Pts requesting Anesthesiologist

[MoMoGesiologist]

I have residency classmates who do 100% supervision who would definitely not feel comfortable if thrown into a room alone, and I'm only 7 years out of training. .

This is one of my fears, that after graduating, I can only find supervision jobs and never get comfortable on my own and develop my own style. Maybe it's just me, but how can I expect to tell a CRNA what or how to do things (aside from the really important stuff) if they've got >5-10 years experience on me, and maybe they are much more slick at their inductions and wake ups and dosing drugs because I've never really done it by myself. And before you say you should learn it all in residency, there are plenty of attendings who do the induction and walk out, patting themselves on the back for a "slick induction", while as a resident you are left with the post induction hypotension. If you're not in the room, you just don't see the consequences of your actions. It's just one example, but if you are really only involved in a small part of the start and end of cases supervising, don't deal with all those little "mini-emergencies" that arise during a case (random desats, rises in peak pressures, etc) can you really argue your anesthetic delivery will be as elegant as the person who sits in the room day in and day out, CRNAs included? Maybe it's just me, but when I work with attendings who have done their own cases on their own before, they usually are more calm, less frazzled and much less particular vs attendings who have only ever supervised (big generalization, not always true).

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[Arch Guillotti]

Maybe it's just me, but how can I expect to tell a CRNA what or how to do things (aside from the really important stuff) if they've got >5-10 years experience on me, and maybe they are much more slick at their inductions and wake ups and dosing drugs because I've never really done it by myself.

I will catch some grief for this probably but my advice is not to micromanage. Sweat the big stuff and be very clear with those you are supervising. I think you will surprise yourself at some important things you pick up on right away that would otherwise go unnoticed.

 

[Consigliere]

I will catch some grief for this probably but my advice is not to micromanage. Sweat the big stuff and be very clear with those you are supervising. I think you will surprise yourself at some important things you pick up on right away that would otherwise go unnoticed.

Great advice. I've noticed that anesthesiologists who micromanage (ie must use vecuronium and not rocuronium) when it makes no difference whatsoever are the worst, most hated anesthesiologists there are.

 

[anbuitachi]

Great advice. I've noticed that anesthesiologists who micromanage (ie must use vecuronium and not rocuronium) when it makes no difference whatsoever are the worst, most hated anesthesiologists there are.

It does make a difference. Rocuronium is more expensive.

 

[Consigliere]

It does make a difference. Rocuronium is more expensive.

Who cares? And I guess we know which category of anesthesiologist you fall under

 

[Noyac]

Depends on the ACT model. Especially in 1:3 coverage, if you sit the case, somebody else has to take your other 2 rooms, meaning 1:4 coverage for them. Far from ideal.

Plus it creates a precedent for the practice. What if more patients wanted solo docs? Those "solo" patients would cost the practice more, so some groups say no to all on principle.

Haven't we been saying on this forum for over 10yrs, that docs are better at anesthesia than nurses? If we want to convince the public that we are the experts and that pts do better under our care then we should be able to accommodate their request when they believe this this is true and ask for one of us to do their case.
But instead we are saying that we are too greedy to actually put our money where our mouth is.

 

[Consigliere]

Haven't we been saying on this forum for over 10yrs, that docs are better at anesthesia than nurses? If we want to convince the public that we are the experts and that pts do better under our care then we should be able to accommodate their request when they believe this this is true and ask for one of us to do their case.
But instead we are saying that we are too greedy to actually put our money where our mouth is.

That's the overwhelming reality.

 

[anbuitachi]

Who cares? And I guess we know which category of anesthesiologist you fall under

save the system money?

 

[deleted171991]

Haven't we been saying on this forum for over 10yrs, that docs are better at anesthesia than nurses? If we want to convince the public that we are the experts and that pts do better under our care then we should be able to accommodate their request when they believe this this is true and ask for one of us to do their case.
But instead we are saying that we are too greedy to actually put our money where our mouth is.

Anybody who's running an ACT practice is not interested in proving solo docs are better.

 

[anonperson]

Just went through this for one of my kids. The anesthesiologists didn't want to ruffle CRNA feathers (either that or couldn't do it on their own). If you've reached the point that you can't practice your own specialty without a midlevel for technical or business reasons but the midlevel can practice without you...you've replaced yourselves.

Not an anesthesiologist but have been reading this thread with some interest.

The example you're giving is pretty sad.

It boggles my mind that some anesthesiologists consider a patient request to have a physician do their anesthesia a major inconvenience for the group. Sure, it may lead to a short term decrease in compensation but the alternative is slowly chipping away at the specialty.

Money is nice and all but at a certain point one has to have some loyalty to the future of their specialty.

 

[Noyac]

All the skills involved in actually physically doing cases yourself from start to finish. And I guess you can argue what you're arguing but it doesn't change the fact that your argument sucks. Trust me, there are PLENTY of procedures to go around when you work solo lol. And you make it sound like these are incredibly technically difficult procedures we're doing when they're nothing close. There's a lot more to the job than being a procedure monkey. If you actually need someone to explain all of this to you, that may be the problem.

Excellent response! I am so dis courage by the greedy groups and their partners that claim to be as good as it gets. I'm on many committees at my facility, I represent our specialty on the state level and I can't believe I am fighting this fight while trolls are out there taking advantage of the efforts of some of us to keep this a medical specialty and not hand it over to the nurses. Then they claim to be even better at anesthesia because they do more invasive lines. WTF?

Another thing to think about in these all for profit groups where no anesthesiologists do cases is how the upcoming Quality Measures will play out with MACRA/MIPS. Let's say you let the nurse do an epidural under your supervision (from the lounge at least, I hope) and she gets a wet tap. Does that fall on the supervising anesthesiologist's Quality Measues report? I sure hope so. If it doesn't then these docs that never do a case won't generate any measures for comparison. I'm sure they will say "great" and continue to claim superiority but I doubt that the government will see it that way. Just some food for thought, carry on with your better than tho practice.

 

[Noyac]

The best of both worlds is being solo 1/3 of the time and the ACT model 2/3 (although I would choose the exact opposite ratio if possible). This keeps your skills as a practitioner of the "art of anesthesia" at a high level while allowing you to perform a large number of procedures 2/3 of the time. The bigger cases and the request cases could be "solo MD" while routine cases and after-hours are all ACT.

These days the biggest issue (only issue??) is the money. That means the 4:1 or even 5:1 model is the norm because the AMC wants to run lean. Private groups want to maximize profits as well so they have done away with the "being solo 1/3 of the time." I firmly believe that isn't a good thing for the specialty no matter how many lines or blocks you place.

Enjoy the MD only model while it lasts; and, it may or may not last depending on the healthcare paradigm the next Democratic President and Congress pass in 2021.

That's exactly how my first gig was. Docs did the big cases ( hearts, heads, major vascular, etc) plus some days at surgery centers just to get a nice easy day here or there. We also covered the plastics office as doc only. These pts paid cash and got a damn good anesthetic, plus it was Cush. We honored all requests as well. We ran doc heavy just enough to make this all work and I gotta say it was awesome. You were not a grunt all day everyday putting out fires and dancing around nurse feelings everyday. But sure we had those days as well. And get this, we made bank too. So you are right Blade, these groups are greedy as it gets and they are ruining this specialty just like the the old guys we complain about on this forum that opened the doors for the nurses. It's pathetic. And it's bullsh*t when someone tells me they are too busy to do a solo case. I have been there. We did it and we did it well and probably still made the same money these ______ are clinging so hard too

 

[Noyac]

As a person who supervises most of the time and usually does my own cases maybe one day a week, I will confirm that your "flow" definitely gets rusty when you haven't done your own cases in a while. If I have a room full of pedi ENT, it takes me a case or two to get into the zone. For me, it's usually the minutiae of electronic charting that gets lost in the shuffle. I have residency classmates who do 100% supervision who would definitely not feel comfortable if thrown into a room alone, and I'm only 7 years out of training. I am in the camp that recognizes the value of sitting your own cases and showing the surgeons/circulators/etc that we are better than the CRNAs at this and get the job done when the rubber hits the road. Very important. I was personally thrilled to get 3 days of solo anesthesia in this week (ortho, GYN, and a day of cardiac). I also think it keeps your options much more open, as you can consider MD only jobs with no hesitation. While I realize that outside factors may influence or preclude this, I think it behooves all ACT groups to try to get their docs into a room periodically (or regularly). It's good for the patients, the docs, the specialty, and the soul.

Awesome post. Thanks.
Btw, we won't even offer an interview to someone that doesn't at least do some of their own cases on a regular basis.

 

[Noyac]

Not an anesthesiologist but have been reading this thread with some interest.

The example you're giving is pretty sad.

It boggles my mind that some anesthesiologists consider a patient request to have a physician do their anesthesia a major inconvenience for the group. Sure, it may lead to a short term decrease in compensation but the alternative is slowly chipping away at the specialty.

Money is nice and all but at a certain point one has to have some loyalty to the future of their specialty.

Mman, are you listening?

 

[deleted162650]

Imagine you called ahead to the OPs ER and said "This Dr. X, I'm coming in with a bad lac, and I'd like one of the docs to sew it up." If they said "Sorry, it'll be a PA and the doc will be supervising from 3 bays over" you'd probably be pretty peeved about that yeah??

 

[pgg]

But if you don't use roc you can't give suggamadex...

I want my zero twitches right to the end dammit!!!

Sugammadex works with vecuronium too.

 

[Arch Guillotti]

It does make a difference. Rocuronium is more expensive.

I'll bet it goes over really good when you argue about this with the nurses!

 

[chocomorsel]

If you 100% supervise then you are losing skills.

Honestly Noyac, how is this not self explanatory. While I understand that you and I are in the minority, how can simple deductive reasoning not explain the loss of skills in supervisory only models.

 

[chocomorsel]

That's the overwhelming reality.

A man who always tells it like it is. No need to sugar coat. That's why I like you. At least you speak your reality.

 

[drmwvr]

save the system money?

Absolutely...And at an OR per minute rate that may vary from 30 to 80 dollars, you might get a parking spot next to the hospital CEO for the month for the couple of bucks per dose you save.

 

[IlDestriero]

Our practice is care team and our staffing is "lean." The only way to get an MD to personally do your case is to schedule it on his post call day or vacation day. We usually assign the top CRNAs to VIP or requests.

Our group can accommodate these requests, but I can see how another group would not be able to.
As much as I am flattered to get a request, I wouldn't be doing it post call or on my vacation.


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Il Destriero

 

[Noyac]

Honestly Noyac, how is this not self explanatory. While I understand that you and I are in the minority, how can simple deductive reasoning not explain the loss of skills in supervisory only models.

Well because if you listen to the ones touting their superior practice arrangement of supervision only they do many more blocks and lines. That apparently is what makes a good anesthesiologist to them.

 

[Noyac]

we don't take any lunch breaks. If we have a doc go into a room, then somebody else has to take their other rooms and increase their work load beyond what we'd otherwise safely do. I mean you could ask for someone to come in on their week of vacation, but good luck with that.

 

[Noyac]

Our group can accommodate these requests, but I can see how another group would not be able to.
As much as I am flattered to get a request, I wouldn't be doing it post call or on my vacation.


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Il Destriero

I have.
And on more than one occasion.
And I'm not lacking in vacation time either.

 

[imfrankie]

This is one of my fears, that after graduating, I can only find supervision jobs and never get comfortable on my own and develop my own style. Maybe it's just me, but how can I expect to tell a CRNA what or how to do things (aside from the really important stuff) if they've got >5-10 years experience on me, and maybe they are much more slick at their inductions and wake ups and dosing drugs because I've never really done it by myself. And before you say you should learn it all in residency, there are plenty of attendings who do the induction and walk out, patting themselves on the back for a "slick induction", while as a resident you are left with the post induction hypotension. If you're not in the room, you just don't see the consequences of your actions. It's just one example, but if you are really only involved in a small part of the start and end of cases supervising, don't deal with all those little "mini-emergencies" that arise during a case (random desats, rises in peak pressures, etc) can you really argue your anesthetic delivery will be as elegant as the person who sits in the room day in and day out, CRNAs included? Maybe it's just me, but when I work with attendings who have done their own cases on their own before, they usually are more calm, less frazzled and much less particular vs attendings who have only ever supervised (big generalization, not always true).

You my friend are wise to feel this way. Get a solo job for a few years, buff up, then decide or be forced to supervise. Guaranteed you will get much more respect--and will deserve it--if you've worked by yourself for a while. I also did a mid-career fellowship a number of years back, and in so doing worked with many attendings of various degrees of competence after years of personal solo experience; consequently I strongly agree with your last sentence also.

 

[Noyac]

This is one of my fears, that after graduating, I can only find supervision jobs and never get comfortable on my own and develop my own style. And before you say you should learn it all in residency, there are plenty of attendings who do the induction and walk out, patting themselves on the back for a "slick induction", while as a resident you are left with the post induction hypotension. If you're not in the room, you just don't see the consequences of your actions. It's just one example, but if you are really only involved in a small part of the start and end of cases supervising, don't deal with all those little "mini-emergencies" that arise during a case (random desats, rises in peak pressures, etc) can you really argue your anesthetic delivery will be as elegant as the person who sits in the room day in and day out, CRNAs included? Maybe it's just me, but when I work with attendings who have done their own cases on their own before, they usually are more calm, less frazzled and much less particular vs attendings who have only ever supervised (big generalization, not always true).

I'm sorry but I can't answer this question for you. Maybe @Mman can?

 

[Noyac]

Been doing this for more than 20 years and can say without hesitation that, on balance, VIP's get the worst care.

Not at my gig.

 

[ZzzPlz]

Not at my gig.

I bet you even preoxygenate the VIP's!

 

[nimbus]

Been doing this for more than 20 years and can say without hesitation that, on balance, VIP's get the worst care.

Agree. And the way to avoid this is by NOT making special concessions or deviating from your routine when taking care of VIPs. If you don't preoxygenate, don't preoxygenate the VIP.

 

[Mman]

Mman, are you listening?

yes I am. Loud and clear. Like I've offered in the past, if you'd like to pay for someone to fly out to have surgery with you be my guest. I don't have a major hospital within a 500 mile drive of me (maybe 1000 miles) that would/could honor the request.

 

[Mman]

It boggles my mind that some anesthesiologists consider a patient request to have a physician do their anesthesia a major inconvenience for the group. Sure, it may lead to a short term decrease in compensation but the alternative is slowly chipping away at the specialty.

It isn't an "inconvenience", it's an impossibility. Honoring that request would mean decreasing care for other patients. And no matter how nice the person making the request, they aren't more important than the other patients.

 

[Mman]

If you're not in the room, you just don't see the consequences of your actions. It's just one example, but if you are really only involved in a small part of the start and end of cases supervising, don't deal with all those little "mini-emergencies" that arise during a case (random desats, rises in peak pressures, etc) can you really argue your anesthetic delivery will be as elegant as the person who sits in the room day in and day out, CRNAs included?

No offense, but if you consider a desat or a rise in peak procedures to be something approaching an emergency you might be one of those that freaks out over the little stuff. And why exactly if I'm supervising do I not see those things? I'm in rooms frequently. I can see the record/vent performance/vitals remotely at other times. You seem to imply that when you supervise you stand there for the intubation and never come back. I'm usually in the room every 20-40 minutes the entirety of the case.

 

[Mman]

If you're that lean maybe you should hire one more doc. Seriously how much would that dilute your income? If your practice has 20 doctors it's less than 5%.

No, we aren't lean, we are appropriately staffed. What we aren't is 4:1 in the morning. Removing a doc to do their own case necessarily dumps their other stuff on other docs that are already busy.

But add a doc a day in case somebody requests MD only care? LOL. I don't think we've had the request in the last several hundred thousand anesthetics we've done.

 

[Mman]

aww, so cute. I'm still waiting for the list of skills someone gets better at by doing their own cases. Certainly isn't anything relevant to better patient outcomes (death, morbidity, postop respiratory failure, PONV, etc). But nice violin...


(and please note, it's not as if I haven't done my own cases, nights and weekends when emergent case volume may infrequently exceed CRNA/AA staffing we have docs on call do their own cases, I just haven't figured out what skill I'm supposed to be improving while doing so)

 

[Consigliere]

save the system money?

Yeah, that's my TOP priority when I get out of bed every day. As I drive to the hospital, I ponder "how can I save THE SYSTEM some money?"

 

[Consigliere]

That's exactly how my first gig was. Docs did the big cases ( hearts, heads, major vascular, etc) plus some days at surgery centers just to get a nice easy day here or there. We also covered the plastics office as doc only. These pts paid cash and got a damn good anesthetic, plus it was Cush. We honored all requests as well. We ran doc heavy just enough to make this all work and I gotta say it was awesome. You were not a grunt all day everyday putting out fires and dancing around nurse feelings everyday. But sure we had those days as well. And get this, we made bank too. So you are right Blade, these groups are greedy as it gets and they are ruining this specialty just like the the old guys we complain about on this forum that opened the doors for the nurses. It's pathetic. And it's bullsh*t when someone tells me they are too busy to do a solo case. I have been there. We did it and we did it well and probably still made the same money these ______ are clinging so hard too

If it was such a utopian practice you were in, why isn't this your current gig? Just asking.....

 

[Consigliere]

Not an anesthesiologist but have been reading this thread with some interest.

The example you're giving is pretty sad.

It boggles my mind that some anesthesiologists consider a patient request to have a physician do their anesthesia a major inconvenience for the group. Sure, it may lead to a short term decrease in compensation but the alternative is slowly chipping away at the specialty.

Money is nice and all but at a certain point one has to have some loyalty to the future of their specialty.

Your analogy is incorrect. An atomic bomb has been dropped on this speciality and it is done. Anecdotes and examples of efforts to maintain the speciality by Noy. et. al are cute and all but they are an extreme minority. Those of us in the know realize that anesthesiology's goose has been cooked.

 

[Consigliere]

Well because if you listen to the ones touting their superior practice arrangement of supervision only they do many more blocks and lines. That apparently is what makes a good anesthesiologist to them.

As opposed to charting vitals q 5 mintues and turning the knob on the sevo vaporizer? Oh......I forgot about the all important task of emptying the foley. That's definitely separating-the-men-from-the-boys territory.

 

[Consigliere]

I have.
And on more than one occasion.
And I'm not lacking in vacation time either.

Folks, here we have the next candidate for martyrdom....allow me to introduce:

SAINT NOYAC

 

[Noyac]

yes I am. Loud and clear. Like I've offered in the past, if you'd like to pay for someone to fly out to have surgery with you be my guest. I don't have a major hospital within a 500 mile drive of me (maybe 1000 miles) that would/could honor the request.

Tell me where you are and I betcha I can find one

 

[Noyac]

If it was such a utopian practice you were in, why isn't this your current gig? Just asking.....

Location.

 

[Noyac]

aww, so cute. I'm still waiting for the list of skills someone gets better at by doing their own cases. Certainly isn't anything relevant to better patient outcomes (death, morbidity, postop respiratory failure, PONV, etc). But nice violin...


(and please note, it's not as if I haven't done my own cases, nights and weekends when emergent case volume may infrequently exceed CRNA/AA staffing we have docs on call do their own cases, I just haven't figured out what skill I'm supposed to be improving while doing so)

So in your opinion the only skills an anesthesiologist needs involves sticking needles in pts.
Once we start to measure outcomes in real practices through NACOR (National Anesthesia Clinical Outcomes Registry) then the differences will become more apparent. We will start with the things that pts attribute to a successful anesthestic: vomiting, gagging on the tube, pain, nausea, recall, residual weakness, shivering, sore throat, somnolence. More and more this information is being made public. Take a look at Medicare's "Physician Compare" website. And "Hospital Compare". Tell me your hospital name and we can compare the two offline just you and I.

 

[Noyac]

Folks, here we have the next candidate for martyrdom....allow me to introduce:

SAINT NOYAC

Thanks but really I'm no Saint.
I do however, like to call out people that are not and that are raping our specialty.
Where should I place you?

 

[Urzuz]

If you were having a major surgery (Whipple, big spine case, something along those lines), and your case was being done by a solo anesthesiologist, would you rather be taken care of by an anesthesiologist who has done all his own cases for the past 20 years, or by an anesthesiologist who has supervised for the past 20 years, or are they equivalent? Serious question, just trying to generate discussion.

 

[Noyac]

Honestly Noyac, how is this not self explanatory. While I understand that you and I are in the minority, how can simple deductive reasoning not explain the loss of skills in supervisory only models.

Because their heads are in the sand purposely. It's easy to ignore reality when you are raking in the cash. Instead they say, what skills?

 

[Noyac]

If you were having a major surgery (Whipple, big spine case, something along those lines), and your case was being done by a solo anesthesiologist, would you rather be taken care of by an anesthesiologist who has done all his own cases for the past 20 years, or by an anesthesiologist who has supervised for the past 20 years, or are they equivalent? Serious question, just trying to generate discussion.

You know who I want.
But some think they are so good that they would probably rather supervise the 20 yr solo guy/gal since it would be a waste of their skills to have to be in the room the entire time charting and whatnot.

 

[BLADEMDA]

Because their heads are in the sand purposely. It's easy to ignore reality when you are raking in the cash. Instead they say, what skills?

It's all about the cash. At 4:1 or even 5:1 the profits can be maximized so the business aspect of the field takes precedent over everything else. Most practices could squeeze in an Appy or Tonsillectomy into the schedule with the MD in the room. The request would need to be the second or third case of the day most likely but it can be done. Legally, I'd need to keep the CRNA with me to do the case because I'm covering the other rooms but I'd manage to be there for the 15-20 minutes.

As for the ACT practice model which I've dealt with for decades, the best part of the model is simply the money it generates; the care is inferior to the MD only model which predominates out West. That said, there is no way economically the MD model works with a lot of CMS patients. The reimbursements are too low.

Like it or not the ACT model is here to stay until it gets replaced by the AANA collaborative model when single payer gets passed. As long as NOY has private payers and a limited amount of CMS he can do his own cases.

I never knew that after Residency my main job was going to be "supervising nurses" who would actually do the cases. During my era I believed that I would actually deliver anesthesia on a personal level day to day. I did that enough for the first half of my career to develop me into an excellent supervisor. The model which exists today of 100% supervision post residency isn't a particularly good one no matter how much money Mman makes each year.

 

[IlDestriero]

Thanks but really I'm no Saint.
I do however, like to call out people that are not and that are raping our specialty.
Where should I place you?

I'm definitely not a Saint. I won't work on my vacation. Nope, nope, nope! I also don't get paid by the case/unit, so I'd be working essentially for free, on my vacation, to accommodate a request that anyone could probably do fine.
I also don't reschedule myself from the generally chill and early exit ambulatory surgery center to do a request case at the big house. "Sorry, I'm not at the main hospital that day." If it's a particularly challenging case/patient, I add a recommendation for someone who is there that day who I think would be a good choice.


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Il Destriero

 

[Gastrapathy]

Enlightening thread. Some Anesthesiologists think they provide better care than CRNAs but will only do so on their own terms when it's convenient or financially favorable. "VIP medicine" which in this context is asking for an anesthesiologist can apparently lead to worse outcomes. Some anesthesiologists can't do the basics anymore.

We're looking at our anesthesia options and I've been an advocate for hiring a physician. I don't think that's changed but now I will scrutinize the cv a little more and maybe care a little less. I guess I didn't understand how completely the CRNA influx has created a nursing culture rather than a physician culture in anesthesia.

 

[pgg]

Enlightening thread. Some Anesthesiologists think they provide better care than CRNAs but will only do so on their own terms when it's convenient or financially favorable. "VIP medicine" which in this context is asking for an anesthesiologist can apparently lead to worse outcomes. Some anesthesiologists can't do the basics anymore.

We're looking at our anesthesia options and I've been an advocate for hiring a physician. I don't think that's changed but now I will scrutinize the cv a little more and maybe care a little less. I guess I didn't understand how completely the CRNA influx has created a nursing culture rather than a physician culture in anesthesia.

Oh come on, this pearl clutching drama is ridiculous.

By all means, scrutinize the CV. You should. But don't make the mistake of thinking that some anesthesiologists' practice setup and reluctance to make exceptions for VIP care* somehow bootstraps CRNA care to be equivalent to physician care. If you're hoping to save a couple bucks by hiring a nurse, and this thread is the excuse you need ... your mind was already made up.



* something widely acknowledged as increasing risk, by the way