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wjs010

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So, I'll be starting med school next fall and have been reading this board for a long while. I see polarized comments that probably leave me more confused than before I came, such as one of you saying that money will only be made in medicine if you go into a high paying specialty, then another doc swearing that high paying specialties like ortho will get drastic cuts due to ACA and therefore is the worst.

So I got to thinking about something very basic : the problem of mid level encroachment. Yes I know that there are a zillion threads on this but I never see this argument: crna's are cheaper and can "sometimes" do the job just like a reals anesthesia physician. So since CRNA's can do a "fair" job, it seems as though they will be taking over anesthesia. But what does that say about the pride of our US healthcare system ? It speaks pretty poorly to me. It's like the government is actually okay with CRNA's taking over. It would be status quo. But status quo isn't good enough. Do CRNA's advance the field of anesthesia? Do they make innovative additions to the field? No, isn't it the anesthesia physicians that do that? The ones who went to medical school and busted their asses to learn everything about anesthesia. The ones who have dedicated their lives to research. Well, do we see CRNA research changing the field of anesthesia for the better? Someone please enlighten me, because it seems that this country is becoming complacent with lesser quality healthcare, and there is less pride and respect for docs than there used to be. How can anesthesia or any field with mid levels make discoveries and change the field for the better if the CRNA's are just doing the technical aspect of anesthesia with having only a fraction of the education? I don't think our current system is trying to be the best . I could be wrong and some doc on this board will say that mid levels will never take over.. But it's just the principle that instead of making innovation the priority and leading to better healthcare, the gov only cares about costs. Surely this field can't grow if there is a status quo

Too long, didn't read?
Question: why isn't innovation and top notch healthcare the main priority in all of medicine? Why do we allow much less quality by letting CRNA's eventually take over? It's the anesthesia docs/PhD who make innovations to this field.. NOT CRNA's.
 

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Are these rhetorical questions?

...It is pretty clear that all the answers largely involve $$$.

Why are CRNA's of interest to employers? cheaper $$$
How are nurse orgs effective with gaining ground? lobbying $$$
Why is the US not focused on HC innovation? cheaper $$$
 

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But what does that say about the pride of our US healthcare system ? It speaks pretty poorly to me. It's like the government is actually okay with CRNA's taking over.
It speaks poorly to all of us on this board I believe and thats why there are very many adamant people who have a very dismal portrayal of the future of anesthesia as a medical specialty. Just do a search. And I don't think they are people who are generally disgruntled. These are practicing docs who call it as they see it. At any rate, I will post another thread about columbus ohio area hospital that is switching to CRNA model. The company taking over is likening anesthesia care team to zone defense rather than man to man (MD ONLY model). And the hospitals are buying it. MISERABLE....
Here is the link..http://www.dispatch.com/content/stories/local/2013/11/30/hospital-to-switch-anesthesia-services.html
 

countingdays

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You are basically right. We are in a race to the bottom- to the minimal education and training to avoid harming so many people that it gets the public's attention.
There is no question what training is the best, but the best is no longer sought after. Good enough is good enough, and if good enough isn't really good enough, reporting and detection of morbidity is so poor that inadequate will seem good enough.
Crnas, pa's, and np's better watch their backs because soon an even lesser trained group will come along claiming that they are just as good. Maybe high school students with a really good iphone app could practice nursing or whatever.
 
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WholeLottaGame7

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Health care is already solidly in the realm of a service industry. As with any service industry, there are a variety of levels of service in order to accommodate different wants/needs of the consumers. I'm guessing that most of us non-attendings don't drive a BMW or Lexus or Range Rover. Why not? They are top-notch, industry-leading cars. They are often at the forefront of new car technology. Why don't we all have one? Because it's not economically feasible for us.

I similarly see health care layering out. Some people will drive 20-year old beaters, some people Kias, some people Mercedes. There will be a place for a variety of different types of providers.

Am I saying this is the ideal scenario? No. But is it also the end of the world for MD anesthesia? I would vote no also, particularly if you are able to show people the benefit of your advanced training and skills. Just my $.02.
 
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wjs010

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Can you imagine where we'd be in the 1950s if we didn't let the guys who knew what they were doing try to go to the moon? We let the best, most educated engineers and physicists make that happen, but the difference is that everyone in the nation was for that innovation. People are NOT for healthcare innovation. I think this is largely because as long as younger people have their smartphones, they will become addicted to its wonders and the populace will just become dumber and dumber.

I'm 24 and I feel 75 talking like this, but I'm ashamed of the values and principles this country has come to place on healthcare and research... Ie, it's eventually going to be like the above poster said: there will be co op high school nursing programs that lead straight into a 1 year CRNA "residency".

The funny part is... I'm not blaming the CRNA's( well , maybe their lobbyists of course). I'm blaming this damn country and how with each generation, we get dumber and dumber! The people I'm charge of healthcare ( not doctors ironically) love this fact!
 
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cognitus

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As an anesthesiologist, just focus on procedures that CRNAs generally don't touch. If you're an attending who strictly does lap appi's or lap chole's, then you will be replaced. Like any service profession, an MD anesthesiologist will be replaced with cheaper labor if he can't demonstrate value. Demonstrate value by being able to provide anesthesia to sicker patients and more complicated cases and you'll be fine. That's what I plan to do. And to answer your question, I think CRNAs preside over healthier and easier cases in which an advanced education is not as necessary. I think the US healthcare system will continue to support MD anesthesiologists for the more complicated cases.
 
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wjs010

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As an anesthesiologist, just focus on procedures that CRNAs generally don't touch. If you're an attending who strictly does lap appi's or lap chole's, then you will be replaced. Like any service profession, an MD anesthesiologist will be replaced with cheaper labor if he can't demonstrate value. Demonstrate value by being able to provide anesthesia to sicker patients and more complicated cases and you'll be fine. That's what I plan to do.
What if CRNA's just learn how to do everything in your niche? Will you keep changing what you do until the swarm becomes overwhelming?
 
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cognitus

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What if CRNA's just learn how to do everything in your niche? Will you keep changing what you do until the swarm becomes overwhelming?
What if nurses learn to do what doctors do? What if PAs learn what physicians do? I'm not worried. To answer your questions, who would you rather have as a primary case provider: A nurse practitioner or an MD?
 
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wjs010

wjs010

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What if nurses learn to do what doctors do? What if PAs learn what physicians do? I'm not worried. To answer your questions, who would you rather have as a primary case provider: A nurse practitioner or an MD?
Me? An MD anytime . But there is a shift in the average person's view of the efficacy of the PA or DNP in healthcare. Even people not caring is bad... Because the mid levels are in fact cheaper. But I'm glad you're not worried. I guess there is too much worry on this site .
 

cognitus

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I was worried too after going on this site. However, I'm less worried after going on a few anesthesia interviews and speaking to anesthesiologists
 

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Dude,

Do NOT get into anesthesia now, unless your endpoint is critical care. Seriously. You'll get great skills and have a great time, but in 15-20 years nobody will care about you. Most people/doctors have no idea what anesthesiologists do, or the value they bring to the table. You will be as respected and and as well-paid as a nurse or tech. More CRNA's have to become completely independent, and thus kill more patients a year, for us to become truly relevant again.

Other anesthesiologists will tell you that I am pessimistic, that there is always a great career ahead for the best, blah-blah, but unless you LOVE this specialty, you will pay dearly for your choice. In 10 years or less, you will be just a surgical hospitalist who will be doing the dirty work for surgeons (taking care of their patients pre- and post-op, taking care of surgical patients overnight, so that surgeons can do only what they like - operate and make money), or an OR fireman and pre-op monkey for CRNA's, but you will not get true one-on-one patient-care in the OR, unless you are one of the best who will take care of the sickest patients. Who do you think will man the "perioperative surgical home"? The surgeons, who are so close to the heart of every hospital administrator?
 
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ssmallz

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As an anesthesiologist, just focus on procedures that CRNAs generally don't touch. If you're an attending who strictly does lap appi's or lap chole's, then you will be replaced. Like any service profession, an MD anesthesiologist will be replaced with cheaper labor if he can't demonstrate value. Demonstrate value by being able to provide anesthesia to sicker patients and more complicated cases and you'll be fine. That's what I plan to do. And to answer your question, I think CRNAs preside over healthier and easier cases in which an advanced education is not as necessary. I think the US healthcare system will continue to support MD anesthesiologists for the more complicated cases.
This sounds like a nice theory but in order for this to work the way in which we are reimbursed needs to change. Fact of the matter is that healthier younger people (<65 y/o) generally have better insurance than older sicker people and quicker simpler cases pay better then big complicated ones. That's where the crux of the problem comes from. You can generate more units and $$ doing b&b g surg and ortho cases than you will doing big complicated hearts and crazy high risk vascular cases with significantly less stress. Until this changes anesthesiologists need to have their hands in the b&b stuff b/c otherwise it won't pay to do the complicated stuff.
 

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+1 what ssmallz said. When the money-making b&b non-Medicrap cases will be given to independent CRNA's, anesthesiologists will become even less relevant for hospital administrators.

There is NO subspecialty that CRNA's will not cannibalize in the end (except ICU). Pandora's box has been opened, much-much more than in other specialties. You want proof? See what happens to a CRNA who talks back to an anesthesiologist (nothing-zilch-nada) versus the surgical NP/PA - surgeon situation (disciplined, possibly even fired if not the first time).

Remember: for a long time, cars were driven only by specialized chauffeurs. Until they became safe enough for the regular moron. Nothing different about anesthesia, slowly applying to the entire medical field.
 
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cognitus

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+1 what ssmallz said. When the money-making b&b non-Medicrap cases will be given to independent CRNA's, anesthesiologists will become even less relevant for hospital administrators.

There is NO subspecialty that CRNA's will not cannibalize in the end (except ICU). Pandora's box has been opened, much-much more than in other specialties. You want proof? See what happens to a CRNA who talks back to an anesthesiologist (nothing-zilch-nada) versus the surgical NP/PA - surgeon situation (disciplined, possibly even fired if not the first time).

Remember: for a long time, cars were driven only by specialized chauffeurs. Until they became safe enough for the regular moron. Nothing different about anesthesia, slowly applying to the entire medical field.
The key is slowly. I'm not concerned. BTW, if you compare anesthesiology to driving a car, then you are really in the wrong profession and don't fully understand your value. In the hospitals I've interviewed at, the CRNAs only do the B&B procedures. It tells me that those who pursue the CRNA don't really have the ambition to cannabalize all of anesthesia procedures. They technically could, but the mindset of CRNAs is to go through a minimal amount of training and then get paid pursuing the low hanging fruit of B&B procedures. Therefore, I think if there were any cannabalization, it would happen VERY slowly since only a small minority of CRNAs would attempt these procedures. Besides, while b&b procedures probably pay better from a time standpoint, I would think that my value as an anesthesiologist would be my ability to perform complicated procedures if necessary. I'd concentrate on mastering those in residency so that when I do apply for attending positions, I will be chosen over a CRNA who can ONLY do b&b procedures. There will always be sick patients, someone has to be able to handle them.
 

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What we need to do is ALLOW crnas to practice independently.

Also, allow them (or their employing hospital) to be sued for malpractice when the spit (inevitably) hits the fan.

It may take a couple years (and wrongful-death lawsuits), but eventually things will work out.
 

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cognitus, you seem to forget that enough technological progress can make any job simple enough. Cardiac echos used to be done by cardiologists for $1000+; nowadays they are done by techs and read by cardiologists for almost peanuts. Remember how difficult certain nerve blocks were before the ultrasound era? Or that people used to die in significant numbers during anesthesia? You just keep concentrating on all those "complicated" procedures that "nobody else" could do. Don't forget that, in the future, any task that is repetitive enough will probably be embedded in a protocol that will not require a physician.

It's not that nobody will need anesthesiologists in the future; they will need us, just way fewer and underpaid. But you go ahead, because I am just a stupid board-certified attending looking pessimistically at the job market, and you are such a highly intelligent residency and internship applicant. You also seem to be older, which will put you in even more trouble than the average graduate. I sincerely hope you have no debts.
 
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cognitus

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cognitus, you seem to forget that enough technological progress can make any job simple enough. Cardiac echos used to be done by cardiologists for $1000+; nowadays they are done by techs and read by cardiologists for almost peanuts. Remember how difficult certain nerve blocks were before the ultrasound era? Or that people used to die in significant numbers during anesthesia? You just keep concentrating on all those "complicated" procedures that "nobody else" could do. Don't forget that, in the future, any task that is repetitive enough will probably be embedded in a protocol that will not require a physician.

It's not that nobody will need anesthesiologists in the future; they will need us, just way fewer and underpaid. But you go ahead, because I am just a stupid board-certified attending looking pessimistically at the job market, and you are such a highly intelligent residency and internship applicant. You also seem to be older, which will put you in even more trouble than the average graduate. I sincerely hope you have no debts.
out of curiosity, how do I sound older? All I know is that MDs are still performing the echos and regional blocks with or without US. You seem bitter though. Why haven't you considered a career change?
 

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cognitus said:
I have an MBA from a top-10 school
I guess you didn't just spend 100 grand without working a few years after that.
 
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wjs010

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spinach that is a great idea. New question: if CRNAs do become independent, do you think they will kill enough patients ( i know this is terrible) to make a statement about the importance of MD/DO anesthesiologists?
 

cognitus

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I guess you didn't just spend 100 grand without working a few years after that.
Well, you are correct about that. I also truly think that MDs will be needed to take care of really sick patients and the CRNAs will not encroach on that. I'd just work on demonstrating your value. FFP, if you had to do it again, what career would you choose? Seems like you regret anesthesiology. I'm interested in what your answer is
 

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You remind me of myself before I started my training. I even remember an interview question asking whether I was afraid of CRNAs or automated systems taking anesthesia over; back then I used the same arguments as you. :)

If I had to choose again, I would not do medicine. I would probably study some form of economics or engineering.

I don't think there is anything else in medicine that is as rewarding as practicing anesthesia one-on-one. I just don't like that it used to be a nursing field, and it seems to be heading back there.
 
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cognitus

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You remind me of myself before I started my training. I even remember an interview question asking whether I was afraid of CRNAs or automated systems taking anesthesia over; back then I used the same arguments as you. :)
When did you get so bitter then? LOL. And if you had to do it again, what would you do?
 

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Pandora's box has been opened, much-much more than in other specialties. You want proof? See what happens to a CRNA who talks back to an anesthesiologist (nothing-zilch-nada) versus the surgical NP/PA - surgeon situation (disciplined, possibly even fired if not the first time).
Seriously? You're clearly in a different reality than I am. Maybe this is more true with academia and hospital-employed CRNA's, but in the private practice world, something would indeed happen.
 

Ronin2258

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Seriously? You're clearly in a different reality than I am. Maybe this is more true with academia and hospital-employed CRNA's, but in the private practice world, something would indeed happen.
This. I rotate with private practice groups. One of them dropped SRNAs rotating through them because they were so useless and gave the group grief. CRNAs have been dropped for attitude and snarkyness like a hot potato.
 

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Hospital-employed CRNA's.
 

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I'm just a resident, so take this with my inexperienced grain of salt: the hospitals I've seen employ CRNAs and have MD groups there for liability and the bigger cases (ie less MDs/jobs), this is true of the private practice groups I've worked with. The academic hospital I work at had a CRNA group, they would negotiate their contract to get picks of cases every so often, they would do liver transplants with 2 CRNAs and an MD supervisor, after all they are there every year and the residents are only there for 4. When pedi spinals came up guaranteed a CRNA would be there. The CRNAs I have to say are better with each other in terms of teaching each other, they're hungry. Academia is lazy, def agree with above: private doesn't put with BS from midlevels, academics does. It's frustrating when an academic just hand-waves over procedures without explanation and bounces out of rooms, this is very variable between attendings to be fair. The strength we need is attendings at an academic level where a large majority of the teaching of residents/CRNAs happen, limits need to be set, instead academia is FMGs and people who don't want to be board certified who want a cushy academic lifestyle. Just my rant for the night...I relieved 2 CRNAs doing a liver transplant last week, no teaching during the case. How things, in my opinion, could be improved:
1. Have residents rate their attendings, lose those who get consistently bad ratings or tie this to a contract/bonus. Some attendings just get everything set up and leave, they are not doing part of their job.
2. Have limits set on who does which cases, make it policy
 

caligas

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What we need to do is ALLOW crnas to practice independently.

Also, allow them (or their employing hospital) to be sued for malpractice when the spit (inevitably) hits the fan.

It may take a couple years (and wrongful-death lawsuits), but eventually things will work out.
The problem is that mds kill patients too. I agree we are better, but proving it may not be practically possible.
 

IlDestriero

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Our hospital employed CRNAs would get counseled, encouraged to seek other employment, and if necessary, fired.
One in recent years got the hint and moved along.
That was something that was discussed when they switched from our employ to hospital employ. The decision on who is a suitable CRNA for our practice rests with the Division chiefs.
 

Planktonmd

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Here is the bottom line:
If you are not already a resident think really hard before you consider anesthesiology.
The concerns expressed by many above are very real and the future of this specialty has never been more uncertain.
 

IkeBoy18

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Here is the bottom line:
If you are not already a resident think really hard before you consider anesthesiology.
The concerns expressed by many above are very real and the future of this specialty has never been more uncertain.
only problem is that all other options for me.. are distant .. as in.. anesthesia>>>>>>>>>>>>rads(IR)>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>surgical subspecialty
Im a third year so I have time, but its not looking good.
 

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Over the years I've watched this argument progress on this forum. I've seen CRNAs and SRNAs pop in from time to time with comments supporting their side of the argument. I can say the following things:

1) CRNAs are the most aggressive of nurses, while Anesthesiologists are the most laid back of physicians. It' just not a good combo (if you're an anesthesiologist) in an era of ever increasing healthcare costs where business-types are always looking for ways to cut costs.

2) CRNAs, unlike other mid-level providers, believe there is nothing that the anesthesiologist does that they can't do. They believe they should perform regional/neuraxial/pain/invasive procedures in the same manner, with the same opportunity, as anesthesiologists. At the same time, in my own experience (med school, residency, and now in private practice, where I perform MD-only anesthesia with no CRNAs) I've never witnessed a CRNA do anything more invasive than an arterial line. I read once on a CRNA forum about a SRNA who watched a few cervical epidurals, looked easy enough, so now he should be doing them unsupervised. That's just crazy talk. I know there are places where CRNAs get training for more invasive procedures, but I believe their training is suboptimal to that of a resident anesthesiologist, and such that they shouldn't be doing the procedures unsupervised. It isn't simply that the procedure is so complex in nature, but it is such that I don't believe they're trained enough to witness and manage complications.

3) complications in the anesthesia world are rare, such that it's very easy for a CRNA to say "Look, my rate of complications is equivalent to that of my MD counterpart, therefore I'm just as good". Heck, the CRNAs have paid to have 'research' state exactly this. This is a huge mistake, and business-types should never buy into that argument. When it hits the fan in our world, it hits fast and hard, and you really need a trained critical thinker who can act fast to correct the problem. To say the independently practicing CRNA can just call in the MD if they ever run into trouble is just crazy talk. In all likelihood, by the time someone shows up to help it'll be too far gone to escape severe morbidity and potential mortality. And to think it won't happen as some point in time, even in the most routine of cases, is crazy talk.

4) in the real world, the CRNA-Anesthesiologist relationship in an ACT practice is generally collegial. My n=2 in this manner, as I witnessed ACT environments in both med school and in residency. However, I did experience CRNAs who seemed 'militant' and those who badmouthed anesthesiologists. These were typically much younger CRNAs who were fresh out of their training. My attendings had no qualms about talking with me about the most dangerous of CRNAs, and guess who they were? The same young CRNAs who believe they needed no oversight and no 'micro-managing'.

5) the fighting between CRNAs and Anesthesiologists is largely political, but it's very vociferous, and anesthesiologists haven't been nearly as vocal as a whole and I'd like us to be. For us to continue to train CRNAs with some of the stuff the AANA has pulled (and almost all CRNAs are serious backers of the AANA) is just nuts.

6) anesthesiologists as a group are greedy. We're in this mess largely because it became financially incentivized to supervise 3 or 4 rooms at a time, rather than do your own case. And you can find some anesthesiologists who would rather do ANYTHING other than be in the room providing direct 1-on-1 care with the patient. There are lazy physicians in every field, and I've run into my fair share in anesthesia.

Anyway, those are my thoughts. By the end of residency I could not envision finding professional happiness in a supervisory practice. I also couldn't imagine providing the type of care that I wanted to provide in supervisory practice. Fortunately, I was able to find solo practice in an area of the country that my family enjoyed. These practices are disappearing quickly though as economic pressures increase, but my own experience since leaving residency tells me that you can do MD-only anesthesia and make a fine living. You won't get rich, but neither will most physicians these days. You need to run lean though, and finding a practice that takes no money from the hospital is key. You're easy pickings if you take a fat subsidy from the hospital.
 

cognitus

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Is there ANY MD-anesthesiology attending on here that doesn't regret going into anesthesiology? Based on the talk in this room, the future seems dire. However, folks tend to be more negative behind the keyboard than in real life.
 

saratoga733

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Is there ANY MD-anesthesiology attending on here that doesn't regret going into anesthesiology? Based on the talk in this room, the future seems dire. However, folks tend to be more negative behind the keyboard than in real life.
I am currently in a MD only practice and living large. I do very well >> mgma avgs mainly based on very busy endo, ob, and ortho services in which we do our own billing. No crnas to deal with is a definite plus. There is talk about hiring a couple to help out in ob but most of the young guys myself included have been very vocal against it. Don't know how long things will stay like this but enjoying it while it lasts...
 
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countingdays

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Is there ANY MD-anesthesiology attending on here that doesn't regret going into anesthesiology? Based on the talk in this room, the future seems dire. However, folks tend to be more negative behind the keyboard than in real life.
Yes, all the old ones.
 
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cognitus

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And then, for those that DO regret going into anesthesiology, what alternative specialty would you have chosen?
 

IlDestriero

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I'm just a resident, so take this with my inexperienced grain of salt: the hospitals I've seen employ CRNAs and have MD groups there for liability and the bigger cases (ie less MDs/jobs), this is true of the private practice groups I've worked with. The academic hospital I work at had a CRNA group, they would negotiate their contract to get picks of cases every so often, they would do liver transplants with 2 CRNAs and an MD supervisor, after all they are there every year and the residents are only there for 4. When pedi spinals came up guaranteed a CRNA would be there. The CRNAs I have to say are better with each other in terms of teaching each other, they're hungry. Academia is lazy, def agree with above: private doesn't put with BS from midlevels, academics does. It's frustrating when an academic just hand-waves over procedures without explanation and bounces out of rooms, this is very variable between attendings to be fair. The strength we need is attendings at an academic level where a large majority of the teaching of residents/CRNAs happen, limits need to be set, instead academia is FMGs and people who don't want to be board certified who want a cushy academic lifestyle. Just my rant for the night...I relieved 2 CRNAs doing a liver transplant last week, no teaching during the case. How things, in my opinion, could be improved:
1. Have residents rate their attendings, lose those who get consistently bad ratings or tie this to a contract/bonus. Some attendings just get everything set up and leave, they are not doing part of their job.
2. Have limits set on who does which cases, make it policy
We don't offer our CRNAs any of that freedom in my academic practice. Though we have more good cases than trainees. Some like to do some things more than others, so they are more frequently assigned those cases (craniofacial, spine, neuro, etc.) but they don't pick them. If lines, blocks, etc need to be done, they are not the ones doing them. They would never do some cases at all, like transplant, fetal, EXIT, etc. They always go to fellows, and we swap them out to make it happen. Having said that, CRNAs may get assigned to "more interesting" cases than some residents, but the resident would be better off in a 6-8 case urology room than a room with one complex case.
At every academic center that I have trained or worked, and probably every academic hospital in the United States, residents and fellows have the obligation to evaluate the faculty. Those evaluations factor into promotions, bonuses, etc. If you have a poor teaching score, you are unpromotable, and if your track is up or out, you're out. Some academic centers may set a very low bar, but it exists. At my current gig, the bar is quite high, but if you don't exceed it significantly you are still unpromotable. They won't even present you to the board for promotion. Again, some schools may place a lower value on teaching.
Not all academic places are bad, though my specialty hospital experiences are probably not the norm either. We don't have problems recruiting or have FMGs, and have to be board certified, etc.
You can't have a policy regarding staffing because you need the flexibility. It would be reasonable to have guidelines though.
 

Southpaw

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Is there ANY MD-anesthesiology attending on here that doesn't regret going into anesthesiology? Based on the talk in this room, the future seems dire. However, folks tend to be more negative behind the keyboard than in real life.
I don't regret the choice as I enjoy my practice currently, but there are probably a great number of anesthesia practices I'd hate working in than ones I could tolerate. Although I don't regret the choice, if I were a 3rd year med student again, I'd aim for either a surgical or medical subspecialty. I think of this fairly often on my call nights as other than the ED doc I'm the only physician in house. All of my surgical colleagues are at home with their wives and children.
 

cognitus

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I don't regret the choice as I enjoy my practice currently, but there are probably a great number of anesthesia practices I'd hate working in than ones I could tolerate. Although I don't regret the choice, if I were a 3rd year med student again, I'd aim for either a surgical or medical subspecialty. I think of this fairly often on my call nights as other than the ED doc I'm the only physician in house. All of my surgical colleagues are at home with their wives and children.
I'm assuming that if you're in-house, then a surgeon has to be there too. Need to have surgery (and a surgeon) for anesthesia to be necessary.
 

WholeLottaGame7

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I think you're just in a bad situation. At our hospital, livers, hearts, thoracic are all resident/fellow only. PNBs and CVLs, also. CRNAs will do some neuraxial, particularly on OB. They will do a-lines, and some big peds, general, neuro cases, just because there are way more rooms than residents/fellows. The only FMGs we have are UK-trained and are there by choice and are excellent.

Just wanted to let you know that your situation is not necessarily the norm (as I recognize mine not be, either).

I'm just a resident, so take this with my inexperienced grain of salt: the hospitals I've seen employ CRNAs and have MD groups there for liability and the bigger cases (ie less MDs/jobs), this is true of the private practice groups I've worked with. The academic hospital I work at had a CRNA group, they would negotiate their contract to get picks of cases every so often, they would do liver transplants with 2 CRNAs and an MD supervisor, after all they are there every year and the residents are only there for 4. When pedi spinals came up guaranteed a CRNA would be there. The CRNAs I have to say are better with each other in terms of teaching each other, they're hungry. Academia is lazy, def agree with above: private doesn't put with BS from midlevels, academics does. It's frustrating when an academic just hand-waves over procedures without explanation and bounces out of rooms, this is very variable between attendings to be fair. The strength we need is attendings at an academic level where a large majority of the teaching of residents/CRNAs happen, limits need to be set, instead academia is FMGs and people who don't want to be board certified who want a cushy academic lifestyle. Just my rant for the night...I relieved 2 CRNAs doing a liver transplant last week, no teaching during the case. How things, in my opinion, could be improved:
1. Have residents rate their attendings, lose those who get consistently bad ratings or tie this to a contract/bonus. Some attendings just get everything set up and leave, they are not doing part of their job.
2. Have limits set on who does which cases, make it policy
 

cognitus

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I could technically take home call, but no one I know feels comfortable covering OB and a running epidural from home.
Ah. You're in OB. I hear that's the worst. Couldn't you avoid that as an attending? Seems like that particular subspecialty also doesn't pay more and doesn't offer any way for an MD to distinguish himself from a CRNA.
 

GasEmDee

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I'm assuming that if you're in-house, then a surgeon has to be there too. Need to have surgery (and a surgeon) for anesthesia to be necessary.
In addition to what southpaw mentioned about OB, consider this:

Any one surgeon might get one or two surgical cases on his call. However, there are multiple surgeons on call for multiple different surgical subspecialties. When you are on call, you are responsible for servicing all of these cases.

The general surgeon might do a lap appy and then go home for the night, but then maybe the orthopedic surgeon needs to hip fracture, then the neurosurgeon gets a subdural hematoma, then the Gyn needs to treat a ruptured ectopic. You get the idea.

I find that I spend MANY more hours in house than most of my surgical colleagues. Even accounting for their clinic time, I still think that I spend far more hours working.
 
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GasEmDee

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Ah. You're in OB. I hear that's the worst. Couldn't you avoid that as an attending? Seems like that particular subspecialty also doesn't pay more and doesn't offer any way for an MD to distinguish himself from a CRNA.
Sometimes, I would love for our group to give up OB. Its exhausting (we do 24 hour shifts and are frequently working all night). You're everyone else's bitch. And most of the work done there is compensated for pennies on the dollar. But on the other hand, there is no way we would voluntarily let another group get a foothold in our hospital.
 

Southpaw

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Ah. You're in OB. I hear that's the worst. Couldn't you avoid that as an attending? Seems like that particular subspecialty also doesn't pay more and doesn't offer any way for an MD to distinguish himself from a CRNA.
I work in a community hospital. My group covers everything that comes in the OR, some off-site anesthesia, and of course OB. Could we dish some unpleasantries off to a few CRNAs and supervise? Sure, we could I guess, but we don't want to. We really enjoy providing MD-only service to the hospital and the community. We take pride in it. Some bad (overnight call) always comes with the good. My group covers everything we're asked to cover, and so far we've maintained a great relationship with the surgeons and the hospital.
 

cognitus

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I work in a community hospital. My group covers everything that comes in the OR, some off-site anesthesia, and of course OB. Could we dish some unpleasantries off to a few CRNAs and supervise? Sure, we could I guess, but we don't want to. We really enjoy providing MD-only service to the hospital and the community. We take pride in it. Some bad (overnight call) always comes with the good. My group covers everything we're asked to cover, and so far we've maintained a great relationship with the surgeons and the hospital.
Are you satisfied with your pay. According to Medscape, median pay is slightly above $300K. How does your salary compare to that?
 

Southpaw

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Sometimes, I would love for our group to give up OB. Its exhausting (we do 24 hour shifts and are frequently working all night). You're everyone else's bitch. And most of the work done there is compensated for pennies on the dollar. But on the other hand, there is no way we would voluntarily let another group get a foothold in our hospital.

Yup, pretty much. I've only been out of residency a few months but there's no way I'd consider my job 'lifestyle' convenient. I feel I work more hours than almost all of my surgical colleagues.
 

Southpaw

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Are you satisfied with your pay. According to Medscape, median pay is slightly above $300K. How does your salary compare to that?
I'm very satisfied with my pay. I feel I'm adequately paid for the work I do. I won't get rich by US standards, but my family should be comfortable and I should be able to provide for what my children need and want.
 
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