Pts requesting Anesthesiologist

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
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
Is asking for MD-only anesthesia really VIP care though?

Members don't see this ad.
 
  • Like
Reactions: 1 users
Is asking for MD-only anesthesia really VIP care though?
Only in an ACT place.

Any place that puts quality before money should push for MD-only anesthesia, with all MDs being equal partners.

@Gastrapathy, before you make up your mind, please also read this and the respective thread.
 
  • Like
Reactions: 1 users
Members don't see this ad :)
@Gastrapathy, before you make up your mind, please also read this and the respective thread.[/QUOTE]

I'm a believer. There's no reason for me to believe that your nurses are better than primary care and I see their suck daily. I was more just irritated that my kid had a pediatric surgeon and a CRNA in the room. It was a long 65 minutes. Finding a quality physician who wants a GI anesthesia practice is a separate discussion.
 
  • Like
Reactions: 1 user
@pgg

Ok.

Its your forum.

Uh, was it really this thread or the consideration of making considerable money off of anesthesia (by paying CRNAs a salary) that led you to consider staffing your clinic with CRNA led anesthesia? I'm dubious if you claim the former, and that's only based on my prior experiences with GI docs.

I don't really get the outcry here, but SDN has a history of being a very odd place. One single doc said his practice couldn't accommodate a MD personally doing the case. So what? Why anyone cares is beyond me. Talk to the surgeon and see if there are alternatives. Another hospital. Another group. There are tons of places, most in fact, that'd be willing to offer a doc do the case. But that's just my feeling as I admittedly don't know for a fact.

A tonsil is a ditzel case. If I have a ditzel problem and show up in the internists office, or the ED, or the GI clinic, and see a NP does that mean the field is absolutely done for and massacred by nurses? Because it's absolutely plausible that'd happen.
 
And some here seem shattered at financial considerations, as if it's isolated to Anesthesia. Those same issues arise in every field of medicine, every day.
 
Last edited:
  • Like
Reactions: 1 user
Gastrapathy said:
I'm a believer. There's no reason for me to believe that your nurses are better than primary care and I see their suck daily. I was more just irritated that my kid had a pediatric surgeon and a CRNA in the room. It was a long 65 minutes. Finding a quality physician who wants a GI anesthesia practice is a separate discussion.
Just don't hire an AMC which advertises MD-only anesthesia, mostly for financial reasons (I see it happening more and more). An overworked employed doc is just not what I associate with quality, even if everything is "protocolized".
 
There's a solid chance if I show up in the ED today, or ANY medical clinic tomorrow, I'm likely to encounter a midlevel provider. Why do people feel it should be different with Anesthesia?
 
Wasn't a tonsil but probably was a ditzel case. She was admitted and it was time to act so there was no shopping around. I caved pretty fast after asking.

I don't want to be more specific but there is not a financial incentive to hiring a CRNA. The main advantage is that if we fund a physician spot, the anesthesia group might not let us have them all the time (call, etc) but they would leave a CRNA alone.
 
There's a solid chance if I show up in the ED today, or ANY medical clinic tomorrow, I'm likely to encounter a midlevel provider. Why do people feel it should be different with Anesthesia?

I guess that's the question. Is it different? I thought anesthesia was higher stakes and more complex than nursemaid elbow reductions in fast-track.
 
  • Like
Reactions: 1 user
I don't want to be more specific but there is not a financial incentive to hiring a CRNA. The main advantage is that if we fund a physician spot, the anesthesia group might not let us have them all the time (call, etc) but they would leave a CRNA alone.

My apologies. Just about every GI doc I know staffs their clinic or their outpatient center with a CRNA who they 'supervise'. They pay the CRNA a salary and make a real nice profit billing for the anesthesia.

With regard to the tonsil I was referring to the OP. As to your daughter, I have children of my own so I understand your stress and where you are coming from. I hope she's okay. I'm sorry you couldn't get an anesthesiologist to do the case solo, but an anesthesiologist supervising a CRNA is a perfectly acceptable and routine way in which many practice every single day across the country.
 
There's a solid chance if I show up in the ED today, or ANY medical clinic tomorrow, I'm likely to encounter a midlevel provider. Why do people feel it should be different with Anesthesia?
Perhaps on an urgent/emergent basis, but if you call a few weeks ahead at most clinics and ask to see a physician it can usually be accommodated.

If I need urgent/emergent surgery then I'll take whoever is available, obviously. If it's an elective case 3 weeks out is it really too much to ask to have MD-only anesthesia.
 
  • Like
Reactions: 2 users
Members don't see this ad :)
Perhaps on an urgent/emergent basis, but if you call a few weeks ahead at most clinics and ask to see a physician it can usually be accommodated.

If I need urgent/emergent surgery then I'll take whoever is available, obviously. If it's an elective case 3 weeks out is it really too much to ask to have MD-only anesthesia.

It's really not! Not even close. And every single doc here said you'd get it, minus one. And if not a single doc in Mman's practice would stay post call, or come in on a day off, to take care of a fellow physician then that's on them. But I don't think it should reflect on the entire specialty which was the direction this thread took.
 
  • Like
Reactions: 5 users
I'm a believer. There's no reason for me to believe that your nurses are better than primary care and I see their suck daily. I was more just irritated that my kid had a pediatric surgeon and a CRNA in the room. It was a long 65 minutes. Finding a quality physician who wants a GI anesthesia practice is a separate discussion.

I totally understand.

My oldest son has twice needed GA. Both times I asked for physician-only anesthesia, and was able to get it.
 
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.


--
Il Destriero
I think you are talking more about "special" request. This thread is just about requesting a doctor, not a nurse. So if I read your post correctly, it is possible to request a doc in your practice.
 
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.
Please don't misunderstand this debate we have going in here. We are comparing anesthesiologists to anesthesiologists. Not anesthesiologists to nurses. Even an anesthesiologist that hasn't done their own cases in years are better than nurses in the long run.
 
  • Like
Reactions: 1 users
A tonsil is a ditzel case. If I have a ditzel problem and show up in the internists office, or the ED, or the GI clinic, and see a NP does that mean the field is absolutely done for and massacred by nurses? Because it's absolutely plausible that'd happen.
Welcome back Southpaw, haven't seen your posts in a while. Or maybe I've just missed them.
I agree that "most" tonsils are dither cases. But I've seen them go badly and that's when you want someone that's been there. Bovie to the carotid comes to mind. Seen it twice. Anyway, it's nothing like a ditzy like in the internists office.
 
  • Like
Reactions: 1 user
There's a solid chance if I show up in the ED today, or ANY medical clinic tomorrow, I'm likely to encounter a midlevel provider. Why do people feel it should be different with Anesthesia?
Because we deal in seconds, not hours.
 
  • Like
Reactions: 5 users
Because we deal in seconds, not hours.


I 100% agree. I absolutely believe that if a patient requests a physician provided anesthetic they should have it. But I also understand that midlevels have a role in healthcare. They aren't going anywhere. I can appreciate what a CRNA brings to the table while at the same time absolutely, vehemently oppose the AANA agenda.

And I shouldn't forget to mention that as a field, we should push for AA legislation in every state.
 
There's a solid chance if I show up in the ED today, or ANY medical clinic tomorrow, I'm likely to encounter a midlevel provider. Why do people feel it should be different with Anesthesia?
ED attending here - where I work, it would depend on your acuity. T Certain complaints that generate a higher ESI based on standard questions, vital signs or nurse impression/upgrade are seen by the ED MD. This is pretty standard across all of the places I've worked so far. That said, certain patients seen by midlevels almost certainly did not meet the ESI criteria and still have something seriously wrong with them. It's up to the midlevel to find and fix that problem or let me know about it - otherwise we don't discuss (shudder) cases until I'm signing the chart (double shudder).

On another thought, it is strange to me how threatened anesthesiologists feel from CRNAs, but that from a job-replacement perspective how comfortable I feel with midlevels in the ED. Maybe I just don't see the sucker punch coming.
 
We use an ACT approach. All the OR staff, surgeons, and family members of staff usually know the rankings of MDA and CRNA. They request both CRNA and MDA and we try to accommodate. Most of us MD's do come in when we can (post call, vacation if in town, or short day). The only people who ask for "MD only" are people who are not familiar with the hospital and how our anes dept works. Once we explain the ACT model, they are fine with it because I tell them when something bad happens, there are two sets of hands and brains trying to solve problems.

We are 'lean.' Aren't you? Who has money to spend for a CRNA or MD just hanging around? Before, the ACT model was about greed, now it is medical economics. Are we MD's entitled to make more than CRNA's? My 8 years versus their 2 1/2 years? Maybe we are not entitled, but hopefully our training has made us better, wiser. The top CRNA's are as good as us, but the rest......are definitely not. I have 'medically directed' 1:3 - 1:4 for many years and I have seen so many 'fires' put out by me or the covering MD. These medical misadventures would have turned into major harm. I don't know if it's serendipity/luck/spider-sense/God, but I have been blessed to check on rooms right as a significant event is occurring. There is a great variance in the quality of CRNA's (I know I have seen it) and I hope you get a good one when your family is under their care. The eyes of CRNA's would be open wide with disbelief if they had to oversee 4 of their colleagues every day for years. The shout of "CRNA's are as good as MD's" would be loud but empty of meaning. Fortunately for me, all our CRNAs are above average to top notch. (We have monitors in our MD office which is basically immediately next to the PACU and OR's. These monitors are connected to all OR monitors so we can see all VS, ECG, p-ox, ETCO2, waveforms..etc. MD and CRNA all carry $600 walkie talkies, and the hospital has a transponder to boost output so they can go through OR walls. PACU and preop area has one too. We also communicate with texts.)

The ACT model does make you rusty in the 'flow.' Put me in a room and it will show--not in quality of care, but speed. I would be slowed down by charting, timing, etc. I would do the one request ENT case, but I would not put myself in the room for all the cases. The ENT would not get to dinner on time. The advantage of the ACT model is I have experienced more than someone who sits in the room and sees 4- 8 cases a day, especially if healthy and uneventful. I am involved in care of 12 - 24+ patients a day -- from preoperative assessment, anesthetic plan, post operative care.. It is a great education, but horrible liability. Most of my patients are not healthy. Healthy, skinny, young patients are the minority to rare. Over the past 5 years in-hospital endoscopy patients have become our sickest patients with the most complications.

The next 10-20 years are going to be interesting. I feel sorry for any medical specialty that has a mid level provider. Not a week goes by when some nurse at my hospital says they are going to nurse practitioner school. This great medical experiment can't be stopped. One day, a patient is going to say, "can I get a MD to do the anesthesia?," and the answer will be "sorry, no MD anesthesia works here."
 
  • Like
Reactions: 2 users
The top CRNA's are as good as us...

Do you truly believe this? Because I genuinely take offense to you thinking a CRNA is as good as me at anything, except for maybe monkey procedural skills like intubating that take no brain power. And I think many on this board would feel similarly.

Fortunately for me, all our CRNAs are above average to top notch.

And if you truly do believe the first quote, it sounds like you think that many of the CRNAs that work with you are as good as the MDs in your group.
 
  • Like
Reactions: 5 users
Do you truly believe this? Because I genuinely take offense to you thinking a CRNA is as good as me at anything, except for maybe monkey procedural skills like intubating that take no brain power. And I think many on this board would feel similarly.



And if you truly do believe the first quote, it sounds like you think that many of the CRNAs that work with you are as good as the MDs in your group.

Yeah....I've worked with I don't know how many hundreds of CRNAs and the best ones (a SMALL minority) are about as good as a pgy2. Haven't met one yet that I would feel safe having solo anesthesia with.
 
  • Like
Reactions: 1 user
Don't think he was trying to be overly sarcastic or condescending. If you read the post again I believe he was saying something like I said two posts ago.

Agreed.

I deleted a post there that was too argumentative anticipating that it was going to lead to the usual GI vs anesthesia tussle.
 
  • Like
Reactions: 1 users
Do you truly believe this? Because I genuinely take offense to you thinking a CRNA is as good as me at anything, except for maybe monkey procedural skills like intubating that take no brain power. And I think many on this board would feel similarly.



And if you truly do believe the first quote, it sounds like you think that many of the CRNAs that work with you are as good as the MDs in your group.

I don't know you. You can be a star. Every anesthesia group has their Jedi. You could be the Jordan of MDA's so no CRNA will come close. One doc in my group is our Yoda. We all ask his opinion on difficult cases or 1st clinical encounters. There are so many skills involved in anesthesia: knowledge, experience, intuition, manual skills, when to intervene or let CRNA figure it out, or let the CRNA make the mistake (as long as it causes no pt harm), how to talk to surgeons, how to compromise, when to hold your ground, when to take risks, courtesy to staff no matter their rank or status, how to talk to patients and make that quick connection so that they trust your care, how to diffuse situations, how to talk to families after poor outcome, to prioritize tasks in critical and immediate situations, etc... Most of medicine is not difficult. The difficult part of medicine is the ungodly amount of information to memorize. Those things that are very difficult in medicine are only difficult because of lack of cumulative training, experience or cursory knowledge.

Do you think just because you are a doctor you are better than every CRNA out there? You never call for help from fellow MD's because you are smarter than all your MD's in your group? You didn't think that many of our medical school classmates were a "bit off," strange, poorly socialized, no common sense, etc. You don't have fellow MDs that make patient decisions that you don't agree with? Maybe you are so smart that no one here on the forum can touch your skills, knowledge, and experience, but there are some smart CRNA's out there. The majority of the CRNA's, I have met, seem less able than a below average MD. Even Yoda's make mistakes: an ortho doc wanted to do a redo TKA (not septic) on a ASA 4 patient. All the MD's said no but our Yoda. He has skills, knowledge and experience. I said the patient would die either in the OR or postoperatively (I know my limitations). I said I would not do the case. The ortho scheduled the case when Yoda was on call. Well, that patient died POD 2. If you are a star, I would put up our Yoda against you any day, even not knowing you.

The most import skill is to know your strengths and weakness so you know when to call for help. Every CRNA has a different 'call for help'-meter. When I get a call from CRNA A, I know that I have to move quick because they rarely call unless it is something difficult and important. Other CRNA's call too early. The worst ones are those who don't call until it is a bit too late.
I know my limitations. Maybe against you, you are better. I am no Yoda, but as an overall package....not many like me. Against CRNA's... ya there were a handful over the past +20 years that were pretty darn good.
In a ACT setup, what is needed from the CRNA's are different from the MD's. We need CRNAs that can do the manual labor efficiently -- quick, careful, quick turnover, don't get into trouble, get along with surgeons, connect with patients, practice great basic anesthesia, and KNOW when to call for help/consult. We need MD's that can efficiently do the juggling of 4 rooms, when to give and take with the surgeons, connect with the patient, know how to put out CRNA fires big and small, great manual skills, and when to say NO.
 
I don't know you. You can be a star. Every anesthesia group has their Jedi. You could be the Jordan of MDA's so no CRNA will come close. One doc in my group is our Yoda. We all ask his opinion on difficult cases or 1st clinical encounters. There are so many skills involved in anesthesia: knowledge, experience, intuition, manual skills, when to intervene or let CRNA figure it out, or let the CRNA make the mistake (as long as it causes no pt harm), how to talk to surgeons, how to compromise, when to hold your ground, when to take risks, courtesy to staff no matter their rank or status, how to talk to patients and make that quick connection so that they trust your care, how to diffuse situations, how to talk to families after poor outcome, to prioritize tasks in critical and immediate situations, etc... Most of medicine is not difficult. The difficult part of medicine is the ungodly amount of information to memorize. Those things that are very difficult in medicine are only difficult because of lack of cumulative training, experience or cursory knowledge.

Do you think just because you are a doctor you are better than every CRNA out there? You never call for help from fellow MD's because you are smarter than all your MD's in your group? You didn't think that many of our medical school classmates were a "bit off," strange, poorly socialized, no common sense, etc. You don't have fellow MDs that make patient decisions that you don't agree with? Maybe you are so smart that no one here on the forum can touch your skills, knowledge, and experience, but there are some smart CRNA's out there. The majority of the CRNA's, I have met, seem less able than a below average MD. Even Yoda's make mistakes: an ortho doc wanted to do a redo TKA (not septic) on a ASA 4 patient. All the MD's said no but our Yoda. He has skills, knowledge and experience. I said the patient would die either in the OR or postoperatively (I know my limitations). I said I would not do the case. The ortho scheduled the case when Yoda was on call. Well, that patient died POD 2. If you are a star, I would put up our Yoda against you any day, even not knowing you.

The most import skill is to know your strengths and weakness so you know when to call for help. Every CRNA has a different 'call for help'-meter. When I get a call from CRNA A, I know that I have to move quick because they rarely call unless it is something difficult and important. Other CRNA's call too early. The worst ones are those who don't call until it is a bit too late.
I know my limitations. Maybe against you, you are better. I am no Yoda, but as an overall package....not many like me. Against CRNA's... ya there were a handful over the past +20 years that were pretty darn good.
In a ACT setup, what is needed from the CRNA's are different from the MD's. We need CRNAs that can do the manual labor efficiently -- quick, careful, quick turnover, don't get into trouble, get along with surgeons, connect with patients, practice great basic anesthesia, and KNOW when to call for help/consult. We need MD's that can efficiently do the juggling of 4 rooms, when to give and take with the surgeons, connect with the patient, know how to put out CRNA fires big and small, great manual skills, and when to say NO.

How does lunch work whil covering 4 rooms? Do people just not eat, or is there another doc getting people out to eat?
 
I don't know you. You can be a star. Every anesthesia group has their Jedi. You could be the Jordan of MDA's so no CRNA will come close. One doc in my group is our Yoda. We all ask his opinion on difficult cases or 1st clinical encounters. There are so many skills involved in anesthesia: knowledge, experience, intuition, manual skills, when to intervene or let CRNA figure it out, or let the CRNA make the mistake (as long as it causes no pt harm), how to talk to surgeons, how to compromise, when to hold your ground, when to take risks, courtesy to staff no matter their rank or status, how to talk to patients and make that quick connection so that they trust your care, how to diffuse situations, how to talk to families after poor outcome, to prioritize tasks in critical and immediate situations, etc... Most of medicine is not difficult. The difficult part of medicine is the ungodly amount of information to memorize. Those things that are very difficult in medicine are only difficult because of lack of cumulative training, experience or cursory knowledge.

Do you think just because you are a doctor you are better than every CRNA out there? You never call for help from fellow MD's because you are smarter than all your MD's in your group? You didn't think that many of our medical school classmates were a "bit off," strange, poorly socialized, no common sense, etc. You don't have fellow MDs that make patient decisions that you don't agree with? Maybe you are so smart that no one here on the forum can touch your skills, knowledge, and experience, but there are some smart CRNA's out there. The majority of the CRNA's, I have met, seem less able than a below average MD. Even Yoda's make mistakes: an ortho doc wanted to do a redo TKA (not septic) on a ASA 4 patient. All the MD's said no but our Yoda. He has skills, knowledge and experience. I said the patient would die either in the OR or postoperatively (I know my limitations). I said I would not do the case. The ortho scheduled the case when Yoda was on call. Well, that patient died POD 2. If you are a star, I would put up our Yoda against you any day, even not knowing you.

The most import skill is to know your strengths and weakness so you know when to call for help. Every CRNA has a different 'call for help'-meter. When I get a call from CRNA A, I know that I have to move quick because they rarely call unless it is something difficult and important. Other CRNA's call too early. The worst ones are those who don't call until it is a bit too late.
I know my limitations. Maybe against you, you are better. I am no Yoda, but as an overall package....not many like me. Against CRNA's... ya there were a handful over the past +20 years that were pretty darn good.
In a ACT setup, what is needed from the CRNA's are different from the MD's. We need CRNAs that can do the manual labor efficiently -- quick, careful, quick turnover, don't get into trouble, get along with surgeons, connect with patients, practice great basic anesthesia, and KNOW when to call for help/consult. We need MD's that can efficiently do the juggling of 4 rooms, when to give and take with the surgeons, connect with the patient, know how to put out CRNA fires big and small, great manual skills, and when to say NO.
Everything you mentioned is subjective. I follow the train of thought, sort of, but it's jumbled and factless. Please either support your contentions or state them as observations of your own.
 
Do you think just because you are a doctor you are better than every CRNA out there?

Yes. Because, by definition, anesthesiology is a practice of medicine, and as a physician, I am better at practicing medicine than any nurse you can find.

If you start including things like talking to families than blurs the line between physicians and nurses, sure they may be better than me. But I am saying I am better at practicing medicine than a nurse, by definition.

Next you should head over to the orthopedics forum and ask the surgeons if they really think they are better at surgery than every PA out there.
 
  • Like
Reactions: 1 users
On another thought, it is strange to me how threatened anesthesiologists feel from CRNAs, but that from a job-replacement perspective how comfortable I feel with midlevels in the ED. Maybe I just don't see the sucker punch coming.

I'm going to preface this with stating I have no real idea how different EDs are staffed or the correlation with acuity and also that I am certainly not saying what you guys do is easy etc.

But I think the difference in our (Anesthesia vs EM) situations other than ours is just much much further along than yours is, is that we consider all of our patients as being in a life endangering status. I have no idea the level of acuity of the place you work in nor how many docs are there per shift, but I imagine the average pt that comes into your ED isn't what most think of as emergencies (again, not implying they can't be sick, or the walking dead that requires your knowledge to differentiate). So as such, on average, you likely have the ability to float and provide care to those most likely to need your attention. It appears the EM world has done well protocolizing this as you speak of some ESI index that filters those that need to see a doc. You also primarily use PAs, which so far, aren't seen as independent providers. Imagine if your hospital only hired DNPs, and then they slowly but surely stopped following your orders, requiring you to "stop micromanaging" to "get along". It wouldn't be long until the DNPs felt they didn't need you, felt underpaid, and admin started thinking maybe they could skimp on a doc here and there to test the waters.

In our world, every single patient is in a pharmacological coma, with ever increasing comorbidities, while a surgeon does a tap dance on their autonomics (at a minimum), and as such, as the saying goes, we live in a world of seconds, not minutes/hours. In our world there is no ESI method. CRNAs for the most part do most cases, hell, at my residency program they did hearts, heads, and transplants. Practices run pretty lean, especially in academics, and as such docs are constantly supervising 2-4 rooms. The CRNAs start to gain leverage once the critical mass is reached as they realize cases don't get done without them.

In the end, it's an ever progressing degradation of physician driven care, and it would be wise to recognize it early.
 
I'm going to preface this with stating I have no real idea how different EDs are staffed or the correlation with acuity and also that I am certainly not saying what you guys do is easy etc.

But I think the difference in our (Anesthesia vs EM) situations other than ours is just much much further along than yours is, is that we consider all of our patients as being in a life endangering status. I have no idea the level of acuity of the place you work in nor how many docs are there per shift, but I imagine the average pt that comes into your ED isn't what most think of as emergencies (again, not implying they can't be sick, or the walking dead that requires your knowledge to differentiate). So as such, on average, you likely have the ability to float and provide care to those most likely to need your attention. It appears the EM world has done well protocolizing this as you speak of some ESI index that filters those that need to see a doc. You also primarily use PAs, which so far, aren't seen as independent providers. Imagine if your hospital only hired DNPs, and then they slowly but surely stopped following your orders, requiring you to "stop micromanaging" to "get along". It wouldn't be long until the DNPs felt they didn't need you, felt underpaid, and admin started thinking maybe they could skimp on a doc here and there to test the waters.

In our world, every single patient is in a pharmacological coma, with ever increasing comorbidities, while a surgeon does a tap dance on their autonomics (at a minimum), and as such, as the saying goes, we live in a world of seconds, not minutes/hours. In our world there is no ESI method. CRNAs for the most part do most cases, hell, at my residency program they did hearts, heads, and transplants. Practices run pretty lean, especially in academics, and as such docs are constantly supervising 2-4 rooms. The CRNAs start to gain leverage once the critical mass is reached as they realize cases don't get done without them.

In the end, it's an ever progressing degradation of physician driven care, and it would be wise to recognize it early.

Em is a relatively new field compared to anesth. Also before anesthesiology developed into a medical field, nurses did the anesthesia part whether it's get the patient drunk on vodka or whatever. So we are much further along than EM is with the mid creeping
 
Do you think just because you are a doctor you are better than every CRNA out there?
Yes.

By definition.
By training.
By experience.

It's pitiful you even ask that question and try to make an argument from it to justify the ACT model that's destroyed this field. If CRNAs are so spectacular why don't they become the firemen and replace you.
 
Last edited:
  • Like
Reactions: 1 users
My 0.02:

Through a couple years of residency, I had one patient that had recurrent surgeries request me each time she came in [near the end she was having monthly tracheal dilations, after multiple thoracotomies/eloesser/trach/serial bronchs/washouts]. Even if I was off-service, my program would go pretty far to get me into her case [or at least come place her IV], so she was happy. This practice was the norm with many request cases at our institution, and I ended up caring for the mothers and fathers of my attendings on several occasions as a result. I don't doubt it had a lot to do with patient satisfaction scores, but it was easy for the boardrunners to accommodate at a massive teaching hospital.

I was a resident, but if all the patient wants is a doctor caring for her, that seems like a terribly reasonable and incredibly easy-to-fulfill request in academic medicine. They had a physician performing their anesthesia. And it didn't mess up our staffing. I can understand it being impossible in some practice models, but in reality some of the statements in this thread are outlandish, given the academic bent of a lot of this forum.

With that said, I had surgery at 1500h on a Friday during residency and had an attending of my choosing caring for me. They once again made the staffing model work, by nominally giving him CRNAs/AAs in the rooms he was supervising so that he could spend 100% of his time in my OR [his choice, not mine].

A huge part of the practice of anesthesiology is enthusiastically providing a worthwhile service to those around us [surgeons, hospital, ICU, PACU nurses], and with so many surrogate goods available, I can't understand why I wouldn't bend over backwards to make these kinds of requests happen, even if it means a little work. Especially so if it makes the surgeon happy in the process.
 
  • Like
Reactions: 1 users
With that said, I had surgery at 1500h on a Friday during residency and had an attending of my choosing caring for me. They once again made the staffing model work, by nominally giving him CRNAs/AAs in the rooms he was supervising so that he could spend 100% of his time in my OR [his choice, not mine].
If you were one of the patients in your attending's other rooms, how would you feel if you found out that he had dedicated all his time to another ("VIP") patient? Do you think that's fair, ethical, or the right thing to do? ;)
A huge part of the practice of anesthesiology is enthusiastically providing a worthwhile service to those around us [surgeons, hospital, ICU, PACU nurses], and with so many surrogate goods available, I can't understand why I wouldn't bend over backwards to make these kinds of requests happen, even if it means a little work. Especially so if it makes the surgeon happy in the process.
You will make a great CRNA, when you're done with your fellowship. Keeping the surgeons happy is what bean counters love to hear, but it's the wrong reason for a good physician. There are even oral board scenarios about making the surgeon unhappy (I had one). Always do what's right for ALL your patients, not just the VIP. If you want to make the surgeon happy, do it in your own spare time, not your patients' OR time.

If the ACT practice doesn't have an extra physician just sitting around at the time of the surgery, it shouldn't happen. The right way to do this is to schedule the case at the end of the day, when there is an extra person available to do the case solo (or take over your rooms). Just because we can cover more rooms, doesn't mean we should, just so that one special patient gets special treatment (on the others' expense). Also, spending time mostly in the VIP room while covering others, too, is a huge ethical (and probably legal) no-no. (Not to mention it's totally hypocritical for a profession which advertises the necessity for medical direction of CRNAs as "When seconds count...".) ;)
 
Last edited by a moderator:
If you were one of the patients in your attending's other rooms, how would you feel if you found out that he had dedicated all his time to another ("VIP") patient? Do you think that's fair, ethical, or the right thing to do? ;)

You will make a great CRNA, when you're done with your fellowship. Keeping the surgeons happy is what bean counters love to hear, but it's the wrong reason for a good physician. There are even oral board scenarios about making the surgeon unhappy (I had one). Always do what's right for ALL your patients, not just the VIP. If you want to make the surgeon happy, do it in your own spare time, not your patients' OR time.

If the ACT practice doesn't have an extra physician just sitting around at the time of the surgery, it shouldn't happen. The right way to do this is to schedule the case at the end of the day, when there is an extra person available to do the case solo (or take over your rooms). Just because we can cover more rooms, doesn't mean we should, just so that one special patient gets special treatment (on the others' expense). Also, spending time mostly in the VIP room while covering others, too, is a huge ethical (and probably legal) no-no. (Not to mention it's totally hypocritical for a profession which advertises the necessity for medical direction of CRNAs as "When seconds count...".) ;)

Don’t straw man me.

The point I made is that safe patient care, a happy surgeon, and a happy patient are not mutually exclusive. I think part of being a good anesthesiologist is reconciling the three in a slick fashion.

Regardless, I was simply offering that in the practice where I trained, requests were easily accommodated. And it has nothing to do with VIP care when it just involves the board runner swapping rooms or having me come down from the CVICU to preop to place an IV and see the patient. At some point when it is that easy, it is the right thing to do.

As for your ethical question, as I mentioned there was an AA that I love assigned to my room and certainly was involved in my care. My point was that it was the attending’s choice to be present, whereas normally he wouldn’t be in the room the whole time. It’s not like he had tons of patients to preop at that time anyway. It wasn’t even something I requested. I simply asked that he staff the case because - life being a mixed bag - there were faculty I didn’t trust with my life in the same practice. Life is filled with good nurses and bad nurses, good doctors and bad doctors - sometimes it’s best to choose your fate when you’re offered a choice. (From the (me) patient’s perspective)
 
If you were one of the patients in your attending's other rooms, how would you feel if you found out that he had dedicated all his time to another ("VIP") patient? Do you think that's fair, ethical, or the right thing to do? ;)

You will make a great CRNA, when you're done with your fellowship. Keeping the surgeons happy is what bean counters love to hear, but it's the wrong reason for a good physician. There are even oral board scenarios about making the surgeon unhappy (I had one). Always do what's right for ALL your patients, not just the VIP. If you want to make the surgeon happy, do it in your own spare time, not your patients' OR time.

If the ACT practice doesn't have an extra physician just sitting around at the time of the surgery, it shouldn't happen. The right way to do this is to schedule the case at the end of the day, when there is an extra person available to do the case solo (or take over your rooms). Just because we can cover more rooms, doesn't mean we should, just so that one special patient gets special treatment (on the others' expense). Also, spending time mostly in the VIP room while covering others, too, is a huge ethical (and probably legal) no-no. (Not to mention it's totally hypocritical for a profession which advertises the necessity for medical direction of CRNAs as "When seconds count...".) ;)

Dude, why you gotta be such a cerebral narcissist all the time?? ;)
 
  • Like
Reactions: 1 user
Don’t straw man me.

The point I made is that safe patient care, a happy surgeon, and a happy patient are not mutually exclusive. I think part of being a good anesthesiologist is reconciling the three in a slick fashion.

Regardless, I was simply offering that in the practice where I trained, requests were easily accommodated. And it has nothing to do with VIP care when it just involves the board runner swapping rooms or having me come down from the CVICU to preop to place an IV and see the patient. At some point when it is that easy, it is the right thing to do.

As for your ethical question, as I mentioned there was an AA that I love assigned to my room and certainly was involved in my care. My point was that it was the attending’s choice to be present, whereas normally he wouldn’t be in the room the whole time. It’s not like he had tons of patients to preop at that time anyway. It wasn’t even something I requested. I simply asked that he staff the case because - life being a mixed bag - there were faculty I didn’t trust with my life in the same practice. Life is filled with good nurses and bad nurses, good doctors and bad doctors - sometimes it’s best to choose your fate when you’re offered a choice. (From the (me) patient’s perspective)
The point I was making is that "slick" doesn't always mean right. When given limited resources, the only way to direct more resources towards a patient is to cut them from another. That's what happened in your case.

Of course, one could argue that the same attending could have just sat in the lounge. But what one should argue is that he should have been logged into his EMR, watching all his rooms like a hawk, regardless how fantastic his midlevels were. Because that's what medical direction means, that's what he bills for, that's what every patient expects. We are not just preop monkeys and firefighters. ;)

Anyway, this is more of an ethical than practical discussion. In the real world, corners get cut all the time to please the mighty surgeon or bean counter (because, if not, he'll "just get somebody else to do it" - another doc today, another group next year). That's how low the specialty has sunk. Hence the ABA scenarios.
 
Last edited by a moderator:
  • Like
Reactions: 1 users
The point I was making is that "slick" doesn't always mean right. When given limited resources, the only way to direct more resources towards a patient is to cut them from another. That's what happened in your case.
.
In my mind "slick" encompasses a lot of things. But good sound practice techniques is definitely at the top of that list. Therefore, slick means "right" in my mind.
 
  • Like
Reactions: 1 user
Don’t straw man me.

The point I made is that safe patient care, a happy surgeon, and a happy patient are not mutually exclusive. I think part of being a good anesthesiologist is reconciling the three in a slick fashion.

Regardless, I was simply offering that in the practice where I trained, requests were easily accommodated. And it has nothing to do with VIP care when it just involves the board runner swapping rooms or having me come down from the CVICU to preop to place an IV and see the patient. At some point when it is that easy, it is the right thing to do.

As for your ethical question, as I mentioned there was an AA that I love assigned to my room and certainly was involved in my care. My point was that it was the attending’s choice to be present, whereas normally he wouldn’t be in the room the whole time. It’s not like he had tons of patients to preop at that time anyway. It wasn’t even something I requested. I simply asked that he staff the case because - life being a mixed bag - there were faculty I didn’t trust with my life in the same practice. Life is filled with good nurses and bad nurses, good doctors and bad doctors - sometimes it’s best to choose your fate when you’re offered a choice. (From the (me) patient’s perspective)
The OP is asking for a Physician to provide care. Not the CRNA/AA physician combo.
 
I am just cerebral. Which is not synonymous with "practical". ;)


But anesthesia and surgery are VERY practical jobs. Our patients come to us for practical solutions to their very practical problems. Like a good plumber or electrician or mechanic we're worth our weight in gold if we do our jobs well. There's no shame in the fact that they are not the most intellectual specialties. They are rather specialties for people who like to solve problems.
 
But anesthesia and surgery are VERY practical jobs. Our patients come to us for practical solutions to their very practical problems. Like a good plumber or electrician or mechanic we're worth our weight in gold if we do our jobs well. There's no shame in the fact that they are not the most intellectual specialties. They are rather specialties for people who like to solve problems.

If anesthesia is not really an intellectual specialty, then why is the OP asking for a physician instead of a CRNA? Or are you saying it's just not as intellectual as IM, but still too difficult for APRNs to do independently? I suppose there are a lot of days and cases where it feels like prop sux tube, turn the knob, rinse and repeat
 
But anesthesia and surgery are VERY practical jobs. Our patients come to us for practical solutions to their very practical problems. Like a good plumber or electrician or mechanic we're worth our weight in gold if we do our jobs well. There's no shame in the fact that they are not the most intellectual specialties. They are rather specialties for people who like to solve problems.
While doing the solo case is practical, it may be very well unethical, thus wrong. Just because we can doesn't mean we should. That's the main difference between a doctor and a CRNA: we don't just "solve problems". Any monkey can "solve problems". We do the right thing for (all) our patients.

Of course most practices will bend over backwards to accommodate a solo request and keep the surgeon (and patient) happy, me included, because that's the real world, and my greedy employer has greedy ethics. But it puts us in an ethical quandary that we, as doctors, should at least realize (and which I have previously explained). So anybody who's so fast at condemning those who say they don't accommodate solo requests should think twice, because those guys may actually be right. Practical doesn't always mean ethical, although it should.

And if you can't get the joke about me not being a cerebral narcissist, just cerebral, that's your problem. Thank you for the career advice, but I don't need it.
 
Last edited by a moderator:
  • Like
Reactions: 1 user
If anesthesia is not really an intellectual specialty, then why is the OP asking for a physician instead of a CRNA? Or are you saying it's just not as intellectual as IM, but still too difficult for APRNs to do independently? I suppose there are a lot of days and cases where it feels like prop sux tube, turn the knob, rinse and repeat

There's a difference between intellectual and well trained. I would not consider most of medicine to be an intellectual endeavor. Physicians are intelligent and very well-trained, that does not make them intellectuals. Anesthesiologists are generally better trained and have a deeper understanding than the average CRNA. I stand by my comment that anesthesia is not a particularly intellectual discipline. Even the most complex cases usually come in 3-4 different flavors. There's not much intellectual challenge. I think FFP would agree. For me the joy and the challenge comes in graceful seamless "slick" execution of these not very intellectual cases. I consider myself a practical problem solver, a doer. We are not tech IP patent lawyers or university math professors. If you think we are using that level of creativity and brain power in our daily tasks, you are kidding yourself.
 
Last edited:
  • Like
Reactions: 1 users
While doing the solo case is practical, it may be very well unethical, thus wrong. Just because we can doesn't mean we should. That's the main difference between a doctor and a CRNA: we don't just "solve problems". Any monkey can "solve problems". We do the right thing for (all) our patients.

Of course most practices will bend over backwards to accommodate a solo request and keep the surgeon (and patient) happy, me included, because that's the real world, and my greedy employer has greedy ethics. But it puts us in an ethical quandary that we, as doctors, should at least realize (and which I have previously explained). So anybody who's so fast at condemning those who say they don't accommodate solo requests should think twice, because those guys may actually be right. Practical doesn't always mean ethical, although it should.

And if you can't get the joke about me not being a cerebral narcissist, just cerebral, that's your problem. Thank you for the career advice, but I don't need it.

I got the joke but I was trying to make a different unrelated point.
 
Top