My Persepective on Fellowships/Academia/Anesthesia

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BLADEMDA

BLADEMDA

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This thread is NOT for debate about CRNAs/Midlevels but rather what you all can do to improve the odds of a long, successful career in Perioperative Medicine.

I say Perioperative Medicine because this field will evolve and is evolving that a Midlevel has the LEGAL RIGHT to do the actual anesthestic solo (currently at 15 states and counting). In addition, CRNA Schools many of which are based in academic medical centers are training Nurses to be the primary provider of the actual anesthetic.

Over time financial pressures and increasing government based health care will force the "stool sitter" to be a midlevel and not a Physician. Of Course, there will always be a niche for Physician provided anesthetic care but that will comprise a smaller and smaller share of the market place.

So, what can the Resident do to prepare for this career in Perioperative Medicine? What can Academia do to help ensure this field survives and its graduates have a job?
 
My next post will address what our Chairs and ASA can do to save this profession. This post is about what you can do to buy some "insurance" for your career. The cost of this insurance is 12 more months of training and some "lost" income upfront.

Tier 1 Fellowships:

1. Pain

2. Critical Care

3. Peds

4. Cardiac with TEE Certification (for now anyway)


Tier 2 Fellowships:

1. Cardiac with Testamur staus only

2. Regional

3. Neuro


Tier 3:

1. OB

2. Ambulatory

3. Advanced Training
 
Cardiac lands in Tier 1 and Tier 2 because most won't become TEE certified. Hence, a motivated individual could do 12 months of Critical Care and sit for the TEE exam allowing Testamur status without completing a Cardiac fellowship.

I would strongly advocate a Cardiac Fellowship is most likely a Tier 2 fellowship because Testamur status is sufficient for 99% of cases and hospitals. Academia should allow Critical Care Fellows to do an additional 3 months of formal training and then become TEE Certified. This 15 month fellowship program makes sense and is the best of both worlds.
 
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As a Perioperative Physician Specialist we need to prove to CEOs, lawyers, politicians, etc. that we have advanced skills and knowledge that midlevels lack in the operating room.

Hence, formal certificates and emphasis on advanced training must be proven to defend against our midlevel adversary.

I propose a complete restructuring of the Anesthesia Training Program from PGY-1 thr PGY-5. At the end of this new perioperative program a graduate would have the following skills/certifications (after passing exams):

1. Anesthesia

2. Critical Care

3. Fellowship training in a subspecialty area


Hence, every graduate would have critical care as part of the mandatory training during PGY1-4. PGY5 would be devoted to a subspecialty area like Pain, Cardiac, Neuro, etc. I would require a PGY-5 year.

Now, future "Zippys" would graduate and burn their Critical Care books. They would not be forced to practice the specialty. But, as future supervisors a formal certificate in critical care as a FOUNDATION for this specialty makes political sense. When the ASA has to battle midlevels over our roles in the O.R. they need a strong basis/foundation. The new mandatory training in this field provides that basis.


Blade
 
BLADEMDA said:
As a Perioperative Physician Specialist we need to prove to CEOs, lawyers, politicians, etc. that we have advanced skills and knowledge that midlevels lack in the operating room.

Hence, formal certificates and emphasis on advanced training must be proven to defend against our midlevel adversary.

I propose a complete restructuring of the Anesthesia Training Program from PGY-1 thr PGY-5. At the end of this new perioperative program a graduate would have the following skills/certifications (after passing exams):

1. Anesthesia

2. Critical Care

3. Fellowship training in a subspecialty area


Hence, every graduate would have critical care as part of the mandatory training during PGY1-4. PGY5 would be devoted to a subspecialty area like Pain, Cardiac, Neuro, etc. I would require a PGY-5 year.

Now, future "Zippys" would graduate and burn their Critical Care books. They would not be forced to practice the specialty. But, as future supervisors a formal certificate in critical care as a FOUNDATION for this specialty makes political sense. When the ASA has to battle midlevels over our roles in the O.R. they need a strong basis/foundation. The new mandatory training in this field provides that basis.


Blade
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Blade,

There is already a huge gap in training between the CRNA and anesthesiologist. Their message is that they provide good outcomes and don't need the extra training. How is MORE training going to help us? And with more training, I can assume that the AANA will just find more ways to confuse the differences between an anesthesiologist with extra training and a CRNA/PhD. Don't get me wrong, I'm strongly considering a pain fellowship, but only because I'm interested in that type of practice. I'm just not sure if more training for all is really the answer to the problem if general anesthesia is what someone is interested in.
 
badgas said:
Blade,

There is already a huge gap in training between the CRNA and anesthesiologist. Their message is that they provide good outcomes and don't need the extra training. How is MORE training going to help us? And with more training, I can assume that the AANA will just find more ways to confuse the differences between an anesthesiologist with extra training and a CRNA/PhD. Don't get me wrong, I'm strongly considering a pain fellowship, but only because I'm interested in that type of practice. I'm just not sure if more training for all is really the answer to the problem if general anesthesia is what someone is interested in.
Click to expand...


I respect your answer but I disagree. This field needs a new shift away from stool sitting and into PERIOPERATIVE MEDICINE. We must defend our presence as Perioperative Specialists ready to save the patient/Grandma from death. Midlevels don't bring formal Critical Care Certification to the O.R. Midlevels don't bring an M.D. to the O.R. Midlevels don't bring superior skills and knowledge to the O.R.

As for the safety issue the data supports the AANA on ASA 1 and 2 patients. But, the data and real world facts just are not there for ASA 3-5. The AANA wants to be a Killing Machine and that must be prevented.

As for those who want to be stool sitters they can enter this field and hope there is NICHE work for them or perhaps, the CRNA DNAP is a better choice for them. The future of this field is NOT sitting on the stool.
 
BLADEMDA said:
I respect your answer but I disagree. This field needs a new shift away from stool sitting and into PERIOPERATIVE MEDICINE. We must defend our presence as Perioperative Specialists ready to save the patient/Grandma from death. Midlevels don't bring formal Critical Care Certification to the O.R. Midlevels don't bring an M.D. to the O.R. Midlevels don't bring superior skills and knowledge to the O.R.

As for the safety issue the data supports the AANA on ASA 1 and 2 patients. But, the data and real world facts just are not there for ASA 3-5. The AANA wants to be a Killing Machine and that must be prevented.

As for those who want to be stool sitters they can enter this field and hope there is NICHE work for them or perhaps, the CRNA DNAP is a better choice for them. The future of this field is NOT sitting on the stool.
Click to expand...

Blade,

The ground that the AANA has gained has been all politics and has nothing to do with a current lack of training on our part. If a shift to perioperative specialists is coming, then fine. However, I don't think that extra training will save the specialty. I also don't think politically that anesthesiologists who desire to be "stool sitters" should just run for the hills without a fight.
 
badgas said:
Blade,

The ground that the AANA has gained has been all politics and has nothing to do with a current lack of training on our part. If a shift to perioperative specialists is coming, then fine. However, I don't think that extra training will save the specialty. I also don't think politically that anesthesiologists who desire to be "stool sitters" should just run for the hills without a fight.
Click to expand...

The problem is that most anesthesiologists don't want to put up the fight. They can't be bothered.
 
ProRealDoc said:
The problem is that most anesthesiologists don't want to put up the fight. They can't be bothered.
Click to expand...

I think it's safe to say that most CRNAs don't want complete independence or to do pain medicine. We need the ASA effectively fight off the AANA.
 
BLADEMDA said:
I respect your answer but I disagree. This field needs a new shift away from stool sitting and into PERIOPERATIVE MEDICINE. We must defend our presence as Perioperative Specialists ready to save the patient/Grandma from death. Midlevels don't bring formal Critical Care Certification to the O.R. Midlevels don't bring an M.D. to the O.R. Midlevels don't bring superior skills and knowledge to the O.R.

As for the safety issue the data supports the AANA on ASA 1 and 2 patients. But, the data and real world facts just are not there for ASA 3-5. The AANA wants to be a Killing Machine and that must be prevented.

As for those who want to be stool sitters they can enter this field and hope there is NICHE work for them or perhaps, the CRNA DNAP is a better choice for them. The future of this field is NOT sitting on the stool.
Click to expand...
I think you are right about this, Blade. It's not just anesthesiology that's evolving like this; all of medicine is. Many surgery patients are healthy enough that they can be taken care of by a midlevel under supervision. But then there will necessarily be fewer supervisory jobs for the same number of anesthesiologists, meaning that not everyone can work in the OR. In contrast, after seeing their first ICU code, no one will doubt the importance of having critical care physicians present in the room at all times. By virtue of it being an ICU, there are no ASA 1 or 2 patients there.

In the same way, my earning a PhD in chemistry instead of stopping at an MS paradoxically made it harder for me to find a pharmaceutical job, not easier. Since PhDs command a higher salary, PhD level positions are often mainly supervisory for BS and MS chemists. Thus, there are many more PhDs than there are positions for all of us, just like what seems to be happening to anesthesiologists in the OR.
 
badgas said:
I think it's safe to say that most CRNAs don't want complete independence or to do pain medicine. We need the ASA effectively fight off the AANA.
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I think my posts need clarification for you. First, I support the ASA and our PACS. I would choose an all out WAR over this issue. However, I am in the minority as Academia has already sold out the "stool sitting" to another Group of providers.

Second, I am makimg my comments with one eye on the past and one on the future. The AANA will win more political victories over the next few years. "Opt-Out" is likely to become the norm and Solo CRNAs, as one on providers, fairly common place. Thus, those who choose to fight for that stool will be paid a stool sitter's wage. CMS (Medicare) pays all stool sitters the same wage today. What about private insurance in 5-10 years (assuming there is private insurance)?

Third, CRNAs will tell you they are happy with the ACT. Well, that is only half true. Many want to function "independently" provided you are there to back them up if needed. In addition, they call you an MDA because you are viewed as an MD "equivalent" of a CRNA. Many CRNAs believe your better training and knowledge can be acquired by a CRNA through on the job training. The AANA's agenda means you are a Physician performing a Nursing level job.

The ASA won't ever fully challenge the AANA agenda. There is too much money at stake in not discrediting the worker bees who make big cash for Academia and Private Practices. Hence, the ASA makes a lot of noise and publishes a lot of rhetoric but there is no substance.

Long term this field's survival depends on producing fewer but better Perioperative Specialists and less stool sitters. Leave the Nursing Level jobs for the midlevels.
 
this is just my opinion - i think that fellowship training in anesthesiology is prudent. i think it will take years to train enough nurses and to have opt-out legislation penetrate the more "civilized" areas (although cali just did it) before we start losing jobs en masse. other variables (healthcare payment, demand for service, etc) are also unpredictable.

job wise, i think the situation will remain adequate for a while.

HOWEVER, i do think we need to step up our game politically. if the vast majority of anesthesiologists do fellowships in specialities that nurses cannot practice independently - TEE, pain, peds, cc, then we as a physician specialty would really be able to claim the provision of additional services that nurses can't provide. unfortunately, at this time if you're not fellowship trained then all you do is ANESTHESIA - and that's also what the nurses think they do.


it's an extra year. and it sucks not to make the double digit monthlies. but, over a life time, it won't matter much, for me.
 
Geez... everytime I browse this forum, I get more and more angry and depressed.

Its like why did I go to medical school again? Why were my parents proud when I held up that diploma?
Oh yeah, so I could be called an MDA (or "anesthesia"), be subjected to scheming recruitment agencies, and lose my job to a nurse after 8-9 years of my life are put on hold for training.

I love Blade as a poster, but I have several problems with his suggestions.

#1) Nurses can play the fellowship game as well...
Aside from CRNAs doing adult hearts here and there, I hear at CHOP there are even nurses who do peds cardiac cases.
Also, we emphasize that we are better at taking care of sick patients, but do we want to be only caring for ASA 3-5 patients in the future?

2) What does a "perioperative doc" do exactly? Will we be critical care physicians or what? If not "stool sitters" meaning doctors who take care of patients in the operating room, then what else do we do? Pain and critical care. They definitely don't need too many "perioperative docs" running around covering the PACU, thats for sure, and the hospital has enough intensivists already.

I think we need a better definition of this role. Its a good idea to emphasize our critical care knowledge and training so that we are seen as more valuable and useful (which we already are, but people don't realize), but I think we need to better define what our roles would be if not in the OR.

Part of the problem is the training during residency. Our scope is already narrowed by default.

Also, part of the problem is that due to the business aspect of things, anesthesiologists are willing to train these CRNAs. CRNAs get a false sense that they can do things themselves, and the government is willing to buy into it to save costs.

I think the best solution is to stop training the CRNAs. It would be drastic, things would be tense at work, I don't even know if it would be feasible man-power-wise... but if anesthesiologists want to survive, don't train the competition. What a crap situation for current residents and fellows... you are worried about your future job security and you come to work everyday seeing your bosses train the competition.
 
Jeff05 said:
this is just my opinion - i think that fellowship training in anesthesiology is prudent. i think it will take years to train enough nurses and to have opt-out legislation penetrate the more "civilized" areas (although cali just did it) before we start losing jobs en masse. other variables (healthcare payment, demand for service, etc) are also unpredictable.

job wise, i think the situation will remain adequate for a while.

HOWEVER, i do think we need to step up our game politically. if the vast majority of anesthesiologists do fellowships in specialities that nurses cannot practice independently - TEE, pain, peds, cc, then we as a physician specialty would really be able to claim the provision of additional services that nurses can't provide. unfortunately, at this time if you're not fellowship trained then all you do is ANESTHESIA - and that's also what the nurses think they do.


it's an extra year. and it sucks not to make the double digit monthlies. but, over a life time, it won't matter much, for me.
Click to expand...


Another nice post Jeff.
 
slunk said:
Geez... everytime I browse this forum, I get more and more angry and depressed.

Its like why did I go to medical school again? Why were my parents proud when I held up that diploma?
Oh yeah, so I could be called an MDA (or "anesthesia"), be subjected to scheming recruitment agencies, and lose my job to a nurse after 8-9 years of my life are put on hold for training.

I love Blade as a poster, but I have several problems with his suggestions.

#1) Nurses can play the fellowship game as well...
Aside from CRNAs doing adult hearts here and there, I hear at CHOP there are even nurses who do peds cardiac cases.
Also, we emphasize that we are better at taking care of sick patients, but do we want to be only caring for ASA 3-5 patients in the future?

2) What does a "perioperative doc" do exactly? Will we be critical care physicians or what? If not "stool sitters" meaning doctors who take care of patients in the operating room, then what else do we do? Pain and critical care. They definitely don't need too many "perioperative docs" running around covering the PACU, thats for sure, and the hospital has enough intensivists already.

I think we need a better definition of this role. Its a good idea to emphasize our critical care knowledge and training so that we are seen as more valuable and useful (which we already are, but people don't realize), but I think we need to better define what our roles would be if not in the OR.

Part of the problem is the training during residency. Our scope is already narrowed by default.

Also, part of the problem is that due to the business aspect of things, anesthesiologists are willing to train these CRNAs. CRNAs get a false sense that they can do things themselves, and the government is willing to buy into it to save costs.

I think the best solution is to stop training the CRNAs. It would be drastic, things would be tense at work, I don't even know if it would be feasible man-power-wise... but if anesthesiologists want to survive, don't train the competition. What a crap situation for current residents and fellows... you are worried about your future job security and you come to work everyday seeing your bosses train the competition.
Click to expand...

Please don't confuse the politics/rhetoric with the actual facts. Leave that for the AANA.

1. Nurses want to make money ASAP. Most won't do one extra day of formal training if not required. They come from an "on the job training" mentality. Why do a fellowship when some Group or Academic center will train you while making $120K? They are willing to do online work as that doesn't interfere with their schedule and income. Thus, unless CRNA fellowships are brief or pay six figures most won't ever do one.

2. Periop Physicians save lives in the O.R. You see midlevels have an A plus propaganda machine working for them. But, the real world reality is that hospitals need someone to put out their fires on a daily basis. How many do we need? At least one MD per 6-7 midlevels. The current system of training and educating a CRNA is poor at best. The "quality" CRNA graduate is a rare commodity.

3. Academia has a moral obligation to NOT train your replacement. CRNAS should be trained by the military and community hospitals only. Large Academic Centers should be training Residents and AAs.

Blade
 
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There are about 37,000 CRNAs in the USA. There are about 35-40,000 Anesthesiologists. There are about 2,000 AAs.

Hence, there are not enough Anesthesiologists available to do the stool sitting even if the ASA were to advocate such a position. Most likely the number of midlevels will continue to rise over the next ten years (AANA data unreliable and biased) while the number of Anesthesiologists declines or remains stable at best.
 
slunk said:
Geez... everytime I browse this forum, I get more and more angry and depressed.

Its like why did I go to medical school again? Why were my parents proud when I held up that diploma?
Oh yeah, so I could be called an MDA (or "anesthesia"), be subjected to scheming recruitment agencies, and lose my job to a nurse after 8-9 years of my life are put on hold for training.

I love Blade as a poster, but I have several problems with his suggestions.

#1) Nurses can play the fellowship game as well...
Aside from CRNAs doing adult hearts here and there, I hear at CHOP there are even nurses who do peds cardiac cases.
Also, we emphasize that we are better at taking care of sick patients, but do we want to be only caring for ASA 3-5 patients in the future?

2) What does a "perioperative doc" do exactly? Will we be critical care physicians or what? If not "stool sitters" meaning doctors who take care of patients in the operating room, then what else do we do? Pain and critical care. They definitely don't need too many "perioperative docs" running around covering the PACU, thats for sure, and the hospital has enough intensivists already.

I think we need a better definition of this role. Its a good idea to emphasize our critical care knowledge and training so that we are seen as more valuable and useful (which we already are, but people don't realize), but I think we need to better define what our roles would be if not in the OR.

Part of the problem is the training during residency. Our scope is already narrowed by default.

Also, part of the problem is that due to the business aspect of things, anesthesiologists are willing to train these CRNAs. CRNAs get a false sense that they can do things themselves, and the government is willing to buy into it to save costs.

I think the best solution is to stop training the CRNAs. It would be drastic, things would be tense at work, I don't even know if it would be feasible man-power-wise... but if anesthesiologists want to survive, don't train the competition. What a crap situation for current residents and fellows... you are worried about your future job security and you come to work everyday seeing your bosses train the competition.
Click to expand...

[FONT=Arial, Helvetica, sans-serif]Currently, intensivists direct the care of only one third of critically ill patients. In recent years, however, the proportion of patients receiving care under the direction of an intensivist has increased dramatically and this trend will likely continue. An upper bound on the demand projections assumes that intensivists direct the care of approximately two thirds of patients in the ICU, while a lower bound assumes that intensivists will continue to direct the care of only a third of critically ill patients. Our analysis supports the findings that demand for intensivists will continue to exceed available supply through the year 2020 if current supply and demand trends continue. .
 
[FONT=Arial, Helvetica, sans-serif]Because critical care is a relatively new and growing specialty, the intensivist workforce is relatively young. Around 2020, the intensivist workforce will likely stabilize as the number of intensivists retiring will approximately equal the number of new intensivists..
[FONT=Arial, Helvetica, sans-serif]The growth and aging of the population alone will increase demand for adult intensivist services by approximately ­38 percent—from 1,900 to 2,600 between—2000 and 2020. This increase represents a lower bound on expected growth in demand and assumes that intensivists continue to treat only a third of critically ill patients. Further, it assumes that supply and demand were in balance in 2000. .
[FONT=Arial, Helvetica, sans-serif]If the proportion of ICU patients whose care is directed by an intensivist were to increase from one third to a more optimal level of two thirds, then intensivist requirements would grow from a need for 3,100 FTE intensivists in 2000 to 4,300 by 2020. This represents a shortage of about 1,200 intensivists in 2000, growing to 1,500 in 2020, or 129 percent above the projected supply. The upper bound on the demand projections reflects the large potential growth in utilization of intensivist services—especially in metropolitan areas. .
[FONT=Arial, Helvetica, sans-serif]Lifestyle issues associated with critical care as it is currently practiced present a barrier to increasing the number of practicing intensivists. Reimbursement for critical care is also perceived by those in the profession as inadequate, making critical care less attractive to newly trained physicians..
[FONT=Arial, Helvetica, sans-serif]Critical care remains an evolving specialty. A significant body of literature indicates that the current supply of practicing intensivists is lower than what is required to care for patients in U.S. ICUs. The evidence indicates that patient outcomes are improved when intensivists are available around-the-clock for patient consultation..
[FONT=Arial, Helvetica, sans-serif]Organizational changes in the way that care is provided to critically ill patients have the potential to improve patient access to cost-effective and quality care—especially in rural areas. One example is the increased use of electronic ICUs where specialist physicians and nurses monitor and help treat critically ill patients in widely scattered hospitals..
 
I would really like to hear your opinions on this. I know that something must have happened in regards to both of you not posting anymore, but we need your valuable advice. Surely you still browse here...right?
 
Quote:
Originally Posted by BLADEMDA
I know the market advertised in that gaswork reference. I know a CRNA earning $300,000 plus in one of those jobs. It involves a lot of hours 60 plus and call avail. most nights. Thus, in order to get to $300,000 you are working a lot and there are no benefits.

That said, a CRNA can earn a W-2 income in a NICE location working 60 hours a week. That CRNA would earn around $250,000 plus benefits while still having some time off (some but not much). Those jobs which offer 24 hour shifts allow a CRNA to do one or two 24 hour shifts per week plus one or two 12 hour shifts. This results in the 60 plus hours needed to earn $250-$290,000 W-2 plus benefits. The benefit package is worth an additional $50,000.

Those type of salaries are real and exist for the upper quartile CRNA.
So, an ICU nurse earning $90,000 per year (this incl. lots of overtime) can TRIPLE his/her income by going to CRNA school for 28 months. Then, he or she can claim "equivalence" to the better educated and more experienced MD Anesthesiologist via the AANA propaganda machine. As one comedian used to say "only in America"!

I REALLY, REALLY, REALLY wish I could post against Blade's post.

Tell you its not true.

BUT IT IS.

Gotta CRNA in my practice, Greg, for whatever non-attractive personal-issue-marriage reasons,

DUDE IS ALWAYS AVAILABLE FOR WHATEVER CALL. OVERNITE. BEEPER ONE. BEEPER TWO. BEEPER THREE. BEEPER FOUR.

Translate the above to Gregs always at the hospital.

But, uhhhhhhhh, said Greg, CRNA, and I'd love to divulge to you what he made last year and what hes on track to make this year....but lets leave it at...

Greg made more last year, and will make more this year, than 98% of our primary care colleagues out there in private practice.

What that means is, if you've been too timid to say it to yourself:

There are CRNAs out there.....NURSES......making MORE than primary care doctors in the community....
__________________
Jet MD, LMFAO
 
If it was up to me, I would convert all residencies to the 5-yr plan Blade outlined and to include ICU, regional and TEE skills. Such training would not be open to non-physicians.

We should continue to train the nurses in droves and make them the primary anesthesia provider in the OR while we concentrate on the physician level tasks and ensure an adequate/oversupply pool of stool sitters. Once our roles are defined as perioperative physicians with adequate skills to back it up, we can move to the consolidation phase.

We then lobby the hell out of CMS and the insurance companies to decrease the anesthesia reimbursement for OR stool sitting (very easy to do) so dramatically that CRNAs end up working for ICU nurse level pay or less; and ensuring increased reimbursement for physician-level tasks.

At the same time, we work on automating many of the stool-sitting tasks to the point their training becomes obsolete effectively making their dreams of dominance a short lived fantasy.

The AA becomes our new wingman and we continue evolving as a medical specialty.
 
2008, 05:56 PM #22 militarymd
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Quote:
Originally Posted by m3unsure
I gather from your multiple posts that you seem anti-MDA and against protecting MDAs.

Are you pro-CRNA, meaning them making anesthesia a nursing specialty?

I'm not anti MDs or Pro-CRNA.

What I am is a realist...and I see that our specialty is changing....because of economics and other reasons.

The days of the MD sitting in a room charting vital signs are probably going to go away...while at the same time, there are many who train to do that...

It's business, and those willing to accept the change and accept that stool sitting and doing ONLY ANESTHESIA is on the way out will be successful.

Those not willing to shift with the tides, will continue to lose their jobs and have to move somewhere else.

The US is a big country...each region is in different phases of change...I'm just calling it like I see it.....I could be wrong, but why hope that I'm wrong...but rather prepare for the possibility that I could be right.
user_offline.gif
 
ProRealDoc said:
If it was up to me, I would convert all residencies to the 5-yr plan Blade outlined and to include ICU, regional and TEE skills. Such training would not be open to non-physicians.

We should continue to train the nurses in droves and make them the primary anesthesia provider in the OR while we concentrate on the physician level tasks and ensure an adequate/oversupply pool of stool sitters. Once our roles are defined as perioperative physicians with adequate skills to back it up, we can move to the consolidation phase.

We then lobby the hell out of CMS and the insurance companies to decrease the anesthesia reimbursement for OR stool sitting (very easy to do) so dramatically that CRNAs end up working for ICU nurse level pay or less; and ensuring increased reimbursement for physician-level tasks.

At the same time, we work on automating many of the stool-sitting tasks to the point their training becomes obsolete effectively making their dreams of dominance a short lived fantasy.

The AA becomes our new wingman and we continue evolving as a medical specialty.
Click to expand...

Great post.👍
 
Interesting.

However, I wonder how long it will be until we as periop physicians start 'teaching' CRNAs. Then they too will want to have the skill sets we do (TEE, regional,etc). I feel like they will try to 'learn' more....You guys know how it is, they want to advance their 'nursing' skills. Some idiot docs out there are going to train them so that they themselves dont have to come in,etc.

Interesting concept and plan though. I also wonder how many med students will be interested in Periop Medicine as opposed to the acuteness of Anesthesiology. It almost sounds as though Periop Medicine will equal ICU medicine, which is not a popular path for many a med student.

Instead of guarding the ship, I wonder if we are abandonning ship only to be pursued by those same sharks in the water.

??? I dont know the answer.
 
Jeff05 said:
i think it will take years to train enough nurses and to have opt-out legislation penetrate the more "civilized" areas (although cali just did it) before we start losing jobs en masse.
Click to expand...

This is one of the biggest fallacies/misunderstandings I see in the debate. Anesthesiologists compete for jobs in a commodity market. Neither surgeons, hospitals or patients have any preference for Dr. A. vs Dr. B. vs. Dr. C. All that has to happen to tank the anes market is to lose just enough jobs that supply exceeds demand. I suspect 5-10% would do the trick. At that point, everyone is scrambling for a job, all the hospital subsidies go away and life sucks.
 
Pilot Doc said:
This is one of the biggest fallacies/misunderstandings I see in the debate. Anesthesiologists compete for jobs in a commodity market. Neither surgeons, hospitals or patients have any preference for Dr. A. vs Dr. B. vs. Dr. C. All that has to happen to tank the anes market is to lose just enough jobs that supply exceeds demand. I suspect 5-10% would do the trick. At that point, everyone is scrambling for a job, all the hospital subsidies go away and life sucks.
Click to expand...

But we are not cars and can't ramp up in just a few months. It takes years if not a decade to change our production numbers.

I encourage the CLOSING of weaker training programs. A decrease of 10-20% in our numbers keep you guys employed for the foreseeable future. But since when does Academia care about you?
 
Did anyone read this month's ASA Newsletter? The newsletter featured an article on Critical Care. While ICU is hard work it does put you in demand at Academic and large community hospitals.

For example, Let's say that 4 of you agree to take a contract at a large community hospital. The hospital wants ICU coverage but currently only has one intensivist from 1981 on Staff. The Anesthesia subsidy is currently $1 mil per year. The old Group of 9 MDs and 14 CRNAs was offered an additional $1 mil to cover the ICU 24/7. They declined the offer because nobody does ICU or wants to do ICU.

Along comes ProReal and 3 of his buddies. He agrees to cover the ICU and gets the Anesthesia and ICU contract for $1.5 mil in subsidy. Proreal hires 4 more ICU/Ansthesia dudes and now has 8 docs covering the O.R. plus ICU 24/7. ProReal is VERY VALUABLE to the Medical Staff and the surgeons. He provides a VALUED service to the hospital besides supervising CRNAs.

Proreal can do the following:

1. One on one anesthesia

2. Supervise CRNAs

3. TEE (testamur status)

4. ICU

5. Bronchoscopy

So, when things get tight in the future do you really only want to have ONE SKILL SET?
 
Why are doctors so insecure about their specialty that you feel you have to "fight" for it.

1) There will ALWAYS be a need for physicians who specialize in the care of the anesthetized patient, No matter what "militant" physicians extenders say or do.

2) There will ALWAYS be a need for physician extenders who anesthetize patients, either independently or under the direction of a physician.

The above statements represent the reality of perioperative care in the 21st century and beyond in the United States.


__________________
X-mmd
 
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02-07-2008, 08:00 PM #165 militarymd
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The future of our specialty lies in ADVANCED training of our physicians...Critical Care Medicine (me),....Pain...peds....NOT sitting on your stool and telling people that you should be paid a "fair" salary, when a nurse can do 95% of what you do.

The future lies in understanding the economics of our healthcare system...less $$ for ALL of us...while MORE and MORE complex work is falls into OUR REALM of responsiblity.

The "gravy" cases that used to pay for our Ferrari's and BMW's WILL become non-physician cases...as is the same for many other specialties...

Sitting there crying foul is not the way to make our specialty stronger.

Making our specialty one of high competition is how we make our specialty stroonger...

I make more than my share of money, but it's because someone, somewhere felt that I added value to their system...as soon as this "value" is not wanted anymore, I can count on a decrease in my pay....OR I will have to take what I bring to the table up another step....

It's business...It's competition....it's the future....

AND i'm glad you're not going to reply anymore.
 
30-2008, 05:55 PM #9 militarymd
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Quote:
Originally Posted by toughlife
But why would we want to leave the decisions that affect anesthesiologists in the hands of the hospital staff? Especially the ones where there are not many anesthesiologists to begin with? You want protections at all levels and, from the decisions made by other medical boards (i.e., wisconsin MB stating anesthesia is the practice of nursing) I would not trust anyone else to decide what is in my best interest or the specialty's.

Your stance only helps to effectively remove any leverage that we may have and completely push hospitals to remove any laws that may require the use of anesthesiologists.

Your position does not make sense unless you want to get rid of anesthesiologists involvement all together.

I would like to:

1) get rid of about 80% of the anesthesiologists out there
2) lenghten training to 5 years MININUM
3) cut number of training slots by 80%
4) improve the quality of anesthesiologists by about 300%...and I'm not talling about monkey sklls
5) 100% anesthesiologist involvement in ALL cases....and if that means MANDATORY stints at rural hospitals....I'll be the first to sign up....I've done my hardship tour in Cuba....I can do it again for my specialty.

Are you or any of you new grads willing to step up to the plate for something like that.

Everyone talks the good talk....but it's really just for themselves...not the specialty.....

You want to fight with CRNA's....go ahead...because you're going to lose in Washington.

It's just turf you're wanting to protect...so that you can maintain your income WITHOUT having to go some place that sucks.....like I did.
 
If you want any more "proof" on how Military MD feels about this issue let me know. He has dozens of posts through the years on SDN.

Blade
 
BLADEMDA said:
[FONT=Arial, Helvetica, sans-serif]Currently, intensivists direct the care of only one third of critically ill patients. In recent years, however, the proportion of patients receiving care under the direction of an intensivist has increased dramatically and this trend will likely continue. An upper bound on the demand projections assumes that intensivists direct the care of approximately two thirds of patients in the ICU, while a lower bound assumes that intensivists will continue to direct the care of only a third of critically ill patients. Our analysis supports the findings that demand for intensivists will continue to exceed available supply through the year 2020 if current supply and demand trends continue. .
Click to expand...

you're right there is a shortage of intensive care docs. What I meant though was that
#1) the ICU docs all have set roles already. Cover the SICU, MICU, etc. I was curious where the role of the perioperative ICU doc comes into play, but I guess you sort of answered it... we would essentially be covering 8 OR's at a time, or providing backup to the independent CRNAs who are manning them.

I don't know if I am misinterpreting, but my question is do we want to be backing up these CRNAs? I thought the whole point of letting them go solo means they sink or swim themselves and get to see what its like to get burnt and regret they wanted independent practice with their measly training.

#2) If everyone who is in anesthesia residency suddenly becomes a FCCM, there definitely will be a huge surplus of critical care doctors.
You said in another post that you would want to decrease the number of residencies and people graduating from them, and this may help prevent a future surplus in perioperative physicians, but what about the argument of strength in numbers? CRNAs continue to be churned out, is it a good idea for us to take the other route? Basically hand over the role of OR provider to them. I'm not sure this is a good idea.

I'm not trying to be critical. I am an anesthesiologist and I want our specialty to survive as well.

As we know, statistics don't mean everything. CRNAs may show studies that they provide equivalent care, but (hopefully) most everyone in the OR knows that this is not the case. I know for a fact, having supervised some as a CA-3 last year at a major academic center. Attending friends of mine echo my sentiment.

Maybe we should do what the opthamologists did when they were at war with the optometrists - full page ad in the NY Times stating who we are (physicians), how our training compares to distinguish us from CRNAs, and what we do in the OR.

The vast majority of patients don't know what we anesthesiologists do. They think we just give a drug to make them go to sleep and go home. They are always surprised when I tell them we are the ones who transfuse blood when needed, and basically watch over them and do things to keep them alive if need be.
 
BLADEMDA said:
There are about 37,000 CRNAs in the USA. There are about 35-40,000 Anesthesiologists. There are about 2,000 AAs.

Hence, there are not enough Anesthesiologists available to do the stool sitting even if the ASA were to advocate such a position. Most likely the number of midlevels will continue to rise over the next ten years (AANA data unreliable and biased) while the number of Anesthesiologists declines or remains stable at best.
Click to expand...


Hey POD,

Did you read my post above? How are we going to provide One on One Anesthesia to every patient in the USA? Or, just those who buy the TV advertisement? There are Not enough Physician Anesthesiologists.

So, should the surgeries get cancelled? Should patients panic? Where is the evidence that the ACT model isn't as safe as the one on one model? PLease show me ANY evidence for that claim.

JPP and I think the ACT model is actually the safest way to deliver an anesthetic provided you have a quality CRNA or AA.
 
slunk said:
you're right there is a shortage of intensive care docs. What I meant though was that
#1) the ICU docs all have set roles already. Cover the SICU, MICU, etc. I was curious where the role of the perioperative ICU doc comes into play, but I guess you sort of answered it... we would essentially be covering 8 OR's at a time, or providing backup to the independent CRNAs who are manning them.

I don't know if I am misinterpreting, but my question is do we want to be backing up these CRNAs? I thought the whole point of letting them go solo means they sink or swim themselves and get to see what its like to get burnt and regret they wanted independent practice with their measly training.

#2) If everyone who is in anesthesia residency suddenly becomes a FCCM, there definitely will be a huge surplus of critical care doctors.
You said in another post that you would want to decrease the number of residencies and people graduating from them, and this may help prevent a future surplus in perioperative physicians, but what about the argument of strength in numbers? CRNAs continue to be churned out, is it a good idea for us to take the other route? Basically hand over the role of OR provider to them. I'm not sure this is a good idea.

I'm not trying to be critical. I am an anesthesiologist and I want our specialty to survive as well.

As we know, statistics don't mean everything. CRNAs may show studies that they provide equivalent care, but (hopefully) most everyone in the OR knows that this is not the case. I know for a fact, having supervised some as a CA-3 last year at a major academic center. Attending friends of mine echo my sentiment.

Maybe we should do what the opthamologists did when they were at war with the optometrists - full page ad in the NY Times stating who we are (physicians), how our training compares to distinguish us from CRNAs, and what we do in the OR.

The vast majority of patients don't know what we anesthesiologists do. They think we just give a drug to make them go to sleep and go home. They are always surprised when I tell them we are the ones who transfuse blood when needed, and basically watch over them and do things to keep them alive if need be.
Click to expand...


I am not advocating we give up the O.R. Rather, like the AANA which advocates for a DNAP and "fellowships" (what a joke) for CRNAs I want to improve the IMAGE of our field.

Hence, a Critical Care Specialist/Perioperative Specialist is the patient's LIFE INSURANCE policy in the O.R. Some of these new, highly trained specialists will do Critical Care; others will seek just O.R. work like they do now. The fact is we only need to formalize the ICU part into our PGY1-4 years so the new graduate gets CC as a bonus. PGY-5 is a fellowship year. Why not embrace more qualifications/certification if it doesn't increase the duration of your training?
 
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12-02-2005, 05:21 PM #5 militarymd
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Quote:
Originally Posted by davvid2700
YOu live to torture me..

You torture me in return...so we're even.. 😀


Quote:
Originally Posted by davvid2700
I work for an all md practice. We have like 15 docs with 3 people off everyday. and i make mid- high 200's.. I dont know where you are getting your 100K figure.

Payer demographics, insurance reimburse, type of insurance, and OR efficiency all factor into the income.

For my hospital, because of its inefficiency (surgeons with 2 rooms, etc.), the total revenue generated per anesthetizing location is very low despite high private insurance rates.

Based on the revenue that we generate right now, and dividing it into the increased number of MDs that we would need yields the figure that I quoted.....a figure lower than what I made in the Navy, while working longer hours....not harder, because of the down time between cases.

The surgeons WOULD NOT support the all MD model if it met they lost their second room, so if we go all MD, we wind up making the quoted figure.

The surgeons feel that CRNAs sitting in the room is fine.....outcome here in the last 10 years....nothing bad...everyone goes home fine...so that's what I have.

100,000 does not include benefits....gross IS 170,000 and change..if your figure includes benefits then it would be similar to pay here, but I suspect your gross is 300,000+.....right? mid 200's plus benefits
 
12-27-2005, 09:27 PM #73 jetproppilot
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davvid2700 said:
Quote:
Originally Posted by Noyac


DUDE, I dont care what you do!. You wanna run a mill of crnas.. thats fine with me. Im not saying that it is wrong. all im saying is that it is dumbing down our specialty. But i will tell you that the bigotry on this board is amazing coming from people who claim to be "educated". MilitaryMD et al...

Saying we run a "mill of crnas" is a completely derogatory comment.

I'm sorry, there is no way an all MD model can compete with the efficiency of a team model.

Even if you're a stud, and you can throw in a central line and an interscalene in 15 minutes plus-or-minus 5 minutes, you cant compete with a model that completely preps the patient while the surgeon is still working on his previous case, which enables you to monitor the surgeon's room, and time when to take the patient into the adjacent OR before the surgeon is done, gettim' on the bed, monitors on, start the prep&drape, so when the surgeon is shooting his gloves into the trashcan, you're biting at his heels to get to the adjacent OR where his next patient is ready. Oh, and Mr Ortho dude, stop at the scrub sink in between your two rooms and scrub your hands before coming in here!

Total turnover time, 3 minutes.

As I have said before, I respect the all MD model, and was headed for one right outta residency (Las Vegas). Fate intervened, I stayed in the southeast, and was exposed to the team approach.

Unless you have spent time working in the team approach model, it is impoossible for you to refute it.

Additionally, regardless of the antagonistic posters here, there simply arent enough MDs to occupy every anesthesia site, and there never will be. But more importantly,

If you are able to take your ego out of the equation (not you personally, you generally, me included), and you are able to ignore the militant posters who insist they are equal to us and can do every thing we can, like the new terrorist Cyndee MSN NP (why is it nurses list EVERY degree/certificate they've ever earned behind their name?),

you would realize the team model is an excellent approach to anesthetic care .
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05-17-2006, 10:10 PM #12 jetproppilot
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Quote:
Originally Posted by NRAI2001
Now thats 1 MDA and 4 CRNAs working in a setting where there may have been 4 MDAs. Will this be the trend? Obviously its cheaper to pay an CRNA 100k over an MDA 400k.

Will this BE a trend?

No Dude.

Thats the way it already IS and HAS BEEN for a long time.

A significant portion of anesthetics (don't know the exact percentage so I'll defer quoting an exact percentage) are performed using the team approach model.

And a shortage of anesthesia providers still exists.
 
I don't think non-supervised CRNA practice is the BEST....

but guess what?

In some areas, thats WHATS REALITY.

I think TEAM APPROACH is the best model.

I don't know how to trump the politically driven in each party to admit this.

MD + CRNA (or AA) is the most efficient,

SAFEST,

model.

Hands down.

MD WITH THIRTEEN YEARS EXPERIENCE.

Word.

JET
 
BLADEMDA said:
Did you read my post above? How are we going to provide One on One Anesthesia to every patient in the USA? Or, just those who buy the TV advertisement? There are Not enough Physician Anesthesiologists.

So, should the surgeries get cancelled? Should patients panic?
Click to expand...

Sorry, I am not at all advocating placing those ads, I posted that as a response to Slunk's idea about placing an ad in newspapers, and as a joke. I removed it because, like I said, crapping all over CRNA's isn't what I am all about. I honestly don't think that ads telling the public who we are and what we do will make any difference. If your goal is to eliminate CRNA's you need something like what I posted. (once again, I am not advocating this)


BLADEMDA said:
Where is the evidence that the ACT model isn't as safe as the one on one model? PLease show me ANY evidence for that claim.

JPP and I think the ACT model is actually the safest way to deliver an anesthetic provided you have a quality CRNA or AA.
Click to expand...

Like I said in the removed post.

Whether you can prove it with data or not, Americans view physician provided care as superior.
Click to expand...

that ad was not claiming that we are safer or we have any data to suggest we are safer, it is just asking people to reflect on who they want to take care of them. Of course it is inferring like hell that we are safer. It would be dirty politics to place it (can you say plausible deniability), but I bet it would be effective. (of course it would royally piss off our surgical colleagues who would now have to discuss this with the patient instead of getting on to the next room)

Now what I might advocate (if the AANA continues on their current trajectory and gets into dirty politics in the pursuit if independent practice) is a version of that ad focused on ensuring that a physician is involved with every anesthetic, ie the ACT model. Then we would be guilty of playing the fear card, but not inferring data that does not exist.

BTW do you think that ACT is safer for ASA IV-V?

- pod
 
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BLADEMDA said:
This thread is NOT for debate about CRNAs/Midlevels but rather what you all can do to improve the odds of a long, successful career in Perioperative Medicine.

I say Perioperative Medicine because this field will evolve and is evolving that a Midlevel has the LEGAL RIGHT to do the actual anesthestic solo (currently at 15 states and counting). In addition, CRNA Schools many of which are based in academic medical centers are training Nurses to be the primary provider of the actual anesthetic.

Over time financial pressures and increasing government based health care will force the "stool sitter" to be a midlevel and not a Physician. Of Course, there will always be a niche for Physician provided anesthetic care but that will comprise a smaller and smaller share of the market place.

So, what can the Resident do to prepare for this career in Perioperative Medicine? What can Academia do to help ensure this field survives and its graduates have a job?
Click to expand...

First of all Blade, thanks for the thread; I think it has been very fruitful thus far.

But my reason for posting is an issue with "perioperative medicine," which I think is a catchy tagline that people like to tout as broadening/"medicinizing" the field but no one really is that interested in.

Anesthesiologists usually aren't interested in doing full preoperative medical evaluation and optimization, haven't created the literature on this (see ACC/AHA guidelines), and probably don't have the training anyway (the residency requirement is pretty new). Postoperatively, they take care of patients in the PACU, briefly, and possibly in an anesthesiologist-directed SICU...that's about it. The surgeon is still the primary, and anesthesiologists simply don't have the training to care for postoperative patients medically or surgically -- that's why there are medical hospitalist and surgical teams out there.

You want to be a perioperative physician? To me that takes a blend of internal medicine/peds, surgery, critical care, and anesthesiology training that simply doesn't exist out there on its own, and to legitimately train anesthesiologists in all of those fields would take a residency of 5-7 years minimum. Do any anesthesiologists really want to titrate beta-blockers in the outpt setting, and manage postoperative pts on inpatients wards, anyway? I think the answer is obvious. Maybe this mega-residency is a possibility in the distant future...but to me, for now, "perioperative medicine" is just a buzzword, and touting a specialty where >95% of its members' time is spent anesthetizing pts in the OR as "perioperative" is just marketing.
 
fakin' the funk said:
First of all Blade, thanks for the thread; I think it has been very fruitful thus far.

But my reason for posting is an issue with "perioperative medicine," which I think is a catchy tagline that people like to tout as broadening/"medicinizing" the field but no one really is that interested in.

Anesthesiologists usually aren't interested in doing full preoperative medical evaluation and optimization, haven't created the literature on this (see ACC/AHA guidelines), and probably don't have the training anyway (the residency requirement is pretty new). Postoperatively, they take care of patients in the PACU, briefly, and possibly in an anesthesiologist-directed SICU...that's about it. The surgeon is still the primary, and anesthesiologists simply don't have the training to care for postoperative patients medically or surgically -- that's why there are medical hospitalist and surgical teams out there.

You want to be a perioperative physician? To me that takes a blend of internal medicine/peds, surgery, critical care, and anesthesiology training that simply doesn't exist out there on its own, and to legitimately train anesthesiologists in all of those fields would take a residency of 5-7 years minimum. Do any anesthesiologists really want to titrate beta-blockers in the outpt setting, and manage postoperative pts on inpatients wards, anyway? I think the answer is obvious. Maybe this mega-residency is a possibility in the distant future...but to me, for now, "perioperative medicine" is just a buzzword, and touting a specialty where >95% of its members' time is spent anesthetizing pts in the OR as "perioperative" is just marketing.
Click to expand...


Marketing is Perception. Perception is reality in the O.R. Reality is what keeps you employed. The AANA has used "marketing" for years and what has it gotten them? How about opt-out in 15 states and the perception among some they can function Solo.

Like it or not we are at war over our role/place in the O.R. food chain. So, I strongly advise a lot of marketing on our behalf to impact perception. Otherwise, you may be doing that TEE in a few years while your CRNA "colleague" does the case solo.

After a completion of a Critical Care Fellowship Perioperative Care should be rather simple. Those who have completed a good ICU Fellowship can handle just about any situation and are well suited for the role. Thus, without at least 6 months of ICU/CCU/NeuroICU. etc. many Anesthesia graduates lack the exposure to be truly perioperative physicians.
 
BTW do you think that ACT is safer for ASA IV-V?

- pod



Yes, especially when both providers play an active role in the case. If the supervising MD steps up his/her game for that case by staying in the room more and frequent visits, etc. the ACT model for ASA 4 cases is the safest model.
 
In this issue of Anesthesiology, Arbous et al.1 provide a jolting report on the positive impact that anesthesia providers can have on their patients. How? Simple anesthetic management principles seem to have a major effect on perioperative mortality. The routine use of an equipment checklist (odds ratio, 0.61), direct availability of an anesthesiologist to help lend a hand or troubleshoot when needed (odds ratio, 0.46), the use of full-time compared with part-time anesthesia team members (odds ratio, 0.41), the presence of two members of the anesthesia team at emergence (odds ratio, 0.69), and reversal of muscle relaxants at the end of anesthesia (odds ratio, 0.10) had dramatic, positive effects that were associated with reduced perioperative mortality within 48 h after surgery and anesthesia.
This report is remarkable in several ways. First, it is one of the few that have shown anesthetic management processes to dramatically reduce perioperative mortality. Second, it reports perioperative mortality rates matching a number of recent reports. Importantly, it supports the recent insightful article by Lagasse2 about perioperative mortality and his suggestion that the US anesthesia community may have overestimated its impact on improving patient safety in the past two decades. Finally, the authors have used a unique and thoughtfully planned multiinstitutional survey and case-control methodology to evaluate this low (but not low enough)-frequency outcome.
It should not be surprising that perioperative anesthetic management processes can make a difference. The US Federal Aviation Administration has long required the use of pilot checklists for evaluating the airworthiness of aircraft and starting procedures, a requirement strongly supported by outcomes of real and simulated air flight. Why would our specialty, so often compared to piloting, be different? The Federal Aviation Administration also requires two pilots for most commercial aircraft operations, nicely matching the report's finding that the presence of two anesthesia providers at emergence is associated with lower perioperative mortality. The positive impacts of immediate availability of an anesthesiologist when needed and continuity of anesthesia providers in the care of individual patients likewise make sense but, until this study, rarely have been shown to be associated with reduced perioperative mortality.
Have we really overestimated our positive impact on patient safety? Clearly, a number of recent studies suggest that our oft-quoted estimate of 1:200,000 or more patients who have an anesthetic-related death may be flawed.2 The basis for this estimate is accurate but usually misinterpreted. Eichhorn et al.3 reported this low rate of anesthetic-related mortality in healthy patients, an important distinction occasionally neglected in anesthesia patient safety statements. This current study, like others, suggests that the anesthetic-related mortality rate is still too high. The good news is that we have room for improvement and, now, data to support anesthetic management changes that may help.
The study of rare medical events is extremely difficult; it often is extraordinarily frustrating to obtain numerators large enough or denominators that are sufficiently robust to allow calculation of frequencies of the events and subsequent analyses for potential risk factors. Arbous et al.1 have used a multiinstitutional study technique common to clinical research in other medical specialties, notably cardiology, but infrequently attempted in anesthesiology and the study of perioperative mortality. This process has provided the authors with (unfortunately) a sufficient number of perioperative deaths to allow case-control analyses, a good way to seek associations between rare events and potential risk factors.
In general, efforts to seek associations between rare medical events and potential risk factors follow a progression. First, case reports and small case series describe unusual outcomes. If enough of these unusual outcomes can be gathered (typically at least 20 are needed, assuming valid controls can be assessed), a case-control methodology can be used to seek possible but not proven risk factors. Subsequently, potential risk factors identified by case-control studies must be evaluated prospectively in large populations to ascertain their validity. Finally, potential interventions to decrease the frequency of these rare events can be tested in randomized, prospective trials. The current study's elegant methodology takes advantage of the large numbers of perioperative death reports that they collected in multiple institutions by creatively and prospectively seeking data from randomly selected controls within each of those institutions. This methodology is applicable to many rare perioperative events and should be a model often copied in the future.
Although conclusions from one study should not lead to wholesale changes in practice, the findings in this study support many plausible assumptions that improvements in anesthetic management processes can positively influence patient outcomes. The use of equipment checklists, immediate availability of anesthesiologists to help when needed, especially to provide extra assistance at emergence from anesthesia, and routine reversal of muscle relaxants are processes that should be seriously considered when seeking opportunities to improve the perioperative outcomes of anesthetized patients.
Mark A. Warner, M.D.
Mayo Clinic College of Medicine, Roches-ter, Minnesota. [email protected]

Back to Top | Article Outline
References

1. Arbous MS, Meursing AEE, van Kleef JW, de Lange JJ, Spoormans HHAJM, Touw P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102:257-68
Cited Here... | View Full Text | PubMed | CrossRef

2. Lagasse RS: Anesthesia safety: Model or myth? A review of the published literature and analysis of current original data. Anesthesiology 2002; 97:1609-17
Cited Here... | View Full Text | PubMed | CrossRef

3. Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572-7
Cited Here... | View Full Text | PubMed | CrossRef
 
Some may say that if EVERY Resident graduates with the right to sit for the Critical Care exam that we would have too many Intensivists. Really?

Do you realize how painful doing ICU/Critical Care can be compared to the O.R. ? How many phone calls at night you may receive? The fact is in order to make Critical Care palatable you need a LOT of Intensivists to take shifts/cover the ICU.

Hence, the more MDs available the easier the coverage and the job. Thus, less burn-out and turn-over for this position. IMHO, we need 3 times the amount of intensivists currently working in the USA. The best model is one where the vast majority of hospital based Anesthesiologists are ICU trained and cross-cover the ICU. Ideally, if an entire Group did ICU the call burden would be tolerable and the patients would receive better care. So, I want EVERY Anesthesiology Graduate to have the skill set necessary to cover the ICU upon completion of a U.S. Residency.
The PGY 1-4 years are more than enough to accomplish this task.
 
You should read this month's ASA Newsletter (Sept. 2009) pages 10 and 11.

Can someone post a link?


"For the present, however, there is a conspicuous and somewhat inexplicable disconnect between the practice of anesthesiology and that of critical care, and anesthesiology critical care today remains a largely academic pursuit confined mostly to university medical centers. Indeed, while 15 percent of academic anesthesiology chairs in this country are members of the American Society of Critical Care Anesthesiologists www.ascca.org, only 2
percent ot the greater ASA physician membership belongs to this group. As the articles in this issue of the NEWSLETTER attest, the achievements of critical care anesthesiologists are substantial, and it is arguable that pur collective contributions have been proportionally greater than our numbers might suggest. Given the likely decline in demands for O.R. services and the unique capacity for our specialty to evolve and fulfill the increasing demand for critical care, now is an opportune time to evaluate anesthesiology's present lack of engagement and to consider ways in which we might become more involved in the future. From the perspective of where we are "going to be," this analysis is particularly relevant for anesthesiology trainess and practitioners who will be active health care providers in 2025 and beyond."

Walter Boyle, MD. FCCM
ASA Newsletter Sept. 2009
 
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By contrast, the phenomenal 75-percent increase in the U.S. population over 65 years of age in the first quarter of this century, as well as the increased demand for state-of-the-art medical care, predicts a dramatic increase in the need for critical care services. At the same time, workforce analyses indicate that a "severe shortgage of physician intensivist is expected
to continue into the next decade and beyond."4"


Walter Boyle, MD F.C.C.M.


 
CRNAs won't be a threat in the ICU. We already have studies showing outcome is better with a Physician Intensivist. CRNAs like PAs and NPs can work UNDER an ICU Physician but NEVER in place of one. The ICU is NOT a place the AANA can claim any particular "heritage" or precedent. Hence, the AANA will not be a threat to that specialty.

Blade

http://jama.ama-assn.org/cgi/content/abstract/288/17/2151

http://qshc.bmj.com/cgi/content/abstract/16/5/329

http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf
 
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