Doom, Gloom and career selection

[LurkNoMore]

As I am still trying to evaluate whether anesthesia is the right field for me I am becoming increasingly scared of where the field is going. Several esteemed members of this forum (Ether, mmd, etc.) who obviously have tons of real-world experience and really know what they are talking about paint a very scary picture for someone who wouldn't be able to practice for another 6-7 years (starting MS4 in July). Are there really so many spots/CRNA positions filling that in 10 years MDAs could realistically (>10% chance) be making <150K a year (or 90K starting out as someone posted somewhere)?? Yes, I know this is a topic that comes up all the time and that "all fields fluctuate" and "no one can predict the future," but the general consensus seems to be that something close to this is bound to happen. I know fields fluctuate, but gas has usually been compensated pretty well (180K in the late 80s, 240K in the mid 90's, 300K+ currently, from various sources), do we really see this trend completely reversing/imploding???? If universal healthcare occurs, and it goes down the way many speculate, it would seem that no specialty would make it out alive, so I guess it wouldn't really matter where you were. I guess what I'm saying is, how much much of a pipe dream would it be on my part to hope for working 50-55 hrs/wk, making what is equivalent ~250K+ in todays money with 6-8 wks off a year when I finally get done with a residency + some fellowship(s) here in 6-7 years (ok, maybe after a couple of years before partnering)???? This forum has a ton of knowledge, and I would be a fool to disregard what is being said, would it really be more wise to look at another field (gosh, something like rads, or ??), really guys, how close to certain is this scenario, b/c you are really starting to scare me (and others I'm sure)!!!

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[Celsus]

MS-3 here. I have been wondering the same thing

 

[n2bait]

Hi. MS-4 here, & going into gas.

You are not likely going to get any responses that are in addition to what's already been beaten to death on this forum. You sound pretty smart and you already said what you really need to know. Doom and gloom is human nature, and is found in every field. Yes, anesthesia does have issues, but IMO you will have job security with a good QOL for the forseeable future. In short, do what you like. Take pay, hours, and conspiracy theories out of the equation and find what field REALLY makes you happy and go with it unless there is a major deterring factor (such as an FP not being able to pay off a 250K debt, etc.).

 

[EtherMD]

As I am still trying to evaluate whether anesthesia is the right field for me I am becoming increasingly scared of where the field is going. Several esteemed members of this forum (Ether, mmd, etc.) who obviously have tons of real-world experience and really know what they are talking about paint a very scary picture for someone who wouldn't be able to practice for another 6-7 years (starting MS4 in July). Are there really so many spots/CRNA positions filling that in 10 years MDAs could realistically (>10% chance) be making <150K a year (or 90K starting out as someone posted somewhere)?? Yes, I know this is a topic that comes up all the time and that "all fields fluctuate" and "no one can predict the future," but the general consensus seems to be that something close to this is bound to happen. I know fields fluctuate, but gas has usually been compensated pretty well (180K in the late 80s, 240K in the mid 90's, 300K+ currently, from various sources), do we really see this trend completely reversing/imploding???? If universal healthcare occurs, and it goes down the way many speculate, it would seem that no specialty would make it out alive, so I guess it wouldn't really matter where you were. I guess what I'm saying is, how much much of a pipe dream would it be on my part to hope for working 50-55 hrs/wk, making what is equivalent ~250K+ in todays money with 6-8 wks off a year when I finally get done with a residency + some fellowship(s) here in 6-7 years (ok, maybe after a couple of years before partnering)???? This forum has a ton of knowledge, and I would be a fool to disregard what is being said, would it really be more wise to look at another field (gosh, something like rads, or ??), really guys, how close to certain is this scenario, b/c you are really starting to scare me (and others I'm sure)!!!

Universal Health Care will affect everyone negatively. You need to coose the area you like best. Consider all factors in your decision: money, lifestyle, hours, type of work, type of people in the field, years of training, etc.
Anesthesiology has its problems and you know what they are. Have you looked at the other specialties as closely? Do the other forums have experienced MD's to explain their specialty to you?

The biggest "negative" in the field of Anesthesiology are the CRNA's seeking more and more independence. The ASA and the Academic Chairs have not done enough to control/stop the AANA. The propoganda by the AANA that CRNA's can do it just as well for half the price will be used by the politicians against the specialty.

 

[LurkNoMore]

No Ether, I haven't looked at other specialties as closely as Anesthesia b/c as I began to look at it, I found many things that I liked about it, so I kept digging to learn as much as I could. You are right, other forums really don't have a committed base of experienced MD's dishing out how things really are the way this one does, that is what I like so much about this forum (that, and the attitudes/personalities of most of the folks on here). You are right, choose what you like, I will know more after an away rotation (assuming I can secure one coming up in July), but I do like to risk-stratify things, including career choice. If I don't fall head-over-heels in love with anesthesia (or anything else for that matter), future concerns will weigh in to my ultimate "objective" decision. Almost every MDA I speak with loves their job, which is very encouraging to me, the question is, how much will everyone hate it if the sky does indeed, start to fall. Thanks again for your input, it is very much appreciated by me and plenty of others on this board (and reflects well on this field that individuals in it care enough to take the time to post!!).

 

[The_Sensei]

No Ether, I haven't looked at other specialties as closely as Anesthesia b/c as I began to look at it, I found many things that I liked about it, so I kept digging to learn as much as I could. You are right, other forums really don't have a committed base of experienced MD's dishing out how things really are the way this one does, that is what I like so much about this forum (that, and the attitudes/personalities of most of the folks on here). You are right, choose what you like, I will know more after an away rotation (assuming I can secure one coming up in July), but I do like to risk-stratify things, including career choice. If I don't fall head-over-heels in love with anesthesia (or anything else for that matter), future concerns will weigh in to my ultimate "objective" decision. Almost every MDA I speak with loves their job, which is very encouraging to me, the question is, how much will everyone hate it if the sky does indeed, start to fall. Thanks again for your input, it is very much appreciated by me and plenty of others on this board (and reflects well on this field that individuals in it care enough to take the time to post!!).

As others have said, do what you like/best "fits" your personality. Just be VERY aware that in the very near future (<5 years) anesthesiologists WILL NOT be making $300k to start. If you fully and truly accept this, you'll be fine.

 

[Bertelman]

This forum has a ton of knowledge, and I would be a fool to disregard what is being said, would it really be more wise to look at another field (gosh, something like rads, or ??), really guys, how close to certain is this scenario, b/c you are really starting to scare me (and others I'm sure)!!!

I think this forum has a ton of opinions which occasionally yield knowledge.

Here's mine. Don't choose a specialty based on number of weeks off or anticipated starting salary. Choose what you love, and all that other stuff will seem far less important. You said most anesthesiologists you have spoken to love their job. I take it that means they love their job more than the reimbursement they are receiving. That's what is important.

 

[militarymd]

No Ether, I haven't looked at other specialties as closely as Anesthesia b/c as I began to look at it, I found many things that I liked about it, so I kept digging to learn as much as I could. You are right, other forums really don't have a committed base of experienced MD's dishing out how things really are the way this one does, that is what I like so much about this forum (that, and the attitudes/personalities of most of the folks on here). You are right, choose what you like, I will know more after an away rotation (assuming I can secure one coming up in July), but I do like to risk-stratify things, including career choice. If I don't fall head-over-heels in love with anesthesia (or anything else for that matter), future concerns will weigh in to my ultimate "objective" decision. Almost every MDA I speak with loves their job, which is very encouraging to me, the question is, how much will everyone hate it if the sky does indeed, start to fall. Thanks again for your input, it is very much appreciated by me and plenty of others on this board (and reflects well on this field that individuals in it care enough to take the time to post!!).

I chat with my mentor quite frequently about the future....

My mentor's stats:

-Mayo clinic Internship
-Air Force flight surgeon (lots of cool stories from the past)
-Stanford residency
-Standford MBA
-30 years of practice experience...including solo practice, CRNA supervision, owning a billing company, AMC, and starter/owner of multiple groups across the US.

I ask him about what the future earnings of STAR anesthesiologists will be...and his response:

"I've been saying ...give me 5 more good years for the last 30 years"

Although he does acknowledge the fact that things look kind of gloomy right now.

 

[me454555]

No one on this forum can give you any answer thats better than any of those guru's picking stocks. If anyone knew the true future of what will be hot next, they would be playing the market and not worried about making money ever again. Long story short, every field has its drawbacks and every field has its perks. Find the one that fits you best and do it well. If you are good at what you do you will never have trouble making money or finding a job

 

[johankriek]

As others have said, do what you like/best "fits" your personality. Just be VERY aware that in the very near future (<5 years) anesthesiologists WILL NOT be making $300k to start. If you fully and truly accept this, you'll be fine.

anesthesiologists NOWdont start at 300K

 

[The_Sensei]

"anesthesiologists NOWdont start at 300K"

I did. Most of the people in my residency class did as well........most of us make >$400k/yr now as well.

 

[lvspro]

"anesthesiologists NOWdont start at 300K"

I did. Most of the people in my residency class did as well........most of us make >$400k/yr now as well.

 

[LurkNoMore]

I didn't intend for this thread to be entirely about salary. My only reason for mentioning salaries is that yes, while I would like nothing more than to find a specialty that I love, I must face the fact that I may not, or it may take me being well on my way to becoming a seasoned pro before I truly love it. Since this sadly may be the case, I am left to make a career path decision on lots of objective evidence (as well as some subjective "gut feeling"). Things such as a large number of happy docs in the field (would most of them be happy if pay was 40% less, and their vacation time was slashed in half??) will weigh pretty heavily in my decision to choose a field that I have some interest in, assuming I don't instantly fall in love with something over the next 6 months.
It is pretty awesome to see what you guys are pulling down now, but numbers like this don't make me want to go into the field more, they just let me move past income concerns to evaluate other parts of the field (anywhere near the figures cited would be more than enough for me and my family to live very well). I would just hate to go into the field for what it is currently and have it change massively before I'm even able to practice in it. For instance, wind up "writing more ICU notes" as MMD has said previously, if indeed, ICU work was not what I desired (I have no idea at this point), or living with a 7:1 MDA:CRNA ratio while running ORs (not to mention the ramifications this ratio would have on the # of MDA jobs available in this nation). In the end it doesn't make much sense to worry about me, I'm just a stressed out, delusional, relatively clueless MS3
thanks again for the comments!

 

[mille125]

I didn't intend for this thread to be entirely about salary. My only reason for mentioning salaries is that yes, while I would like nothing more than to find a specialty that I love, I must face the fact that I may not, or it may take me being well on my way to becoming a seasoned pro before I truly love it. Since this sadly may be the case, I am left to make a career path decision on lots of objective evidence (as well as some subjective "gut feeling"). Things such as a large number of happy docs in the field (would most of them be happy if pay was 40% less, and their vacation time was slashed in half??) will weigh pretty heavily in my decision to choose a field that I have some interest in, assuming I don't instantly fall in love with something over the next 6 months.
It is pretty awesome to see what you guys are pulling down now, but numbers like this don't make me want to go into the field more, they just let me move past income concerns to evaluate other parts of the field (anywhere near the figures cited would be more than enough for me and my family to live very well). I would just hate to go into the field for what it is currently and have it change massively before I'm even able to practice in it. For instance, wind up "writing more ICU notes" as MMD has said previously, if indeed, ICU work was not what I desired (I have no idea at this point), or living with a 7:1 MDA:CRNA ratio while running ORs (not to mention the ramifications this ratio would have on the # of MDA jobs available in this nation). In the end it doesn't make much sense to worry about me, I'm just a stressed out, delusional, relatively clueless MS3
thanks again for the comments!

I am a realist. As I realist I must admit that pay is an important factor in making your career decision. There would be a lot less people passing gas if it paid a pediatric salary. There would be a lot less nurses becoming CRNA's if it paid near an RN's salary. Look at the most competitive and highly sought after residencies (optho, ortho, neurosurg, derm). What do they have in common (I will let you figure it out)? Lets be real, it IS about the benjamins.


With all of that said, I still advise you to do what you enjoy....It costs a whole lot more to change careers (in time, money and heartache)............

 

[mille125]

"anesthesiologists NOWdont start at 300K"

I did. Most of the people in my residency class did as well........most of us make >$400k/yr now as well.

Sensei.....come on...these are med students...tell them the truth......


Average anesthesiology salary academics (starting) 140K-150K
Average anesthesiology salary private practice (starting) 170-200K
Average partnership 2-3 years
Average partnership salary (private practice) 250-450K
Average salary by MGMA 240K which justifies these numbers


what do i base this on....contracts......all of my resident collegues knew that I was going into private practice and that I would start my own solo pain practice....most of them sent there contracts to me to analyze...i have collected over 20 anesthesiology contracts.....these are the numbers...MGMA supports this...........Most contracts that vary from this have a reason...a former collegue of mine took a job out of residency in rural Alabama...he was paid near 400K starting...there were 4 in his group each with 12 weeks vacation....that made his call q3 most weeks...this is why they paid him so much....he did not mind and knew this....his goal was to pay off some loans and move on............My point is that there are some contracts that deviate from these averages. However, there is usually a catch.. MS3's and 4's: believe me this is the truth.......

 

[The_Sensei]

Sensei.....come on...these are med students...tell them the truth......


Average anesthesiology salary academics (starting) 140K-150K
Average anesthesiology salary private practice (starting) 170-200K
Average partnership 2-3 years
Average partnership salary (private practice) 250-450K
Average salary by MGMA 240K which justifies these numbers


what do i base this on....contracts......all of my resident collegues knew that I was going into private practice and that I would start my own solo pain practice....most of them sent there contracts to me to analyze...i have collected over 20 anesthesiology contracts.....these are the numbers...MGMA supports this...........Most contracts that vary from this have a reason...a former collegue of mine took a job out of residency in rural Alabama...he was paid near 400K starting...there were 4 in his group each with 12 weeks vacation....that made his call q3 most weeks...this is why they paid him so much....he did not mind and knew this....his goal was to pay off some loans and move on............My point is that there are some contracts that deviate from these averages. However, there is usually a catch.. MS3's and 4's: believe me this is the truth.......

This is my truth; this is my reality. Yours may be different. Students - check out GasWork.com for yourselves.

 

[EtherMD]

This is my truth; this is my reality. Yours may be different. Students - check out GasWork.com for yourselves.

Data is old and skewed to the low end. Real world income always higher than published data. Here is the real world data:

1. Academics- 50th percentile around $240,000 plus benefits. A new graduate would start around $180-$200,000. After three years expect 50th percentile pay.

2. Private Practice- Expect low to mid 200's for First year position. Second year position high 200's or low 300's. Tough jobs like mine start high 200's or around 300,000 mark with fellowship. Average REAL world practice income is in the mid to high 300's. Good partnerships are worth over 400,000 with the upper 10% making more than 500,000. Most partnership tracks are 24-36 months with 24 months the norm.

 

[EtherMD]

Data is old and skewed to the low end. Real world income always higher than published data. Here is the real world data:

1. Academics- 50th percentile around $240,000 plus benefits. A new graduate would start around $180-$200,000. After three years expect 50th percentile pay.

2. Private Practice- Expect low to mid 200's for First year position. Second year position high 200's or low 300's. Tough jobs like mine start high 200's or around 300,000 mark with fellowship. Average REAL world practice income is in the mid to high 300's. Good partnerships are worth over 400,000 with the upper 10% making more than 500,000. Most partnership tracks are 24-36 months with 24 months the norm.

I want to add one more thing: completing a fellowship helps in securing the better jobs particularly the one's in the top 10% for pay.

The most successful Groups look for outstanding new graduates that can help the Group from day one. Hence, the value of the additional year in Hearts, Critical Care, Peds, Pain Management, etc.

 

[EtherMD]

Did any of you read this month's ASA newsletter? The article on why we need to be involved politically and financially said that without the ASA fighting for us we would be getting 5-6 per unit instead of 16.

Talk about doom and gloom. The newsletter added that we can expect more cuts from Medicare every year. The only good news is that Medicare pays us so little that proportionally to the private payers the cuts are not as meaningful. As long as the private payers continue to reimburse our 3.5 multiple of Medicare we will do fine. I expect the multiple to increase to 4 times Medicare very soon.

Did anyone see the comments by Rep. Tancredo about health care? Too bad this guy won't go anywhere in the Presedential race. He thinks the government should be out of all social welfare programs with Medicare being the prime example.

 

[VolatileAgent]

Average anesthesiology salary academics (starting) 140K-150K
Average anesthesiology salary private practice (starting) 170-200K
Average partnership 2-3 years
Average partnership salary (private practice) 250-450K
Average salary by MGMA 240K which justifies these numbers

where did you get these numbers?

a no-experience first-year attending out our institution starts at $209k. i will be starting in the midwest in august at $260k with a 2-year partner track. city i wanted (wife and kids), etc., etc.

 

[mille125]

where did you get these numbers?

a no-experience first-year attending out our institution starts at $209k. i will be starting in the midwest in august at $260k with a 2-year partner track. city i wanted (wife and kids), etc., etc.

I got the numbers from the 20+ contracts that are sitting right in front of me (2003-2006). There is not one salary that is over 200K. After looking at them further, I must say that most are in the southern geographic areas which may account for some of the difference you are seeing. Most are in popular urban areas with a lot of competition. My residency was in the south and most of my classmates migrated to southern cities. A no experience first year attending at my institution starts at 145K.


I congratulate you on your 260K, two year partnership job in the city that you wanted. For those that are still in the job search, my first piece of advice is to look at the total compensation package (not just salary). Malpractice, health insurance, retirement, etc should be included. If not you have to deduct these from the salary. A 300K salary that does not include any benefits is actually only worth about 230K.

 

[proman]

Funny you mention the South. The practice where I was a student had a 3 year partnership track starting at 250k going up by 25K each year and increasing vacation.

A practice I spent a week with recently (locally) was saying how they couldn't hire anyone at the rates they could pay because no one was accepted more than a 2 year track (they offered 3) and nothing less than 250K starting. So, they've had the 2 spots filled with part timers and locums but aren't happy.

What are you calling the South?

 

[EtherMD]

90th percentile per the "book" is $523,000 (includes salary, benefits, malpractice, etc.). This is for the Southeast and is 2006 data. Official Source used by hospitals and recruiters. Want to earn this level of income?
iF you Finish a Top Program and a good Fellowship your chances are much greater than the "average" Joe to land such a job.

By the way, most Anesthesia Management companies will pay you in the low 300's (no benefits but malpractice included) as a salaried employee. Average work week is 45 hours with 8-10 weeks vacation. Tons of these jobs available on www.gaswork.com in the SouthEast.

 

[divinemsm]

..regardless of pay-scale, perceived or actual, all I know is :
1. NO CLINIC
2. No rounding
3. Concise notes
4. No real need for an actual " office "
5. No patient visits for " medical issues " which are really red flags for underlying anxiety ( granted ..pain management falls into this heavily...I loathe pain medicine)= NO CLINIC
6. NO CLINIC
....these , as the more superficial, yet pivotal , aspects of the field justify it enough for me....even at 150K or whatever is deemed a " bad " salary by the harbingers of doom..it's a sweet, sweet deal.....

 

[sevo85288]

Kaiser Permenente is the largest employer of M.D.s, CRNAs, and RNs in California. They use the ACT model with M.Ds doing 1/3 of cases and "supervising" CRNAs for the rest. Despite the fact that this large HMO could save millions of $$ by getting rid of M.D.s, they have actually kept a ratio of 2 MDs to 3 CRNAs in their hospitals. They are actively seeking fellowship (cardiac, peds, Neuro) and non fellowship trained anesthesiologist. Board Certified Anesthesiologist are highly trained, regarded and sought after in N. Calif. where I practice. Starting salaries are around 250-280K plus benefits with ample vacation time. Most hospitals have also instituted a stipend for call coverage trauma//cardiac/OB. No one can tell you what the future will bring, but the talk of CRNAs taking over goes back about 30yrs.

Good Luck

 

[mille125]

90th percentile per the "book" is $523,000 (includes salary, benefits, malpractice, etc.). This is for the Southeast and is 2006 data. Official Source used by hospitals and recruiters. Want to earn this level of income?
iF you Finish a Top Program and a good Fellowship your chances are much greater than the "average" Joe to land such a job.

By the way, most Anesthesia Management companies will pay you in the low 300's (no benefits but malpractice included) as a salaried employee. Average work week is 45 hours with 8-10 weeks vacation. Tons of these jobs available on www.gaswork.com in the SouthEast.

i thought that we were giving averages.....last time I checked averages were the 50th percentile and not the 90th.....

 

[mille125]

Funny you mention the South. The practice where I was a student had a 3 year partnership track starting at 250k going up by 25K each year and increasing vacation.

A practice I spent a week with recently (locally) was saying how they couldn't hire anyone at the rates they could pay because no one was accepted more than a 2 year track (they offered 3) and nothing less than 250K starting. So, they've had the 2 spots filled with part timers and locums but aren't happy.

What are you calling the South?

The contracts were from North Carolina (Raleigh/Durham), Alabama (Birmingham), Texas (San Antonio, Austin, Dallas), and Georgia (Atlanta). I do believe that this IS the south. They were all in urban areas with a lot of competition. It is good to hear that people are doing well. However, when comparing contracts, there are a lot of variables to look at.
1) Rural vs Urban (pay may be higher in rural)
2) Level of competition (ie other groups/hospitals)
3) Benefits
4) Partnership
5) Hours/vacation schedule
6) Many others...but I am tired of listing them

It is really hard to compare apples to apples. However, if you got 250-260K first year in an area that you like with a decent call schedule then I am happy for you. Several years ago when I was interviewing, recruiters (Merritt Hawkins) and MGMA (who has very good data) suggested that the starting salary is 180-220K for private practice. The contracts that I have looked at support this. However, there are opportunities to make more and there are exceptions which are usually dictate by circumstance....

 

[Taurus]

the talk of CRNAs taking over goes back about 30yrs.

But were those CRNA's fighting for and getting independent practice rights 30 years ago? The next 30 years probably won't look the same as the previous 30.

 

[urgewrx]

If Anesthesiology as a field continues to be tought the same way it has been for the past many years, there is no doubt in my mind that its end will be sooner than later. One of the main reasons for this is that a resident can finish his residency and pass the board just by reading Morgan and Mikhail. The very same book CRNA's read in school. How can we be much better if we have the same "book knowledge"? What SHOULD be telling us apart from nurses is being SMARTER than them. Either thru more book reading/studying or just plain genetics. We can hope that we as a group are smarter than nurses if we assume that med school screens out the stupid ones better than nursing school does. But we cannot rely on this alone because as far as I know there is no hard evidence published on the subject. I think we can still control the future of our specialty and I encorage the residents and current practitiones to tackle the big books, Barash/Miller, so that there is no doubt that we are a better provider than the nurses.

Another idea that has been roaming my mind is that too much time of residency is being wasted with the current curriculum. Clinical base CA-1 residents spend too much time doing MAC and simple general anesthesia cases(lap chole, breasts, etc) losing valuable time that could be used to advance anesthesiology's strenght. I work with residents, Anesthesia Assistants (AA), Med students, and AA students during their cardiac rotation(no CRNA's, thank God). I have to admit that you cannot tell apart a PGY3-CA2 resident from a second year AA student from their performace. It's almost unbealivable that a Doctor with 2 years of residency on his belt is not much different in clinical practice than somebody with a bachelor's and 1 year of anesthesia experience. But it is not so hard to believe if you consider that CA-1's are assigned to easy cases most of the time. Handing over patients to cardiac ICU nurses(which were already enrolled in CRNA school) had me thinking about the fact that CRNA must do a year of ICU(for which they are getting paid a good amount of money barely working 40 hr/week while they are actually learning) in order to start CRNA school. In this year they learn about drugs( like levophed, milrinone, vasopressin, dobutamine, amiodarone, etc.), ballon pumps, ventricular assist devices, ect., which I can attest that most residents know sht about. I think every anesthesiology resident should be able to complete 12 months of ICU rotations within current training lenght. Be it in 3 mo during CA1 year, 3 during CA2 year, and 6 during CA3 year, or some other combination maybe including clinical base year, so that they could sit for the Critical Care board at the end of residency. This would solidify our position as masters of emergency care and hopefully increase our participation in patient care outside the OR.

Just venting. I feel much better now.

 

[EtherMD]

If Anesthesiology as a field continues to be tought the same way it has been for the past many years, there is no doubt in my mind that its end will be sooner than later. One of the main reasons for this is that a resident can finish his residency and pass the board just by reading Morgan and Mikhail. The very same book CRNA's read in school. How can we be much better if we have the same "book knowledge"? What SHOULD be telling us apart from nurses is being SMARTER than them. Either thru more book reading/studying or just plain genetics. We can hope that we as a group are smarter than nurses if we assume that med school screens out the stupid ones better than nursing school does. But we cannot rely on this alone because as far as I know there is no hard evidence published on the subject. I think we can still control the future of our specialty and I encorage the residents and current practitiones to tackle the big books, Barash/Miller, so that there is no doubt that we are a better provider than the nurses.

Another idea that has been roaming my mind is that too much time of residency is being wasted with the current curriculum. Clinical base CA-1 residents spend too much time doing MAC and simple general anesthesia cases(lap chole, breasts, etc) loosing valuable time that could be used to advance anesthesiology's strenght. I work with residents, Anesthesia Assistants (AA), Med students, and AA students during their cardiac rotation(no CRNA's, thank God). I have to admit that you cannot tell apart a PGY3-CA2 resident form a second year AA student from their performace. It's almost unbealivable that a Doctor with 2 years of residency on his belt is not much different in clinical practice than somebody with a bachelor's and 1 year of anesthesia experience. But it is not so hard to believe if you consider that CA-1's are assigned to easy cases most of the time. Handing over patients to cardiac ICU nurses(which were already enrolled in CRNA school) had me thinking about the fact that CRNA must do a year of ICU(for which they are getting paid a good amount of money barely working 40 hr/week while they are actually learning) in order to start CRNA school. In this year they learn about drugs( like levophed, milrinone, vasopressin, dobutamine, amiodarone, etc.), ballon pumps, ventricular assist devices, ect., which I can attest that most residents know sht about. I think every anesthesiology resident should be able to complete 12 months of ICU rotations within current training lenght. Be it in 3 mo during CA1 year, 3 during CA2 year, and 6 during CA3 year, or some other combination maybe including clinical base year, so that they could seat for the Critical Care board at the end of residency. This would solidify our position as masters of emergency care and hopefully increase our participation in patient care outside the OR.

Just venting. I feel much better now.

I agree. I have been posting for months that Resident need a better Certificate than "Consultant in Anesthesiology" upon completion of training. The Certificate should include Critical Care (as you suggest) and Basic TEE, U/S guidance and basic pain management. Then, I would encourage an additional 12 months of subspecialty training in your area of choice.

The more you do to PROVE that you are not a glorified CRNA the better off you will be down the road.

 

[swpm]

One of the main reasons for this is that a resident can finish his residency and pass the board just by reading Morgan and Mikhail.

The difficulty of the anesthesiology written boards is a source of consternation for me.

On one hand, in recent years 15-20% or more of eligible CA-3s fail it each year. (The failure rate was 55% in 2000!) On the other hand, it's pretty common for people to put up a passing score at the end of the CA-1 year. About half of this year's CA-3 class at my program did so. And if my AKT-6 score is any indication of where I stand nationally, I'll pass it as a CA-1 too.

Is the test not hard enough? Why do so many people fail it? Are a lot of programs working their residents so hard that they just don't have time to read?

 

[Coastie]

I've never quite understood that either

The difficulty of the anesthesiology written boards is a source of consternation for me.

On one hand, in recent years 15-20% or more of eligible CA-3s fail it each year. (The failure rate was 55% in 2000!) On the other hand, it's pretty common for people to put up a passing score at the end of the CA-1 year. About half of this year's CA-3 class at my program did so. And if my AKT-6 score is any indication of where I stand nationally, I'll pass it as a CA-1 too.

Is the test not hard enough? Why do so many people fail it? Are a lot of programs working their residents so hard that they just don't have time to read?

 

[morpheus md]

We need to do away with the "prelim year" BS...a year of general internal medicine social work, or a vacation in a transitional year, or as a scut monkey surgery intern is not going to be of much use. This should be an ICU intensive year...6 + months of ICU, maybe a couple of basic months of anesthesia, and a month or 2 of consult type service such as cardiology, pulmonology etc just to make it reasonable. I agree that it is outrageous that the average ICU nurse knows more about taking care of sicker patients than the average CA1-2...but it not surprising seeing considering the amount of time you are simply volunteer scut fodder as a medical student and intern...these are system-level chages in philosophy that need to take place here.

 

[opa beleza?]

We need to do away with the "prelim year" BS...a year of general internal medicine social work, or a vacation in a transitional year, or as a scut monkey surgery intern is not going to be of much use. This should be an ICU intensive year...6 + months of ICU, maybe a couple of basic months of anesthesia, and a month or 2 of consult type service such as cardiology, pulmonology etc just to make it reasonable. I agree that it is outrageous that the average ICU nurse knows more about taking care of sicker patients than the average CA1-2...but it not surprising seeing considering the amount of time you are simply volunteer scut fodder as a medical student and intern...these are system-level chages in philosophy that need to take place here.

Agree with the recs for PGY-1 year. HOWEVER I totally disagree with this:"I agree that it is outrageous that the average ICU nurse knows more about taking care of sicker patients than the average CA1-2...
" Sorry it is simply not true in any reality based sense.

 

[militarymd]

Agree with the recs for PGY-1 year. HOWEVER I totally disagree with this:"I agree that it is outrageous that the average ICU nurse knows more about taking care of sicker patients than the average CA1-2...
" Sorry it is simply not true in any reality based sense.

Depends on the ICU nurse.....there are many who are VERY knowledgeable.

 

[EtherMD]

The difficulty of the anesthesiology written boards is a source of consternation for me.

On one hand, in recent years 15-20% or more of eligible CA-3s fail it each year. (The failure rate was 55% in 2000!) On the other hand, it's pretty common for people to put up a passing score at the end of the CA-1 year. About half of this year's CA-3 class at my program did so. And if my AKT-6 score is any indication of where I stand nationally, I'll pass it as a CA-1 too.

Is the test not hard enough? Why do so many people fail it? Are a lot of programs working their residents so hard that they just don't have time to read?

I have posted this before regarding the current number of new graduates: there are too many. The specialty is better served by graduating a higher quality individual. In other words, "lean and mean" should be the ABA philosophy. The Programs want cheap labor at all costs. The test is too easy and a new graduate should reflect the philosophy of the ABA/ASA as a knowledgeable Consultant in the field.

In short, if we reduce the number of positions the quality should go up. The specialty needs to stop worrying about producing quantity and produce quality. The test needs to be beefed up a bit and those scoring below a certain level consistently (CA-1 thru CA-3) need to think about another specialty. I am sorry if this sounds harsh but with the AANA and CRNA's claiming equivalence we need ONLY top notch new graduates representing the specialty today.

 

[Unconscious]

Agree with the recs for PGY-1 year. HOWEVER I totally disagree with this:"I agree that it is outrageous that the average ICU nurse knows more about taking care of sicker patients than the average CA1-2...
" Sorry it is simply not true in any reality based sense.

I kinda agree with opa beleza, we need to remember what is the def. of consultant. many ICU nurses apear to know lots about drips but the they don't fully understand the whole physiology behind it. so that brings me to why we're different, obviously because as consultants in anes. we should know medicine (IM) we should understand pathophysiology, be the internist/cardiologist/pulmonologist/etc.. in the OR, thats what sets us apart. med. students going into anes. should have read Robins, ref. harrison's/braunwald. many anes. interns gringe at the thought of medicine months while they should try to learn as much as they can. you can see this in many pre-ops that are done by CA1's...

 

[Unconscious]

I also want to add to the above by trying to answer the original question in this thread. Med students should choose Anes. not for hours/salary/job sec. (I know these are important, I won't lie) but because of what you want from it. to me, its all about being the internist/cardio/etc... in the OR, also its the only medical specialty where you get to learn applied physiology. if residents and programs keep pushing for better AKT/inservice scores, res. are only going to study for these tests and not learn anesthesia. Just like Med. school, everybody studies for the damn USMLE/COMLEX with board review corses/books, nobody learns the art and science of medicine so no wander why CRNA's think they can do our job , I don't blame them (many of them are very good at what they do, that is the technical aspects of Anes.) so back to the future of anes. it is in our hands and not in outhers, we should stop blaming others and start learning how to be real consultants in anes.

 

[militarymd]

The difficulty of the anesthesiology written boards is a source of consternation for me.

On one hand, in recent years 15-20% or more of eligible CA-3s fail it each year. (The failure rate was 55% in 2000!) On the other hand, it's pretty common for people to put up a passing score at the end of the CA-1 year. About half of this year's CA-3 class at my program did so. And if my AKT-6 score is any indication of where I stand nationally, I'll pass it as a CA-1 too.

Is the test not hard enough? Why do so many people fail it? Are a lot of programs working their residents so hard that they just don't have time to read?

As an employer....who attained ownership of a group pretty much via mutiny over the folks who were present before me.....and pretty much fired everyone of them....and then hired and interviewed many folks over the last few years.....

I will testify in court that the anesthesia training programs crank out a lot of losers......explaining the fail rate.....which based on what I've seen is probably too low.

 

[VolatileAgent]

I will testify in court that the anesthesia training programs crank out a lot of losers......explaining the fail rate.....which based on what I've seen is probably too low.

anesthesiology programs, over the past several years, have accepted far more competitive, intelligent, motivated applicants than they did when you were in training. i suspect that your assessment of the current situation with regards to the competitiveness and competency of those completing residency and competing for jobs in the private practice market will change drastically over the upcoming years. your own practice may not even be as secure as you now seem to think.......

 

[militarymd]

anesthesiology programs, over the past several years, have accepted far more competitive, intelligent, motivated applicants than they did when you were in training. i suspect that your assessment of the current situation with regards to the competitiveness and competency of those completing residency and competing for jobs in the private practice market will change drastically over the upcoming years. your own practice may not even be as secure as you now seem to think.......

There are NO practices that are secure.....

Furthermore ....there are NO JOBS that are secure in anesthesia...especially if one is an employee...you can ask those who I've deep sixed in the last 2 years....or any number of new grads who don't make partnership.

Fortunately, I can walk away from the OR on any given day and still have a job.

 

[swpm]

Fortunately, I can walk away from the OR on any given day and still have a job.

This is because of your CCM fellowship, I'm assuming? Stands to reason that those with top knowledge, skills, and the fellowship to prove it have the most secure jobs.

Is there a list of all anesthesiology fellowships available nationwide? I'm a CA-1 but am increasingly thinking that a fellowship is in my future; don't know where or what yet, other than that it won't be pain or peds. Would be nice to get an idea of what's out there.

How can you best set yourself up for getting a competitive fellowship? Is it all ITE/board exam scores and LORs? Is nepotism/inbreeding a big obstacle? How competitive are most fellowships? Is there a lot of self-selection, or do many wannabe-fellows wind up disappointed?

 

[militarymd]

This is because of your CCM fellowship, I'm assuming?

Yes...however, in the current market, I suspect that I would take a pretty big hit in terms of $$$$....however, if I had to leave the OR, then the $$$ is probably going to be pretty bad also.....

This is a list of ACGME recognized programs.

As for your other questions.....yes....there is nepotism...but it changes year to year....and program to program....Very hard to say how exactly things will work out for you.

 

[swpm]

This is a list of ACGME recognized programs.

Strange, there are really only three recognized cardiothoracic programs? Henry Ford, Mount Sinai, and Baylor are the only ones listed under Adult Cardiothoracic Anesthesiology ... but a quick Google search turned up programs at Mayo, Stanford, Mass Gen, and others.

These appear to be reputable programs, so is ACGME recognition really important?

 

[VolatileAgent]

There are NO practices that are secure.....

Furthermore ....there are NO JOBS that are secure in anesthesia...especially if one is an employee...you can ask those who I've deep sixed in the last 2 years....or any number of new grads who don't make partnership.

Fortunately, I can walk away from the OR on any given day and still have a job.

residents take note. an example of a type of practice you will have to deal with when you enter the dog-eat-dog real world.

certain practice owners, like this poster, will milk you for all the work they can get out of you, and then have no qualms about turning you loose. there's no such thing as "career development" in their minds.

my advice? do what i did. come to the table with your lawyer and an employment agent. get everything in writing. work beyond the letter of the contract, document everything you do beyond the scope of the contract, and demand that they put in writing, at least semi-annually, a performance evaluation until you make partner. work to structure the contract so it's painful for them if they choose to "deep six" you at the end of the employment term (for example, they cut me loose, they pay the tail).

equally important, tally-up and document each time they violate the contract. be sure that you have a clear record that you abided by all terms, and when they dump you after you've fulfilled your obligations to that practice giving you no clear reason as to why, call that lawyer back and take 'em to court.

be wary that there are practices out there that operate like this. you can be friendly with your partners, but never forget that it's business and you've got to protect yourself.

and, most importantly, if you don't like the terms or they are being particularly rigid and you start to have those feelings of doubt, just keep looking. it is an employee's market right now in our field. there are tons of jobs out there. if you're a good catch and have the skills, you will be highly sought after. rigid, highly self-serving practices that operate the way milmd's do only get the dregs of subpar leftover candidates, and that's why i don't think he should really be suprised that the candidates, and subsequent employees who agree to his terms, he gets through his door are problematic. most of us wouldn't tolerate his practice's management style and certainly wouldn't sign the undoubtedly one-sided contract that he'd put in front of us.

 

[militarymd]

Contracts work both ways.

The contract can protect you, but then, according to the contract....you can be deep sixed.

And remember....there's ALWAYS a termination clause....for everyone...the group, the hospital....and especially for the new grad, employee...who thinks too highly of themself.



And the group's lawyers will always be better than yours.....because the group has more resources than the new grad.....so I would have to say that the lawyer is not going to be that helpful......unless you're independently wealthy and can afford one....but if that's the case....why bother working?

 

[militarymd]

A few things about my practice that Volatile is talking trash about:

1) everyone gets paid the same....new grad/owner/partner/BC/nonBC...no secret bonuses.

2) everyone takes the same number of calls

3) everyone takes turn at doing ALL the cases.

4) The only difference between partners and non-partners is that non partners can be deep sixed w/o an unanimous vote of the partners.

5) Partners/owners can also be let go....but requires the unanimous vote of all other partners.


The folks that I have let go:

1) none were new grads
2) none were BC by the ABA
3) all were present in the group multiple years before I signed on
4) all were given chances to "come onboard" to the new management style

Anyone who is interested can PM me for the profiles of these people to see if you would have been one of these folks.

 

[VolatileAgent]

and, most importantly, if you don't like the terms or they are being particularly rigid and you start to have those feelings of doubt, just keep looking.

i cannot emphasize this enough.

this is the key. i got very far into negotiations with one group, and even flew out there to work a day in their OR. they made me an offer, i accepted it verbally contingent upon signing the contract, and said let's start formalizing this thing. we got to the table, and they started to get very technical and slippery about a few, what in my mind, were minor things i wanted changed in the contract. i asked them flat out if they'd had a particular problem in the past and that was why they were being so rigid, and they said that they had. i assured them that they didn't have to worry about that, but that i needed these few minor things changed (and one huge one concerning the convenant not to compete). they wouldn't budge, but reassured me that 90% of their associates made partner.

i said, "sorry, then. i can't work for you guys." never get emotionally invested in anything that involves money.

went to my number two, which was slightly more money to begin with (but still less than a two-hour's drive from my parents-in-law). the other practice (a much larger one) really didn't care all that much about accomodating me. ultimately, they'll get exactly the type of employee they are looking for and shouldn't be surprised if/when that person becomes problematic.

having worked years in the business world, i understand better than most that the type of employee you attract and ultimately hire is 100% your own doing.

 

[VolatileAgent]

A few things about my practice that Volatile is talking trash about:

no one has to "deep six" anyone, if they hire the right person in the first place. apparently you've had to do this more than once. i think that speaks volumes.

 

[militarymd]

A few things about my practice that Volatile is talking trash about:

1) everyone gets paid the same....new grad/owner/partner/BC/nonBC...no secret bonuses.

2) everyone takes the same number of calls

3) everyone takes turn at doing ALL the cases.

4) The only difference between partners and non-partners is that non partners can be deep sixed w/o an unanimous vote of the partners.

5) Partners/owners can also be let go....but requires the unanimous vote of all other partners.


The folks that I have let go:

1) none were new grads
2) none were BC by the ABA
3) all were present in the group multiple years before I signed on
4) all were given chances to "come onboard" to the new management style

Anyone who is interested can PM me for the profiles of these people to see if you would have been one of these folks.

Hey Volatile..

Being a stickler for details...and having all that business experience....I would have imagined that you would read my posts before replying in an errouneous manner....

Every SINGLE person that I hired....has become owners....and are here for the long haul.

It would appear that you don't heed your own advice....Why is that?