Currently in fellowship and hating it.....thoughts?

[Disciple]

.

---

Members don't see this ad.

 

[olafa]

PP gets worse. I liked my fellowship year. It was a super easy schedule and great procedures. Pain patients are pain patients. Whatever class they are from you have depressed, pathetic people. Id say I had basically the same folks in poor academic setting and rich PP setting.

The biggest thing for me that made me leave pain now that I look back on it is waking up in the morning with a sense of "how much can i make today and when can i get home". Is it Friday yet? Very rarely did i feel that i was doing something worthwhile medically. And that would probably be starting someone on neurontin with good effect. Small potatoes. Many times i felt that i was enabling terrible people. I think the idea of solving the mystery diagnosis with slick physical exam/diagnostic skills is just not a reality. Patients come to you for opiates and injections. Follow up with someone else.

I used to have the mindset of who cares what i do as long as i make a lot of money, this is a job.... but as corny as it sounds doing anesthesia makes me feel good inside and gives me a sense of purpose and authenticity that i didnt feel in pain, or i should say that pain made me appreciate. Is this what you went to med school for? Is this how you want to leave your mark?

Pain management isn't for everyone.... clearly seem as if you werent cut out for and is good you realized that and changed focus to make your self happy. The idea you have about "how much money can I make" should be the last thing to think about when trying to help these challenging patients. They are challenging for a reason; no one else has been able to help them and if you can change that for them it is quite rewarding. Thats why I like what I do. To each their own, I respect that.

 

[Stim4me]

Sounds like he's saying that based on his experience, Jewish attendings/residents are often given leeway to decline to participate in late term D&Cs, where others are not.

Don't know whether that's true or not, but don't think it's a racist statement.

Yes, it Never meant to be a racist comment. Just that in an academic program with exponentially more conservative (Jewish or catholic) attendings, the nightmare cases are distributed to others. Again it's an anesthesia and societal issue, and follows from the fact that nobody wants those type of cases in the first place. I pain medicine you typically provide elective ethical non-conflicting options.

 

[neutro]

Pain management isn't for everyone.... clearly seem as if you werent cut out for and is good you realized that and changed focus to make your self happy. The idea you have about "how much money can I make" should be the last thing to think about when trying to help these challenging patients. They are challenging for a reason; no one else has been able to help them and if you can change that for them it is quite rewarding. Thats why I like what I do. To each their own, I respect that.

Practicing medicine is a service based business. If I, or a colleague or you provide excellent service in an ethical manner, then we should all be fairly compensated.
Why do doctors have this defeatest and guilty attitude towards money? Like we should not even talk about money and just "care for the patient"? Why is it so taboo? Why cant we have both? I do not understand that. I don't see lawyers and accountants having that attitude?
My lawyer doesnt - he charges $300/ hour [INCLUDING emails and telephone encounters], but he's great, so I pay him for his time and service. He stated his rate within 2 minute of my first meeting and I said ok.
I see nothing wrong with providing good service to a subset of patients who truly need it, and being compensated for it in a reasonable manner. Yes injections take time and skill and years of experience - I want to be compensated for that. Medical management of pain carries many challenges, risk stratification based on patient's clinical condition, and a lot of competence on top of that - not everyone can do it. I would like to be compensated for my time and skill. Its only fair.

 

[hyperalgesia]

I used to have the mindset of who cares what i do as long as i make a lot of money, this is a job....

This mindset is pretty much guaranteed to lead to a hellish existence in pain mgmt.

 

[DrCommonSense]

You guys are seriously doing total joints on immobile nursing home patients? What part of the country is this? 98 percent of our total knees and hips are walking on POD 0 or POD 1.

http://abcnews.go.com/Health/knee-replacement-outcome-data-fall-short/story?id=15853594

Dunno guess which part of the country?

Researchers noted " that an international panel reported last year that surgeons' recommendations for knee replacement were not significantly correlated with pain, disability, or radiographic severity."

Doesn't seem very isolated to me.

Considering there are NO LONG TERM OUTCOME studies for knee replacement surgery, I find it laughable that you can conclude such a high success rate.

Furthermore, knee replacement studies have only shown benefit for HEALTHY patients with NO COMORBIDITIES such as obesity, heart disease, stroke, diabetes, smoking, etc.

TKR has only really been shown to be effective on patients with ISOLATED joint disease in healthy patients (even this cohort has significant complication rates though).

Are you seriously arguing that the vast majority of knee replacement patients don't have these problems?

Here's an interesting study of of Europe on THR:

http://emjreviews.com/news-updates/patients-no-more-active-after-hip-replacement/

Patients on average are NO MORE ACTIVE after surgery than BEFORE surgery. Now we can try to argue well "maybe patients dont want to be more active but they could!" like some of the surgeon arguments against this study. But in the end of the day, they are NOT more active regardless.

Ergo, you are spending >50K alone for anesthesia/surgery/hospital costs/ medications without considering long term rehab/pain meds/etc. for a surgery that does NOT show to improve functional outcome for the majority of patients.

Even this stem cell guy breaks it down well in his graphic:

http://www.regenexx.com/knee-and-hip-arthritis-joint-replacement-vs-stem-cells/

Now clearly, I don't agree with his BS about stem cells being a great alternative at this time for advanced OA, however, his facts about the surgery that is SOURCED through medical articles sheds some light on the average VAS after surgery and functional outcomes.

They are far from impressive.

Considering these are the ortho procedures with the MOST evidence, it would be very scary for me to get into meniscus surgeries, rotator cuff surgeries, fusion surgeries, etc.

Dont even get me into stents for stable CAD, CABGs for normal EF, statin medications, most CA drugs in the last 15 years, etc.

So, my argument is for people living in glass houses, maybe throwing stones isn't so good?

 

[DrCommonSense]

Being or not being a surgeon's bitch is completely dependent on the type of anesthesiologist and a person you are.
I know anesthesia doctors who are collaborative, respectful, and great with CRNAs - and will wiggle when they can and have to, and not wiggle when not and make sure that the surgeon understands it.
This is where knowledge, competence, and being able to defend your position becomes very important. Its not different in Anesthesiologist vs. surgeons, vs. Pain doctors vs. difficult patients.

I didn't say I agreed with all those anti anesthesiologist arguments. I have alot of sympathy for the BS that anesthesiologists had to deal with (I remember VERY vividly)!

I was playing devil's advocate about what people say about anesthesiologists in general being "unethical" and "greedy".

Don't let me get into some of the economists at Harvard's take on anesthesiologists either.

What im trying to say is that being "unethical" is definitely in the eye of the beholder.

These are COMMENTS being made by CRNAs, economists, DNC politicians, etc about anesthesiologists in general.

Forget about the statements about "procedural medicine" in particular. The NYT absolutely ravages physicians for being "unethical" scum that get rich on doing "useless procedures".

https://www.nytimes.com/2016/08/04/...now-that-an-operation-is-next-to-useless.html

Here's an article about tons of medical procedures/drugs being used by docs unethically by NYT:

http://well.blogs.nytimes.com/2013/07/26/medical-procedures-may-be-useless-or-worse/

Here is a medical oncologist speaking about Swan Ganz catheters:

"He cited as an example the Swan-Ganz catheter, a device threaded into the heart to monitor heart function and blood flow. It gives accurate information, Dr. Prasad said, “but that information doesn’t help. We continue to introduce new catheters all the time, lacking good evidence that they work. This is a tremendous waste of resources.”

Basically, the implication is that anesthesiologists who bill for these procedures are crooks wasting resources.

Another article on America's epidemic of useless care:

http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

Basically, docs are doing procedures in MOST fields just to make money at the expense of patients.

If you add up all the procedures these people find to be useless combined with increased utility of CRNAs, ultimately these forces would cull anesthesiologist salaries dramatically and/or eliminate a huge segment of them.

 

[neutro]

I understand.

IMO being hospital based/ an employee a lot of avenues to be unethical are removed from general anesthesiologists. GA doesnt bill for unnecessary service, provide unnecessary consults. That comes when patients come to you for something.
Anesthesiologists provide a temporary service to the patient who is coming for surgery. Their involvement is very little and temporary. vs. lets say some PP doc selling DMEs from office, or taking a cut from ordering UDS from a certain company, etc etc. In that aspect, Anesthesia is a VERY clean profession.

Anesthesia overhead is very little. It actually brings money in for the hospital.

Regarding CRNAs. I mean, generally, unless you are at a really terrible place, I do not think CRNAs can compare to MDs. I took a 2 year hiatus from anesthesia and then re-started anesthesia recently, and now supervise CRNAs, but the level and depth of knowledge, and the ability to be a "doctor" and look at the whole picture to make critical decisions is way different. Then there is always a philosophical difference between a doctor and a nurse. We are just different species. I have always felt that way, and practice that way too. It is the anesthesiologist's fault if they do not respect themselves to stand up for their beliefs - be it surgeon or CRNA. And unfortunately, that is part of the problem. A lot of our colleagues are passive - anesthesia as a specialty is attractive to those types of people and the culture is such to avoid confrontation and be passive and easy going. That is good approach most of time, but not always.

I am not going to comment on the economics, etc. But you have to also realize the cost [financial, emotional and time] to be an anesthesiologist. All of 20's and early 30s spent on education, and 250K in loans is not a joke. These critics do not understand that. I read these articles and I brush them off as garbage. Its what they are - opinions from those who are uninformed.

RE: Swan Ganz. Thats a typical medicine guy criticism, that it does not work. Ok, fine. Maybe you are right. But what about the CONTEXT of the situation? it also depends on the culture of the institution and on the patient. How many medicine guys can first of all:
1) place a swan, without contaminating it, and
2) interpret the data in clinic setting, esp. in surgical ICU?
3) Do a TEE which is TRULY diagnostic of hypotension.

My answer is probably <2%. Its mostly surgical intensivists and anesthesia ICU docs that can really use this monitor. At the end of the day, it is a monitor - it does not replace the doctor making decisions behind it. But thats what these medicine guys do. They do a BMP, check K and given KlorCon.

I trained at a place where we did use Swan quite frequently, esp. if EF , 30% and valves. How many of these sick patients is this oncologist managing?
Other times we would do it on a case by case basis.

Same goes on with colloid vs. crystalloid debate. Colloid doesnt work blad blah...I agree, but what about acute hypotension and as a temporizing measure? What aout teh context?

The biggest waste of resource by far is BMP and CBC everyday on hospital floors.

Everyone wastes money - I wont call it waste, rather spend. We all know this. The difference is are you spending money to genuinely help the patient, or your RVUs/ facility fee in the ASC you own/ Lab you own?

 

[DrCommonSense]

I understand.

IMO being hospital based/ an employee a lot of avenues to be unethical are removed from general anesthesiologists. GA doesnt bill for unnecessary service, provide unnecessary consults. That comes when patients come to you for something.
Anesthesiologists provide a temporary service to the patient who is coming for surgery. Their involvement is very little and temporary. vs. lets say some PP doc selling DMEs from office, or taking a cut from ordering UDS from a certain company, etc etc. In that aspect, Anesthesia is a VERY clean profession.

Anesthesia overhead is very little. It actually brings money in for the hospital.

Regarding CRNAs. I mean, generally, unless you are at a really terrible place, I do not think CRNAs can compare to MDs. I took a 2 year hiatus from anesthesia and then re-started anesthesia recently, and now supervise CRNAs, but the level and depth of knowledge, and the ability to be a "doctor" and look at the whole picture to make critical decisions is way different. Then there is always a philosophical difference between a doctor and a nurse. We are just different species. I have always felt that way, and practice that way too. It is the anesthesiologist's fault if they do not respect themselves to stand up for their beliefs - be it surgeon or CRNA. And unfortunately, that is part of the problem. A lot of our colleagues are passive - anesthesia as a specialty is attractive to those types of people and the culture is such to avoid confrontation and be passive and easy going. That is good approach most of time, but not always.

I am not going to comment on the economics, etc. But you have to also realize the cost [financial, emotional and time] to be an anesthesiologist. All of 20's and early 30s spent on education, and 250K in loans is not a joke. These critics do not understand that. I read these articles and I brush them off as garbage. Its what they are - opinions from those who are uninformed.

RE: Swan Ganz. Thats a typical medicine guy criticism, that it does not work. Ok, fine. Maybe you are right. But what about the CONTEXT of the situation? it also depends on the culture of the institution and on the patient. How many medicine guys can first of all:
1) place a swan, without contaminating it, and
2) interpret the data in clinic setting, esp. in surgical ICU?
3) Do a TEE which is TRULY diagnostic of hypotension.

My answer is probably <2%. Its mostly surgical intensivists and anesthesia ICU docs that can really use this monitor. At the end of the day, it is a monitor - it does not replace the doctor making decisions behind it. But thats what these medicine guys do. They do a BMP, check K and given KlorCon.

I trained at a place where we did use Swan quite frequently, esp. if EF , 30% and valves. How many of these sick patients is this oncologist managing?
Other times we would do it on a case by case basis.

Same goes on with colloid vs. crystalloid debate. Colloid doesnt work blad blah...I agree, but what about acute hypotension and as a temporizing measure? What aout teh context?

The biggest waste of resource by far is BMP and CBC everyday on hospital floors.

Everyone wastes money - I wont call it waste, rather spend. We all know this. The difference is are you spending money to genuinely help the patient, or your RVUs/ facility fee in the ASC you own/ Lab you own?

So facilitating surgeries on very sickly people that won't benefit them and will likely cause more harm then good isn't really the anesthesiologists fault because he/she was essentially taking orders from the surgeon? So essentially its the Eichmann defense of "taking orders" right? Just taking the money to do the anesthesia for the surgery while maintaining a significantly higher salary than if these surgeries were curtailed dramatically is very moral because well its the surgeon who decided it right?

And what do you mean very "temporary"?

You don't think the multiple hours of anesthesia provided to an older patient who is already sickly/partially demented doesn't take a toll on their cognitive function or other bodily functions? I think you're underestimating the effects of just the anesthesia on these patients. Recent studies on pediatric patients show the anesthesia affects long term cognitive function. I highly doubt its different for older patients.

Read the story on the 82 year old that was given a 3 vessel CABG and scheduled for Carotid surgeries whereby his benefit profit was approximately 1%/year but risk was 15% of having a stroke.

http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

Is this not happening every day in the ORs by the millions per year?

What about the many fusions, TKR on elderly patients in poor health, arthroscopic surgeries, etc that are being performed as well?

 

[DrCommonSense]

I understand.

IMO being hospital based/ an employee a lot of avenues to be unethical are removed from general anesthesiologists. GA doesnt bill for unnecessary service, provide unnecessary consults. That comes when patients come to you for something.
Anesthesiologists provide a temporary service to the patient who is coming for surgery. Their involvement is very little and temporary. vs. lets say some PP doc selling DMEs from office, or taking a cut from ordering UDS from a certain company, etc etc. In that aspect, Anesthesia is a VERY clean profession.

Anesthesia overhead is very little. It actually brings money in for the hospital.

Regarding CRNAs. I mean, generally, unless you are at a really terrible place, I do not think CRNAs can compare to MDs. I took a 2 year hiatus from anesthesia and then re-started anesthesia recently, and now supervise CRNAs, but the level and depth of knowledge, and the ability to be a "doctor" and look at the whole picture to make critical decisions is way different. Then there is always a philosophical difference between a doctor and a nurse. We are just different species. I have always felt that way, and practice that way too. It is the anesthesiologist's fault if they do not respect themselves to stand up for their beliefs - be it surgeon or CRNA. And unfortunately, that is part of the problem. A lot of our colleagues are passive - anesthesia as a specialty is attractive to those types of people and the culture is such to avoid confrontation and be passive and easy going. That is good approach most of time, but not always.

I am not going to comment on the economics, etc. But you have to also realize the cost [financial, emotional and time] to be an anesthesiologist. All of 20's and early 30s spent on education, and 250K in loans is not a joke. These critics do not understand that. I read these articles and I brush them off as garbage. Its what they are - opinions from those who are uninformed.

RE: Swan Ganz. Thats a typical medicine guy criticism, that it does not work. Ok, fine. Maybe you are right. But what about the CONTEXT of the situation? it also depends on the culture of the institution and on the patient. How many medicine guys can first of all:
1) place a swan, without contaminating it, and
2) interpret the data in clinic setting, esp. in surgical ICU?
3) Do a TEE which is TRULY diagnostic of hypotension.

My answer is probably <2%. Its mostly surgical intensivists and anesthesia ICU docs that can really use this monitor. At the end of the day, it is a monitor - it does not replace the doctor making decisions behind it. But thats what these medicine guys do. They do a BMP, check K and given KlorCon.

I trained at a place where we did use Swan quite frequently, esp. if EF , 30% and valves. How many of these sick patients is this oncologist managing?
Other times we would do it on a case by case basis.

Same goes on with colloid vs. crystalloid debate. Colloid doesnt work blad blah...I agree, but what about acute hypotension and as a temporizing measure? What aout teh context?

The biggest waste of resource by far is BMP and CBC everyday on hospital floors.

Everyone wastes money - I wont call it waste, rather spend. We all know this. The difference is are you spending money to genuinely help the patient, or your RVUs/ facility fee in the ASC you own/ Lab you own?

Also, anesthesia is considered a COST for the hospital that is often subsidized by a significant stipend. When the MBAs that run medicine look at anesthesia, they look at as a COST not a REVENUE generator (unlike surgeons).

That is why the AMCs have gotten such a strong share of the market by "decreasing" the need for the stipend, often by lowering anesthesiologist salaries and increasing CRNA usage (so their investors can get a profit).

You need to learn the basic economics of the anesthesia market when you are looking at it from the hospital administrator segment.

The CRNA argument has been made by the CRNAs with "11 studies". I used this argument to show that CRNAs often look at anesthesiologists as "crooks" (as do many economics, administrators, etc) that are overpaid for a service that can be done by a technician and standardized.

Ergo, the statement about "living in glass houses" when it comes to morality.

 

[nimbus]

http://abcnews.go.com/Health/knee-replacement-outcome-data-fall-short/story?id=15853594

Dunno guess which part of the country?

Researchers noted " that an international panel reported last year that surgeons' recommendations for knee replacement were not significantly correlated with pain, disability, or radiographic severity."

Doesn't seem very isolated to me.

Considering there are NO LONG TERM OUTCOME studies for knee replacement surgery, I find it laughable that you can conclude such a high success rate.

Furthermore, knee replacement studies have only shown benefit for HEALTHY patients with NO COMORBIDITIES such as obesity, heart disease, stroke, diabetes, smoking, etc.

TKR has only really been shown to be effective on patients with ISOLATED joint disease in healthy patients (even this cohort has significant complication rates though).

Are you seriously arguing that the vast majority of knee replacement patients don't have these problems?

Here's an interesting study of of Europe on THR:

http://emjreviews.com/news-updates/patients-no-more-active-after-hip-replacement/

Patients on average are NO MORE ACTIVE after surgery than BEFORE surgery. Now we can try to argue well "maybe patients dont want to be more active but they could!" like some of the surgeon arguments against this study. But in the end of the day, they are NOT more active regardless.

Ergo, you are spending >50K alone for anesthesia/surgery/hospital costs/ medications without considering long term rehab/pain meds/etc. for a surgery that does NOT show to improve functional outcome for the majority of patients.

Even this stem cell guy breaks it down well in his graphic:

http://www.regenexx.com/knee-and-hip-arthritis-joint-replacement-vs-stem-cells/

Now clearly, I don't agree with his BS about stem cells being a great alternative at this time for advanced OA, however, his facts about the surgery that is SOURCED through medical articles sheds some light on the average VAS after surgery and functional outcomes.

They are far from impressive.

Considering these are the ortho procedures with the MOST evidence, it would be very scary for me to get into meniscus surgeries, rotator cuff surgeries, fusion surgeries, etc.

Dont even get me into stents for stable CAD, CABGs for normal EF, statin medications, most CA drugs in the last 15 years, etc.

So, my argument is for people living in glass houses, maybe throwing stones isn't so good?

I have many friends, partners, and acquaintances who've had total joints. Almost all of them have had great results. The most common thing I hear them say is, "I should have had it done years ago." And I see many patients coming back for the opposite joint. It's not because the first side failed.

 

[DrCommonSense]

I have many friends, partners, and acquaintances who've had total joints. Almost all of them have had great results. The most common thing I hear them say is, "I should have had it done years ago."

I have many "friends, partners, acquaintances" who have done well after fusion surgeries and reported they should have done it "years ago"
I have many "friends, partners, acquaintances" that have been cured from severe PNA with Chiropractic therapy
I have many "friends, partners, acquaintances" that have been cured from cancer due to Pat Robertson praying for them on television

 

[nimbus]

I have many "friends, partners, acquintainces" who have done well after fusion surgeries and reported they should have done it "years ago"
I have many "friends, partners, acquintances" that have been cured from severe PNA with Chiropractic therapy
I have many "friends, partners, acquintances" that have been cured from cancer due to Pat Robertson praying for them on television

Whatever. These are real people who've been limping around in pain for years and are now pain free. 2 anesthesiologists, an ob/gyn, 3 nurses, and multiple acquaintances in the neighborhood.

 

[DrCommonSense]

Whatever. These are real people who've been limping around in pain for years and are now pain free.

These are real people who had Cancer that disappeared after Pat Robertson prayed for them on television too.

Want me to send you the stories?

 

[nimbus]

These are real people who had Cancer that disappeared after Pat Robertson prayed for them on television too.

Want me to send you the stories?

Ok

 

[DrCommonSense]

Ok

http://www1.cbn.com/stage-iv-cancer-healed

Here you go champ

 

[nimbus]

These are real people who had Cancer that disappeared after Pat Robertson prayed for them on television too.

Want me to send you the stories?

Seriously if you think what we do is a sham, what are you doing here? Go do something you believe in.

 

[DrCommonSense]

Seriously if you think what we do is a sham, what are you doing here? Go do something you believe in.

You must have missed my arguments, scroll up and come back to me.

 

[nimbus]

http://www1.cbn.com/stage-iv-cancer-healed

Here you go champ

That is awesome. Good for her.

 

[DrCommonSense]

That is awesome. Good for her.

Seems like Pat Robertson should be an oncologist.

Has he looked into Prostate CA treatment? Might be able to do better than the surgical approach.

http://www.huffingtonpost.com/entry...-and-surveillance_us_57daf8dfe4b0071a6e05fb53

 

[neutro]

Are you an anesthesiologist?

https://www.openanesthesia.org/or_costs_labor_vs_materials/

"Anesthesia accounts for 5.6% of perioperative costs. The operating room as a whole accounts for 40% of total hospital expenses, and it generates 70% of the revenue."

Actually, anesthesia salaries have tended to go UP every year. Check medscape and MGMA data.

Taking orders? Huh? If you are so interested in pre-opping the patient and checking the morality of surgery, maybe set up a peri-operative clinic which screens appropriate surgeries. Instead of sharing your opinion on SDN, you should get politically involved. You seem like you have good ideas!

Unfortunately, it is not for you to decide or chime in between the decision and consent between the surgeon and the patient. I am sure you would not like a cardiac surgeon tell you your ESIs are useless long term. Do your job as an anesthesiologist and that's it and dont be unnecessarily obstructive.
If you feel strongly about a specific surgery, then decide PRIOR to the patient walking into same day surgery as to avoid wasting their time. Go out of your way to communicate and decline providing anesthesia for surgery. But I bet 98% of anesthesia doctors wont do it because that takes time and resources.
Don't sit and point that that surgery wont help. You dont know that. It may. It does. Not all surgery ends up with "post laminectomy pain syndrome"

 

[DrCommonSense]

Are you an anesthesiologist?

https://www.openanesthesia.org/or_costs_labor_vs_materials/

"Anesthesia accounts for 5.6% of perioperative costs. The operating room as a whole accounts for 40% of total hospital expenses, and it generates 70% of the revenue."

Actually, anesthesia salaries have tended to go UP every year. Check medscape and MGMA data.

Taking orders? Huh? If you are so interested in pre-opping the patient and checking the morality of surgery, maybe set up a peri-operative clinic which screens appropriate surgeries. Instead of sharing your opinion on SDN, you should get politically involved. You seem like you have good ideas!

Unfortunately, it is not for you to decide or chime in between the decision and consent between the surgeon and the patient. I am sure you would not like a cardiac surgeon tell you your ESIs are useless long term. Do your job as an anesthesiologist and that's it and dont be unnecessarily obstructive.
If you feel strongly about a specific surgery, then decide PRIOR to the patient walking into same day surgery as to avoid wasting their time. Go out of your way to communicate and decline providing anesthesia for surgery. But I bet 98% of anesthesia doctors wont do it because that takes time and resources.
Don't sit and point that that surgery wont help. You dont know that. It may. It does. Not all surgery ends up with "post laminectomy pain syndrome"

Wow your argument for anesthesiology economics is very poor and misunderstands how the business world looks at the subject.

Anesthesia is considered a COST. That is due to the fact that Anesthesiologists DONT BRING PATIENTS into the hospital. On the line item, they are considered a highly expensive cost (comparable to OR techs, scrub nurses, equipment, hospital building, etc)

Do you know why that is? Because SURGEONS bring the patients into the hospitals whereby they GENERATE the income through facility fees and ancillary services. SURGEONS can BRING THEIR PATIENTS TO OTHER HOSPITALS which would remove revenue and ancillary benefits to the hospital, therefore, they are considered REVENUE generators.

Anesthesiologists cant leave hospitals to bring patients anywhere.

Ergo, MBAs who look at this subject whereby the anesthesiologist is considered a COST will look for the CHEAPEST option. This is why AMCs have grown dramatically offering cheaper options. This is why CRNAs are clamoring to lower costs.



Also, if you haven't been paying attention, my scrutiny of others "evidence" came AFTER people were attacking pain physicians. Maybe you should get the sequence of events correct.

 

[Stim4me]

Dr commonsenses's premise over the months has been; if you challenge pain Medicine and interventions with harsh EBM scrutiny, then one must judge every specialty in the same fashion ... he's not a nihalist in general. People are too literal online.. geez

 

[neutro]

drcommonsense:
lol anesthesia doesnt bring in patients, but surgeons cannot do surgery without anesthesia. imagine a vascular surgeon talking to his patient and using local only for fem pop...haha
your arguments are circular, tangential and quite ridiculous and so is your conduct thus far, unfortunately.

In regards to EBM for anesthesia, I do not think the level of EBM scrutiny applies to anesthesia as it does for outpatient elective pain procedures which have KNOWN unscruplous practitioners injecting everyone without much thought...yes, they exist in PP and know one can touch them, because there is no oversight...

anesthesia has very little overhead, no office space, no complicated medical billing, no extra rent for clinic, no fancy equipment besides anesthesia machines and ultrasound which are one time costs. even pulmonary guys use more bronchoscopes than we use...

i do not believe that there is any validity in your argument.

as i said before, if you feel this passionately about uniform application of EBM to other specialties (which I am pretty sure DOES exist), instead of making noise on SDN - that will be more productive.


thanks.

/end argument

 

[DrCommonSense]

Dr commonsenses's premise over the months has been; if you challenge pain Medicine and interventions with harsh EBM scrutiny, then one must judge every specialty in the same fashion ... he's not a nihalist in general. People are too literal online.. geez

Correct.

Also, I am actually shocked after doing research into this subject about how little "evidence" there is for most of procedural medicine when you apply "level 1" guidelines.

Literally, almost NONE of modern medicine's procedures have level 1 evidence in support and quite a few are against.

The rundown from what I've seen so far is such:

1) Level 1 evidence AGAINST Stents for stable CAD, Arthroscopic/Meniscus surgery for basically any indication, Prostate Surgery for CA in >95% of cases considering most are "early" onset (>10 year mortality shows no benefit), CABG surgery for normal EF patients, Lumbar Fusion surgery for ANY indication outside of Scoliosis. Prospective "outcomes" studies on THR/TKR past 3 years have been quite negative in terms of functional benefit as well.

Forget about imaging studies or medications. That list would be ENDLESS.

The whole field of psychiatry has negative/zero EBM when it comes to medications/psychoanalysis.

2) Procedures with No "Level 1" evidence in support: TKR/THR outside of 2 to 3 years on besides HEALTHY patients with zero comorbidities, zero evidence for rotator cuff surgery for any substantial duration/benefit, zero evidence for laminectomy surgery for stenosis OUTSIDE OF 1-2 years for ONE LEVEL spinal stenosis.

Ablation Procedures for Atrial Fibrillation that is STABLE on medications (>98% of cases) for mortality benefit.

No level 1 evidence for any antidepressant medications in terms of depression benefit or decreased suicide risk (in fact, some studies show INCREASED suicide risk with antidepressants).

3) Procedures with conflicting Level 1 evidence: Kyphoplasty (after most recent randomized study), Mammograms for Breast CA, most cancer screening doesn't clearly show mortality benefit. CABGs for low EF show slight mortality benefit over 10 years but NOT clearly in patients over 70 considering their longevity parameters already.

4) Procedures with clear level 1 evidence: Appendectomy for acute appendicitis and Trauma Surgery.

I think that about sums it up with some being left out but covering most major procedures.

 

[DrCommonSense]

drcommonsense:
lol anesthesia doesnt bring in patients, but surgeons cannot do surgery without anesthesia. imagine a vascular surgeon talking to his patient and using local only for fem pop...haha
your arguments are circular, tangential and quite ridiculous and so is your conduct thus far, unfortunately.

In regards to EBM for anesthesia, I do not think the level of EBM scrutiny applies to anesthesia as it does for outpatient elective pain procedures which have KNOWN unscruplous practitioners injecting everyone without much thought...yes, they exist in PP and know one can touch them, because there is no oversight...

anesthesia has very little overhead, no office space, no complicated medical billing, no extra rent for clinic, no fancy equipment besides anesthesia machines and ultrasound which are one time costs. even pulmonary guys use more bronchoscopes than we use...

i do not believe that there is any validity in your argument.

as i said before, if you feel this passionately about uniform application of EBM to other specialties (which I am pretty sure DOES exist), instead of making noise on SDN - that will be more productive.


thanks.

/end argument

The argument has "ended" because I have easily won it by logic.

Lets perform this analysis again so you can understand:

Anesthesia FACILITATES the utilization of MILLIONS of highly invasive surgical procedures that have zero evidence of benefit/negative evidence of benefit every year in the United States (see post above) while exposing patients to TOXIC general anesthesia that has been PROVEN to cause problems in the elderly/pediatric populations in terms of cognition/other bodily functions.

The Anesthesiologist is PAID a HIGH SALARY that is MAINTAINED because the sheer volume of these procedures.

Ergo, the general Anesthesiologist who is GETTING PAID to FACILITATE countless unnecessary procedures is NO MORE MORAL than the pain physician who runs a "procedure mill".

In fact, considering the HUGE cost to the system/morbidity/mortality that is added by all these UNPROVEN HIGHLY INVASIVE surgeries, it can be argued that the "procedure mill" pain physician DOES FAR LESS DAMAGE to the system than the anesthesiologist in terms of cost/morbidity/mortality.

So from a "moral" standpoint in terms of general damage to the society in terms of cost/mortality/morbidity, the anesthesiologist is actually far worse than the "procedure mill" pain physician that purposely does many procedures to keep a high income that haven't benefited the patient

 

[EtherBunny]

Interesting/lively debate here. I can see both sides of the argument. On the one hand, I agree that there is a paucity of level 1 evidence to support procedural medicine. It's unfortunate, but there are some huge logistical barriers to randomized controlled trials for procedures. First, it's very difficult to standardize the procedures. Surgical skill varies considerably among providers. Inevitably there are all kinds of lovely anatomical surprises for surgeons when they operate that may cause deviations from the "standard approaches" for the experiment. Second, it's insanely expensive to do a LARGE, well designed RCT for procedural medicine. Thus, these studies tend to be underpowered, which raises the probability of a type II statistical error. Third, it's very difficult to convince patients to enroll in these kinds of studies, especially if the "placebo" arm of the study is a sham procedure. Fourth, it's extremely difficult to blind the surgeons/proceduralists, which is a setup for bias. Finally, with respect to pain medicine in particular, even if you perform a well designed, large RCT to evaluate a particular intervention, you always have to worry about placebo effect, which we're only now beginning to understand. Once again, the placebo effect can increase the probability of a type II error.

Thus, it's not surprising that there is a paucity of level 1 evidence to support procedural medicine. In an ideal world, we would have it, but there are some enormous logistical barriers to accomplishing this goal. The fact that proceduralists/surgeons continue to operate and do procedures despite solid, level 1 evidence to support their interventions isn't necessarily a reflection of unethical practice, it's a reflection of an imperfect scientific milieu that makes it very difficult/damn near impossible to generate the level 1 data. Thus, proceduralists/surgeons have to operate on the limited evidence available, provided that there is a "trend" in the literature that supports their medical decision making. It's not ideal, but that's reality.

I agree that there is some facilitation on the part of anesthesiologists regarding the propagation of unethical /unindicated surgeries. However, I would argue that in many cases, the anesthesiologist simply doesn't know enough to declare a surgery unethical/unindicated. After all, anesthesiologists are not surgeons. Aside from the obvious ridiculous cases (e.g., the 1 million year old nursing home patient presenting for a total joint replacement), it's not that straightforward. An orthopedic surgeon knows infinitely more about joint pathology, indications, contraindications, outcomes, and complications regarding joint replacement surgery than an anesthesiologist. That asymmetry in knowledge applies to virtually all surgical subspecialties compared to anesthesiology.

I don't know enough about the toxicity issue related to anesthesia to comment meaningfully on it. The last time I looked at the literature in detail was residency a few years ago. At that time, the jury was still out on whether general anesthesia was detrimental in pediatric settings. I can't remember the findings in geriatric populations, but I do remember some controversy regarding the role of anesthesia in cognitive outcomes after cardiac and vascular surgery. But even if anesthesia is found to be somewhat "toxic," what exactly is the alternative? Whiskey and then chew on a stick of wood so you don't scream? It's not like patients are going to stop needing surgery for various things, which essentially require a general anesthetic.

With respect to the economics of anesthesia vs surgery--the bottom line is that it's an arbitrary, largely ******ed distinction. Yes, surgeons are "revenue generators" for hospitals under the current system that rewards volume over value. They generate facility fees. They implant things that the hospital can mark up and profit from. They hospitalize patients and order tests that are profitable for the hospital. But here's the thing: the current model is not sustainable. Surgeons, in the final analysis, rack up ENORMOUS bills for insurance companies and the federal government to pay. Bills for surgical implants. Bills for facility fees. Bills for hospitalizations. The list goes on an on. Ultimately, where do you think that money comes from? Patients and taxpayers. When you focus on the big picture, the tremendous "revenue generation" by surgeons isn't necessarily a good thing. Ultimately it translates into two things: higher insurance premiums and either higher federal debt or more taxes.

Like it or not, we are moving to a value based system that does NOT reward volume. Anesthesiologists do provide an excellent value to health care as a whole, especially if all of the ridiculous hospital subsidies are eliminated (which will inevitably happen). Relative to surgeons, anesthesiologists don't cost the "system" that much (broadly speaking) and we provide an essential service. Would you want to undergo open heart surgery without anesthesia? Um, yeah...I don't think so. Being conscious for the sternotomy isn't exactly a great situation in my book, regardless of the possible "toxic" effects of anesthesia. Some things are worse than a mild cognitive hit.

 

[DrCommonSense]

Interesting/lively debate here. I can see both sides of the argument. On the one hand, I agree that there is a paucity of level 1 evidence to support procedural medicine. It's unfortunate, but there are some huge logistical barriers to randomized controlled trials for procedures. First, it's very difficult to standardize the procedures. Surgical skill varies considerably among providers. Inevitably there are all kinds of lovely anatomical surprises for surgeons when they operate that may cause deviations from the "standard approaches" for the experiment. Second, it's insanely expensive to do a LARGE, well designed RCT for procedural medicine. Thus, these studies tend to be underpowered, which raises the probability of a type II statistical error. Third, it's very difficult to convince patients to enroll in these kinds of studies, especially if the "placebo" arm of the study is a sham procedure. Fourth, it's extremely difficult to blind the surgeons/proceduralists, which is a setup for bias. Finally, with respect to pain medicine in particular, even if you perform a well designed, large RCT to evaluate a particular intervention, you always have to worry about placebo effect, which we're only now beginning to understand. Once again, the placebo effect can increase the probability of a type II error.

Thus, it's not surprising that there is a paucity of level 1 evidence to support procedural medicine. In an ideal world, we would have it, but there are some enormous logistical barriers to accomplishing this goal. The fact that proceduralists/surgeons continue to operate and do procedures despite solid, level 1 evidence to support their interventions isn't necessarily a reflection of unethical practice, it's a reflection of an imperfect scientific milieu that makes it very difficult/damn near impossible to generate the level 1 data. Thus, proceduralists/surgeons have to operate on the limited evidence available, provided that there is a "trend" in the literature that supports their medical decision making. It's not ideal, but that's reality.

I agree that there is some facilitation on the part of anesthesiologists regarding the propagation of unethical /unindicated surgeries. However, I would argue that in many cases, the anesthesiologist simply doesn't know enough to declare a surgery unethical/unindicated. After all, anesthesiologists are not surgeons. Aside from the obvious ridiculous cases (e.g., the 1 million year old nursing home patient presenting for a total joint replacement), it's not that straightforward. An orthopedic surgeon knows infinitely more about joint pathology, indications, contraindications, outcomes, and complications regarding joint replacement surgery than an anesthesiologist. That asymmetry in knowledge applies to virtually all surgical subspecialties compared to anesthesiology.

I don't know enough about the toxicity issue related to anesthesia to comment meaningfully on it. The last time I looked at the literature in detail was residency a few years ago. At that time, the jury was still out on whether general anesthesia was detrimental in pediatric settings. I can't remember the findings in geriatric populations, but I do remember some controversy regarding the role of anesthesia in cognitive outcomes after cardiac and vascular surgery. But even if anesthesia is found to be somewhat "toxic," what exactly is the alternative? Whiskey and then chew on a stick of wood so you don't scream? It's not like patients are going to stop needing surgery for various things, which essentially require a general anesthetic.

With respect to the economics of anesthesia vs surgery--the bottom line is that it's an arbitrary, largely ******ed distinction. Yes, surgeons are "revenue generators" for hospitals under the current system that rewards volume over value. They generate facility fees. They implant things that the hospital can mark up and profit from. They hospitalize patients and order tests that are profitable for the hospital. But here's the thing: the current model is not sustainable. Surgeons, in the final analysis, rack up ENORMOUS bills for insurance companies and the federal government to pay. Bills for surgical implants. Bills for facility fees. Bills for hospitalizations. The list goes on an on. Ultimately, where do you think that money comes from? Patients and taxpayers. When you focus on the big picture, the tremendous "revenue generation" by surgeons isn't necessarily a good thing. Ultimately it translates into two things: higher insurance premiums and either higher federal debt or more taxes.

Like it or not, we are moving to a value based system that does NOT reward volume. Anesthesiologists do provide an excellent value to health care as a whole, especially if all of the ridiculous hospital subsidies are eliminated (which will inevitably happen). Relative to surgeons, anesthesiologists don't cost the "system" that much (broadly speaking) and we provide an essential service. Would you want to undergo open heart surgery without anesthesia? Um, yeah...I don't think so. Being conscious for the sternotomy isn't exactly a great situation in my book, regardless of the possible "toxic" effects of anesthesia. Some things are worse than a mild cognitive hit.

The purpose of my argument about "morality" was to refute the notion that somehow performing anesthesia makes one very noble/moral compared to a pain physician, which was strongly implied by another poster.

Here are some links with articles talking about newer studies on the toxicity of anesthesia:

https://www.cincinnatichildrens.org/news/release/2015/surgery-anesthesiology-06-08-2015

http://www.medicaldaily.com/general...more-likely-develop-alzheimers-disease-246392

http://www.dailymail.co.uk/health/a...der-patients-develop-memory-loss-surgery.html

So by logical extension of a previous poster, exposing patients to procedures that have NO level 1 evidence for efficacy, especially to the known potential toxicity in pediatric/geriatric populations, would be VERY unethical.

Ergo, "feeling better ethically" about doing anesthesiology is a non sequitur considering the logical fallacy of such an argument. If you add up the cost/mortality/morbidity associated by anesthesiologists coupled with the inherent toxicity of the anesthetic in susceptible populations, you really have no case to feel more "moral" as an anesthesiologist comparatively speaking.

 

[Hoya11]

The purpose of my argument about "morality" was to refute the notion that somehow performing anesthesia makes one very noble/moral compared to a pain physician, which was strongly implied by another poster.

Here are some links with articles talking about newer studies on the toxicity of anesthesia:

https://www.cincinnatichildrens.org/news/release/2015/surgery-anesthesiology-06-08-2015

http://www.medicaldaily.com/general...more-likely-develop-alzheimers-disease-246392

http://www.dailymail.co.uk/health/a...der-patients-develop-memory-loss-surgery.html

So by logical extension of a previous poster, exposing patients to procedures that have NO level 1 evidence for efficacy, especially to the known potential toxicity in pediatric/geriatric populations, would be VERY unethical.

Ergo, "feeling better ethically" about doing anesthesiology is a non sequitur considering the logical fallacy of such an argument. If you add up the cost/mortality/morbidity associated by anesthesiologists coupled with the inherent toxicity of the anesthetic in susceptible populations, you really have no case to feel more "moral" as an anesthesiologist comparatively speaking.

I wrote a mean response but I respectfully deleted it

 

[BobBarker]

That wasn't very nice.

 

[sge1970]

I am a current fellow, but was a general anesthesiologist for three years before coming back to train. Although there was much I enjoy about anesthesia - I will not miss the all nighters; either on the labor deck running between rooms for epidurals / scurrying back for sections or night OR call doing back to back to back organ-ectomies. I will not miss scurrying in the morning to set up my room for the 0645 team steps only to have to wait for the surgeon to stroll in 30 minutes late. Coming back to fellowship is painful and I sometimes ask myself - "what was I thinking?" But when I'm 50 plus I'll appreciate the regular hours, idle weekends and not being at the beck and call for "anesthesia - head up, right side down... I mean up..." Congratulations on us being half-way done!

 

[Ducttape]

drcommonsense, just because no one has responded doesn't mean you are right. it only means that no one feels it is worth their time correcting your multitude of fallacious arguments.

thinking about that, now, I don't either...