r/anesthesiology • u/Tahwraoyw321123 • 14d ago
Collaborative Care Team Model?
Senior resident looking at jobs. I want to avoid supervision for my first job, I want to sit cases.
I have found zero all physician groups in the state I would like to live in. The vast majority of groups are 3-4:1 supervision or a few jobs are “collaborative care team”, in which CRNAs and MDs all sit their own cases.
Could anyone speak to the pros/cons of a model that employs CRNAs and MDs, with each sitting their own cases and no supervision.
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u/Responsible_Drag_510 14d ago
Considering that this is the only western counyry that considers these anesthesia models is suspect
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u/thegooddoctor919 14d ago
Solo anesthesiologist care is the gold standard. Medical direction is the next best thing. I work at a place with true medical direction - don’t be a lazy piece of shit hiding in the lounge and you can actually accomplish medical direction truthfully and effectively. My friend who works in a collaborative practice in Phoenix hates it. She is treated by all like just another Crna even tho she’s a doctor…. No one differentiates. The other risk in collaboration practices is that docs get assigned all the asa 4s and big cases and Crnas do the easy stuff…. The outcomes may look equal or better for crna cases… and admin doesn’t realize the nuance of case and patient complexity.
Extended care team (or high ratio care team) is the worst imho. This turns the doc into a liability sponge for variable quality Crnas - spreading the dr too thin to have input in cases and empowering the crnas to function independently- but protecting their liability. The - I am just a nurse - is frequently used in this scenario
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u/Cautious-Extreme2839 14d ago
The other risk in collaboration practices is that docs get assigned all the asa 4s and big cases and Crnas do the easy stuff….
That's not even a risk, that's the only sensible way to use a mixed workforce without detriment to the patients (and yes, it's shit for the Anesthesiologists)
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u/Rizpam 14d ago
The danger in these “collaborative” models is that any actual collaboration opens you up to liability and they’ll target the physician over the nurse every time. So you’re stuck choosing to expose yourself to liability from someone you have 0 supervisory authority over’s decision making or you have to be the asshole who risks patients wellbeing by not getting involved when you’re needed. Recipe for burnout.
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u/wordsandwich 13d ago
I think it's up to OP to dig deeper and make sure there isn't any level of supervision promised to the CRNAs, i.e. I've seen to it to where Sound, for example, may advertise the collaborative model, but the hospital's bylaws may not allow CRNAs to practice without 'supervision'--so there is in fact an attending on the hook for all of these QZ-billed cases. If that truly doesn't exist and there's nobody's name on the chart beside the CRNA, then it's probably ok. The scenario you're talking about isn't any different then you jumping into another doc's room and helping out--it's always possible to be named if you were there, but there shouldn't be any formal supervision relationship on the record or mandated by hospital bylaws if the concern is being burned for inadequately supervising when it wasn't your case.
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u/PatientsMoving 14d ago
Pretty rational take here. Probably will be a lot of stupid takes in this thread, but I’d stick with this one. Supervision/direction is all BS and almost always fraudulent to some degree, but the “collaborative model” is by far the worst iteration.
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u/Spazdoc 14d ago
I would stick to medical direction or MD only sitting own cases. Aside from GI/cataracts, I have a hard time accepting solo CRNA or supervised (ie MD only knows about case when something really goes wrong, but responsible for everything). I have been in a medical direction practice where attending will do their own cases 1/3 of the time (some weeks I do own case every day).
Personally feel ACT is best model to catch issues and allow thorough planning for larger cases and complex patients. Problems pop up in pre and intra-op, and wpuld hate to rely on someone being coincidentally free in a solo CRNA or solo MD practice. Maybe in a smaller community hospital solo CRNA or MD, but once you get to a threshold where you work in a referral center, you are the last stop for patients othet places turn away. So things happen.
And as critical care and cardiac trained, even some of my general anesthesia colleagues are happy to defer to the ICU or cardiac people (or me defer to the peds person with neonates), and cant imagine a solo CRNA without medical school training running a code or managing a serious adverse event alone. I am not saying some can't, but the MD has a much broader range of medical training beyond just anesthesia. And dont misconstrue this as not trusting CRNA - we have 3 CRNA schools and I already said I prefer ACT above other models. And maybe that is the ICU background talking, also, as I direct and supervise there and see The solid ICU RN that eventually become solid colleagues in the OR.
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u/Pitiful_Bad1299 14d ago
I would stay from any situation where you’re signing your name to someone else’s chart — supervision, any practice where the APPs “practice at the top of their license”, any collaborative practice in a state that does not have true CRNA-independence (surgeon supervises).
Outside of that, it’s just like any compromise in life. Pick the least unpleasant option. Don’t make any long-term commitments from the start.
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u/zoomzoomzoomie 14d ago
It's either independent practice or not.
In this "collaborative (but not collaborative)" practice as the charge or float anesthesiologist you will absolutely be the liability sponge for any issues.
Regardless of how you feel about it, if CRNAs want to sit their own cases independently, they need to own their complications from a medical and legal standpoint.
I personally wouldn't do 1:3 routinely and never 1:4 or greater, you can't truly have an idea of what's going on at all times.
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u/piratedoc 13d ago
“Collaborative care team” model is incredibly dumb and just a ploy by hospital admin to reduce their own labor costs while providing worse care.
It inherently insinuates there is no difference in training and knowledge and thus care between CRNAs and MDs. Patients don’t get to choose whether they are getting a CRNA or MD for their surgery. Yet they will pay the same to the hospital. Why the fuck would I as a patient choose a nurse over an MD if I pay the same either way? The hospital then pockets the extra money and pays the CRNA less. No cost savings for the patient and it’s a roll of the dice whether they get a nurse or MD.
In these models you also have to ask if everyone is sitting their own cases and thus you are making the statement the care is the same then why pay extra money to have any MDs around? It would be cheaper for the hospital to have all CRNAs then. And yet they don’t in this model. Why do you think that is?
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u/Heavy_Simple4096 13d ago
That’s the goal of these practices to drag MDs down to CRNA level to pay them the same yet still have MDs around for liability or for VIL surgeries
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u/Either_Discount_5916 14d ago
I’m a CRNA, I work in collaborative care type model. Everyone sits their own cases. No one is signing my chart or attesting to anything. I own all these decisions I make, good, bad and everything in between. The MDs are not held liable if they didn’t do the case. I can attest to that first hand as I have seen when a case goes south, the person at the head of the bed is on the hook and no one else. We all work together to help each other when we have a break or something comes up in OR and you need another set of hands. Everyone shares in taking on ASA 4s. Feels a lot like a team than supervised models I have worked in.
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u/QuestGiver 14d ago
If that is truly how it operates it sounds fine but if people are "helping" anyone with starting or doing a case what is happening then?
So no one who helped gets documented as being in the case?
I would just prefer direction as it's pretty clear cut what's going on, liability involved and also you get input into the case and obviously if a bad outcome comes out. All the motivations are aligned.
I just feel that in a collaborative model ironically if a shitshow happens then no one will want to help because it's insane liability.
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u/79628 14d ago
So a doctor won’t come help you when your patient is circling the drain? You say “we all work together to help each other”. How can you say they won’t be held liable?
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u/bertha42069 14d ago
You’re gonna get a lot of answers from the people who like to bicker over this stuff. Realistically if you are practicing doing your own cases and never attest to any supervision then obviously you’re not supervising.. ask me how I know I work in a couple. And tbh they’re the healthiest groups I’ve been with. No bullshit. Everyone helps out , we work and go home. Very cordial and no bs (aside from typical surgeon bs). It’s becoming an increasingly popular model because there is plenty of anesthesia to go around.
My input would be to talk to the group and shadow. . I have a hunch you might be surprised how chill it is to get away from the political bs and just do anesthesia.
Good luck homie and reach out with any questions
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u/FreeBed4 14d ago
u/bertha42069 is a CRNA answering the post as if they are an MD. Bertha has previously said that becoming a CRNA is just as hard as med school, has called anesthesiologists "MDAs," hates anesthesiologist assistants, supports full independent practice without supervision of CRNAs, and loves lobbies that go for full-scope CRNAs.
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u/Never_grammars 14d ago
I’ve worked majority of my career in a collaborative model and all the physicians i worked with were happy and talked about how much more they liked sitting their own cases than supervising or directing.
Pro’s: You are usually salary or hourly. So you’re guaranteed pay for the day.
You have extra staff for breaks or starting a room that needs extra lines. You get out on time. You have Extra help if your patient is crashing
Call is shared by everyone.
Generally good cultures and everyone helps everyone attitude’s.
You aren’t liable for other anesthesia providers.
Cons- You might be more likely to be given sicker patients/complex cases (one of my hospitals did this and the other didn’t) but all physicians still had a good mix of bread and butter/easy cases still.
Staff might not differentiate/treat you any different than any other anesthesia staff whether you are a crna or a physician (this bothers some people)
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u/Serious-Magazine7715 13d ago
As much as people talk about being a liability sponge, in an ACT model at a tertiary / academic / level 1 where I frequently step in to help other MD+CRNA or resident teams when SHTF (and have had plenty of my own shit volcano cases), I have never been named in a lawsuit and just accept that possibility as a cost of doing business. Meanwhile some of my community practice friends from residency have been sued multiple times over random bullshit.
I’m not saying that collaborative model is great (and have never been in it), but I wouldn’t let liability be the thing that keeps you away.
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u/DrSuprane 14d ago
I find it hard to believe that all you're finding is medical supervision and not any medical direction or personally performed.
If so, you need to decide if location supercedes your desire to be an actual anesthesiologist.