Future of Anesthesia new CMS rule

[fakin' the funk]

I had an OB kick me out of a room because she doesn't want anesthesia residents working on her patients, she demands a CRNA.

FWIW, I had an OB patient who requested an epidural, who was some sort of medicine fellow (heme onc or somesuch). She refused me (CA-2) placing her epidural, and insisted the attending place it.

Meanwhile, she had originally planned a homebirth with a doula. And now had a midwife.

There's no accounting for idiocy.

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[G0S2]

We have a new faculty member in my program who graduated from a reputable anesthesia residency and did a CT fellowship there. Told him about my interest in a CCM fellowship at his alma and he told me that the unit is essentially run by NPs. Referred to it as the "Duke Method." Some faculty have quit attending in the unit. I always though I would sort of be protected by going into CCM but I guess not. I'm still going through with the training though b/c I enjoy it.

 

[El Dooderino]

Obviously no one can predict the future but let's go with the hypothetical and say crna's gain all this power. It seems peds and pain might be the safest bet in terms of MD's keeping power. CCM might be okay but I think you're at a big disadvantage to pulm/ccm guys, at least in the private world. Anyone else have any ideas in terms of the safest fellowships to pursue?

 

[drpainfree]

no one is immune. the more likely you're going to be employed by hospitals, the more likely you'll be replaced by CRNA, PA/NP. the most independent subspecialty is pain, but it's already been squeezed very hard by medicare and will be even more by ACO model in the near future.

Obviously no one can predict the future but let's go with the hypothetical and say crna's gain all this power. It seems peds and pain might be the safest bet in terms of MD's keeping power. CCM might be okay but I think you're at a big disadvantage to pulm/ccm guys, at least in the private world. Anyone else have any ideas in terms of the safest fellowships to pursue?

 

[bedrock]

no one is immune. the more likely you're going to be employed by hospitals, the more likely you'll be replaced by CRNA, PA/NP. the most independent subspecialty is pain, but it's already been squeezed very hard by medicare and will be even more by ACO model in the near future.

What's the ACO model?

 

[drpainfree]

accountable care organization, or another name for national HMO...specialist suffers under this model.

 

[Stank811]

We have a new faculty member in my program who graduated from a reputable anesthesia residency and did a CT fellowship there. Told him about my interest in a CCM fellowship at his alma and he told me that the unit is essentially run by NPs. Referred to it as the "Duke Method." Some faculty have quit attending in the unit. I always though I would sort of be protected by going into CCM but I guess not. I'm still going through with the training though b/c I enjoy it.

I have a cousin who has been an ICU nurse for some time and she asked me if I thought it would be a good idea to become a CRNA....my advice was that the CRNA profession is not going away but I dont think it is heading in the right direction in regards to salary or lifestyle. So I told her if she wanted to be in the OR and the person who monitors the pt while be supervised (aka an ICU nurse in the OR) then become a CRNA....if she liked the ICU and didnt mind shift work to become an acute care NP. I also told her I thought the NP in the ICU were the next "CRNA of the 80-90's in that they will be making more than CRNAs.

 

[BLADEMDA]

Just remember we are Federal workers in most practices. In many Groups CMS can be 50% of revenues. This means we sold out to Medicare a long time ago. Now, we must suffer the consequences of that decision.

The time is coming when the illusion of "Independent" practice ends and Federal health care provider becomes reality. Obama wants to speed up the day of reckoning when you join his troops of Federal workers. I have no doubt our Union is just a decade away.

There will be two types of providers: The MD who refuses govt. insurance and the one who is EMPLOYED by the govt (either directly or indirectly).

 

[Taurus]

I also told her I thought the NP in the ICU were the next "CRNA of the 80-90's in that they will be making more than CRNAs.

I don't think so. The CRNA's have a huge monopoly in the midlevel anesthesia market. NP's don't have that in the ICU. The PA's are there to counterbalance the NP's, which is severely lacking with the CRNA's.

 

[ryanjmy]

I think the lawyers will save us on this. If a hospital tries to save money by getting rid of anesthesiologists then it opens itself to liability when things go wrong. Even if they are not required by law to have an anesthesiologist involved in a pts care if its standard of care in that area to have an anesthesiologist signing off then the hospital is on the hook. If a lawyer can prove that someone suffered mortality or morbidity because hospital admins were trying to cut corners=mega bucks.

 

[deleted126335]

I think the lawyers will save us on this. If a hospital tries to save money by getting rid of anesthesiologists then it opens itself to liability when things go wrong. Even if they are not required by law to have an anesthesiologist involved in a pts care if its standard of care in that area to have an anesthesiologist signing off then the hospital is on the hook. If a lawyer can prove that someone suffered mortality or morbidity because hospital admins were trying to cut corners=mega bucks.

Hospitals aren't stupid, a mechanism will be put in place so that an anesthesiologist can be available by telephone or video conference... thus implying meaningful physician input occurred, and responsibility diluted out... Getting the hospital off the hook.

CRNAs aren't stupid either. You can bet they will pick up the phone and call a doc @ home...just to let him know...then document case discussed with Dr.X...implying meaningful physician input occurred, and responsibility diluted out...Getting the CRNA off the hook.

Responsibility without authority is our future.

 

[drpainfree]

it's already legal to allow CRNAs to give anesthesia without supervision. So legally, yes, legally, CRNAs can be hired by hospitals to replace anesthesiologist. Okay, pretend some administrators will have conscience (really? do they actually exist?) to care about patient safety instead of pure financial profit, they will hire 9 CRNAs instead of 10, and replace all 10 anesthesiologists except one.

So now you have an anesthesia department consisted of 9 CRNAS, and 1 MD (probably as the chief), saving a load of money for the hospital. As the one and only anesthesiologist, not only you will have the responsibilities to "medically direct", but the toughest case for yourself, and you will be isolated by majority of CRNAs as a puppet. You won't have any respect, but you'll have tons of pressure from the administration, and tons of disrepect from the CRNAs because they are actually running the department.

This is essentially the state of affairs in VA anesthesia department. The ratio might not be 1 to 10, but close. Once the balance of is tipped to CRNAs, it spells the end of MDs in the department.

In the mean time, 9 anesthesiologists are just out of jobs.

Anyway to stop this? Nope.

You might think surgeons will step in to voice their concerns and refuse to bring cases over. Yes, initially, some might, and some don't care. But eventually, hospitals will acquire surgical specialty clinics in the process of becoming ACO, surgeons will be hospital-employed. Look at Kaiser, CRNAs are used all the time and surgeons don't make a fuzz.

Anesthesia is doomed, just like the rest of medical specialties. This time is real.

I think the lawyers will save us on this. If a hospital tries to save money by getting rid of anesthesiologists then it opens itself to liability when things go wrong. Even if they are not required by law to have an anesthesiologist involved in a pts care if its standard of care in that area to have an anesthesiologist signing off then the hospital is on the hook. If a lawyer can prove that someone suffered mortality or morbidity because hospital admins were trying to cut corners=mega bucks.

 

[aneftp]

The ASA should just point this out. If they want Crna practicing solo. Than why this

1. Why does a sitting VIP member of the executive branch go to a certain well known facility where their are "militant Crnas" and the office requests a MD to do the case. Why doesn't the militant Crna do the case if they think they can practice solo

2. Why does a high ranking member of the executive branch specifically request the the MD to be the anesthesia provider for his semi urgent surgery?

If the politicians who are in charge of HHS want this cms rule, why are they being hypocrites when it comes to their family members or love ones getting anesthesia? They don't mind if members of the public get put to sleep by Crna (even if the costs are really the same). But whe it comes to their own care they want the MD.

 

[Osteoimperfecta]

it's already legal to allow CRNAs to give anesthesia without supervision. So legally, yes, legally, CRNAs can be hired by hospitals to replace anesthesiologist. Okay, pretend some administrators will have conscience (really? do they actually exist?) to care about patient safety instead of pure financial profit, they will hire 9 CRNAs instead of 10, and replace all 10 anesthesiologists except one.

So now you have an anesthesia department consisted of 9 CRNAS, and 1 MD (probably as the chief), saving a load of money for the hospital. As the one and only anesthesiologist, not only you will have the responsibilities to "medically direct", but the toughest case for yourself, and you will be isolated by majority of CRNAs as a puppet. You won't have any respect, but you'll have tons of pressure from the administration, and tons of disrepect from the CRNAs because they are actually running the department.

This is essentially the state of affairs in VA anesthesia department. The ratio might not be 1 to 10, but close. Once the balance of is tipped to CRNAs, it spells the end of MDs in the department.

In the mean time, 9 anesthesiologists are just out of jobs.

Anyway to stop this? Nope.

You might think surgeons will step in to voice their concerns and refuse to bring cases over. Yes, initially, some might, and some don't care. But eventually, hospitals will acquire surgical specialty clinics in the process of becoming ACO, surgeons will be hospital-employed. Look at Kaiser, CRNAs are used all the time and surgeons don't make a fuzz.

Anesthesia is doomed, just like the rest of medical specialties. This time is real.

My point exact, that is why I don't like hearing the whole "I will switch to X specialty to save myself". All physicians need to make a stand a protect the profession COLLECTIVELY, i.e no man left behind. This might just be my ex-marine instincts kicking in, but I just don't see how physicians' will survive if we keep thinking of ourselves as separate entities, when in fact we get paid from the same pot. Can we win the fight? Very much so and I dare say easily, but physicians just aren't bred to fight. Unfortunately, in politics, if you don't fight, you loose. So our real threat is from within.

 

[bronx43]

My point exact, that is why I don't like hearing the whole "I will switch to X specialty to save myself". All physicians need to make a stand a protect the profession COLLECTIVELY, i.e no man left behind. This might just be my ex-marine instincts kicking in, but I just don't see how physicians' will survive if we keep thinking of ourselves as separate entities, when in fact we get paid from the same pot. Can we win the fight? Very much so and I dare say easily, but physicians just aren't bred to fight. Unfortunately, in politics, if you don't fight, you loose. So our real threat is from within.

Divide and conquer. Create artificial rifts between specialties, then take them down one by one. I'm sure surgeons are probably laughing their asses off at anesthesia's plights. I'm pretty sure if derm went down the drain, every other field would be high fiving each other. I'm sure PCPs would be in a permanent high if every other field plummeted.

 

[anynoise]

I don't think so. The CRNA's have a huge monopoly in the midlevel anesthesia market. NP's don't have that in the ICU. The PA's are there to counterbalance the NP's, which is severely lacking with the CRNA's.

i always maintained we need to hire PAs and AAs. We need to support legislation to bring these providers to every OR in the country.

 

[Monty Python]

it's already legal to allow CRNAs to give anesthesia without supervision. .

In only ~25 states. Not in the other ~25 states.

So legally, yes, legally, CRNAs can be hired by hospitals to replace anesthesiologist. .

Regardless of state law, hospital staff bylaws can always mandate anesthesiologist supervision of CRNA practice.



.

 

[BLADEMDA]

it's already legal to allow CRNAs to give anesthesia without supervision. So legally, yes, legally, CRNAs can be hired by hospitals to replace anesthesiologist. Okay, pretend some administrators will have conscience (really? do they actually exist?) to care about patient safety instead of pure financial profit, they will hire 9 CRNAs instead of 10, and replace all 10 anesthesiologists except one.

So now you have an anesthesia department consisted of 9 CRNAS, and 1 MD (probably as the chief), saving a load of money for the hospital. As the one and only anesthesiologist, not only you will have the responsibilities to "medically direct", but the toughest case for yourself, and you will be isolated by majority of CRNAs as a puppet. You won't have any respect, but you'll have tons of pressure from the administration, and tons of disrepect from the CRNAs because they are actually running the department.

This is essentially the state of affairs in VA anesthesia department. The ratio might not be 1 to 10, but close. Once the balance of is tipped to CRNAs, it spells the end of MDs in the department.

In the mean time, 9 anesthesiologists are just out of jobs.

Anyway to stop this? Nope.

You might think surgeons will step in to voice their concerns and refuse to bring cases over. Yes, initially, some might, and some don't care. But eventually, hospitals will acquire surgical specialty clinics in the process of becoming ACO, surgeons will be hospital-employed. Look at Kaiser, CRNAs are used all the time and surgeons don't make a fuzz.

Anesthesia is doomed, just like the rest of medical specialties. This time is real.

That's why the job market for Anesthesiologists may start to tilt heavily away from hundreds of jobs on Gaswork to just dozens; these jobs will be filled by abundant, cheap, CRNA labor. Now that the CRNA Schools are pumping out thousands of new graduates per year CRNA wages are FALLING For the first time in my career. FALLING significantly. CRNAS can be hired for $110-115K out of school. 2 years ago these CRNAs were getting $125K and a sign on bonus. Maybe, in 2014 the newly minted CRNA will be getting $100K.
This means the pressure on Groups is to hire MORE CRNA labor and do without an MD. I can see Groups going 6:1 as soon as CMS passes these new rules.

 

[BLADEMDA]

In only ~25 states. Not in the other ~25 states.



Regardless of state law, hospital staff bylaws can always mandate anesthesiologist supervision of CRNA practice.



.

Once CMS changes Federal Law to allow Solo CRNA practice the AANA will really start the pressure cooker on the States. One by one they will Fall and I expect Sebelius to spear head the effort.

Hospital By Laws will be the last barrier for CRNAS. This will occur more slowly over the next ten years. Economics will dictate that hospitals pony up for MD Supervisors or go with the AANA Propaganda and allow more Independent CRNA providers. Once they decide the subsidy can be cut or eliminated by going with the CRNA this will force many Anesthesiologists to work for CRNA wage plus 20%.

As Rome burns don't expect the Chairpersons to even lift a finger about the fire.

 

[BLADEMDA]

The future of this field is BLEAK ten years out; in fact, Primary Care may get a salary boost while Anesthesia becomes the domain of Nursing at $110K per year.

I truly see a strong possibility that in ten years we earn less than Family Practice; even worse we will be the Rodney Dangerfield of the Operating room.

 

[BLADEMDA]

A $100,000 plus Medical School Education to become a Glorified CRNA?

 

[BLADEMDA]

We in the 7th Inning of this game. AANA 3... ASA 0. Either the ASA starts sponsoring real studies showing our value and role in the O.R. or we are finished.

I support a PAC which will sponsor the research needed to give the malpractice lawyers the evidence to clamp down on the Solo CRNA once and for all via lawsuits.

 

[BLADEMDA]

"Low-end consumers of anesthesia services regard the ability to safely produce a deeply sedated or anesthetized patient who is happy at the end of the procedure as a commodity, where the key differentiators—compensation and fit with the procedure area workflow—boil down to cost. "

Time for you all to re-read Mark Lema on the future of this specialty.
Note he predicts 10:1 ratios as possible and MORE Solo CRNA practice.

 

[Monty Python]

Once CMS changes Federal Law to allow Solo CRNA practice the AANA will really start the pressure cooker on the States. One by one they will Fall and I expect Sebelius to spear head the effort.

.

Blade, I'll bet you a six-pack of your favorite off-duty beverage. I really don't see the ~25 individual separate state legislatures and governors doing this. For one, state legislators tend to really resent federals telling them how to conduct their state-level business. Second, the AMA, ASA, state ASA chapters, PACs, and hired public relations experts will be all in the legislators' faces to counter any effort.

In my state it would require separate bills to be introduced in appropriate committees in both the House of Representatives and the Senate. Then to be favorably voted out of both committees, to go to the floor of the entire House and separate Senate. Then be passed, separately, in both the House and Senate. And then for the governor to sign (and not veto) the bill.

That's a monumental undertaking. And it might just happen in few states, primarily the ones with a very small population of anesthesiologists. But just a few.

Let's touch base in ten years on this. Just to warn you, I've developed a taste for expensive Belgian beer, courtesy of my time at Landstuhl Army hopsital.

 

[Taurus]

I'm sure that many CRNA's read this forum. Before they start their gloating, they should realize that a national opt-out will not only hurt anesthesiologists but everyone in anesthesia including CRNA's.

First, there will be fewer job opportunities for anesthesiologists. There will still be a demand for anesthesiologists for the most complex cases and CYA by the hospital, but there will be less need for them.

Second, as more and more anesthesia is delivered by midlevels, CMS will begin to see anesthesia delivery as a midlevel profession and not a medical one. And CMS will no doubt change the reimbursement levels to reflect that. Remember that CRNA's are riding the coattails of anesthesiologists when it comes to reimbursement levels.

In the future, I would be surprised if CRNA's on average gross more than 100k. If you also consider that CRNA's are thinking of mandating the DNAP, then anesthesia isn't that attractive to many people anymore.

 

[BLADEMDA]

If you are providing a one on one anesthetic to an ASA 1 patient at an outpatient center which "product performance" best describes your job?

If the center can replace you with a BASIC COMMODITY LEVEL PROVIDER for half the cost at the same quality will they do so?

If the government isn't willing to pay any more money for the HIGH END product vs. the LOW END product who is willing to sell them the high end product? How long can the seller of the high end product stay in business once the PRIVATE BUYERS no longer pay a premium for the high end product?

 

[Monty Python]

If you also consider that CRNA's are thinking of mandating the DNAP, then anesthesia isn't that attractive to many people anymore.

All CRNA programs must be doctorally-based by, I think, 2025. Courtesy of a mandate from the American Association of Colleges of Nursing. The AACN initially wanted an earlier date, but got enough push-back that 2025 was agreed-upon.

 

[BLADEMDA]

Blade, I'll bet you a six-pack of your favorite off-duty beverage. I really don't see the ~25 individual separate state legislatures and governors doing this. For one, state legislators tend to really resent federals telling them how to conduct their state-level business. Second, the AMA, ASA, state ASA chapters, PACs, and hired public relations experts will be all in the legislators' faces to counter any effort.

In my state it would require separate bills to be introduced in appropriate committees in both the House of Representatives and the Senate. Then to be favorably voted out of both committees, to go to the floor of the entire House and separate Senate. Then be passed, separately, in both the House and Senate. And then for the governor to sign (and not veto) the bill.

That's a monumental undertaking. And it might just happen in few states, primarily the ones with a very small population of anesthesiologists. But just a few.

Let's touch base in ten years on this. Just to warn you, I've developed a taste for expensive Belgian beer, courtesy of my time at Landstuhl Army hopsital.

Of course, my PAC and other State ASA PACS are going to stop you. I have no plans on laying down my sword anytime soon. This is a fight to the dealth (metaphorically speaking of course). We must mobilize and defend the specialty. However, every few years there is another AANA victory. At best, we are just holding the line at times. We must mount an aggressive RESEARCH And P.R. campaign to crush the AANA once and for all. Will it happen? Yes. But, will it be too late?

 

[BLADEMDA]

I'm sure that many CRNA's read this forum. Before they start their gloating, they should realize that a national opt-out will not only hurt anesthesiologists but everyone in anesthesia including CRNA's.

First, there will be fewer job opportunities for anesthesiologists. There will still be a demand for anesthesiologists for the most complex cases and CYA by the hospital, but there will be less need for them.

Second, as more and more anesthesia is delivered by midlevels, CMS will begin to see anesthesia delivery as a midlevel profession and not a medical one. And CMS will no doubt change the reimbursement levels to reflect that. Remember that CRNA's are riding the coattails of anesthesiologists when it comes to reimbursement levels.

In the future, I would be surprised if CRNA's on average gross more than 100k. If you also consider that CRNA's are thinking of mandating the DNAP, then anesthesia isn't that attractive to many people anymore.

Agree. The CRNA wage is already falling and it will get worse. There is a glut of CRNAs on the market and it will get worse (or better depending on your point of view).

Wages of CRNAS could fall as low as $90K over the next 5 years.

 

[Monty Python]

Of course, my PAC and other State ASA PACS are going to stop you. I have no plans on laying down my sword anytime soon. This is a fight to the dealth (metaphorically speaking of course). We must mobilize and defend the specialty. However, every few years there is another AANA victory. At best, we are just holding the line at times. We must mount an aggressive RESEARCH And P.R. campaign to crush the AANA once and for all. Will it happen? Yes. But, will it be too late?

Dude, I have no dog in this fight. My last intubation is in the very near future. JPP taught me vicariously a long time ago to accrue an FU account. Mine is accrued, and continously enjoying compound interest. Thanks, JPP and Forbes magazine.

Anesthesia is not what I enjoyed at the beginning. The glut of schools turning out graduates who cannot critically think their way out of a wet paper bag is disturbing. It's all about the schools chasing the almighty tuition dollar. To heck with the quality of their matriculants .. it's all about quantity.

My post-9/11 GI bill is going to pay for a nice new degree out of the OR.


.

 

[BLADEMDA]

Dude, I have no dog in this fight. My last intubation is in the very near future. JPP taught me vicariously a long time ago to accrue an FU account. Mine is accrued, and continously enjoying compound interest. Thanks, JPP and Forbes magazine.

My post-9/11 GI bill is going to pay for a nice new degree out of the OR.

I don't mean to attack you personally. I apologize if that is the way you took my posts. Rather, I am discussing national, anesthesia related politics.

I wish you well and am glad that F U account has held up in this market environment.

What are you planning on studying with GI bill? Pilot? Economics?

 

[Monty Python]

I don't mean to attack you personally. I apologize if that is the way you took my posts. Rather, I am discussing national, anesthesia related politics.

I wish you well and am glad that F U account has held up in this market environment.

What are you planning on studying with GI bill? Pilot? Economics?

No worries ... you know that I agree with your sentiments the vast majority of the time, and when we don't agree it's professional, not personal. Already have the pilot license. Still enjoying the luxury of time to make a leisurely decision about my life's next chapter. Thinking about getting a psychiatric NP. In addition to anesthesia, I also have a Master's degree in Counseling Psychology. Getting the psychiatric NP would not take that much additional classwork (primarily lots of practicuum). I can see myself doing that for much longer into the future than giving anesthesia. And there's a definite need within the military for folks in that field, with a noticeable shortage of providers. Having been downrange myself I can relate.

 

[A Whole]

The impending national opt-out for CRNAs is the beginning of the end for us.

As a CA-2, I can't f'ing believe that I have wasted the last 7 years of my life for a dead end career.

I busted my ass to get where I am today. I graduated summa cum laude from a respected national university. I scored in the 99th percentile on the MCAT and in the 99th percentile on the USMLE examinations. I went to a top tier medical school and I graduated in the top 25% of my class.

I have $200,000 of educational debt.

I've endured countless sleepless nights as a medical student, intern, and resident on call.

All of this hard work and sacrifice. For what? So a person with half the duration of formal training, a person that has endured a fraction of the rigorous examination requirements that I have--a nurse that I've been issuing orders to for the last few years--can take my job?

Unf'ingbelievable.

WTF is wrong with the academic leadership in anesthesiology? Why are CRNAs still being trained by anesthesiologists? Are academic anesthesiologists really that clueless and detached from reality?

This whole situation is absolutely infuriating.

 

[AK1010]

Here's how I see it. This issue is about to come to a head. As anesthesiologists (and prospective ones), we see our patients in a completely different light than the CRNA...

Complications mean so much more to us who have pored over the science behind the physiology in that we can act infinitely more sensibly than the trained monkey.
Eventually, the country will see this. Unfortunately, it looks like they will find out the hard way - well before any unbiased study can show them.

The insurance companies will take note first. Anesthesiologists have enjoyed the benefit of lowered rates over the years due to fewer complications....CRNA's will bare the brunt of the full load of liability.

The for-profit CRNA factories will keep saturating the market, and as CRNA salaries continue to drop, the malpractice insurance will rise. Keep in mind...these are already people with nursing degrees and years spent in nursing (ie: not the most financially sound individuals to begin with).

The CRNA bubble will burst. CRNA's will no longer be able to afford the astronomical malpractice fees, Surgeon's will be fed up with the liability as well, and the life of the CRNA will be worse off than it was before this push for autonomy, as hospitals will just straight up stop employing them at surgeon's requests.

I for one think CRNA's do have a place in medicine (as do many mid-level care providers)...If they stay in their place, harmony can be maintained. They are the autopilot of the jet liner....programs exist that would launch and land planes sans pilot, but how many passengers would submit their take-off and landing to the autopilot program just to save a few dollars on their boarding pass.

 

[Gasworks]

WTF is wrong with the academic leadership in anesthesiology? Why are CRNAs still being trained by anesthesiologists? Are academic anesthesiologists really that clueless and detached from reality?

Ding ding ding!!! we have a winner!! I lost count of the number of times our chairman kicked ca1/2 residents out in favor of a crna because she had a "meeting to attend" or "paperwork to do". When we had a couple of crna's out on extended medical leave we were offered the "opportunity" of covering their shifts.. for $20/hr!!! These prize winners who couldn't handle a single day in private practice are the same people who climb the ranks of local & national associations which you are looking to as the saviors of our profession.

 

[drpainfree]

Here's how I see it. This issue is about to come to a head. As anesthesiologists (and prospective ones), we see our patients in a completely different light than the CRNA...

Complications mean so much more to us who have pored over the science behind the physiology in that we can act infinitely more sensibly than the trained monkey.
Eventually, the country will see this. Unfortunately, it looks like they will find out the hard way - well before any unbiased study can show them.

The insurance companies will take note first. Anesthesiologists have enjoyed the benefit of lowered rates over the years due to fewer complications....CRNA's will bare the brunt of the full load of liability.

The for-profit CRNA factories will keep saturating the market, and as CRNA salaries continue to drop, the malpractice insurance will rise. Keep in mind...these are already people with nursing degrees and years spent in nursing (ie: not the most financially sound individuals to begin with).

The CRNA bubble will burst. CRNA's will no longer be able to afford the astronomical malpractice fees, Surgeon's will be fed up with the liability as well, and the life of the CRNA will be worse off than it was before this push for autonomy, as hospitals will just straight up stop employing them at surgeon's requests.

I for one think CRNA's do have a place in medicine (as do many mid-level care providers)...If they stay in their place, harmony can be maintained. They are the autopilot of the jet liner....programs exist that would launch and land planes sans pilot, but how many passengers would submit their take-off and landing to the autopilot program just to save a few dollars on their boarding pass.

the answer to your question depends on how you define "passengers"...if you are talking to a family member of an anesthesiologist, I'm sure very few of us will allow ourselves or our family members to be put down by a CRNA. However, the average joe might know the difference between CRNA and anesthesiologists, or NOT.

More importantly, you are assuming US healthcare still operates as a free-market system. It's not and it will not in the future. Welcome to obamacare pushing it one more step closer nationalized healthcare. Consumers don't have as much of choice as you think in this system. The number crunchers in CMS will only be looking at cost containment and private insurance will follow and maximize their profit even further by using midlevel providers.

Okay, so you think they will be any studies showing CRNA are inferior to MD anesthesiologists. I tell you such studies don't exist and even if it's carried by ASA, they won't show much statistically significance.


why?

because anesthesiologists are assigned for more complex surgical cases with ASA III/IV patients.

It's not an apple-to-apple comparison. It will never be. It's artificially segregated sample so that CRNAs are "autopiloting" easier cases and healthier patients and MDs are doing tougher cases. Their experience is balanced out the complexities of cases.

This is the 2nd reason why I believe anesthesiologists are doomed besides financial pressure. We'll be working with less pay, but more risky/stressful cases.

 

[IDBasco]

Can someone post this study that shows CRNAs equal to physicians? Either an author or title, etc. is fine. I want to read this thing.

 

[Fah-Q]

The CRNA problem was created by anesthesiologists. Don't ever forget that. It is a great lesson for all fields of medicine. If you train the competition they will eventually replace you. Do not train, employ, or supervise any midlevels ever.

If you train, employ, or supervise a CRNA then you are part of the problem. There are no exceptions. You are ****ing your profession and endangering patients. It's just that simple.

Anesthesiologists need to learn how to work again without CRNA's. No more shifts. No more breaks during cases. No more post-call days. Do your own cases in one room. Be a physician, not a shift worker.

 

[AK1010]

drpainfree, Obamacare is indeed concerning, and it is the push to nationalized healthcare that requires constant activism on our part. One of the most effective ways we can advocate for ourselves is to educate the public about the discrepancy. Simply letting the public know that they may actually be letting a CRNA gas them unwittingly might be more than the push we need to turn the tides.

On a different note, it is EXACTLY the ASA III/IV cases that will put CRNA's back in their place (or out of business completely). Assume the worst - Obamacare passes, and CRNA's win complete independence from any rational oversight. The oversaturated market will pay the CRNA's 80-90K/year. Obamacare will force surgeons to load up their schedules to make a profit. CRNA's will find themselves working 70 hour weeks for minimum pay. This is no better than what they were making as a nurse at their job pre-CRNA school. Many unemployed CRNA's will find regular RN jobs, many will quit completely. CRNA schools will have to shut down, the lobby will weaken and the field will fizzle out.

So where are the MDA's through all this? Still in business thanks to the IIIs/IVs. It isnt the MDA who is at risk of becoming obsolete, its the CRNA...and it is exactly for that reason that they maintain such a strong lobby. Unfortunately for the CRNA's it is all their rah-rah-ing that will ultimately be the end of them.

 

[cfdavid]

Guys, this is getting a little bit out of control. Surely we have problems to be solved in our profession. But, they are fixable. These problems can and will be solved by the younger generations of anesthesiologists.

Take this message board for example, and in "real life" I've had many of our own attendings voice similar concerns and these are men/women whom can and will do something about these "issues". The point is that awareness couldn't be any higher.

I know this topic is ages old, but the fact is that more and more of us are "getting it". Realizing that we can't continue on with the status quo is almost universal amongst the "younger" crowd.

AND, the DNP is going to cause similar concerns to a plethora of other specialties. This WILL for sure unify physicians in future battles against mid-level encroachment.

Sure, our specialty will change. We'll be more apt to handle the ASA 3 and above cases etc. But this game is far from over. I've said this sh.t as a med student, but it remains true to this day. This battle is ours to lose. It will not be lost, btw.

Additionally, I've (in a few short months) had CRNA's (not SRNA's) speak highly of the "amount of knowledge" and "having to know "everything"" of the "MDA" (which is about the only less than desireable terminology/aspect of what we tolerate at our institution). So, many CRNA's are NOT malignant. Surely, though, their organizations is, let's be honest about that. (somehow I feel few of us with be disagreeing on that one).

The fact is that leadership is a matter of perspective. It's a matter of ATTITUDE. I feel that we are begining to attract more asertive types to our profession. Men and women whom have the balls to make tough decisions regardless if they "rock the boat" a little bit.

Case in point, when the market gets saturated for CRNA's, do you think it's more or less likely (and easy) to begin instituting limited scopes of CRNA pracrtice withing any individual institution? Do not underestimate the power of this.

Our profession will do alright, provided we stay vigilant and know the stakes involved and whom our "enemies" are.

 

[jwk]

The impending national opt-out for CRNAs is the beginning of the end for us.

As a CA-2, I can't f'ing believe that I have wasted the last 7 years of my life for a dead end career.

I busted my ass to get where I am today. I graduated summa cum laude from a respected national university. I scored in the 99th percentile on the MCAT and in the 99th percentile on the USMLE examinations. I went to a top tier medical school and I graduated in the top 25% of my class.

I have $200,000 of educational debt.

I've endured countless sleepless nights as a medical student, intern, and resident on call.

All of this hard work and sacrifice. For what? So a person with half the duration of formal training, a person that has endured a fraction of the rigorous examination requirements that I have--a nurse that I've been issuing orders to for the last few years--can take my job?

Unf'ingbelievable.

WTF is wrong with the academic leadership in anesthesiology? Why are CRNAs still being trained by anesthesiologists? Are academic anesthesiologists really that clueless and detached from reality?

This whole situation is absolutely infuriating.

If you're as good as you think you are, then you'll be fine. There will ALWAYS be room for good anesthesiologists.

Yes the market is tight - but my group is still growing, with at least 1/2 a dozen new anesthesiologists coming on board.

 

[Osteoimperfecta]

Agree with cfdavid, no need freaking out over a fixable problem unless you don't plan on fixing it. This is a pure and simple political fight. It is not complicated; if you raise more money and make your presence more apparent politically, then you win. I really encourage the ones that have given up hope and only see doom to quit/switch fields and allow others handle business. My prediction is that anesthesiologist and PCPs will come out of this mid-level mess just fine if they applied the minimal amount of effort needed to fix it.

 

[dbth77]

drpainfree, Obamacare is indeed concerning, and it is the push to nationalized healthcare that requires constant activism on our part. One of the most effective ways we can advocate for ourselves is to educate the public about the discrepancy. Simply letting the public know that they may actually be letting a CRNA gas them unwittingly might be more than the push we need to turn the tides.

On a different note, it is EXACTLY the ASA III/IV cases that will put CRNA's back in their place (or out of business completely). Assume the worst - Obamacare passes, and CRNA's win complete independence from any rational oversight. The oversaturated market will pay the CRNA's 80-90K/year. Obamacare will force surgeons to load up their schedules to make a profit. CRNA's will find themselves working 70 hour weeks for minimum pay. This is no better than what they were making as a nurse at their job pre-CRNA school. Many unemployed CRNA's will find regular RN jobs, many will quit completely. CRNA schools will have to shut down, the lobby will weaken and the field will fizzle out.

So where are the MDA's through all this? Still in business thanks to the IIIs/IVs. It isnt the MDA who is at risk of becoming obsolete, its the CRNA...and it is exactly for that reason that they maintain such a strong lobby. Unfortunately for the CRNA's it is all their rah-rah-ing that will ultimately be the end of them.

you sound like an absolute idiot when you use the term MDA, just letting you know

 

[sevo85288]

Interesting discussion. A few thoughts.

1) There are no safe havens. All of medicine, nursing, hospital/medicine business will take substantial financial cuts due to impending federal budget crisis.
2) CRNAs will be able to practice independently BUT for a much lower rate than they are used to. Independent practice will means more work, calls, coverage, etc AND substantially lower reimb due to federal budget crunch as well as possibly the ACO model treating CRNAs as nurses and compensating rates similar to that. (ACO model is still in infancy/may not take hold; but health care reform and painful cuts are real and coming)

3) All specialities are screwed or will be getting screwed. All most all face financial cuts and most feel midlevel pressure of some sort.

4) There will be 2 levels of care: 1) Medicaid/govt 2) private insured. Towns will have the "county" hospital staffed by just CRNAs employed by hospitals or private practice hospitals with large medical groups affiliated with hospitals; they will have M.D or mix anes practice.

5) Physicians need to think big. Get an MBA and run these hospitals and practices. Be at the top of these chains. Become the administrator.

6) Support your PAC.

7) Take good care of pts and your local hospital/group will defend you.

 

[drpainfree]

very thoughtful points!

I'd have to break this out to residents and med students, while it's hopeful to remain optimistic, the fight to win battle over CRNA is already lost.

why? because at this point it's no longer about who provides better care (which is highly debatable among non-anesthesiologists especially considering MD will be shouldering more risky/complex cases), at this point and moving forward, it will be purely based on who's cheaper to pay.

unless you're willing to be paid less than CRNA/AA, an anesthesiologist has a losing battle to fight.

here I will give you an analysis what you will come across when you come out of training and looking for real jobs,

- the best, fee-for-service, meaning you're independent and get reimbursed for what you do. this is the best case, but disappearing fast and quick

- anesthesia group, promise you a partnership track 1 or 2 year down the road. be careful, the whole concept hings upon on the group will continue the contract in that time frame and continue to hold on to that contract after you become the partner. healthcare is changing rapidly. I guarantee you the medicine landscape will be different in 5 years (therefore the very fundamental assumption of partnership will be questionable). this anesthesia group/partnership track could be the best option 10 years ago. It's really questionable for newbies just coming out facing this uncertain time in medicine.

- anesthesia MANAGEMENT company, they are taking over contracts throughout the country, whether locally or nationally. Their motives are pure financial. Forget about partnership, forget about benefit, they will use you and tell you up front, and pay you per unit and rip the margin on your work. If medicare reduce reimbursement, they will reduce yours proportionally, but they will keep their margins. This is the worst you can get as an anesthesiologist. And I see the this trend becoming ever more omnipresent.

Where does CRNA/AA fit into this? They will infiltrate every level as a cost replacement.

I'm not discouraging new residents or medical students from entering the field, but this is coming to the entire medical field. No one is immune. You need to think about alternatives or get used to what's coming in the train wreck.

Interesting discussion. A few thoughts.

1) There are no safe havens. All of medicine, nursing, hospital/medicine business will take substantial financial cuts due to impending federal budget crisis.
2) CRNAs will be able to practice independently BUT for a much lower rate than they are used to. Independent practice will means more work, calls, coverage, etc AND substantially lower reimb due to federal budget crunch as well as possibly the ACO model treating CRNAs as nurses and compensating rates similar to that. (ACO model is still in infancy/may not take hold; but health care reform and painful cuts are real and coming)

3) All specialities are screwed or will be getting screwed. All most all face financial cuts and most feel midlevel pressure of some sort.

4) There will be 2 levels of care: 1) Medicaid/govt 2) private insured. Towns will have the "county" hospital staffed by just CRNAs employed by hospitals or private practice hospitals with large medical groups affiliated with hospitals; they will have M.D or mix anes practice.

5) Physicians need to think big. Get an MBA and run these hospitals and practices. Be at the top of these chains. Become the administrator.

6) Support your PAC.

7) Take good care of pts and your local hospital/group will defend you.

 

[jetproppilot]

I had an OB kick me out of a room because she doesn't want anesthesia residents working on her patients, she demands a CRNA.

And my dept. chair lets it happen. And, JPP just so you know this happened at your alma.

Thus is the state of anesthesia. It breaks my soul. The only reason I chose medical school was to give an anesthetic. I have always wanted to give anesthesia. But when I mention that I would be willing to move to a remote location to give my own anesthesia, I have a CRNA . . . A NURSE scoff and say 'they will never hire you because they dont need you.'

Well, maybe they dont. Im just about done fighting the battles for this profession where I cant even ask to be referred to as 'Dr.' without being thought of as a pompous ass. Funny, the surgery intern is Dr. but im 'hey anesthesia' -- just another CRNA/resident on the stool. **** they are interchangeable, right? God knows, I sign my name on a lot of forms where I have to scratch through a line saying 'CRNA name'

I wonder if I could make it through a family medicine residency without being suicidal. F*ck that makes me sad.

OK dude, before I respond, gimme more info.

Are you at Lakeside?

 

[Josh1]

@IDBasco

Can someone post this study that shows CRNAs equal to physicians? Either an author or title, etc. is fine. I want to read this thing.

The study cited by CRNA's is ""Surgical Mortality and Type of Anesthesia Provider." by Pine, which also picks apart a study done by Silber that showed there was difference when an anesthesiologists wasn't present, I mentioned it in my other post on this same thread. The study was legit, what we need is our own study to stratify if it mattered how complex the patient was. If CRNAs keep getting trained by anesthesiologists they will eventually handle ASA3/4 because they'll basically have a residency by getting on the job training for 10 years, think of it as a slow residency, except with good pay.

 

[ComfortableWolf]

This is one of the most depressing threads I have read in a long time...

If all the above is accurate than Anesthesia residency Is just one huge Ponzi Scheme... It is one thing to work your tail off for <50k a year if your are being trained/apprenticed to become a high earning professional, it is a completely different thing to go through med school to become a "glorified CRNA.". I had recently decided to switch into anesthesiology from a different residency because I had seen ICU/Cardiac Anesthesiologists do the most amazing things with unstable patients... Truly masters of physiology... Some of the best doctors I have seen...
I am at a "top ten" academic institution ( whatever that means) and CRNAs are not a major presence.
I did my research and understood there would be some battle with mid levels... But I plan on doing cardiac or ICU and thought that this would provide relative shelter


I am one of those "top tier" non-passive types who has made a switch because I developed a deep respect the Anesthesiologists mastery of physiology


But this thread is killing my enthusiasm... It is hitting me in the gut
I am truly worried I have made the wrong decision. Have I been played the fool?
I guess this post is mostly a visceral response with out much added content,but g-d damn this thread is making me depressed and angry.

Thanks for tolerating the venting.

 

[El Dooderino]

This is one of the most depressing threads I have read in a long time...

If all the above is accurate than Anesthesia residency Is just one huge Ponzi Scheme... It is one thing to work your tail off for <50k a year if your are being trained/apprenticed to become a high earning professional, it is a completely different thing to go through med school to become a "glorified CRNA.". I had recently decided to switch into anesthesiology from a different residency because I had seen ICU/Cardiac Anesthesiologists do the most amazing things with unstable patients... Truly masters of physiology... Some of the best doctors I have seen...
I am at a "top ten" academic institution ( whatever that means) and CRNAs are not a major presence.
I did my research and understood there would be some battle with mid levels... But I plan on doing cardiac or ICU and thought that this would provide relative shelter


I am one of those "top tier" non-passive types who has made a switch because I developed a deep respect the Anesthesiologists mastery of physiology


But this thread is killing my enthusiasm... It is hitting me in the gut
I am truly worried I have made the wrong decision. Have I been played the fool?
I guess this post is mostly a visceral response with out much added content,but g-d damn this thread is making me depressed and angry.

Thanks for tolerating the venting.

To be fair, this thread is basically three posters who think they can predict the future running around like chickens with their heads cut off. Will they be right, who knows? I certainly wouldn't get depressed over it or change the way you see the field

 

[bronx43]

To be fair, this thread is basically three posters who think they can predict the future running around like chickens with their heads cut off. Will they be right, who knows? I certainly wouldn't get depressed over it or change the way you see the field

Actually, everyone basically agrees that the current trend spells doom for anesthesiology. It's just that a few posters think it's too late for reversal of said trend.