fellowship perspectives: which safeguard your future best???

[Robert Loblaw]

I initially became interested in anesthesia via an interest in possibly doing cardiac anesthesia...I have since developed an interest, however, in both critical care and pain, probably because (1) i enjoy them, albeit to a lesser degree than cardiac, and (2) given the prevailing political winds, I think that the best way to safeguard my future in the coming decade (read: enjoy my job while making, at the very least, greater than 220K/year) is to be able to function, in whole or in part, completely independent from the OR.

Is this line of reasoning correct? Is the specialized skill set in cardiac anesthesia protected? Is Pain Medicine the best way to survive? Ultimately, which fellowships are sufficiently specialized as to "safeguard one's future?"

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[EtherMD]

I initially became interested in anesthesia via an interest in possibly doing cardiac anesthesia...I have since developed an interest, however, in both critical care and pain, probably because (1) i enjoy them, albeit to a lesser degree than cardiac, and (2) given the prevailing political winds, I think that the best way to safeguard my future in the coming decade (read: enjoy my job while making, at the very least, greater than 220K/year) is to be able to function, in whole or in part, completely independent from the OR.

Is this line of reasoning correct? Is the specialized skill set in cardiac anesthesia protected? Is Pain Medicine the best way to survive? Ultimately, which fellowships are sufficiently specialized as to "safeguard one's future?"

Critical Care Medicine and Pain Management are Physician based practices. While the AANA and N.P.'s may make a dent (small) in these areas they will never replace the Physician. While I want to defend Cardiac Anesthesia and TEE in the same manner I can not do so. I believe with the advancement of technology CRNA's will continue to make inroads in this area.

 

[Robert Loblaw]

alas, this is as I feared...I suppose there will always be a room for such cardiac dinosaurs in such museums as academic ORs--I can't imagine some of our cardiac surgeons dealing with CRNAs.

 

[shortbread9]

I just don't see how a CRNA can make a dent in cardiac anesthesia. The TEE skill is tough enough to aquire as a full physician. On top of that cardiac patients are some of the sickest in the hospital and cardiac surgeons are notoriously uptight. I can see a CRNAs monitoring the vitals and sats while the anesthesiologist works the TEE but not them doing it alone. If we can't keep cardiac for ourselves then there is absolutly no reason to train an anesthesiologist. Cardiac anesthesia is some of the most technically demandings cases so if CRNAs can truely do a cardiac case alone then they certainly can practice independantly.

I think you should also add peds to the list. There is already a shortage of peds anesthesiologists and I can't see how there would be any CRNA competition.

 

[EtherMD]

I just don't see how a CRNA can make a dent in cardiac anesthesia. The TEE skill is tough enough to aquire as a full physician. On top of that cardiac patients are some of the sickest in the hospital and cardiac surgeons are notoriously uptight. I can see a CRNAs monitoring the vitals and sats while the anesthesiologist works the TEE but not them doing it alone. If we can't keep cardiac for ourselves then there is absolutly no reason to train an anesthesiologist. Cardiac anesthesia is some of the most technically demandings cases so if CRNAs can truely do a cardiac case alone then they certainly can practice independantly.

I think you should also add peds to the list. There is already a shortage of peds anesthesiologists and I can't see how there would be any CRNA competition.

Technology does not stand still for anyone. Imagine 3-D TEE in 5 years then computer assisted 3-D interpretation in 7. At some point in the future TEE will become a non-issue for CRNA's. As for being the sickest patients I agree but if Universal Health Care hits (I should say when) you can bet the Mid-Levels will be doing more Cardiac cases.

As for Pediatrics, I agree a CRNA is limited here by experience and knowledge for ASA 4 Peds. But what about ASA 1 and ASA 2 Peds which is most pediatrics? Certainly, with experience they can do those cases.

So, I stand by my original statement about Pain and Critical Care being Physician based areas.

 

[Bertelman]

Technology does not stand still for anyone. Imagine 3-D TEE in 5 years then computer assisted 3-D interpretation in 7. At some point in the future TEE will become a non-issue for CRNA's.

If you believe CRNAs will gain the ground to become TEE-certified and bump MDs out of heart rooms, I don't see any avenue of anesthesiology that is sacred.

 

[EtherMD]

If you believe CRNAs will gain the ground to become TEE-certified and bump MDs out of heart rooms, I don't see any avenue of anesthesiology that is sacred.

I did not say that CRNA's will become TEE Certified. I said the technology will become very user friendly which means that an Advanced Nurse along with a Board Certified Cardiothoracic Surgeon will be able to handle the interpretation of the Echo Without an Anesthesiologists at the head of the table.

Once computer assisted interpretation comes along the Cardiothoracic Surgeons may feel comfortable with just a CRNA. Again, this is hypothetical for the future. Currently, Cardiac MD/DO Anesthesia is "hot" and the market place is paying well for those added credentials.

 

[ABCsMan]

Any hope that these ideas are feasible:

1. Institute a requirement that because of their less intensive training, CRNAs will need a minimum time (in years) of supervision before they can become eligible to practice independently (It seems that experience CRNAs with 15 years experience may have enough exposure to do cases) Of course, I hope that reason and patient safety will win out, and supervision will become the law of the land

2. The ASA should mandate that their certicification exam be increased in difficulty/scope of knowledge (If they want to be independent like doctors, they should prove to their patients that they have adequate understanding)

Just a general question, I may not be fully aware but have nurses tried to pursue other lucrative avenues such as entering fields such as pathology or even diagnostic radiology (where 2-3 years of "certification" seems adequate to read a slide or read an xray film). If not, is it too difficult because those fields will not allow them to enter their fields, or there are not programs that will support training nurses (If this is the case, I hope the ASA gets their act together and decreases the number of CRNAs or threaten to strike.... yes, I said it... healthcare is profitable business for everyone involved in its realm, except the lowly doctor.... we can only be pushed so far)

 

[EtherMD]

Any hope that these ideas are feasible:

1. Institute a requirement that because of their less intensive training, CRNAs will need a minimum time (in years) of supervision before they can become eligible to practice independently (It seems that experience CRNAs with 15 years experience may have enough exposure to do cases) Of course, I hope that reason and patient safety will win out, and supervision will become the law of the land

2. The ASA should mandate that their certicification exam be increased in difficulty/scope of knowledge (If they want to be independent like doctors, they should prove to their patients that they have adequate understanding)

Just a general question, I may not be fully aware but have nurses tried to pursue other lucrative avenues such as entering fields such as pathology or even diagnostic radiology (where 2-3 years of "certification" seems adequate to read a slide or read an xray film). If not, is it too difficult because those fields will not allow them to enter their fields, or there are not programs that will support training nurses (If this is the case, I hope the ASA gets their act together and decreases the number of CRNAs or threaten to strike.... yes, I said it... healthcare is profitable business for everyone involved in its realm, except the lowly doctor.... we can only be pushed so far)

You can complain all you want to about CRNA Independence. The AANA and the Nursing Boards control the action of Nurses. At the State and Federal level you will get no where with this issue.

The ASA has NO SAY in CRNA qualifications for practice. This is determined by the AANA and the Board of Nursing in each State. If you expect "help" from the Federal level it will NEVER happen.

All the ASA needs is to alter the market 10% in Mid-Levels. Yes, you read it right just a 10% change from new CRNA graduates to AA graduates will have a huge impact on the AANA and the Mid-Level market. We don't need federal or state help to do this. All we need is good leadership and academic Chairs who care more about the specialty and the Residents then their own pocket book. The place to start is closing 10 academic CRNA schools and opening 10 AA schools. The AANA will hear the message load and clear.

Time to take the gloves off and give the AANA a beating it won't soon forget.
90% of the AANA's membership work in the ACT model. I think the real number is even higher but even the AANA propoganda machine lists the % at 80; but, when you look at supervision instead of Medical direction and use an unbiased source I bet the % in more than 90. Let the AANA know we mean business and that CRNA's can be replaced by AA's in most practices.
The window of opportunity to do this may not be open much longer so the ASA and academic chairs must act soon. Failure to act is not an option because this means your academic chairs are selling you down the river without a paddle.

 

[me454555]

I did not say that CRNA's will become TEE Certified. I said the technology will become very user friendly which means that an Advanced Nurse along with a Board Certified Cardiothoracic Surgeon will be able to handle the interpretation of the Echo Without an Anesthesiologists at the head of the table.

Once computer assisted interpretation comes along the Cardiothoracic Surgeons may feel comfortable with just a CRNA. Again, this is hypothetical for the future. Currently, Cardiac MD/DO Anesthesia is "hot" and the market place is paying well for those added credentials.

So you're trying to say that the only thing a cardiac anesthesiologist has above a CRNA is that he/she can read the TEE? What happened to all our years of training and experience? All the tough fluid shifts and problems to anticipate and manage in a cardiac case?

If you're telling me a CRNA can do all this stuff and the only thing holding them back is better imageing equipmant then our field is dead already. There is no reason an anesthesiologist should be doing any cases and we should disband our residencies and train soley in pain or critical care.

You can make the same argument for any field of medicine and you can make the same argument for most careers in general. Why haven't FPs been replaced by NPs, surgeons by PAs in surgery, or EM docs by PAs? Simple b/c what we think is easy, is actually pretty hard. Yeah its true a PA could prolly do 80% of the work of an ER doc. Hell a 4th year medical student does about 50% of it by the end of his/her month. The reason ER docs and FPs are still critical is b/c of that other 15% of the time. The MI that would have been missed by the PA in the ER or the complicated case that the NP doesn't have the knowledge to handle. Same with anesthsiologists. We don't get paid for 85% of the stuff we do. Thats the easy stuff, we get paid for the 15% when a CRNA woulda screwed up and the pt woulda died or had serious complications. The problem is that we've gotten so good at it we think our jobs are so easy. We take for granted the amount of training that got us the point we are at now and we believe anyone could it. Its all about perspective.

 

[Robert Loblaw]

i guess one of my concerns about cardiac anesthesiology is the use, at least in smaller volume private hospitals, of cardiologists for TEE plus anethesia person, be that a non-TEE anesthesiologist or CRNA...it seems as though this has been a viable option, although I must admit i don't know the benefits, if any, of the particular economics of this arrangement. is this a valid concern?

 

[EtherMD]

i guess one of my concerns about cardiac anesthesiology is the use, at least in smaller volume private hospitals, of cardiologists for TEE plus anethesia person, be that a non-TEE anesthesiologist or CRNA...it seems as though this has been a viable option, although I must admit i don't know the benefits, if any, of the particular economics of this arrangement. is this a valid concern?

Negative. Cardiologists are too busy running an efficient office and doing Caths/Echo's to come to the O.R. routinely. They do it on occasion for one of their patients. But, "routine" would ruin them financially.

The TEE is left to the Physicians in the room. This is an area the CRNA is not qualified to handle at this time.

I do not mean to diminish the reality of MD/DO skill and knowledge compared to a CRNA. But, the fact remains we are losing the propoganda war with the AANA at the State/local level and have lost the war at the Federal level. If the money is not there then you can bet your Anesthesia machine the CRNA will be doing the case regardless of the ASA classification or pathophysiology involved. Economics drives Medicine and this is the reality of the USA.

 

[bullard]

Computer-assisted interpretation of TEE? WTF? Computers can't even accurately interpret EKGs.

 

[EtherMD]

Computer-assisted interpretation of TEE? WTF? Computers can't even accurately interpret EKGs.

Never Underestimate the advancement of technology provided there is a market. Now, beam me up Scotty!

Seriously, look at the advances of the past ten years. 3-D Echo is coming courtesy of the Japanese.

 

[me454555]

But, the fact remains we are losing the propoganda war with the AANA at the State/local level and have lost the war at the Federal level. If the money is not there then you can bet your Anesthesia machine the CRNA will be doing the case regardless of the ASA classification or pathophysiology involved. Economics drives Medicine and this is the reality of the USA.

This is simply not true. Economics will drive the business if MD/DO anesthesia is as safe as CRNA anesthesia. This is simply not true in todays society and will not be true in the forseable future. They can make things easier to read and more efficient to use but we all know nothiing can replace experience and human knowledge.

 

[EtherMD]

Economics drive Medicine and the world. If there is no money to pay the provider then who will do the work? This is why "opt-out" exists in some States. The case load is such that the hospitals claim they can only afford a CRNA. They claim no MD/DO Anesthesiologist will work at their facility because of location and pay.

Whenever someone tells you its not about the money it means its about the money.