What's it like to be a CRNA? Why do they get paid a lot?

[TooMuchPressure]

I know this is the wrong forum but I can't find a nursing section. As of now I'm pre-med but I am curious if there are any CRNA's out there. If there a sub section were this post belongs can someone move it there?

So everywhere I read the way to become a CRNA is to become a nurse, get ICU experience (1-2 years+), apply to the program(with good grades of course). How competitive is it really? Also, why do they get paid a lot, almost as much as primary care physicians? I'm a bit ignorant on this subject matter so enlighten me.

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[shaggybill]

The Student Doctor Network forum is intended for discussions pertaining to medicine and those pursuing it. Please find an appropriate nursing forum to help you with questions regarding that profession. Closing thread.



Just kidding. I'm not a moderator.

 

[Mr.Zero]

You can try the forums on allnurses.

 

[DocJL]

From talking to a couple of them, it is EXTREMELY competitive.

Not that many slots available, and as they can make 3 times more than an average RN, you can imagine how many people would be vying for those slots.

Pay is commensurate with the responsiblity.

Essentially doing the same job as an anesthesiologist, although I would imagine that they would be doing the more straightforward cases that are not challenging to manage, from a medical standpoint (I had a rotator cuff repair several years ago, and it was a military trained CRNA that did the anesthesia for me - I assume most of his cases were like me, relatively young and very healthy).


I would surmise that going into nursing planning to become a CRNA would be even chancier than entering dental school planning to be an orthodontist or oral surgeon, mathematically speaking.

 

[jqueb29]

Essentially doing the same job as an anesthesiologist

No

 

[medic86]

No

Eh. It kind of is.

They handle the induction and manage the airway of patients in surgical cases. Kind of like what anesthesiologists do when they're in the OR.

 

[WholeLottaGame7]

You can try the forums on allnurses.

Or www.nurse-anesthesia.org

 

[ridethecliche]

I've watched a chordoma resection. I'm basically an ortho oncologist.

 

[medic86]

I changed my own oil once, so I'm basically a certified mechanic.

That's not a good analogy.

It's obvious that their level of education and credentials are profoundly different. This does not change the fact that their roles in the OR are essentially the same. Your apparent disdain for CRNAs does not make this any less true.

 

[URMD]

That's not a good analogy.

It's obvious that their level of education and credentials are profoundly different. This does not change the fact that their roles in the OR are essentially the same. Your apparent disdain for CRNAs does not make this any less true.

I think he's talking more about how you agreed that a CRNA is basically an anethesiologist.
You see the difference between that statement and "they have similar roles in the OR?"

By @Tired changing is own oil, he is performing the same role as a mechanic. But that does not make him "basically a mechanic".

 

[medic86]

The only disdain I expressed was towards your ignorance. I'm guessing you've never been in an OR with a complex case, or when things go bad. Or maybe you've never been in an OR at all? Either way, after you see that once, you'll never make a statement like that again.

My ignorance? And you go and show your ignorance about what I've experienced in my life. That's ironic.

I've been in the OR during plenty of surgical cases - some complicated, and some where things have gone wrong.

Resorting to ad hominem because 1) you're butthurt, and 2) you assume I'm an average pre-med who hasn't set foot in a hospital. Good job.

I think he's talking more about how you agreed that a CRNA is basically an anethesiologist.
You see the difference between that statement and "they have similar roles in the OR?"

By @Tired changing is own oil, he is performing the same role as a mechanic. But that does not make him "basically a mechanic".

I did not. Nice projection, though.

 

[URMD]

Essentially doing the same job as an anesthesiologist

No

Eh. It kind of is.

They handle the induction and manage the airway of patients in surgical cases. Kind of like what anesthesiologists do when they're in the OR.

True, you didn't agree that they're basically an anesthesiologist. My bad

 

[Ismet]

The only disdain I expressed was towards your ignorance. I'm guessing you've never been in an OR with a complex case, or when things go bad. Or maybe you've never been in an OR at all? Either way, after you see that once, you'll never make a statement like that again.

Granted my only experience is my surgery and anesthesiology clerkship, but from observing and working with anesthesiologists, anesthesiology residents, and CRNAs, when there's a complex case or when things go bad, the same thing happened regardless of if the person in charge of the airway was a CRNA or a resident. The attending was there, helping out/giving advice/ready to take over/taking over if necessary.

Of course the CRNA doesn't have the autonomy, scope, or knowledge base of an anesthesiologist. But for the majority of the routine cases I was involved with, the CRNAs ran the show and the attending was called in to be present when it was time to wake up/extubate. Not saying that CRNA = anesthesiologist, but to compare an experienced CRNA to someone who has changed oil a couple times is a little unfair, no?

 

[medic86]

True, you didn't agree that they're basically an anesthesiologist. My bad

I agreed that in the OR they are essentially doing the same job as an anesthesiologist. This is not the same thing as saying "they're basically anesthesiologists".

 

[Spinach Dip]

Well that thread went downhill in record speed.

 

[medic86]

No ad hominem, it's usually worthwhile to tell people when they don't know what they're talking about, even if it hurts their feelings. And no butthurt. I'm from surgery, so need for me to defend another specialty.

Maybe you've "seen" cases, but you evidently didn't know what was going on. CRNAs only "basically do the same thing as an anesthesiologist in the OR" if you view anesthesia as putting in a tube and turning on the gas.

Hopefully you limit these kinds of statements to the internet. With education and experience comes knowledge. In the interim, you should try to sound less foolish.

There is no difference between a CRNA placing a tube and turning on the gas and an anesthesiologist placing a tube and turning on the gas. The MD behind the name doesn't magically make this process different.

I'm going to assume our experiences are quite different - and I'm going to assume you're going through your residency program at a decently-sized hospital that has decent resources (i.e., plenty of anesthesiologists, residents, and CRNAs available). At the hospital I worked at, there was only one anesthesiologist on staff, with the rest of the anesthesia department being composed of CRNAs. Those CRNAs even handled complex cases in their entirety. When things go wrong during a case, they don't have an anesthesiologist around to take over (i.e. at night during obstetric cases).

This in no way reflects my opinion on CRNA vs. anesthesiology. This is just the way it is, based on my experience.

I'm not sure how this makes me a fool. Thanks for the education, though.

 

[Wordead]

There is no difference between a CRNA placing a tube and turning on the gas and an anesthesiologist placing a tube and turning on the gas. The MD behind the name doesn't magically make this process different.

I'm going to assume our experiences are quite different - and I'm going to assume you're going through your residency program at a decently-sized hospital that has decent resources (i.e., plenty of anesthesiologists, residents, and CRNAs available). At the hospital I worked at, there was only one anesthesiologist on staff, with the rest of the anesthesia department being composed of CRNAs. Those CRNAs even handled complex cases in their entirety. When things go wrong during a case, they don't have an anesthesiologist around to take over (i.e. at night during obstetric cases).

This in no way reflects my opinion on CRNA vs. anesthesiology. This is just the way it is, based on my experience.

I'm not sure how this makes me a fool. Thanks for the education, though.

It seems that way because all you see is someone turning knobs and putting in a tube and you have 0 idea what anesthesiology even is.

 

[allantois]

At my hospital (where I've shadowed in the OR), the majority of anesthesia is handled by AAs (in fact I don't think we have CRNAs).

And we are by no means in a rural area with a lack of anesthesiologists!

You guys should all stop arguing with each other, and better think on how to convince hospital administrators why they shouldn't rely on CRNAs or AAs for the majority of cases. And no, emotional responses won't do it for anyone. If we are to keep our job, it is our duty to educate the public and each other on what we do and why we should be paid for it.

 

[medic86]

It seems that way because all you see is someone turning knobs and putting in a tube and you have 0 idea what anesthesiology even is.

Yeah, okay.

Even if this were true, how does refute any assertion I made in this thread? Roger. Got it.

 

[TooMuchPressure]

Well this thread escalated quickly...

 

[Spinach Dip]

It seems that way because all you see is someone turning knobs and putting in a tube and you have 0 idea what anesthesiology even is.

Perhaps instead of cockily implying there is a difference, you could explain what that difference is?

 

[Wordead]

Yeah, okay.

Even if this were true, how does refute any assertion I made in this thread? Roger. Got it.

You said:
"There is no difference between a CRNA placing a tube and turning on the gas and an anesthesiologist placing a tube and turning on the gas. The MD behind the name doesn't magically make this process different."

I said you don't even understand the tube or the gas and what factors can change. So yeah, it completely refutes the "There is no difference" part.

But I mean, what do I know. I've only just finished a month of anesthesia and am going into surgery. Tired's probably just a dumb surgeon too and doesn't know what he's talking about either.

 

[medic86]

You said:
"There is no difference between a CRNA placing a tube and turning on the gas and an anesthesiologist placing a tube and turning on the gas. The MD behind the name doesn't magically make this process different."

I said you don't even understand the tube or the gas and what factors can change. So yeah, it completely refutes the "There is no difference" part.

But I mean, what do I know. I've only just finished a month of anesthesia and am going into surgery. Tired's probably just a dumb surgeon too and doesn't know what he's talking about either.

Um. Did you even make a point?

You refuted nothing. Whether I individually understand the intricacies of management of a patient under anesthesia has no bearing on the fact that an intubation is an intubation, induction is induction, and management of the patient during the case is the same for a CRNA and an anesthesiologist.

Congrats on finishing your 1 month anesthesia rotation, guy. You're an expert now.

 

[Wordead]

Um. Did you even make a point?

You refuted nothing. Whether I individually understand the intricacies of management of a patient under anesthesia has no bearing on the fact that an intubation is an intubation, induction is induction, and management of the patient during the case is the same for a CRNA and an anesthesiologist.

Congrats on finishing your 1 month anesthesia rotation, guy. You're an expert now.

Bold? That was the point. *Shrug* I don't particularly care. Enjoy life, bro. Peace and love.

 

[deleted480308]

There is no difference between a CRNA placing a tube and turning on the gas and an anesthesiologist placing a tube and turning on the gas. The MD behind the name doesn't magically make this process different.

I'm going to assume our experiences are quite different - and I'm going to assume you're going through your residency program at a decently-sized hospital that has decent resources (i.e., plenty of anesthesiologists, residents, and CRNAs available). At the hospital I worked at, there was only one anesthesiologist on staff, with the rest of the anesthesia department being composed of CRNAs. Those CRNAs even handled complex cases in their entirety. When things go wrong during a case, they don't have an anesthesiologist around to take over (i.e. at night during obstetric cases).

This in no way reflects my opinion on CRNA vs. anesthesiology. This is just the way it is, based on my experience.

I'm not sure how this makes me a fool. Thanks for the education, though.

A hospital with complicated anesthesia being performed by unsupervised crnas is evidence of dangerous staffing decisions, not equality of skill.

I can drive a car, jeff gordon can drive a car...I'm an idiot if I assume that my foot on the pedal means I can drive like jeff gordon

 

[Spinach Dip]

I can drive a car, jeff gordon can drive a car...I'm an idiot if I assume that my foot on the pedal means I can drive like jeff gordon

Once again you speak a colorful analogy saying that the two are different, but avoid telling us HOW they are different.

Please enlighten us as to how CRNAs and MDAs practice differently.



(And yes, I used the feared MDA acronym. So sue me.)

 

[NickNaylor]

For CRNAs that have years and years of experience, I might agree that in some ways they're similar to an anesthesiologist. However, for a CRNA a year out from school there's a huge difference. We do an anesthesia block as part of our surgery rotation, and the difference between new CRNA vs. experience CRNA vs. anesthesiologist is wide. It's just like any other mid level provider vs. an MD. The "good" (and I mean slight reassuring though discomforting all at once) news is that in 99% of cases in otherwise healthy people it doesn't make a difference. But make no mistake: CRNAs in my experience are little more than technicians. Pressures dropping? The CRNA will respond with better push some phenyl. An anesthesiologist likely would as well, but the difference is what's going on mentally. End tidal CO2 dropping? Oh noes, probably a kink in the tube, and let's turn up that oxygen while we're add it - that'll fix the numbers. A good anesthesiologist will be coming up with a differential for why the pressure is dropping and will try and figure out what's happening. This is because the breadth and depth of training for an anesthesiologist (and any MD) is an order of magnitude greater in both breadth and depth. The generalist education in medical school and the overall approach of training under the medical model assists in that. The CRNA will likely continue to push phenyl or turn up the oxygen or whatever the first step in response to a problem is to keep the numbers on the screen acceptable. The differences begin once you start having to go to plan B and plan C. I've seen this difference in approach many, many times. Again, for 99% of people that are otherwise healthy and in a "straightforward" case it doesn't matter. The problems begin when you arrive at a 1% case that isn't straightforward. That's where the real danger lies. Most CRNAs recognize their limits, but I've seen a few that are reluctant to call for back up because "they can handle it" and that's what can really result in danger to someone's life.

 

[Ismet]

For CRNAs that have years and years of experience, I might agree that in some ways they're similar to an anesthesiologist. However, for a CRNA a year out from school there's a huge difference. We do an anesthesia block as part of our surgery rotation, and the difference between new CRNA vs. experience CRNA vs. anesthesiologist is wide. It's just like any other mid level provider vs. an MD. The "good" (and I mean slight reassuring though discomforting all at once) news is that in 99% of cases in otherwise healthy people it doesn't make a difference. But make no mistake: CRNAs in my experience are little more than technicians. Pressures dropping? The CRNA will respond with better push some phenyl. An anesthesiologist likely would as well, but the difference is what's going on mentally. End tidal CO2 dropping? Oh noes, probably a kink in the tube, and let's turn up that oxygen while we're add it - that'll fix the numbers. A good anesthesiologist will be coming up with a differential for why the pressure is dropping and will try and figure out what's happening. This is because the breadth and depth of training for an anesthesiologist (and any MD) is an order of magnitude greater in both breadth and depth. The generalist education in medical school and the overall approach of training under the medical model assists in that. The CRNA will likely continue to push phenyl or turn up the oxygen or whatever the first step in response to a problem is to keep the numbers on the screen acceptable. The differences begin once you start having to go to plan B and plan C. I've seen this difference in approach many, many times. Again, for 99% of people that are otherwise healthy and in a "straightforward" case it doesn't matter. The problems begin when you arrive at a 1% case that isn't straightforward. That's where the real danger lies. Most CRNAs recognize their limits, but I've seen a few that are reluctant to call for back up because "they can handle it" and that's what can really result in danger to someone's life.

Of course there's a big difference between a new CRNA and one who has been working for a decade or more. There's a big difference between a PGY2 and PGY4. A difference between a junior attending and one on the verge of retirement. But you hit the nail on the head with realizing their limits. Everyone, whether CRNA or resident or attending, needs to check their ego and ask for help when they need it.

 

[Winged Scapula]

Please get this thread back on topic or it will be closed (i'm not going to get into the cRNA versus anesthesiologist argument except to say there's a reason I refuse to work with the former and it's a very good one, speaking from more than one bad experience).

 

[Psai]

Please get this thread back on topic or it will be closed (i'm not going to get into the cRNA versus anesthesiologist argument except to say there's a reason I refuse to work with the former and it's a very good one, speaking from more than one bad experience).

It's not our fault that we have a dentist and a premed telling us about CRNAs
should i go on dentistry.com and tell them how easy it is to fill cavities and how they are basically the same as dental hygienists or premedsrus.com and tell them about how funny it is that they obsess about things that don't matter

 

[DocJL]

It's not our fault that we have a dentist and a premed telling us about CRNAs
should i go on dentistry.com and tell them how easy it is to fill cavities and how they are basically the same as dental hygienists or premedsrus.com and tell them about how funny it is that they obsess about things that don't matter

Try to remember this is a professional forum, and conduct yourself as such.

There is no need to attack me.

I replied, in good faith, to the specific questions posed by the OP, concerning CRNA pay levels, and how competitive it is to become one.

The pay is commensurate with the work they do, and the responsibilities they have in the OR, I was also very clear on the differences in cases they would most likely be handling, due to level of training vs. an anesthesiologist. I have great respect for both professions, and only a very insecure individual would interpret my comments as demeaning to either.

Having a friend who is a CRNA that I met when I did a GPR residency at a naval hospital, and another dentist friend who is married to a CRNA, I do have some insight into these elements of their profession.

I would also hazard that an MD anesthesiologist (and I know several of them also, both as long term patients of mine, and through my children's private school), still makes approximately 3 times what a CRNA makes. Again, this is commensurate with their level of training, expertise, and responsibility.


Neither the OP, nor myself, posted anything which could remotely be construed as trying to incite a flame war over the professions.

 

[TooMuchPressure]

Please get this thread back on topic or it will be closed (i'm not going to get into the cRNA versus anesthesiologist argument except to say there's a reason I refuse to work with the former and it's a very good one, speaking from more than one bad experience).

I apologize for the war that have started I was just looking for some insight. :s

 

[happy887]

I have a lot of friends who are CRNA's. This was my original career goal, but couldn't do it. I can tell you they get paid $200K. With OT 55-60 hours/week you can make 250kish. However, OT is over. At my friends hospital all CRNA's are capped to 40 hours. No OT is allowed. I see CRNA's making less and less as time goes on. After shadowing them multiple times, I could never do it. You're basically at a machine the whole time monitoring vital signs, oxygen levels, etc... There is very little patient interaction. To me it's a pretty boring thing to do. Also, the stress at times is VERY intense. I have a friend that has to take BP medication who is a ONLY when he's working because the stress is so intense.

 

[Neutropix]

I apologize for the war that have started I was just looking for some insight. :s

Don't apologize. You just helped me kill 15 minutes of my day. Now, c'mere *hugs*

 

[DocJL]

I have a lot of friends who are CRNA's. This was my original career goal, but couldn't do it. I can tell you they get paid $200K. With OT 55-60 hours/week you can make 250kish. However, OT is over. At my friends hospital all CRNA's are capped to 40 hours. No OT is allowed. I see CRNA's making less and less as time goes on. After shadowing them multiple times, I could never do it. You're basically at a machine the whole time monitoring vital signs, oxygen levels, etc... There is very little patient interaction. To me it's a pretty boring thing to do. Also, the stress at times is VERY intense. I have a friend that has to take BP medication who is a ONLY when he's working because the stress is so intense.

Great post.

Very informative.

 

[StudyLater]

They can be paid more than PCP's. Probably because they're literally dealing with life and death constantly throughout their work day. I think a more appropriate comparison is that they seem to be around the level of a (probably <= PGY2-3) resident, and, like an anesth. resident, they do need constant support from their supervising anesthesiologist (DO or MD), without which they could not properly function.

I say this because, when shadowing gas, the residents were in a similar position as the CRNAs, working the OR and being supervised by the overseeing anesthesiologist DO/MD. But the main difference I noticed was that the supervising anesthesiologist would spend a lot more time providing advice/education to the residents, versus the CRNAs which were largely left to their own devices. This is to be expected, though.

 

[moisne]

If something goes wrong and CRNA was not working under an anesthesiologist... who gets sued? I'm probably just being naive since someone said CRNA can work independently...

 

[Screwtape]

CRNAs can practice independently in over 20 states currently and with several others in the near future (I know personally they are pushing hard in illinois right now). Yes anesthesiologists' training is much more in depth, but when it comes down to it they are doing the same job, no? I understand CRNAs couldn't/shouldn't be doing the high risk patients but in the OR where there is no anesthesiologist oversight (independent practice states), a CRNA is performing the same duties an anesthesiologist would in the same place/time.

 

[freemontie]

I wish someone moved this to the Anesthesiology sub-forum. Would've been more fun.

 

[WholeLottaGame7]

I wish someone moved this to the Anesthesiology sub-forum. Would've been more fun.

There is not nearly enough vitriol and ad hominem attacks to make it into the Anesthesiology forum. It is pretty entertaining to watch a bunch of non-anesthesiologist/non-CRNAs duke it out, however.

I do appreciate the vote of support from our surgical colleagues, though. Love you guys. Most of you, anyway.

One of the problems with anesthesia is how poorly understood it is (which doesn't keep people from thinking they understand it), even in the field of medicine. Even surgeons, who are in the best position to understand it, typically don't. Some go above and beyond to try to understand, but that is not universally the case.

I hope every anesthetic I do looks boring, because that means I've done a good job taking care of the patient. But that doesn't mean it is. The more I see and do and gain respect for the variability of humans, the more I'm amazed that complications from surgery and anesthesia are as low as they are.

 

[DocJL]

There is not nearly enough vitriol and ad hominem attacks to make it into the Anesthesiology forum. It is pretty entertaining to watch a bunch of non-anesthesiologist/non-CRNAs duke it out, however.

None of which had anything to do with the original questions posed by the OP, nor by my well-intentioned reply.

Folks need to lighten up.

 

[WholeLottaGame7]

None of which had anything to do with the original questions posed by the OP, nor by my well-intentioned reply.

Folks need to lighten up.

No no, I'm saying if they want to be worthy of inclusion into the MD vs CRNA Thread Hall of Fame, they need to step their game up. This is like JV team trash talk.

 

[DocJL]

No no, I'm saying if they want to be worthy of inclusion into the MD vs CRNA Thread Hall of Fame, they need to step their game up. This is like JV team trash talk.

I see where this debate has been alluded to earlier.


I'll have to look this thread up when I am a lot more bored.


A. LOT. MORE. BORED.

 

[SpeedySavior]

I'm a senior in high school and have no real place on this forum.

That being said, I've shadowed a lot of doctors and a few surgeons. But this thread has been a lot better than all that.

 

[SteyrFWB]

The major difference is this:

In the OR, the surgeon is the general, CRNA is a private. Private does what general dictates.

In the OR, the surgeon is the general, anesthesiologist is also a general. So they NEGOTIATE !!

 

[WholeLottaGame7]

FWIW, I hate all of you.

But I hate your nursing overlords more.

So, you know... I guess that makes us best buddies.

Ha, you're welcome to perform any surgery you like without anesthesia. It's how it used to be done back in the day. Now most surgeons I know seem to need paralysis to do a simple I&D.

Kidding, mostly.

Nursing overlords are the worst.

 

[mmag]

The pay of nurse anesthetists is dictated in part by the high level of insurance reimbursement for their services and their political clout. Overall it's not a great gig without the blood sweat and tears of being a physician. As nurses, they get to benefit from the privilege of working set hours with breaks, overtime, and protection from nursing unions. In states where they have to be supervised, the anesthesiologist is still saddled with final responsibility for patient care so if something bad happens, the CRNA can get someone else to bail them out. They generally carry lower malpractice liability so even when they are are sued, the surgeon and hospital gets sued along side and very often as the only physician in the OR the surgeon gets saddled with responsibility for the CRNA as "captain of the ship".
Years ago American anesthesiologists have created this situation because they could make a lot more money supervising multiple CRNA's than being in the OR for just one case/patient at a time. In most developed countries, only physicians can administer anesthesia. Over time, CRNA's have grown more powerful and some speculate will end anesthesiology as a medical practice. In certain areas of the country, it is much easier to find a job as a CRNA than as an anesthesiologist not to mention the downward pressure on physician salaries.
I think that yes being a CRNA is the smart thing to do with high pay and less ultimate patient responsibility. You won't know what you don't know and there's always a physician to back you up. It's just the sad state of affairs in this country that CRNA's make more money than primary care physicians. There are PA's and NP's that make more money than pediatricians and other primary care physicians as well. Ultimately though if you want to have the most training and deepest knowledge set with regard to patient care, you'd want to be an anesthesiologist.
Note: I do not use MDA as I think it's a pejorative term employed by CRNA's to make it seem like a physician is equal to a nurse. Oncology NP's don't refer to oncologists as MDO's. RNFA's (registered nurse first assistant) don't refer to the second surgeon who scrubs into a big complex surgery as MDFA.

 

[NickNaylor]

CRNAs are not going to be the end of anesthesiology any more than mid level providers will be the end of other fields. At worst it will simply push physicians into more of a managerial role while stepping in when necessary if the case is too complex or if things go wrong. There are enough people out there - both patients and physicians - who prefer to work with physicians rather than other folks to keep the field viable.

 

[Doudline]

CRNAs are not going to be the end of anesthesiology any more than mid level providers will be the end of other fields. At worst it will simply push physicians into more of a managerial role while stepping in when necessary if the case is too complex or if things go wrong. There are enough people out there - both patients and physicians - who prefer to work with physicians rather than other folks to keep the field viable.

Physicians being cattered to a managerial role means they will get LESS clinical experience than CRNAs. What objective authority would they have to step in on a tough case, then? The CRNA will likely be more competent to handle it.

 

[NickNaylor]

Physicians being cattered to a managerial role means they will get LESS clinical experience than CRNAs. What objective authority would they have to step in on a tough case, then? The CRNA will likely be more competent to handle it.

Agreed that the CRNA might be more fresh with respect to actual skills, but the difference is in training - both breadth and depth. More than anything, though, it's just a bureaucratic hurdle to satisfy reimbursement. Until hospitals feel comfortable having CRNAs totally on their own with very little to no physician oversight there will almost certainly be physician "managers" at some level if only to say that they're there, regardless of how "good" their skills might be if not practicing much.