Northstar's latest?

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hypnosMD

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Take heed. As new grads look at practice opportunities, some of the AMC's (such as Northstar) have creative ways to "flex" their doc/cRNA staffing ratios to over 4:1, increasing your liability and work burden, putting patients at risk, and decreasing their staffing costs in the name of profit. 2 days ago a patient allegedly died at a Northstar facility in Kentucky due to local anesthetic systemic toxicity from a block. Could this have been due to the "hurry up" culture of an understaffed/unsafe supervisory model? Or was it a CRNA who did the block under the doc's "supervision" (another common Northstar practice)? If you want to start your career with these kinds of AMC risks, be my guest. Otherwise, you better make sure your contract EXPLICITLY lays out that CRNA's will never be unsupervised and/or supervised at a ratio greater than 4:1. Any other creative staffing model will be playing Russian roulette with your license/malpractice/future.

Additionally, larger and larger ratios discredit the importance of a physician's role in patient safety/patient care and serve ONLY to line the pockets of those signing your checks (possibly at the expense of the patient), all while decreasing job opportunities. Be very weary of anyone who would argue for such a model due to obvious conflicts of interest. These are the small battles that are waged daily against the role of the physician by the bean counters who don't realize that real peoples' lives are at stake here.

When we discuss the importance and future of our specialty, this is the elephant in the room.
 
GA8314 said:
Agreed. I sit my cases, you sit yours, and there is no cross cover expected. Fine. Better than being the fireman.
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I may be mistaken, but don't you have a lot of CRNAs in your current practice? where do you draw the line at ratios?
 
We already know Northstar is one of the worst AMCs..... nothing new to see here.
 
dchz said:
I may be mistaken, but don't you have a lot of CRNAs in your current practice? where do you draw the line at ratios?
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We are medical direction compliant, so no more than 4. We try hard to minimize 4 rooms and usually it involves something like a flip/flop total joint room (almost always spinals with a block) with maybe 1 general and then 1 MAC room. We typically run 2-3 rooms and egress to more as day goes on, but we really are trying to minimize 4 rooms for an entire day. That can get exhausting for sure.
 
So reportedly at one of their KY facilities in a major metro they have given the last of the original docs his walking papers (by allegedly escorting him to his car one day with no advanced warning). Now, the hospital system they have partnered with is supposedly looking to implement CRNA's working independently (CRNA's be warned: they ain't gonna pay you a nickle more for shouldering that additional liability). All of this couldn't have anything to do with the CEO and admin in this non-profit hospital being some of the highest paid in the country could it?!
 
hypnosMD said:
So reportedly at one of their KY facilities in a major metro they have given the last of the original docs his walking papers (by allegedly escorting him to his car one day with no advanced warning). Now, the hospital system they have partnered with is supposedly looking to implement CRNA's working independently (CRNA's be warned: they ain't gonna pay you a nickle more for shouldering that additional liability). All of this couldn't have anything to do with the CEO and admin in this non-profit hospital being some of the highest paid in the country could it?!
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If I were a competing hospital system in Louisville, I’d take out print ads and billboards letting the public know there are unsupervised nurses administering anesthesia there.
I guess we will see what happens, I’d be surprised if Norton actually allows that. You know how the rumor mill is.
 
Man o War said:
If I were a competing hospital system in Louisville, I’d take out print ads and billboards letting the public know there are unsupervised nurses administering anesthesia there.
I guess we will see what happens, I’d be surprised if Norton actually allows that. You know how the rumor mill is.
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But how much of the public would know the difference? How many would even care?

these are rhetorical questions of course.
 
Twiggidy said:
But how much of the public would know the difference? How many would even care?

these are rhetorical questions of course.
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Not sure.
I think there would be surgeons who would have an issue with it.
There would be patients who would have an issue with it, most likely the more educated ones who tend to have private insurance.
I know this hospital system, and it would really surprise me if they went this route with the environment in Louisville being what it is.
 
hypnosMD said:
So reportedly at one of their KY facilities in a major metro they have given the last of the original docs his walking papers (by allegedly escorting him to his car one day with no advanced warning). Now, the hospital system they have partnered with is supposedly looking to implement CRNA's working independently (CRNA's be warned: they ain't gonna pay you a nickle more for shouldering that additional liability). All of this couldn't have anything to do with the CEO and admin in this non-profit hospital being some of the highest paid in the country could it?!
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Let them. We all know how that's going to turn out.
 
dr doze said:
Yes. Swept under the rug.
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Agreed. Anesthesia has gotten safe enough that there won’t be a NOTICEABLE (and that is the key word) difference. For cases like hearts and kids they will probably stick with docs. Everything else is fair game. Let’s be honest with ourselves. We don’t contribute that much to the case in a 4:1 supervision model. Independent CRNA practice is not that much different.
 
dannyboy1 said:
Agreed. Anesthesia has gotten safe enough that there won’t be a NOTICEABLE (and that is the key word) difference. For cases like hearts and kids they will probably stick with docs. Everything else is fair game. Let’s be honest with ourselves. We don’t contribute that much to the case in a 4:1 supervision model. Independent CRNA practice is not that much different.
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maybe for you...
 
eikenhein said:
maybe for you...
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That’s kind of the point. I’m sure there are docs that do a detailed history and physical on every patient and formulate a detailed plan with their CRNA for each and every patient. But quite a few (majority?) are simply signing charts and giving breaks. Somehow the cases are still cranked out and the patients are getting to PACU alive and neurologically intact. AMC’s do not care about great anesthesia or even good anesthesia. The truly disastrous intra operative events are rare enough that they can get away with it.
 
eikenhein said:
maybe for you...
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Yeah, that hasn’t been the case in all the time I supervised. Some of the situations I had to bail them out of were ludicrous. Not to mention how many of them couldn’t competently do even the most basic procedures which are required to do our job.
More missed airways than I could even begin to count.
 
dannyboy1 said:
Agreed. Anesthesia has gotten safe enough that there won’t be a NOTICEABLE (and that is the key word) difference. For cases like hearts and kids they will probably stick with docs. Everything else is fair game. Let’s be honest with ourselves. We don’t contribute that much to the case in a 4:1 supervision model. Independent CRNA practice is not that much different.
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It's definitely gotten safer and easier, but the main problem is, as I mentioned in another thread, we're still training them to do this "safe and easy field". As Man O War said, we're still around basically to serve as firemen (women) and put out any fires they start. It can be something as simple as putting in an Iv to losing airways.

This is part of the reason fellowships are becoming more important to the skillset and CV, because otherwise in the future people will view us having the same abilities as the nurses, then you get these situations.

I never trained with a CRNA who knew how to come off pump and I'll never train a CRNA to come off pump, and that's going to be the small way I protect our futures.
 
Twiggidy said:
I never trained with a CRNA who knew how to come off pump and I'll never train a CRNA to come off pump, and that's going to be the small way I protect our futures.
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In about 20 years, almost nobody will need to know how to come off pump anyway.

Plus, let's be serious: a lot of surgeons like to decide everything, including what happens when coming off pump, regardless who the monkey behind the drapes is.
 
FFP said:
In about 20 years, almost nobody will need to know how to come off pump anyway.

Plus, let's be serious: a lot of surgeons like to decide everything, including what happens when coming off pump, regardless who the monkey behind the drapes is.
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It's true. 90% of the time a computer program could probably do what i do....it's that 10% when my fellowship proves itself though. sure, some suit probably doesn't care about that and most surgeons just want a human with heartbeat behind the drapes.....but I argue prove your worth. or just show the nurses how to do everything and have a coffee break
 
We can all take wild stabs at what percent of the time our training is “needed”. I spend a butt load on various insurances knowing that the chance of me ever needing it is low. But if I didn’t have it, a loss could be catastrophic.
I’d be interested to hear from others who do hearts if your surgeons dictate your practice? Ours don’t, and I haven’t had that experience elsewhere. Sure, we have conversations about what we are doing, but they’re in no way telling me how to come off bypass. We do have one guy who likes to bitch about various aspects of management he doesn’t agree with, but I just do what I want anyway. He just needs to gripe for a minute and then he moves on.
 
I did a few hearts in PP. I stopped doing them once I had enough of being told what to do (including what to run when coming off pump). Ignoring the TEE he could not understand (even when explained) and making all decisions based on the archaeology of the CVP and PA.

Both in my residency and CCM fellowship, the cardiac surgeons had to approve most of the important anesthetic decisions. One just didn't run whatever one wanted post-bypass. It was one of the reasons I did not do a cardiac fellowship (I don't do well with instructions from people who know less).

I would be shocked if the majority of cardiac surgeons are much different. They are usually among the cockiest dinguses in the surgical (and medical) world I have ever met.
 
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FFP said:
I did a few hearts in PP. I stopped doing them once I had enough of being told what to do (including what to run when coming off pump). Ignoring the TEE he could not understand (even when explained) and making all decisions based on the archaeology of the CVP and PA.

Both in my residency and CCM fellowship, the cardiac surgeons had to approve most of the important anesthetic decisions. One just didn't run whatever one wanted post-bypass. It was one of the reasons I did not do a cardiac fellowship (I don't do well with instructions from *****s).

I would be shocked if the majority of cardiac surgeons are much different. They are among the cockiest dinguses in the surgical (and medical) world.
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That sucks, I’d actually nominate ortho for that honor. But yes, the cardiac surgeon personality can be challenging at times. No doubt. Actually thoracic is worse now that I’m thinking about it from my experience.
 
Man o War said:
That sucks, I’d actually nominate ortho for that honor. But yes, the cardiac surgeon personality can be challenging at times. No doubt. Actually thoracic is worse now that I’m thinking about it from my experience.
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Good lord.....yes to this. My worst fellowship days were thoracic days despite being pretty interesting cases.

When I started at my practice I played the Gagne, now with experience I know what to do usually before we’re even coming off and thankfully our surgeons are pretty easy going which is a rarity. They’re fairly quick on pump so we usually need very little or nothing heading to ICU. They have some old school ways they’re stuck in and on easy cases I just do it and go but if it’s a sick patient and I know more than “cookbook cardiac surgery” is needed I use my training and give an explanation of my thinking. Most of the time there’s no fighting
 
Twiggidy said:
Most of the time there’s no fighting
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That's what's wrong with this entire specialty. I don't think there is any other specialist that would not say, after a while: mind your own business. And THAT'S WHY people think we can be replaced by CRNAs, i.e. just another species of monkey who do what they are told.

You don't get to tell me what anesthesia to use.
You don't get to tell me what pressors to use.
You don't get to tell me what/how much fluids to give.
You don't get to tell me when to give blood products and which ones.
Etc, etc, etc... This is a VERY long list.

Generally, you don't get to tell me anything about what I am board-certified in. I AM NOT YOUR MONKEY!
 
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FFP said:
That's what's wrong with this entire specialty. I don't think there is any other specialist that would not say, after a while: mind your own business. And THAT'S WHY people think we can be replaced by CRNAs, i.e. just another species of monkey who do what they are told.

You don't get to tell me what anesthesia to use.
You don't get to tell me what pressors to use.
You don't get to tell me what/how much fluids to give.
You don't get to tell me when to give blood products and which ones.
...
Generally, you don't get to tell me anything about what I am board-certified in. I AM NOT YOUR MONKEY!
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Everything you’re saying is correct

*take note medical students*
 
hypnosMD said:
So reportedly at one of their KY facilities in a major metro they have given the last of the original docs his walking papers (by allegedly escorting him to his car one day with no advanced warning). Now, the hospital system they have partnered with is supposedly looking to implement CRNA's working independently (CRNA's be warned: they ain't gonna pay you a nickle more for shouldering that additional liability). All of this couldn't have anything to do with the CEO and admin in this non-profit hospital being some of the highest paid in the country could it?!
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Going back to the original update:

Good lord if this is true
 
I'm surprised no one from Northstar trolls on here to defend their company. I know there was one person a few threads back who tried to say it wasn't as bad as we make it but since then it's been crickets.
 
Twiggidy said:
I'm surprised no one from Northstar trolls on here to defend their company. I know there was one person a few threads back who tried to say it wasn't as bad as we make it but since then it's been crickets.
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I had a med student come to me recently
to help him look at programs. North Star took over Detroit Medical Center and the training program that came with it. Based on what I heard when I made some calls, I would steer anyone away from that program. They also have a CRNA training program. North Star was started partially by a CRNA-enough said.
So students, take note. I’m not thinking detroit is high on anyone’s list anyway, but just in case.
 
Twiggidy said:
medicine rounds will do that. 98% of the reason i chose anesthesiology
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Bad medicine rounds. During my fellowship, I used to round with the APRNs in the MICU, average of 15 minutes per patient. Done by 10 am, and that included breakfast.
 
FFP said:
That's what's wrong with this entire specialty. I don't think there is any other specialist that would not say, after a while: mind your own business. And THAT'S WHY people think we can be replaced by CRNAs, i.e. just another species of monkey who do what they are told.

You don't get to tell me what anesthesia to use.
You don't get to tell me what pressors to use.
You don't get to tell me what/how much fluids to give.
You don't get to tell me when to give blood products and which ones.
Etc, etc, etc... This is a VERY long list.

Generally, you don't get to tell me anything about what I am board-certified in. I AM NOT YOUR MONKEY!
Click to expand...

Honestly this is what stresses me the most about my future. Once I am an attending with the appropriate experience, I don't think I'm going to do well being "told" what to do by colleagues in a different specialty.

This is why I'm confused when people are against the perioperative surgical home. It seems to me once we have a little more ownership of the patients pre/post-op, even if it's not you, but someone in your department, even if the services are mid-level heavy (which truthfully is how most all medicine is now anyways), if the attending is an anesthesiologist I think this would help to avoid the monkey situation?
 
LunchMD said:
Honestly this is what stresses me the most about my future. Once I am an attending with the appropriate experience, I don't think I'm going to do well being "told" what to do by colleagues in a different specialty.

This is why I'm confused when people are against the perioperative surgical home. It seems to me once we have a little more ownership of the patients pre/post-op, even if it's not you, but someone in your department, even if the services are mid-level heavy (which truthfully is how most all medicine is now anyways), if the attending is an anesthesiologist I think this would help to avoid the monkey situation?
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It wouldn't, as long as the surgeons are still primary. We would just become the periop monkey, instead of the intraop monkey.

The way to do PSH is the Austrian model (if I remember correctly): anesthesia does everything medically pre- and postop, and scheduling-wise, the surgeons just show up to operate and do wound care postop. I am not sure many of my colleagues would like that, given their profound dislike for anything that smells remotely like internal medicine. Also, that system wouldn't work well in the US, where reimbursements for monkey skills are much higher than for real medicine (i.e. thinking, diagnosing, optimizing, first doing no harm).
 
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Man o War said:
Yeah, that hasn’t been the case in all the time I supervised. Some of the situations I had to bail them out of were ludicrous. Not to mention how many of them couldn’t competently do even the most basic procedures which are required to do our job.
More missed airways than I could even begin to count.
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I
LunchMD said:
Honestly this is what stresses me the most about my future. Once I am an attending with the appropriate experience, I don't think I'm going to do well being "told" what to do by colleagues in a different specialty.

This is why I'm confused when people are against the perioperative surgical home. It seems to me once we have a little more ownership of the patients pre/post-op, even if it's not you, but someone in your department, even if the services are mid-level heavy (which truthfully is how most all medicine is now anyways), if the attending is an anesthesiologist I think this would help to avoid the monkey situation?
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id rather be the surgeons monkey all day long than have to do anything remotely resembling clinic work. The greatest part of this specialty is the ability do drop the patient in pacu and never see them again. The perioperative surgical home thing seems to have died down. Surgeons don’t want it, anesthesiologists don’t want to do it (and frankly are probably not trained enough to do it well). Nobody can figure out how to pay for it and hospitals want their anesthesiologist in the OR cranking out cases.
 
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