CRNA vs. Anesthesiologist Surgery Help

[nimbus]

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

No she was non-ethnic, trained at a top program, icu fellowship, military experience, overall impressive resume. She talked up a storm about how she was going to implement QA/QI initiatives to show our value. Among her problems was she couldn't start an Aline to save her or anyone else's life. Last I heard she was getting an MBA or MPH somewhere on the east coast.

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[jwk]

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.

Yours is not an ACT practice., and your assertion is incorrect. All due respect - what do you do?

In a medically directed ACT practice, run properly and in compliance with TEFRA, there is ALWAYS time for the anesthesiologist to be present at induction. The case doesn't start otherwise. It's that simple.

What you describe is a supervisory practice - or worse, "collaborative". Neither has the best interests of the patient in mind.

 

[2Fast2Des]

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 ****.

I hear this term and see some stuff in my program, but what are some of the questionable and strange things you see them do?

 

[Mat007]

Why do people on this site feel the need to attack others that are basically on the same side as them?
This is unnecessary.

You shouldn't attack anyone, period.

 

[narcotics999]

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.

When it is implemented, it can be painful. At my old place, AMC lost the contract. All but three had to leave the hospital. The radius was 3 miles (there are quite some hospitals in 3 miles). Two out of the other 3 were forced to transfer a year later because the AMC lawyer found that they were still bound by the non-compete cause.

The AMC had nothing to gain from it. Yet it wanted you to suffer.

 

[narcotics999]

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.

Dont know other hospitals. At my old place (part of a major east coast academic center), crna are hired and paid by the hospital. They are free labor for the anesthesiology department, which can afford an 1:2 supervision ratio.

 

[Modanq]

So what strategy do we anesthesiologists have. There must be a 10 year - 20 year outlook. A mission statement so to speak. Where do you guys/gals see the field going. The ASA answer is peri operative surgical home or an ostrich head in the sand approach. Sounds like the folks in power have no idea what is happening on the ground...

Questions I think about:
Should Anesthesiologists only perform "anesthesia"? Whats the name of our department? Look at how each department brands itself...
Can we bill for our decisions peri-op unlinked to OR time? ASA IV, DLT, AFOI, Central access, LVAD is not equal to ASA I lap chole
How do we unlink reimbursement from OR anesthesia time?

Why do we even compare CRNAs to MDs? Are plastic surgery PAs better or worse than plastic surgeons closing breast implants? Are these new GI ANP doing endoscopy "fellowships" better or worse than GI docs? Who manages the services better - tenured NP/PA/Minions ICU folks or junior MD residents? Do you ever know if the ED PA is calling or the ED doc is calling? To me it is likely that if any of those questions were put to an RCT there would be no statistical difference, but the issue is reductionist in my opinion. Its like asking is an MD better or worse than a CRNA in placing an IV? Its non-relevant and a TRAP - but its the conversation that the AANA wants us to meddle in and then point at the study and say hey look we are equal. So then the next question I have is what is the fundamental difference between MD and all else RT/PA/NP/Perfusionist/CRNA? is it Procedures/Surgery? Patient expectations? Knowledge base? Years in training? Titles?

Where does our role begin? Pre-op? Can we bill for pre-op clinic and why or why not? Can we bill for our own Echos? PFTs? Sleep studies?
When do we stop doing "anesthesia" - the PACU or ICU hand off? Should we all be board certified in ICU? Should we have Post ICU clinics and follow up all our patients there too? Can we bill for having a post-anesthesia clinic? Why not?

What is it like in Europe?

Why do we only emphasize the non-surgical airway pathway in anesthesia. If we are MDs can't we just train our residents to do the surgical airway pathway too? Why can't we all get boarded in Echo? Cards does this all the time... They just take whatever service line they want and subsume it into their department. Which then begs the question - Do we actually as anesthesiologists group/society whatever you want to call it actually want patient responsibility? Or are we ok with Supervising and only doing OR anesthetizing?

As a positive - I think Anesthesiologists are light years ahead on the midlevel encroachment conversation. We have some semblance of rules for CRNAs...In the next couple of years I have a feeling that family medicine, emergency medicine, hospitalists, etc will also be facing the gauntlet of issues we have been adressing over the last 20 years of doom and gloom.

Any answers or thoughts? Sorry I was all over the place in my thread...

 

[aneftp]

When it is implemented, it can be painful. At my old place, AMC lost the contract. All but three had to leave the hospital. The radius was 3 miles (there are quite some hospitals in 3 miles). Two out of the other 3 were forced to transfer a year later because the AMC lawyer found that they were still bound by the non-compete cause.

The AMC had nothing to gain from it. Yet it wanted you to suffer.

Did they work at the other hospital? Or try to stay at the current hospital?

AMC just don’t want you staying at the same hospital for obvious reasons. But my point is you can just go across the street to another hospital and the amc doesn’t care.

But if you try to remain at than current hospital. Than they will enforce it.

 

[2Fast2Des]

Did they work at the other hospital? Or try to stay at the current hospital?

AMC just don’t want you staying at the same hospital for obvious reasons. But my point is you can just go across the street to another hospital and the amc doesn’t care.

But if you try to remain at than current hospital. Than they will enforce it.

But if the non-compete isn't really legal in the view of court than how can it be truly enforced?

 

[AdmiralChz]

So what strategy do we anesthesiologists have. There must be a 10 year - 20 year outlook. A mission statement so to speak. Where do you guys/gals see the field going. The ASA answer is peri operative surgical home or an ostrich head in the sand approach. Sounds like the folks in power have no idea what is happening on the ground...

Questions I think about:
Should Anesthesiologists only perform "anesthesia"? Whats the name of our department? Look at how each department brands itself...
Can we bill for our decisions peri-op unlinked to OR time? ASA IV, DLT, AFOI, Central access, LVAD is not equal to ASA I lap chole
How do we unlink reimbursement from OR anesthesia time?

Why do we even compare CRNAs to MDs? Are plastic surgery PAs better or worse than plastic surgeons closing breast implants? Are these new GI ANP doing endoscopy "fellowships" better or worse than GI docs? Who manages the services better - tenured NP/PA/Minions ICU folks or junior MD residents? Do you ever know if the ED PA is calling or the ED doc is calling? To me it is likely that if any of those questions were put to an RCT there would be no statistical difference, but the issue is reductionist in my opinion. Its like asking is an MD better or worse than a CRNA in placing an IV? Its non-relevant and a TRAP - but its the conversation that the AANA wants us to meddle in and then point at the study and say hey look we are equal. So then the next question I have is what is the fundamental difference between MD and all else RT/PA/NP/Perfusionist/CRNA? is it Procedures/Surgery? Patient expectations? Knowledge base? Years in training? Titles?

Where does our role begin? Pre-op? Can we bill for pre-op clinic and why or why not? Can we bill for our own Echos? PFTs? Sleep studies?
When do we stop doing "anesthesia" - the PACU or ICU hand off? Should we all be board certified in ICU? Should we have Post ICU clinics and follow up all our patients there too? Can we bill for having a post-anesthesia clinic? Why not?

What is it like in Europe?

Why do we only emphasize the non-surgical airway pathway in anesthesia. If we are MDs can't we just train our residents to do the surgical airway pathway too? Why can't we all get boarded in Echo? Cards does this all the time... They just take whatever service line they want and subsume it into their department. Which then begs the question - Do we actually as anesthesiologists group/society whatever you want to call it actually want patient responsibility? Or are we ok with Supervising and only doing OR anesthetizing?

As a positive - I think Anesthesiologists are light years ahead on the midlevel encroachment conversation. We have some semblance of rules for CRNAs...In the next couple of years I have a feeling that family medicine, emergency medicine, hospitalists, etc will also be facing the gauntlet of issues we have been adressing over the last 20 years of doom and gloom.

Any answers or thoughts? Sorry I was all over the place in my thread...

Great post, I think medicine as a whole is in a state of “wait and see” with all the uncertainty surrounding the future of healthcare. But anyone who is or has recently trained at a major academic center has seen the massive Expansion of mid level training programs - most of the “big” name critical care programs now have NP/PA CC fellowships and many have ER as well. If you don’t think they want full autonomy like their IM/FM compatriots then you aren’t paying attention. Even PAs are pushing to be called “Physician Associates” with full practice authority. Anesthesiologists have known about this for a longtime so have it under control for the most part, but the other societies haven’t really protected themselves much.

Medicine as a whole needs to figure out what to do going forward with mid levels, they’re already dealing with severe IM/FM outpatient encroachment (see: the VA where they have full autonomy) and I would fully expect to see it being pushed in other realms. I’d like to see the AMA or some other large, national organization tackle it but for now the AMA is too focused on being a adversarial political body similar to our Congress. The only thing I’ve seen so far is condemnation of the “nursing collective” (or something like that) that allows NPs to have one license that’s valid in numerous states. As physicians, we really should stop all the lame infighting about who is better at X procedure (see: every post about airway management) and start banding together more as professionals.

 

[aneftp]

But if the non-compete isn't really legal in the view of court than how can it be truly enforced?

In regards of anesthesia since we don’t “steal patients”. Surgeons and other providers bring patients to us

A non compete clause of 1 mile-1000 miles means nothing and is rarely enforced.

What any business in anesthesia wants is to prevent you from stealing the contract from the actual facility you are working with.

So if u worked at X facility with AMC. They don’t want u stealing X facility anesthesia contract since you work there. But if you went across the street to work at Y facility even with a 3 mile radius. Since you aren’t stealing patients and they aren’t due irreparable had they will likely not go after u.

Only if u tried to stay on at x facility

 

[Arch Guillotti]

A non compete clause of 1 mile-1000 miles means nothing and is rarely enforced.

Maybe not but I know at least a couple of folks that had their noncompete enforced.

 

[GA8314]

I too feel that there is a high degree of variability among CRNA knowledge. Much less so than the differences which of course also exist amongst the docs.

I like our CRNA's for the most part and quite a few I like a lot. It's a minority that I don't like as much. Most are hard working folks that just want the best for their families. A few are militant behind our backs I am sure.....

 

[aneftp]

Maybe not but I know at least a couple of folks that had their noncompete enforced.

What were their situations?
Did they work at the same hospital?

Did they work at another hospital within X miles and were told they couldn’t?

Usually more to the story. Like the Michigan doc sold out and got paid by amc and violated his non compete agreement by working within 30 mile radius vs some employed w2 doc with no buy out is a different story.

 

[AdmiralChz]

What were their situations?
Did they work at the same hospital?

Did they work at another hospital within X miles and were told they couldn’t?

Usually more to the story. Like the Michigan doc sold out and got paid by amc and violated his non compete agreement by working within 30 mile radius vs some employed w2 doc with no buy out is a different story.

Two close friends of mine have (still are? I'll have to check in with them) dealt with it. Some of the AMCs have pretty wide non-competes in major metropolitan areas, and both tried to jump ship to other practices within the umbrella - the new practices weren't at the same hospital as the 1st. I'm unsure of the details or how it was found out but the AMC sent notice of possible breach of contract. The noncompete clauses I believe were for 2 and 4 years. I'll have to ask them what happened, they were super angry about it because it looked like they'd either have to stay with the AMC (no thanks) or completely move away.

 

[aneftp]

Two close friends of mine have (still are? I'll have to check in with them) dealt with it. Some of the AMCs have pretty wide non-competes in major metropolitan areas, and both tried to jump ship to other practices within the umbrella - the new practices weren't at the same hospital as the 1st. I'm unsure of the details or how it was found out but the AMC sent notice of possible breach of contract. The noncompete clauses I believe were for 2 and 4 years. I'll have to ask them what happened, they were super angry about it because it looked like they'd either have to stay with the AMC (no thanks) or completely move away.

So they were trying to move to new practice within same amc? That would make sense since amc would have to approve such transfer.

They weren’t trying to jump from amc a to amc b? But amc a to amc a?

 

[narcotics999]

Did they work at the other hospital? Or try to stay at the current hospital?

AMC just don’t want you staying at the same hospital for obvious reasons. But my point is you can just go across the street to another hospital and the amc doesn’t care.

But if you try to remain at than current hospital. Than they will enforce it.

Not just the same hospital, any hospital with 3 miles radius.

 

[AdmiralChz]

So they were trying to move to new practice within same amc? That would make sense since amc would have to approve such transfer.

They weren’t trying to jump from amc a to amc b? But amc a to amc a?

I know one was transferring out of the AMC into an independent PP at different hospitals.

Unsure about the other one, but she didn't make it sound like she was trying to move within the same AMC.

 

[Arch Guillotti]

What were their situations?
Did they work at the same hospital?

One AMC with a ridiculous noncompete radius and one academic place.

 

[aneftp]

One AMC with a ridiculous noncompete radius and one academic place.

Sucks.

My friend who worked for mednax basically ignored their 30 mile radius noncompete and went to work for Napa. Mednax tried to huff and puff and he just gave them the middle finger and left. That was up north.

Same with my other friend who left academic medical center with similar 20 mile radius noncompete. He literally went across the parking lot to work for the VA facility

Especially with anesthesia. Non competes while legal are blowing a lot of smoke from the emoloyers and rarely enforced.

 

[Arch Guillotti]

Sucks.

My friend who worked for mednax basically ignored their 30 mile radius noncompete and went to work for Napa. Mednax tried to huff and puff and he just gave them the middle finger and left. That was up north.

Same with my other friend who left academic medical center with similar 20 mile radius noncompete. He literally went across the parking lot to work for the VA facility

Especially with anesthesia. Non competes while legal are blowing a lot of smoke from the emoloyers and rarely enforced.

Your point is well taken. It takes a lot of guts to violate a noncompete though. Especially with a big AMC, not everyone is willing to do it.