Surgeons don't care if a monkey is turning the dials on the anesthesia machine

[militarymd]

That title is very accurate. They REALLY don't care....and the hospital administration doesn't care either.

However, there are a few things that they DO care about.

1) Cases don't get delayed...even if they are late
2) Cases don't get cancelled.....you won't learn this in academia
3) Costs are kept low.(personnel, supply, drugs)
4) Order only preop tests that the hospital can get reimbursed for.
5) late cases and night cases get covered.
6) JCAHO measures are kept up for the sake of accreditation.

Those are the things that surgeons and administrators care about....it means the monkey that gets to sit in the chair is a monkey whose willing to work harder, stay longer, and take MORE risk than the next monkey.

One thing that I have learned behind closed doors....Adverse outcome IS accepted.

It's all about the money....for everyone...including the monkey.

The high horse of academia frequently won't make the cut.

---

Members don't see this ad.

 

[Conflicted]

oh so true


Now, what happened recently for you to mention it?

 

[militarymd]

oh so true


Now, what happened recently for you to mention it?

Nothing,

just something that I thought would be good to remind folks about....something Johan said made me think of this.

Also, we are in the process of revising our pre-operative testing protocol....essentially eliminiating it.....No abnormal labs for one to cancel a case over

 

[Conflicted]

heehhehehe

Nothing,

just something that I thought would be good to remind folks about....something Johan said made me think of this.

Also, we are in the process of revising our pre-operative testing protocol....essentially eliminiating it.....No abnormal labs for one to cancel a case over

 

[IN2B8R]

What a striking reminder! I also see monkeys performing laparotomies all the time.

 

[hoboken]

That title is very accurate. They REALLY don't care....and the hospital administration doesn't care either.

However, there are a few things that they DO care about.

1) Cases don't get delayed...even if they are late
2) Cases don't get cancelled.....you won't learn this in academia
3) Costs are kept low.(personnel, supply, drugs)
4) Order only preop tests that the hospital can get reimbursed for.
5) late cases and night cases get covered.
6) JCAHO measures are kept up for the sake of accreditation.

Those are the things that surgeons and administrators care about....it means the monkey that gets to sit in the chair is a monkey whose willing to work harder, stay longer, and take MORE risk than the next monkey.

One thing that I have learned behind closed doors....Adverse outcome IS accepted.

It's all about the money....for everyone...including the monkey.

The high horse of academia frequently won't make the cut.

I have been taking with a number of lawyers recently about hospital liability and they have told me that most many hospitals have significant immunity. So, they have little fear of huge loss due to a bad outcome. They also have significant immunity for the action of licensed practitioners at their faculty. This may vary in different jurisdictions and due to the type of entity public versus private hospital. The net effect is they have almost no liability over anesthesia as long as they see that a licensed provider is giving the anesthesia. The administrators do not care who is doing the anesthesia as long as they are licensed providers. Thus their only motivation is as Mil said to make sure all the cases are covered in a way that is the least expensive to the hospital and is most profitable and least work to the administrators.

Hospitals operate to the sole benefit of the administrators and what ever makes their pay greater and their job easier is their sole motivation and hence the de facto policy of the hospital. The surgeons are important only since they bring patient to the hospital to make money, if that income stream is threatened or the surgeon is to demanding the surgeons will be replaced.

 

[VolatileAgent]

Also, we are in the process of revising our pre-operative testing protocol....essentially eliminiating it.....No abnormal labs for one to cancel a case over

what other risks/compromises are you willing to take/make in order to protect your contract? this is important information for those of us ready to leap into the private practice world.

 

[militarymd]

what other risks/compromises are you willing to take/make in order to protect your contract? this is important information for those of us ready to leap into the private practice world.

Whatever it takes.

 

[aredoubleyou]

Whatever it takes.

That means that your risk is related to the discretion of the surgeon on how he chooses to decide who is appropriate for surgery. At some certain level of compromise you will anesthetize any patient that the surgeon wants to operate on. Theoretically, if a surgeon was more mindful of the bottom line than pt care, could he not take someone to the OR with, for example, a full stomach for an elective case, thereby increasing your risk for litigation as it seems the anesthesiologist are the ones who get ultimately sued for these types of things? Maybe a bad example, but u get the idea.

 

[DrDre']

Lately, all these threads worry/piss me off. I didn't go into "business" for a reason. I guess I will have to do LT or academia if I want to be to the side of these issues.

To the attendings on here:

there seems to be such a dichotomy between what academia teaches and how PP practices. As "cavalier" as you PP guys sound, it makes me think one of several things: either anesthesia is so easy and safe that anyone could do it on any pt and thus I will be bored to death in short order or you guys are pushing the envelop constantly on what is reasonably safe for a given pt...

I know you guys are good at what you do but these posts about making the surgeon happy at any cost seems dangerous to me.

That means that your risk is related to the discretion of the surgeon on how he chooses to decide who is appropriate for surgery. At some certain level of compromise you will anesthetize any patient that the surgeon wants to operate on. Theoretically, if a surgeon was more mindful of the bottom line than pt care, could he not take someone to the OR with, for example, a full stomach for an elective case, thereby increasing your risk for litigation as it seems the anesthesiologist are the ones who get ultimately sued for these types of things? Maybe a bad example, but u get the idea.

 

[Planktonmd]

Whatever it takes.

Are you serious?
this is a very strong statement!
Will you really do anything just to keep the contract??

 

[Conflicted]

Hmm

I understand what mil is saying totally.

It has been established in the literature that the majority of preop labs/tests are TOTALLY uneeded. So it isnt like he is putting patients at risk. However, its always nice to do a few tests prior just to know for sure, but its a comfort thing.

The other issue is having a job. If it is the case that you will lose a contract over doing something that isnt supported (ergo: not paid for) then why not comply? What is it he is doing that is so dangerous and wrong? The fact is, the preops done in teaching institutions are NOT nessairy.

 

[Noyac]

That title is very accurate. They REALLY don't care....and the hospital administration doesn't care either.

However, there are a few things that they DO care about.

1) Cases don't get delayed...even if they are late
2) Cases don't get cancelled.....you won't learn this in academia
3) Costs are kept low.(personnel, supply, drugs)
4) Order only preop tests that the hospital can get reimbursed for.
5) late cases and night cases get covered.
6) JCAHO measures are kept up for the sake of accreditation.

Those are the things that surgeons and administrators care about....it means the monkey that gets to sit in the chair is a monkey whose willing to work harder, stay longer, and take MORE risk than the next monkey.

One thing that I have learned behind closed doors....Adverse outcome IS accepted.

It's all about the money....for everyone...including the monkey.

The high horse of academia frequently won't make the cut.

While all of this is true, very true in fact. I will submit that surgeons do care who is turning the dials in certain circumstances. Most of you here know that I have taken over a practice that fell apart some 4 years ago. I know that my job is only as secure as the next persons job. But after going through 1 year of locums only, this place isn't about to put themselves in that position again in the near future, as long as the points Mil mentioned above are covered. Our surgeons are involved in the interviewing of new prospects and are very interested in who we hire. It is ultimately our choice but they are aware of the choice and why. We still get special request for certain cases from surgeons (we are trying to qwell that however) b/c of their belief that not all anesthesiologists are equal. Bottomline, don't be too discouraged. They do care who is turning the dials as long as all the chips are in order. But if it comes down to doing the case or not, they could care less usually.

 

[GasEmDee]

The high horse of academia frequently won't make the cut.

The "high horse of academia" does not care about making the cut, because he or she, by definition, is more interested in working in an academic setting to advance the scope and knowledge base of the specialty, than in making money alone. This is not meant to be a cut on private practitioners, which obviously are essential to our field, but rather to counter your continual open disdain of academic medicine in general and academic anesthesia in particular.

You should appreciate the distinction between how things ought to be done, and how things are actually done in practice to accomodate real-world circumstances. It is certainly true that in the academic environment, there are many things that are inefficient and unnecessary. However, I think both perspectives are important. One could not do without the other.

Without the advances in anesthesia that have been propelled by academia, your job as you know it would not exist. Why do you continue to bite the hand that raised and fed you?

 

[GasEmDee]

That title is very accurate. They REALLY don't care....and the hospital administration doesn't care either.

However, there are a few things that they DO care about.

1) Cases don't get delayed...even if they are late
2) Cases don't get cancelled.....you won't learn this in academia
3) Costs are kept low.(personnel, supply, drugs)
4) Order only preop tests that the hospital can get reimbursed for.
5) late cases and night cases get covered.
6) JCAHO measures are kept up for the sake of accreditation.

Those are the things that surgeons and administrators care about....it means the monkey that gets to sit in the chair is a monkey whose willing to work harder, stay longer, and take MORE risk than the next monkey.

One thing that I have learned behind closed doors....Adverse outcome IS accepted.

It's all about the money....for everyone...including the monkey.

The high horse of academia frequently won't make the cut.

If these are the true priorities of the anesthesiologist, then I genuinely believe it ought to be purely a nursing specialty. There is no point in having a medical degree if you are going to defer all clinical judgement to the surgeon and cater soley to the surgeon and not the patient.

 

[salmonella]

I thought anesthesiology was originally a nursing specialty back in the old days...when did physicians take over the specialty? And as anesthesia becomes safer and machines/technology advances, don't you think in a couple decades anesthesia will become so easy and safe that nurses can practice it?

 

[mick2003]

[

 

[mick2003]

[

 

[fakin' the funk]

Surgeons don't care who's doing ANY job as long as it gets done...anesthesiology, scrubs, circulators, etc etc. They're surgeons. That's their deal. So what's your point?

I concur that the "open disdain" for academic anesthesiology on this forum is weird and puzzling. God forbid anyone advance research and education in a discipline that needs it badly. Isn't academia part of what keeps anesthesiology a medical specialty instead of a nursing specialty (as Salmonella suggests it is)?

 

[dogbone65]

I

thought anesthesiology was originally a nursing specialty back in the old days...when did physicians take over the specialty? And as anesthesia becomes safer and machines/technology advances, don't you think in a couple decades anesthesia will become so easy and safe that nurses can practice it?

We do and have been for over a hundred years.

 

[mick2003]

I

We do and have been for over a hundred years.

Reminds me of this...

I'm Not One Of Those Fancy College-Educated Doctors
By Dr. Mike Ruddy

I'm Not One Of Those Fancy College-Educated Doctors

I'm a doctor, and I'm damn good at it. Why? Because I learned to be a doctor
the old-fashioned way: gumption, elbow grease, and trial and error. I'm not
one of these blowhards in a white coat who'll wear your ears out with 10
hours of mumbo-jumbo technical jargon about "diagnosis" this and "prognosis"
that, just because he loves the sound of his own voice. No sir. I just get
the job done.

Those fancy-pants college-boy doctors are always making a big deal about
their "credentials." But I'm no show-off phony with a lot of framed pieces
of paper on the wall-I'm the real deal. I got my M.D. on the street. These
people think they're suddenly a "doctor" because they memorized a lot of big
words and took a bunch of formal tests. But there's plenty of things about
being a doctor they'll never learn in their ivory-tower medical school.
For example, did you know that human intestines, if they spill out of the
abdomen during surgery, can spool out all over the floor if you're not
careful? You won't find that in a book, my friend.
When it comes to practicing medicine, I focus on the basics. In a
life-threatening situation, you've got to think on your feet. I don't waste
time going on and on about which virus is which or whose blood type is
whose. I get out the tools, roll up the shirt sleeves, slick back my hair,
and get in there all the way up to the elbows. The patient's not going to
magically heal just because you know a lot of complicated terms like "bovine
spongiform encephalitis," or "antibiotics."
You want to know where I got my doctor's degree? At the Medical School of
Hard Knocks, that's where. No matter what they say, advanced graduate
studies won't teach you when somebody needs a shot of whiskey. Yale and
Harvard don't tell you when to throw a bucket of water on a patient. And
they can never teach you how to tell when someone just needs a good solid
punch in the nose to bring them around.

While they were cooped up in some dorm room reading about being a doctor, I
was out there in the real world, being a doctor. And there's no substitute
for hands-on experience.

Not to mention, my rates are a hell of a lot more reasonable than what one
of those college- and med-school-educated doctors will charge you, because I
take out all the bells and whistles. You won't catch me pressuring my
customers into paying for expensive MRIs and IV drips and electronic X-Ray
Vision machines and who the hell knows what else.
Jesus, you ever look at one of those scans? They're just a lot of crazy
shapes. The only sure-fire method for figuring out what's inside a man's
body is to go in there and take a look for yourself. And if you want to put
a shunt or a valve into a person, you don't rely on gimmicks like tubes and
syringes. You get your hands a little dirty, you open them up, and shove it
right in there where it belongs.

I hate these elitist doctors almost as much as I hate their Ivy League
glee-club buddies, the lawyers. Between their constant "writs" and "summons"
and all their hot air about "malpractice" and "licenses," they're enough to
drive a man to the point where he can't even practice medicine under his own
name anymore, and is forced to pull all his ads from bus-stop benches.
If you need a good doctor, you just keep your ears to the ground, and my
name will eventually come up-people know how to get ahold of me. When all is
said and done, the customer can tell the difference between a real doctor
and some dime-store college-educated phony decked out in stethoscopes and
ear-flashing things who's never put in an honest day's work in his life. But
me, I'm the real deal, salt of the earth, and I don't need a diploma to tell
me that.

 

[The_Sensei]

I thought anesthesiology was originally a nursing specialty back in the old days...when did physicians take over the specialty? And as anesthesia becomes safer and machines/technology advances, don't you think in a couple decades anesthesia will become so easy and safe that nurses can practice it?

No.

 

[GasEmDee]

This reminds me of MilitaryMDs view on academic anesthesia vs. private practice anesthesia.

"I'm not one of those fancy academic anesthesiologists...."

Reminds me of this...

I'm Not One Of Those Fancy College-Educated Doctors
By Dr. Mike Ruddy

I'm Not One Of Those Fancy College-Educated Doctors

I'm a doctor, and I'm damn good at it. Why? Because I learned to be a doctor
the old-fashioned way: gumption, elbow grease, and trial and error. I'm not
one of these blowhards in a white coat who'll wear your ears out with 10
hours of mumbo-jumbo technical jargon about "diagnosis" this and "prognosis"
that, just because he loves the sound of his own voice. No sir. I just get
the job done.

Those fancy-pants college-boy doctors are always making a big deal about
their "credentials." But I'm no show-off phony with a lot of framed pieces
of paper on the wall-I'm the real deal. I got my M.D. on the street. These
people think they're suddenly a "doctor" because they memorized a lot of big
words and took a bunch of formal tests. But there's plenty of things about
being a doctor they'll never learn in their ivory-tower medical school.
For example, did you know that human intestines, if they spill out of the
abdomen during surgery, can spool out all over the floor if you're not
careful? You won't find that in a book, my friend.
When it comes to practicing medicine, I focus on the basics. In a
life-threatening situation, you've got to think on your feet. I don't waste
time going on and on about which virus is which or whose blood type is
whose. I get out the tools, roll up the shirt sleeves, slick back my hair,
and get in there all the way up to the elbows. The patient's not going to
magically heal just because you know a lot of complicated terms like "bovine
spongiform encephalitis," or "antibiotics."
You want to know where I got my doctor's degree? At the Medical School of
Hard Knocks, that's where. No matter what they say, advanced graduate
studies won't teach you when somebody needs a shot of whiskey. Yale and
Harvard don't tell you when to throw a bucket of water on a patient. And
they can never teach you how to tell when someone just needs a good solid
punch in the nose to bring them around.

While they were cooped up in some dorm room reading about being a doctor, I
was out there in the real world, being a doctor. And there's no substitute
for hands-on experience.

Not to mention, my rates are a hell of a lot more reasonable than what one
of those college- and med-school-educated doctors will charge you, because I
take out all the bells and whistles. You won't catch me pressuring my
customers into paying for expensive MRIs and IV drips and electronic X-Ray
Vision machines and who the hell knows what else.
Jesus, you ever look at one of those scans? They're just a lot of crazy
shapes. The only sure-fire method for figuring out what's inside a man's
body is to go in there and take a look for yourself. And if you want to put
a shunt or a valve into a person, you don't rely on gimmicks like tubes and
syringes. You get your hands a little dirty, you open them up, and shove it
right in there where it belongs.

I hate these elitist doctors almost as much as I hate their Ivy League
glee-club buddies, the lawyers. Between their constant "writs" and "summons"
and all their hot air about "malpractice" and "licenses," they're enough to
drive a man to the point where he can't even practice medicine under his own
name anymore, and is forced to pull all his ads from bus-stop benches.
If you need a good doctor, you just keep your ears to the ground, and my
name will eventually come up-people know how to get ahold of me. When all is
said and done, the customer can tell the difference between a real doctor
and some dime-store college-educated phony decked out in stethoscopes and
ear-flashing things who's never put in an honest day's work in his life. But
me, I'm the real deal, salt of the earth, and I don't need a diploma to tell
me that.

 

[militarymd]

This reminds me of MilitaryMDs view on academic anesthesia vs. private practice anesthesia.

"I'm not one of those fancy academic anesthesiologists...."

Actually, I AM one of those "fancy academic type" anesthesiologists.....I just choose to ignore my instincts.

 

[ecCA1]

Gasemdee butt-flopped trying to spin the joke her way.

lol

 

[Conflicted]

Hmm

Would you go so far as to say "Fancy Pants" Anesthesiologist? Or do you only sit the plain "fancy" subset?

Actually, I AM one of those "fancy academic type" anesthesiologists.....I just choose to ignore my instincts.

 

[GasEmDee]

Actually, I AM one of those "fancy academic type" anesthesiologists.....I just choose to ignore my instincts.

Don't you run an anesthesia group? What instincts are you talking about?

 

[militarymd]

Don't you run an anesthesia group? What instincts are you talking about?

I AM in private practice.

The instincts that I'm ignoring right now:

1) urge to order tests
2) urge to cite articles in the literature
3) urge to argue with surgeons over medical issues that amount to nothing.
4) urge to demonstrate my superior intellilect to the surgeon
5) urge to delay cases because it is the "right" thing to do.

 

[salmonella]

Is kissing up to the surgeons important for continuing a contract in private practice? Is it bad for anesthesiologists to stand up for themselves and chew out a surgeon? What's the worst that can happen?

 

[GasEmDee]

I AM in private practice.

The instincts that I'm ignoring right now:

1) urge to order tests
2) urge to cite articles in the literature
3) urge to argue with surgeons over medical issues that amount to nothing.
4) urge to demonstrate my superior intellilect to the surgeon
5) urge to delay cases because it is the "right" thing to do.

You are a private practitioner, but you consider yourself an academic anesthesiologist because you have these "urges"?

 

[GasEmDee]

I AM in private practice.

The instincts that I'm ignoring right now:

1) urge to order tests
2) urge to cite articles in the literature
3) urge to argue with surgeons over medical issues that amount to nothing.
4) urge to demonstrate my superior intellilect to the surgeon
5) urge to delay cases because it is the "right" thing to do.

Dont know any academic anesthesiologists with the urge to do any of these things, except for (2), but then again thats why its academia.

(5) is rare. At our institution, if someone feels that the patient needs more preop evaluation, then the patient gets the additional testing that same day, and the schedule is modified so that the patient is scheduled later in the day. Again, that is rare. When it does happen though, thankfully, someone had the sack to stand up for what he believes is "right" rather than succumb to surgeon pressure.

All this stuff about arguing and intellectual grandstanding is just hyperbole.

 

[GasEmDee]

Gasemdee butt-flopped trying to spin the joke her way.

lol

Huh?

 

[BeatrixKiddo]

I don't get it, what does this mean... =\

 

[Noyac]

Is kissing up to the surgeons important for continuing a contract in private practice? Is it bad for anesthesiologists to stand up for themselves and chew out a surgeon? What's the worst that can happen?

I wouldn't call it kissing up. I would call it working with.

Never is it bad to stand up for yourself. Chewing out is another beast and its not accepted from either side.

Worst that can happen? I don't know. But if you can't discuss issues with the surgeons in a professional manner, you might find out.

 

[Noyac]

I don't have much beef with academia. If it were not for the academic side of our specialty or any specialty for that matter, medicine would not be advancing as it is. I think everyone hear understands that. One thing I do see however, is that academics and new grads have a very rigid approach. I know this b/c I was rigid in my approach when I came out of training. In PP flexibility is key. I would never advise someone to be flexible to the point that they are unsafe.

 

[GasEmDee]

In PP flexibility is key. I would never advise someone to be flexible to the point that they are unsafe.

I agree.

 

[militarymd]

You are a private practitioner, but you consider yourself an academic anesthesiologist because you have these "urges"?

I spent 5 years after fellowship training in an academic environment ...3 of them as the Chairmen of the Education Committee at one of the Navy's big 3....but small compared to civilian academic environment....so "academia" comprise the majority of my professional life.

This is what I have noticed....the academics and those who recently came from academia (new grads)...tend to (NOT EVERYONE, just the majority) be fairly rigid in what they consider as safe...tend to look for ways to delay/cancel rather than ways to speed up/facilitate.

Some tempering/seasoning occurs during the first years out....that changes you....this tempering/seasoning doesn't happen to everyone...why? I don't know.

But I see this transition from academia to PP.......there is a difference....I'm not disparaging academic types.....just making an observation that that type of practice "loses" in private practice.

One of the reason that we are recruiting only folks 5 years out from training....same as Noyac's group.

And you will learn that what you think is "unsafe" at the time after you finish training.....will be very different from what you think is "unsafe" after some seasoning/tempering in private practice.

 

[VolatileAgent]

i've personally never cancelled a case. i've been in situations where the surgeon decides to cancel the case, though, based on new information or a change in the patient's health, meds, (etc.) since they were last seen. my experience has tended to be more, "these are the (new) facts about this patient. what do you want to do?" any concern is also discussed with the patient.

if that's rigid, then i'm rigid.