Anesthesiologists, how are you now, in 2015?

[Block-Buster]

Hey, CA1 here (and long-time lurker of this board). I'm enjoying the discussion. I haven't had my OB rotation yet and I'm wondering why everyone seems to dislike OB so much? Is there a difference in private practice vs during residency?

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[teeva]

Many reasons.

Unpredictability! Especially on call.

Lots of fat patients with no palpable landmarks you're sticking a sword or spear into blindly.

Many whiney and needy pts who scream at you in pain just for trying to feel the iliac crest to get a landmark because they're the size of a beached whale.

Needy teenage preggers. Childbirth is the least of their pain/problems. And the needy 30yo grandma.

Annoying baby daddy or just some dude who's not the father. Fights, weapons, police, restraining orders...seen it all, no joke!

Chaos when mom or fetus crashes suddenly - real or not but you are obligated to do whatever OB wants to lessen your liability.

Change of shift, change of plan. Stable pt needs stat c/s suddenly at 7am or 5pm when OB changes shift.

The random pt whose spinal or epidural just doesn't work even through performing them was textbook perfect.

Slow as f*ck OB who puts in one f*cking stitch per minute because academics and teaching and incompetent veterinary butchery.

Midwifery, birth plans, and dealing with consequences of f*cked up decision making by others.

The above was my academic experience. Now in PP, I just pop in the epidural and go home, or pop in a spinal, do the charting, and by the time I'm done the c/s is over and I can go home. Pts are way skinner too. Still have the annoying pts here and there, but I just ignore it and continue pushing the Tuohy needle, chart, and go home.

 

[pjl]

The above was my academic experience. Now in PP, I just pop in the epidural and go home, or pop in a spinal, do the charting, and by the time I'm done the c/s is over and I can go home. Pts are way skinner too. Still have the annoying pts here and there, but I just ignore it and continue pushing the Tuohy needle, chart, and go home.

Best part is that a "long" C/S with "slow" surgeon is 45-50 minutes.

 

[teeva]

Yeah, in my academics OB training, slow was 2h and fast/normal was 1h. Literally one stitch per minute and BBQing anything that wasn't already burned to charcoal. Not an exaggeration.

It depends though. In my med school, OB residents were doing 30 min C/S with the attending and med student doing the retracting and assisting.

 

[pgg]

I like OB anesthesia. They're the only patients who are (usually) happy to be in the hospital, for a (usually) happy occasion, and they're (almost) always glad to see me.

The occasional chaos and surgical misadventures suck, but that's exactly where good anesthesiologists are needed.

My practice though has a near-zero rate of teenage pregnancy, drug use, super-morbid-obesity (plenty of garden-variety new-normal obese though), no uninsured patients, everyone had prenatal care. Our reward:BS ratio is pretty good.

 

[Pooh & Annie]

I'm about 5 years in and still very happy.

 

[abolt18]

Now for the real trick. How did I manage to keep this good thing going?
I surrounded myself with some very talented and smart individuals.
Everyone has something to offer.
I'm probably the least knowledgeable person in this group when it comes to issues outside of the OR but I do know how to assimilate all the data. I just sit back and tap into everyone's specific talents and knowledge.

My grandfather (a VERY successful general contractor in southern CA) has always told me a major key to success is finding people that are smarter than you and hiring them to work for you.

 

[Planktonmd]

I like OB anesthesia.

You must be crazy!

 

[teeva]

OB is different, easy, and even likable with a privately or self-insured patient population. The OB doc is likable too, and they bring in normal healthy happy patients.

 

[urge]

OB is different, easy, and even likable with a privately or self-insured patient population. The OB doc is likable too, and they bring in normal healthy happy patients.

Smells funky though.

 

[Twiggidy]

Many reasons.

Unpredictability! Especially on call.

Lots of fat patients with no palpable landmarks you're sticking a sword or spear into blindly.

Many whiney and needy pts who scream at you in pain just for trying to feel the iliac crest to get a landmark because they're the size of a beached whale.

Needy teenage preggers. Childbirth is the least of their pain/problems. And the needy 30yo grandma.

Annoying baby daddy or just some dude who's not the father. Fights, weapons, police, restraining orders...seen it all, no joke!

Chaos when mom or fetus crashes suddenly - real or not but you are obligated to do whatever OB wants to lessen your liability.

Change of shift, change of plan. Stable pt needs stat c/s suddenly at 7am or 5pm when OB changes shift.

The random pt whose spinal or epidural just doesn't work even through performing them was textbook perfect.

Slow as f*ck OB who puts in one f*cking stitch per minute because academics and teaching and incompetent veterinary butchery.

Midwifery, birth plans, and dealing with consequences of f*cked up decision making by others.

The above was my academic experience. Now in PP, I just pop in the epidural and go home, or pop in a spinal, do the charting, and by the time I'm done the c/s is over and I can go home. Pts are way skinner too. Still have the annoying pts here and there, but I just ignore it and continue pushing the Tuohy needle, chart, and go home.

That's not just academics, if you in certain areas of the country that can be PP too.
The bolded quote baffles be but that discussion as been had elsewhere.

OB in my experience is a Jekyll and Hyde monster. ALOT of it has to do with nursing. If the nurses are cool then life is cool, if they're "you know whats" then you can take OB anesthesia and shove it. Also, as stated elsewhere, it's one part of anesthesia where 90% of the time they're glad to see you, minus the "I want to go natural and can't do it so I'm taking my anger out on everyone patients, and you also get to immediately see results. It can be very rewarding to see a patient go from ....

to.....

but being on call and stuck in the hospital babysitting epidurals takes years off you life and time away from you where you can be doing other things. you're getting paid, but still, i'd rather be living life..

i think the "pop an epidural in and go home" statement is rare and probably shouldn't be promoted/advertised to MS /residents because it paints a false picture of the real world. 99% of places, put in an epidural and you in "OB jail"

 

[teeva]

That might be true. I don't know how common it actually is.

 

[Urzuz]

Now in PP, I just pop in the epidural and go home, or pop in a spinal, do the charting, and by the time I'm done the c/s is over and I can go home. Pts are way skinner too. Still have the annoying pts here and there, but I just ignore it and continue pushing the Tuohy needle, chart, and go home.

You don't stay in-house when you have a running epidural? Is this common?

 

[Noyac]

I pop mine in and go home.

 

[Twiggidy]

You don't stay in-house when you have a running epidural? Is this common?

No..it's not. To be honest, I think it's dependent by state but I could be wrong on that one.

 

[urge]

You don't stay in-house when you have a running epidural? Is this common?

At a busy place there is no going home.

I remember placing 10 to 12 epidurals a night as a resident. No matter how hard I tried each would consume like half an hr between preop assessment, consent, positioning, waiting for the woman to stop screaming between contractions, placing the catheter, setting up the machine for the drip, treating hypotension, and writing the anesthesia chart.

5 to 6 hrs gone just placing epidurals. Then constantly interrupted for top ups, and to remove catheters (the nurses wouldn't do it).

If you had a section or two you were screwed. 90 min for a primary section.

OR call was much better. Usually by midnight you would go to bed until the next day.

 

[Hockeyguy]

Hey, CA1 here (and long-time lurker of this board). I'm enjoying the discussion. I haven't had my OB rotation yet and I'm wondering why everyone seems to dislike OB so much? Is there a difference in private practice vs during residency?

I used to like it and I don't mind the medicine or the patients but I hate the "OB culture". They need an epidural 25 minutes before shift change almost without fail. They always wait till the OR is packed until calling that STAT section that should have gone hours ago because everyone knew there was no way the patient was going to deliver vaginally. OB will always be busy on the holidays - especially Christmas. Women at 38 weeks or more freak out on Christmas and have to get to the hospital. Same with Thanksgiving and with fourth of July but not as bad as Christmas.

 

[teeva]

Smells funky though.

Rich areas of NYC. And when your hospital is the birth center for your hospital's employee insurance.

 

[jollygoodfellow]

where is this magical place

that is hilarious.

 

[Carbocation1]

Myth buster: Analysis shoots down economic notions in anesthesia
October 25, 2015

"The idea that moving from physician-only staffing to medical-direction staffing will reduce staffing sounds equally plausible. The median annual compensation for private practice anesthesiologists is $412,000, for academic anesthesiologists $300,000 and for CRNAs $186,000.

The raw numbers are misleading, Dr. Abouleish explained. The typical anesthesiologist works about 2,750 regular hours per year compared to 1,760 hours for the typical CRNA. That is equivalent to $110 to $150 per hour for physicians. CRNAs earn $106 per hour, similar to the median compensation for instructors and assistant professors.

If an academic department needs to cover an additional site, an instructor/assistant professor not only provides clinical services at CRNA cost levels but also provides academic services. Physician-only staffing is more cost effective. In other settings, the total staffing cost depends on the precise mix of sites, hours, types of cases, on-call needs, payers and other factors."

http://asa-365.ascendeventmedia.com...is-shoots-down-economic-notions-in-anesthesia

 

[Carbocation1]

Compensation

The following are based on the Medscape Anesthesiologist Compensation Report 2015.

7. Compensation — $358,000; ranking fourth highest-paid specialty

Compensation based on employment

8. Self-employed —$410,000

9. Employed — $318,000

Compensation based on practice setting

10. Office-based single-specialty group practice — $429,000

11. Hospital — $359,000

12. Outpatient clinic — $316,000

"If anesthesiologists don't want to relinquish their private practice freedom in a sale, they can fight. Practices should strengthen relationships with all facilities to which they provide services, leaving no doubt that its anesthesiologists are the best. The focus of relationship-building should not only encompass more hospitals, but outpatient surgery centers as well. Bigger doesn't necessarily mean better, but it does mean power. Practices should also consider merging forces with other anesthesia practices to leverage better payer contracts."

http://www.beckersasc.com/anesthesia/18-things-to-know-about-anesthesia.html

 

[lunaire]

Myth buster: Analysis shoots down economic notions in anesthesia
October 25, 2015

"The idea that moving from physician-only staffing to medical-direction staffing will reduce staffing sounds equally plausible. The median annual compensation for private practice anesthesiologists is $412,000, for academic anesthesiologists $300,000 and for CRNAs $186,000.

The raw numbers are misleading, Dr. Abouleish explained. The typical anesthesiologist works about 2,750 regular hours per year compared to 1,760 hours for the typical CRNA. That is equivalent to $110 to $150 per hour for physicians. CRNAs earn $106 per hour, similar to the median compensation for instructors and assistant professors.

If an academic department needs to cover an additional site, an instructor/assistant professor not only provides clinical services at CRNA cost levels but also provides academic services. Physician-only staffing is more cost effective. In other settings, the total staffing cost depends on the precise mix of sites, hours, types of cases, on-call needs, payers and other factors."

http://asa-365.ascendeventmedia.com...is-shoots-down-economic-notions-in-anesthesia

Well, the problem is that we don't have enough anesthestiologist to staff all of the ORs, and CRNA + anesthesiologist coverage obviously cost more than CRNA solo.

I'm also not convinced that we need an anesthesiologist to push propofol in GI endoscopy suites, or to babysit intraop sedation ortho cases with successsful blocks. A non-CRNA nurse can do that. It's un-economic to have us staff these common scenarios.

 

[NightNight]

Well, the problem is that we don't have enough anesthestiologist to staff all of the ORs, and CRNA + anesthesiologist coverage obviously cost more than CRNA solo.

I'm also not convinced that we need an anesthesiologist to push propofol in GI endoscopy suites, or to babysit intraop sedation ortho cases with successsful blocks. A non-CRNA nurse can do that. It's un-economic to have us staff these common scenarios.

Dude. Did you not just see the thread about a CRNA clean kill on a woman in an endoscopy suite? It was like two weeks ago.

 

[Man o War]

Well, the problem is that we don't have enough anesthestiologist to staff all of the ORs, and CRNA + anesthesiologist coverage obviously cost more than CRNA solo.

I'm also not convinced that we need an anesthesiologist to push propofol in GI endoscopy suites, or to babysit intraop sedation ortho cases with successsful blocks. A non-CRNA nurse can do that. It's un-economic to have us staff these common scenarios.

I strongly disagree with this. When I was teaching I always beat it into the residents' heads that the endo suite can be the most dangerous place to supervise and practice depending on the patient.

 

[Mman]

I strongly disagree with this. When I was teaching I always beat it into the residents' heads that the endo suite can be the most dangerous place to supervise and practice depending on the patient.

doing MAC cases with someone else instrumenting the airway so you can't intervene easily is one of the most dangerous things we do. Shooting for that sweet spot of not gagging but still breathing is a very fine line in some patients.

 

[mostwanted]

http://www.omic.com/co-defendant-crna-denies-responsibility-for-failed-resuscitation/


http://www.painterfirm.com/a/170/Me...opofol-causing-death-of-45yearold-woman#tab-1

 

[IlDestriero]

These case reports scare the **** out of me. This MFer couldn't intubate a patient, hasn't intubated in 5 years in fact, and then when everything pointed to the tube being somewhere other than the trachea, he supposedly checked and this unskilled douche insisted that the tube was in place. Clean kill.
Then he tried to hide behind the surgeon as the captain of the ship. That guy wouldn't know normal breath sounds if his life depended on it. What a joke.

 

[Man o War]

doing MAC cases with someone else instrumenting the airway so you can't intervene easily is one of the most dangerous things we do. Shooting for that sweet spot of not gagging but still breathing is a very fine line in some patients.

Residents get way too comfortable down there, and CRNAs for that matter. Patients are getting fatter and sicker, it's a mistake to be casual in our approach to these seemingly "simple, quick" cases.

These case reports scare the **** out of me. This MFer couldn't intubate a patient, hasn't intubated in 5 years in fact, and then when everything pointed to the tube being somewhere other than the trachea, he supposedly checked and this unskilled douche insisted that the tube was in place. Clean kill.
Then he tried to hide behind the surgeon as the captain of the ship. That guy wouldn't know normal breath sounds if his life depended on it. What a joke.

And then the CRNA gets in a shoving match with the paramedic who called out his incompetence. This is awful.

 

[IlDestriero]

In that particular situation, the Paramedic was definitely the airway expert in the room. And if your ETT ain't working, you don't have anything to lose by maybe putting in an LMA, because, you know, your tube's probably not in, and the patient is about to die.
Hubris.
Neither of them probably knew what breath sounds sounded like anymore.
I particularly liked that the paramedic dislodged the tube according to the crack CRNA, but when the paramedic intubated, the Spo2 came back. And the whole no CO2 thing...

 

[deleted59964]

Awesome! Brilliant! Lots of fun. But I'm in Australia where there are no CRNAs disrespecting attending anesthesiologists or worse, to my knowledge no AMCs buying out private groups across the nation, where the vast majority of surgeons regard anesthesiologists as professional colleagues rather than hired help, where anesthesiologists do their own cases basically 1:1, where lifestyle is far better for the same or similar starting salaries, etc. There are downsides since nothing is perfect, but from my perspective they're far outweighed by the upsides.

hmmm

 

[deleted59964]

What's so "hmmm" about this? I've done several rotations as a med student here in Australia. I've seen what it's like. How is what I said wrong? If it is, feel free to correct it.

You have a strange obsession thinking I'm misrepresenting myself and calling me dishonest. But I've never said I was an anesthesia attending. I'm more than happy to say I'm an Aussie med student.

well there is the title of the thread "anaesthesiologists, how are you now in 2015'. it's not ... 'med students aspiring to be anaesthesiologists - how are you in 2015'.

a lot of your posts give the impression you're much more progressed in your career.

you are surprisingly well informed for a med student. I wish you every success in your career, and consider this matter finished.

 

[criticalelement]

I have ptsd in this career just so you know...

 

[amLOLdipine]

I have ptsd in this career just so you know...

How about switching careers or finding a new job?

Posting on SDN is unlikely to make your current job any better.

 

[Consigliere]

How about switching careers or finding a new job?

Posting on SDN is unlikely to make your current job any better.

Finding a new job ----> likely
Finding a better job ---> unlikely
Switching careers ------> impossible

 

[amLOLdipine]

Finding a new job ----> likely
Finding a better job ---> unlikely
Switching careers ------> impossible

There are several people on these subforums who have posted that they love their jobs. There are others who are less happy with it, but nobody else on these forums is having pseudo-breakdowns in their posts.

So I am inclined to believe that the problem, at least in his case, is not the field of anesthesiology.

 

[caligas]

I have ptsd in this career just so you know...

I actually think that probably does happen to some that are over worked or that face too many stressful situations. That's my primary concern for myself, far more than the financial elements that have been pretty good for me so far. Will those rare moments-of-terror add up to take a toll?

BTW why are you on double-secret probation?

 

[BLADEMDA]

I actually think that probably does happen to some that are over worked or that face too many stressful situations. That's my primary concern for myself, far more than the financial elements that have been pretty good for me so far. Will those rare moments-of-terror add up to take a toll?

BTW why are you on double-secret probation?

Yes, the bad outcomes do add up over the decades and add to mental stress. Once bad **** actually happens to you (and it will) it moves from the theoretical to the real world. It makes you a better provider though even if you aren't a happy one.

 

[waterbottle10]

65 on average.

Surgeons keep getting slower.

Robotic hysteroscopy today took 2 hours just to dock the robot. i wanted to punch someone in the face

 

[deleted171991]

Robotic hysteroscopy today took 2 hours just to dock the robot. i wanted to punch someone in the face

Now imagine your induction or emergence taking 2 hours, and guess what would happen then.

 

[pgg]

Now imagine your induction or emergence taking 2 hours, and guess what would happen then.

I know your question is rhetorical, but if your emergence takes two hours, you probably should've left the OR 90+ minutes earlier and taken the patient to the PACU or ICU to emerge in a less expensive, less inconvenient place ... or gone to CT as part of a delayed emergence workup. Or done anything except stand there looking at your feet for two hours. You deserve a scolding.

What are you getting at? That bad anesthesiologists get the scoldings they deserve, but bad surgeons don't? That there are no consequences for bad surgeons?

That's really not true in any sense that matters. The hospital/OR's response to slow surgeons is subtler and less direct, but it's there. They get less desirable block time. They get bumped by faster surgeons (who have higher $ value to the hospital). They are limited in the number of cases they can schedule. The OR staff talks smack behind their back.

And of course their patient outcomes are worse. This is probably the only real metric that matters, and it's undeniable and unavoidable.


We provide a commodity service, and are (generally) easier for a hospital to replace than a surgeon with an established practice and patient base ... but let's not pretend that competence has anything at all to do with that economic issue.

Are you lamenting the perception that incompetent anesthesiologists get less slack than incompetent surgeons?

 

[GA8314]

I know your question is rhetorical, but if your emergence takes two hours, you probably should've left the OR 90+ minutes earlier and taken the patient to the PACU or ICU to emerge in a less expensive, less inconvenient place ... or gone to CT as part of a delayed emergence workup. Or done anything except stand there looking at your feet for two hours. You deserve a scolding.

What are you getting at? That bad anesthesiologists get the scoldings they deserve, but bad surgeons don't? That there are no consequences for bad surgeons?

That's really not true in any sense that matters. The hospital/OR's response to slow surgeons is subtler and less direct, but it's there. They get less desirable block time. They get bumped by faster surgeons (who have higher $ value to the hospital). They are limited in the number of cases they can schedule. The OR staff talks smack behind their back.

And of course their patient outcomes are worse. This is probably the only real metric that matters, and it's undeniable and unavoidable.


We provide a commodity service, and are (generally) easier for a hospital to replace than a surgeon with an established practice and patient base ... but let's not pretend that competence has anything at all to do with that economic issue.

Are you lamenting the perception that incompetent anesthesiologists get less slack than incompetent surgeons?

This is spot on.

 

[deleted171991]

This is spot on.

Spot on what?

 

[deleted171991]

I know your question is rhetorical, but if your emergence takes two hours, you probably should've left the OR 90+ minutes earlier and taken the patient to the PACU or ICU to emerge in a less expensive, less inconvenient place ... or gone to CT as part of a delayed emergence workup. Or done anything except stand there looking at your feet for two hours. You deserve a scolding.

What are you getting at? That bad anesthesiologists get the scoldings they deserve, but bad surgeons don't? That there are no consequences for bad surgeons?

That's really not true in any sense that matters. The hospital/OR's response to slow surgeons is subtler and less direct, but it's there. They get less desirable block time. They get bumped by faster surgeons (who have higher $ value to the hospital). They are limited in the number of cases they can schedule. The OR staff talks smack behind their back.

And of course their patient outcomes are worse. This is probably the only real metric that matters, and it's undeniable and unavoidable.


We provide a commodity service, and are (generally) easier for a hospital to replace than a surgeon with an established practice and patient base ... but let's not pretend that competence has anything at all to do with that economic issue.

Are you lamenting the perception that incompetent anesthesiologists get less slack than incompetent surgeons?

I admire your optimism.

In my world, many incompetent surgeons get themselves shiny resumes and pompous titles, and take two hours to undock the robot. I have seen a department head, full pompous professor, losing one liter of blood in a procedure that produces 50-100 cc's of blood loss in most hands, all because he was too lazy to cauterize properly for hours. Good luck reporting him, or anybody else for that matter. As you pointed out, it's mostly about money. And as I pointed out, anesthesiologists are not worth any in most markets.

 

[ERRES2288]

I have ptsd in this career just so you know...

Really? I never would have thought you'd say something like this..

 

[Nivens]

I admire your optimism.

In my world, many incompetent surgeons get themselves shiny resumes and pompous titles, and take two hours to undock the robot. I have seen a department head, full pompous professor, losing one liter of blood in a procedure that produces 50-100 cc's of blood loss in most hands, all because he was too lazy to cauterize properly for hours. Good luck reporting him, or anybody else for that matter. As you pointed out, it's mostly about money. And as I pointed out, anesthesiologists are not worth any in most markets.

Im assuming you still have your fair share of surgeon v anesthesiologist violence in the SICU, no? I realize the is beside the point, just curious if you escaped to a more even ground as the ICU attending.

 

[deleted171991]

Im assuming you still have your fair share of surgeon v anesthesiologist violence in the SICU, no? I realize the is beside the point, just curious if you escaped to a more even ground as the ICU attending.

I have yet to experience life as an ICU attending but, during fellowship, I have seen my share of arrogant surgeons. It does require diplomacy, especially since some surgeons have no idea how little they know (and many think they are your equal in critical care). The sad part is that they indoctrinate their residents, too, by being bad role models.

As with anesthesiologists, most good surgeons will learn to appreciate a good intensivist. It just takes a few saves to prove one's worth to them. Unfortunately, in the surgical world, there are much fewer closed ICUs than in the medical. I personally love closed ICUs; that's how all of them should (and will) be.

The good news is that, in the ICU, the intensivist is on almost equal footing with the surgeon. I personally have zero problems in suggesting a surgeon that his opinions are consultative, both regarding my anesthesia care in the OR and my intensive care in the ICU. The difference is that, in the ICU, the nurses and many of the families think the same way; in the OR, the surgeon is the king.