Questions for MilitaryMD (anesthesiologist)

[ADMIN]

Hello all

There are some very complicated politics between the AANA and the ASA. However, Anesthesiologists and Nurse Anesthetists work togeather successfully and apolitically everyday.

There are many questions that people have in regards to the issues between the two groups and I thought it would be beneficial to have a chance to ask a respected Anesthesiologist their opinion on the issues. MilitaryMD is a former military physician who is very used to working with CRNAs.

This thread is in the spirit of cooperation and understanding. Please feel free to ask questions. However, attacks on our guest will not be tolerated.

Ask away ;)

[MmacFN]

Ill start!

Hi Mil, Welcome to the forum!

I have been reading the anesthesiology forum on SDN for sometime now and i have noticed that many of the physicians there feel the term "MDA" is derogatory. However, in daily practice many of us have heard and seen this used without any offence meant or being taken.

Is this offensive? Why is it? and how do you feel about it?

[RN29306]

Not that it being on paper makes it right and I don't have the information on who specifically came up with our OR paperwork, but our OR flowsheet and PACU papers show the term "MDA".

The preop sheets show 'anesthesiologist' for signature reasons.

[militarymd]

Ill start!

Hi Mil, Welcome to the forum!

I have been reading the anesthesiology forum on SDN for sometime now and i have noticed that many of the physicians there feel the term "MDA" is derogatory. However, in daily practice many of us have heard and seen this used without any offence meant or being taken.

Is this offensive? Why is it? and how do you feel about it?


"offense" like "beauty" is in the eye of the beholder.....I don't find it offensive....but then again....I find that I can learn things from experiened non-physician providers.........whereas many of the ones who take offense at MDA think their training teaches them everything they need to know...

short answer....I don't know why it is offensive.

[Flipballin80]

Question for Mil,

Since working with CRNA's in the military, do you find any difference in the teamwork and collaboration with CRNA's and Anesthesiologists, or even CRNA's and Surgeons outside of the military?

Ron :laufband:

[militarymd]

Question for Mil,

Since working with CRNA's in the military, do you find any difference in the teamwork and collaboration with CRNA's and Anesthesiologists, or even CRNA's and Surgeons outside of the military?

Ron :laufband:

The anesthesia team in the military and in my current private practice is essentially the same for me....In private practice, I'm more involved, and the pace is faster, but as for my working relationship with the anesthetists.....no different.

I think it is probably the same for CRNA/surgeon relationships.

But remember, I'm one person...at one practice.

I have caused a number of other physicians (bad ones) to leave my current practice....their relationship with CRNA's (with other anesthesiologists and surgeons for that matter) was very dysfunctional...passive aggrressive...hateful....I certainly hope it is not the norm.

One of the guys that I fired...moved on to a job where he is training SRNAs....:eek2: ...My first response when I found out was "GREAT, A whole other generation of CRNAs who will hate doctors!!"

[MmacFN]

sad! Ah well. at least you try and make a difference!

[MmacFN]

Mil

From your perspective, why do you think there is such hostility on a fourm like SDN? Are the new people taught that or do they just come up with it on there own?

[Flipballin80]

Thanks Mil! Hopefully there are more Anesthesiologists out there with the same mentality as yours. In fact, I hope there are PEOPLE with the same mentality as yours!!

"Can't we all just get along"

Ron :laufband:

[jwk]

Mil

From your perspective, why do you think there is such hostility on a fourm like SDN? Are the new people taught that or do they just come up with it on there own?
I think a lot of them are residents who really don't have any clue how the real world operates outside of their academic setting. Some get into the politics, some don't, but it's not much different than nurse anesthesia students or even AA students - some do, some don't. Some care about the politics and "the profession" (pick any profession really) and others just want to do their thing and be left alone.

[militarymd]

the folks who post there probably self-selects...ie the ones that post are the ones that need a forum to voice their opinions.

You see the frequent attacks I get for students and residents for shooting what I think is straight.

I don't know what the proportion of good vs bad guys are like out there..

I've only been out of the Navy a couple of years and have been in only one practice....and all the folks are folks I picked....so no duds.

[LouCRNA]

No questions right now, but wanted to welcome you to the site, Doc.

Lou

[MmacFN]

Hey Mil (im full of questions)

I was wondering how you see the medicare cuts in anestheisa effecting the current anesthesia landscape? Do you see this decreasing the numbers of physicians entering the profession as a "lifestyle" profession? Or will that really matter?

I have heard many times that private insurance follows medicare. Do you see this happening as well?

Whats your general take on it?

as always, thanks.

[militarymd]

Hey Mil (im full of questions)

I was wondering how you see the medicare cuts in anestheisa effecting the current anesthesia landscape? Do you see this decreasing the numbers of physicians entering the profession as a "lifestyle" profession? Or will that really matter?

I have heard many times that private insurance follows medicare. Do you see this happening as well?

Whats your general take on it?

as always, thanks.

I don't know what it means in the short term....but in the long term, there "lifestyler"s will seek other specialties...as they did in the 90's.

[london88]

Welcome MilitaryMD. I have read many of the threads on SDN and your voice always seems to be the voice of reason, and I must admit sometimes I just crack up reading some of your responses as they are so amusing.

[militarymd]

Welcome MilitaryMD. I have read many of the threads on SDN and your voice always seems to be the voice of reason, and I must admit sometimes I just crack up reading some of your responses as they are so amusing.

Yes...but I'm always serious

[ethernaut]

Mil

From your perspective, why do you think there is such hostility on a fourm like SDN? Are the new people taught that or do they just come up with it on there own?

hey, remember too mac, that sdn, like this website and allnurses just the same, basically represent about 1% of 1% out there.. so, the number is relatively small, but can just the same be loud.. i, for one, am not going to worry about what ANYONE says against me as i willl choose to do the best i can no matter what.. as Military, and others for that matter, have stated, it's pretty much important to do what you make of it and to do the best to get along with those you work and learn with.. it's unfortunate the uneasiness that will most likely continue into the next milennia between (atleast) med students and srna/crnas...
just my thoughts...
now, if you'll excuse me, i have to tend to my '5 finals in 10 days' procrastination..

[MmacFN]

Hey Mil

Do you think there is a signifigant difference between how Military trained Anesthesiologists feel about CRNAs than private ones?

The threads on SDN have been pretty nasty at times by people like volatileAgent, I assume he is taught this sortof anger? Where do they learn it?

As usual, thanks, its been great to have you here.

[militarymd]

Hey Mil

Do you think there is a signifigant difference between how Military trained Anesthesiologists feel about CRNAs than private ones?

The threads on SDN have been pretty nasty at times by people like volatileAgent, I assume he is taught this sortof anger? Where do they learn it?

As usual, thanks, its been great to have you here.

I don't think there is a difference between military and civilian.....

As for volatile...I think he's just an ass....even before he became a doctor....and then the degree just elevated his level of asshole-ness....if that's a word.

[MmacFN]

hehheheh

asshole-ness has now been added to my vocabulary with 'see volatile' after it ;)

[athomas91]

welcome militarymd !! i have enjoyed all of your posts and look forward to more.
Andrea

[MmacFN]

Mil

Have you ever seen or heard of an Anesthesiologist run grp allowing CRNAs to become partners or profit sharing in the same way as the MDs?

Why do you suppose most CRNAs are employees as opposed to eligible for partnership in anesthesiologist groups? Is it related to profitability potential of a CRNA vs MD?

Any insight into the matter would be great. I know nothing about the economics of a practice.

[militarymd]

Absolutely...CRNA owned groups certainly exist....and not just in small towns...

I'm pretty sure there is one in Birmingham...and a doc who will be joining me next month came from a CRNA owned group...no MD partners at all.

As for why they are not common....I don't know the answer to that question.

One of the CRNAs that I work with now left a CRNA owned group to become an employee because he wanted the predictable hours of an employee as opposed to fee for service where your hours are much less predictable.

For a brief time, we had talks of forming a combined MD/CRNA group where I am, but due to politics and timing, and reimbursement issues, it didn't happen.

[MmacFN]

Wow

You are very progressive.

So if there was a CRNA/MD grp where everyone had the same oppertunities within the grp, is there a disparity b/t how much a CRNA can bring into a grp vs an MD?

I guess what im thinking is that an MD who was supervising 4 CRNAs may well bring in more income to the grp than a CRNA alone. My understanding is that both can charge the same for anesthesia alone, but only an MD can supervise. If thats the case, i can see how this would be an issue.

[militarymd]

The revenue generated is based on who is paying.....

private insurance....all different
medicare/mediaid....some differences based on state
person receiving care......ability to pay...

We never got to this point, but I suspect the fight is and always will be over how to divide the pie.....between MD/CRNA...MD/MD....CRNA/CRNA....

Oh...and we have AA's too....so it becomes even more complicated.

[MmacFN]

Oh my

the economics of heathcare! hehe. Its the entire reason there is tension b/t MDs and CRNAs from my perspective. Whats you take on that?

From what i hear in the Military there are few (if any) issues b/t MD/CRNA since $$$ isnt an issue. Not surprising.

[militarymd]

Oh my

the economics of heathcare! hehe. Its the entire reason there is tension b/t MDs and CRNAs from my perspective. Whats you take on that?

From what i hear in the Military there are few (if any) issues b/t MD/CRNA since $$$ isnt an issue. Not surprising.

It's more than the money...I think....because there were problems in the military also.....

Practice rights etc.....Although money isn't involved in the military.....issues leading to rank was always there....

Who's in charge? The Captain MD...or the Major CRNA....constant power struggle.

I believe the root of the conflict is because there is so much overlap in what we do.....and most MDs AND CRNAs AND patients don't know the differences.

Such is the system that we have..

[MmacFN]

Thanks Mil

I appreciate your candid answers and i think everyone else does as well. It is always dfficult to see the big picture when its so damn out of focus :)

Keep the rubber side down.

[assilem]

now the pay for crnas on the military side is not competitive when compared to the civilian side, right? i was wondering about the anesthesiology side. are the two comparable or is civilian always going to be better?

[militarymd]

now the pay for crnas on the military side is not competitive when compared to the civilian side, right? i was wondering about the anesthesiology side. are the two comparable or is civilian always going to be better?

While active duty...many of my CRNA colleagues made more money than I did because of their higher rank and longer years in service...

In the civilian world...everyone does better.

[nojrevorg]

Hey Mil,
I am a fairly new student, and just getting into the world of anesthesia. I am glad that you are here to represent your profession in such a collaborative light. I read some of the other forums, SDN for example, and i had alot of the same questions that others did. When you were in residency or fellowship, did others try to get you to rise up against the nurses that were learning anesthesia? I just wonder sometimes where it starts. I in Nursing practice have frequently seen the RN to MD tension, I just wonder when it starts. Please dont take me the wrong way. Their are plenty of MD's that are wonderful co-workers, and really seem to want team work (You seem to fall into this category based on your threads). I guess I am wondering what to expect through my education. Thanks.
BTW great idea for a thread, ADMIN.

[militarymd]

Hey Mil,
I am a fairly new student, and just getting into the world of anesthesia. I am glad that you are here to represent your profession in such a collaborative light. I read some of the other forums, SDN for example, and i had alot of the same questions that others did. When you were in residency or fellowship, did others try to get you to rise up against the nurses that were learning anesthesia? I just wonder sometimes where it starts. I in Nursing practice have frequently seen the RN to MD tension, I just wonder when it starts. Please dont take me the wrong way. Their are plenty of MD's that are wonderful co-workers, and really seem to want team work (You seem to fall into this category based on your threads). I guess I am wondering what to expect through my education. Thanks.
BTW great idea for a thread, ADMIN.

Honest truth, is I don't know. During my Navy residency, there was some tension as fostered by my attendings....but not the good attendings...only the lesser ones...the great teachers did NOT try to instill any animosity.

[okanesthesia]

Hey Mil-

Glad to see that you are alive and well. I am a long time lurker over at SDN, and I for one miss your knowledge/input/humor over there!!

[MmacFN]

I am very happy you continue to reply to this thread Mil. Really, you are a credit to professionalism.

Thanks again!

[militarymd]

Hey Mil-

Glad to see that you are alive and well. I am a long time lurker over at SDN, and I for one miss your knowledge/input/humor over there!!

I stopped posting there because I got tired of the unprofessionalism that the doctors and doctors-to-be display to non-physicians.

[MmacFN]

wow

Well Mil, its really nice to know there are Docs out there with your attitude.

[MmacFN]

Hey Mil

Alot of people on this website get pretty frustrated with the comments we often see on SDN. People like toughlife for instance, and his cadre of followers concern many of us.

Is this in anyway reflective of the general midset out there as you see if? Or is this only a couple of individuals who now have a stage to spew their opinion?

Anyway, figued Id ask someone who would know better.

[armygas]

wow

Well Mil, its really nice to know there are Docs out there with your attitude.

The majority of MDs are of his mindset and are great to work with.........

Fighting politics is one thing, working together is another (that is what defines professionalism).

[militarymd]

I think more folks are like me than Tough. Remember, he's a just a CA-1.

The battles that are fought between CRNAs and MDs is about politics and business.

And I think it's healthy..meaning that CRNAs will continue to improve their stance (through education and patient care) while the MD's will need to justify their stance.

In the end, it's good for the patients..(my opinion).

I'm friends with all of the CRNAs that I work with...and I know that some of them feel my presence is not necessary....and that's ok....it's business/politics...and we leave it at that.

Like Army says...professionalism..and I think most of us (MD's) are.


Hey Mil

Alot of people on this website get pretty frustrated with the comments we often see on SDN. People like toughlife for instance, and his cadre of followers concern many of us.

Is this in anyway reflective of the general midset out there as you see if? Or is this only a couple of individuals who now have a stage to spew their opinion?

Anyway, figued Id ask someone who would know better.

[TJ8A]

MilitaryMD,

Hello and thanks for participating thoughtfully in our forum. When I first joined this forum, I appreciated reading your posts. Glad to see you post again. I do have a couple questions to ask you…

1. Do you think it is a good idea for the ASA to be pushing for more AA programs? Does it complicate the issues between the AANA and ASA as they stand?

2. Are you as concerned as some of those that post on SDN of CRNA’s ‘taking over’…relegating future MDA’s into a perioperative physician role?

3. Do you think regional anesthesia and pain management can be safely performed by properly trained CRNA’s?

4. Do you believe the DNP (doctorate of nursing practice) is a good thing for CRNA’s? Will it impact anesthesia as negatively as those on SDN believe it will?

TJ8A

[MmacFN]

I appreciate your being here man. Thanks again and an excellent post as usual.

[militarymd]

MilitaryMD,

Hello and thanks for participating thoughtfully in our forum. When I first joined this forum, I appreciated reading your posts. Glad to see you post again. I do have a couple questions to ask you…

These are only my personal opinions.


1. Do you think it is a good idea for the ASA to be pushing for more AA programs? Does it complicate the issues between the AANA and ASA as they stand?

It's just business on the ASA's parts to develop a cadre of physician extenders who will be more dependent on the MD's...and yes, it will complicate things. Whether this is good or bad..I don't know.


2. Are you as concerned as some of those that post on SDN of CRNA’s ‘taking over’…relegating future MDA’s into a perioperative physician role?

The practice of anesthesiology and medicine will be changing drastically in the coming years whether we all want to admit it or not. I personally have accepted that things will change and am not concerned about it. It will be what it will be...fighting it and looking foolish while fighting it is not something I believe in.


3. Do you think regional anesthesia and pain management can be safely performed by properly trained CRNA’s?

Regional anesthesia...without a doubt, if it was in the scope of your training.

Interventional pain....probably not...just because I don't think that a CRNA will be able to get all the training necessary....


4. Do you believe the DNP (doctorate of nursing practice) is a good thing for CRNA’s? Will it impact anesthesia as negatively as those on SDN believe it will?

I don't know.


TJ8A

[armygas]

4. Do you believe the DNP (doctorate of nursing practice) is a good thing for CRNA’s?

I hope Mil doesn't mind my take on this......

Not as it currently stands, no thought has really been put into this IMHO. Not clinically based (just look at the curriculum of most programs, no standardization, no extended clinical hours....)

[Sleptym]

I hope Mil doesn't mind my take on this......

Not as it currently stands, no thought has really been put into this IMHO. Not clinically based (just look at the curriculum of most programs, no standardization, no extended clinical hours....)
Army:

I've been silent on this issue for quite a while, but feel it is time to express my thoughts. Let me preface my comments by saying, as humans, the vast majority of us probably feel that our approach to a matter is the "correct" approach. Certainly, if we did not think and act that way, our behaviors would be terribly illogical. With that said:

I chose the Rush DNP Program specifically because it is not clinically based. If I have kept current in the professional literature, of what additional benefit would a clinically based program be to me, other than to serve as a broad review? I wasn't interested in a broad review: I was interested in gaining new knowledge in Executive Administration and Management, which is exactly what is being taught in my program.

Your PhD program is teaching you to be a researcher; it is also teaching you how to critically evaluate others' research; it is most likely not enhancing your anesthesia knowledge in any broad sense. It may be enhancing a very narrow portion of your anesthesia knowledge, but that is only in the area that pertains to your current research, or in the enhancement of your ability to critically assess other research. But, overall, your research-oriented program is not making you a better clinical practitioner. Nor will it necessarily make you a better "teacher". Those educational skills and knowledge are much better learned pursuing an EdD or a PhD in Education.

If we are to suggest that the DNP should be a clinical doctorate focused primarily on clinical skills, are we then suggesting that, in the absence of that DNP, our clinical knowledge is deficient? Is everyone without a clinically-oriented DNP an unsafe practitioner? If we follow that line of reasoning, then we are saying what the MDAs have been saying for years. Myself, I tend to disagree with that line of reasoning. I also feel that line of thinking might be somewhat unnerving to the millions of patients CRNAs attend to each year in this country.

My point is: If you want to be a researcher, pursue a PhD. A researcher is what a PhD is preparing you to be. If you want to be an educator, pursue a PhD in Education or an EdD. That is what those degree tracts are preparing their students for. If you want to be in Advanced Practice Executive Management, pursue a DNP. That is what the majority of those programs are preparing their students for. If all you want to do is practice anesthesia nursing, save your money. Because a PhD will not make you a better clinician, nor will an EdD, an educationally oriented PhD or a management-based DNP.

I think the biggest folly is the DANP; it is little more than an expensive review of everything we have already studied (notice, I did not say “learned”). Certainly, if it isn't, the individual in question has far greater professional problems than simply trying to decide which degree tract to pursue. The DNP has its place. The problem is that there are folks in New York City trying to make it out to be something it isn't. That is where we are headed in the wrong direction.

[armygas]

George,

Let's start a different thread for this, I will post it

[armygas]

MilMD,

I do have a question on the pain issue, while I am not 100% sure that we should run our own pain service...... How do you feel about CRNAs performing the technical/procedural aspects of pain management (i.e. if an intervention is prescribed)? That seems like a logical extension of our skillset.

[militarymd]

MilMD,

I do have a question on the pain issue, while I am not 100% sure that we should run our own pain service...... How do you feel about CRNAs performing the technical/procedural aspects of pain management (i.e. if an intervention is prescribed)? That seems like a logical extension of our skillset.

I (personally) see no problems with that. I see that as no differently than CMS's definition of "medical direction" in the OR.

And aspects of that exists in different areas of the country already.

And certainly many "Pain Doctors" and nothing more than glorified needle jockeys who will immediately separate patients from their clinics once the needle parts are done with.

Because your question addresses an area of medicine in which I don't practice, my opinion is pretty much worthless.

[militarymd]

I just browsed this thread to see if I've changed my mind about any of the things I said a year ago....

and, I'm happy to say....I haven't changed.

[MmacFN]

Hey guys.


I was wondering about the practices where you both work. When you work with CRNAs do you come for all inductions and emergence? Are their hospital policies that dictate how you must interact with the CRNAs? Do you both work for grps or the hospital itself and do the CRNAs work for the same ppl?

Anywho, thanks

[militarymd]

Hey guys.


I was wondering about the practices where you both work. When you work with CRNAs do you come for all inductions and emergence? Are their hospital policies that dictate how you must interact with the CRNAs? Do you both work for grps or the hospital itself and do the CRNAs work for the same ppl?

Anywho, thanks

yes

yes

the md's are on the medical staff

the crna are hospital employees.

[MmacFN]

Thanks Mil

Just out of curiosity, are you there for emergence and induction just to meet TEFRA for billing (and just do so for all cases to make it easier), or is it a policy?


yes

yes

the md's are on the medical staff

the crna are hospital employees.

[militarymd]

for all of the above.

Obviously for legal reasons I / we have to do it....and sometimes for clinical reasons.

and there is something to be said for 2 people getting the patients to sleep....

Our Chief crna and me can get a routine patient tubed and released from anesthesia in less than 3 minutes from wheeling him through the or doors.

our circulators are worthless.


Thanks Mil

Just out of curiosity, are you there for emergence and induction just to meet TEFRA for billing (and just do so for all cases to make it easier), or is it a policy?

[MmacFN]

hehe

Yah i hear yah. It is a bit more speedy to have the extra set of hands. I learned what it was like to do everything by myself on an anesthesia mission I recently took. It adds just another layer of work to do. However, i taught the RNs down there how to help and so they did.

Our circulators vary in how non-helpful they are during induction..... sadly..

thanks for the answers man, you are always forthright.



for all of the above.

Obviously for legal reasons I / we have to do it....and sometimes for clinical reasons.

and there is something to be said for 2 people getting the patients to sleep....

Our Chief crna and me can get a routine patient tubed and released from anesthesia in less than 3 minutes from wheeling him through the or doors.

our circulators are worthless.