Luckily, the CVICU team has a great group of nurse practitioners who help us out. These are some of the best NPs I've worked with as a medical student and resident. Some have been with the CVICU for a long time. There is always a nurse practitioner on during the daytime, and one on nearly every night. They share the patients with the residents and fellows, helping to balance out the workload.
Working with an advanced nurse practitioner is interesting from the perspective of a resident. I have come to admire, respect, and appreciate their training and strengths as well as recognize some of their limitations. They are staples in our system, providing grounding by being there all the time; the surgeons and nurses like them, they know how to manage common situations, and they can act independently. Most importantly, they can get things done. They know how to expedite radiology studies, contact the surgical chiefs, meet protocol parameters. We help each other all the time, whether with making decisions, interpreting data, performing echos, managing emergencies, and getting through the long nights. They are an essential part of the team.
Subscribe to:
Post Comments (Atom)
Posts
4 comments:
Thanks, any thoughts on CRNAs and anesthesia? How does the job market look for anesthesiologists given these sorts of complexities?
Hi, that's a great question, and I don't think anyone knows the answer. What CRNAs mean for anesthesiologists is a complex issue that varies with hospital and geography. For example, at Stanford, we employ very few CRNAs. Historically, our department prefers solo MD anesthesiologists or anesthesia attendings covering residents over attendings covering CRNAs. However, we do have some working in endoscopy, the eye center, and other "out-of-OR" locations. At the VA and at our county hospitals, more CRNAs are employed and part of the culture.
I think that medically, CRNAs can perform anesthesia safely and efficiently, particularly in straightforward cases without complex patients. The anesthesia care team model with a supervising MD and several CRNAs is a great model for an ambulatory or outpatient surgery center. However, at a teritary academic center, our patient population and cases benefit from physician anesthesiologists. For example, yesterday I had an add-on case with a patient in septic and cardiogenic shock on maximum epinephrine, vasopressin, dopamine, and high-level norepinephrine with a troponin of >40. It was a challenging anesthetic, but over the case, guiding my therapy with a pulmonary artery catheter, I was able to titrate the patient off vasopressin and come down on the epi. These are cases where anesthesiologists with advanced training make a difference.
Your question, though, is more directed at CRNAs and jobs. This is a tougher question, and I'm not sure I have a good answer. The American Society of Anesthesiologists has always maintained that a supervised care team model led by an MD is superior to independently practicing CRNAs, but a few states and the VA system allow independent CRNAs. Part of this issue is that nursing groups have an extraordinary lobbying influence. When encountering these issues, though, we have to make sure patient safety is the most important priority. The ASA is trying hard to limit the scope of nurses practicing anesthesia and pain medicine. If this is successful, I believe there will always be a role and value in the anesthesiologist. If nurses continue to gain ground in independent practice, then the job market may be unpredictable.
For now, the advice for anesthesia residents is to strongly consider fellowships as further advanced training helps us distinguish ourselves and prove that we add value to patient care.
Thanks for the question - what are you thoughts on this?
Thanks for responding. I'm only a med student, but very interested in anesthesiology.
However, anesthesiologists have told me not to go into anesthesiology in part because of the challenge from CRNAs and as you mentioned the powerful lobbying which may lead to CRNAs practicing independently. As well as for other reasons like anesthesiologists in the future should not expect to make partnerships any more, or at least not without some undesirable terms. But instead anesthesiologists should expect most likely to be employed by a large anesthesia management company (AMC), directly with a hospital, or working in academia. In the future, it seems like there will be a loss of independence, greater hours, and lower salaries for anesthesiologists. Anesthesiologists where I am have told me they hate to say it but that I should consider another specialty like IM then pulm/critical care, or like you said if I realy want to do anesthesiology then to do a fellowship.
But that's just what I have heard from talking to lots of anesthesiologists in my hospital as a med student. I was hoping it wouldn't be as bad elsewhere. At the same time I'm an optimist, and hope the future won't be as bad as it sounds! I really still like anesthesiology a lot.
Thanks for the comment - I will write a full post on this soon!
Post a Comment