confused about anesthesia

[kazuma]

You're probably right. I still see surgeons doing every cataract with a retrobulbar block, 30 minutes just till incision. They are private and nobody can do anything about it. The hospital loves them because of the higher facility fees for longer surgeries. The same goes for some plastic surgeons who take double the time their private counterparts do.

I can see this becoming a problem in the era of bundled payments, when the hospitals won't get extra facility money for the extra surgical time.

I don't think I've done a cataract since CA1 year and I don't remember our surgeons doing retrobulbar blocks. My surgeon friend who works in a busy PP in the midwest thinks they are barbaric and unnecessary.

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[deleted171991]

My surgeon friend who works in a busy PP in the midwest thinks they are barbaric and unnecessary.

I concur. I also work with a private ophthalmologist who does them in less than 10 minutes surgical time, <20 minutes OR time, with eye drops. No difference in outcome, and this guy doesn't even need to advertise his services; you wouldn't find him online.

 

[pgg]

What about the guy/gal who takes 80 minutes to do a cataract? or 3 hours to do a typical one hour procedure? Should we all eat the loss in revenue because that person has poor surgical skills? I'm willing to bet that cataract is really well over an hour as surgical times less than 20 minutes is considered excellent.

It's interesting reading about surgeons getting leaned on to operate faster because of new market forces.

I spent 12 hours doing a 3-4 hour case the other day and, with all that time to stare at the wall and think, I started thinking about whether there was a line somewhere dividing a surgeon who was merely slow, and one who was dangerously slow to the point he shouldn't be credentialed.

Would be interesting if the evil market middlemen could solve the academic and .mil/VA salaried slowpoke problem.

 

[IanMcGalt]

Let them practice independently, I have no interest in supervising anybody. Perhaps I'm naive, but I wouldn't have a problem working side by side with independent CRNA's as long as I'm not signing charts for cases that I'm not involved with. I would be working along side of independent CRNA's at one of the two jobs I'm seriously considering. The other job is an all MD/DO group which is well established and as of now, doesn't take a subsidy. They take a loss for uninsured patients and providing services that are poorly compensated such as having staff available for remote sites, cath lab etc. But it allows them to function autonomously and I would argue, makes it difficult for an AMC to take over unless they could negotiate insurance rates that would allow the AMC to pay a "kick back" to the hospital. But even then, the hospital and surgeons are very happy with this group so it doesn't seem likely that the hospital would take on an AMC unless there was a significant kickback involved.

Despite my significant student loan debt (~$300K), I'd rather make less and do my own cases. Had I not gone into anesthesiology, I would have done IM/Pulm or FP and it doesn't seem likely that our salaries could fall much below pulm and they should stay well above FP. Remember, CRNA's don't cost less, the whole point of "opt out" is that they are able to bill CMS independently in 17 states. The bill is the same whether Tis an MD or nurse doing the case. The independent CRNA's I know make the same salary as anesthesiologists in their area. There should be plenty of good jobs available for those who are personable, hard working, and highly skilled. Maybe not for the lazy, out of practice folks who want to sit around, sign charts and drink coffee while flirting with the circulators and scheduling clerks. As reimbursement continues to decline, we'll all feel the squeeze including surgical specialties. Eventually the costs of attending medical school may exceed the benefits but we're not there yet IMO. Medicine seems like a pretty good gig overall. All of the anesthesiologists I know are happy and have a decent income, none of them are in the hellish situations I read about on SDN, at least for now.

In terms of ACO's and bundled payments, take a look at the pioneer ACO's. Most of them aren't doing well and it doesn't seem like a viable practice model. The current system isn't sustainable either, so clearly something needs to change. I'm already in too deep, I have no choice but to work hard, live conservatively, pay down my debt and ride it out. I was miserable working in a lab before medical school, I couldn't imagine doing that for the rest of my life. My engineering friends seem bored and unsatisfied with their work and they aren't making the killer salaries you see quoted on SDN. Every one of them is looking for their exit plan with hopes of eventually landing a job that pays >$120K.

I love anesthesiology and I can't think of another job that I'd be more excited to do each day. Even as a resident, I enjoy waking up and coming into work most days. Tis Christmas Eve and I'm on an elective rotation. I could have slept in but instead I came in to work for a few hours this morning so the pre-OB call person can have the day off and the OB call person can sleep in. I worked the OB floor while my wife and kids were sleeping and I have the rest of the day and tomorrow to spend with my family. I would never volunteer to go see FP clinic patients on a day off. That to me is the difference between doing a job vs. a career you enjoy.

Billing has nothing to do with your paycheck in the corporate medicine world.

 

[Sirach38]

Let them practice independently, I have no interest in supervising anybody. Perhaps I'm naive, but I wouldn't have a problem working side by side with independent CRNA's as long as I'm not signing charts for cases that I'm not involved with. I would be working along side of independent CRNA's at one of the two jobs I'm seriously considering. The other job is an all MD/DO group which is well established and as of now, doesn't take a subsidy. They take a loss for uninsured patients and providing services that are poorly compensated such as having staff available for remote sites, cath lab etc. But it allows them to function autonomously and I would argue, makes it difficult for an AMC to take over unless they could negotiate insurance rates that would allow the AMC to pay a "kick back" to the hospital. But even then, the hospital and surgeons are very happy with this group so it doesn't seem likely that the hospital would take on an AMC unless there was a significant kickback involved.

Despite my significant student loan debt (~$300K), I'd rather make less and do my own cases. Had I not gone into anesthesiology, I would have done IM/Pulm or FP and it doesn't seem likely that our salaries could fall much below pulm and they should stay well above FP. Remember, CRNA's don't cost less, the whole point of "opt out" is that they are able to bill CMS independently in 17 states. The bill is the same whether Tis an MD or nurse doing the case. The independent CRNA's I know make the same salary as anesthesiologists in their area. There should be plenty of good jobs available for those who are personable, hard working, and highly skilled. Maybe not for the lazy, out of practice folks who want to sit around, sign charts and drink coffee while flirting with the circulators and scheduling clerks. As reimbursement continues to decline, we'll all feel the squeeze including surgical specialties. Eventually the costs of attending medical school may exceed the benefits but we're not there yet IMO. Medicine seems like a pretty good gig overall. All of the anesthesiologists I know are happy and have a decent income, none of them are in the hellish situations I read about on SDN, at least for now.

In terms of ACO's and bundled payments, take a look at the pioneer ACO's. Most of them aren't doing well and it doesn't seem like a viable practice model. The current system isn't sustainable either, so clearly something needs to change. I'm already in too deep, I have no choice but to work hard, live conservatively, pay down my debt and ride it out. I was miserable working in a lab before medical school, I couldn't imagine doing that for the rest of my life. My engineering friends seem bored and unsatisfied with their work and they aren't making the killer salaries you see quoted on SDN. Every one of them is looking for their exit plan with hopes of eventually landing a job that pays >$120K.

I love anesthesiology and I can't think of another job that I'd be more excited to do each day. Even as a resident, I enjoy waking up and coming into work most days. Tis Christmas Eve and I'm on an elective rotation. I could have slept in but instead I came in to work for a few hours this morning so the pre-OB call person can have the day off and the OB call person can sleep in. I worked the OB floor while my wife and kids were sleeping and I have the rest of the day and tomorrow to spend with my family. I would never volunteer to go see FP clinic patients on a day off. That to me is the difference between doing a job vs. a career you enjoy.

Thanks for the awesome post kazuma.

 

[Wiscoblue]

So working side by side...will you be doing asa 3 and up while they do the Asa 1 and 2 cases?

 

[deleted171991]

Thanks for the awesome post kazuma.

That's wishful thinking from kazuma, no offense. Hospitals don't want solo MD-practice, because it doesn't squeeze all the juice from the money lemon. They want physicians to practice "at the top of their license", as recently posted by a department chair on this forum and as the ASA doctrine goes nowadays. They want CRNAs to do the same. There will be mixed departments with CRNAs doing easy cases independently or with minimal supervision (whatever the law/CMS require), and MDs supervising CRNAs doing complicated cases, while doing firefighter work for independent CRNAs. There might be some openings for solo MDs, but expect to be paid accordingly (solo work = less work = stool sitting, in the eyes of the bean counters).

I don't know why kazuma expects anesthesia never to fall to the level of FP, while exactly the same market forces will be at work: overproduction of physicians, encroachment by midlevels, corporate medicine. It's such wishful thinking. Whoever gets into anesthesia now should be prepared to work for FP hourly salaries and workload. If that's not acceptable for you, you are definitely in the wrong specialty.

Expect to be punished/fired if not able to preop patients fast enough, if not able to run 4 fast rooms while giving breaks and whatever the crap else they will want from you. God forbid to catch your breath more than for the 15-30 minutes/day you will have as official breaks, including restroom breaks. Especially in the desirable areas, they will have so many suckers with medical and anesthesia diplomas they will be able to hire one the next minute after they fired you.

History always repeats itself. Look at what happened to Law, and learn from it. It will be not at all different in Medicine, now that Wall Street is taking us over, except that we as anesthesiologists (and many other service specialties) will not have any "clients" to follow us if we decide to leave (plus anyway the noncompetes are written in such a way that it's impossible) . We will be just "paralegals" for all intents and purposes.

Pray for a change after 2016, but I am not optimistic. Things got exponentially faster after Obamacare went live, and the ACA still has parts yet to become active, so undesirable change will only accelerate in the next 5 years. Stop dreaming and plan a life in a completely corporate assembly-lane blue-collar world. Whatever paradise you are practicing in right now will not last long. The forces of Mordor are incredibly strong.

These are savage capitalists who care only about two things: making money and... making more money. They will not let you have a better lifestyle in exchange for lower salaries, as long as they have suckers to work 70-80 hours/week. More hours worked, more profit for the overlords. They care about you as much as you care about the livestock that you eat daily. Don't expect a Google-like atmosphere, more like a Walmart one. Very few greedy people become rich by/while being nice to other people.

And, no, my middle name is not Cassandra. My middle name is Herodotus.

 

[Sirach38]

That's wishful thinking from kazuma, no offense. Hospitals don't want solo MD-practice, because it doesn't squeeze all the juice from the money lemon. They want physicians to practice "at the top of their license", as recently posted by a department chair on this forum and as the ASA doctrine goes nowadays. They want CRNAs to do the same. There will be mixed departments with CRNAs doing easy cases independently or with minimal supervision (whatever the law/CMS require), and MDs supervising CRNAs doing complicated cases, while doing firefighter work for independent CRNAs. There might be some openings for solo MDs, but expect to be paid accordingly (solo work = less work = stool sitting, in the eyes of the bean counters).

I don't know why kazuma expects anesthesia never to fall to the level of FP, while exactly the same market forces will be at work: overproduction of physicians, encroachment by midlevels, corporate medicine. Tis such wishful thinking. Whoever gets into anesthesia now should be prepared to work for FP hourly salaries and workload. If that's not acceptable for you, you are definitely in the wrong specialty.

Being prepared for the worst but still having hope for something better seems to sit well with me.

 

[pgg]

So working side by side...will you be doing asa 3 and up while they do the Asa 1 and 2 cases?

In a word, yes.

 

[kazuma]

Tis interesting reading about surgeons getting leaned on to operate faster because of new market forces.

I spent 12 hours doing a 3-4 hour case the other day and, with all that time to stare at the wall and think, I started thinking about whether there was a line somewhere dividing a surgeon who was merely slow, and one who was dangerously slow to the point he shouldn't be credentialed.

Would be interesting if the evil market middlemen could solve the academic and .mil/VA salaried slowpoke problem.

We'd have a serious surgeon shortage at my shop if they cracked down on slow/dangerous surgeons. The sad thing is that it's not the residents or teaching that slows them down.

 

[deleted171991]

We'd have a serious surgeon shortage at my shop if they cracked down on slow/dangerous surgeons. The sad thing is that Tis not the residents or teaching that slows them down.

The academic surgeons are usually the worst. There is a reason they are academic: they would not survive elsewhere, and their pompous titles attract patients who would never look at them in private practice.

Once you get out in PP and see a good private surgeon, you will be the one feeling slow (as a fresh graduate). This is also why anesthesiologists who work with good private surgeons tend to run circles around people working with academic ones. And this is why one has to work solo for the first 3-5 years post-graduation, preferably in a private setting.

When we pair some purely academic people solo with our private surgeons, we almost always hear back negative things, either from the surgeon or the anesthesiologist.

 

[epidural man]

Hey all...I'm currently a third year and am feeling the pressure to figure out what I'm going to he when I grow up...I'm pretty torn and feeling like I don't have enough information to make a decent choice. I've been leaning towards emergency medicine but am trying to make sure that I give everything a look. I've been reading through the old threads around here but still have a couple of questions. My schools hospital only uses md's to start the case and then they go hang out in the break room while the crna's manage the rest. As far as the procedures I've read about y'all doing...at my place its always the surgery residents who do everything. So basically I have no idea what an anesthesiologist really does outside of what I've read here.

If you don't mind...could you maybe ballpark how much of your time is spent in the or vs how much is doing the lines and epidurals and things like that? I wasn't a huge fan of being in the or all day...are you spending a significant portion of the day managing other issues outside or is it pretty much all done in the or?

I really like the idea of having such a commanding knowledge if pharm as well as being one of the main guys counted on in a code situation. Is that a legit reason to pursue anesthesiology?

Sorry for the randomness of this post...I'd appreciate any advice and insight anyone could give though. Thanks!

Sorry no one has answered your question....people on forums tend to do that - answer with what they want to talk about and ignore your question.

Anyway, from my perspective.

Anesthesia - how much time in the OR? At our hospital, there is no supervision of CRNA's but supervision of students (med students, interns, residents, srna's) - but a non-fellowshiped trained anesthesiologist spends probably 0.85 FTE in the OR. Surgeons only do lines in the unit - they never do them in the OR. You will do all the lines on your patients. I think this is pretty standard at MOST hospitals. Very little time is spent out of the OR managing issues. However, when I am on the acute pain service, we manage floor patients and do blocks. No time is spent in the OR. However, you say you don't want to be in the OR all day, but it is actually one of the best places to be in the hospital. For one, you have a chair you can sit in most of the time. Two, the people in the OR are usually great fun and you basically get paid to shoot the shizzle with the surgeons (if they are cool), the cute nurses, or the funny murse. Or if you don't want to talk, play craps on your iphone. When I as an MS3, I didn't like the OR either. I think it is just a manner of being unfamiliar in a strange environment - but that changes once you spend time there. Finally, on the OB labor deck, you will do a day of placing epidurals and sometimes going to the OR to do c/sections.

Absolutely I think loving physiology is a great reason to do anesthesia. It is incredibly fun. As others have said, not very many other medicine jobs are likely to be as enjoyable. That is the main reason I pursued anesthesia - and I have not been dissappointed.

HOWEVER - if you can, do radiation oncology. Seriously. What a freakin' cool job. Finally, you could still quite, go to dental school, and finish sooner than you would now, and make a lot more money and not deal with many of the issues people have discussed on this thread.

 

[GA8314]

That's wishful thinking from kazuma, no offense. Hospitals don't want solo MD-practice, because it doesn't squeeze all the juice from the money lemon. They want physicians to practice "at the top of their license", as recently posted by a department chair on this forum and as the ASA doctrine goes nowadays. They want CRNAs to do the same. There will be mixed departments with CRNAs doing easy cases independently or with minimal supervision (whatever the law/CMS require), and MDs supervising CRNAs doing complicated cases, while doing firefighter work for independent CRNAs. There might be some openings for solo MDs, but expect to be paid accordingly (solo work = less work = stool sitting, in the eyes of the bean counters).

I don't know why kazuma expects anesthesia never to fall to the level of FP, while exactly the same market forces will be at work: overproduction of physicians, encroachment by midlevels, corporate medicine. Tis such wishful thinking. Whoever gets into anesthesia now should be prepared to work for FP hourly salaries and workload. If that's not acceptable for you, you are definitely in the wrong specialty.

Expect to be punished/fired if not able to preop patients fast enough, if not able to run 4 fast rooms while giving breaks and whatever the crap else they will want from you. God forbid to catch your breath more than for the 15-30 minutes/day you will have as official breaks, including restroom breaks. Especially in the desirable areas, they will have so many suckers with medical and anesthesia diplomas they will be able to hire one the next minute after they fired you.

History always repeats itself. Look at what happened to Law, and learn from it. It will be not all different in Medicine, now that Wall Street is taking us over, except that we as anesthesiologists (and many other service specialties) will not have any "clients" to follow us if we decide to leave (plus anyway the noncompetes are written in such a way that Tis impossible) . We will be just "paralegals" for all intents and purposes.

Pray for a change after 2016, but I am not optimistic. Things got exponentially faster after Obamacare went live, and the ACA still has parts yet to become active, so undesirable change will only accelerate in the next 5 years. Stop dreaming and plan a life in a completely corporate assembly-lane blue-collar world. Whatever paradise you are practicing in right now will not last long. The forces of Mordor are incredibly strong.

These are savage capitalists who care only about two things: making money and... making more money. They will not let you have a better lifestyle in exchange for lower salaries, as long as they have suckers to work 70-80 hours/week. More hours worked, more profit for the overlords. They care about you as much as you care about the livestock that you eat daily. Don't expect a Google-like atmosphere, more like a Walmart one. Very few people become billionaires by/while being nice to other people.

And, no, my middle name is not Cassandra. My middle name is Herodotus.

All you can do is advocate for our future via sources available to us. ASA-PAC basically, and getting involved in your state society.

Look, surely there's always a possibility that reimbursements will go down. Does anyone really think our desperate system will INCREASE reimbursements down the road? Unlikely, then again we are a country who's policies are made via powerful lobbies and things don't always go the way they "should". So who knows.

Life is about attitude. Ours specialty will change. I don't know of a single business, new economy or old, that hasn't undergone MASSIVE change over the past decade. And most of those changes are along the lines of more pressure on the worker (whatever level), less vacation not more, less pensions (pen-what??) not more. Less job security not more. Less 401k matching by corporations not more. Meantime higher education expenses are going UP for pretty much all young people.

It is what it is. Perhaps this is the end result of the ultra-capitalist society we've created and inherited. But, that's another story.

Work hard, hone your craft. Like Kazuma said, get along with people. Be able to work FAST (since when is this necessarily bad???). Be good at what you do. I will guarantee you that if you do this day in and day out, people will KNOW who the good anesthesiologist is. When your group folds, or gets forced out and the new "boss" is looking for recommendations from those that are staying (such as OR nurses, mid-management etc.) your name will come up repeatedly. Guess what? Even in this sky falls down on your group scenario, YOU will have a place at the table.

What more can one expect? You can only control so much of your destiny. But, it can amount to a lot. Don't be a lazy fu.cking chart signing chump. When push comes to shove, those are the chumps who's job a hard working, likable CRNA will steal. NOT yours. I am very sure of this.

Look. Our baby boomers are approaching maximum surgical need in the coming decade. For the next decade or more, the system will struggle with a lot of things and will come under strain. But, DEMAND is also a powerful force. There will be a demand for those who know our trade. Some of those will likely be CRNAs to one degree or another (and they already are).

Meantime, work hard, save, get out of debt, and enjoy your life because life is short and very random. And, yes, you'll make enough to enjoy this short life as long as you don't envision a summer home and lots and lots of toys. But, you CAN earn a comfortable living and enjoy what you have.

Merry Christmas everyone.

 

[Physician Mom]

What about the guy/gal who takes 80 minutes to do a cataract? or 3 hours to do a typical one hour procedure? Should we all eat the loss in revenue because that person has poor surgical skills? I'm willing to bet that cataract is really well over an hour as surgical times less than 20 minutes is considered excellent.

Sorry to tell you that you are wrong. The conversation happened exactly as stated. And I know for a fact that her surgical time is excellent - just not as fast as Dr. X. Which is why this is so outrageous. But running an OR means paying for techs and nurses and if you are doing 10 cataracts in a day and your colleague finishes 45 - 50 minutes before you that's 1 hour less of tech/OR nurse/recovery time that factors in to the already low reimbursement rate for the facility fee.
By the way - the only people who take 80 minutes to do an uncomplicated cataract might be a resident, and even they are faster. Anyone taking that long has long ago switched to medical ophthalmology, medical retina, neuroophthalmology or some other non surgical field. The patients couldn't stand holding still for so long.

 

[deleted171991]

Sorry to tell you that you are wrong. The conversation happened exactly as stated. And I know for a fact that her surgical time is excellent - just not as fast as Dr. X. Which is why this is so outrageous. But running an OR means paying for techs and nurses and if you are doing 10 cataracts in a day and your colleague finishes 45 - 50 minutes before you that's 1 hour less of tech/OR nurse/recovery time that factors in to the already low reimbursement rate for the facility fee.
By the way - the only people who take 80 minutes to do an uncomplicated cataract might be a resident, and even they are faster. Anyone taking that long has long ago switched to medical ophthalmology, medical retina, neuroophthalmology or some other non surgical field. The patients couldn't stand holding still for so long.

With a technically so simple surgery as cataract, it's not at all surprising that the bean counters can have their choice of surgeons.

I strongly advise students to read about Warren Buffett's "moat" concept, and to choose a specialty with a strong moat (high barrier of entry).

 

[kazuma]

That's wishful thinking from kazuma, no offense. Hospitals don't want solo MD-practice, because it doesn't squeeze all the juice from the money lemon. They want physicians to practice "at the top of their license", as recently posted by a department chair on this forum and as the ASA doctrine goes nowadays. They want CRNAs to do the same. There will be mixed departments with CRNAs doing easy cases independently or with minimal supervision (whatever the law/CMS require), and MDs supervising CRNAs doing complicated cases, while doing firefighter work for independent CRNAs. There might be some openings for solo MDs, but expect to be paid accordingly (solo work = less work = stool sitting, in the eyes of the bean counters).

I don't know why kazuma expects anesthesia never to fall to the level of FP, while exactly the same market forces will be at work: overproduction of physicians, encroachment by midlevels, corporate medicine. Tis such wishful thinking. Whoever gets into anesthesia now should be prepared to work for FP hourly salaries and workload. If that's not acceptable for you, you are definitely in the wrong specialty.

Expect to be punished/fired if not able to preop patients fast enough, if not able to run 4 fast rooms while giving breaks and whatever the crap else they will want from you. God forbid to catch your breath more than for the 15-30 minutes/day you will have as official breaks, including restroom breaks. Especially in the desirable areas, they will have so many suckers with medical and anesthesia diplomas they will be able to hire one the next minute after they fired you.

History always repeats itself. Look at what happened to Law, and learn from it. It will be not all different in Medicine, now that Wall Street is taking us over, except that we as anesthesiologists (and many other service specialties) will not have any "clients" to follow us if we decide to leave (plus anyway the noncompetes are written in such a way that Tis impossible) . We will be just "paralegals" for all intents and purposes.

Pray for a change after 2016, but I am not optimistic. Things got exponentially faster after Obamacare went live, and the ACA still has parts yet to become active, so undesirable change will only accelerate in the next 5 years. Stop dreaming and plan a life in a completely corporate assembly-lane blue-collar world. Whatever paradise you are practicing in right now will not last long. The forces of Mordor are incredibly strong.

These are savage capitalists who care only about two things: making money and... making more money. They will not let you have a better lifestyle in exchange for lower salaries, as long as they have suckers to work 70-80 hours/week. More hours worked, more profit for the overlords. They care about you as much as you care about the livestock that you eat daily. Don't expect a Google-like atmosphere, more like a Walmart one. Very few greedy people become rich by/while being nice to other people.

And, no, my middle name is not Cassandra. My middle name is Herodotus.

Probably is wishful thinking and most of us will probably end up supervising eventually. I'd like to do my own cases for 5-10 years though if that's possible.

I know that CMS pays ~20 cents on the dollar compared to private insurance and that we will see more and more CMS patients in the future. I have heard that an individual seeing primarily CMS would probably make <$200K and would need a subsidy to maintain a higher income.

I'm not pretending to be an expert on this subject, but it seems that a private group that provides great service (great OR management, covers all the hospital's needs and keeps the surgeons happy) and doesn't take a subsidy would be able to continue to practice in an MD/DO model for another decade or so unless private insurance dies out before then.

Are ACT groups any more efficient than an MD/DO group? The private groups I am familiar with seem to run very efficiently and without any "cost" to the hospital. If you're not taking a subsidy, what cost is there that the bean counters would worry about? With that said, one I the groups I am talking to might consider taking a small subsidy now that level 1& 2 trauma centers require an anesthesiologist to be "promptly available for emergency cases and airways" which translates into 24hr in house calls for anesthesiologists. But currently they are independent, they don't answer to any hospital accountants as there isn't a subsidy involved. I suppose an AMC could come in and try to compete and pay the hospital a fee for allowing them to practice there, but why would a hospital do that if the current group is well run, efficient, provides all the necessary services (even at a loss in some cases) and keeps the surgeons happy?

Of course this model isn't viable in areas with a poor payer mix, which may eventually include entire country in the future. I'm trying to be optimistic in the meantime and I'm planning on the worst possible outcome.

 

[deleted171991]

You should always consider the bean counters inside your own private group, too. If you are not a partner, you are highly vulnerable, especially if they decide to switch to a more profitable ACT model, or sell out to an AMC.

 

[kazuma]

The academic surgeons are usually the worst. There is a reason they are academic: they would not survive elsewhere, and their pompous titles attract patients who would never look at them in private practice.

Once you get out in PP and see a good private surgeon, you will be the one feeling slow (as a fresh graduate). This is also why anesthesiologists who work with good private surgeons tend to run circles around people working with academic ones. And this is why one has to work solo for the first 3-5 years post-graduation, preferably in a private setting.

When we pair some purely academic people solo with our private surgeons, we almost always hear back negative things, either from the surgeon or the anesthesiologist.

Yeah, it's frustrating. My first anesthesia rotations and all of my surgery rotations in my training have been at private hospitals. My colleague was told to slow down once by an attending, "hard work is only rewarded with more hard work!" he says. Those of us that are going into PP try to hustle so it won't be as big of a shock when we start practicing. I usually keep my turnover times around 10 min or less and I always try to have the tube out as I'm taking down the drapes if not before while they are placing the dressings. But I'm sure it will still feel slow when I'm working with surgeons who do lap chole's in 10 minutes.

 

[deleted171991]

My colleague was told to slow down once by an attending, "hard work is only rewarded with more hard work!" he says.

100% true in a corporate environment.

I have always wondered why nurses work so slowly in a shift environment. That's the explanation. It's human psychology. One should give employees a certain amount of pay for a certain amount of work and, when that work is done, they should be able to go home.

One of my favorite cases about the power of incentives is the Federal Express case. The heart and soul of the integrity of the system is that all the packages have to be shifted rapidly in one central location each night. And the system has no integrity if the whole shift can’t be done fast. And Federal Express had one hell of a time getting the thing to work. And they tried moral suasion, they tried everything in the world, and finally somebody got the happy thought that they were paying the night shift by the hour, and that maybe if they paid them by the shift, the system would work better. And lo and behold, that solution worked .

http://www.joshuakennon.com/the-psychology-of-human-misjudgment-by-charlie-munger/

 

[deleted171991]

I usually keep my turnover times around 10 min or less.

That will not happen when you are an attending, unless you deal with ASA 1/2 patients. I would guess that you are not the one preop-ing the patients.

Or maybe we have a different definition for turnover time (the time between leaving the OR with one case and taking the next patient back). That's what the hospital bean counters measure. Not the time between anesthesia end (in the PACU) and the next anesthesia start.

 

[kazuma]

You should always consider the bean counters inside your own private group, too. If you are not a partner, you are highly vulnerable, especially if they decide to switch to a more profitable ACT model, or sell out to an AMC.

Definitely. Fortunately the groups I'm talking to have 1 or 2 year partnership tracks, some make you an equity partner day one but have a 1-2 year period that protects the group in case the new partner turns out to be a complete DB. But money talks.

Are ACT models really that much more profitable? Seems like a lot more headaches than it's worth.

 

[deleted171991]

Definitely. Fortunately the groups I'm talking to have 1 or 2 year partnership tracks, some make you an equity partner day one but have a 1-2 year period that protects the group in case the new partner turns out to be a complete DB. But money talks.

Are ACT models really that much more profitable? Seems like a lot more headaches than Tis worth.

Let's suppose that a group hires CRNAs, for half an anesthesiologist's salary.

In a 3:1 medical direction setting, the group would save 0.5 anesthesiologist salaries for every 3 rooms = 0.166 x salary/room. In a 4:1 setting, the savings would be 0.25 x salary/room. Huge incentive for ACT in a group with few partners and many employees.

 

[kazuma]

That will not happen when you are an attending, unless you deal with ASA 1/2 patients. I would guess that you are not the one preop-ing the patients.

Or maybe we have a different definition for turnover time (the time between leaving the OR with one case and taking the next patient back). That's what the hospital bean counters measure. Not the time between anesthesia end (in the PACU) and the next anesthesia start.

My attendings almost never pre-op patients. Most of our patients are phone screened ahead of time and many of the ASA3/4's go to the pre-op clinic for big cases. But that is a luxury I won't have in PP, with the exception of one group I interviewed with.

 

[deleted171991]

My fastest personal turnover times are under 10 minutes, and that includes 4-5 minutes for getting the patient to PACU, giving report, wasting drugs and getting new ones, going to the nearby admitting area, and 3-5 minutes for preop-ing and consenting a previously looked up average ASA 1-3 patient. (ASA 4 or difficult patients will take longer.)

Then I grab a coffee or water for 10-15 minutes, till my room is ready.

 

[Random Anesthesiologist]

My fastest turnovers are 9-10 minutes, and that includes 4-5 minutes for getting the patient to PACU, giving report and going to the nearby admitting area, and 4-5 minutes for preop-ing and consenting a previously looked up average ASA 1-3 patient. ASA 4 or difficult patients will take longer.

I can't remember if you are in PP or not. Do you have access to prepare drugs for the next case?

The biggest hiccup in my turnover time is that we are only allowed one narc "pack" per person, and have to switch out each time at pharmacy. Even if we take extra to draw up for the next case, we still spend 3-5 mins walking back and forth to pharmacy (depending on what room you're in and if they left for a minute).

I usually have all of my equipment ready to go and a preop note skeleton ready. Just having to deal with pharmacy every time is a pain, especially if I'm doing a TIVA.

 

[IkeBoy18]

what abt a peds cardiac fellowship post peds fellowship? will 2 extra yrs of slave labor keep ones demand/salary higher than avg in the future?

 

[Sirach38]

what abt a peds cardiac fellowship post peds fellowship? will 2 extra yrs of slave labor keep ones demand/salary higher than avg in the future?

Yes. From previous threads it appears that CRNAs won't be touching high risk peds anytime soon. But I may be wrong...anyone who actually knows what they are talking about care to chime in? Lol

 

[deleted171991]

I can't remember if you are in PP or not. Do you have access to prepare drugs for the next case?

The biggest hiccup in my turnover time is that we are only allowed one narc "pack" per person, and have to switch out each time at pharmacy. Even if we take extra to draw up for the next case, we still spend 3-5 mins walking back and forth to pharmacy (depending on what room you're in and if they left for a minute).

I usually have all of my equipment ready to go and a preop note skeleton ready. Just having to deal with pharmacy every time is a pain, especially if I'm doing a TIVA.

I get my drugs from a Pyxis machine for every patient separately, and waste them at the Pyxis with a nurse.

 

[deleted171991]

what abt a peds cardiac fellowship post peds fellowship? will 2 extra yrs of slave labor keep ones demand/salary higher than avg in the future?

Probably yes, but only as long as not many peds anethesiologists will do a peds cardiac fellowship. When/if peds anesthesia starts going sour (no CRNAs in peds is wishful thinking), guess what will happen to the number of peds cardiac people, while the number of cases will remain constant?

 

[Physician Mom]

With a technically so simple surgery as cataract, it's not at all surprising that the bean counters can have their choice of surgeons.

I strongly advise students to read about Warren Buffett's "moat" concept, and to choose a specialty with a strong moat (high barrier of entry).

Technically simple? You obviously are not an ophthalmologist.

 

[Random Anesthesiologist]

I get my drugs from a Pyxis machine for every patient separately, and waste them at the Pyxis with a nurse.

There are rumors we will get a med Pyxis

 

[deleted171991]

No, I have only watched a few hundreds of them. Like most medical procedures, except for some complicated cases, it probably could be taught to almost anyone. Just like an ophthalmologist could be taught how to intubate with a videolaryngoscope. It's not brain surgery.

It probably requires steady hands, good hand-eye coordination, and good knowledge of local anatomy, but I don't really see other big challenges. No offense.

 

[bonedrone14]

Sorry no one has answered your question....people on forums tend to do that - answer with what they want to talk about and ignore your question.

Anyway, from my perspective.

Anesthesia - how much time in the OR? At our hospital, there is no supervision of CRNA's but supervision of students (med students, interns, residents, srna's) - but a non-fellowshiped trained anesthesiologist spends probably 0.85 FTE in the OR. Surgeons only do lines in the unit - they never do them in the OR. You will do all the lines on your patients. I think this is pretty standard at MOST hospitals. Very little time is spent out of the OR managing issues. However, when I am on the acute pain service, we manage floor patients and do blocks. No time is spent in the OR. However, you say you don't want to be in the OR all day, but it is actually one of the best places to be in the hospital. For one, you have a chair you can sit in most of the time. Two, the people in the OR are usually great fun and you basically get paid to shoot the shizzle with the surgeons (if they are cool), the cute nurses, or the funny murse. Or if you don't want to talk, play craps on your iphone. When I as an MS3, I didn't like the OR either. I think it is just a manner of being unfamiliar in a strange environment - but that changes once you spend time there. Finally, on the OB labor deck, you will do a day of placing epidurals and sometimes going to the OR to do c/sections.

Absolutely I think loving physiology is a great reason to do anesthesia. It is incredibly fun. As others have said, not very many other medicine jobs are likely to be as enjoyable. That is the main reason I pursued anesthesia - and I have not been dissappointed.

HOWEVER - if you can, do radiation oncology. Seriously. What a freakin' cool job. Finally, you could still quite, go to dental school, and finish sooner than you would now, and make a lot more money and not deal with many of the issues people have discussed on this thread.

Thanks for your insight! I think this thread has really shown me that I could actually be happy in a lot of fields and I need to investigate as much as I can the rest of third year.

 

[pgg]

No, I have only watched a few hundreds of them. Like most medical procedures, except for some complicated cases, it probably could be taught to almost anyone. Just like an ophthalmologist could be taught how to intubate with a videolaryngoscope. It's not brain surgery.

It probably requires steady hands, good hand-eye coordination, and good knowledge of local anatomy, but I don't really see other big challenges. No offense.

I'm not sure what point you're trying to make here. OK, so maybe a cataract is a monkey skill that can be mechanically picked up by anyone, like intubating an airway. But that's not what makes medicine hard or specialized doctors important.

Knowing when to do the surgery vs other treatment, the risks/benefits as they relate to a specific patient and that patient's comorbidities, avoiding and managing complications, how to adjust the approach mid-procedure if something is a bit off. Those are bigger challenges.

 

[Physician Mom]

No, I have only watched a few hundreds of them. Like most medical procedures, except for some complicated cases, it probably could be taught to almost anyone. Just like an ophthalmologist could be taught how to intubate with a videolaryngoscope. It's not brain surgery.

It probably requires steady hands, good hand-eye coordination, and good knowledge of local anatomy, but I don't really see other big challenges. No offense.

No offense taken, but out of every group of residents I see coming through I see at least one that cannot master the techniques necessary and goes on to do peds ophtho, medical glaucoma, medical retina etc. for that specific reason.

 

[Sketcha]

With a technically so simple surgery as cataract, it's not at all surprising that the bean counters can have their choice of surgeons.

I strongly advise students to read about Warren Buffett's "moat" concept, and to choose a specialty with a strong moat (high barrier of entry).

Which specialties would you promote as having a high barrier of entry?

 

[BLADEMDA]

As Medicaid Rolls Swell, Cuts in Payments to Doctors Threaten Access to Care

http://www.nytimes.com/2014/12/28/us/obamacare-medicaid-fee-increases-expiring.html

Medicaid is a Death Sentence to Anesthesiology as you now know it.

 

[Carbocation1]

What other non-surgical specialty options are there that is recommended for medical students? Doing 3 years of chasing lab values, social work, and paperwork in IM before having a shot at cards/gi/onc doesn't appeal to me at this point. Besides, cards has a terrible lifestyle, GI will inevitably get when slashed scope compensation gets cut, and onc I believe has already gotten hit. Neurology/Rads/Path/Primary care? No thanks. Pmr is decent, but anatomy is not my favorite subject (this is why I don't want to do surgery). Don't like dermatology. I don't see myself doing anything else but gas - love physio/pharm, being vigilant, doing non-invasive procedures, and intense pt encounters.

 

[Sirach38]

What other non-surgical specialty options are there that is recommended for medical students? Doing 3 years of chasing lab values, social work, and paperwork in IM before having a shot at cards/gi/onc doesn't appeal to me at this point. Besides, cards has a terrible lifestyle, GI will inevitably get when slashed scope compensation gets cut, and onc I believe has already gotten hit. Neurology/Rads/Path/Primary care? No thanks. Pmr is decent, but anatomy is not my favorite subject (this is why I don't want to do surgery). Don't like dermatology. I don't see myself doing anything else but gas - love physio/pharm, being vigilant, doing non-invasive procedures, and intense pt encounters.

If you love gas, do gas. But, don't do it for any other reason because lifestyle, salary, etc. will likely be very different in the future and not in a good way. I have spent many hours reading this forum and this is seems to be the bottom line. (Maybe this is the bottom line for any specialty choice)

 

[Carbocation1]

If you love gas, do gas. But, don't do it for any other reason because lifestyle, salary, etc. will likely be very different in the future and not in a good way. I have spent many hours reading this forum and this is seems to be the bottom line. (Maybe this is the bottom line for any specialty choice)

I agree.

So are you set on gas? What other specialties are you considering?

 

[IlDestriero]

IR. That's where it's at.

 

[Carbocation1]

IR. That's where it's at.

IR sounds nice but I worry about career longevity - wearing a 15 lb lead suit for 10 hrs/day and being exposed to radiation worries me.

 

[IkeBoy18]

IR. That's where it's at.

oh man... i have the inside track to IR.. i could always switch.. but.. really......i just.. idk..

 

[Sirach38]

IR. That's where it's at.

Not so much.

 

[Sirach38]

I agree.

So are you set on gas? What other specialties are you considering?

I am set on gas (with a likely CCM afterwards). Before deciding on gas I was considering general surgery, vascular integrated, IR, EM, IM, and urology. In the end, I went with my heart. A wise man once told me, "Live with your heart and you'll never regret it." Hope he was right

 

[BLADEMDA]

I am set on gas

Now that you know the problems this specialty faces going forward I hope you have a plan for your career. Fellowship? Work hard and stand out? These days it isn't enough to finish an Anesthesia Residency, you must excel at it.

 

[Postictal Raiden]

IR. That's where it's at.

Isn't their job market is supersaturated and their salaries are in a free fall? That's what I have been reading on their forum.

 

[Sirach38]

Now that you know the problems this specialty faces going forward I hope you have a plan for your career. Fellowship? Work hard and stand out? These days it isn't enough to finish an Anesthesia Residency, you must excel at it.

I plan on doing a CCM fellowship and if I can come up with the energy, a cardiac fellowship as well. I will be going into gas because I love it so working hard and standing out shouldn't be a problem. When you do what you love, it's not hard to stand out.

 

[Sirach38]

Yes that is what many IR folks are saying...plus, going through all the diagnostic radiology to get to IR, yuck!

 

[IkeBoy18]

Yes that is what many IR folks are saying...plus, going through all the diagnostic radiology to get to IR, yuck!

this is my issue.. i know theres the direct pathway, but soo much dr.. im not interested in that as much