A discussion of surpluses/shortages of anesthesiologists/CRNAs, state by state.

[Ochempwnsme]

Warning: loooong post.

So, I'm a premed, and today I read a post of someone in the premed forum who is concerned about surpluses of anesthesiologists and radiologists and it developed into a discussion of surpluses/shortages for the country as a whole, as well as major metro areas vs rural, etc. Being someone who loves statistics, and who is also considering anesthesiology along with internal medicine as a career choice, I decided to look into this some more.

After searching the anesthesiology subforum on here I stumbled upon the RAND workforce survey from 2010. It is available here: http://www.rand.org/content/dam/rand/pubs/technical_reports/2010/RAND_TR688.pdf

It doesn't appear that the data was ever delved into that deeply on the forums, so I wanted to post some rambling thoughts on it. According to RAND, of the 49 states they examined for anesthesiologist demand (data for one state was unavailable), 24 of the 49 had a surplus of anesthesiologists, with the remaining 25 facing an anesthesiologist shortage. Regarding CRNAs, RAND found that 28 of 47 state surveyed had a surplus of CRNAs, with the remaining 19 states having a shortage of CRNAs. States vary widely in population as we all know, so some of the states in which there is a surplus of anesthesiologists may still have more ABSOLUTE positions available than states in which there is a shortage. Example: Although demand for anesthesiologists way outstrips supply in South Dakota, there are probably more total jobs for anesthesiologists available in New York State, where there is a surplus of anesthesiologists.

All that being said, these state shortages are unadjusted for population. If a state in the list has opted out of the federal requirement for supervision of anesthesia (list here: http://www.beckersasc.com/anesthesi...physician-supervision-of-anesthesia-rule.html) I have also noted it below. Here are the 25 states with anesthesiologist shortages as of 2010, listed in order from greatest shortage to least.

1) Alabama - largest shortage of the 25 listed
2) South Dakota: opt-out state
3) Minnesota: opt-out state
4) Louisiana
5) North Carolina
6) South Carolina
7) New Hampshire: opt-out state
8) Tennessee
9) Florida
10) Michigan
11) Connecticut
12) Kansas: opt-out state
13) North Dakota: opt-out state
14) Ohio
15) Rhode Island
16) Georgia
17) Pennsylvania
18) Virginia
19) Missouri
20) West Virginia
21) Delaware
22) Maine
23) New Jersey
24) Illinois
25) Nebraska: opt-out state, smallest shortage of the 25 listed

17 states have opted out of the federal requirement for anesthesia supervision, and 6 of those 17 states are on this list.

Interestingly, of the top 10 states with the largest shortages of anesthesiologists, only 3 have opted out. Alabama has the greatest shortage of anesthesiologists by far, yet it is not an opt-out state. On the other hand, 11 of the 17 states that have opted out currently have a surplus of anesthesiologists.

At this point, I wanted to look more closely at the 17 opt-out states to determine whether they have surpluses or shortages of anesthesiologists and CRNAs:

Iowa: Opted out in 2002, and as of 2010, Iowa had the second largest surplus of anesthesiologists relative to supply. They have a large shortage of CRNAs in Iowa, however.

Nebraska: opted out in 2002 for the same reason, and currently has a shortage of anesthesiologists and a surplus of CRNAs.

Idaho: opted out in 2002 and currently has a surplus of both anesthesiologists and CRNAs.

Minnesota: opted out in 2002 and currently has a shortage of anesthesiologists and a surplus of CRNAs.

New Hampshire: opted out in 2002 and currently has a shortage of anesthesiologists and a surplus of CRNAs.

New Mexico: opted out in 2002 and currently has a surplus of both anesthesiologists and CRNAs.

Kansas: opted out in 2003 and currently has a shortage of anesthesiologists and a surplus of CRNAs.

North Dakota: opted out in 2003 and currently has a shortage of both anesthesiologists and CRNAs.

Washington: opted out in 2003 and currently has a surplus of both anesthesiologists and CRNAs.

Alaska: opted out in 2003 and no data available for either anesthesiologist or CRNA demand.

Oregon: opted out in 2003 and has a surplus of anesthesiologists and CRNAs.

Montana: opted out in 2004 and has a surplus of anesthesiologists with no data on CRNA demand.

South Dakota: opted out in 2004 and has a shortage of anesthesiologists and a surplus of CRNAs.

Wisconsin: opted out in 2005 and has a surplus of anesthesiologists and a shortage of CRNAs.

California: opted out in 2009 and has a surplus of both anesthesiologists and CRNAs.

Colorado: opted out in 2010 and has a surplus of both anesthesiologists and CRNAs.

Kentucky: opted out in 2012 and has a surplus of both anesthesiologists and CRNAs.

There is anesthesiologist demand data for 16 of the 17 opt-out states and CRNA demand data for 15 of the 17 opt-out states. In 10 of the 16 opt-out states for which there is data, there is actually a surplus of anesthesiologists. We have CRNA demand data for 15 of the 17 opt-out states. In 12 of the 16 opt-out states for which there is data, there is a surplus of CRNAs. In 7 of the 16 opt-out states for which there is data, there is a surplus of both anesthesiologists and CRNAs.

One of the 16 opt-out states for which there is data on anesthesiologists, 1 is located in the South, and that is Kentucky. One of the 16 is located in the Northeast and that is Kentucky. 7 of the 16 are located in the Midwest. 7 of the 16 are located in the West. It is interesting that only 1 of the 16 opt-out states is in the South, because the South as a whole has a shortage of both anesthesiologists and CRNAs. It is interesting that 7 of the 16 are in the West because the region as a whole appears to have a significant surplus of both anesthesiologists and CRNAs.

This is just my observation, but perhaps the fact that opt-out states are concentrated in the West is because there are a surplus of CRNAs in these states. Having more CRNAs than other regions of the country allows for more concentrated political power. If CRNAs want to increase their income and there is a surplus of them in the state, they can protect their profession as a whole by moving for independent practice, which increases their flexibility and mitigates some of the downward pressure on their income that a surplus would normally exert.

By contrast, because there is a shortage of CRNAs in the South, they may have less leverage, and so there is less political pressure to allow CRNAs to practice independently. 4 of the 11 Southern states have a shortage of CRNAs, while 8 of the 11 Southern states have a shortage of anesthesiologists. If opting out was being done to increase patient access to necessary anesthesiology services, you might imagine that there would be more than one opt-out state in the South, given the fact that 8 of 11 have a shortage of anesthesiologists, and the three that don't (Mississippi, Arkansas and Kentucky) have only tiny surpluses of anesthesiologists.

When you look at the Midwest region (North Dakota, South Dakota, Nebraska, Iowa, Minnesota, Wisconsin and Kansas), 4 of the 7 opt-out states have a surplus of CRNAs. 3 of the 7 states have a shortage of CRNAs. This might have occurred because of the same thing which I suggest happened in the West. A surplus of CRNAs in the Midwest and fewer anesthesiologists than there are in the West could have lead to diminished political power for the physicians' lobby to prevent states from opting-out.

The fact that there is only one opt-out state in the Southern region, as I mentioned, suggests to me that the likelihood of a state opting out may be more dependent on the amount of CRNAs in the state than the actual need. The South as a whole appears to be in desperate need of both anesthesiologists and CRNAs, yet has only one-opt out state.

12 of the 16 opt-out states for which there is data have a surplus of CRNAs. In 10 of the 16, there is a surplus of anesthesiologists. Of the 10 states with the greatest need for anesthesiologists, only 3 have opted out (New Hampshire, Minnesota and South Dakota), and all three currently have a surplus of CRNAs.

Anyhow, I hope some of you appreciate this post. Perhaps the list of states with anesthesiologist shortages will help those who are in their second or third year of anesthesiology residency and are currently searching for jobs. Comments and questions welcomed.

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[Gern Blansten]

Most predictions are wrong. There are too many variables to get a true estimate of need. What will the staffing model be? Will CRNA's practice independently? How will Obamacare effect this? Will the economy turn around allowing the old folks to retire or will they work into their 70's? Will AMC's buy up all groups? Will all be hospital employees? What political forces are at play? So many questions...

 

[Ochempwnsme]

Will CRNA's practice independently?

This is the biggest factor. The other ones you mentioned should not reduce the demand for anesthesiology services a large amount, and as the study mentions it should increase faster than it has been due to the rapid aging of the US population. The other factors are relatively minor in comparison, but independent practice and the expansion of anesthesia care teams are the big unknowns. From the way that I understand it, opt-out states allow independent practice. Is that correct? Please correct me if I'm wrong. If so, we would need to examine the frequency of independent practice and whether it is increasing as a as a percentage of anesthesia services as a whole. Just because a state may allow it doesn't mean that an insurance company or hospital will be fine with it. If anesthesiology moves toward anesthesia care teams with anesthesiologists each supervising 3 rooms of CRNAs (as an example), that would presumably mean that the need for anesthesiologists would be substantially reduced.

Edit: The primary concern should not be reduction in salaries (although that is a concern), but rather the elimination of anesthesiologists as suitable anesthesia providers in the name of cost savings. If salaries fell too far, however, many hospitals who could attract anesthesiologists would continue to prefer employing many of them, because the cost savings may not justify the risk. If it ever came to be that anesthesiologists and CRNAs were paid the same, then any location that could attract anesthesiologists would have no need to employ CRNAs

 

[AnesThrow]

The primary concern should not be reduction in salaries (although that is a concern), but rather the elimination of anesthesiologists as suitable anesthesia providers in the name of cost savings. If salaries fell too far, however, many hospitals who could attract anesthesiologists would continue to prefer employing many of them, because the cost savings may not justify the risk. If it ever came to be that anesthesiologists and CRNAs were paid the same, then any location that could attract anesthesiologists would have no need to employ CRNAs

Current practicing anesthesiologists are also included in the "aging" population. If these anesthesiologists don't retire, and residencies keep pumping out new grads, available jobs will keep decreasing.

If the salary for anesthesiology severely drops to the level of a CRNA and CRNAs are allowed to practice independently, most people will not go to medical school to be an anesthesiologist when they can be a CRNA for substantially less social and economic sacrifice. Furthermore, it may get to the point where it is more cost effective to leave anesthesiology and do residency in another field or work in a non-clinical job for an EMR company, pharmaceutical company, as an expert witness, etc.

The chance of it getting to this point, in my opinion, is low and if it does happen will be transient. While paying someone less looks good on paper, I personally believe you need a strong medical background to handle sick patients. As a medical student with some anesthesiology experience under my belt, I could 'probably' successfully run some ASA1 and ASA2 cases by myself but any patients sicker than that and boy am I screwed. The hospitals are going to see what happens when CRNAs run ASA3+ cases independently. Regardless of whatever 'sponsored' research militant CRNA organizations release, It'll be a great time for medical malpractice lawyers.

 

[gasattack3]

Current practicing anesthesiologists are also included in the "aging" population. If these anesthesiologists don't retire, and residencies keep pumping out new grads, available jobs will keep decreasing.

If the salary for anesthesiology severely drops to the level of a CRNA and CRNAs are allowed to practice independently, most people will not go to medical school to be an anesthesiologist when they can be a CRNA for substantially less social and economic sacrifice. Furthermore, it may get to the point where it is more cost effective to leave anesthesiology and do residency in another field or work in a non-clinical job for an EMR company, pharmaceutical company, as an expert witness, etc.

The chance of it getting to this point, in my opinion, is low and if it does happen will be transient. While paying someone less looks good on paper, I personally believe you need a strong medical background to handle sick patients. As a medical student with some anesthesiology experience under my belt, I could 'probably' successfully run some ASA1 and ASA2 cases by myself but any patients sicker than that and boy am I screwed. The hospitals are going to see what happens when CRNAs run ASA3+ cases independently. Regardless of whatever 'sponsored' research militant CRNA organizations release, It'll be a great time for medical malpractice lawyers.

Just in my own little local world, it SEEMS like the people whom maybe would have retired 5 years ago (before taking massive hits to their investment portfolios) are starting to indeed target retiring over the next few years. This is local, but it's something I'm seeing in a very large group of anesthesiologists.

Anyone else seeing this?

 

[chessknt]

Will the economy turn around allowing the old folks to retire or will they work into their 70's?

I honestly have no idea what more old people could want from the economy. They have their untouchable social programs and US stock markets are at an all-time high. If I get half of that at their age I will believe in Santa.

 

[Ochempwnsme]

Current practicing anesthesiologists are also included in the "aging" population. If these anesthesiologists don't retire, and residencies keep pumping out new grads, available jobs will keep decreasing.

The best way to determine the current job market would be to ask graduating residents from this year and last year, certainly. FRIEDA does survey graduating anesthesiology residents and fellows and only 0.2% were unemployed. The survey had an 84% response rate.

If the salary for anesthesiology severely drops to the level of a CRNA and CRNAs are allowed to practice independently, most people will not go to medical school to be an anesthesiologist when they can be a CRNA for substantially less social and economic sacrifice. Furthermore, it may get to the point where it is more cost effective to leave anesthesiology and do residency in another field or work in a non-clinical job for an EMR company, pharmaceutical company, as an expert witness, etc.

If US MD students shy away from it, then matching in it will become less competitive, their spots will merely be filled by DOs or IMGs/FMGs. The spots will fill regardless of whether less US MD students choose to specialize in anesthesiology. I'd imagine that many FMGs would gladly work as an anesthesiologist for the current CRNA salary, especially if it becomes significantly less competitive than fields such as IM.

The chance of it getting to this point, in my opinion, is low and if it does happen will be transient. While paying someone less looks good on paper, I personally believe you need a strong medical background to handle sick patients. As a medical student with some anesthesiology experience under my belt, I could 'probably' successfully run some ASA1 and ASA2 cases by myself. The hospitals are going to see what happens when CRNAs run ASA3+ cases independently. Regardless of whatever 'sponsored' research their militant organizations release, It'll be a great time for medical malpractice lawyers.

This is an interesting question regarding ASA levels of cases. I did not know what ASA cases were until I read the Rand study that I linked in the original post, but the study does address it on page 34 Overall, 9.3% of patients anesthetized by CRNAs were ASA 4/5, compared to 12.1% of patients anesthetized who were ASA 4/5. This varies by region, however, and the study also examined the working patterns of CRNAs and anesthesiologists. CRNAs are most likely to practice independently or with less anesthesiology supervision in the West , where they work with an average of 0.9 anesthesiologists per procedure (compared to 1.8 anesthesiologists per procedure in the Northeast). What you might expect to happen might already be the status quo. Only 6.0% of the patients anesthetized by CRNAs out west were ASA 4/5, compared to 11.2% of those patients anesthetized by anesthesiologists. In the Northeast, the region with the heaviest supervision 10.5% of patients anesthetized by CRNAs were 4/5, compared to 12.2% of those anesthetized by anesthesiologists. This would presumably make sense, because there's also a chart by region on page 34 detailing the % of time that anesthesiologists work on their own cases. In the West, anesthesiologists spend 76.1% of the time doing their own cases. In the other three regions of the country, the % of time that anesthesiologists do their own cases are all between 38 and 40%. So what most likely happens is that the anesthesiologists out West do most of the more complex patients, while CRNAs do the easier patients. In the other three regions (and to a greatest extent in the Northeast), because CRNAs are under significantly heavier supervision, they do a higher percentage of ASA 4/5 cases.

So, the natural question is what would result from independent practice. Interestingly, anesthesiology as a whole seems to have gotten much safer in the past 40 years, if you look at it in terms of deaths per million or so anesthetics administered. Due to this fact, an appropriate study with a sample size large enough to compare the efficacy of CRNAs and anesthesiologists on patients (especially more complex patients like ASA 4/5s) would probably take decades to complete. If the other regions move to mirror the West and have more CRNAs practicing independently, then it is possible that CRNAs would spend almost none of their time anesthetizing ASA 4/5 cases, while anesthesiologists would spend a significant percentage of their time working on these complex patients.

Currently, approximately 10% of anesthesia patients are ASA 4/5, at least according to the RAND study. If CRNAs move from a caseload of 6-10% ASA 4/5 patients to a caseload comprised of 2-3% ASA 4/5 patients, and anesthesiologists perform more of the ASA 4/5s, then anesthesiologists doing their own cases could find their caseloads now comprised of 20% or more 4/5 ASA patients, and possibly even higher. While anesthesia has gotten safer, if this ever happened, this would seem to me to be a bad outcome for the specialty. Anesthesiologists would be taking on a higher percentage of ASA 4/5 patients (many of whom have Medicare/Medicaid which reimburses at a lower rate than private insurance), while CRNAs would be taking on a higher percentage of healthy patients (many of whom have private insurance policies). This would result in a situation where anesthesiologists take on more risk in the form of lawsuits because a higher percentage of their caseloads will involve sicker patients, in return for less compensation. I don't know if this would ever happen, but one of the primary flaws I found with studies funded by nurse anesthetist organizations is that they fail to take into account the health of the patients. You might even expect that in a system like this, CRNAs would provide equally safe care to patients when compared to anesthesiologists, and the studies bear that out. The metric would be flawed, because the patient populations would be significantly different, so it wouldn't really be equal. Out west, anesthesiologists work 15 more hours a week than do CRNAs, so this could result in your average anesthesiologist anesthetizing 3 times as many ASA 4/5 patients per week as your average CRNA. You do the math.

Interested to hear your thoughts.

 

[AnesThrow]

The best way to determine the current job market would be to ask graduating residents from this year and last year, certainly. FRIEDA does survey graduating anesthesiology residents and fellows and only 0.2% were unemployed. The survey had an 84% response rate.



If US MD students shy away from it, then matching in it will become less competitive, their spots will merely be filled by DOs or IMGs/FMGs. The spots will fill regardless of whether less US MD students choose to specialize in anesthesiology. I'd imagine that many FMGs would gladly work as an anesthesiologist for the current CRNA salary, especially if it becomes significantly less competitive than fields such as IM.



This is an interesting question regarding ASA levels of cases. I did not know what ASA cases were until I read the Rand study that I linked in the original post, but the study does address it on page 34 Overall, 9.3% of patients anesthetized by CRNAs were ASA 4/5, compared to 12.1% of patients anesthetized who were ASA 4/5. This varies by region, however, and the study also examined the working patterns of CRNAs and anesthesiologists. CRNAs are most likely to practice independently or with less anesthesiology supervision in the West , where they work with an average of 0.9 anesthesiologists per procedure (compared to 1.8 anesthesiologists per procedure in the Northeast). What you might expect to happen might already be the status quo. Only 6.0% of the patients anesthetized by CRNAs out west were ASA 4/5, compared to 11.2% of those patients anesthetized by anesthesiologists. In the Northeast, the region with the heaviest supervision 10.5% of patients anesthetized by CRNAs were 4/5, compared to 12.2% of those anesthetized by anesthesiologists. This would presumably make sense, because there's also a chart by region on page 34 detailing the % of time that anesthesiologists work on their own cases. In the West, anesthesiologists spend 76.1% of the time doing their own cases. In the other three regions of the country, the % of time that anesthesiologists do their own cases are all between 38 and 40%. So what most likely happens is that the anesthesiologists out West do most of the more complex patients, while CRNAs do the easier patients. In the other three regions (and to a greatest extent in the Northeast), because CRNAs are under significantly heavier supervision, they do a higher percentage of ASA 4/5 cases.

So, the natural question is what would result from independent practice. Interestingly, anesthesiology as a whole seems to have gotten much safer in the past 40 years, if you look at it in terms of deaths per million or so anesthetics administered. Due to this fact, an appropriate study with a sample size large enough to compare the efficacy of CRNAs and anesthesiologists on patients (especially more complex patients like ASA 4/5s) would probably take decades to complete. If the other regions move to mirror the West and have more CRNAs practicing independently, then it is possible that CRNAs would spend almost none of their time anesthetizing ASA 4/5 cases, while anesthesiologists would spend a significant percentage of their time working on these complex patients.

Currently, approximately 10% of anesthesia patients are ASA 4/5, at least according to the RAND study. If CRNAs move from a caseload of 6-10% ASA 4/5 patients to a caseload comprised of 2-3% ASA 4/5 patients, and anesthesiologists perform more of the ASA 4/5s, then anesthesiologists doing their own cases could find their caseloads now comprised of 20% or more 4/5 ASA patients, and possibly even higher. While anesthesia has gotten safer, if this ever happened, this would seem to me to be a bad outcome for the specialty. Anesthesiologists would be taking on a higher percentage of ASA 4/5 patients (many of which are reimbursed by Medicare at a lower rate than private insurance), while CRNAs would be taking on a higher percentage of healthy patients (many of whom have private insurance policies). This would result in a situation where anesthesiologists take on more risk in the form of lawsuits because a higher percentage of their caseloads will involve sicker patients, in return for less compensation. I don't know if this would ever happen, but one of the primary flaws I found with studies funded by nurse anesthetist organizations is that they fail to take into account the health of the patients. You might even expect that CRNAs would provide equally safe care to patients when compared to anesthesiologists, and the studies bear that out. The metric would be flawed, of course, because the patient populations are significantly different. Out west, anesthesiologists work 15 more hours a week than do CRNAs, so this could result in your average anesthesiologist anesthetizing 3 times as many ASA 4/5 patients per week as your average CRNA. You do the math.

Interested to hear your thoughts.

Is this study looking only at independent CRNAs, supervised ones or both? I would like to see the statistics for the percentage of unsupervised CRNAs independently anesthetizing ASA 4/5s. Supervising anesthesiologists of CRNAs running ASA4/5 cases are under litigation risk regardless of whether or not the CRNA sat in the case. Furthermore, let's take the average figure of $120k/yr for a CRNA and $300k/yr for an anesthesiologist. Will a hospital risk litigation from ASA4/5 (and others) cases to save $180k/yr when a successful lawsuit can cost a whole lot more? If a hospital is already going to be paying an anesthesiologist salary to run these high-level cases, it doesn't make economic sense to restrict that anesthesiologist to only those cases and let the CRNAs run the others. It's not like there's an ASA5 case per minute at most hospitals. ASA1/2 level case are for the most part healthy patients but the litigation risk for them is even higher should something go wrong. An ASA1 crashing for whatever reason during a surgery is not best handled by a CRNA.

 

[PonyUp]

Is this study looking only at independent CRNAs, supervised ones or both? I would like to see the statistics for the percentage of unsupervised CRNAs independently anesthetizing ASA 4/5s. Supervising anesthesiologists of CRNAs running ASA4/5 cases are under litigation risk regardless of whether or not the CRNA sat in the case. Furthermore, let's take the average figure of $120k/yr for a CRNA and $300k/yr for an anesthesiologist. Will a hospital risk litigation from ASA4/5 cases to save $180k/yr when a successful lawsuit can cost a whole lot more? If a hospital is already going to be paying an anesthesiologist salary to run these high-level cases, it doesn't make economic sense to restrict that anesthesiologist to only those cases and let the CRNAs run the others. It's not like there's an ASA5 case per minute at most hospitals.

Good of you to reference the captain of the ship doctrine...

Not to nitpick, but most of the salary averages I can google for a CRNA are all $160,000+.

With that said, I can also see all of our faculty salaries [public info as I'm at a state school] and they range from Assistant Professors making $169k to $249k, $315k for CV fellowship trained CV anesthesiologists, with the Chair as an aberration making substantially more. Thus the disparity, at least in an academic environment, is much less than the $180,000 "savings" you have articulated. I only voice this regarding academics because I'm sure a large subset of the ASA4/5's end up at an academic center. I know that a good portion of stable CV cases go to a private hospital in town but I'm positive we get 100% of the open ruptured AAA's.

 

[Ochempwnsme]

Is this study looking only at independent CRNAs, supervised ones or both? I would like to see the statistics for the percentage of unsupervised CRNAs independently anesthetizing ASA 4/5s. Supervising anesthesiologists of CRNAs running ASA4/5 cases are under litigation risk regardless of whether or not the CRNA sat in the case. Furthermore, let's take the average figure of $120k/yr for a CRNA and $300k/yr for an anesthesiologist. Will a hospital risk litigation from ASA4/5 (and others) cases to save $180k/yr when a successful lawsuit can cost a whole lot more? If a hospital is already going to be paying an anesthesiologist salary to run these high-level cases, it doesn't make economic sense to restrict that anesthesiologist to only those cases and let the CRNAs run the others. It's not like there's an ASA5 case per minute at most hospitals. ASA1/2 level case are for the most part healthy patients but the litigation risk for them is even higher should something go wrong. An ASA1 crashing for whatever reason during a surgery is not best handled by a CRNA.

I'm pretty sure the independent CRNA cases are lumped in with the supervised CRNA cases. From the way I interpreted the data, any case in which the CRNA is the main deliverer of anesthesia is classified as a CRNA case, and any case which the anesthesiologist does him or herself is classified as an anesthesiologist case. The study did say that in the West, the common pattern is to have anesthesiologists and CRNAs working separately and not coming into much contact with her. I imagine that the anesthesiologists are found more often in the urban areas with the CRNAs more in the rural areas.

I agree with you that they are under litigation risk regardless of whether the CRNA sat on the case, but if they are supervising 3 or 4 rooms and that is commonly accepted as being a standard, I'd imagine that an error in CRNA supervision would result in less liability risk than a case that the anesthesiologist is performing solo. After all, anesthesiologists cannot be everywhere at once, can they?

I don't think a hospital would risk litigation from an ASA in that situation under our current system, but if we move toward single-payer health care (which I believe is the trend, like it or not), we could end up with a malpractice system similar to Canada's in which province organizations provide the malpractice insurance for physicians. http://www.tampabay.com/news/canada-keeps-malpractice-cost-in-check/1021977 The insurance in Canadian provinces is affordable and it also protects the physician more. There are significantly fewer med mal cases filed in Canada per capita and
the average award is substantially lower, because the Canadian Supreme Court capped damages for pain and suffering in 1978. The cap is around $350,000, and it is adjusted for inflation. Canadian personal injury firms also require plaintiffs to front the costs of their cases, compared to here where it's "free unless we win your case", as advertised on TV. Neurosurgeons there often pay less than $20,000 for their malpractice insurance, which is a small, small fraction of what it is here. The point I'm making is that if we ever transition to a system like this, hospitals will have less to worry about in allowing CRNAs to practice independently.

 

[AnesThrow]

Good of you to reference the captain of the ship doctrine...

Not to nitpick, but most of the salary averages I can google for a CRNA are all $160,000+.

With that said, I can also see all of our faculty salaries [public info as I'm at a state school] and they range from Assistant Professors making $169k to $249k, $315k for CV fellowship trained CV anesthesiologists, with the Chair as an aberration making substantially more. Thus the disparity, at least in an academic environment, is much less than the $180,000 "savings" you have articulated. I only voice this regarding academics because I'm sure a large subset of the ASA4/5's end up at an academic center. I know that a good portion of stable CV cases go to a private hospital in town but I'm positive we get 100% of the open ruptured AAA's.

Academic positions are a whole different ballgame. I want to quote IlDestriero who is an academic anesthesiologist that posts on this forum.

"I'm an academic anesthesiologist in a prominent Children's Hospital. I have a non research track position. Promotion is related to superior clinical skills and teaching, and I have no research requirements. I took the job because of it's significant, to me, lifestyle benefits. (teaching, pace of day, diversity of cases, abundance of very challenging cases, quality of surgeons, innovation, fair $$, hours/free time, lighter call, etc.) There are lifestyle oriented PP jobs, but that is not the norm. I make about the same as the national average anesthesiologist salary. (By design to attract and retain quality physicians.) I only work about 40-45 hours a week, the research folks work fewer clinical hours, to make time for research activities. If I wanted to work harder/faster and about 20% more hours, I could make 25-75% more. Keep in mind that the highest paying jobs are often quite competitive and/or usually in locations I would want to live. Partnerships are not guaranteed in PP, and there may also be "superpartners" siphoning off $$. There is also uncertainty about future contracts in PP which don't really exist in Academics. I also have a generous benefits package. You can find good benefits in PP as well however. Every practice and/or medical school is different. You have to evaluate the whole package.
BTW, UCSF pay is ludicrous because all UC hospital anesthesia pay is a joke, not because UCSF is a top program. Harvard affiliated hospital pay is lower than the norm because it's harvard, and many people want to work there. I'll take the same lifestyle and significantly more money elsewhere. It's also worth noting that higher paying academic jobs are more the exception than the rule. "

 

[AnesThrow]

I don't think a hospital would risk litigation from an ASA in that situation under our current system, but if we move toward single-payer health care (which I believe is the trend, like it or not), we could end up with a malpractice system similar to Canada's in which province organizations provide the malpractice insurance for physicians. http://www.tampabay.com/news/canada-keeps-malpractice-cost-in-check/1021977 The insurance in Canadian provinces is affordable and it also protects the physician more. There are significantly fewer med mal cases filed in Canada per capita and
the average award is substantially lower, because the Canadian Supreme Court capped damages for pain and suffering in 1978. The cap is around $350,000, and it is adjusted for inflation. Canadian personal injury firms also require plaintiffs to front the costs of their cases, compared to here where it's "free unless we win your case", as advertised on TV. Neurosurgeons there often pay less than $20,000 for their malpractice insurance, which is a small, small fraction of what it is here. The point I'm making is that if we ever transition to a system like this, hospitals will have less to worry about in allowing CRNAs to practice independently.

A whole lot would have to change for this to become a reality and it is a huge IF. A hospital's reputation is also important and I think a big factor left out of this conversation are surgeons. Surgeons bring in the big bucks for hospitals and will surgeons really accept doing high-level cases with CRNAs and risk malpractice regardless of whether or not the hospital will have to pay for it? There are also a million other factors and in truth, nobody really knows what is going to happen.

 

[B-Bone]

I agree with you that they are under litigation risk regardless of whether the CRNA sat on the case, but if they are supervising 3 or 4 rooms and that is commonly accepted as being a standard, I'd imagine that an error in CRNA supervision would result in less liability risk than a case that the anesthesiologist is performing solo. After all, anesthesiologists cannot be everywhere at once, can they?

absolutely false. for liability purposes, it is exactly as if you were in the room the entire time. you are required to be immediatey available to all the rooms you are covering at all times.

 

[Ochempwnsme]

absolutely false. for liability purposes, it is exactly as if you were in the room the entire time. you are required to be immediatey available to all the rooms you are covering at all times.

Well, that is incredibly unfortunate. What if you have two emergencies at once? I guess you just have to deal.

 

[Ochempwnsme]

Just in my own little local world, it SEEMS like the people whom maybe would have retired 5 years ago (before taking massive hits to their investment portfolios) are starting to indeed target retiring over the next few years. This is local, but it's something I'm seeing in a very large group of anesthesiologists.

Anyone else seeing this?

I know a few who have recently retired in their late 50s/early 60s.

 

[Mman]

Well, that is incredibly unfortunate. What if you have two emergencies at once? I guess you just have to deal.

you have other colleagues around that can assist you with your rooms should the need arise

 

[Random Anesthesiologist]

There is no way Illinois has an anesthesiologist shortage.

Unless they just mean there are areas without anesthesiologists (rural), and in that case CRNAs have cornered the market.

 

[Consigliere]

There is no anesthesiologist shortage. I have a buddy who is actively looking for a job now...

 

[jwk]

Is this study looking only at independent CRNAs, supervised ones or both? I would like to see the statistics for the percentage of unsupervised CRNAs independently anesthetizing ASA 4/5s. Supervising anesthesiologists of CRNAs running ASA4/5 cases are under litigation risk regardless of whether or not the CRNA sat in the case. Furthermore, let's take the average figure of $120k/yr for a CRNA and $300k/yr for an anesthesiologist. Will a hospital risk litigation from ASA4/5 (and others) cases to save $180k/yr when a successful lawsuit can cost a whole lot more? If a hospital is already going to be paying an anesthesiologist salary to run these high-level cases, it doesn't make economic sense to restrict that anesthesiologist to only those cases and let the CRNAs run the others. It's not like there's an ASA5 case per minute at most hospitals. ASA1/2 level case are for the most part healthy patients but the litigation risk for them is even higher should something go wrong. An ASA1 crashing for whatever reason during a surgery is not best handled by a CRNA.

Outside of academia and government-run hospitals, where does everyone get the idea that hospitals employ anesthesiolgists? I think that's the exception, not the rule.

 

[aneftp]

The older you get (with family/kids etc), the less desirable HSA's can get.

When I started in 2004. HSA was just signed into law. It's changed a lot over the past 6-7 years.

When it first came out, if you had a $1500 high deductible, the most you could contribute was to the actual deductible limit but they also capped the number.

Congress has tweaked HSA the past few years regarding contribution limits.

But do the math for yourself. If you are healthy (or have heavy spouse). A $6250 contribution is essentially a $2000 plus tax savings.

Say I pay close to $9K in health premiums for family of 4 with high deductible of $7000. I know my max out of pocket expense will be $16K for the year. (but I get a $2000 tax savings with HSA). So my real time potential max expense could be $14K.

Or I could choose to use a high premium with a non HSA eligible acct. I could end up paying $12K for the health premiums with a max out of pocket expense (with co pays,co insurance) of $4200. So it could end up costing me potentially $16200 without any tax benefit.

It's all a calculated gamble on your health or your kids health.

But I think if the Democrats take control of both house and senate with Obama in office, look for major restrictions to HSAs in the near future. Dems know the only people taking advantage of the HSAs are primarily upper middle class/upper class folks.

So take advantage of the HSA deduction while you can. Dems have already assaulted flex spending account and made the max spending limit $2500 this year.

Who knows if they will try to restrict HSAs in the future.

 

[PonyUp]

The older you get (with family/kids etc), the less desirable HSA's can get.

When I started in 2004. HSA was just signed into law. It's changed a lot over the past 6-7 years.

When it first came out, if you had a $1500 high deductible, the most you could contribute was to the actual deductible limit but they also capped the number.

Congress has tweaked HSA the past few years regarding contribution limits.

But do the math for yourself. If you are healthy (or have heavy spouse). A $6250 contribution is essentially a $2000 plus tax savings.

Say I pay close to $9K in health premiums for family of 4 with high deductible of $7000. I know my max out of pocket expense will be $16K for the year. (but I get a $2000 tax savings with HSA). So my real time potential max expense could be $14K.

Or I could choose to use a high premium with a non HSA eligible acct. I could end up paying $12K for the health premiums with a max out of pocket expense (with co pays,co insurance) of $4200. So it could end up costing me potentially $16200 without any tax benefit.

It's all a calculated gamble on your health or your kids health.

But I think if the Democrats take control of both house and senate with Obama in office, look for major restrictions to HSAs in the near future. Dems know the only people taking advantage of the HSAs are primarily upper middle class/upper class folks.

So take advantage of the HSA deduction while you can. Dems have already assaulted flex spending account and made the max spending limit $2500 this year.

Who knows if they will try to restrict HSAs in the future.

Fairly sure you meant to post this in the HSA thread.

 

[IM15An]

Good of you to reference the captain of the ship doctrine...

Not to nitpick, but most of the salary averages I can google for a CRNA are all $160,000+.

With that said, I can also see all of our faculty salaries [public info as I'm at a state school] and they range from Assistant Professors making $169k to $249k, $315k for CV fellowship trained CV anesthesiologists, with the Chair as an aberration making substantially more. Thus the disparity, at least in an academic environment, is much less than the $180,000 "savings" you have articulated. I only voice this regarding academics because I'm sure a large subset of the ASA4/5's end up at an academic center. I know that a good portion of stable CV cases go to a private hospital in town but I'm positive we get 100% of the open ruptured AAA's.

I think the career of an anesthesiologist is forever changed with the huge increase in CRNAs. I also think also of primary care physicians. If you look around, there are massive amount of PA schools opened. There is going to be a glut in the market. To cut costs, companies are going to choose PAs, NPs, CRNAs. I am going into medicine and am interested in global health. I may choose general surgery because those skills cannot be easily replaced. I loved the OR too. Medicine is in an interesting state. PAs, NPs, CRNAs may be the new physicians.

 

[Sirach38]

I think the career of an anesthesiologist is forever changed with the huge increase in CRNAs. I also think also of primary care physicians. If you look around, there are massive amount of PA schools opened. There is going to be a glut in the market. To cut costs, companies are going to choose PAs, NPs, CRNAs. I am going into medicine and am interested in global health. I may choose general surgery because those skills cannot be easily replaced. I loved the OR too. Medicine is in an interesting state. PAs, NPs, CRNAs may be the new physicians.

PAs, NPs, and CRNAs will not replace MDs but they may compete with them. Worst case scenario, this will just drive MD salaries down to the current PA, NP, and CRNA level and all of these extra PAs, NPs, and CRNAs will be out of jobs or will have to take jobs where no MD wants to go. If a hospital can pay a PA 120,000 or an MD 120,000, guess who will be hired and who will be out of a job?

 

[deleted171991]

PAs, NPs, and CRNAs will not replace MDs but they may compete with them. Worst case scenario, this will just drive MD salaries down to the current PA, NP, and CRNA level and all of these extra PAs, NPs, and CRNAs will be out of jobs or will have to take jobs where no MD wants to go. If a hospital can pay a PA 120,000 or an MD 120,000, guess who will be hired and who will be out of a job?

The MD will be out of a job wherever possible. Don't forget that many hospitals are run by militant people, either MBA suits or nurses, who see eliminating MDs as a form of class warfare and payback for the decades of "exploitation". Especially the younger nurse generations are indoctrinated against doctors starting in nursing school.

You think the independent CRNAs just happened overnight against the will of hospital administrators? Nope, they are the "future", and the precedent to prove that NPs/PAs/Joe Nobody can practice medicine unsupervised and people still survive. This is combined with an increase of the number of healthcare graduates (including MDs), thus driving down salaries. Plus they made sure they destroy the private medical practitioner with Obamacare.

The MDs will continue to exist for the ****ty cases the "midlevels" don't want to take care of alone. Firefighter jobs. Puppets who move as dictated by hospital "protocols" designed by nurses for the sake of "patient safety". I wouldn't go into medicine today even if it were the only postgraduate degree in the world. As a doctor, you can't even open your mouth to criticize something without being branded in some way and having your career jeopardized. It's 1984 for doctors, Newspeak and Big Brother coming everywhere. Just watch the generalized and concerted media and political circus against us. Somebody up there (on Wall St) doesn't love you.

This is not doom and gloom. This is market economy in a market that's rigged against doctors.

 

[BLADEMDA]

PAs, NPs, and CRNAs will not replace MDs but they may compete with them. Worst case scenario, this will just drive MD salaries down to the current PA, NP, and CRNA level and all of these extra PAs, NPs, and CRNAs will be out of jobs or will have to take jobs where no MD wants to go. If a hospital can pay a PA 120,000 or an MD 120,000, guess who will be hired and who will be out of a job?

$120K?? What does the education and training cost to produce one Anesthesiologist? And you expect that person to work for $120k?

 

[Sirach38]

The MD will be out of a job wherever possible. Don't forget that many hospitals are run by militant people, either MBA suits or nurses, who see eliminating MDs as a form of class warfare and payback for the decades of "exploitation". Especially the younger nurse generations are indoctrinated against doctors starting in nursing school.

You think the independent CRNAs just happened overnight against the will of hospital administrators? Nope, they are the "future", and the precedent to prove that NPs/PAs/Joe Nobody can practice medicine unsupervised and people still survive. This is combined with an increase of the number of healthcare graduates (including MDs), thus driving down salaries. Plus they made sure they destroy the private medical practitioner with Obamacare.

The MDs will continue to exist for the ****ty cases the "midlevels" don't want to take care of alone. Firefighter jobs. Puppets who move as dictated by hospital "protocols" designed by nurses for the sake of "patient safety". I wouldn't go into medicine today even if it were the only postgraduate degree in the world. As a doctor, you can't even open your mouth to criticize something without being branded in some way and having your career jeopardized. It's 1984 for doctors, Newspeak and Big Brother coming everywhere. Just watch the generalized and concerted media and political circus against us. Somebody up there (on Wall St) doesn't love you.

This is not doom and gloom. This is market economy in a market that's rigged against doctors.

Idk man. It doesn't make a lot of financial sense to keep MDs around just for the s**** cases. If you have an MD that you can use and pay them the same as you would a PA/NP/CRNA it doesn't make much sense to hire them instead if the MD from a safety and financiañ stand point. An MD is just willing (in general) to work much harder and is much more useful. MDs are used to taking call and working till the work is done. They don't have a shift mentality. They are able to take on much more resposiblity and they are able to generate more income for the hospital. They are in general much smarter than midlevels and more fit for positions of leadership. They are able to take the responsibility and law suits when sh** hits the fan. Then there are patients. Patients want a doctor taking care of them. Very few patients would ever prefer a nurse to care for them and their loved ones regardless of the field. I see things potentially getting bad for a while but things will swing back. What has us in this predicament in the first place is the lack of political involvement that MDs have in this country and the outspoken and militant midlevels that take advantage of this. MDs rarely get involved in politics because they are too busy taking care of patients (taking call, staying late, etc.) maybe if nurses start taking care of all the patients, there will be many more MDs with time to get involved in politics. All I know is that MDs aren't going to go easily and quietly and this battle has a long time to go before the final result. Likely the final result will be somewhere in the middle and not at the extremes that people describe. If not, there's always Canada or Europe

 

[deleted171991]

Idk man. It doesn't make a lot of financial sense to keep MDs around just for the s**** cases.

There are enough ****ty cases to go around, especially if you overwork those MDs. See hospitalists, see PCPs.

If you have an MD that you can use and pay them the same as you would a PA/NP/CRNA it doesn't make much sense to hire them instead if the MD from a safety and financiañ stand point.

But it makes a lot of sense from organizational standpoint. If you are a smart administrator, the fewer smart people in your organization, the easier is to "lead". Codeword: sheep. Why do you think the communists killed their intellectuals first thing?

An MD is just willing (in general) to work much harder and is much more useful.

An MD also has an IQ and a personality. An MD is more difficult to trample on. Which makes the MD less desirable in the eyes of dear corporate leaders.

MDs are used to taking call and working till the work is done. They don't have a shift mentality.

That will also change in the future. When it's not your business, why would you work your butt off, for marginally better net income, while you are paying more taxes and spend less time with your family?

They are able to take on much more resposiblity and they are able to generate more income for the hospital.

For now. Once you will have laws mandating "equal pay for equal service" in all states, the midlevels will be paid the same.

They are in general much smarter than midlevels and more fit for positions of leadership.

So how many American hospitals run mostly by doctors do you know?

They are able to take the responsibility and law suits when sh** hits the fan.

And the latter is the main reason we are still around and not sleeping with the dinosaurs.

Then there are patients. Patients want a doctor taking care of them. Very few patients would ever prefer a nurse to care for them and their loved ones regardless of the field.

How many patients have you seen stand up and leave when they hear they will be taken care of by a CRNA? In 3 years of residency I met only one. Same goes for NPs. Once the population gets used to midlevels, the next step (already happening all around you) is to give midlevels right to independent practice. With all the PhD and DNPs and male bovine excrement nursing degrees flying around, with all the "providers" dressed the same, using the same colored badges, the population has no idea who's a physician and who's not. Smoke and mirrors. By the time they find out, it will be used as proof that physicians are not really needed for most of the healthcare stuff.

I see things potentially getting bad for a while but things will swing back.

These "whiles" tend to last for decades. That's OK if your family owns a company in the field and you'll do decently regardless but, for a private individual, it's the difference between being a General Motors worker in the 60's and one in the 90's. You are just cannon fodder.

What has us in this predicament in the first place is the lack of political involvement that MDs have in this country and the outspoken and militant midlevels that take advantage of this. MDs rarely get involved in politics because they are too busy taking care of patients (taking call, staying late, etc.) maybe if nurses start taking care of all the patients, there will be many more MDs with time to get involved in politics.

As a group, MDs have about as much business sense as Mother Theresa. And, also as a group, they have about as much spine as Machiavelli, without the street smarts.

All I know is that MDs aren't going to go easily and quietly and this battle has a long time to go before the final result.

I don't see any physician unions popping up, any strikes etc. All this while the percentage of employed physicians is at all time high.

Likely the final result will be somewhere in the middle and not at the extremes that people describe.

That's true for most things in life. It's always safer to bet on the average. Except that, in this case, the average sucks just slightly less than the lower extreme.

If not, there's always Canada or Europe

Because those are not the countries where many of these high-scoring foreign medical grads come from, right?

 

[Sirach38]

Really? I don't see any physician unions popping up, any strikes etc.

There are already some hospitalist unions popping up in different parts of the country. I anticipate that this will be the norm and in the not too distant future most specialties will be unionized. While this may not be a great thing, it will certainly add more stability to the whole situation.

All this while the percentage of employed physicians is at all time high.

Oh trust me, there will be plenty of strikes/political activity when the percentage of UNEMPLOYED physicians is at an all time high...

You make some excellent points. However, I have already chosen medicine and I have already chosen anesthesiology so all I have left is to fight teeth and nail against anything that threatens our field and out patient's safety. Be it midlevels or something else.

 

[deleted171991]

However, I have already chosen medicine and I have already chosen anesthesiology so all I have left is to fight teeth and nail against anything that threatens our field and out patient's safety. Be it midlevels or something else.

I know the feeling. I am in the same boat.

 

[Sirach38]

I know the feeling. I am in the same boat.

If not Canada or Europe, there's always CCM if the boat sinks

 

[deleted171991]

If not Canada or Europe, there's always CCM if the boat sinks

What country is that?

By the way, you WILL need CCM for Europe. For Canada, you can get away with any one-year ACGME fellowship.

 

[Carbocation1]

http://www.anesthesiologynews.com/V...+2014&i_id=1131&a_id=28870&tab=RecentComments

 

[deleted171991]

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=December 2014&i_id=1131&a_id=28870&tab=RecentComments

Excellent article.

 

[BLADEMDA]

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=December 2014&i_id=1131&a_id=28870&tab=RecentComments

Evolve or die

 

[Sirach38]

I guess fellowship is one way to protect yourself from midlevels...for a while. Until CRNAs want to start doing complex cardiac cases, complex peds cases, and running their own pain clinics. By the way, why the heck are we teaching CRNAs to do complex cardiac, peds, and chronic pain? It's almost like anesthesiologists are killing their own specialty. I don't see general surgeons teaching their PAs how to do lap choles, appendectomies, or hernia repairs or ophthalmologists teaching optometrists how to do cataract surgery. Same with the surgical home concept...eventually CRNAs will want a piece of that pie too if it ever develops into a reality. When will this end? Physicians develop new protocols and perfect techniques through painstaking research and endless hours of experience, only to teach some monkey who doesn't understand or appreciate the science, some cookie cutter way to carry out these procedures and techniques. When will we wake up?

Will it always be "evolve or die" and then "evolve again" because midlevels are once more trying to destroy your career? Why not take the approach of protecting what is ours instead of having to constantly change to cater to midlevels?

 

[exsanguination]

When will this end? Physicians develop new protocols and perfect techniques through painstaking research and endless hours of experience, only to teach some monkey who doesn't understand or appreciate the science, some cookie cutter way to carry out these procedures and techniques. When will we wake up?

Why not take the approach of protecting what is ours instead of having to constantly change to cater to midlevels?

MDs will never wake up to this because there's too much economic incentive to the ones who originally train these midlevels. Maybe some MD in his pain clinic sees that he can train an NP to crank out any number of procedures or whatever. Other NPs catch on, they want to be trained too. They start working in the select few offices of those willing to train them (makes their bottomline look better too since their volume skyrockets), and there you have it. The snowball starts and eventually becomes the avalanche that destroys the mountainside.

 

[exsanguination]

Not trying to hijack this thread at all, but to offer a perspective from another side of the hospital, I'd like to share my experience in the ED. I'm an EM PGY1 and at many of the places I've rotated at or visited, a large majority of the "non- or semi-acute" patients are staffed by the PA/NP, and I hate to admit it, but they do it at an "acceptable" safety level. When I say acceptable, I mean it from an administrative/risk point of view. I'm sure at some point some sack of dog slobber sat down with the C-suite and calculated how many RVUs they generate vs. the additional risk in terms of $/year lost to lawsuits or what have you. Pay them 1/3rd of what they pay an EM MD, and they get almost similar productivity (roughly 2-2.5 patients per hour) for the semi-acute patient. It's not hard to imagine a future where it's mostly PAs and NPs seeing patients in an ED with only single MD coverage providing the "supervision." This MD would stomach all the liability, the hospital only has to pay one doc, and the C-suite goes home to a new Range Rover.

Medicine is really screwed. Go into surgery (if you can deal with that kind of life)

 

[gasdoc77]

Not trying to hijack this thread at all, but to offer a perspective from another side of the hospital, I'd like to share my experience in the ED. I'm an EM PGY1 and at many of the places I've rotated at or visited, a large majority of the "non- or semi-acute" patients are staffed by the PA/NP, and I hate to admit it, but they do it at an "acceptable" safety level. When I say acceptable, I mean it from an administrative/risk point of view. I'm sure at some point some sack of dog slobber sat down with the C-suite and calculated how many RVUs they generate vs. the additional risk in terms of $/year lost to lawsuits or what have you. Pay them 1/3rd of what they pay an EM MD, and they get almost similar productivity (roughly 2-2.5 patients per hour) for the semi-acute patient. It's not hard to imagine a future where it's mostly PAs and NPs seeing patients in an ED with only single MD coverage providing the "supervision." This MD would stomach all the liability, the hospital only has to pay one doc, and the C-suite goes home to a new Range Rover.

Medicine is really screwed. Go into surgery (if you can deal with that kind of life)

Thank you for contributing. That is in fact interesting to hear (or read).

 

[deleted171991]

I will remind everybody to read "The Rape of Emergency Medicine". That's exactly what's coming to Anesthesia and most medical fields. Funny thing: it was written in 1992, so the big boys have been planning and perfecting this for a looong time.

Best medical specialty for the future: Em.Bee.Ay. As in don't even bother to go to medical school.

 

[deleted171991]

Will it always be "evolve or die" and then "evolve again" because midlevels are once more trying to destroy your career? Why not take the approach of protecting what is ours instead of having to constantly change to cater to midlevels?

Because there are powerful interests at play here. Medicine is now caught in the rat race. It's not a professional job anymore, it's becoming a blue-collar job.. It's all about making money for the puppet masters, for all the worthless middlemen who explain their existence by increasing "healthcare efficiency", and patient "safety" and "satisfaction". Of course they and their stupid regulations cost way more than they would ever save, but as long as it does not come out of the patients' pockets, nobody cares. And the bean counters are very careful about taking money from us, not the patients.

This is something that will not end, not until medical income drops to a level where almost nobody with higher intelligence will pursue the career. It's exactly what happened in many foreign countries, hence why many FMGs came to US (and other countries). From a healthcare point of view, the US will become the equivalent of a second-world country, with medicine practiced by average minds with frequent mistakes that are caught by nobody, since most "practitioners" will be as stupid as the next one. I have seen it happening in my native country. All it takes is bean counters and/or populists at power and enough time. In the US, we might have 1-2 decades left, but that's about it.

Get out of medicine while you can. Or be prepared to live abroad for a better life(style).

This is not doom and gloom. This will not get better, regardless which party is at power, because neither party believes in a free healthcare market. This is history repeating itself. Just look at the British NHS. If you want to be a faceless corporate assembly lane worker for the rest of your life, wondering whether you'll make enough money to pay back your huge educational debts, you are in the right place. Learn from what happened to the lawyers, where it's not worth to pursue the career anymore unless one gets into the top 10 law schools in the country.

 

[BLADEMDA]

Because there are powerful interests at play here. Medicine is now caught in the rat race. It's not a professional job anymore, it's becoming a blue-collar job.. It's all about making money for the puppet masters, for all the worthless middlemen who explain their existence by increasing "healthcare efficiency", and patient "safety" and "satisfaction". Of course they and their stupid regulations cost way more than they would ever save, but as long as it does not come out of the patients' pockets, nobody cares. And the bean counters are very careful about taking money from us, not the patients.

This is something that will not end, not until medical income drops to a level where almost nobody with higher intelligence will pursue the career. It's exactly what happened in many foreign countries, hence why many FMGs came to US (and other countries). From a healthcare point of view, the US will become the equivalent of a second-world country, with medicine practiced by average minds with frequent mistakes that are caught by nobody, since most "practitioners" will be as stupid as the next one. I have seen it happening in my native country. All it takes is bean counters and/or populists at power and enough time. In the US, we might have 1-2 decades left, but that's about it.

Get out of medicine while you can. Or be prepared to live abroad for a better life(style).

This is not doom and gloom. This will not get better, regardless which party is at power, because neither party believes in a free healthcare market. This is history repeating itself. Just look at the British NHS. If you want to be a faceless corporate assembly lane worker for the rest of your life, wondering whether you'll make enough money to pay back your huge educational debts, you are in the right place. Learn from what happened to the lawyers, where it's not worth to pursue the career anymore unless one gets into the top 10 law schools in the country.

For Lawyers it means graduating from a top 14 law school. For Doctors it means a residency in a top specialty. Thus, the fact you got into a med school isn't the final hump; one must land a residency in an elite specialty to escape mediocrity. Hence, only 10-15% of Med Students will enjoy the lifestyle that 85% of Physicians have enjoyed in the past. Fields dominated by management companies, HMOs, etc are the ones to avoid provided you have the grades and scores to do so.

 

[Sirach38]

For Lawyers it means graduating from a top 14 law school. For Doctors it means a residency in a top specialty. Thus, the fact you got into a med school isn't the final hump; one must land a residency in an elite specialty to escape mediocrity. Hence, only 10-15% of Med Students will enjoy the lifestyle that 85% of Physicians have enjoyed in the past. Fields dominated by management companies, HMOs, etc are the ones to avoid provided you have the grades and scores to do so.

Blade, here's a question for both you and FFP and anyone else who cares to give their opinion. If you were a 3rd year medical student today with a mid 230s step 1, what specialty would you do? Would you still do anesthesia?

For an applicant with this step 1, what is the best economic specialty choice in your opinion?

If you could get into an integrated 5 year vascular surgery program would you do it instead of doing gas?

Would you do general surgery instead of anesthesia?

Would you do IR instead of gas?

Or would you try to get into something like urology despite not liking the field much, biting the bullet just for the economics of it?

Or, would you just do gas and go for a CCM and/or cardiac fellowship?


Perhaps none of these? Perhaps just drop out of med school?

 

[norwood]

Blade, here's a question for both you and FFP and anyone else who cares to give their opinion. If you were a 3rd year medical student today with a mid 230s step 1, what specialty would you do? Would you still do anesthesia?

For an applicant with this step 1, what is the best economic specialty choice in your opinion?

If you could get into an integrated 5 year vascular surgery program would you do it instead of doing gas?

Would you do general surgery instead of anesthesia?

Would you do IR instead of gas?

Or would you try to get into something like urology despite not liking the field much, biting the bullet just for the economics of it?

Or, would you just do gas and go for a CCM and/or cardiac fellowship?


Perhaps none of these? Perhaps just drop out of med school?

This is one area where opinions are going to be like noses: everyone has one, and they all kinda smell. =)

What you're hoping for is a prediction of how the world of medicine will be 1.5 years from now - plus 3 to 5 years, when you finish residency. So we're looking 5-7 years in the future. Will Obamacare be repealed? Probably not. But will it be changed significantly? Maybe. Will it break the system as it was designed to do, leading to single payer? Yeah, probably (and if it fails to do so, it will probably be modified to do so) - but on what time frame?

Absolutely agree with Blade that any corporatized field in medicine is one to avoid. Sure, there are lots of jobs outside medicine where you might work for a big company and not make what you deserve, but most of those don't involve anything like the stress and liability we have in medicine. Working for an AMC basically means you have all of the stress and all of the liability for the unsafe staffing the AMC dictates, while the AMC reaps most of the profits. No thanks.

Whatever field you choose, live a modest lifestyle and get free from debt as early as humanly possible. AMCs and similar medical sweatshops are able to staff themselves because some people are living paycheck to paycheck and can't afford to be unemployed for more than a brief period. IMHO unless you're a very recent grad or have very unique life circumstances, that's absolutely ridiculous for people making MD wages.

 

[Sirach38]

I guess the main question that I'm struggling with at this point is, I love gas and it is my first choice right now. The only other things I could ever imagine myself doing are CT surgery or vascular surgery but I want to avoid the lifestyle of these if at all possible. What I am really interested in knowing from those already practicing anesthesia is, is the future for gas so grim that if given a chance, you would rather take on the lifestyle of a CT or vascular surgeon (including residency) than continue in anesthesia despite liking it more. I know surgeons are the most protected in the future but is anesthesia so doomed that this protection is worth taking on a gen surg/ct/vascular lifestyle?

 

[gasdoc77]

I guess the main question that I'm struggling with at this point is, I love gas and it is my first choice right now. The only other things I could ever imagine myself doing are CT surgery or vascular surgery but I want to avoid the lifestyle of these if at all possible. What I am really interested in knowing from those already practicing anesthesia is, is the future for gas so grim that if given a chance, you would rather take on the lifestyle of a CT or vascular surgeon (including residency) than continue in anesthesia despite liking it more. I know surgeons are the most protected in the future but is anesthesia so doomed that this protection is worth taking on a gen surg/ct/vascular lifestyle?

The difference in lifestyle you refer to has become less and less over the last 5-10 years due to the influence of the suits. It may in fact be nonexistent within another 5 years.

 

[Random Anesthesiologist]

The difference in lifestyle you refer to has become less and less over the last 5-10 years due to the influence of the suits. It may in fact be nonexistent within another 5 years.

I'd go do EM in bfe before I let a noctor be my boss.

 

[Sirach38]

The difference in lifestyle you refer to has become less and less over the last 5-10 years due to the influence of the suits. It may in fact be nonexistent within another 5 years.

So you're saying there is little difference in lifestyle between a vascular surgeon and an anesthesiologist? In the future anesthesiologist will be working the same long, unpredictable schedules as vascular surgeons and will be taking the similar call?


If this is the case I would do vascular just based on future job security.

 

[BLADEMDA]

So you're saying there is little difference in lifestyle between a vascular surgeon and an anesthesiologist? In the future anesthesiologist will be working the same long, unpredictable schedules as vascular surgeons and will be taking the similar call?


If this is the case I would do vascular just based on future job security.

Some of us work harder than our Surgical Colleagues; we cover all specialties 24/7 and that can mean a pretty brutal schedule.

 

[deleted171991]

If this is the case I would do vascular just based on future job security.

That's also very relative. Expect most if not all of your patients to be Medicare, which almost guarantees you end up as an employee. Plus people will choose IR over surgery anytime they can.

 

[Sirach38]

That's also very relative. Expect most if not all of your patients to be Medicare, which almost guarantees you end up as an employee. Plus people will choose IR over surgery anytime they can.

Sh**!!! So no matter where I go I'm screwed hahaha is there no hope for the average medical student in today's world?

I guess I better start at the end of that unemployment line...