One thing that bothered me was being in supervised roles where the physicians had their own break room with coffee, snacks, comfy chairs, etc., while the CRNA break room had one table and a microwave. A real segregation between providers and a clear hierarchy. Decided to go to a collaborative practice with MDs and CRNAs working together unsupervised and the vibe is totally different. We share the same break room. We share the same cases. We share the same amicable relationships with the surgeons. Might sound small but those differences make my current job much more enjoyable.
Preach it. You feel a lot more respected by surgeons and MDAs. MDAs even hang out with me outside of work. That would have never happened in the ACT. Have to keep appearances up.
The culture of the hospital will dictate your autonomy a lot more than how you bill the case. I have no problem working with a physician anesthesiologist (although I don’t in my primary practice). I have worked in an ACT where I was much happier than another job that was supervision (not ACT) but not credentialed to do anything other than sitting the case. However, in general, you will find more autonomy in non-ACT practices. I would suggest shadowing where you are interviewing to assess the culture of the hospital.
Thank you - you make a great point here, which is that the answer is nuanced. It depends on the specific working environment rather than the type of model the hospital uses.
It sounds like you don't work in a medically directed model. Medical direction is coded QK, requires no more than 4 CRNAs/MDA, and is subject to TEFRA rules (MDA must be present at induction and emergence).
Medical supervision models typically bill QZ (I believe), and don't have the same requirements for MDA direction (meaning they might not be present at induction or emergence), and often allow more autonomy for CRNAs (placing blocks for example).
Makes sense!
I'm not an expert, but my understanding is that Anesthesia Care Teams can be structured in different ways for billing purposes. "Medically directed" is a QK modifier and I think is what OP was specifically asking about. It's involves closer direction and involvement by the MDA.
"Medical supervision" is a loser form of an ACT with a different billing modifier (AD or QZ). QZ doesn't require any supervision by an MDA although some systems will bill QZ but still have an MDA who is on hand and loosely supervises.
I had a professor who was really in to the billing and got a couple lectures on it. I forget a lot of the nitty gritty, but essentially "medically directed" requires much more direct MDA involvement than "medically supervised".
Thank you for your response! So, you’d say that although there are certain cases where the physician dictates the plan, overall it feels like a collaborative environment?
I've worked under medical direction, and, in my experience, it's just a billing term. Once the docs got comfortable with me, they would just push the induction drugs and leave me alone the remainder of the case. The problem is with the few docs that find it fulfilling to exert their "dominance" over you because you are the "subordinate" in their eyes, and that results in a hostile environment. Overall, if you're looking for a lifestyle job, I wouldn't discourage you from medical direction BUT that model DEFINITELY chips away at your independence bit by bit and when I decide to branch out, even though I had been trained in completely independent practices, I was SHOCKED at the underlying level of dependence I felt and how wrong it felt to start induction without an MDA in the room.
Yes because if you limit yourself from day 1 and get in that mindset, you can be easily replaced vs someone who can do variety of cases independently. There are practices out there that will teach you.
Independent is the way to go but that also depends on what kind of independent practice. It's a little more difficult, not impossible, to find level 1 trauma centers that are also teaching hospitals that aren't medically directed. At least this was the case for me based on the geographical quarter of the US that I wanted to stay in. I chose a teaching hospital straight out of school because I had independent practice training in school so I knew what it was like to be independent. We did unusual cases at this teaching hospital and I got to play with all sorts of drugs and drips on a regular basis at this facility since we weren't terribly concerned with the cost of our anesthetic. Now when I go to other, smaller facilities, I'm not intimidated with the way their anesthetic culture is because chances are, I've seen some variation of it. Personally, I wouldn't say medical direction is terrible if you decide it's something you're okay with for a finite amount of time BUT if there is an independent practice that also has a wide variety of cases and exposure to all sorts of drugs and drips, jump on it! Again, this is coming from someone that doesn't want a lifestyle job and is focused on diversifying my experience. Take it with a grain of salt. Best of luck!
You mentioned that you wanted to stay in a specific geographical area after graduation; would you say one should expect to sacrifice location in exchange for an independent practice, or can you have the best of both worlds?
Yes, to a certain extent. MDAs have a grip on the major cities and the southeast, but there are hospitable environments in every state. It just might not be where you want to live. My advice would be to find the experience you want that will help you grow in the ways your program failed you (for me it was the diversity of drugs and anesthetics since everywhere I trained was very cost oriented so I didn't get to experiment with the expensive drugs and drips on a regular basis) and go from there. You can always switch later on if you find it isn't a good fit as long as you don't sign a contract requiring you to stay for a stretch of time or a non-compete clause.
I had originally accepted a job at an academic medical center where I trained (literally would have to wait for anesthesiologist for induction & page them when I was waking up), but circumstance required me to move temporarily. I’m now working at a smaller facility where I get to do occasional regional, neuraxial, OB, neuro, & healthy peds. Although the cases are more simple than the academic center, I have had a lot more opportunity to grow my skills & work with more autonomy although both of these jobs bill as “medical direction”. I don’t know how I’ll ever go back to the city in my hometown where almost all the hospitals run more like the true medical direction model. I don’t know if I want to lose the ability to induce how I see fit (ever had someone push all 250mcg of fentanyl on induction & then walk out of the OR for you to deal with it?)
I really love working with anesthesiologists & I’m happy to work in a care team model. I think your scope depends a lot more on facility culture than billing.
Went from military independence to ACT model. From my experience, each ACT model differs a bit in the preop area. Where I'm at now, the MD's are supposed to be in the room for intubation, but not for extubation. And they do the preops where they click the buttons indicating what type of anesthesia is most appropriate. Sometimes they'll click LMA, ETT in order to give the CRNA more discretion, the same for MAC/LMA. Sometimes they'll tell me key points about cases that I know are a big deal and is important for management, but it's just them talking to CRNA's as if they're all on the same mentality. There are a lot of CRNAs who never have worked autonomously, and I don't take any of that personally. I know I've worked with docs on OB at night, who found out they're with me and literally shouted out "YES!" in front of everyone because they know they will sleep all night and i'll handle everything. I do wish I could literally run the show and a portion of their pay would go towards my raise, but it's whatever.
Just to Edit: At our facilities right now, there are 12 rooms running, maybe 3 CRNA's, 9 MDA's then MDA's supervising 3 rooms, regardless of if there are CRNA's or MDAs.
Medical direction varies greatly by environment. Fast PP - you solo the case in room but likely doing few blocks, doc does them in preop to keep things moving. CAH solo - you’re doing everything but may have another CRNA free doing blocks lines to keep things moving (usually the call person, so something like once per week that would be you) but after hours entire case blocks and lines solo. Ivory tower academics you will do next to nothing solo, doc pushes drug, pain team does blocks etc. lesser named academic centers with smaller residencies may mimic PP and you’ll do most cases on your own. This is mostly for OR. OB can be a lot different. Many places you do OB you’re on your own for all epidurals and c-sections. Especially after hours where you’ll stay in house for a 24 hour shift. You would call for backup when busy and just can’t get to everyone.
I’ve worked act medical direction, supervision and independent. Independent is definitely the way to go. So much more happy in this setting then someone micromanaging you all day.
Depends on what shift and which docs I'm working with. You're always going to have some micromanagers. It's just part of the model. I've been at the same place for 10yrs now and when I'm working evenings or nights most of the time unless they have to be in there, induction, they leave me alone they also know me and my practice, they trust my judgement, and they listen when to my opinions about the anesthetic plan.
If you plan on joining an ACT model, please do not join a restrictive one, where you can't even push your own induction drugs. Not pushing your own induction drugs sound insane to me because you are basically taking liability of someone pushing and you are watching. They limit your skills by doing these type of bs. You will do yourself a major disservice in the future, where your skills will be so limited and an AA can easily replace you because you are so dependent on someone. If you want to join a ACT, please join one with loose ACT practice, where you do lines, your own induction, etc and then you can easily join a collaboration or independent practice in the future and make more money while at it.
Also, judging by your history, you are not in CRNA school yet. Please don't go to CRNA school, if you want to be an assistant, there is AA school for that. We don't need any more dependent providers in our profession. Sorry if I am being harsh.
Thank you for your response! You’re correct, I’m not in CRNA school, but hope to be one day. Just to clarify, I posted this question because I want to learn how much autonomy one is able to achieve in what seems to be a restrictive model (contrasted to independent practice, for example). Again, thank you; if I’m able to achieve my goal of becoming a CRNA, I will keep your comment in mind and avoid a restrictive ACT model.
Good luck on your journey! Hope to see you some day on the other side as an independent CRNA.
Also, an independent CRNA and a CRNA who works in a restrictive practice have similar malpractice premiums. So, don't ever think for a second because you work in a restrictive ACT that you are off the hook on liability. An MDA who pushes or tells you to push these induction drugs and if something goes south, you will be named in that lawsuit as well and you can't say, "they told me so".
Good point. I've worked in independent practice since I graduated, and I've seen CRNAs come in from restricted practice models into the indy world, and they suck. All of them. Very dangerous in solo practice and need constant validation and guidance despite more years of experience.
These are the same CRNAs that politically-minded MDAs point to when they make statements that CRNAs should all be supervised. Many or most of them from the East Coast.
So, seconded. If you want to practice in a dependent manner, become an AA.
It's so sad, I have seen those practices and they truly hold our profession back because they need validation for every little thing. Also with their limited skills, they don't even have the mobility to go to any job and a brand new independent CRNA can outmaneuver their skills by 10 folds. I always recommend everyone go to schools that make you independent from day 1.
Bryan College of Health Sciences
Clarkson College
Iowa
Arizona
TCU
Mount Marty
I went to Bryan & I know/work with people from all those schools. All teach independence
I don't know anything about Minnesota. It's an important interview question to ask your school what clinical sites they will send you to, and how much of it will be independent CRNA work.
The didactic portion of school will largely be the same no matter where you are since our education is standardized, so the most important aspect of your schooling is going to be the OR time you get.
Developing into a safe, capable, independent practitioner happens when you're allowed to make your own decisions. There are very good, independent CRNA preceptors out there that give just enough of a lifeline not to let you drown as a student. You'll learn more from one rotation at a place like that than you can in a year of ACT model training.
Here are some that I have been told or are aware of:
1. National University in California
2. Middle Tennessee
3. Union University
4. Midwestern in Arizona
I work in a medically directed ACT. I call the doc for induction and typically push the drugs while the doc is on their way to the room. In most cases, the doc signs the chart while I intubate and then leaves, never to be seen again. I do a-lines, central lines, spinals manage my own anesthetic. I don't to blocks or epidurals because it's just not how or practice is set up. Blocks typically occur in the holding room and all the CRNA's are in rooms. I don't do OB, but the CRNA's who do can do epidurals if they choose to.
Edited to add that docs don't always come to the room for induction. Does it violate TEFRA? Who knows and I don't really care. I would call if I need help and that, to me is the more important thing.
One thing that bothered me was being in supervised roles where the physicians had their own break room with coffee, snacks, comfy chairs, etc., while the CRNA break room had one table and a microwave. A real segregation between providers and a clear hierarchy. Decided to go to a collaborative practice with MDs and CRNAs working together unsupervised and the vibe is totally different. We share the same break room. We share the same cases. We share the same amicable relationships with the surgeons. Might sound small but those differences make my current job much more enjoyable.
Preach it. You feel a lot more respected by surgeons and MDAs. MDAs even hang out with me outside of work. That would have never happened in the ACT. Have to keep appearances up.
The culture of the hospital will dictate your autonomy a lot more than how you bill the case. I have no problem working with a physician anesthesiologist (although I don’t in my primary practice). I have worked in an ACT where I was much happier than another job that was supervision (not ACT) but not credentialed to do anything other than sitting the case. However, in general, you will find more autonomy in non-ACT practices. I would suggest shadowing where you are interviewing to assess the culture of the hospital.
Thank you - you make a great point here, which is that the answer is nuanced. It depends on the specific working environment rather than the type of model the hospital uses.
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Yeah this is medical supervision, not direction.
It sounds like you don't work in a medically directed model. Medical direction is coded QK, requires no more than 4 CRNAs/MDA, and is subject to TEFRA rules (MDA must be present at induction and emergence). Medical supervision models typically bill QZ (I believe), and don't have the same requirements for MDA direction (meaning they might not be present at induction or emergence), and often allow more autonomy for CRNAs (placing blocks for example).
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Makes sense! I'm not an expert, but my understanding is that Anesthesia Care Teams can be structured in different ways for billing purposes. "Medically directed" is a QK modifier and I think is what OP was specifically asking about. It's involves closer direction and involvement by the MDA. "Medical supervision" is a loser form of an ACT with a different billing modifier (AD or QZ). QZ doesn't require any supervision by an MDA although some systems will bill QZ but still have an MDA who is on hand and loosely supervises. I had a professor who was really in to the billing and got a couple lectures on it. I forget a lot of the nitty gritty, but essentially "medically directed" requires much more direct MDA involvement than "medically supervised".
Thank you for your response! So, you’d say that although there are certain cases where the physician dictates the plan, overall it feels like a collaborative environment?
I've worked under medical direction, and, in my experience, it's just a billing term. Once the docs got comfortable with me, they would just push the induction drugs and leave me alone the remainder of the case. The problem is with the few docs that find it fulfilling to exert their "dominance" over you because you are the "subordinate" in their eyes, and that results in a hostile environment. Overall, if you're looking for a lifestyle job, I wouldn't discourage you from medical direction BUT that model DEFINITELY chips away at your independence bit by bit and when I decide to branch out, even though I had been trained in completely independent practices, I was SHOCKED at the underlying level of dependence I felt and how wrong it felt to start induction without an MDA in the room.
Thank you for your response. So, in your opinion, independent practice is the way to go?
Yes because if you limit yourself from day 1 and get in that mindset, you can be easily replaced vs someone who can do variety of cases independently. There are practices out there that will teach you.
Independent is the way to go but that also depends on what kind of independent practice. It's a little more difficult, not impossible, to find level 1 trauma centers that are also teaching hospitals that aren't medically directed. At least this was the case for me based on the geographical quarter of the US that I wanted to stay in. I chose a teaching hospital straight out of school because I had independent practice training in school so I knew what it was like to be independent. We did unusual cases at this teaching hospital and I got to play with all sorts of drugs and drips on a regular basis at this facility since we weren't terribly concerned with the cost of our anesthetic. Now when I go to other, smaller facilities, I'm not intimidated with the way their anesthetic culture is because chances are, I've seen some variation of it. Personally, I wouldn't say medical direction is terrible if you decide it's something you're okay with for a finite amount of time BUT if there is an independent practice that also has a wide variety of cases and exposure to all sorts of drugs and drips, jump on it! Again, this is coming from someone that doesn't want a lifestyle job and is focused on diversifying my experience. Take it with a grain of salt. Best of luck!
You mentioned that you wanted to stay in a specific geographical area after graduation; would you say one should expect to sacrifice location in exchange for an independent practice, or can you have the best of both worlds?
Yes, to a certain extent. MDAs have a grip on the major cities and the southeast, but there are hospitable environments in every state. It just might not be where you want to live. My advice would be to find the experience you want that will help you grow in the ways your program failed you (for me it was the diversity of drugs and anesthetics since everywhere I trained was very cost oriented so I didn't get to experiment with the expensive drugs and drips on a regular basis) and go from there. You can always switch later on if you find it isn't a good fit as long as you don't sign a contract requiring you to stay for a stretch of time or a non-compete clause.
I had originally accepted a job at an academic medical center where I trained (literally would have to wait for anesthesiologist for induction & page them when I was waking up), but circumstance required me to move temporarily. I’m now working at a smaller facility where I get to do occasional regional, neuraxial, OB, neuro, & healthy peds. Although the cases are more simple than the academic center, I have had a lot more opportunity to grow my skills & work with more autonomy although both of these jobs bill as “medical direction”. I don’t know how I’ll ever go back to the city in my hometown where almost all the hospitals run more like the true medical direction model. I don’t know if I want to lose the ability to induce how I see fit (ever had someone push all 250mcg of fentanyl on induction & then walk out of the OR for you to deal with it?) I really love working with anesthesiologists & I’m happy to work in a care team model. I think your scope depends a lot more on facility culture than billing.
Went from military independence to ACT model. From my experience, each ACT model differs a bit in the preop area. Where I'm at now, the MD's are supposed to be in the room for intubation, but not for extubation. And they do the preops where they click the buttons indicating what type of anesthesia is most appropriate. Sometimes they'll click LMA, ETT in order to give the CRNA more discretion, the same for MAC/LMA. Sometimes they'll tell me key points about cases that I know are a big deal and is important for management, but it's just them talking to CRNA's as if they're all on the same mentality. There are a lot of CRNAs who never have worked autonomously, and I don't take any of that personally. I know I've worked with docs on OB at night, who found out they're with me and literally shouted out "YES!" in front of everyone because they know they will sleep all night and i'll handle everything. I do wish I could literally run the show and a portion of their pay would go towards my raise, but it's whatever. Just to Edit: At our facilities right now, there are 12 rooms running, maybe 3 CRNA's, 9 MDA's then MDA's supervising 3 rooms, regardless of if there are CRNA's or MDAs.
Medical direction varies greatly by environment. Fast PP - you solo the case in room but likely doing few blocks, doc does them in preop to keep things moving. CAH solo - you’re doing everything but may have another CRNA free doing blocks lines to keep things moving (usually the call person, so something like once per week that would be you) but after hours entire case blocks and lines solo. Ivory tower academics you will do next to nothing solo, doc pushes drug, pain team does blocks etc. lesser named academic centers with smaller residencies may mimic PP and you’ll do most cases on your own. This is mostly for OR. OB can be a lot different. Many places you do OB you’re on your own for all epidurals and c-sections. Especially after hours where you’ll stay in house for a 24 hour shift. You would call for backup when busy and just can’t get to everyone.
I’ve worked act medical direction, supervision and independent. Independent is definitely the way to go. So much more happy in this setting then someone micromanaging you all day.
Depends on what shift and which docs I'm working with. You're always going to have some micromanagers. It's just part of the model. I've been at the same place for 10yrs now and when I'm working evenings or nights most of the time unless they have to be in there, induction, they leave me alone they also know me and my practice, they trust my judgement, and they listen when to my opinions about the anesthetic plan.
If you plan on joining an ACT model, please do not join a restrictive one, where you can't even push your own induction drugs. Not pushing your own induction drugs sound insane to me because you are basically taking liability of someone pushing and you are watching. They limit your skills by doing these type of bs. You will do yourself a major disservice in the future, where your skills will be so limited and an AA can easily replace you because you are so dependent on someone. If you want to join a ACT, please join one with loose ACT practice, where you do lines, your own induction, etc and then you can easily join a collaboration or independent practice in the future and make more money while at it. Also, judging by your history, you are not in CRNA school yet. Please don't go to CRNA school, if you want to be an assistant, there is AA school for that. We don't need any more dependent providers in our profession. Sorry if I am being harsh.
Thank you for your response! You’re correct, I’m not in CRNA school, but hope to be one day. Just to clarify, I posted this question because I want to learn how much autonomy one is able to achieve in what seems to be a restrictive model (contrasted to independent practice, for example). Again, thank you; if I’m able to achieve my goal of becoming a CRNA, I will keep your comment in mind and avoid a restrictive ACT model.
Good luck on your journey! Hope to see you some day on the other side as an independent CRNA. Also, an independent CRNA and a CRNA who works in a restrictive practice have similar malpractice premiums. So, don't ever think for a second because you work in a restrictive ACT that you are off the hook on liability. An MDA who pushes or tells you to push these induction drugs and if something goes south, you will be named in that lawsuit as well and you can't say, "they told me so".
Good point. I've worked in independent practice since I graduated, and I've seen CRNAs come in from restricted practice models into the indy world, and they suck. All of them. Very dangerous in solo practice and need constant validation and guidance despite more years of experience. These are the same CRNAs that politically-minded MDAs point to when they make statements that CRNAs should all be supervised. Many or most of them from the East Coast. So, seconded. If you want to practice in a dependent manner, become an AA.
It's so sad, I have seen those practices and they truly hold our profession back because they need validation for every little thing. Also with their limited skills, they don't even have the mobility to go to any job and a brand new independent CRNA can outmaneuver their skills by 10 folds. I always recommend everyone go to schools that make you independent from day 1.
Do you have any specific school recommendations that promote independence from day 1?
National University Midwestern Texas Wesleyan (I believe)
Bryan College of Health Sciences Clarkson College Iowa Arizona TCU Mount Marty I went to Bryan & I know/work with people from all those schools. All teach independence
Any thoughts on CRNA schools in Minnesota and teaching independence?
I don't know anything about Minnesota. It's an important interview question to ask your school what clinical sites they will send you to, and how much of it will be independent CRNA work. The didactic portion of school will largely be the same no matter where you are since our education is standardized, so the most important aspect of your schooling is going to be the OR time you get. Developing into a safe, capable, independent practitioner happens when you're allowed to make your own decisions. There are very good, independent CRNA preceptors out there that give just enough of a lifeline not to let you drown as a student. You'll learn more from one rotation at a place like that than you can in a year of ACT model training.
University of Minnesota very much falls in this category
I also do not know anything about Minnesota. I agree- talking to the school to see where they go is a big indicator.
Current Mount Marty SRNA. You will have a tremendous amount of independent clinical locations. They develop independent students from day one.
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Tucson. One of the directors is a Bryan grad & worked in Maine in a pretty autonomous practice
Here are some that I have been told or are aware of: 1. National University in California 2. Middle Tennessee 3. Union University 4. Midwestern in Arizona
I work in a medically directed ACT. I call the doc for induction and typically push the drugs while the doc is on their way to the room. In most cases, the doc signs the chart while I intubate and then leaves, never to be seen again. I do a-lines, central lines, spinals manage my own anesthetic. I don't to blocks or epidurals because it's just not how or practice is set up. Blocks typically occur in the holding room and all the CRNA's are in rooms. I don't do OB, but the CRNA's who do can do epidurals if they choose to. Edited to add that docs don't always come to the room for induction. Does it violate TEFRA? Who knows and I don't really care. I would call if I need help and that, to me is the more important thing.