I’ll be coming up to my 2 year anniversary since beginning my career as a CRNA. My full time job is at a major academic medical center, but I’ll moonlight at multiple surgery centers around the city. I started my foray into private practice around 6 months into being a full-fledged CRNA and boy, was that experience an education.
Most CRNAs recommend that those who are nascent in their careers work a few years to get some experience under your belt before going into private practice and for good reason, too, but not in the way you’d expect. Clearly, you want to make sure you have a strong set of clinical skills (e.g., IVs, regional blocks, etc.), but if you went to a strong program that focused heavily on developing your clinical skills (which I was fortunate to be apart of) then that’s the least of your concerns (relatively speaking).
It’s the intangibles (one, specifically) that I would say one needs to possess in order to do well in private practice. It’s the ability to say no. What I’ve come to realize working in private practice is that you truly are alone in your decision making. No one is going to help you determine whether or not your patient is optimized for anesthesia and that alone can feel like a huge burden. More on this in a bit…
You truly are alone in your decision making.
I’ve come to greatly appreciate being an employee at a hospital and being surrounded by anesthesiologists and CRNAs because the culture at where I work is heavily focused on patient safety. Yes, healthcare is a business and ultimately, it IS about the money, but I’m grateful that I work at an institution that values patient safety. So, what do I mean when I say patient safety?
Let’s say I’m assigned to work at an ambulatory surgery center at this institution. If I come across an elderly patient who has a BMI of 35, COPD, CHF and DM, but he doesn’t have a cardiac workup, I have the backing of my attending along with all the members of the patient’s surgical team to either 1) delay surgery until he/she has been cleared by cardiology and 2) outright cancel the procedure, have the patient see cardiology and potentially reschedule the procedure at the main hospital. As I said before, this seems pretty obvious, but I’ve come to appreciate that the culture where I work supports that kind of decision making because it’s the right thing to do.
If that example were applied to a private practice setting, you’d experience a completely different kind of scenario. If you expressed concern about proceeding, you’d get an earful from the surgeon and would probably never be invited back to the center again, which is fine by me, but the point I’m illustrating is that you don’t have the same institutional support at a private practice setting like you would if you worked in a hospital setting.
The challenge is knowing how far to push the boundary but not so far that it violates standards of care.
What’s even more alarming is how you’re all alone with your decision in determining whether it’s safe to proceed with a procedure because if the patient experiences any kind of adverse event, guess who’s going to get blamed? It’s “easy” (again, relatively speaking) to provide care to ASA 1s and 2s, but what happens when you come across ASA 3s and sometimes 4s, but the procedure itself is a 3-minute colonoscopy or 10-minute carpal tunnel release where you’re doing the procedure under MAC? This is where it gets challenging because it’s not realistic for you to say no to every procedure. The challenge is knowing how far to push the boundary but not so far that it violates standards of care.
Is private practice worth it? Hard to say
That’s a problematic issue because every provider has a different threshold for what is and is not appropriate. I’ve found that being in private practice, you have to have a little more flexibility than you normally would in a hospital setting. Things you would NEVER move forward with in a hospital setting, well, you’d probably do in a private practice setting. I would say proceed with caution and think through whether or not it’s worth the risk to yourself and your patient. You have to know when to say no and when you do, just back it up with objective facts and no matter what the surgeon or anyone else at these centers say to you, they can’t argue with your assessment. You’ll meet and work with other anesthesia providers who will do things totally egregious and risks harm to the patient. All you can do is focus on your patient and make sure you do right by him/her no matter what kind of pressure is being exerted upon you.
So, is private practice worth it? Hard to say. I think it think it depends on the individual and his/her ability to tolerate risk. Like I said before, you’re going to have to be okay with doing things at these centers that you normally would not do in a hospital setting. At the same time, you also have to know when to push back and be prepared to defend your assessment. There are a lot of people out there who are just in it for the money and if you do anything to disrupt their pursuit, you’re going to be on the receiving end of a lot of backlash, but that’s okay because it’s not worth the risk. Don’t get me wrong. It’s nice to earn a little extra cash on the side, but not at the expense of your patient’s safety and the threat of losing your license…so, if you’re thinking about trying out private practice, think carefully about what you’re getting yourself into.
2 thoughts on “Private Practice: Is It Worth It?”
When you talk about cancelling cases (especially in an office) – If you work with a good surgeon that has some sense about him such as I work with, that surgeon will have no problem with you cancelling a case if you don’t feel it is safe. Hopefully they will do a good job in medically clearing the patient first. One of the surgeons I work with (in his office) has told me he has no problem cancelling a case if I don’t feel comfortable. So I think it is important when looking at working for a surgeon in their office evaluating:
what quality of surgeon are they?
their office setup?
how healthy are the patients that they bring into their office?
Are they trying to “sneak” an ASA3 or ASA4 patient into their office schedule? I have heard of this happening but never experienced.
Remember, you are providing a service that they need, sometimes it is hard to find consistent anesthesia services for an office(surgeons want to find consistent help), so really you are in the driver seat – you can move on down the road if you don’t like what you see in an office setting(there’s plenty of work out there), the surgeon will be the loser in the end.
Thanks for expressing exactly the conversations I often have to have with docs about why I am not comfortable moving ahead with some cases whether they are or not. You are so right… It often causes dissension and the need to move on rather than practice in a fashion that cannot be defended, outside of the accepted standard of care for that patient and that case. The boundaries are often pushed and some of us actually do stand up and push back and respectfully, say “No, I cannot do this case.” Even though we know it is the right thing to do, we do need to have solid evidence based reasons for saying “No”, or we risk not only appearing to be “difficult to work with”,and want to leave them with a reason to respect us for the decisions we make on behalf of the patient.