CRNA vs. Anesthesiologist Surgery Help

[Mman]

Great post, Sevo. I understand that life can lock you into to certain locales (wife, kids, etc.). But no one should be miserable with their career. Everyone has worked
too hard for too long to be here. Some of you who deal with the CRNA nonsense sound absolutely miserable. Come on, don't live like that. Make a change.

The simple fact is that anesthesia has had a doom and gloom future since the 1970s, if not longer, depending on who you ask. It got acutely worse in the mid 1990s. And yet here we are. There is plenty of doom and gloom on this forum today, just as there was 10 years ago. I choose to be open and honest and point out that I love my job and it includes supervising CRNAs. I wouldn't change a thing. Every day is a challenge, but it is very rewarding and interesting and it's why I went into medicine.

Some people like their jobs, some people dislike their jobs. There is nothing magical about anesthesia either way. The future continues to be doom and gloom and yet we go on. On a note related to that, I've heard more smoke about discontentment at several major hospitals that are under AMC contracts that could potentially fall.

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[Mman]

Something doesn't quite add up in these discussions of MD only anesthesia vs ACT model. If the MD model can be more cost effective and more efficient than an ACT model then why is the overwhelming majority of practices in the population centers of the east coast the ACT model?

Occam's Razor says that it can't be more efficient and more cost effective or we already would've seen it take over those desirable locations. I also have done the math and do not know how it could be cheaper and I do not know how it could be more efficient than a well run ACT practice. I'm not saying it can't be done well.

 

[epidural man]

I don't think you or anyone else is a whining idiot- those are your words. You def. sing the far side of the discussion though and that's fine.
Good context to hear everyones perspective. This forum has always been an open mic... so go for it.
You do sound angry. Probably angry at your current situation I would imagine. Probably had a bad set of cards dealt to you and it has left a bad taste in your life. IDK. So question...?

Why don't you move out? It sounds grinding. You might find that your outlook isn't as caustic if you tried something else.

The changes that are happening to all of us isn't just in anesthesia. You know this. It's the entire health care field that is morphing.

And honestly, you are def. looking at the wrong groups if this is what you are getting ---> "if the CRNAs don't like you, you can F' off"
I mean really? Do you really think CRNAs are THAT powerful? Forget THAT. That is the weakest sauce I've heard in a while. Why even bother with something like that? Just find an MD practice and don't worry about that crap.

Here is the deal and why I still have a positive outlook on anesthesiology:

I left the midwest and looked all over the West Coast- this was just 3 years ago.
Found tons of great gigs. Offered jobs at all of them.
All were MD-only. And heck, I was interviewing for an anesthesia position. It was fun meeting all these groups of great set of dudes-- that were happy.
I know a lot of people out here that have amazing jobs in great places. No CRNAs. This is fact and I'm not talking about a handful of groups.

If you are not happy get out man. It's that simple and all I can really tell you.
The Sky isn't crashing down despite what you may think. The landscape is ALWAYS going to be changing- always has (today, 5 years ago, 15 years ago, 20 years ago- always changing).

Rise above it. Change with it and figure it out.
Try something new. You'll never know any different otherwise.
No need to waste this life. It's here for the taking.

Been on this forum for 14 years. These discussions are not new.

West is best!

 

[deleted162650]

ACT is clearly more profitable when running 4:1. At 3:1 it's variable, and anything lower ration than that favors MD only. I think many ACT practices would be surprised to learn just how well they could do comparatively running MD only. Unless you're a hardcore 4:1 the overwhelming majority of the time, the salary difference will be small. What will change though is the amount of late days and vacation time as more MD's are required to be there physically doing cases at these times. This may or may not be offset by the reduction in primary call depending on the individual practice.

It should be noted that the only people that come out ahead are the practice owners (MD partners/AMC/hospital if group are employees). The cost to the system (insurance companies, Medi-care/Medi-caid/patient is exactly the same regardless of the model used).

 

[BLADEMDA]

West is best!

I have had the privilege of doing my own cases a great deal at the start of my career as well as primarily supervision of CRNAs later in my career. IMHO, I recommend doing your own cases as much as possible for a number of reasons:

1. Makes you better at giving anesthesia
2. Makes you a better supervisor
3. Less stress than covering 4:1 (only 2:1 coverage is easier than doing your own cases)
4. More enjoyable long term career
5. Better patient care (yes, better care if you are personally performing the anesthetic rather than covering 3-4:1)

I'm sure there are countless other reasons like respect in the hospital, etc but overall, if you can do your own cases that is the way to go.

 

[Arch Guillotti]

On a note related to that, I've heard more smoke about discontentment at several major hospitals that are under AMC contracts that could potentially fall.

It's not smoke, it's a full-blown dumpster fire. MEDNAX is having some tough times now that the original length of the buyout period is ending and the chickens are coming home to roost.

 

[aneftp]

It's not smoke, it's a full-blown dumpster fire. MEDNAX is having some tough times now that the original length of the buyout period is ending and the chickens are coming home to roost.

Yes. My buddy was one of those groups. Negotiations have dragged on for months now.

Mednax executives have clearly under estimated the market conditions thinking its it can maintain profit margins by under paying the market.

The simple facts are that the company simply spent a lot of money with acquisitions from 2009-2014. The stock grew during those times but has stagnated the past couple of years

Executives are under extreme pressure from shareholders to continue to show value. Anesthesia component of mednax was big revenue driver. But they face issues with retaining costly anesthesia providers. Because recruitment is always expensive. It's a delicate balancing act

 

[Arch Guillotti]

Anesthesia component of mednax was big revenue driver. But they face issues with retaining costly anesthesia providers. Because recruitment is always expensive. It's a delicate balancing act

This could get very costly for them.

 

[Mman]

The simple facts are that the company simply spent a lot of money with acquisitions from 2009-2014. The stock grew during those times but has stagnated the past couple of years

Executives are under extreme pressure from shareholders to continue to show value. Anesthesia component of mednax was big revenue driver. But they face issues with retaining costly anesthesia providers. Because recruitment is always expensive. It's a delicate balancing act

The problem with their anesthesia business in terms of stock price wasn't the low cost providers, it was that they were showing revenue/profit growth through massive amounts of acquisitions. None of the acquisitions was actually growing independently, but when you added a bunch every year it made it appear like it was growing every year.

As Ben Graham said, be wary of serial acquirers. They look like they are growing businesses, but not really as they are only constantly buying other businesses. In the anesthesia world, that stream of businesses for purchase ran out and now they are left with no growth essentially which is a big drag on your P/E ratio.

 

[Mman]

It's not smoke, it's a full-blown dumpster fire. MEDNAX is having some tough times now that the original length of the buyout period is ending and the chickens are coming home to roost.

I don't know how to actually verify any of it as all I hear are rumors, but if the rumors are even 50% true there are going to be some big hospital departments that were formerly profitable private groups acquired by AMCs that are going to be either taken over by hospitals or turned back into private groups. Many hospitals have never been thrilled with the AMC model in the first place.

 

[deleted162650]

I don't know how to actually verify any of it as all I hear are rumors, but if the rumors are even 50% true there are going to be some big hospital departments that were formerly profitable private groups acquired by AMCs that are going to be either taken over by hospitals or turned back into private groups. Many hospitals have never been thrilled with the AMC model in the first place.

Dude, how sweet would that be. You sell your group and pocket a cool 7 figures. Live out your 5 or whatever years of indentured servitude, and then reform your private group again like nothing ever happened.

 

[Man o War]

It's not smoke, it's a full-blown dumpster fire. MEDNAX is having some tough times now that the original length of the buyout period is ending and the chickens are coming home to roost.

Burn baby, burn.

 

[IMGASMD]

So start forming own private practices in FL?

 

[Mman]

Dude, how sweet would that be. You sell your group and pocket a cool 7 figures. Live out your 5 or whatever years of indentured servitude, and then reform your private group again like nothing ever happened.

I suspect it wouldn't be the same docs that got paid off. Their noncompetes are far more enforceable than the "partnership track" docs that didn't get paid off.

 

[aneftp]

Mednax made a critical error in North Carolina. Hospital employed CRNAs and wanted Mednax to employ them. Mednax said no. Now the hospital collects the anesthesia fees and "rents" the docs from Mednax. The Mednax docs are screwed.

 

[Noyac]

Mednax made a critical error in North Carolina. Hospital employed CRNAs and wanted Mednax to employ them. Mednax said no. Now the hospital collects the anesthesia fees and "rents" the docs from Mednax. The Mednax docs are screwed.

I can't say I feel bad for the docs there if this is the case.

 

[GA8314]

Something doesn't quite add up in these discussions of MD only anesthesia vs ACT model. If the MD model can be more cost effective and more efficient than an ACT model then why is the overwhelming majority of practices in the population centers of the east coast the ACT model? We keep talking about the fact that part of the reason for lower compensation on the east coast is the fact that there is essentially an oversupply of anesthesiologists who want to live and work there? Then why not go to all MD models on the east coast if it is so efficient?

All things being equal in terms of workload, call schedule, etc...I know for a fact that I would prefer to do my own cases over supervising CRNAs. It is my honest opinion that a big factor in CRNA spread is frankly laziness and skill atrophy. I saw it in attendings during residency and I see it in older anesthesiologists now. There are plenty of exceptions, of course. However, there is a significant portion of anesthesiologists who would rather be watching Fox News in the lounge than "stool sitting." There are plenty of anesthesiologists who defer clinical judgment to CRNAs or give them a wide range of latitude in clinical decision making. Essentially, there are a lot of anesthesiologists who take a pretty "hands-off" approach to working with CRNAs. I think our specialty needs to take a hard look at itself if it wants to put up any sort of significant fight against the AANA or to simply justify its existence if it comes to that in the future.

I know the majority of the people reading this or participating in the discussions on this board likely do not fall into the previously mentioned category. The simple fact that you read and participate in discussions about anesthesia in your spare time likely means that you care about your career and the direction of this profession more than some others. There are constant discussions on here about lesser trained professions claiming similar expertise and lack of respect from physicians, patients, and administrators. Unfortunately, I think that some of those troubles have been "earned," so to speak.

There is some truth to the bold. I saw the same thing as a resident, and see it now, a bit in a minority of my partners in our mostly ACT practice. The minority do not prefer sitting rooms whereas I love to when I get the chance. I tell any resident or interested student not to EVER lose one's skills. This is a matter of priority and motivation versus apathy, but it is not in any way inevitable in an ACT model. Still lots of opportunities to be hands on and maintain skills.

But, yeah, we know who the problem people are in our profession, and chief among them are the abusers of the ACT model.......I've always thought this and still do.

 

[deleted162650]

I suspect it wouldn't be the same docs that got paid off. Their noncompetes are far more enforceable than the "partnership track" docs that didn't get paid off.

Would the non-compete still be in effect once the initial contract has run its course and expired? Would seem to me then the non-compete is gone, just like the rest of your employment contract. It's not like you up and left mid-contract. But I'm no JD.

 

[GravelRider]

Would the non-compete still be in effect once the initial contract has run its course and expired? Would seem to me then the non-compete is gone, just like the rest of your employment contract. It's not like you up and left mid-contract. But I'm no JD.

I actually had a conversation about this recently. If the practice loses it's contract, but still exists they can certainly try to enforce the noncompete. A practice (like Mednax) will likely try to enforce it's noncompete even if they really don't stand to gain anything by doing so. If anything, their hope is that by aggressively enforcing the noncompete that there will be less of a desire to give the contract to someone else. If Mednax just shrugs their shoulders at one noncompete at a place they lose a contract then that makes their restrictive covenant look weak and they would be losing contracts all over the place. If they show that they are willing to aggressively enforce the noncompete then other hospitals might not risk the turnover that would occur by awarding the contract to another group.

 

[deleted162650]

I actually had a conversation about this recently. If the practice loses it's contract, but still exists they can certainly try to enforce the noncompete. A practice (like Mednax) will likely try to enforce it's noncompete even if they really don't stand to gain anything by doing so. If anything, their hope is that by aggressively enforcing the noncompete that there will be less of a desire to give the contract to someone else. If Mednax just shrugs their shoulders at one noncompete at a place they lose a contract then that makes their restrictive covenant look weak and they would be losing contracts all over the place. If they show that they are willing to aggressively enforce the noncompete then other hospitals might not risk the turnover that would occur by awarding the contract to another group.

Well that doesn't really answer my question. The question is: Is your non-compete still in effect once your employment contract with the AMC expires? Has nothing to do with the AMC's contract with the hospital.

 

[GravelRider]

Well that doesn't really answer my question. The question is: Is your non-compete still in effect once your employment contract with the AMC expires? Has nothing to do with the AMC's contract with the hospital.

I would assume so, but I have no idea. I probably depends on the wording. For example my noncompete says it applies for 2 years following termination of the agreement between employer and employee. That counts whether the termination is by me, for cause, without cause, or non-renewal of the agreement. I think if the contract expires (or not renewed) then the noncompete would still apply.

 

[BLADEMDA]

Well that doesn't really answer my question. The question is: Is your non-compete still in effect once your employment contract with the AMC expires? Has nothing to do with the AMC's contract with the hospital.

Yes.

 

[deleted162650]

I would assume so, but I have no idea. I probably depends on the wording. For example my noncompete says it applies for 2 years following termination of the agreement between employer and employee. That counts whether the termination is by me, for cause, without cause, or non-renewal of the agreement. I think if the contract expires (or not renewed) then the noncompete would still apply.

So they can fire you, with or without cause, and then enforce the non-compete?? That is beyond F'd up.

 

[GravelRider]

So they can fire you, with or without cause, and then enforce the non-compete?? That is beyond F'd up.

Yup.

Noncompetes can protect a small group from contract takeovers by larger companies. However, they also stifle true competition in medicine.

 

[aneftp]

Non competes in the general anesthesia world are rarely enforced. While I know even big management companies have local subsidiaries with different language in contract.

The two recent (2016) contracts I looked at with Sheridan/team health there was no non compete radius. The only non compete applied to the places you actually worked for them. Say at X hospital. They don't want you taking over contract only at X hospital and "competiting" with them for 12 months from the time you leave. But you are free to go to Y hospital down the street.

Now usap. I looked at their contract for a friend and they had a larger radius. Again. If you don't like it. Tell them to modify it. If they don't. Make ur own decision.

 

[GravelRider]

Non competes in the general anesthesia world are rarely enforced. While I know even big management companies have local subsidiaries with different language in contract.

The two recent (2016) contracts I looked at with Sheridan/team health there was no non compete radius. The only non compete applied to the places you actually worked for them. Say at X hospital. They don't want you taking over contract only at X hospital and "competiting" with them for 12 months from the time you leave. But you are free to go to Y hospital down the street.

Now usap. I looked at their contract for a friend and they had a larger radius. Again. If you don't like it. Tell them to modify it. If they don't. Make ur own decision.

I've seen noncompetes where you can't work at the current hospital for another entity for a set period of time. I've also seen it apply to any of the AMC's hospitals anywhere. The radius thing seems to be less common in anesthesia. The worst I've seen is a non-compete listing competitors that you can't work for if you leave....like NAPA saying you can't work for MEDNAX.

Unless your state has legal precedent that noncompetes are not enforceable then you should always assume that it will be fully enforced and have the language changed before you sign a contract.

 

[GA8314]

Yup.

Noncompetes can protect a small group from contract takeovers by larger companies. However, they also stifle true competition in medicine.

So, a private group can have partners sign non-competes which would then make it difficult for, say, Northstar to come in an wiggle their magic subsidy-elimination wand and take over the contract?

 

[ElmerFudd]

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.

As an anesthesiologist in private practice, I'm going to level with you:

If you're having your surgery in any private hospital, there's a 50:50 chance the attending physician won't even be in the room for induction. There's just not enough time. We make sure you're safe for anesthesia and surgery, determine the type of anesthetic and airway (LMA vs tube), and then leave the CRNAs to it. If the surgery were complex or if you had a very complex medical history where we really felt we needed to be there to supervise your induction, we'd make sure we were there. Otherwise, we are simply around to put out fires. I've had plenty of CRNAs induce without even contacting me by my zone phone or cell.

If you want an anesthesiologist's care, ask that you have an anesthesiologist provide the anesthesia for you directly.

 

[ElmerFudd]

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

I'd reverse your 2 and 3.

I'll take any anesthesiologist in the room directly caring for me any day over a CRNA in the room. Because, the reality is that once the supervising anesthesiologist leaves the room, the CRNA is pretty much going to do whatever they want. And Lordy....some of their decision-making is extremely questionable. In my practice, even the CRNAs who are considered to be "good", I've seen doing some really stupid ****.

 

[ElmerFudd]

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


Sent from my iPhone using SDN mobile app

Precisely. And most of the time, you'll never know.

 

[Noyac]

I'd reverse your 2 and 3.

I'll take any anesthesiologist in the room directly caring for me any day over a CRNA in the room. Because, the reality is that once the supervising anesthesiologist leaves the room, the CRNA is pretty much going to do whatever they want. And Lordy....some of their decision-making is extremely questionable. In my practice, even the CRNAs who are considered to be "good", I've seen doing some really stupid ****.

For the most part this is true but I have seen some deplorable anesthesiologists as well. We just had one as a locums this past year. She was so confident and walked around telling people how good she was but I now have to review two Peer Review cases for her and she was only here for a few weeks. I think my wife could have done better than her and she isn't even in the medical field.

 

[nimbus]

For the most part this is true but I have seen some deplorable anesthesiologists as well. We just had one as a locums this past year. She was so confident and walked around telling people how good she was but I now have to review two Peer Review cases for her and she was only here for a few weeks. I think my wife could have done better than her and she isn't even in the medical field.

I think I she came through our practice a few years ago

 

[Arch Guillotti]

For the most part this is true but I have seen some deplorable anesthesiologists as well. We just had one as a locums this past year. She was so confident and walked around telling people how good she was but I now have to review two Peer Review cases for her and she was only here for a few weeks. I think my wife could have done better than her and she isn't even in the medical field.

How do you find your locums?

 

[Noyac]

How do you find your locums?

We usually go to the "soup kitchen" where they feed the homeless. Why? Where do you get yours?

 

[Arch Guillotti]

We usually go to the "soup kitchen" where they feed the homeless. Why? Where do you get yours?

We use ones that we know and trust, not some random that the hospital or recruiter finds.

 

[deleted162650]

We usually go to the "soup kitchen"

Oh god. I hope not:

Urban Dictionary: soup kitchen

 

[deleted162650]

I think I she came through our practice a few years ago

She wasn't Indian with a Neuro fellowship was she? Yeesh.

 

[Noyac]

Oh god. I hope not:

Urban Dictionary: soup kitchen

Oh **** you must have a different lifestyle than I. That is just way beyond anything I could have thought of.

But I'm not sure this last locums wasn't from your "soup kitchen".

 

[Noyac]

She wasn't Indian with a Neuro fellowship was she? Yeesh.

Nah!

She was from a hospital across town that had some local surgeons that operate at both facilities who vouched for her. Apparently, they don't do anything over an ASAII pt.

Her classic line, since she is her only fellowship trained pedi anesthesiologist in town, was "I'm the only qualified anesthesiologist in this town to do pedi cases."

I knew she was a specimen when I heard this Bullsh*t. Worst of all, she was clueless to her inadequacies. Or she didn't care because she would sort of laugh and shrug them off.

 

[Noyac]

We use ones that we know and trust, not some random that the hospital or recruiter finds.

That is our attempt as well. See above, she was verified by surgeons we work with.

 

[aneftp]

That is our attempt as well. See above, she was verified by surgeons we work with.

How long was she there? Not making excuses. But some people take a bit to get up to speed at new facilities. While anesthesia is anesthesia. Environmental changes does affect someone especially when they do primarily healthy patients and switch to a new place with a little more chaos.

Wouldn't just be easier for everyone sake to put new people in easier cases (gyn, general)

 

[Noyac]

Wouldn't just be easier for everyone sake to put new people in easier cases (gyn, general)

That's what we do, gen surge and gyn all day for them. She screwed that up enough that we put her strictly in Endo everyday.
Funny thing is that one of our more medically challenged GYN's came to me to tell me how good this locums doc was. I nearly blew coffee in her face I laughed so hard. The GYN liked her cuz she was "nice". Totally clueless.

 

[Mman]

Her classic line, since she is her only fellowship trained pedi anesthesiologist in town, was "I'm the only qualified anesthesiologist in this town to do pedi cases."

At the risk of completely stereotyping, of any fellowship in our field there is a higher percentage of pediatric anesthesiologists that struggle to perform something outside their fellowship than anything else.

 

[Libertas]

At the risk of completely stereotyping, of any fellowship in our field there is a higher percentage of pediatric anesthesiologists that struggle to perform something outside their fellowship than anything else.

Worse than chronic pain? Haha.

 

[pgg]

Worse than chronic pain? Haha.

Perioperative fellowship?

 

[Mman]

Worse than chronic pain? Haha.

yes, 100% of our pain docs are capable in the OR and work there periodically, although I can see that some who have not been in an OR for years would not be

 

[Noyac]

At the risk of completely stereotyping, of any fellowship in our field there is a higher percentage of pediatric anesthesiologists that struggle to perform something outside their fellowship than anything else.

I wouldn't let her even take care of a pedi pt.

 

[Consigliere]

She screwed that up enough that we put her strictly in Endo everyday.

Ballsy move. I know you didn't have much choice, but I think putting a borderline competent doc in endo is dangerous.

 

[Noyac]

Ballsy move. I know you didn't have much choice, but I think putting a borderline competent doc in endo is dangerous.

I totally agree. We poppedin often and were overly cautious. Then she had an issue there as well. We ran out of places to put her. Chanced her assignment.

 

[pgg]

There are some dodgy locums out there for sure.

At my old moonlighting job, where I was "locums" on and off for about 5 years, we had an anesthesiologist come through who was a disaster. He had a death during a trach on his first or second day. I went in to help, CPR in progress, and the sevo dial was at 8%. Vfib, no meds or shocks delivered. ACLS? What's that? Then he leaves the hospital immediately afterward. Not a word to the family. Said something like "Sometimes you lose one."

Group asks me to keep an eye on him. A day or two later I walk in on a sitting shoulder in an old guy with chronic HTN ... where he's running deliberate hypotension ... because that's what we do to reduce blood loss.

Next day he was doing endo and was found multiple dipping a 100 mL propofol bottle to save money.

He was not invited back for a second week.


So certainly bad doctors exist. That said, the CRNA bell curve is to the left of the anesthesiologist bell curve, and the floor of our skills/knowledge/safety is both higher and more consistent. For every residency program that we look at a little sideways - their residents still graduated from medical school and passed the USMLE (or COMLEX), they still meet the ACGME minimums, and their graduates still take written and oral board exams.

The proliferation of CRNA puppy mills is in another league entirely.