For FT ansth based pain docs - if you could go do it again...

[neutro]

would you continue doing OR anesthesia when you were just starting out?

I am currently doing both anesthesia (1 day/ week) and pain (4 days a week). I have been doing anesthesia for the past year after 18 months of hiatus post residency and finally getting comfortable.

I want to relocate to a different area, and I have a really good FT pain medicine contract in hands- FT OP pain medicine, no call, no weekends. It rules out the possibility of doing any anesthesia during the week.

What kind of a contract do I negotiate?

Anyone doing anesthesia and pain together? How are you managing it?

Should I just fore-go anesthesia and stick with pain medicine?

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[drusso]

would you continue doing OR anesthesia when you were just starting out?

I am currently doing both anesthesia (1 day/ week) and pain (4 days a week). I have been doing anesthesia for the past year after 18 months of hiatus post residency and finally getting comfortable.

I want to relocate to a different area, and I have a really good FT pain medicine contract in hands- FT OP pain medicine, no call, no weekends. It rules out the possibility of doing any anesthesia during the week.

What kind of a contract do I negotiate?

Anyone doing anesthesia and pain together? How are you managing it?

Should I just fore-go anesthesia and stick with pain medicine?

I can't address the opportunity costs of OR versus pain clinic practice, but I wonder why you want to commit fully to pain right now. It's kind of banana-land out here for we "terminally differentiated" pain doctors...is the OR/anesthesia lifestyle really that bad?

 

[neutro]

I do not want to give up anesthesia at all.
But I am finding it hard to find jobs that will accommodate pain and anesthesia, unless its academics which I am not interested in.
They both have their pros and cons. That is why I started doing anesthesia in the first place. It s a good break from FT pain mgt and constant sparring with patients over opioids.
For instance, the current contract I am negotiating is a really good pain medicine contract with a high base as well as a low threshold to attain bonus. However, they are asking for 5 day/ week commitment which rules out any anesthesia.
The same hospital has a FT anesthesia opening with call through a contracted group, but I do not know how I will incorporate pain medicine. The bonus structure isnt as good with anesthesia, but its more vacation...

For doctors who are doing both GA and pain - what is your schedule like?

Ideally, I would like to have 1/2 pain and 1/2 GA kind of a set up. Like one week pain and one week GA. Not sure if those kind of jobs exist.

 

[SeniorWrangler]

I think it's very hard to make this work outside of academia, for the simple reason that it's not cost-effective to have a pain clinic, C-arm, nurses, etc. all in place and not being used because the pain doctor is in the OR half the time. I certainly don't see any ads for half/half private practice positions.

EDIT: I think what would work best would be a job where you combine regional anesthesia with pain, since both jobs involve the same skill set (wearing scrubs and playing with ultrasound machines).

 

[willabeast]

i did anesthesia full time for about 5 years then i did pain 4 days a week and anesthesia 1 day a week for about 15-20 years then did anesthesia 1 day a month for a few years then full time pain/spine.
the downside is trying to keep up in two very different specialties. it is easy to know everything when you are < 10 years after leaving residency.
after 10 years the amount of new information made it very difficult for me to keep up. for example while i was out of training propofol was brought to the USA and the LMA. new equipment would appear in the OR constantly and no one ever in serviced me on it. very tough to make department meetings (QA, M+M etc.) in two departments. the anesthesiologists resent having someone doing cases in the day and not taking OR call. here is the thing - maybe you can stand being mediocre in one specialty but i could not. admittedly i am pretty OCD but my life got 200% better when i could just do one specialty. wish i had done it sooner. BTW where i worked the pay was the same no matter what i did.

 

[neutro]

hmmmmm, i see

thanks for the input.

 

[nvrsumr]

I have always disliked being on call.

 

[craigkes]

I currently do both. I am not that far ahead of you in terms of getting out of residency/fellowship. You are correct...it is difficult to find the mix outside of academics but it is possible. I am in a multispecialty group and my clinic alone barely pays the bills (however that doesn't include procedures, ancillary services, internal referrals, etc.). I also do anesthesia one day per week. I wouldn't change a thing. My contract is up this summer and I have already discussed continuing with the same setup. I look forward to my anesthesia days and my pain days. I know if I had to do either one exclusively right now I wouldn't like it as much. I like sleeping in my own bed every night and not taking call right now for the OR (this could change at any time though). I don't do hearts, heads, or vascular any more but I have asked to be involved with those on my days in the OR. I agree....it's tough to be up-to-date in both...and honestly I am probably not doing a great job on my journal reading. I wouldn't change a thing but I realize this setup could change in a heartbeat.

 

[Aether2000]

I am doing half time pain working for a well established high referral base pain clinic (on 7 work days in a row) then off 8 work days in a row. During the 8 work days, I do prn anesthesia for an anesthesiology group whose main function it is to plug the holes in OR schedules at several centers, mainly outpatient but a few hospitals also. I am paid for a minimum of 6 hours for surgery centers and 8 hours for hospitals, no matter how little I may work in a day. Using this setup I have no nights, weekends, or holidays, and I do not take call. This works well for me and I am lovin' it. Weekends are completely free without any work obligations.

 

[neutro]

I currently do both. I am not that far ahead of you in terms of getting out of residency/fellowship. You are correct...it is difficult to find the mix outside of academics but it is possible. I am in a multispecialty group and my clinic alone barely pays the bills (however that doesn't include procedures, ancillary services, internal referrals, etc.). I also do anesthesia one day per week. I wouldn't change a thing. My contract is up this summer and I have already discussed continuing with the same setup. I look forward to my anesthesia days and my pain days. I know if I had to do either one exclusively right now I wouldn't like it as much. I like sleeping in my own bed every night and not taking call right now for the OR (this could change at any time though). I don't do hearts, heads, or vascular any more but I have asked to be involved with those on my days in the OR. I agree....it's tough to be up-to-date in both...and honestly I am probably not doing a great job on my journal reading. I wouldn't change a thing but I realize this setup could change in a heartbeat.

Curious, your employer - are they the same group? I mean do you do both anesthesia and pain medicine under one employer, or are they different?

I am running into this issue because pain medicine offer is through hospital and anesthesia is through a group which is contracted by the hospital.

 

[neutro]

I am doing half time pain working for a well established high referral base pain clinic (on 7 work days in a row) then off 8 work days in a row. During the 8 work days, I do prn anesthesia for an anesthesiology group whose main function it is to plug the holes in OR schedules at several centers, mainly outpatient but a few hospitals also. I am paid for a minimum of 6 hours for surgery centers and 8 hours for hospitals, no matter how little I may work in a day. Using this setup I have no nights, weekends, or holidays, and I do not take call. This works well for me and I am lovin' it. Weekends are completely free without any work obligations.

That's really nice and seems ideal, how did you negotiate this?
You are probably quite experienced. Is money a huge factor for you at this time? or lifestyle and choice of work? Sorry if that is a silly question - but these are the questions I am trying to answer.
Regarding gaining mastery in one vs. the other. I was clear with my current anesthesia group to slowly increase the complexity of my cases. So started with ASA 2 LMA/ D and C last summer and now to now major vascular cases...so lately, I have been doing all ASA3, 4s (no cardiac or peds yet - do not think I will do peds, as the last time I did a peds case was April 2013).
It took a lot of effort and confidence to get here esp. after a hiatus, and I feel that I should not throw away this skill. I am very grateful to our chairman also for accommodating me. They actually wanted me to do full time GA and pain on the side only, and that is ideal set-up - but I am thinking of relocating due to my wife's employment.
To me, anesthesiology is far more robust and has core science and physiology behind it than pain medicine, hence the reluctance to give it up.

 

[Nivens]

To me, anesthesiology is far more robust and has core science and physiology behind it than pain medicine, hence the reluctance to give it up.

I think this is a very interesting statement, and gets to the heart of something I think about a lot.

What I think you mean is "anesthesiology... has (established) core science and physiology behind it", and I wonder if that makes it more or less likely to remain the territory of physicians. Conversely, does the "grayness" of pain medicine not make it perfectly suited for the sort of systematic scientific inquiry we were trained for?

I think the history of anesthesia and anesthesiology is illustrative. Once a fringe discipline delegated to the nurse or lowest-ranking physician present, anesthesia was kind of a gray specialty until physicians got involved. The "science-ing", if you will, was a slow process led by physicians (and of course scientists and nurses as well). But now that we have it "down to a science", it has been transformed to a *largely* technical activity performed increasingly more often by highly-skilled laborers under the direction of physician managers.

Pain medicine (analgesiology?)- and I mean that in the broadest sense- seems to still be in those early stages, but has all the building blocks of a robust scientific and medical discipline. There's a considerable market unfortunately destined to grow (think of the forces that drive cardiology), industrial interest, and rapidly expanding knowledge of neurological science, which has until recently been largely a black box. Sure, the "grayness", and uncertainty about what works and doesn't work, opens the door for charlatans and snake-oil salesmen to take advantage of a vulnerable patient population, but their ability to do so will be reduced as we understand better what to do and who to do it for.

And is that not what we as physicians- not anesthesiologists or psychiatrists or physiatrists or radiologists or neurologists (whew), but doctors- were trained for?

 

[DrCommonSense]

I think this is a very interesting statement, and gets to the heart of something I think about a lot.

What I think you mean is "anesthesiology... has (established) core science and physiology behind it", and I wonder if that makes it more or less likely to remain the territory of physicians. Conversely, does the "grayness" of pain medicine not make it perfectly suited for the sort of systematic scientific inquiry we were trained for?

I think the history of anesthesia and anesthesiology is illustrative. Once a fringe discipline delegated to the nurse or lowest-ranking physician present, anesthesia was kind of a gray specialty until physicians got involved. The "science-ing", if you will, was a slow process led by physicians (and of course scientists and nurses as well). But now that we have it "down to a science", it has been transformed to a *largely* technical activity performed increasingly more often by highly-skilled laborers under the direction of physician managers.

Pain medicine (analgesiology?)- and I mean that in the broadest sense- seems to still be in those early stages, but has all the building blocks of a robust scientific and medical discipline. There's a considerable market unfortunately destined to grow (think of the forces that drive cardiology), industrial interest, and rapidly expanding knowledge of neurological science, which has until recently been largely a black box. Sure, the "grayness", and uncertainty about what works and doesn't work, opens the door for charlatans and snake-oil salesmen to take advantage of a vulnerable patient population, but their ability to do so will be reduced as we understand better what to do and who to do it for.

And is that not what we as physicians- not anesthesiologists or psychiatrists or physiatrists or radiologists or neurologists (whew), but doctors- were trained for?

Many crnas still believe anesthesia is a nursing profession and almost got the va to go along with it. Most of the "efficiency" experts have concluded that there is no difference between a crnas and anesthesiologist in terms of outcome.

Ergo, anesthesiologist are considered parasites who live off crnas supervision at increased cost to the system.

Just food for thought before we consider anesthesiology as a non nursing field and very important scientifically

 

[Nivens]

Many crnas still believe anesthesia is a nursing profession and almost got the va to go along with it. Most of the "efficiency" experts have concluded that there is no difference between a crnas and anesthesiologist in terms of outcome.

Ergo, anesthesiologist are considered parasites who live off crnas supervision at increased cost to the system.

Just food for thought before we consider anesthesiology as a non nursing field and very important scientifically

I agree that is the perception *now*, but am pointing out that there was a point in time (when anesthesia wasn't as well understood and therefore a lot less safe) that this was very much not the case.

 

[DrCommonSense]

I agree that is the perception *now*, but am pointing out that there was a point in time (when anesthesia wasn't as well understood and therefore a lot less safe) that this was very much not the case.

My argument was for the anesthesia guy trying to strongly promote anesthesia as a "mature physician field". This is clearly not accurate according to the militant CRNAs who are actively attempting to become independent and believe anesthesiologists are way overpaid/overeducated in useless book learning.

Ergo, all of that "deep knowledge" can easily be learned by an advanced nurse and performed just as well by that nurse. So again what makes it such an advanced field if nurses can essentially do the same work as the doctors in the vast majority of cases?

http://www.kevinmd.com/blog/2011/01/md-anesthesiologists-victims-excellence.html

Here is the Lewin Group (with the RAND corp) showing that "anesthesiologists aren't worth the cost" and "CRNA independent models" are the best:

http://www.lewin.com/content/dam/Lewin/Resources/AANA-CEA-May2016.pdf

I am truly not convinced that the vast majority of anesthetics performed wouldn't be done just as well by an "experienced" CRNA that has done just as many intubations, lines, epidurals, etc.

Unless the anesthesiologist is doing advanced cardiac/peds cases ( those seem to be the only exceptions to the cases I've seen in private practice/academics) where there is a clear benefit of a fellowship trained anesthesiologist who is experienced in these cases.

However, those are less than 1% of cases.

Its the bread and butter stuff, vascular, OB, etc that can be done with the same mortality rates for an experienced CRNA as it is for an anesthesiologist.

 

[neutro]

^ why are you so concerned about what CRNAs think?

the depth, or the lack of, can usually be exposed 30 seconds into a conversation pertaining to any topic within anesthesia.

not to bash CRNAs (and I do believe that they are needed in todays care model to conduct anesthesia as we just do not have enough manpower), just last week, one of my CRNAs asked about giving ketamine post op to reverse opioid induced hyperalgesia that he thought occured from 100 mcg of fentanyl that we gave on induction. Apparently the patient was tachy despite deepening volatiles.... he thought that ketamine will help with NMDA receptor modulation.
*palmface*
It was just inadequate analgesia...
Among many incorrect assumptions in his thought process, he was politely educated that OIH is unlikely to be diagnosed in an intubated patient, who has never been on chronic opioid therapy. It is something we do in pain clinics after seeing patients who are on COT. He then stayed quiet.
We did not give the ketamine ofcourse.

the patient was discharged home safely after his elective cholecystectomy.

case in point - just because you can intubate and stay in OR for 90% of the case, does not mean that you can provide clinical context and think like a doctor. yes, there are lazy docs who take advantage of CRNAs, but that is our own fault. Part of it is demands of the profession.

this is apparently one of the better CRNAs we have btw.

anyway, I don't want to get side tracked, but I value our profession and will always be an anesthesiologist first to each his own.

 

[Nivens]

^ why are you so concerned about what CRNAs think?

the depth, or the lack of, can usually be exposed 30 seconds into a conversation pertaining to any topic within anesthesia.

not to bash CRNAs (and I do believe that they are needed in todays care model to conduct anesthesia as we just do not have enough manpower), just last week, one of my CRNAs asked about giving ketamine post op to reverse opioid induced hyperalgesia that he thought occured from 100 mcg of fentanyl that we gave on induction. Apparently the patient was tachy despite deepening volatiles.... he thought that ketamine will help with NMDA receptor modulation.
*palmface*
It was just inadequate analgesia...
Among many incorrect assumptions in his thought process, he was politely educated that OIH is unlikely to be diagnosed in an intubated patient, who has never been on chronic opioid therapy. It is something we do in pain clinics after seeing patients who are on COT. He then stayed quiet.
We did not give the ketamine ofcourse.

the patient was discharged home safely after his elective cholecystectomy.

case in point - just because you can intubate and stay in OR for 90% of the case, does not mean that you can provide clinical context and think like a doctor. yes, there are lazy docs who take advantage of CRNAs, but that is our own fault. Part of it is demands of the profession.

this is apparently one of the better CRNAs we have btw.

anyway, I don't want to get side tracked, but I value our profession and will always be an anesthesiologist first to each his own.

I think you misunderstand me

I'm trying to draw a parallel between pain now and anesthesiology in it's infancy as a field to suggest that through the efforts of physicians pain may become something we can treat as easily and a safetly as we put people under anesthesia.

I have thoughts in response to your message above, and would be happy to discuss elsewhere, but totally agree: let's not sidetrack your thread.

SDN has plenty of CRNA vs anesthesia threads

 

[neutro]

^ i wasnt replying to you, rather drcommonsense.

 

[Nivens]

^ i wasnt replying to you, rather drcommonsense.

Well that's no fun ;P

 

[gasdoc77]

My argument was for the anesthesia guy trying to strongly promote anesthesia as a "mature physician field". This is clearly not accurate according to the militant CRNAs who are actively attempting to become independent and believe anesthesiologists are way overpaid/overeducated in useless book learning.

Ergo, all of that "deep knowledge" can easily be learned by an advanced nurse and performed just as well by that nurse. So again what makes it such an advanced field if nurses can essentially do the same work as the doctors in the vast majority of cases?

http://www.kevinmd.com/blog/2011/01/md-anesthesiologists-victims-excellence.html

Here is the Lewin Group (with the RAND corp) showing that "anesthesiologists aren't worth the cost" and "CRNA independent models" are the best:

http://www.lewin.com/content/dam/Lewin/Resources/AANA-CEA-May2016.pdf

I am truly not convinced that the vast majority of anesthetics performed wouldn't be done just as well by an "experienced" CRNA that has done just as many intubations, lines, epidurals, etc.

Unless the anesthesiologist is doing advanced cardiac/peds cases ( those seem to be the only exceptions to the cases I've seen in private practice/academics) where there is a clear benefit of a fellowship trained anesthesiologist who is experienced in these cases.

However, those are less than 1% of cases.

Its the bread and butter stuff, vascular, OB, etc that can be done with the same mortality rates for an experienced CRNA as it is for an anesthesiologist.

So it required an independent consulting firm (Lewin) to draw the conclusion that, on a strictly financial basis, an all CRNA model is the most cost effective?

 

[craigkes]

Curious, your employer - are they the same group? I mean do you do both anesthesia and pain medicine under one employer, or are they different?

I am running into this issue because pain medicine offer is through hospital and anesthesia is through a group which is contracted by the hospital.

Yep, same group. I think would be tough otherwise. I get what your saying. Would be tough to Satisfy both groups....so different contracts I assume?

 

[Aether2000]

Money is not a motivator for me- I could retire now if I wanted, so it is working just for fun. And it is fun. I stumbled into both jobs without looking, and in one I am a part time employee (pain) and in anesthesia I am an independent contractor. It makes for some interesting times trying to figure out the contributions towards a penson plan in one and a SEP in the other....

 

[IN2B8R]

Must realize that if you are doing both anesthesia and pain with same group that you will, inevitably, run into scheduling conflicts. And that is not even mentioning the resentment of your colleagues.... if you decide to do anesthesia, you will have to juggle your clinic schedule around the OR schedule--that is a very tall task quite often.... At the end of the day, you will get tired of doing that and tired of the group politics associated with an anesthesia group. In addition, Mother Nature will not allow your body to recover as well from those miserable anesthesia call nights. Just been my experience, good luck!


Sent from my iPhone using SDN mobile app

 

[neutro]

Yep, same group. I think would be tough otherwise. I get what your saying. Would be tough to Satisfy both groups....so different contracts I assume?

yeah...different. the anesthesia contract is open to me doing pain on the side, but eventhough call is q8-1st and 2nd (so essentially q4), and its 10 week off, it starts at 645 am - these are 24 hour calls...not weekday 16 hour calls starting at 3 pm...so i am a little iffy about that.
seems like doing FT pain through the hospital is best and then doing anesthesia at a different facility maybe half a day a week would be good....maybe ill take less vacation and sell vacation time for anesthesia

 

[neutro]

p.s. my intention one day is to start my own pain set up and i have this strategy that it can be done while doing locums anesthesia...but that would require

Must realize that if you are doing both anesthesia and pain with same group that you will, inevitably, run into scheduling conflicts. And that is not even mentioning the resentment of your colleagues.... if you decide to do anesthesia, you will have to juggle your clinic schedule around the OR schedule--that is a very tall task quite often.... At the end of the day, you will get tired of doing that and tired of the group politics associated with an anesthesia group. In addition, Mother Nature will not allow your body to recover as well from those miserable anesthesia call nights. Just been my experience, good luck!


Sent from my iPhone using SDN mobile app

thank you for your reply.
how did you transition from anesthesiology/pain to FT pain? are you solo pain doc in PP or are you employed?

 

[DrCommonSense]

^ why are you so concerned about what CRNAs think?

the depth, or the lack of, can usually be exposed 30 seconds into a conversation pertaining to any topic within anesthesia.

not to bash CRNAs (and I do believe that they are needed in todays care model to conduct anesthesia as we just do not have enough manpower), just last week, one of my CRNAs asked about giving ketamine post op to reverse opioid induced hyperalgesia that he thought occured from 100 mcg of fentanyl that we gave on induction. Apparently the patient was tachy despite deepening volatiles.... he thought that ketamine will help with NMDA receptor modulation.
*palmface*
It was just inadequate analgesia...
Among many incorrect assumptions in his thought process, he was politely educated that OIH is unlikely to be diagnosed in an intubated patient, who has never been on chronic opioid therapy. It is something we do in pain clinics after seeing patients who are on COT. He then stayed quiet.
We did not give the ketamine ofcourse.

the patient was discharged home safely after his elective cholecystectomy.

case in point - just because you can intubate and stay in OR for 90% of the case, does not mean that you can provide clinical context and think like a doctor. yes, there are lazy docs who take advantage of CRNAs, but that is our own fault. Part of it is demands of the profession.

this is apparently one of the better CRNAs we have btw.

anyway, I don't want to get side tracked, but I value our profession and will always be an anesthesiologist first to each his own.

Im concerned because they are very loud in their arguments against physicians being "cost effective" and are strongly lobbying for independence to eliminate physicians.

That is largely why the VA was trying to give them "independence" to make further studies to show that they are "equivalent". How hard will that be for them to do?

 

[DrCommonSense]

Money is not a motivator for me- I could retire now if I wanted, so it is working just for fun. And it is fun. I stumbled into both jobs without looking, and in one I am a part time employee (pain) and in anesthesia I am an independent contractor. It makes for some interesting times trying to figure out the contributions towards a penson plan in one and a SEP in the other....

How much do you think you need to retire?

 

[DrCommonSense]

So it required an independent consulting firm (Lewin) to draw the conclusion that, on a strictly financial basis, an all CRNA model is the most cost effective?

Is that any different than any of the other "efficiency" consultant firms brought in discussing any issue?