn't constitute any harm to the patient so when I come after and put the tube in there is no harm no foul.

If someone wants to argue that having the physician in the room the entire time means that maybe you have one less BP reading below whatever threshold you want during the case because you picked it up quicker and treated it faster and more appropriately, well OK make that argument (but at least tell me you've got an electronic record that is keeping the data and not a paper chart). But if you want to stretch that to say your patient is (risk adjusted) less likely to have a periop MI or stroke or will have a shorter hospital length of stay, well then you are just exaggerating because objective data disagrees with you.

I work in a 550 bed level 1 trauma center. No CRNAs, no AAs, no residents. Don't need them. We have another practice site with heart n lung transplants, also attending MD only. And another site with an active liver transplant program also with no residents or CRNAs.

 

[deleted162650]

So if you exclude academic centers and Kaiser from your analysis which both utilize an ACT model, what is left that you'd consider a major medical center? Any 1000+ bed level 1 trauma centers?

Academic Centers are supervising residents >>> CRNA's and either way they are only supervising at 2:1. Kaisers do not supervise at high ratios. The only hospital around the approaches 1000 beds is Cedars and no CRNA's there. I stand by what I said - no high ratio ACT practices like yours anywhere near me. Just isn't the model out here. Plenty of large level 1 and 2 trauma centers and tertiary referral centers around, and I can't name one with an anesthesia department that is all ACT like yours.

I think we are arguing over nothing at this point. Is ACT safe? - yeah I think it is. I also think your group probably does it better than the overwhelming majority of places out there so I'm not sure you can extrapolate your experience to the rest of the country. Do I think ACT is as good as MD only - no I don't, and you can't convince me otherwise. Do I have data to support that? - no I don't and we have discussed ad nauseam on this board why a meaningful study to show that can't and won't ever happen so please stop bringing up that point. Do I think you would be here espousing the greatness of the ACT model if didn't line your pockets the way it does - nope.

 

[deleted171991]

so all those hospitals use the ACT model except where they don't have enough staff?

I guess so. Why else use a solo doc in one room, and ACT in another?

Even with it's ACT, it's overwhelmingly 2:1 though.

 

[Noyac]

I doubt it. Before medical school I worked at a semi-conductor plant as an implant engineer than a reliability engineer. The place was filled with electrical engineers and other type of folks like PhD in physics and such.

Those guys where way smarter than Doctors.

I've always said - it is a sad thing in this world. Are the smartest and brightest working on curing cancer and figuring out how to fix Hashimoto thyroids? Nope. The smartest and brightest go to Microsoft and Google and Intel and Pixar and are making our phones work faster, and our video games better.

(After reading this, it may seem like I was putting myself in that category. Absolutely NOT. In fact, I mostly left because I was way out of my league. I said...these guys are way smarter than me and I can't keep up. I better go to medical school.)

My comment was definitely tongue in cheek. So hard to convey on the web.

 

[Mman]

Academic Centers are supervising residents >>> CRNA's and either way they are only supervising at 2:1. Kaisers do not supervise at high ratios. The only hospital around the approaches 1000 beds is Cedars and no CRNA's there. I stand by what I said - no high ratio ACT practices like yours anywhere near me. Just isn't the model out here. Plenty of large level 1 and 2 trauma centers and tertiary referral centers around, and I can't name one with an anesthesia department that is all ACT like yours.

I think we are arguing over nothing at this point. Is ACT safe? - yeah I think it is. I also think your group probably does it better than the overwhelming majority of places out there so I'm not sure you can extrapolate your experience to the rest of the country. Do I think ACT is as good as MD only - no I don't, and you can't convince me otherwise. Do I have data to support that? - no I don't and we have discussed ad nauseam on this board why a meaningful study to show that can't and won't ever happen so please stop bringing up that point. Do I think you would be here espousing the greatness of the ACT model if didn't line your pockets the way it does - nope.

1) What exactly is the difference between 2:1 ratio supervising residents and as high as 4:1 supervising AAs or CRNAs if the cases are appropriate? No offense to them, but I spend more time with each patient than my attendings in residency did and I personally perform the invasive procedures on them rather than teaching someone to do it for their first time. The ratio of cases covered depends on the complexity and turnover. Nothing more, nothing less. The argument made here by some is that having the board certified anesthesiologist in the room every second of the case makes a measurable difference. Residency programs don't do that and so by definition the overwhelming majority of the best and biggest hospitals in the country don't do that. Also please don't talk about why we can't have a study adequately comparing MD only vs ACT model. That would be totally ethical to do. What wouldn't be ethical is the study comparing unsupervised CRNAs. That is the study we can't really do. But anybody could do a study comparing MD only vs ACT model. I mean we already know the answer, though.

2) I'd personally work in an ACT model for less money than it would take me to do MD only. I find it far more fun and interesting to do what I do than to sit in a room doing 1 case at a time. I get to do way more procedures and see where more pathology than one after another cases. You'd have to pay me mega bucks to sit in a room scratching my eyeballs out in the middle of a case. I also don't know how much the model is enriching me as it's tough to guesstimate what per unit rates we could get for MD only care.

I'm not here to argue MD only care for anesthesia is worse than ACT model. I'd be just as safe if I was in the room myself. But it certainly isn't safer for me to be there by myself instead of appropriate supervision of an AA or CRNA. I mean that's funny to stop and think about if you approach it rationally. The malpractice insurers sure don't think it's any more dangerous and they have the actual math to determine that.

 

[Mman]

I guess so. Why else use a solo doc in one room, and ACT in another?

Even with it's ACT, it's overwhelmingly 2:1 though.

Is someone attempting to argue that ACT at 2:1 is inherently better than 4:1? I've never seen that argument and I'm not sure how someone could make it with a straight face. I mean it's not like I'm supervising 4 CABGs at a time. Hell we don't even do more than 1 heart at a time, yet it is very common for academic cardiac attendings to have 2 heart cases at the same time.

What determines the safety of ACT model is appropriate staffing of cases and mix of cases you have to cover, not the simple ratio of 2:1, 3:1, or 4:1. If you do it appropriately, it is as safe as it gets.

 

[Mman]

I work in a 550 bed level 1 trauma center. No CRNAs, no AAs, no residents. Don't need them. We have another practice site with heart n lung transplants, also attending MD only. And another site with an active liver transplant program also with no residents or CRNAs.

I was actually wondering about large hospitals, but that's more medium size-ish, though sounds like fun case mix.

 

[epidural man]

My comment was definitely tongue in cheek. So hard to convey on the web.

Oh yeah...totally missed this the first time. Hard to convey jokes sometimes..

Now re-reading, obviously tongue in cheek.

 

[nimbus]

I was actually wondering about large hospitals, but that's more medium size-ish, though sounds like fun case mix.

I only chimed in because people were implying that MD only anesthesia is not feasible or practical in situations like trauma centers or large busy practices or whatever and I'm saying that not only is it practical but it happens all the time. The great thing about this forum is that it crosses regions and opens us up to practices outside our own separate little worlds.

 

[Noyac]

1) What exactly is the difference between 2:1 ratio supervising residents and as high as 4:1 supervising AAs or CRNAs if the cases are appropriate? No offense to them, but I spend more time with each patient than my attendings in residency did and I personally perform the invasive procedures on them rather than teaching someone to do it for their first time. The ratio of cases covered depends on the complexity and turnover. Nothing more, nothing less. The argument made here by some is that having the board certified anesthesiologist in the room every second of the case makes a measurable difference. Residency programs don't do that and so by definition the overwhelming majority of the best and biggest hospitals in the country don't do that. Also please don't talk about why we can't have a study adequately comparing MD only vs ACT model. That would be totally ethical to do. What wouldn't be ethical is the study comparing unsupervised CRNAs. That is the study we can't really do. But anybody could do a study comparing MD only vs ACT model. I mean we already know the answer, though.

2) I'd personally work in an ACT model for less money than it would take me to do MD only. I find it far more fun and interesting to do what I do than to sit in a room doing 1 case at a time. I get to do way more procedures and see where more pathology than one after another cases. You'd have to pay me mega bucks to sit in a room scratching my eyeballs out in the middle of a case. I also don't know how much the model is enriching me as it's tough to guesstimate what per unit rates we could get for MD only care.

I'm not here to argue MD only care for anesthesia is worse than ACT model. I'd be just as safe if I was in the room myself. But it certainly isn't safer for me to be there by myself instead of appropriate supervision of an AA or CRNA. I mean that's funny to stop and think about if you approach it rationally. The malpractice insurers sure don't think it's any more dangerous and they have the actual math to determine that.

I'm sorry but I'm having a difficult time following your post.

 

[deleted171991]

I'm sorry but I'm having a difficult time following your post.

That's because you are reading it solo.

 

[Urzuz]

What determines the safety of ACT model is appropriate staffing of cases and mix of cases you have to cover, not the simple ratio of 2:1, 3:1, or 4:1. If you do it appropriately, it is as safe as it gets.

Whether intentional or not, this sentence is scary. This sounds like something that hospitals and AMCs would say when trying to justify a CRNA-only practice with 20 rooms and 1 MD firefighter. "The cases are bread and butter...the staffing of cases is appropriate to have one physician cover all 20 of our ORs."

And let us run a thought experiment: you say that having just you in a room is no more safe than having you supervise 1 CRNA in 1 room. Then, what if it's 2:1 coverage? As you say, it depends on the caseload. 3:1? 4:1? Eventually you will agree there will come a breaking point where it is no longer safe, regardless of how simple the cases are (since you yourself are advocating that CRNA-only practices are not as safe). My question to you is, wouldn't you consider even adding one CRNA to the mix in 1:1 supervision is a slippery slope? You are justifying non-inferiority, saying that adding CRNAs doesn't add a measurable increase to your rate of complications. But why go down that road when we are dealing with peoples' lives, not just nameless, faceless statistics? It is perfectly acceptable to say that you accept a higher (albeit small) increase in morbidity to make more money, live in a certain area of the country, or to "see more pathology" as you said. But let's call a spade and spade.

Finally, just to play devil's advocate: why is it so unethical to compare CRNA-only versus MD-only practice, but it's perfectly acceptable to compare ACT versus MD-only? Are CRNA-only practices really putting so many patients in their graves that an IRB would never approve it? Or is it because it's a slippery slope, and giving them full autonomy will eventually lead to worse outcomes even if there isn't a statistically (or clinically) significant difference? See above.

 

[Noyac]

1) What exactly is the difference between 2:1 ratio supervising residents and as high as 4:1 supervising AAs or CRNAs if the cases are appropriate? No offense to them, but I spend more time with each patient than my attendings in residency did and I personally perform the invasive procedures on them rather than teaching someone to do it for their first time. The ratio of cases covered depends on the complexity and turnover. Nothing more, nothing less. The argument made here by some is that having the board certified anesthesiologist in the room every second of the case makes a measurable difference. Residency programs don't do that and so by definition the overwhelming majority of the best and biggest hospitals in the country don't do that. Also please don't talk about why we can't have a study adequately comparing MD only vs ACT model. That would be totally ethical to do. What wouldn't be ethical is the study comparing unsupervised CRNAs. That is the study we can't really do. But anybody could do a study comparing MD only vs ACT model. I mean we already know the answer, though.

2) I'd personally work in an ACT model for less money than it would take me to do MD only. I find it far more fun and interesting to do what I do than to sit in a room doing 1 case at a time. I get to do way more procedures and see where more pathology than one after another cases. You'd have to pay me mega bucks to sit in a room scratching my eyeballs out in the middle of a case. I also don't know how much the model is enriching me as it's tough to guesstimate what per unit rates we could get for MD only care.

I'm not here to argue MD only care for anesthesia is worse than ACT model. I'd be just as safe if I was in the room myself. But it certainly isn't safer for me to be there by myself instead of appropriate supervision of an AA or CRNA. I mean that's funny to stop and think about if you approach it rationally. The malpractice insurers sure don't think it's any more dangerous and they have the actual math to determine that.

A few thoughts or critiques:
Point #1, amount of time spent with the pt does not translate to better care. Residency programs are not the gold standard for anesthesia practices. They are there to train the future anesthesiologists. They have very different goals.
I know the answer to MD vs ACT in my mind but I don't know what your answer is so I wouldn't assume anyone else does as well. It's all agenda based. Let me at least put this out there, there isn't great variability btw anesthesia outcomes in my group (all MD/DO)because we recruit very carefully. But there are some subtle differences which I will go out on a limb and say are important but difficult to study or even quantitate. Just like the difference btw two orthopods doing hips. Both have acceptable outcomes but if you were aware of the differences, you would choose one over the other. We do it all the time.
Point #2, that's your prerogative. Nobody is calling you out for that. We are just discussing the differences btw the two.

Since when are the malpractice insurance companies the gold standard of medical practice? They are completely reactionary. And since a large part of this country is ACT care they are on board. They don't dictate how we practice. Especially, since ACT has shown to be safe because of the due diligence of anesthesiologists. But not better.

 

[Noyac]

But even in your practice, can you honestly say that you haven't had to bail out a CRNA that got themselves into a situation that they should never have gotten themselves into in the first place? Do you really believe that that isn't inferior care to not getting into near misses like that in the first place??

This point can't be passed over.
Just think about the times you ACT docs are called to a room and you find the midlevel has done something that you would not have.
Sure, it gets fixed and never gets the slightest recognition by any study or insurance company. So how do we study this? The ACT docs won't report it because their income depends on this model being viewed as safe. It's a game. We all play it. I know things happen in MD only rooms as well that don't get mentioned. But will anyone argue that this is more common than in the ACT room? I won't.

 

[Noyac]

Academic Centers are supervising residents >>> CRNA's and either way they are only supervising at 2:1.

I don't practice in academics but I recall when I was a resident that there was a lot of discussion and disbelief that the government decided to allow supervision of nurses(1:3/1:4) at a greater ratio than supervision of residents (1:2) before cutting the funds reimbursed. Is this still the case? If so then the argument continues to lose face.

 

[Noyac]

Let me state it another way for those of you in ACT care.
Think about or start to make a mental note of the times you are called to a room to assist with the anesthetic, whether urgently or non. Feel free to post what you think those numbers are but please be honest.
In my practice, I haven't been called into a room in over a year (maybe even a couple years when strictly talking about my partners) and we have a float just for these situations and other duties as well.

 

[pjl]

Let me state it another way for those of you in ACT care.
Think about or start to make a mental note of the times you are called to a room to assist with the anesthetic, whether urgently or non. Feel free to post what you think those numbers are but please be honest.
In my practice, I haven't been called into a room in over a year (maybe even a couple years when strictly talking about my partners) and we have a float just for these situations and other duties as well.

Better question is how many times you should have been called, but weren't.


Sent from my iPhone using SDN mobile app

 

[Noyac]

Better question is how many times you should have been called, but weren't.


Sent from my iPhone using SDN mobile app

Well, in that situation I would hope it only occurred once with that midlevel. If they remained in the group afterwards I would be very curious as to why?

 

[Cantsmellthegas]

Hi Everyone,

I am a big fan Anesthesiology and toyed with the idea of entering the field. I am a current resident in another field in need of an operation next week that is relatively routine (1-1.5 hr procedure). However, I expressed to the surgeon and his staff that I do NOT want a CRNA (I believe in "your" field's training) caring for me during the operation (MD/DO Anesthesiologist only)

I was informed that an Anesthesiologist would be present for induction intubation/extubation. But, there is a circulating CRNA who may come to the room to watch over me. This concerns me less. However, I am not sure how big a "stink" to make about it. I pushed pretty hard about not wanting a CRNA.

I appreciate everyone's thoughts and inputs. I will continue to be your advocate outside your speciality.

What are your reasons for not wanting a CRNA?

You also mention "your" field's training as a reference to MD/DO training. The first professional group to provide anesthesia in the US was nurses. So what do you mean by "your" field?

The saying goes that the person who graduated last in Medical School is still an MD. Would it be fair for me to request care from only those who graduated in the top 25%, 5%? As smart as those top notch students are, how does that translate to clinical practice? Most residents require the guidance and direction of the nursing staff regardless of whichever top tier medical school and class ranking they bring to the table.

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

By all means continue to believe that your white coat colleagues are better, that is your right. As a CRNA I get paid less to do the same cases, whilst able to work better hours and "have a life." I also don't compare myself to MD's because I value the background and training that everyone brings. So instead of sitting here lambasting CRNA's, get educated and realize that we all work together for patients.