Residency Training in Anesthesiology

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We all know that politicians and hospital administrators are ignorant *****s, stupid, and don't give a damn about quality care. They are interested in one thing: cutting costs as much as possible without killing an unacceptable number of patients. In this regard, CRNAs fit their bill. But do you honestly believe they don't already know that anesthesiologists are far more trained than CRNAs? It's not that they don't know this. It's that they don't care. So why force upon the profession more training to widen the training discrepancy, when the existing training discrepancy between anesthesiologists and CRNAs already doesn't matter to the powers that be?

I don't disagree that they only care about $.

Here's the thing, if what you're saying is true then Anesthesia for MDs is already dead.

I think Blade is right, there needs to be a larger and marketable difference between the CRNA and the MD. If the gap remains the same then the trends will remain the same.

What is the solution? To keep the gap the same and to compete for the same patients? I guess I did see that one operative home model where the anesthesiologists basically run an inpatient floor for perioperative patients.

The Perioperative Surgical Home (PSH) Model of Care
The Problem:
Too often, perioperative care plans are variable and fragmented. The surgical-need decision often disconnects patients from their typical medical care. Surgical patients may experience lapses in care, duplication of tests and preventable harm. Costs rise, complications occur, physicians and other health care team members are frustrated, and the patient and family endure a lower-quality experience of care.

The Solution:

ASA recognizes that innovation must occur within the patient’s episode of surgical/procedural care, and a new model of perioperative care must be developed in our patient’s best interests. To address such issues, ASA has committed to the Perioperative Surgical Home (PSH) model of care – A patient-centered, physician-led system of coordinated care striving for better health, better health care and reduced costs of care.

These goals will be met through shared decision-making and seamless continuity of care for the surgical patient, from the decision for surgery through recovery, discharge and beyond. Each patient will receive the right care, at the right place and the right time.

The Role of the Anesthesiologist in the PSH:
Anesthesiologists will need to view becoming perioperative physicians as an expansion of the specialty as we learn to navigate and negotiate in the face of finite, if not decreasing fiscal resources. The PSH model will broaden the anesthesiologist’s scope of practice in order to promote standardization and improve clinical outcomes as we move toward more patient-centered continuity of care throughout the preoperative, intraoperative and postoperative periods.

Visit the Perioperative Surgical Home website for more information on this new model of care.

I guess this is another solution. The trends dictate that MDs need to do something.

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Not doing fellowship has nothing to do with laziness. Some of the best, hardest working, fire-breathing residents just want to get started and get down to business.

In my own large practice, we have many fellowship trained partners who don't do subspecialty practice. We have peds fellows from Hopkins and Boston Children's who do zero peds. Heart fellows who do zero hearts. Critical care fellows who do zero ICU work. And regional fellows who do a lot less regional than non fellowship trained partners. This is the real world.
 
Not doing fellowship has nothing to do with laziness. Some of the best, hardest working, fire-breathing residents just want to get started and get down to business.

In my own large practice, we have many fellowship trained partners who don't do subspecialty practice. We have peds fellows from Hopkins and Boston Children's who do zero peds. Heart fellows who do zero hearts. Critical care fellows who do zero ICU work. And regional fellows who do a lot less regional than non fellowship trained partners. This is the real world.


The real world is changing fast. The PGY-1 needs to be prepared for those changes for the next 30 years. A fellowship makes you more marketable in a field where only 1/3 of job openings offer partnership track.

Don't twist my words about being lazy. My reference was about MS-4 deciding on whether to match into Anesthesiology or not because of the extra year:

Current Track 4 years:

Anesthesiologist= CRNA in many states

_________________________________

5 year track Proposal:

Anesthesia
Critical Care
Pediatric Fellowship

A smart med student would quickly recognize the value of my 5 year track vs the current MD(A)= CRNA pathway
 
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Why not change it to 4 years of Anesthesia+Critical Care, resulting in double board certification, and without a separate internship, the way it's done in European countries? Those guys get certified in both, and they work much less than 70 hours/week during their residencies. In America, we are wasting a bunch of months on worthless stuff during the intern year.
 
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I don't disagree that they only care about $.

Here's the thing, if what you're saying is true then Anesthesia for MDs is already dead.

I think Blade is right, there needs to be a larger and marketable difference between the CRNA and the MD. If the gap remains the same then the trends will remain the same.

What is the solution? To keep the gap the same and to compete for the same patients? I guess I did see that one operative home model where the anesthesiologists basically run an inpatient floor for perioperative patients.



I guess this is another solution. The trends dictate that MDs need to do something.

What you and Blade are proposing is basically morphing the anesthesiologist into another kind of physician, and to eventually cede the ground currently being lost to CRNAs - which is pretty much the entire OR environment. (This proposal of defining anesthesiologist and CRNA territories by "easy vs difficult cases" or "ASA 1's and 2's vs ASA 3's and 4's" is glaringly obtuse, as those kinds of distinctions are already blown up on a daily basis and could never be instituted now).

I agree with you that anesthesiology in its current form will not survive - certainly not with the indifferent, pacifist leadership in every private hospital, academic center, and nationally in the ASA and ABA. But with the proposed changes, perhaps you should also redefine the profession altogether - maybe call the field "operative medicine / critical care" or something along those lines, and seek to make that the new scope.
 
In Europe it's "Anesthesia - Critical Care". The scope is double: OR and ICU.

We must not give up the OR to nurses. We should extend our reach in hospitals, which will make us way more influential than they will ever be.
 
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Why not change it to 4 years of Anesthesia+Critical Care, resulting in double board certification, and without a separate internship, the way it's done in European countries? Those guys get certified in both, and they work much less than 70 hours/week during their residencies. In America, we are wasting a bunch of months on worthless stuff during the intern year.

Anesthesia is 5 years in nearly every other 1st world country. This typically includes more generalist training than we receive here. UK its 9 years post medical school (2 foundation, 2 core, 5 specialty). Now you are correct that this is the only country that doesn't wrap anesthesia and critical care together.
 
Just based on Wikipedia:
Germany - 5 years, but they are also ER-trained (not clear if during those 5 years)
Holland - 5 years, but the last is elective subspecialty
Italy - 4 years
UK - 9 years (I'd rather be shot)
 
Just based on Wikipedia:
Germany - 5 years, but they are also ER-trained (not clear if during those 5 years)
Holland - 5 years, but the last is elective subspecialty
Italy - 4 years
UK - 9 years (I'd rather be shot)

Canada is also 5 years. Most provinces will accept ACGME training as long as you complete the equivalent number of post graduate training years. Blade's proposition is a sound plan that would give newly minted anesthesiologists more options in a rapidly changing health care environment,
 
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(This proposal of defining anesthesiologist and CRNA territories by "easy vs difficult cases" or "ASA 1's and 2's vs ASA 3's and 4's" is glaringly obtuse, as those kinds of distinctions are already blown up on a daily basis and could never be instituted now).

I'm not going to make the argument that this kind of stratification is either desirable (for us) or safe (for patients) ... but it actually can work in practice. Mostly.

The AANA often points to the military as an example of safe independent CRNA practice for all comers. This is at best a half-truth that sometimes applies to small facilities that generally only see ASA 1 and 2 patients in the first place. It's a simple lie where the larger hospitals are concerned, because scheduling is done by an anesthesiologist and there absolutely is deliberate triage of the 3s and 4s to anesthesiologists. In the event that a CRNA has a 3+ patient the policy requires consultation with an anesthesiologist.

I bet we see more of that arrangement in the civilian world in the future too, and I guess it might work. I think it'll work less well than the military system, because civilian-trained CRNAs are very frequently a pale, inept, deer-in-headlights shadow of military-trained CRNAs.
 
A friend of mine in peds residency posted this to her Facebook page. We need a graphic like this for public relations. Ideally with the CRNA breakdown too, to visualize the vast difference.
ImageUploadedBySDN Mobile1399128573.686063.jpg
 
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These things are ok but are also misleading. 1hr MD training >>> 1 hr RN training for clinical judgement and decision making and actually even for monkey skills because A. We're quicker on the uptake, B. Our hours are more intense on average, C. We have better teachers.
 
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A friend of mine in peds residency posted this to her Facebook page. We need a graphic like this for public relations. Ideally with the CRNA breakdown too, to visualize the vast difference.

Surgeons have Grey's Anatomy, ID guys had House... Maybe we should make a TV show to prove our importance to the public... That'll totally work, right? ;)
 
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Surgeons have Grey's Anatomy, ID guys had House... Maybe we should make a TV show to prove our importance to the public... That'll totally work, right? ;)

If so, I hope it's lighthearted like scrubs. They had excellent writers. And for the most part, anesthesiologists have great attitudes. ;)

I realize graphics like this don't tell the whole story as we know it, but the public needs to see something that shows a big gap in knowledge. Including the usmle hoops, board hoops, malpractice hoops, etc. Something like my friend posted is understandable by most people I think (hope).
 
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The ASA recently released a similar comparison on their F-B page. But I can't post it here with my phone.
 
I disagree with you here. The % of Anesthesia Residents doing fellowships is on the rise. Current number is 34% and rising each year. The Specialty shouldn't dumb down because a few lazy individuals don't recognize the value of subspecialty training. The field needs more motivated, intelligent Med Students willing to do the time required to make a difference for the patient.

I wouldn't be concerned one bit if the specialty loses those unwilling to put in the extra year. There will be another who recognizes the value of Fellowship certification.

This is more propaganda. More fellowships does not mean better patient safety.

That's overkill and I don't think Blade has any idea where to draw the line where overkill is. Not even sure the notion registers.

You can administer anesthesia safely and effectively for 95% of cases after a good 4 year training program. I'll be doing everything but neonates next year in private practice (only reason I could not do neonates was because of credentialing requirements) and I feel comfortable with that.
 
This is more propaganda. More fellowships does not mean better patient safety.

That's overkill and I don't think Blade has any idea where to draw the line where overkill is. Not even sure the notion registers.

You can administer anesthesia safely and effectively for 95% of cases after a good 4 year training program. I'll be doing everything but neonates next year in private practice (only reason I could not do neonates was because of credentialing requirements) and I feel comfortable with that.
>99%
 
This is more propaganda. More fellowships does not mean better patient safety.

That's overkill and I don't think Blade has any idea where to draw the line where overkill is. Not even sure the notion registers.

You can administer anesthesia safely and effectively for 95% of cases after a good 4 year training program. I'll be doing everything but neonates next year in private practice (only reason I could not do neonates was because of credentialing requirements) and I feel comfortable with that.


Altering the training program to reflect Canadian and European standards (5 years) makes sense in a changing environment where Anesthesiologists end up as part of an ACO or an employee of a hospital. The 5 years would bring the USA in line with Canada and allow the opportunity to revamp the training to include Critical Care and Subspecialty training. This thread has NOTHING to do with patient safety and a good program prepares one to do most cases after the current 48 months of training.
 
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Getting double board certified right out of residency would be wonderful. It would be great if that could be accomplished in 4 years, though as someone who is already interested in doing a fellowship, adding a 5th doesn't seem that terrible.

On a side note:

Is this what you were talking about?

10259817_843578505656970_25682483271812502_n.png

Is this getting any kind of push other than on a FB page?
 
Altering the training program to reflect Canadian and European standards (5 years) makes sense in a changing environment where Anesthesiologists end up as part of an ACO or an employee of a hospital. The 5 years would bring the USA in line with Canada and allow the opportunity to revamp the training to include Critical Care and Subspecialty training. This thread has NOTHING to do with patient safety and a good program prepares one to do most cases after the current 48 months of training.

Okay, let it be known that your strategy has nothing to do with delivering anesthesia safely which is what residency training is all about. You want residents to spend another year of their lives doing something that probably won't impact patient care.

Not all anesthesia practitioners work at large multi-specialty hospitals. In fact, the minority work there full-time.

Fellowships provide higher specialization, not broader skill sets. Let's not confuse the two. I know some great cardiac guys who could not do an interscalene block if you asked them to and peds guys who run from morbid cardiac patients.

Sorry, unless you can argue that this actually improved patient care, which you cannot even begin to, this is propaganda.
 
Okay, let it be known that your strategy has nothing to do with delivering anesthesia safely which is what residency training is all about. You want residents to spend another year of their lives doing something that probably won't impact patient care.

Not all anesthesia practitioners work at large multi-specialty hospitals. In fact, the minority work there full-time.

Fellowships provide higher specialization, not broader skill sets. Let's not confuse the two. I know some great cardiac guys who could not do an interscalene block if you asked them to and peds guys who run from morbid cardiac patients.

Sorry, unless you can argue that this actually improved patient care, which you cannot even begin to, this is propaganda.


CRNAs deliver anesthesia safely with a broad skill set. They are competent to do most cases which you see out of the current 48 month training program. What sets your skills/credentials apart from the CRNA? My proposals for the 5 and 6 year anesthesiology residency program makes a physician a true Perioperative expert with credentials in anesthesia, critical care and a subspecialty. These advanced board certifications combined with the better training in the 60 month program makes one a better anesthesiologist.

Your argument has the same tone as the AANA which claims equivalency to your current 48 months of training.
 
CRNAs deliver anesthesia safely with a broad skill set. They are competent to do most cases which you see out of the current 48 month training program. What sets your skills/credentials apart from the CRNA? My proposals for the 5 and 6 year anesthesiology residency program makes a physician a true Perioperative expert with credentials in anesthesia, critical care and a subspecialty. These advanced board certifications combined with the better training in the 60 month program makes one a better anesthesiologist.

Your argument has the same tone as the AANA which claims equivalency to your current 48 months of training.

The only problem with this is the length of training. Medical students are cognizant of the training time for residency. They will not be willing to put up with the extra years and accumulate interest debt just to be a "glorified CRNA" in the end, no matter how much extra training you get or skilled you are.

You might as well go into surgery and be the hot shot of the hospital if that is the case.
 
My proposals for the 5 and 6 year anesthesiology residency program makes a physician a true Perioperative expert with credentials in anesthesia, critical care and a subspecialty.

How about this proposal? You let CRNAs practice independently. You also reduce the amount of anesthesia training for general anesthesiologists from 4 years to 3 years like it used to be. Then you let the other subspecialists undergo the training you describe if they want to.

Then everyone is free to do their own cases. Turn 'em loose. Let the chips fall where they may.
 
The only problem with this is the length of training. Medical students are cognizant of the training time for residency. They will not be willing to put up with the extra years and accumulate interest debt just to be a "glorified CRNA" in the end, no matter how much extra training you get or skilled you are.

You might as well go into surgery and be the hot shot of the hospital if that is the case.

well CRNA is like a glorified regular nurse... and Anesthesiologists are like glorified CRNA.. or... like SUPER glorified nurses... cools
 
In Europe it's "Anesthesia - Critical Care". The scope is double: OR and ICU.

We must not give up the OR to nurses. We should extend our reach in hospitals, which will make us way more influential than they will ever be.
Not in every country.
A lot of countries also had four year programs not that long ago but cheap labor is hard to resist. Coming from a 5 year training i don't feel superior to a US trained MD. Our training is university based and not hospital based so we go from one university affiliated hospital to another with different quality of teaching and cases.
If our training was better programmed 4 years would be sufficient, i think if you could fit 6 months of icu in your intern year you would be fine.
 
The only problem with this is the length of training. Medical students are cognizant of the training time for residency. They will not be willing to put up with the extra years and accumulate interest debt just to be a "glorified CRNA" in the end, no matter how much extra training you get or skilled you are.

You might as well go into surgery and be the hot shot of the hospital if that is the case.

Med students are running out of places to match into. There is a physical shortage of residency positions available to all those seeking spots. In other words, build it and they will still come .... In droves.

An Anesthesiologist who is Boarded in critical care and Echo (for example) is a long way from the typical AANA CRNA whose skill set may include Glidescope intubation if you Are lucky.
 
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CRNAs deliver anesthesia safely with a broad skill set. They are competent to do most cases which you see out of the current 48 month training program. What sets your skills/credentials apart from the CRNA? My proposals for the 5 and 6 year anesthesiology residency program makes a physician a true Perioperative expert with credentials in anesthesia, critical care and a subspecialty. These advanced board certifications combined with the better training in the 60 month program makes one a better anesthesiologist.

Your argument has the same tone as the AANA which claims equivalency to your current 48 months of training.

I disagree. I fervently believe that my skill set is much broader than a graduating cRNAs. As for the cRNAs at our institution, I am more flexible and adept at handling a broad array of cases, from regionals and blocks to sick cardiac patients to neonates. Of course you will find specialized hospitals that employ cRNAs who find a niche in a subspecialty, but even then, I can hold serve there and perform a multitude of other types of cases compared to them.

True story: a year ago I was doing a CT/vascular month at an outside institution that employs cRNAs. The vascular surgeon asked for a surgical block for an AVF creation on a sick patient and my attending and their cRNAs were absolutely floored. Not kidding. Their words were along the lines of "we don't do that stuff here".

Anyways, agree to disagree. Specialization does not mean higher sophistication. Focusing on specialization would come at the cost of sacrificing a broader skill set, as highlighted above. We need specialists, but we don't all need to be them.
 
I disagree. I fervently believe that my skill set is much broader than a graduating cRNAs. As for the cRNAs at our institution, I am more flexible and adept at handling a broad array of cases, from regionals and blocks to sick cardiac patients to neonates. Of course you will find specialized hospitals that employ cRNAs who find a niche in a subspecialty, but even then, I can hold serve there and perform a multitude of other types of cases compared to them.

True story: a year ago I was doing a CT/vascular month at an outside institution that employs cRNAs. The vascular surgeon asked for a surgical block for an AVF creation on a sick patient and my attending and their cRNAs were absolutely floored. Not kidding. Their words were along the lines of "we don't do that stuff here".

Anyways, agree to disagree. Specialization does not mean higher sophistication. Focusing on specialization would come at the cost of sacrificing a broader skill set, as highlighted above. We need specialists, but we don't all need to be them.


In a few years most CRNAs will be able to do the Block with the 3-D U/S from GE or Sonosite. I bet the needles glow like flashlights and the nerve bundles show up in an enhanced color. In other words, the technology is advancing at a rapid pace so I wouldn't count on procedural skills to set you apart from the CRNA.

Instead, the Critical Care Certification along with Echo Certification will be the type of skill set which the hospital, patient and surgeon all need when that AV fistula patient goes into fulminant CHF or has a BP of 65/40 post dialysis. Over the past 2-3 years my patient population has slowly progressed from ASA 3 to an ASA 4 minus. The exact type of patient which would benefit from a solid Critical Care Foundation (e.g, Boarded in Critical Care) and a screening TTE by the Echo certified Attending. The Perioperative Physician of the future will leave most of the monkey business to the monkeys.
 
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True story: a year ago I was doing a CT/vascular month at an outside institution that employs cRNAs. The vascular surgeon asked for a surgical block for an AVF creation on a sick patient and my attending and their cRNAs were absolutely floored. Not kidding. Their words were along the lines of "we don't do that stuff here".

Were you embarrassed for them standing there? I would be. In this day and age there is no excuse for this except pure laziness. That attending deserves to be replaced by a smart CRNA.

Pathetic. Some of us are our own worst enemies.
 
Were you embarrassed for them standing there? I would be. In this day and age there is no excuse for this except pure laziness. That attending deserves to be replaced by a smart CRNA.

Pathetic. Some of us are our own worst enemies.
I don't know if he needs to be replaced by a CRNA, but it explains why his group will have no surgical allies when the AMC takes their contract in a few years.
 
Med students are running out of places to match into. There is a physical shortage of residency positions available to all those seeking spots. In other words, build it and they will still come .... In droves.

Wait, that doesn't compute. Or I don't understand your point.

If med students are running out of places to match into, because there's a physical shortage of positions (this is true) ... the solution is to extend residency programs from 4 to 5 years? If there's room for 20 anesthesiology residents at a hospital, that could be 5 each of CA-0 -1 -2 and -3 ... or 4 each of CA-0 -1 -2 -3 and -4. That makes the "running out of places to match" problem worse.

Or, you decide to have 25 residents, 5 of each year. That will dilute the cases by an extra year's worth of people. There aren't extra (good) cases to do - if there were, then there'd already be more than 20 residents at this hypothetical program.
 
Wait, that doesn't compute. Or I don't understand your point.

If med students are running out of places to match into, because there's a physical shortage of positions (this is true) ... the solution is to extend residency programs from 4 to 5 years? If there's room for 20 anesthesiology residents at a hospital, that could be 5 each of CA-0 -1 -2 and -3 ... or 4 each of CA-0 -1 -2 -3 and -4. That makes the "running out of places to match" problem worse.

Or, you decide to have 25 residents, 5 of each year. That will dilute the cases by an extra year's worth of people. There aren't extra (good) cases to do - if there were, then there'd already be more than 20 residents at this hypothetical program.

I think the point is anesthesia will fill even as the outlook for the specialty gets worse because it's better than nothing and with a shortage of residency slots, nothing is a real possibility.
 
Does CC actually open up that many doors for an anesthesiologist? I know a couple guys that do a day or two of CC in the SICU, but this is at a big academic facility where we can fit people like that in. Can CC anesthesiologists find positions outside of teaching hospitals that utilize the CC portion of their training regularly enough for it to be worthwhile?
 
My personal recent experience…..was very difficult to get ICU position. Was even wanting to do 100% ICU with occasional locums anesthesia work. Most ICU groups want Pulm/CC because they want a pulm guy to do consults and clinic. Most anesthesia groups want you in OR. Job after job was this way. Academic and VA were open, but not what I wanted. So I went in a complete opposite direction. Still value my training.
 
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I think the point is anesthesia will fill even as the outlook for the specialty gets worse because it's better than nothing and with a shortage of residency slots, nothing is a real possibility.

Sure, but this is a zero sum game. A hospital can only support so many anesthesiology residents. Extend residency, train fewer anesthesiologists. (Unless you dilute the quality of the training available, but then why are you extending residency in the first place?) I guess training fewer anesthesiologists would eventually be good for wages and supply/demand market forces, dermatology style. Is that the point of the exercise?

Blade wrote "build it they will come" but my source of confusion is that you're not "building" anything by extending residencies - you're removing spots for med students to match into. Of course the residencies will still fill, there are fewer slots. You'd have to cut categorical CA-0 or advanced CA-1 positions in order to have a CA-4 class. (Or build new hospitals or get more federal funding and/or park a resident in the eyeball room every day.)
 
Sure, but this is a zero sum game. A hospital can only support so many anesthesiology residents. Extend residency, train fewer anesthesiologists. (Unless you dilute the quality of the training available, but then why are you extending residency in the first place?) I guess training fewer anesthesiologists would eventually be good for wages and supply/demand market forces, dermatology style. Is that the point of the exercise?

Blade wrote "build it they will come" but my source of confusion is that you're not "building" anything by extending residencies - you're removing spots for med students to match into. Of course the residencies will still fill, there are fewer slots. You'd have to cut categorical CA-0 or advanced CA-1 positions in order to have a CA-4 class. (Or build new hospitals or get more federal funding and/or park a resident in the eyeball room every day.)
If it integrates CC for a fifth year, couldn't you just make the bulk of the added months ICU time? You'd end up with the same number of cases you'd see in a 4 year residency overall but an extra year of ICU time. I'm just some dude though, there might be reasons for this not working that I can't see.
 
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