Other articles in Spring 2009
The All-Anesthesiologist Model of Anesthesia Care
Richard Bindseil, O.D. and Stephen Weddell, M.D.
Longmont Anesthesia Associates, Longmont, Colorado
The more we experience life and work, the more we realize there are many ways to accomplish a goal. As anesthesiologists, we know different anesthetic techniques can each yield acceptable results. Likewise, different anesthesia group models can each provide acceptable anesthesia services for their respective communities. Why different models have developed in communities depends on many factors including manpower availability, number of anesthetizing locations, and professional goals.
In our community, Longmont, Colorado, these factors have allowed us to be able to provide our clients (surgeons, medical institutions, and our patients) with an all-anesthesiologist care team. We are blessed to have a cohesive, cooperative, and happily inter-dependent group that can offer high level anesthesia care at all times for all our clients. We find the all-anesthesiologist model to be the best for us and feel it is the best for our clients.
Not only have CRNAs worked in our community, but some of our group members have worked as part of an anesthesia care team before coming to work here in Colorado. We have certainly considered integrating CRNAs into out practice on numerous occasions we have simply never reached a consensus that it was the right thing to do.
One of our members observed that “anesthesiology is probably the most boring specialty to watch someone do, but the most exciting and fun to actually do yourself.” It can be a challenge to gain a patient’s trust and confidence during the pre-surgical period when they are anxious and concerned about the outcome of their procedure, but it is very rewarding to manage them safely and successfully through the trauma of surgery and recovery. We take full responsibility for knowing the patient’s history and medical circumstances so that when a problem develops, we can quickly and effectively provide a solution. It is not as if we do not already work as a team with the surgeon and the medical staff, we just do not choose to share our responsibilities for the management of the anesthesia with CRNAs.
Individually and collectively, the members of our group take responsibility for a positive peri-operative experience for our patients. We share all responsibilities such as call equally. We also share all benefits equally. Even financially, we have a shared incentive to do what is right for the patients and our customers. It has been our view that the inclusion of non-physician employees would needlessly complicate the equation. We may be forgoing some income in the process, but this is a price we have chosen to pay.
It should also be noted that since we are a relatively small practice, the logistics of coverage do not lend themselves to a care team model. Our group currently covers 11 anesthetizing locations, including OB coverage, between an outpatient surgery center and a community hospital. We seldom run more than one operating room after normal hours or on the weekends. It makes little sense to have an employed CRNA working during these times, as it would mean one anesthesiologist would be supervising one CRNA. It makes no sense, economically or otherwise, for the employed CRNA to share in the after-hours call for only one case at a time while being appropriately supervised by an anesthesiologist. Thus, were we to have CRNAs in our group, only the physicians would be working the after hours and weekend call. It makes more sense to us to dilute the undesirable working hours among all of us, rather than among a lesser number of supervisory physicians.
Some members are very familiar with the medical direction of CRNAs and have found this role to be difficult at best. From a standpoint of delivering proper medical care, adhering to the seven basic principles of medical direction can be nearly impossible when directing multiple CRNAs, especially when providing anesthesia for short cases. From a standpoint of a well coordinated team, some CRNAs have resented supervision, at times waiting too long to call for assistance. Some have addressed themselves to the patients as “Doctor.” While seeming to want equal medical status as the supervisory anesthesiologist (or other physician), the CRNAs have been notably less interested in assuming the responsibilities and commitments required of the physicians.
On the other hand, each member of our anesthesia team is an equal partner and therefore each has a vested interest in the overall success of the group. This is manifested by each member’s willingness to step up to not only help cover any anesthesia need, but to participate in administrative functions with our institutional clients and the medical staffs. Each member of our team realizes how essential extra effort is to fulfill the contractual obligations of the group. It has not been our experience that medically directed CRNAs have the same level of commitment to the other members of the anesthesia group, nor to the efforts that must be put forward to assure the continuing excellence and success of the group.
We recognize that an anesthesia model that includes employed CRNAs can work well in many situations. We feel our all-anesthesiologist group can give the best and most consistent care to our patients, the best service to our institutional customers, and the most professional satisfaction to the members of the group. We hope that the demographics of our community and our manpower resources will allow us to continue this model of anesthesia practice for years to come.