Are You Ready For Private Practice?

[The_Sensei]

filthy potty mouth

Yeah, yeah...........give Sturaitis, Ford and Nath a kiss with your "clean" mouth for me, Jason.

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[jetproppilot]

I wrote this a long time ago.

I bumped it for the benefit of my CA-3 colleagues who are going out on their own in a cuppla months.

 

[jetproppilot]

I wrote this a long time ago.

I bumped it for the benefit of my CA-3 colleagues who are going out on their own in a cuppla months.

I wrote this a long time ago.

A cuppla years ago I bumped this thread and said the same

yeah hi, I wrote this a long time ago.

ITS THAT TIME OF THE YEAR!!

April...

cuppla more months and current CA-3s will become attendings!!

Very exciting to say the least.

I've been in private practice for fifteen years. I still love my job. Current day I'm at a life changing gig.

There's alotta wisdom in this post I made long ago, and it holds true today.

The things reflected in it helped me get to where I am.

 

[Trisomy13]

I read this post a few years back. A lot of it is common sense, and now having been out in a busy PP environment for almost a year, I can confirm that there is indeed some wisdom here. Could be I'm an easy-going guy to begin with, but the "roll-with the punches without being a total doormat" approach has worked for me (they want a brachial art-line for this case? uh ok, if that's the way they do a heart here...), and I feel like I complain less (i.e. I'm happier) than some of my colleagues who fight the minor battles.

good bump, sir. good bump.

 

[deleted171991]

Let's bump this again because, besides Jet's great initial post, it's funny how many of Volatile's predictions from 2006 have come true.

 

[Sirach38]

Wow it's like Volatile had a crystal ball...

 

[dhb]

no problems. keep doing what your doing. good luck to you. i hope, for your sake (and the sake of our profession), that you're right. we'll see if that's true by no later than about 2015 in my estimation.

Nice call

 

[Consigliere]

Not that difficult to predict the demise of this speciality. I don't know why you're so impressed by VolatileAgent's "precognition." It would be like me saying the Dallas Cowgirls won't be going to the Superbowl and everyone being amazed at my predictive abilities.

 

[deleted171991]

In 2006, things looked much rosier than today.

Maybe people will start listening to the pessimists now.

 

[Consigliere]

I'm not a pessimist. I'm a realist.

 

[Sirach38]

Are worst case scenarios realism?

 

[Planktonmd]

Are worst case scenarios realism?

The bottom line is that the good old days of this specialty are well behind us and the gravy train has left the station long time ago.
What's ahead is a struggle to redefine our role and to hold on to some of our constantly shrinking territory.
Unfortunately our leading organization has a vision of the future that is incompatible with the huge numbers of new grads being dumped on the market every year.
The ASA wants anesthesiologists to become peri-operative physicians and basically have less involvement with intra-operative management which will be dominated by mid-level providers.
That sounds great theoretically but they are forgetting that if we are less involved intra-op then there is no need for that many of us, and if we are doing the jobs of hospitalists and primary physicians then there is no reason why we should be paid more than them.
They are also forgetting that practicing perioperative medicine is not that difficult and it's a matter of time before mid-levels start claiming it as their domain as well.
This is the fundamental issue with our future, the lack of a meaningful strategy.

 

[Consigliere]

Are worst case scenarios realism?

Yes

 

[GA8314]

The bottom line is that the good old days of this specialty are well behind us and the gravy train has left the station long time ago.
What's ahead is a struggle to redefine our role and to hold on to some of our constantly shrinking territory.
Unfortunately our leading organization has a vision of the future that is incompatible with the huge numbers of new grads being dumped on the market every year.
The ASA wants anesthesiologists to become peri-operative physicians and basically have less involvement with intra-operative management which will be dominated by mid-level providers.
That sounds great theoretically but they are forgetting that if we are less involved intra-op then there is no need for that many of us, and if we are doing the jobs of hospitalists and primary physicians then there is no reason why we should be paid more than them.
They are also forgetting that practicing perioperative medicine is not that difficult and it's a matter of time before mid-levels start claiming it as their domain as well.
This is the fundamental issue with our future, the lack of a meaningful strategy.

Plankton, I've always respected your opinions/ideas/input.

It's true that our field has challenges. But, so does every field. In my current ACT model I am able to find meaningful ways of staying very relevant on a daily basis. I view myself as akin to that of an ICU doc but in the operative arena. With that, I use my medical knowledge on a daily basis, and make decisions accordingly. So do all of you.

I realize that mid-level enchroachment is everywhere. Some specialties more than others..... But, a 4:1 ACT model (rarely do I supervise 4 rooms but it does happen, more like 3 or even 2) is a pretty efficient way to run an OR. It frees the Anesthesiologist up to put efforts into those patients and procedures warranting his/her more advanced skills and training.

I know legislatively, we have big battles to fight. We can do this via our PAC. I feel the PSH, promoted by the ASA, is a fine way to go. It's an augmentation of our specialty, and I'm not seeing it as a REPLACEMENT of what we do. In any group, you could rotate the assigned PSH doc Q7 days, for example. Maybe the PSH doc carries the acute pain pager...... In a lower volume OB suite, maybe that doc carries the acute pain pager, runs the PSH duties (yet to be fully defined), and covers OB. It's not that big a deal. It will either work or it won't.

What is wrong with our field such that we are SO HYPERCRITICAL of ourselves. Sure, some healthy self-reflection is wise. But, we sell OURSELVES short all the time on these forums.

I think we get so good at what we do that we OURSELVES begin to believe it's all so routine (and indeed it CAN be) and even "easy". But, stop for a minute. Think about all of the skills that an anesthesiologist has in his/her arsenal. It's very substantial when you really reflect on it.

I just do not see the major catastrophe coming our way. Sure, reimbursements are likely to go down. Gravy train days of private planes and multiple home? Gone. Way gone. But, those of us coming up the pipeline already KNEW that.

The DEMAND for anesthesia services is INCREASING. Surely, we need to defend that demand, and we will. PACs, while imperfect, are a good place to start. Getting involved locally, and in your hospital is important to any group. But, doom and gloom? No. Opportunities? Yes.

We MISS opportunities every single day in this business. More on that perhaps later.

Yes, CRNA's (via the AANA) is a real pain in the neck. But, for relevant docs (i.e. up to date without major skill attrition) there will be work. It will always be good work.

For the younger docs. Tackle your debt. If the sky falls and whatever structure pays you $225K in the future, well, it's not a horrible thing. Do we accept it or WANT it? No. But, the fact is that the BOTTOM of our likely pay scale is still a very nice living and if it gets to that, then there will likely be concurrent changes (improvements) in lifestyle such as doing that for a regular 8 hr day. Or having the ability to make $50k more covering overnight OB or some other service.

Yes, we have challenges. But, anyone suggesting that any decent anesthesiologist won't have a good job ahead of him/her in the future isn't being realistic about the opportunities in our field. You will be able to do some nice things, live in a decent area, put your kids through college, have some nice stuff etc. If you want to make more money, just like today, you can always work your a.ss off further and take more call. Or work at multiple sites to get your "hours" up. But, there will be opportunities in this biz. I am certain of that.

 

[Consigliere]

I am certain of that.

I'm not.

 

[norwood]

But, a 4:1 ACT model (rarely do I supervise 4 rooms but it does happen, more like 3 or even 2) is a pretty efficient way to run an OR

(elided)

But, for relevant docs (i.e. up to date without major skill attrition) there will be work. It will always be good work.

Working 4:1 (to say nothing of 6:1 or 8:1) for an AMC is not good work. It is the anesthesia equivalent of a sweatshop.

The salary is not the issue. The issue is that anesthesiologists are expected to assume 100% of the responsibility for the inevitable bad outcomes - which will arise specifically because they're stretched too thin - while someone else pockets the money that should have gone to pay for adequate anesthesiologist staffing.

 

[pgg]

The salary is not the issue. The issue is that anesthesiologists are expected to assume 100% of the responsibility for the inevitable bad outcomes - which will arise specifically because they're stretched too thin - while someone else pockets the money that should have gone to pay for adequate anesthesiologist staffing.

That's a nightmare but it's not the future I think is most likely.

I think the future of the hospital setting is independent CRNAs working in the OR next door to an anesthesiologist who is not involved in the CRNA's case. Low acuity and easy cases are triaged via the schedule to the CRNA. The future is CRNAs taking the easy cases and low hanging fruit with an anesthesiologist around to do the sick people, put out CRNA fires, and occasionally do procedures 90%+ of CRNAs can't do (lines, blocks).

Which isn't the best outcome but it's better than the nightmare because we won't be responsible for their cases.

This is the reality I live in the military and at one of my locums jobs. It's not the best possible care for patients, but on the whole it's safe enough (see the Fight Club auto recall formula), and it's tolerable for us as anesthesiologists precisely because we're not liable for anything they do.

So the question then becomes, will there be enough jobs to employ all of us if that's the model? I think so, but who knows.


Medical direction / supervision at 3:1 or worse is my nightmare.

 

[Sirach38]

I guess in a way, as much as all the doom and gloom on this forum is discouraging, it's probably a great thing. Hearing the worse possible scenario is a really good thing for medical students considering the specialty. Anesthesiology will no longer be a "lifestyle" specialty that students with decent step 1 scores will chose because it will provide them with a great living. Maybe this doom and gloom will weed out med students that are thinking about gas for all the wrong reasons and we'll end up with a bunch of applicants who are doing gas because they love the specialty and are willing to fight for the specialty instead of looking for a nice "lifestyle". Maybe all of this doom and gloom will benefit the specialty in the end.

Or maybe the opposite will happen and matching into gas will become so easy because all of the smart kids will go for other specialties, that underqualified students who couldn't get into anything else will start applying to gas.

Who knows.

 

[Planktonmd]

Once the CEO of the hospital is allowed to have an "ACT" model where you supervise 6,7 or 8 OR's and run a whole anesthesia department with 2 "perioperative" doctors like you and 14 CRNA's do you think that CEO is going to say no?
This is the future and this is why we need less new grads.

Plankton, I've always respected your opinions/ideas/input.

It's true that our field has challenges. But, so does every field. In my current ACT model I am able to find meaningful ways of staying very relevant on a daily basis. I view myself as akin to that of an ICU doc but in the operative arena. With that, I use my medical knowledge on a daily basis, and make decisions accordingly. So do all of you.

I realize that mid-level enchroachment is everywhere. Some specialties more than others..... But, a 4:1 ACT model (rarely do I supervise 4 rooms but it does happen, more like 3 or even 2) is a pretty efficient way to run an OR. It frees the Anesthesiologist up to put efforts into those patients and procedures warranting his/her more advanced skills and training.

I know legislatively, we have big battles to fight. We can do this via our PAC. I feel the PSH, promoted by the ASA, is a fine way to go. It's an augmentation of our specialty, and I'm not seeing it as a REPLACEMENT of what we do. In any group, you could rotate the assigned PSH doc Q7 days, for example. Maybe the PSH doc carries the acute pain pager...... In a lower volume OB suite, maybe that doc carries the acute pain pager, runs the PSH duties (yet to be fully defined), and covers OB. It's not that big a deal. It will either work or it won't.

What is wrong with our field such that we are SO HYPERCRITICAL of ourselves. Sure, some healthy self-reflection is wise. But, we sell OURSELVES short all the time on these forums.

I think we get so good at what we do that we OURSELVES begin to believe it's all so routine (and indeed it CAN be) and even "easy". But, stop for a minute. Think about all of the skills that an anesthesiologist has in his/her arsenal. It's very substantial when you really reflect on it.

I just do not see the major catastrophe coming our way. Sure, reimbursements are likely to go down. Gravy train days of private planes and multiple home? Gone. Way gone. But, those of us coming up the pipeline already KNEW that.

The DEMAND for anesthesia services is INCREASING. Surely, we need to defend that demand, and we will. PACs, while imperfect, are a good place to start. Getting involved locally, and in your hospital is important to any group. But, doom and gloom? No. Opportunities? Yes.

We MISS opportunities every single day in this business. More on that perhaps later.

Yes, CRNA's (via the AANA) is a real pain in the neck. But, for relevant docs (i.e. up to date without major skill attrition) there will be work. It will always be good work.

For the younger docs. Tackle your debt. If the sky falls and whatever structure pays you $225K in the future, well, it's not a horrible thing. Do we accept it or WANT it? No. But, the fact is that the BOTTOM of our likely pay scale is still a very nice living and if it gets to that, then there will likely be concurrent changes (improvements) in lifestyle such as doing that for a regular 8 hr day. Or having the ability to make $50k more covering overnight OB or some other service.

Yes, we have challenges. But, anyone suggesting that any decent anesthesiologist won't have a good job ahead of him/her in the future isn't being realistic about the opportunities in our field. You will be able to do some nice things, live in a decent area, put your kids through college, have some nice stuff etc. If you want to make more money, just like today, you can always work your a.ss off further and take more call. Or work at multiple sites to get your "hours" up. But, there will be opportunities in this biz. I am certain of that.

 

[Carbocation1]

For the life of me, I just can't understand how patients are OK with the 4:1 model. If something goes wrong with the airway, it takes just 4 minutes until the patient is braindead.

I can't wait until people start questioning the need for 1 pilot per airplane, and come up with ways a single pilot can monitor multiple planes with "advanced software."

 

[IkeBoy18]

Of course Im not very knowledgable when it comes to the politics of this; arent residents cheaper than CRNAs? If money is driving the machine to 1:5+ supervision models, how will it be possible to convince anesthesia departments (or hospital admin) to spend money to hire more CRNAs and decrease the # of residents in order to again spend more money on the back end (if this method increases demand) to pay the few anesthesiologists?

Also, with CRNAs at that point doing the vast majority of anesthetics, could this have the opposite effect and prove that MDs are not needed for the majority of cases and feed higher ratios or as pgg says, just have one MD in the building working in a collaborative model?

Decreasing spots seems like a good thought, Im just not sure how that would happen in money driven medicine. Especially when the money changers dont care about the state of any field in medicine, but the profit they can make.

edit: I get that we can get rid of many attendings to free up money for CRNAs, Im just not sure this method without some other intervention isnt also detrimental to the field.

 

[norwood]

For the life of me, I just can't understand how patients are OK with the 4:1 model. If something goes wrong with the airway, it takes just 4 minutes until the patient is braindead.

I can't wait until people start questioning the need for 1 pilot per airplane, and come up with ways a single pilot can monitor multiple planes with "advanced software."

Although I agree with the gist of your message, I feel compelled to say: commercial transport airplanes always have two pilots! This is crucial because one will, very occasionally, become incapacitated.

Needless to say, the aviation world's AMC equivalents have been trying to do away with the 2nd pilot for years.

 

[norwood]

That's a nightmare but it's not the future I think is most likely.
...
This is the reality I live in the military and at one of my locums jobs. It's not the best possible care for patients, but on the whole it's safe enough (see the Fight Club auto recall formula), and it's tolerable for us as anesthesiologists precisely because we're not liable for anything they do.
...
Medical direction / supervision at 3:1 or worse is my nightmare.

Yeah, I'd be much more OK with side-by-side practice than with 4:1 or worse. 3:1, under the right circumstances (read: healthy pts, not major procedures, and competent CRNAs), I could deal with.

I guess in a way, as much as all the doom and gloom on this forum is discouraging, it's probably a great thing. Hearing the worse possible scenario is a really good thing for medical students considering the specialty. Anesthesiology will no longer be a "lifestyle" specialty that students with decent step 1 scores will chose because it will provide them with a great living. Maybe this doom and gloom will weed out med students that are thinking about gas for all the wrong reasons and we'll end up with a bunch of applicants who are doing gas because they love the specialty and are willing to fight for the specialty instead of looking for a nice "lifestyle". Maybe all of this doom and gloom will benefit the specialty in the end.

Or maybe the opposite will happen and matching into gas will become so easy because all of the smart kids will go for other specialties, that underqualified students who couldn't get into anything else will start applying to gas.

Who knows.

The problem is that there are currently more people trying to match, than positions. It's already been empirically proven that it's hard for a program to be sufficiently malignant and undesirable that *nobody*, not even hungry IMGs, will take it.

 

[Postictal Raiden]

For the life of me, I just can't understand how patients are OK with the 4:1 model. If something goes wrong with the airway, it takes just 4 minutes until the patient is braindead.

I can't wait until people start questioning the need for 1 pilot per airplane, and come up with ways a single pilot can monitor multiple planes with "advanced software."

Are there even enough CRNA's to support the 4:1 model? Currently, CRNA programs are pumping ~1.5x the number of total anesthesiology grads.

 

[deleted171991]

Are there even enough CRNA's to support the 4:1 model?

Absolutely. All you need to do is fire some anesthesiologists.

 

[IlDestriero]

Working 4:1 (to say nothing of 6:1 or 8:1) for an AMC is not good work. It is the anesthesia equivalent of a sweatshop.

The salary is not the issue. The issue is that anesthesiologists are expected to assume 100% of the responsibility for the inevitable bad outcomes - which will arise specifically because they're stretched too thin - while someone else pockets the money that should have gone to pay for adequate anesthesiologist staffing.

Exactly.
4:1 is a sweat shop. That's something you electively do to yourself as a partner to make yourself wealthy. That's not something you want to do as an employee at 300k while making others wealthy. For 600+, sure, I've got plenty of running shoes.
People that think employed 4:1 is fine don't understand what a well run 4:1 practice is doing in the real world.

 

[Postictal Raiden]

Absolutely. All you need to do is fire some anesthesiologists.

Ouch!

 

[deleted171991]

What I was trying to suggest is that the ACT model is probably used in about 75% of anesthetics, in a 2:1-4:1 model. If one goes from a 3:1 model to a 4:1, one needs 25% less anesthesiologists. If going from solo to 3:1, one needs 66% less anesthesiologists! Do you like it yet? If, on top of this, you add the CRNAs that will take care independently of ASA 1-2 patients in the future, it's even fewer anesthesiologists.

We are as f*cked up as primary care, and whoever thinks we won't end up in the same deep feces as them should stop drinking the Kool-aid now.

 

[norwood]

What I was trying to suggest is that the ACT model is probably used in about 75% of anesthetics, in a 2:1-4:1 model.

Big difference between 2:1 and 4:1, though...

 

[Planktonmd]

For the life of me, I just can't understand how patients are OK with the 4:1 model. If something goes wrong with the airway, it takes just 4 minutes until the patient is braindead.

I can't wait until people start questioning the need for 1 pilot per airplane, and come up with ways a single pilot can monitor multiple planes with "advanced software."

Most patients don't know anything about our role, and the majority of them think anesthesia providers are the people with syringes who inject the drugs when the doctor (the surgeon) orders them to do so.

 

[deleted171991]

Most patients don't know anything about our role, and the majority of them think anesthesia providers are the people with syringes who inject the drugs when the doctor (the surgeon) orders them to do so.

That's correct. We are part of the "OR staff". We are neither "the doctor" or "a doctor" for most patients. We are just the ones to blame and to complain to the surgeon about if anything doesn't go spa perfect, as expected by the uneducated. Of course, there are always the 10-20% exceptions, which make the job pleasant but, for most people, we are just a notch above the OR nurse.

If we were so important, we would get requests all the time from patients referred by our former patients, as every significant physician does. Most of us, as individual anesthesiologists, are about as important to the patients as the brand of lactated ringer's. And as replaceable.

 

[BuzzPhreed]

Exactly.
4:1 is a sweat shop. That's something you electively do to yourself as a partner to make yourself wealthy. That's not something you want to do as an employee at 300k while making others wealthy. For 600+, sure, I've got plenty of running shoes.
People that think employed 4:1 is fine don't understand what a well run 4:1 practice is doing in the real world.

This is 100% truth. Do not bust your balls in a practice if there is no clear pathway to partnership.

If you even remotely suspect that whatever practice you're considering joining is engaged in this type of operation, don't walk -- run -- away from them. Believe me, even waking to a house on the beach every day won't make it worth the hell you will endure at work. Remember too that it can all be taken away from you with one lawsuit, especially when that CRNA says "I called the doc to help, but they didn't come right away" nevermind that you were putting out some fire in another OR.

 

[kazuma]

That's correct. We are part of the "OR staff". We are neither "the doctor" or "a doctor" for most patients. We are just the ones to blame and to complain to the surgeon about if anything doesn't go spa perfect, as expected by the uneducated. Of course, there are always the 10-20% exceptions, which make the job pleasant but, for most people, we are just a notch above the OR nurse.

If we were so important, we would get requests all the time from patients referred by our former patients, as every significant physician does. Most of us, as individual anesthesiologists, are about as important to the patients as the brand of lactated ringer's. And as replaceable.

Yeah, I'd be broke if I worked based of requests, I've only had 4 requests by patients to do their cases during residency.

However, at least at my place many of the surgeons do make requests and don't view us as replaceable. At least we have that going for us.

 

[Planktonmd]

Yeah, I'd be broke if I worked based of requests, I've only had 4 requests by patients to do their cases during residency.

However, at least at my place many of the surgeons do make requests and don't view us as replaceable. At least we have that going for us.

Trust me... you are replaceable... those surgeons who love you now wouldn't mind having a chimpanzee at the head of the table if the chimps were the only anesthesia providers the hospital offered.

 

[Planktonmd]

Welcome to the future of anesthesiology!

 

[Carbocation1]

From Becker's:


"4. Hospitals are emphasizing value over productivity. In order to combat increased financial pressures such as the aforementioned boost in benefit plan costs, hospitals have traditionally encouraged higher levels of productivity. However, the fee-for-service environment is becoming a thing of the past. Focusing on volume is not a silver bullet in an increasingly value-based environment, but at the same time, hospitals cannot just "let physicians do what they want in terms of productivity," Dr. Flannery says.

Therefore, in compensation plans, hospitals are incentivizing physicians to focus their energy and efforts on high-level cases instead of "churning numbers." Instead, advanced practice clinicians, such as nurse practitioners and physician assistants, are helping with simpler cases, a process that has boosted their compensation as well.

"Physicians have to practice at the top of their skill level, and that's not happening," Dr. Flannery says. "When we see physicians operating at the top of their skill level, pediatricians aren't seeing strep throat and ear infections — those are being seeing by nurse practitioners. Therefore, nurse practitioners need to operate at the top of their skill level, too. When the value goes up, compensation goes up, and it frees up time for more complicated cases for physicians"

So mid-levels taking care of simpler cases is definitely here to stay as we move away from the fee for service model. But why does this lead to increasing compensation for physicians? Because they get reimbursed much higher for taking care of complex cases? This article makes it sounds like CRNAs are a boon to physicians. Am I reading this wrong?

 

[BuzzPhreed]

This article makes it sounds like CRNAs are a boon to physicians. Am I reading this wrong?

CRNAs think they can -- and they should -- also be able to take care of the complex cases without necessarily your input or support. You should just shut-up, sign the chart, and be lucky you are collecting any fee.

 

[nimbus]

So mid-levels taking care of simpler cases is definitely here to stay as we move away from the fee for service model. But why does this lead to increasing compensation for physicians? Because they get reimbursed much higher for taking care of complex cases? This article makes it sounds like CRNAs are a boon to physicians. Am I reading this wrong?

It's actually the opposite in anesthesia. Because the government programs pay so poorly, you get paid more for taking care of healthy young patients usually getting simple procedures. The 88yo ESRD COPD AS 20%EF with aortic arch dissection for repair on circ arrest undoubtedly has Medicare/Medicaid paying $20/unit. You have to subsidize their care with knee scopes and breast augs.

 

[Carbocation1]

CRNAs think they can -- and they should -- also be able to take care of the complex cases without necessarily your input or support. You should just shut-up, sign the chart, and be lucky you are collecting any fee.

It's actually the opposite in anesthesia. Because the government programs pay so poorly, you get paid more for taking care of healthy young patients usually getting simple procedures. The 88yo ESRD COPD AS 20%EF with aortic arch dissection for repair on circ arrest undoubtedly has Medicare/Medicaid paying $20/unit.

I had my heart set on Gas but stuff like this makes just want to go IM-->Cards instead. 443/487 of US grads match cards (91%) so it doesn't seem as competitive as people make it seem. Maybe managing chronic diseases/owning the patient won't be as bad as I think.

 

[Planktonmd]

From Becker's:


"4. Hospitals are emphasizing value over productivity. In order to combat increased financial pressures such as the aforementioned boost in benefit plan costs, hospitals have traditionally encouraged higher levels of productivity. However, the fee-for-service environment is becoming a thing of the past. Focusing on volume is not a silver bullet in an increasingly value-based environment, but at the same time, hospitals cannot just "let physicians do what they want in terms of productivity," Dr. Flannery says.

Therefore, in compensation plans, hospitals are incentivizing physicians to focus their energy and efforts on high-level cases instead of "churning numbers." Instead, advanced practice clinicians, such as nurse practitioners and physician assistants, are helping with simpler cases, a process that has boosted their compensation as well.

"Physicians have to practice at the top of their skill level, and that's not happening," Dr. Flannery says. "When we see physicians operating at the top of their skill level, pediatricians aren't seeing strep throat and ear infections — those are being seeing by nurse practitioners. Therefore, nurse practitioners need to operate at the top of their skill level, too. When the value goes up, compensation goes up, and it frees up time for more complicated cases for physicians"

So mid-levels taking care of simpler cases is definitely here to stay as we move away from the fee for service model. But why does this lead to increasing compensation for physicians? Because they get reimbursed much higher for taking care of complex cases? This article makes it sounds like CRNAs are a boon to physicians. Am I reading this wrong?

If physicians are going to treat only the difficult and complicated cases then you need less physicians because 90% of daily practice is bread and butter easy stuff.
So, you can't say physicians are here only to handle the rare stuff and keep producing all these new physicians and telling them they will still find jobs and get well compensated.

 

[Carbocation1]

If physicians are going to treat only the difficult and complicated cases then you need less physicians because 90% of daily practice is bread and butter easy stuff.
So, you can't say physicians are here only to handle the rare stuff and keep producing all these new physicians and telling them they will still find jobs and get well compensated.

Exactly, and I think the more behind the scenes role of the anesthesiologist only exacerbates this issue. Most patients are unaware and won't know the difference if a CRNA took care of them instead of an MD. On the other hand, I don't know if any patient would be OK with seeing a nurse cardiologist instead of an MD cardiologist. But they said that about replacing bankers with ATMs/online banking and now nobody goes to a banker anymore.

 

[GA8314]

o.k. the pessimism on this thread is getting to the point of over the top. Guys, healthcare is changing. Who knows how it will all play out. RATES of enchroachment in anesthesia are nowhere near the rates of mid-level's moving into many other fields. Almost all major specialties are using them. They are physician extenders.

In our field, if PGG's predictions are true (I could see this and it seems many of us all agree that it wouldn't be the total end of the world. Safest? Best? Probably not, but that's a decision society will both make and need to live with), then those of us in ACT practices have EVEN MORE impetus to REMAIN hands on and to avoid skill attrition.

Nevertheless, as I've stated in past threads, it's not as "easy" to lose skills as I even thought it would be, in an ACT model.

If you are good at giving anesthesia, fast, efficient, and have a good personality, then there WILL be plenty of jobs in the future giving direct care if that's where we are headed.

Meantime, work hard, enhance your skills, get better, enjoy your life, be prepared for some change. But, don't prepare for the end of the world. Because, life is too short and your own quality of life will go down if you obsess about the "coulds"..... Be vigilant but not obsessive about this stuff....

 

[Carbocation1]

o.k. the pessimism on this thread is getting to the point of over the top. Guys, healthcare is changing. Who knows how it will all play out. RATES of enchroachment in anesthesia are nowhere near the rates of mid-level's moving into many other fields. Almost all major specialties are using them. They are physician extenders.

Out of curiosity, can you name a few?

 

[RxBoy]

(ADDENDUM: I wrote this a cuppla years ago. Its got alotta useful information in it for you. I'm bumping it for the benefit of my CA-3 colleagues who may have missed it and are gonna be on their own in a few months.)

Ill tell you guys something, coming from a guy who was mr academia resident that transitioned into a busy, highly efficient and lucrative private practice gig.

Read every word in Jet's post. EVERY SINGLE WORD. Learning the clinical stuff is important with SDN.

But nothing is more important than this post for the private practice anesthesiologist. Accommodation, proficiency, and speed are the greatest value you can provide.

One of the best posts Ive read.

 

[k12balla]

A lot of doom and gloom as usual, but what are our actual solutions?

1. Practice in an MD only model - while ideal, its going by the wayside. There is just no way to sustain this and compete with AMCs/ACT model in terms of cost and productivity.

2. Continue with the ACT model - Anesthesia is only getting safer technology wise, and the suits will have no problem sacrificing patient safety for profits. Those with no supervision will be 2:1-3:1 initially, 2:1 practices will go to 4:1, and eventually we will be 6:1, 8:1, maybe even 10:1 as longs as its reimbursable. Taking on the added liability while padding your own pockets is perfectly reasonable, but doing so as an employee with a fixed salary makes little rational sense.

3. Practice in a collaborative model - "MDAs" and our bastard step siblings with less intellect and louder mouths, practicing side by side. Our parents would be so proud. Again, as many have mentioned, CRNAs will likely get to pick the low hanging fruit, ASA 1s/2s with better rates, while all that extra training will allow us to do their procedures/lines, put out fires, and stabilize the sicker patients with no insurance. Overtime, apples to orange analyses will be done showing more "optimal" care and less morbidity/mortality under their watch. We will kick and scream, and no one will listen. Our reimbursements will continue to decrease, and begin to mirror each others, since we will essentially be "equivalent" through the suit's eyes.

4. Get on board with the PSH model - Carving out a niche is great and all, but rounding on patients and handing out patient satisfaction surveys can also be done by a trained monkey/mid level provider so don't fool yourselves or us into believing this is the wave of the future. It does not take a rocket science to understand that a collaborative team effort with protocols for regional/neuroaxial anesthesia on ortho patients will lead to less pain, shorter hospital stay, and more money. But yet again, in an AMC model, we will be volunteering these extra services, while seeing little to if any of the reward, all for the purpose of trying to prove our worth and indispensability. Meanwhile we're doing the exact opposite of the things that enticed us into the field of Anesthesiology.

5. Obtain fellowship in Pain/CCM/CV - While they are somewhat viable solutions, you will likely be sacrificing OR time. A year of extra training doing hearts/TEE sounds well worthwhile, but its only a matter of time before CRNAs start having their own "fellowships" following their "residencies" and are allowed to do this case under supervision or independently.

6. Bust your ass while you can and save for the inevitable demise of our specialty. Invest and live well below your means, and maybe one day open a day spa and do botox injections all day.

Sorry for the rant, but I think that pretty much summarizes where we're at and our options. Feel free to chime in with your own predictions.

 

[pgg]

443/487 of US grads match cards (91%) so it doesn't seem as competitive as people make it seem.

There is significant self-selection clouding those numbers. Weak or average applicants don't apply at the same rates strong applicants do.

Out of curiosity, can you name a few?

Primary care. FP, IM, peds ... 'course, those fields seem to be beneath most on this forum in the first place, so I guess they don't count.

 

[G0S2]

"Bust your ass while you can and save for the inevitable demise of our specialty. Invest and live well below your means, and maybe one day open a day spa and do botox injections all day. "


Honestly exactly what I have been thinking. All MD practice now but I know it will not last. Huge market in this city, especially on my side, for Botox. I actually may attend one of those $$ one day courses. I know plastics looks down on other specialties doing it but f*ck it; it's my future and I have 3 little ones.

 

[criticalelement]

If you are good at giving anesthesia, fast, efficient, and have a good personality, then there WILL be plenty of jobs in the future giving direct care if that's where we are headed.
...

You may be correct about your assumption but how much will those jobs pay? Why pay a doc 240K when according to an administrator A CRNA can do the same job for 160k? Suddenly you are working for less because A job is better than NO job right? That doesnt sound like a recipe for professional satisfaction.

This specialty took a massive downturn when the anesthesia management companies started to proliferate. Now they control how you are going to practice not YOU. If they want you to supervise 4 crnas.. Not much you can do about it unless you leave. Now your credentials dont necessarily speak for themselves. What someone else thinks about your credentilals is what matters.

Are there going to be jobs out there in anesthesia in the near future? Perhaps. . They wont necessarily be professionally satisfying job though.

 

[Mman]

Exactly, and I think the more behind the scenes role of the anesthesiologist only exacerbates this issue. Most patients are unaware and won't know the difference if a CRNA took care of them instead of an MD. On the other hand, I don't know if any patient would be OK with seeing a nurse cardiologist instead of an MD cardiologist. But they said that about replacing bankers with ATMs/online banking and now nobody goes to a banker anymore.

What's a "banker"? People go online and use ATMs to replace things they used to do with tellers. You know those folks that may or may not even have a high school diploma that stand there and put your money in a machine to count it out for you and check your ID.

 

[GA8314]

Making $200k for a 40 hour week, no call, no weekends (unless you volunteer for it and thus will earn more) isn't exactly the end of the world. I would not LIKE it, but it's basically an absolute worst case scenario. Meantime, may hay while you can. Enjoy your job. Realize we are in a squeeze economy and always have been, only now medicine is no longer an exception and will be exposed to the same "efficiency" rules that everyone else has been dealing with for years.

Clear up your debt. Keep your fixed expenses reasonable. Enjoy your life. Don't worry about sh.t you can't control. Do what you can to impact that which you can effect, but don't be a martyr.

Yes, there are plenty of things a physician can do. The ranks of the anti-aging medicine docs are filled with MD/DO's from many other specialties, but not likely anesthesiologists. Perhaps that will change. Who knows.

Again, be good at your craft. Maintain your skills. Be fast and work hard. Be likable. If you can do those things, you WILL have a job.