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Anesthesia vs IM

Discussion in 'Anesthesiology' started by msmith83, Feb 25, 2014.

  1. FFP

    FFP Grunt, cog, body, pompous ass
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    I know one pain guy who went back to OR anesthesia in an AMC place, and one who is thinking about it. Both are over 40, PP, both good.
     
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  3. LeverArm

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    Its roughly what I hear and have seen. I'm not just talking steroid injections for low back pain (most of those drs are suffering now). Im talking about everything from migraines to failed back surgery to cancer pain to crps. Do you think less than 40% get benefit from interventions? I can provide more specific numbers if you like. Im happy that those pushing drugs and just doin shots for everyone are leaving.
     
  4. nimbus

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    That must be a local phenomenon. Our cardiologists and GI guys and gals are some of the happiest doctors I know. EP, TAVRs, endoscopic US. Tons of cool stuff going on for them. None of them say they wish they did anesthesia….haha. Thats a big f***in joke.
     
  5. FFP

    FFP Grunt, cog, body, pompous ass
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    Same here. I have a number of GI friends who can't understand why I am unhappy with my job. And when I tell them real-life stories, they are perplexed.

    Regardless, I think a good number of specialties still live in a Matrix dreamworld, and ours is the real one. They are up for a very nasty surprise in the future.
     
  6. BLADEMDA

    BLADEMDA ASA Member
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    The world of Residency and Fellowship isn't the real world. Think about the THREE PLUS Decades after training in which you will practice your chosen specialty. 30-35 years.

    Anesthesia is NOT a lifestyle specialty which involves as much work as any other specialty in medicine. Night work? You bet. Weekends? Yes. Holidays? Hell yes.
    On top of that you are NOT viewed in the same league as those Physicians who bring patients to the hospital or surgicenter. Go where the money is as Jet has posted in the past. Save yourself a 30-35 year career being someone else's bitch in the O.R. AMCs or Hospital employed positions will keep slashing your pay until it approaches Family Practice. In fact, hour for hour FP will likely earn more money than GAS in 5 years.

    Now, on top of all this non lifestyle work, being someone else's bitch in the OR, coerced into doing ASA4 cases which should be cancelled there is the CRNA problem.
    They are winning the war and will be taking jobs from Anesthesiologists over the next few years. Hospital Administrators and AMCS will force you to supervise 5 or 6:1 in order to keep from hiring another MD.

    Pain Medicine is seeing big cuts by CMS; They too will feel the pain.

    You have been warned that the view from academia is simply wrong; choose another path before it's too late.
     
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  7. Psai

    Psai Snitches get zero vicryl
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    What do you guys think of doing anesthesia with the aim of doing peds or critical care?
     
  8. IkeBoy18

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    well.. if not anesthesia.. i have no clue what i would do.. i absolutely hated IM, surgery was ok but not something I love or even liked all that much. psych was boring, neuro was boring, ob gyn was ok, but not something i could do forever, fam med..no, peds.. hell no. Ill never see the inside of a urology or ent OR before its too late. my only other interest is interventional radiology and they all claim is sky is falling as well.
     
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  9. Silent Cool

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    The problem is that no one knows how reimbursements will change in 2, 5 or 10 years. 30 years back IM and Surg were tops, and Ortho was at the bottom. Now, Ortho is tops and IM gets the shaft. GI will probably get cut big time, not to mention that it's hard as hell to match GI. No one knows how payments will change in the next 5 years.

    Re: work hours, aren't GAS docs still paid bank for working high hours? There are plenty of gigs on gaswork offering 400K for a normal work week. I would have to imagine that if you are picking up weekends, nights, etc.., that you are making 600K+. That still seems like a good deal.
     
  10. sakata8242

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    There's always Path...
     
  11. BLADEMDA

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    The FUTURE is easy to see. in 5 years 80% of all positions will be AMC, Hospital Employee or Academic. This leaves 20% for true Private practice. Now, the assumption that 20% will MAKE you a partner is a big one. Perhaps, 10% of those groups will be fair and make you a partner after 3 years. This means 90% of all future GAS jobs are FIXED SALARY or SALARY With specified bonus. These SALARIES Are coming down each year NOT Going up. Hence, GAS is relegated to $250K-$275K for 45 hours per week. It's possible your 50 hour per week Hospital job may pay you $400 but I wouldn't count on it.

    Ortho made more than anesthesia in the 1990s and 2000s. They will ALWAYS make more than anesthesia in the USA. Ditto for Neurosurgery and Urology. ENT will likely do better than GAs as well.

    Optho looks like about the same income as GAS but 1/2 the work and significantly better lifestyle. Optho dudes who own their surgicenter make double the average Gas attending.

    The bottom line is GAS is relegated to the bottom of the heap. The CRNA issue is hurting the specialty as well because AMCS want as many CRNAs as possible with FULL PRACTICE privileges to save money.

    I can see from a newbie perspective how the future looks blurry and unpredictable. But, from my perspective the future is quite clear. The vast majority of my peers agree with me as the number of private groups selling to AMCs continues the trend of getting out while the getting is good.
     
  12. BLADEMDA

    BLADEMDA ASA Member
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    I've got ZERO issues with those who choose Anesthesiology as their specialty. I hope smart young people keep matching into the field. But, I will continue to post the truth as they deserve to know what the future holds for them.

    The glass will remain half full. But, for many of us the glass is half empty. With that said pick what you want to do with your life but realize $250K pre-tax won't be buying you the American dream.
     
  13. IkeBoy18

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    i worked at md anderson for 2 years .. in cytology.. def not a fan of path. its super boring
     
  14. AnesDiva

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    I think we can all agree that anesthesiologists are solid contributors and that the field has immense potential to provide safe and quality care. Is the future uncertain? Of course. Is it as dramatic as this board makes it seem? I think probably not but maybe it is.

    But if we can all agree that we have mutual purpose in providing a service that no one else can provide as well as anesthesiologists can, and we can thus all have a baseline level of mutual respect, then maybe we can all encourage our best and brightest to join together with us as we try to articulate our worth and strengthen our field's future.

    Alas, I too am just an MS4 -- yes.

    But I have seen in my life a field (outside of medicine) who's future was uncertain get revolutionized by a new crop of dedicated, smart, and creative individuals. I'm going into anesthesia to help articulate the field's current worth and future potential.

    And from my experiences on the trail, I'm not alone in this pursuit.

    My cohort has much to learn, yes. But our enthusiasm, while obviously naive, is an asset.

    So please, just this one time, try and keep the cynicism in check, throw ego out the window, and recognize that there is an opportunity for anesthesia to have a fantastic and important future. And that opportunity is hugely benefited by bright eyed and intelligent people like myself who could've done anything and -- as informed as possible-- chose anesthesiology, flaws and all, for the field that it is and the opportunity the future provides.

    If intelligent and motivated people stop going into the field -- that's when the field will have a scary, scary future.
     
  15. BLADEMDA

    BLADEMDA ASA Member
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    1. AMC or Hospital Employee- Salaries will keep going down until they bottom around $250
    2. CRNAs- continue to gain ground. More "collaborative" practice models to save money. More CRNAs with DNAP calling themselves Doctors of Anesthesia.
    3. Income vs. intelligence- The two don't always go together. One doesn't guarantee the other.
    4. Naivete- It's what Academia is counting on to fill all their slots with American Medical Graduates

    Anesthesia is commodity like a TV or Computer. No matter how good the product or the advancement prices only go in one direction: Down.
     
    #64 BLADEMDA, Mar 2, 2014
    Last edited: Mar 2, 2014
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  16. AnesDiva

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    I can see how these points are worthwhile but, unless I'm missing something which is very possible, your argument is semi-straw-man here. It can be applied to most fields as well, not that I agree with it. If anesthesia is a commodity, then so is the rest of medicine. The commoditization of medicine doom has surfaced recently and yes I think it's a real threat... Mostly to salaries, but again that's a threat that is certainly not unique to anesthesia. Commoditization? Look at how rads feels about that.

    Now, I'd obviously prefer $350+. But I'm comfortable with the uncertainty surrounding salary. If a student chose anesthesia expecting a salary of $X -- heck if any of my peers chose any field with any real expectations that things will stay the same monetarily-- then I'd join you in dissuading them. But I don't think that's what's happening here. Most MS4s I met on the trail- and we chatted about this at many of the pre interview dinners-- are pretty open about accepting this particular unknown.

    A few thoughts, in no particular order, even though I still hold that your arguments are non sequitur-ish unless I'm missing something.

    1) commodities are breathing living things. Apple has certainly proved you wrong on how a product can change what people will pay for it.

    2) I agree, income and intelligence are not tied together at all. Not sure if this is crucial to any argument but I agree with you here.

    3) mid levels rise in power is a response to a market failure to provide services to meet demand. Fact. How the future assigns duty to the different players is constantly in flux.

    4) honestly... Every field is scared about mid levels taking over. I'm so sick of hearing about it. Not that it's not worth talking about. I'm just at the point where I feel every attending I've worked with in any field (ESP pp attendings) brings this up about their field... Except for surg. Whatever. It's happening. We still need to pick fields and I don't want to be a surgeon.
     
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  17. Silent Cool

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    That's a total of, what, 1200 spots per year? And there are how many medical graduates? 25K or something? Clearly, those fields will not be available to everyone. So what are most medical graduates going to do? These threads always boil down to something akin to, "the field is going down the tube--I can't easily make 500K anymore." Well, 80% of physicians aren't making half that. Second, these fields will fluctuate over time with supply and demand. Last, I don't think that in any field you can expect to be well off just from practicing your field. You need to take the money you make and invest it. So instead of buying a 70K BMW, why not take that 70K and buy a rental house?

    Also, what can anesthesia groups do to compete against the AMCs? How would an enterprising Anes. doc go about this?
     
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  18. msmith83

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    Can I ask where most of the attending anesthesiologist practice? Does practicing in a rural area present with more options or a brighter future perhaps?
     
  19. BLADEMDA

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    Naivete- Here is what you don't understand:
    Right now a CRNA can go to the O.R. and administer an anesthetic WITHOUT An Anesthesiologist being present or on Staff. The Surgicenter can hire all CRNAS to do the job the Anesthesiologists were doing the previous day. Strawman? WTF? This has happened at 3 surgicenters in my State. That's the really world honey. These jobs went to CRNAS and the Anesthesiologists were let go so the OWNERS could pocket the difference.

    AMCS are doing this with new contracts they acquire every day. Groups are bought out then CRNAs are added instead of Anesthesiologists. Salaries are also cut.

    What other field has this stuff going on right now? Please stop with B.S. and give me a real world example.

    Best of luck with Gas.
     
  20. BLADEMDA

    BLADEMDA ASA Member
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    Here is a question for all MS-4s:

    What Specialties allow Nurses to perform the exact same duty/function/task as their Physician Colleagues:

    Answer:

    1. Family practice
    2. Anesthesia
     
  21. AnesDiva

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    I know. On my rotations in anesthesia there were several days when I was paired with a CRNA for the day with no physician supervision. And I spent a few days at a surgicenter that was effectively CRNA run. I don't think either of those experiences were ideal for a med student rotating....but I'm not naive enough to have missed that reality in certain clinical environments.

    I think that either certain CRNA-run cases/centers/whatever in certain contexts will prove unsafe and the situation will revert to the former status quo (unlikely based on what I've observed).

    Or... there are certain situations that a midlevel will be able to handle without supervision 99.9999% of the time. If that's the case I'm OK with that. I think there will be a lot of change in the scope of how anesthesiologists practice in response to changes like those you describe, change that will push anesthesiologists to practicing in situations that really do require a physician. As the midlevels' scope changes, so will the physicians'.

    I personally did not go into anesthesia to do cases that don't, honestly, require all of the training I will have had.

    Anyways, I'm (respectfully) done. I never comment here because I don't think these arguments ever get anywhere useful. I do want you to know that I appreciate your concerns; and I certainly have not posted simply to win. My goal was to give a voice to those who, like me, honestly gave this decision a lot more thought than it appears posters like you give us credit for. I also wanted to point out that one person's gloom and doom is another person's opportunity. The changes the field will go through are coming. What these changes are, and how the field adapts, remains to be seen. What an opportunity to contribute.

    I'll simply agree-to-disagree with you on the broader point that our best and brightest should avoid anesthesia. I think that our best and brightest, if they truly are passionate about anesthesia based on their experiences, should absolutely go for it. I'm young, yes. But I think that I've made an informed decision.

    To any med students in their third year scared ****less about the future of anesthesia, please PM me. I'll give you my 2 cents and nothing more.
     
    #70 AnesDiva, Mar 2, 2014
    Last edited: Mar 2, 2014
  22. BLADEMDA

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    Let's review you previous post for accuracy:

    1. CRNA run centers- They do ASA 1 and 2 cases. They do just fine with those cases. There will be no "reversion" back to MD Anesthesiologists.
    2. Midlevels- Expanding their scope of practice daily but ours remains status quo. Your statement is erroneous.
    3. You will be delegated to ASA 4 cases. AMC or Employee. 4:1 ratio. low salary
    4. The CRNA won't always follow your orders or your plan.

    Like it or not you are clueless about the future of this specialty because you have no idea what its like out there; 20 plus years at this gig and it's never been this ugly.
    It's good to stay positive but it isn't good to avoid reality.
     
  23. AnesDiva

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    Yikes. That's some intense wordage...clueless...no idea what it's like...avoiding reality....

    Just to factually correct #1 and #2:

    1) if you re-read my post, you'll notice that I actually said that I do **not** expect there to be any "reversion." So thus, I take it we are in agreement here?

    2) My statement was about how I believe that the scope of anesthesiologists *will* change. I respect your 20 years in the field; so much so that I'll accept that this as "ugly" as it's every been for you. :) I was suggesting that I believe something will happen, not that something has been happening, because there are a *lot* of people talking about ways to make said changes happen. Things get better; we can make them get better.

    You can mock my positive attitude all you want-- that's OK if you feel it necessary to articulate your opinions but it doesn't really advance your argument much for me.

    Side note: I think this forum would be a lot more active if people did not get so... intense. This is the most obvious thing to point out ever, I know. But consider it. I fully anticipate being mocked for even mentioning this -- I can imagine several responses just thinking about it.

    Mutual purpose, mutual respect.

    Now I'm actually done. Haha.

    Happy March everyone.
     
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  24. LeverArm

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    As a med student I spent a couple days with a crna and was bored out of my mind then I spent a few Weeks in complex cases with attendings and senior residents and time flew by and thats realizing that watching anesthesia would be nothing like doing it myself. Id rather take a pay cut and work in a tertiary care center with asa3/4 than make more and act like a crna or most other jobs in medicine ive seen.
     
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  25. FFP

    FFP Grunt, cog, body, pompous ass
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    AnesDiva, respectfully, you are way too optimistic. Even for a medical student. This is about money, money that's moving away from doctors to the healthcare industrial complex and the government. Those guys are not the kind who can be easily persuaded to give it back.

    Stop dreaming; it's already happening, and not only in anesthesia. Yours is exactly the kind of wishful thinking people had 10-20 years ago when their jobs started moving offshore; some of them even trained their Indian replacements (unknowingly).
     
  26. bronx43

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    Hospital administrators reading this thread (heaven forbid) must be salivating at the influx of new talent that is so willing to lay down arms and concede to CRNA encroachment and loss of income.
     
  27. Consigliere

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    You obviously aren't aware of the drastic cuts pain medicine physicians are dealing with. Go ahead....go into pain.
     
  28. FFP

    FFP Grunt, cog, body, pompous ass
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    All these enthusiastic anesthesia applicants need pain. :D

    When the number of cases needing MDs decreases (because of the CRNAs), and the number of MDs stays the same (or even increases due to the influx of pain subspecialists), who do you think has the upper hand in the negotiations?
     
    #77 FFP, Mar 2, 2014
    Last edited: Mar 2, 2014
  29. Silent Cool

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  30. DrBB

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    To the original poster: I'm currently a first year IM resident who was dealing with the same issues you are currently dealing with. Had a very difficult time choosing between IM and anesthesia. Ended up going IM, and am hoping to pursue a fellowship after. Each field clearly has its pluses and minuses. Anesthesia you're dealing with CRNAs, a-hole surgeons. IM you're getting patient dumps from all services and have to deal with all the social work. On the plus side, anesthesia can be pretty cool (you get to be the hero at codes and in the OR at times) and you can specialize in pain or critical care. With IM, you have many options to specialize if you are still unsure. You really just have to go with what you think you'll like best. Do you like the OR environment, which in anesthesia can be very intense and stressful at times, but also chill at times? Or, do you prefer seeing patients on the medical floor and trying to work them up through labs/imaging/physical exam?

    In terms of money/lifestyle - anesthesia is by no means a lifestyle field. I think that misconception came from the fact that many anesthesiologists get >4 weeks vacation per year. What you have to understand is that anesthesia hours are long (start very early in the AM) and they have to take in-house call which means night's/weekends. The cool thing with anesthesia is that it is shift-work so theoretically as an attending you can tailor your schedule based on how much $$ you want to make. You can work half the year if you really want to. Or you can go do locums in Hawaii for a few months then come back to the states and work here. Can't really do that with IM.
     
  31. FFP

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    Why not, as a hospitalist?
     
  32. Silent Cool

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    #3 is 100% true, and is exactly what Milton Friedman predicted 30 years ago. To paraphrase: the supply of physicians has been kept artificially low since the 1930s with the goal of artificially inflating incomes; either the supply of physicians must be increased to meet increased demand, or other health care providers with different training will find a way to provide the service. My grandfather had the same criticism of medicine back in the 1960s. For the record, he was a Republican. He had a picture of George Bush in his kitchen.

    So you can take a lower income by training more anesthesiologists, or you can accept competition from a different health care provider (in this case, a CRNA) and also have your income threatened. Pick your poison.
     
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  33. bronx43

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    Wait, wait, wait... not sure if srs. Hospitalist. That is all. Oh, and I bet that the hospitalist can find a gig in Hawaii much easier than an anesthesiologist.
     
  34. msmith83

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    So the general consensus from the anesthesia attendings on here is do not go into Anesthesia?
     
  35. Disciple

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    Pain guy here.


    Confirmed.
     
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  36. IkeBoy18

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    seemingly, thats the consensus. youll either be miserable practicing something you dont like at all, or miserable practicing anesthesia.
     
  37. gas2014

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    Would some graduating CA3's going into private practice this summer post-residency please give some insight into what types of job offers they got and for roughly what range?

    How tight is the job market outside the saturated markets on the two coasts?
     
  38. msmith83

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    Tough one right there

    Though in general the consensus is that nearly every specialty other than surgery is not what it used to be and is facing the same challenges. With this being the case, it doesn't really help in my decision of IM vs Anesthesia unfortunately
     
  39. FFP

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    The part I cannot quote is the 2 medical students actually liking this post (and me banging my head into the wall from their display of sheer...).

    That numerus clausus Silent Cool is talking about, was the protection for all the years of sacrifices doctors make before reaching their productive years. You take that away by decreasing salaries, and in 10 years the best American undergrads won't spend a second thinking about applying to medical school.

    I understand that some people think that $150-200k should be a reasonable salary when the average household income is around $50-60k, but not if you take into account the many years of lost productivity, the educational loans, the sacrifices, the stress, the responsibility, the malpractice, the hours etc. And, on top of that, you are not your own boss anymore, you don't really have meaningful doctor-patient relationships anymore, you end up doing something quite different than what you went to medical school for, etc.; you are just a highly-educated, well-paid, blue-collar, assembly lane worker/supervisor.

    The reason medical science (especially in anesthesia) has gotten so far is because all the bright minds practicing medicine. If you replace them with mediocrities, the results will be mediocre. But hey, medicine will be cheap, like Walmart.
     
    #88 FFP, Mar 2, 2014
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  40. bronx43

    bronx43 Word.
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    Most subspecialties in IM aren't really facing the same challenges as anesthesiology. There is great value to be a patient-facing specialty, as it presents you an element of control over the flow of patients - ultimately more difficult to commoditize. If you've ever done a rotation in hematology/oncology, you'll see that the patients would follow their oncologist to the ends of the Earth (bit of a hyperbole but you get the point).
    There are midlevels scattered around in IM subspecialties, but for the most part, it's nowhere near the presence that CRNAs have in anesthesia.
     
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  41. FFP

    FFP Grunt, cog, body, pompous ass
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    Not yet. If they manage to partially replace doctors in one of the specialties with the highest levels of acuity (i.e. anesthesia), the sky is the limit.

    IM guys have their easy patients, too, probably around 50% of their cases. Those will all be stolen by midlevels. Not tomorrow, but in 10-15 years. Just watch.

    Doctors are so stupid. They think that this stuff will never happen to their specialty, just to FP, or just to Anesthesia, or Psych. Reminds me of this:
     
    #90 FFP, Mar 2, 2014
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  42. Disciple

    Disciple Senior Member
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    Already happening.

    My local community hospital (nice suburb) sponsors a mid-level run primary care clinic in the local Walmart. Not sure who is supervising in there.
     
  43. bronx43

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    Who is "they?" The thing with anesthesia is that your older generation sold you guys out. No one in IM is set to sell out their field - well, not as far as I know. There are whispers of allowing midlevels to do screening colonoscopies from lone centers, but that was met with bitter vitriol from the rest of the field. Our interventional cardiologists aren't letting a midlevel in the cath lab, let alone setting up shop to train legions of nurse interventionalists. Our EP nurse practitioner can barely read a ECG better than a MS2 let alone be able to care for even the easier half of EP patients.
     
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  44. bronx43

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    Dude, this happened to anesthesia because you guys ALLOWED this to happen. You guys let the boogieman in the door, and are now feeling the pain. The older anesthesiologists who trained the CRNAs have blood on their hands - not the hospital administrators. FP and psych are low hanging fruit, so I can easily see how one can drink their milkshake.
     
  45. Silent Cool

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  46. FFP

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    Midlevels might not get to do procedures soon (they are pretty limited in anesthesia, too), but they sure as hell will take over the care of the more straightforward patients. You really think this midlevel revolution will stop here,? IM docs will end up supervising 2-3 NPs the same way we supervise CRNAs. It's just a matter of time (unless the winds change significantly in the Congress and the White House).
    And you think other specialties are not so low-hanging? I wouldn't be so sure. Anything that is recipe-/algorithm-based, which is 90% of internal medicine. What do you think anesthesia is, if not acute and intensive care internal medicine, with some airway management and other procedural skills on top of it? If anything, we should have been less endangered by midlevels than internists. Heck, if we become (surgical) hospitalists, internists might find us competing for some of their night-time coverage jobs.

    Plus, as in anesthesia, there is always Dr. Google the midlevel can consult for help. :p
     
    #95 FFP, Mar 2, 2014
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  47. bronx43

    bronx43 Word.
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    Google or not, as long as our specialists don't actively go sleep with the enemy, we can stave off the encroachment for awhile longer.
     
  48. Silent Cool

    Silent Cool Member
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    Milton Friedman Health Care in a Free Market

    Most relevant: 1:30-7:30

     
  49. FFP

    FFP Grunt, cog, body, pompous ass
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    But they will sleep with the enemy, as private practices disappear, reimbursements decrease, and the bean counters will try to decrease costs even further. They will take the anesthesia care team model and apply it to other specialties. If a hospital makes just extra 0.5-1% in profit, that's huge (and what a nice incentive pay it is for the CEO and the old boys).
     
  50. FFP

    FFP Grunt, cog, body, pompous ass
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    Irrelevant. This is not a free market; this is corporate capitalism, and pretty monopolistic regionally on top of that.

    A free market is one in which a small but innovative business can realistically compete with the huge dinosaurs, as in "may the best man win". How many Microsofts, Googles, Facebooks have you seen in healthcare? You can't even own a hospital as a doctor anymore.
     
    #99 FFP, Mar 2, 2014
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  51. Silent Cool

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    The question is this:

    What can you do to regain control of billing? Of the cash flow?
    I've said it before: you have to find a way to OWN something, whether it is an urgent care center, an ASC, or simply the person who contracts with a hospital to provide the anesthesia. If an AMC can do it, so can an enterprising group of anesthesiologists. I have full confidence that opportunities exist--physicians just have to find them.
     
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