How Long?

[Guillemot]

Yup.

And as salaries improve, they need to work less to make the same salary, so then you see an increased labor shortage.


Often the new grads are faster, more personable and better at regional than the 20 year vets. You just have to hire the right ones.

And once you get from about year 3 to year 15, they are generally more productive than the 20 year vet.

My experience has been that if someone is weak clinically or otherwise dysfunctional, it’s almost always a 20 year vet vs new grad.

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[nimbus]

Yup.

And as salaries improve, they need to work less to make the same salary, so then you see an increased labor shortage.

This is exactly what happened with travel nurses. Many of them were working a month, then taking a month off.

 

[dabears505]

I think the boom will last a while. Nobody wants to waste their life taking a bunch of in house calls anymore. I think the shortage will last as fewer people are willing to work horrible hours.

 

[Beeftenderloin]

Just focus on learning the trade for the sake of your patients. As a new grad you don't have the knowledge, speed or skill to demand the same pay as a 20 year vet. The last few new grads we hired were the perfect combination of lazy, incompetent and entitled. Almost makes you want to burn down the whole thing down rather than hand them the keys.

Anyway, with rising Medicare, the No Surprises Act and astronomical labor costs it's almost better to be employed or do locums now. Perfect timing for me to slow down. Probably will be closing shop sooner than later.

All the people in my group who complain about working hours to no end, complain about how sick everyone is, complain about how obese everyone is, complain about assignments, complain about call, calling for help with procedures, taking a full hour to get a heart asleep and lined up when I can do the exact same in 20 mins, these are almost always the 20+ year vets.

 

[sbmed100]

How do you reason this out? If there’s more retirements and demand than there are new grads, which there are, then the problem will get worse, which it will.

Around here most of those who were contemplating retirement did so during these challenging last few years. Now you have high salaries and a depressed stock market so…

 

[MirrorTodd]

Around here most of those who were contemplating retirement did so during these challenging last few years. Now you have high salaries and a depressed stock market so…

Oh baby, that's the perfect time to sell cause I can reposition when it goes lower!

 

[dizzy21]

I agree with almost all your points, esp supply and demand…but I do see the trend of manpower shortage improving within two years with all the new grads (both MD and AA/CRNA.)

I live in a city that has had an explosion of surgical centers and surgeons building ORs in their own offices. That’s a large increase in the number of 730am starts even if the surgical volume wasn’t increasing (which it is). It’s not just demography but the fact that new ORs are being built everywhere. This will need to level off as well before we see a significant decrease in demand.

Not to mention in the peds anesthesia world there is a lot of increasing demand for out of OR work such as peds dental. Had some colleagues leave hospitals to do peds dental full time out of dentist offices. That’s yet more bodies gone from the hospital. Not to mention almost no one is doing peds fellowship lately.

Really needs to be a regulatory or technological change to change this trajectory.

 

[GravelRider]

Just focus on learning the trade for the sake of your patients. As a new grad you don't have the knowledge, speed or skill to demand the same pay as a 20 year vet. The last few new grads we hired were the perfect combination of lazy, incompetent and entitled. Almost makes you want to burn down the whole thing down rather than hand them the keys.

Anyway, with rising Medicare, the No Surprises Act and astronomical labor costs it's almost better to be employed or do locums now. Perfect timing for me to slow down. Probably will be closing shop sooner than later.

Nope. You’re just not paying enough. With a competitive market, you have to pay competitively to get the best candidates. You want to nickel and dime every new grad who comes out and tell them stories about how it was back in your day then expect to hire some whiners.

 

[ambiturner]

All the people in my group who complain about working hours to no end, complain about how sick everyone is, complain about how obese everyone is, complain about assignments, complain about call, calling for help with procedures, taking a full hour to get a heart asleep and lined up when I can do the exact same in 20 mins, these are almost always the 20+ year vets.

Have these people always worked in your group or were they elsewhere ‘supervising’ before?

 

[Dr. Rude]

People tend to rise (or fall) to the level of their incentive. Give a young hungry well trained debt burdened doc the opportunity to make big bucks for working hard they will almost every time. Don't give them that and they will have the civil servant mentality. Conversely, As one gets older, priorities often change. TIme vs. Money. Low intensity work vs. Hight intensity work. Security and comfort of the familiar being valued above instability and new challenges. Today's gung ho cutting edge recent grads are tomorrows lazy fat cats.
It will happen to a lot of you. Not all of you.

 

[drdan4]

Nope. You’re just not paying enough. With a competitive market, you have to pay competitively to get the best candidates. You want to nickel and dime every new grad who comes out and tell them stories about how it was back in your day then expect to hire some whiners.

I don't think you understand. Starting at over 600k and 6 weeks vaca we don't have trouble getting new grads. I am telling you they are not that good. There is a level of efficiency and work ethic that is needed to function in an all MD busy Private Practice. I will concede the sweet spot seems to be the experienced Private Practice guys 5-15 years out of Residency...some of them are absolute rockstars. Comes with time...end of Residency is just the beginning.

 

[abolt18]

My residency hired a few docs in the last few years who were PP solo guys for 20+ years and 2/3 are... Not great.

 

[UscGhost]

I don't think you understand. Starting at over 600k and 6 weeks vaca we don't have trouble getting new grads. I am telling you they are not that good. There is a level of efficiency and work ethic that is needed to function in an all MD busy Private Practice. I will concede the sweet spot seems to be the experienced Private Practice guys 5-15 years out of Residency...some of them are absolute rockstars. Comes with time...end of Residency is just the beginning.

The sweet spot begins around year 3-5. At that point you have 95% of the experience you need so the experience benefit of a 20 year vet is minimal.

However, the year 5 guy is generally faster, more pleasant, more efficient and gets along with the staff better.

A brand new grad? Yes it takes them some time, but generally by month 3-6 they are quite productive

 

[coffeebythelake]

My residency hired a few docs in the last few years who were PP solo guys for 20+ years and 2/3 are... Not great.

As much as people on SDN talk down on academics, we've had a few "solid" PP guys that joined our academic department that are absolutely terrible and led to disastrous patient outcomes.

 

[UscGhost]

As much as people on SDN talk down on academics, we've had a few "solid" PP guys that joined our academic department that are absolutely terrible and led to disastrous patient outcomes.

It's definitely difficult to jump from one arena to another.

Spend enough time in one arena and you lose the skills necessary for the other.

PP guys know all the tricks and shortcuts, but residents shouldn't really learn those early on. Need to learn the basics and then learn the tricks at the end.

 

[coffeebythelake]

It's definitely difficult to jump from one arena to another.

Spend enough time in one arena and you lose the skills necessary for the other.

PP guys know all the tricks and shortcuts, but residents shouldn't really learn those early on. Need to learn the basics and then learn the tricks at the end.

My view as an academic guy: the PP guys out in the community hospitals deal with healthier, simpler and more predictable cases. They aren't working with a surgeon trying out a new technique, trying out a 6 hour robotic chole, or resecting a massive tumor next to the aorta. The patients aren't critically ill or have conditions that put them 2 paces away from coding on induction. And case-in-point, few community hospitals run by PP are level 1 trauma centers. The priorities are probably different. PP bust their butt because they run things super-lean and they gotta make those sweet billing units and ply their tricks and shortcuts to make things efficient. And it's probably a great environment for a polished and efficient anesthesiologist where they work with the same small, predictable group of surgeons. No worries about residents and students. Doesn't really matter if the preop block worked because the patient is getting a general anesthetic anyways. Timing the wakeups are probably a lot easier when you don't have a medical student fumbling about. Probably fewer immediate complications. And the disasters and postsurgical complications get shipped off to the big house where someone else deals with it.

Regarding losing skills: being able to recognize an unstable patient is a skill that is necessary for ALL anesthesiologists. The PP dude was more interested in documenting to cover his ass rather than help out during the emergent take-back that ensued.

Academics and PP are both places where people push the limits. In academics it is pushing the limits of sick patients and advanced surgeries that can only exist in tertiary and quaternary centers with the uber-specialists. In PP it is pushing the limits with how much of the corners they can snip off and get away with it.

 

[vector2]

As much as people on SDN talk down on academics, we've had a few "solid" PP guys that joined our academic department that are absolutely terrible and led to disastrous patient outcomes.

The biggest issue I've seen when PP docs join an academic practice is that a whole bunch of their tricks and techniques are occasionally just wayyy too cavalier for the acuity / pt sickness level / random sht you run into in a tertiary center.

You can get away with a lot in community hospital / ASC PP settings, even with fat sick"ish" ASA 3s and the occasional 4, but some guys run right into a wall when they come to the mothership and think they can prop/sux/tube the mediastinal thyroid or severe pulm HTN pt coming for a lap chole.

 

[gunnershow]

The biggest issue I've seen when PP docs join an academic practice is that a whole bunch of their tricks and techniques are occasionally just wayyy too cavalier for the acuity / pt sickness level / random sht you run into in a tertiary center.

You can get away with a lot in community hospital / ASC PP settings, even with fat sick"ish" ASA 3s and the occasional 4, but some guys run right into a wall when they come to the mothership and think they can prop/sux/tube the mediastinal thyroid or severe pulm HTN pt coming for a lap chole.

I've had both those pathologies at my level 2 PP center in the past week. Both patients got a far more intelligently designed anesthetic than prop/sux/tube except with minimal MAFAT. But I concede that a lot of these "PP guys" who focus so much on being slick are probably just substandard anesthesiologists taking shortcuts.

 

[UscGhost]

My view as an academic guy: the PP guys out in the community hospitals deal with healthier, simpler and more predictable cases. They aren't working with a surgeon trying out a new technique, trying out a 6 hour robotic chole, or resecting a massive tumor next to the aorta. The patients aren't critically ill or have conditions that put them 2 paces away from coding on induction. And case-in-point, few community hospitals run by PP are level 1 trauma centers. The priorities are probably different. PP bust their butt because they run things super-lean and they gotta make those sweet billing units and ply their tricks and shortcuts to make things efficient. And it's probably a great environment for a polished and efficient anesthesiologist where they work with the same small, predictable group of surgeons. No worries about residents and students. Doesn't really matter if the preop block worked because the patient is getting a general anesthetic anyways. Timing the wakeups are probably a lot easier when you don't have a medical student fumbling about. Probably fewer immediate complications. And the disasters and postsurgical complications get shipped off to the big house where someone else deals with it.

Regarding losing skills: being able to recognize an unstable patient is a skill that is necessary for ALL anesthesiologists. The PP dude was more interested in documenting to cover his ass rather than help out during the emergent take-back that ensued.

Academics and PP are both places where people push the limits. In academics it is pushing the limits of sick patients and advanced surgeries that can only exist in tertiary and quaternary centers with the uber-specialists. In PP it is pushing the limits with how much of the corners they can snip off and get away with it.

Haha.. definitely sounds like the perspective of someone who is bitter about PP guys.

The academic guys don't survive in private practice because they don't know how to be efficient. It's not about which corners to cut...it's about understanding what things need to be worried about and what not to be worried about.

You don't get 45 mins to do a block in PP. You got 5 mins and it better work or the PP Ortho will request someone else.

The academic guys, on average, aren't as skilled because they don't do the cases themselves. The residents and CRNAs so them. So they naturally lose their skills over time.

I would trust a PP guy doing solo cases in a trauma center far more than an academic guy from a trauma center

 

[vector2]

Haha.. definitely sounds like the perspective of someone who is bitter about PP guys.

The academic guys don't survive in private practice because they don't know how to be efficient. It's not about which corners to cut...it's about understanding what things need to be worried about and what not to be worried about.

You don't get 45 mins to do a block in PP. You got 5 mins and it better work or the PP Ortho will request someone else.

The academic guys, on average, aren't as skilled because they don't do the cases themselves. The residents and CRNAs so them. So they naturally lose their skills over time.

I would trust a PP guy doing solo cases in a trauma center far more than an academic guy from a trauma center

The supervision vs solo thing is a separate question from the PP vs academic thing. There are plenty of supervisory PPs filled with unslick chart watchers.

But as far as supervising in the academic setting, for me what that means is that by the time it's my turn to jump in, someone (frequently inexperienced) has already blown a try on the most suitable IV spot, a-line spot, central line spot, or best (first) laryngoscopy attempt. I'm good at difficult things because for one reason or another I'm more frequently the clean-up man. That being said, I do have some colleagues (mostly older) who would be totally incapable of doing cases or many procedures solo if put on the spot.

 

[Beeftenderloin]

Have these people always worked in your group or were they elsewhere ‘supervising’ before?

Everyone in that range of experience has been with the group at least 10+ years, many of them their whole career.

 

[coffeebythelake]

Haha.. definitely sounds like the perspective of someone who is bitter about PP guys. The academic guys don't survive in private practice because they don't know how to be efficient. It's not about which corners to cut...it's about understanding what things need to be worried about and what not to be worried about.

I'm not bitter (okay maybe a little bit) about PP guys, but I want to push back against all the snide comments made by PP about academics. Decision-trees about "efficiency" and "what to be worried about" is largely dependent on the type of surgery and the type of surgeon. Is this a bread-and-butter case? Is this a good surgeon that a single IV will be fine? Or is this a surgeon that often downplay the patient's condition, get themselves into unexpected blood baths that a second IV and an art line will be needed? What else is there to be efficient about? I concede that I am a little more aggressive in my approach compared to some of my academic colleagues. I am pretty quick with my wake ups, usually within 5 minutes of case end even after those 6 hour surgeries. I don't violate NPO guidelines. I don't pull the ETT and wheel the patient to PACU when the patient is unconscious because the PACU nurses will lose their minds. Do you do these things?

You don't get 45 mins to do a block in PP. You got 5 mins and it better work or the PP Ortho will request someone else.

Yes, and that's exactly why PP rarely do block + sedation. They do block + GA so even if that block is patchy or didn't set up correctly the case still goes on. There is less pressure to do it right because they aren't relying on the block to do the heavy lifting. When a block "must be perfect" every time, it will take more than 5 minutes to put it in... that's reality.

The academic guys, on average, aren't as skilled because they don't do the cases themselves. The residents and CRNAs so them. So they naturally lose their skills over time.

Perhaps you are talking about solo PP where you "do everything yourself".
I doubt the same can be said of PP where you are supervising 4+ CRNAs from your computer workstation.

I would trust a PP guy doing solo cases in a trauma center far more than an academic guy from a trauma center

I think I'm pretty slick and efficient. I do a lot of solo cases as an attending. I know the in-and-outs of the anesthesia machine and can trouble shoot most problems. When I do my room checks I draw up my drugs and set up my equipment and machine in about 5 minutes (the machine itself takes about 4 minutes to do a boot up and system check). I can intubate, place a couple IVs and an art line in a deathly ill patient in the space of 10 minutes. Add another 10 minutes to place a central line. BUT I disagree that solo approach is the best approach for a truly unstable trauma case where mortality is in the cards. This is a situation that slickness isn't enough. You need extra hands, from techs if not from other anesthesiologists. To watch the monitors. To push levo or bolus fluids when I am in the middle of working on that extra access. I don't have any preconceptions that I myself can and will do everything. I don't have that kind of ego. And face it when a patient is so sick they could die that's when it really matters. Not the "patient broke a bone must fix" kind of trauma. And also face it, the academic anesthesiologists taking "trauma call" aren't usually from the general pool of academics.

 

[Volatile]

My view as an academic guy: the PP guys out in the community hospitals deal with healthier, simpler and more predictable cases. They aren't working with a surgeon trying out a new technique, trying out a 6 hour robotic chole, or resecting a massive tumor next to the aorta. The patients aren't critically ill or have conditions that put them 2 paces away from coding on induction. And case-in-point, few community hospitals run by PP are level 1 trauma centers. The priorities are probably different. PP bust their butt because they run things super-lean and they gotta make those sweet billing units and ply their tricks and shortcuts to make things efficient. And it's probably a great environment for a polished and efficient anesthesiologist where they work with the same small, predictable group of surgeons. No worries about residents and students. Doesn't really matter if the preop block worked because the patient is getting a general anesthetic anyways. Timing the wakeups are probably a lot easier when you don't have a medical student fumbling about. Probably fewer immediate complications. And the disasters and postsurgical complications get shipped off to the big house where someone else deals with it.

Regarding losing skills: being able to recognize an unstable patient is a skill that is necessary for ALL anesthesiologists. The PP dude was more interested in documenting to cover his ass rather than help out during the emergent take-back that ensued.

Academics and PP are both places where people push the limits. In academics it is pushing the limits of sick patients and advanced surgeries that can only exist in tertiary and quaternary centers with the uber-specialists. In PP it is pushing the limits with how much of the corners they can snip off and get away with it.

All I can add as someone who did locums for two years at level 1 academic centers and community hospitals….it was always a nice break being at the level 1 centers. Yes the occasional patient was sicker but honestly felt about the same except I had more resources available to me at the level 1. Slower pace, less needy surgeons who were used to dealing with trainees, just overall easier $$ IMO. I guess everyone’s experiences are different though

 

[GravelRider]

My view as an academic guy: the PP guys out in the community hospitals deal with healthier, simpler and more predictable cases. They aren't working with a surgeon trying out a new technique, trying out a 6 hour robotic chole, or resecting a massive tumor next to the aorta. The patients aren't critically ill or have conditions that put them 2 paces away from coding on induction. And case-in-point, few community hospitals run by PP are level 1 trauma centers. The priorities are probably different. PP bust their butt because they run things super-lean and they gotta make those sweet billing units and ply their tricks and shortcuts to make things efficient. And it's probably a great environment for a polished and efficient anesthesiologist where they work with the same small, predictable group of surgeons. No worries about residents and students. Doesn't really matter if the preop block worked because the patient is getting a general anesthetic anyways. Timing the wakeups are probably a lot easier when you don't have a medical student fumbling about. Probably fewer immediate complications. And the disasters and postsurgical complications get shipped off to the big house where someone else deals with it.

Regarding losing skills: being able to recognize an unstable patient is a skill that is necessary for ALL anesthesiologists. The PP dude was more interested in documenting to cover his ass rather than help out during the emergent take-back that ensued.

Academics and PP are both places where people push the limits. In academics it is pushing the limits of sick patients and advanced surgeries that can only exist in tertiary and quaternary centers with the uber-specialists. In PP it is pushing the limits with how much of the corners they can snip off and get away with it.

As much as it’s the fault of the “new” PP guy, it’s also an indictment of departmental leadership. There should be some mentorship and an easing back into academic life. How hard is it to have someone help the new guy get up to speed? Whenever I have started a new job, it is almost a universal law that the new guy is getting the cases no one wants for the first few months. Whether that is the assassin surgeon who turns a simple procedure into a bloodbath or the disaster patients who already have a toe in the grave. PP guys do benefit from better surgeons (the bad ones can’t cut it in PP) and better patient selection. However, it is also up to the department hiring a new person to help get them up to speed with how cases are typically run there. There is absolutely nothing done in an academic center that a PP guy can’t do, so long as he is alerted to the challenges beforehand.

It’s also not corners being cut. As you mentioned, procedures may be simpler, surgeons are better, and patients may be healthier. It’s more of a matter of only doing what is needed and nothing more. That’s not cutting corners, that’s the efficiency you refer to. Calling it cutting corners makes it sound like substandard care. For some procedures, I would MUCH rather have them done at a good community hospital versus a big academic center.

 

[Anesthesia_Guy]

14 months (ie two more graduating classes) and the tide will turn. Will NEVER be as short as 2022. The issue like I said before is that salaries (compensation) are high due to the manpower shortage -but in real terms revenue (the money being brought in from collections) keeps falling. So when the tide turns lots of folks gonna be caught with their pants down wondering what the hell happened.

Not I. Pants, belt, and suspenders in effect!

 

[coffeebythelake]

As much as it’s the fault of the “new” PP guy, it’s also an indictment of departmental leadership. There should be some mentorship and an easing back into academic life. How hard is it to have someone help the new guy get up to speed? Whenever I have started a new job, it is almost a universal law that the new guy is getting the cases no one wants for the first few months.

I don't disagree.

Whether that is the assassin surgeon who turns a simple procedure into a bloodbath or the disaster patients who already have a toe in the grave. PP guys do benefit from better surgeons (the bad ones can’t cut it in PP) and better patient selection. However, it is also up to the department hiring a new person to help get them up to speed with how cases are typically run there.

It makes it easier when everyone is on the same page about management of a patient. And that means some degree of solidarity among the anesthesiologists. You can't have one anesthesiologist refuse to the do the case because the patient needs medical optimization, and then the anesthesiologist next door says "it's fine I'll do it"

There is absolutely nothing done in an academic center that a PP guy can’t do, so long as he is alerted to the challenges beforehand.

I mean the same can be said about academics going into PP.

It’s also not corners being cut. As you mentioned, procedures may be simpler, surgeons are better, and patients may be healthier. It’s more of a matter of only doing what is needed and nothing more. That’s not cutting corners, that’s the efficiency you refer to. Calling it cutting corners makes it sound like substandard care. For some procedures, I would MUCH rather have them done at a good community hospital versus a big academic center.

It would be considered substandard care because that is not how it is taught in the textbooks. But I will digress about the semantics.

 

[GravelRider]

I don't disagree.


It makes it easier when everyone is on the same page about management of a patient. And that means some degree of solidarity among the anesthesiologists. You can't have one anesthesiologist refuse to the do the case because the patient needs medical optimization, and then the anesthesiologist next door says "it's fine I'll do it"


I mean the same can be said about academics going into PP.


It would be considered substandard care because that is not how it is taught in the textbooks. But I will digress about the semantics.

Example?

 

[coffeebythelake]

Example?

Recent one and a simple one. Anesthesiologist wanted to delay elective case for NPO violation. Upset the surgeon and got chided by the head of the anesthesia group because the "patient is going to be intubated anyway". I don't have to deal with this sort of crap in academics. I do what I feel is in the best interest of my patient without having to simultaneously navigate a minefield of OR politics.

 

[thinkorswim]

Yes, and that's exactly why PP rarely do block + sedation. They do block + GA so even if that block is patchy or didn't set up correctly the case still goes on. There is less pressure to do it right because they aren't relying on the block to do the heavy lifting. When a block "must be perfect" every time, it will take more than 5 minutes to put it in... that's reality.

This is somewhat incorrect. I believe it has more to do with billing than anything.

A block with GA allows you to bill for the block as postoperative pain control, but if you do sedation instead then the block is considered the primary anesthetic technique and isn’t billable separately.

 

[coffeebythelake]

This is somewhat incorrect. I believe it has more to do with billing than anything.

A block with GA allows you to bill for the block as postoperative pain control, but if you do sedation instead then the block is considered the primary anesthetic technique and isn’t billable separately.

whatever the deeper purpose is, the result is the same.

PP isn't more efficient at placing blocks. That needs to be put to rest. PP don't need it to be perfect so doing it in 5 minutes is fine. the GA is the heavy lifting.

 

[Guillemot]

Academics, PP, new, old, etc. It is not necessarily accurate to attribute these factors as the reason for why an individual is good or bad. Some (many) people are just f@cking dumb.

 

[GravelRider]

Recent one and a simple one. Anesthesiologist wanted to delay elective case for NPO violation. Upset the surgeon and got chided by the head of the anesthesia group because the "patient is going to be intubated anyway". I don't have to deal with this sort of crap in academics. I do what I feel is in the best interest of my patient without having to simultaneously navigate a minefield of OR politics.

You can’t generalize bad care to being a characteristic of PP. I can assure you that many PPs are actually more cautious than necessary.

 

[coffeebythelake]

You can’t generalize bad care to being a characteristic of PP. I can assure you that many PPs are actually more cautious than necessary.

Then, can you please elaborate on what constitutes efficient care that is wholly missing in academics? I've described how I practice above.

 

[GravelRider]

whatever the deeper purpose is, the result is the same.

PP isn't more efficient at placing blocks. That needs to be put to rest. PP don't need it to be perfect so doing it in 5 minutes is fine. the GA is the heavy lifting.

This sentence makes no sense. You are basically saying PP docs are doing fake blocks and billing for it. Believe me, the orthopedic surgeons know who is good at blocks and who isn’t.

 

[Beeftenderloin]

It makes it easier when everyone is on the same page about management of a patient. And that means some degree of solidarity among the anesthesiologists. You can't have one anesthesiologist refuse to the do the case because the patient needs medical optimization, and then the anesthesiologist next door says "it's fine I'll do it"

Can confirm, life is much easier when this is the case. When someone in our group cancels a case, it’s as if the whole group cancelled it. That’s the end of it. There is no shopping around for a different doc. The assumption from everyone else in the group is that they did it for a valid reason, and even if they didn’t, that’s still the end of it because that’s one less case for everyone to get done that day. At the moment we are too busy as a dept, so trimming fat in the schedule is always welcome news.

 

[thinkorswim]

whatever the deeper purpose is, the result is the same.

PP isn't more efficient at placing blocks. That needs to be put to rest. PP don't need it to be perfect so doing it in 5 minutes is fine. the GA is the heavy lifting.

I think your argument is unsound. Quality and efficiency aren’t one and the same, and both depend more on the practitioner than the setting.

Why do you assume a nerve block in private practice has lower standards than one in academics? Do you think every GA with a nerve block gets heavy narcotics and full paralysis?

I would argue that there’s more pressure to have a good block in private practice since there’s more emphasis on throughput. Do you think surgeons will just let it slide if all their patients are piling up in PACU with pain issues, unable to work with PT or be discharged?

For what it’s worth, I trained at a residency with an ortho hospital and now do a fair amount of nerve blocks in practice. I feel that the only efficiency I have gained is by not having an attending hovering over my shoulder and pushing the local for me. A 6 minute block in residency is now a 5 minute block in practice.

 

[GravelRider]

Then, can you please elaborate on what constitutes efficient care that is wholly missing in academics? I've described how I practice above.

I don’t know. I asked you for an example because you are the one who said it. Your thesis that PP docs are efficient because they cut corners is what I am questioning.

 

[coffeebythelake]

I think your argument is unsound. Quality and efficiency aren’t one and the same, and both depend more on the practitioner than the setting.

Why do you assume a nerve block in private practice has lower standards than one in academics? Do you think every GA with a nerve block gets heavy narcotics and full paralysis?

I would argue that there’s more pressure to have a good block in private practice since there’s more emphasis on throughput. Do you think surgeons will just let it slide if all their patients are piling up in PACU with pain issues, unable to work with PT or be discharged?

For what it’s worth, I trained at a residency with an ortho hospital and now do a fair amount of nerve blocks in practice. I feel that the only efficiency I have gained is by not having an attending hovering over my shoulder and pushing the local for me. A 6 minute block in residency is now a 5 minute block in practice.

Blocks take time to set up. When you do a block in 5 minutes and wheel the patient back immediately, it might not have set up by the time incision is made especially when injecting around the nerve and not directly into it. The former is favored for many blocks because less theoretical risk of nerve injury. And perhaps eventually it will set up so by end of case it will be fine.

@GravelRider who said anything about "fake blocks"? That is billing fraud. I said no such thing.

@UscGhost claims PP fo blocks in 5 minutes that is superior while academics take 45 min. I think that is the claim here thay stretches to incredulity.

So... do you sedate the patients you do your blocks for? Or do you GA them? Is it an analgesic block or a surgical block? That is at the heart of my comments.

PP don't need it to be perfect so doing it in 5 minutes is fine. the GA is the heavy lifting.

They do block + GA so even if that block is patchy or didn't set up correctly the case still goes on. There is less pressure to do it right because they aren't relying on the block to do the heavy lifting. When a block "must be perfect" every time, it will take more than 5 minutes

Doesn't really matter if the preop block worked [right away] because the patient is getting a general anesthetic anyways.

 

[coffeebythelake]

I don’t know. I asked you for an example because you are the one who said it. Your thesis that PP docs are efficient because they cut corners is what I am questioning.

Not my thesis. Read the thread. Someone else pro-PP claimed all the tricks and shortcuts are learned in PP. Is that the same as saying cutting corners? I don't know because I think I'm pretty damn efficient without using "tricks or shortcuts"

 

[dizzy21]

I dunno, I’ve seen both. New grads that are a hot mess, boomer colleagues that are great. I’ve also seen the opposite.

I will say consistently the worst I’ve seen is the anesthesiologist who is out of practice for a couple years whether for personal reasons or were in a 100% pain practice and came back to OR anesthesia. It’s really incredible how something that seems second nature to a lot of us can quickly be forgotten if you’re out of practice for a few years.

 

[coffeebythelake]

Why do you assume a nerve block in private practice has lower standards than one in academics? Do you think every GA with a nerve block gets heavy narcotics and full paralysis?

I'm confused how you interpret what I wrote as this?

I think there is "less on the line" when doing a block for analgesic purposes compared to a surgical block. The latter requires a "perfect block" and that needs more time to do and confirm. This is true regardless of PP or academics.

However PP is more likely to do blocks for analgesic purposes and put the patient under GA after

and you don't need "narcotics and full paralysis" with the GA. that's red herring and you know it.

 

[GravelRider]

When you do a block in 5 minutes and wheel the patient back immediately, it might not have set up by the time incision is made especially when injecting around the nerve and not directly into it. The former is favored for many blocks because less theoretical risk of nerve injury. And perhaps eventually it will set up so by end of case it will be fine.

@GravelRider who said anything about "fake blocks"? That is billing fraud. I said no such thing.

@UscGhost claims PP fo blocks in 5 minutes that is superior while academics take 45 min. I think that is the claim here thay stretches to incredulity.

So... do you sedate the patients you do your blocks for? Or do you GA them? Is it an analgesic block or a surgical block? That is at the heart of my comments.

You implied it. You said PP docs are just putting blocks in that don’t work or work poorly and getting by with doing the cases under GA.

 

[coffeebythelake]

You implied it. You said PP docs are just putting blocks in that don’t work or work poorly and getting by with doing the cases under GA.

I'm terribly sorry you misunderstood, and upon that make a ridiculous claim that I am suggesting fake blocks and billing fraud

my point is you can do a 5 minute analgesic block but you might not be able to do a 5 minute surgical block.

you want to answer the question I asked?

 

[GassYous]

Blocks take time to set up. When you do a block in 5 minutes and wheel the patient back immediately, it might not have set up by the time incision is made especially when injecting around the nerve and not directly into it. The former is favored for many blocks because less theoretical risk of nerve injury. And perhaps eventually it will set up so by end of case it will be fine.

@GravelRider who said anything about "fake blocks"? That is billing fraud. I said no such thing.

@UscGhost claims PP fo blocks in 5 minutes that is superior while academics take 45 min. I think that is the claim here thay stretches to incredulity.

So... do you sedate the patients you do your blocks for? Or do you GA them? Is it an analgesic block or a surgical block? That is at the heart of my comments.

Monitor on, block in room, lma in within 10 mins

 

[coffeebythelake]

Monitor on, block in room, lma in within 10 mins

My point.

 

[psychbender]

What block could possibly take 45 minutes to do? The assertion that it takes this much time to do a block and make sure it works is bull****. When I was in the military, ISBs and SCBs were still <5min blocks, and we did a lot of block with moderate sedation, because billing wasn't an issue. I do the same blocks now, but will drop an LMA or ETT and run a little gas, because otherwise, I'm not paid for the block.

From where does your notion of how things are in PP come? Have you worked out in the community, or just cleaned up messes that got shipped?

 

[coffeebythelake]

What block could possibly take 45 minutes to do? The assertion that it takes this much time to do a block and make sure it works is bull****. When I was in the military, ISBs and SCBs were still <5min blocks, and we did a lot of block with moderate sedation, because billing wasn't an issue. I do the same blocks now, but will drop an LMA or ETT and run a little gas, because otherwise, I'm not paid for the block.

From where does your notion of how things are in PP come? Have you worked out in the community, or just cleaned up messes that got shipped?

I would assume that @UscGhost conflated doing a 5-minute SCB as being PP and doing a 45-minute multi-block for AKA or a catheter as being academics.

Perhaps you can elaborate on the benefit to the patient (not to your billing) of doing an analgesic block plus general anesthesia, when just a surgical block would be sufficient? IMO the worst offenders are doing a spinal followed by a general anesthetic. Seems like taking upon extra risk. And the patient is going to get good postop analgesia either way. Actually seems like a pretty inefficient way of doing things with the extra steps but i'm sure it pads the paycheck quite nicely.

 

[GravelRider]

I'm terribly sorry you misunderstood, and upon that make a ridiculous claim that I am suggesting fake blocks and billing fraud

my point is you can do a 5 minute analgesic block but you might not be able to do a 5 minute surgical block.

you want to answer the question I asked?

What’s the difference? Is there a technique difference that I’m not aware of?

What question do you want me to answer? I’m too busy doing ineffective blocks quickly to go back and look.

 

[coffeebythelake]

What’s the difference? Is there a technique difference that I’m not aware of?

What question do you want me to answer? I’m too busy doing ineffective blocks quickly to go back and look.

You read intently but miss the point entirely. Maybe the same with your blocks. I'm done.

 

[UscGhost]

Academics, PP, new, old, etc. It is not necessarily accurate to attribute these factors as the reason for why an individual is good or bad. Some (many) people are just f@cking dumb.

That's true.

However, certain people tend to gravitate towards certain areas and there is a reason many PP groups don't hire from academia and vice versa.

PP need fast, efficient, effective and low cancellation rates. We can't cancel every K 5.6 or every patient who drank a sip of water

Blocks take time to set up. When you do a block in 5 minutes and wheel the patient back immediately, it might not have set up by the time incision is made especially when injecting around the nerve and not directly into it. The former is favored for many blocks because less theoretical risk of nerve injury. And perhaps eventually it will set up so by end of case it will be fine.

@GravelRider who said anything about "fake blocks"? That is billing fraud. I said no such thing.

@UscGhost claims PP fo blocks in 5 minutes that is superior while academics take 45 min. I think that is the claim here thay stretches to incredulity.

So... do you sedate the patients you do your blocks for? Or do you GA them? Is it an analgesic block or a surgical block? That is at the heart of my comments.

For myself, I have done 5-10 thousand blocks, if not more, so I can easily do it in 5 mins and it will work perfectly well. They all take time to set up though.

We don't do sedation Ortho cases unless requested and the blocks would work fine for that too.

The key is whether someone does their own cases or not. If they do their own cases in a tertiary trauma center, whether academic or not, then they will more than likely be quite skilled.

If they watch residents and CRNAs do everything (whether PP or acad) they will likely be slow and inefficient and rusty after a few years.