Future of Anesthesia new CMS rule

[Chocolateagar04]

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Members don't see this ad.

How do you gusy feel about this? I saw thsi in the ASA newsletter. Looks like CRNAs might have more power than ever before?

"On Tuesday, the U.S. Department of Health and Human Services (HHS) officially announced that the Centers for Medicare & Medicaid Services (CMS) is developing a proposed rule to remove "obsolete or burdensome requirements" from the agency's existing regulatory structure. The rule, expected to be released in September, could include changes to anesthesia-related rules.
In a Wall Street Journal op-ed published Tuesday ("Washington is Eliminating the Red Tape") to accompany the department's announcement, an administration official states "The Department of Health and Human Services will soon propose to remove unnecessary regulatory and reporting requirements now imposed on hospitals and other health-care providers, potentially saving $4 billion over the next five years."
As part of the process to review existing rules, the department will consider changes to the hospital conditions of participation. Of particular interest to anesthesiologists, on page 41 of the HHS "Plan for Retrospective Review of Existing Rules," the department acknowledges receiving comments requesting that CMS consider elimination of the current physician supervision requirements imposed for anesthesia care, a component rule of the conditions of participation.
As ASA members know, over the last several years ASA has made clear to policymakers its perspectives on a number of regulations that impact anesthesiologists and their patients, including the Society's continued strong support for the physician supervision patient safety standard.
ASA will continue to inform the ASA membership of developments as they occur. "

 

[Consigliere]

You're expendable. Get used to it.

 

[anynoise]

if this goes through.. the specialty has become a nursing profession.... its just a matter of time thats all.. i dont think anything is official yet though... the feds are saying that they dont need us. and i love how they say.. burdensome requirement of physician supervision.. i didnt know we were such burdens and i guess the Anesthesiologist Assistants would be exempt from this requirement also since the statute includes them too. So they can operate independently too. oh this is so bad..

 

[JLM]

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.

 

[Mman]

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.

Your dept chair needs to grow a spine or a sack (or both). Your attending for the day should've had a discussion with that OB and clarified the situation.

 

[Osteoimperfecta]

Solution remains the same; stay politically active, donate money, educate the public and politicians. Sorry, but in politics, there is no free lunch. On the other hand, freaking out over a winnable battle is a futile use of energy.

 

[RT2MD]

In a way I feel fortunate that I'm just starting my second year, because I think that a lot of this mess will shake out by the time I'm going through the match... but at the same time, it really bums me out that it's even an issue.

Obviously I haven't gone through an anesthesia rotation yet, but I've gotten a LOT more exposure to various medical fields than the average second year (from previous work experiences). I've spent a lot of time around anesthesia (either in the ORs, or around residents/attendings) and I haven't found anything that I dislike about anesthesia. I know that there will be things that I don't like, but there is just so much damn cool stuff!

I've worked quite a bit in a free, student run clinic... which has been good experience, and I've enjoyed it, but it has reinforced that I don't like clinic. At this stage of the game, I'd have to say that I agree with another poster on here - I'd rather make family medicine money while practicing anesthesia, than making anesthesia money while practicing family medicine.

I've been interested in doing a fellowship for almost as long as I've been interested in anesthesia. I really like critical care, and I know that is one area that will belong much more to physicians, but the possibilities of these changes makes me wonder how incredibly competitive these fellowship spots will become. It really makes me happy to hear about the "new generation" of anesthesia residents coming through... You know, the ones that are completely driven to kick @ss. I really hope that is the case, because I think that's what this field needs to really survive... and that's all I really care about. I (naively?) don't really care that much about the money. It'll be a bunch more than what I made before med school... I just want to be able to have a career that I love, doing something that I love, while striving to do the best that I can possibly do. I just hope that the doomsdayers (did I just make that up?) aren't totally right, and I still get a chance to do anesthesia.

Sorry for the rambling post...

 

[jwk]

if this goes through.. the specialty has become a nursing profession.... its just a matter of time thats all.. i dont think anything is official yet though... the feds are saying that they dont need us. and i love how they say.. burdensome requirement of physician supervision.. i didnt know we were such burdens and i guess the Anesthesiologist Assistants would be exempt from this requirement also since the statute includes them too. So they can operate independently too. oh this is so bad..

AA scope of practice is a function of state law, not federal. Please don't lump us in with the nurses.

 

[RussianJoo]

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.

Yeah, I've wanted to be an anesthesiologist since high school. In my program I feel like the attendings like to work more with the crna's than the residents, because they get 4 rooms with crna's and only 2 with residents. Some of them give me the feeling that they think working with the residents is a punishment. Really sucks... Worst case scenario i'll do a ccm fellowship work in a closed ICU and say fck you to the OR and all the arshole surgeons.

 

[foxtrot]

Yeah, I've wanted to be an anesthesiologist since high school. In my program I feel like the attendings like to work more with the crna's than the residents, because they get 4 rooms with crna's and only 2 with residents. Some of them give me the feeling that they think working with the residents is a punishment. Really sucks... Worst case scenario i'll do a ccm fellowship work in a closed ICU and say fck you to the OR and all the arshole surgeons.

That is really a shame. Why is academic medicine selling out our profession? I know not all academic departments are like this. There are some good ones out there but there are a lot of them just like this. Keep your chin up and just get through it. Do a fellowship since that seems to be the requirement to get a descent job anymore.

 

[countingdays]

Yeah, I've wanted to be an anesthesiologist since high school. In my program I feel like the attendings like to work more with the crna's than the residents, because they get 4 rooms with crna's and only 2 with residents. Some of them give me the feeling that they think working with the residents is a punishment. Really sucks... Worst case scenario i'll do a ccm fellowship work in a closed ICU and say fck you to the OR and all the arshole surgeons.

Trust me. No one prefers 4 rooms to 2 rooms.
They probably feel like you are more likely to mess up than the crnas.
They might prefer two rooms with fellows or ca-3s, maybe even hand picked ca-2s if that were an option.

 

[HumNbrd]

How do you gusy feel about this? I saw thsi in the ASA newsletter. Looks like CRNAs might have more power than ever before?

"On Tuesday, the U.S. Department of Health and Human Services (HHS) officially announced that the Centers for Medicare & Medicaid Services (CMS) is developing a proposed rule to remove "obsolete or burdensome requirements" from the agency's existing regulatory structure. The rule, expected to be released in September, could include changes to anesthesia-related rules.
In a Wall Street Journal op-ed published Tuesday ("Washington is Eliminating the Red Tape") to accompany the department's announcement, an administration official states "The Department of Health and Human Services will soon propose to remove unnecessary regulatory and reporting requirements now imposed on hospitals and other health-care providers, potentially saving $4 billion over the next five years."
As part of the process to review existing rules, the department will consider changes to the hospital conditions of participation. Of particular interest to anesthesiologists, on page 41 of the HHS "Plan for Retrospective Review of Existing Rules," the department acknowledges receiving comments requesting that CMS consider elimination of the current physician supervision requirements imposed for anesthesia care, a component rule of the conditions of participation.
As ASA members know, over the last several years ASA has made clear to policymakers its perspectives on a number of regulations that impact anesthesiologists and their patients, including the Society's continued strong support for the physician supervision patient safety standard.
ASA will continue to inform the ASA membership of developments as they occur. "

Am I the only one having trouble opening the link? I'd really like to see exactly what it says. Thanks!

 

[Josh1]

The link is a pdf file, you have to download it or you can open it up in google docs.

This is severely disappointing as a med student thinking about going into anesthesiology, anesthesiology seems so interesting but if I make a nurse's salary it will be harder to pay off loans and pay for a house etc.
Ultimately this seems to be decided by what is economical. It would seem to me that anesthesiology will be dealing more with higher risk patients, or maybe CRNA will get 'advance certification' or something to deal with higher risk patients.
I would like to give uncle sam a swift kick right now

 

[TakingBakSunday]

Maybe I'm mistaken but this was in the section where a forum was opened up for public comments on the future review of existing rules. Don't you think they've already heard about the MD vs. crna debate and this is possibly the aana submitting a comment? They're just acknowledging the receipt of the comment, not currently proposing a change and this wasn't included in their initial assessment.

I'd be more concerned as a radiologist about their plan for telemedicine and not needing to be credentialed at all hospitals requesting services.

 

[BLADEMDA]

Since this is my job according to Sebelius do you think I'm eligible for the Glock Pistol First responder discount?

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=663198&highlight=future+of+anesthesia

I've been predicting this new anesthesia paradigm since 2007. We still have a shot to defeat it, albeit, a small shot. Defeat Obama and repeal Obamacare in 2012.
This will turn back the tide. However, if Sebelius and Obama implement their new plan for NPs, CRNAS, etc. next year before re-election occurs it may be too late to turn back the clock.

 

[Consigliere]

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.

You need to buy this shirt:

 

[Quirk11]

Blade is right about our lack of vision / direction for this field irrespective of CMS / provider politics. Here is what we are trying to "figure out":

https://www.faer.org/programs/students/projects.php

There are some great projects going on to be sure, with real clinical applications. However, where are the projects highlighting the importance of the field or its subspecialties. Ie Washington State just told the pain folks that their procedures are "not effective" as did some larger insurers?

Where is the response ? Where are our studies?

Not only should the laptops be put down, we should make every study for the next 3 years about defending the importance of the field and all its subspecialties...otherwise there won't be any point to the research...

Since this is my job according to Sebelius do you think I'm eligible for the Glock Pistol First responder discount?

 

[Stank811]

"It this goes through the specialty becomes a nursing profession"....hahah...and that would last maybe two seconds...what nurses; the ones that watch residents do all the complex cases....or the ones that only read about regional blocks....or the ones that worked 2 yrs in the ER or NICU followed by weak CNRA training....probably not. The CRNA profession is unable to educate themselves....the militant CRNAs who claim they can do everything only got to that point from working in large tertiary centers were staff allowed them to do to much and they gained enough experience to allow them to work their way through cases in rural america without supervision. Again to all the staff out there that reads this...stop letting them do procedures and complex cases. This is a result of the political climate regarding healthcare (ObamaCare) and effects every physician in america (surgeons likely most protected). But every other profession has a million nurses or midlevels claiming they can do the same for less.

 

[BLADEMDA]

"It this goes through the specialty becomes a nursing profession"....hahah...and that would last maybe two seconds...what nurses; the ones that watch residents do all the complex cases....or the ones that only read about regional blocks....or the ones that worked 2 yrs in the ER or NICU followed by weak CNRA training....probably not. The CRNA profession is unable to educate themselves....the militant CRNAs who claim they can do everything only got to that point from working in large tertiary centers were staff allowed them to do to much and they gained enough experience to allow them to work their way through cases in rural america without supervision. Again to all the staff out there that reads this...stop letting them do procedures and complex cases. This is a result of the political climate regarding healthcare (ObamaCare) and effects every physician in america (surgeons likely most protected). But every other profession has a million nurses or midlevels claiming they can do the same for less.

Obama plans on turning those Nurses loose on Society. This will drive down cost and increase access (per the AANA and Obama). Perhaps, the real agenda is to get Physicians to join the AFL-CIO?

Sebelius will be turning those Nurses loose in short order. You can count on it.

"Change you can Believe in" remember?

 

[BLADEMDA]

"By the last count there were well over 5000 Independent CRNA practices across the country and that number is growing yearly. This being the case and knowing there are only 115 programs with about 2K students in any program year, it could be done."

Leader of Murseanesthesia.org

 

[dizzy21]

Yea well given the coming CRNA surplus, even CRNAs are worried about CRNAs.

 

[sevoflurane]

over 5000 Independent CRNA practices

Geesh.

 

[deleted126335]

"by the last count there were well over 5000 independent crna practices across the country and that number is growing yearly. This being the case and knowing there are only 115 programs with about 2k students in any program year, it could be done."

leader of murseanesthesia.org

5000? B.s.

 

[bronx43]

"By the last count there were well over 5000 Independent CRNA practices across the country and that number is growing yearly. This being the case and knowing there are only 115 programs with about 2K students in any program year, it could be done."

Leader of Murseanesthesia.org

You sure it's not over 9000?


Sorry... couldn't resist.

 

[anynoise]

"It this goes through the specialty becomes a nursing profession"....hahah...and that would last maybe two seconds...what nurses; the ones that watch residents do all the complex cases....or the ones that only read about regional blocks....or the ones that worked 2 yrs in the ER or NICU followed by weak CNRA training....probably not. The CRNA profession is unable to educate themselves....the militant CRNAs who claim they can do everything only got to that point from working in large tertiary centers were staff allowed them to do to much and they gained enough experience to allow them to work their way through cases in rural america without supervision. Again to all the staff out there that reads this...stop letting them do procedures and complex cases. This is a result of the political climate regarding healthcare (ObamaCare) and effects every physician in america (surgeons likely most protected). But every other profession has a million nurses or midlevels claiming they can do the same for less.

you are still in denial. IT doesnt matter what the truth is.. It really doesnt. and it doesnt matter how much you and I scream about how much we know the nurses cannot do the job adequately. It matters what the perception of the truth is. And the perception of the truth is that yes CRNAs can do the job most of the time. There are hospitals that have only CRNAS. thats it. no input from anesthesiologist.. Never mind that some of the time complications will happen and those complications in our field is pretty major. Never mind that it doesnt involve major involved cases. Never mind it doesnt involve tricky cases that involve difficult judgement calls. It matters what is going on in washington.. and for some reason and i dont know why nobody wants to appreciate our expertise. we are in major trouble. and i have no idea why our leaders are taking the high road. Medicare will save 5 billion dollars or so over 10 years. Is that the n umber i read? In my opinion thats freakin peanuts compared to the can of worms they are opening. So yes if this goes through, thats what CMS is saying, its a nursing profession if there needs to be no oversight or judegement by a physician prior to patients undergoing probably one of their stressful periods of their life. Just a two year trained nurse who never took an advanced mathematics course, or chemistry course for that matter. I am personally disgusted and ashamed.

 

[Josh1]

I think quirk is 100% correct. Politicians are in a fiscal mess, if crnas are perceived as just as efficient and cost that's what will be used, and that's what is currently being used. The hospital I'm at, we did all of the laparoscopic procedures and there was never an anesthesiologist in the room. Crna are cheaper and in a hospital CFO's mind just as efficient. This will push anesthesiologist to handling only high risk/peds/CT cases, possibly critical care but that's most likely going to be pulms; this essentially means a lot less jobs for anesthesiologists and less pay for those in jobs as the market gets glutted.

What should be done: a study, politicians can't act in the face of evidence that it is riskier, otherwise if something bad happens they'll be strung up as endangering lives when it was known that it was risky. However we don't have any studies 🙁
Ugh, I'm applying for residency in 3 years and I had my heart set on anesthesia, this sucks!

 

[Gasworks]

In the course of all this political activity, has the ASA ever reached out to the ACOS/AAOS/etc? One would think hospitals would start caring if the surgeons voted with their feet. You may be able to "replace" an MD with a CRNA, but nursing can never bring the surgical cases in the door in the first place.

What makes you think the surgeons are going to come running to our rescue? I work at a couple of hospitals as well as some surgery centers, and the surgeons who own shares in the centers are drooling over the prospect of hiring crna's who will sign over billing rights and earn them extra profits. These are the same guys who pat you on the back in the hospital telling you how they would never let a crna touch their patients and then go off to shareholder meetings planning your demise.

The only end game I see here involves all of us taking a massive cut in pay or finding a new line of work. As far as surgeons and administrators are concerned we are simply another cost center like dietary and housekeeping. Nobody cares how good you are at mopping the floors as long as they get mopped as cheaply as possible.

If you are looking for someone to blame, just look around at the next department meeting you attend. Blame academic anesthesiologists who have grown accustomed to sitting on their ever fattening rear ends while crna's wooed and won over surgeons. Blame department chairs who continue to allow srna training while the same students are actively campaigning to being an end to MD anesthesia. Blame worthless greedy private practices that spend all day trying to F the nurses while crna's are busy doing 100% of the work.

OK thats about the end of my rant.

 

[BLADEMDA]

Yes. The previous poster pretty much hit the nail on the head.

 

[Monty Python]

How do you gusy feel about this? I saw thsi in the ASA newsletter. Looks like CRNAs might have more power than ever before?

"On Tuesday, the U.S. Department of Health and Human Services (HHS) officially announced that the Centers for Medicare & Medicaid Services (CMS) is developing a proposed rule to remove "obsolete or burdensome requirements" from the agency's existing regulatory structure. The rule, expected to be released in September, could include changes to anesthesia-related rules.
In a Wall Street Journal op-ed published Tuesday ("Washington is Eliminating the Red Tape") to accompany the department's announcement, an administration official states "The Department of Health and Human Services will soon propose to remove unnecessary regulatory and reporting requirements now imposed on hospitals and other health-care providers, potentially saving $4 billion over the next five years."
As part of the process to review existing rules, the department will consider changes to the hospital conditions of participation. Of particular interest to anesthesiologists, on page 41 of the HHS "Plan for Retrospective Review of Existing Rules," the department acknowledges receiving comments requesting that CMS consider elimination of the current physician supervision requirements imposed for anesthesia care, a component rule of the conditions of participation.
As ASA members know, over the last several years ASA has made clear to policymakers its perspectives on a number of regulations that impact anesthesiologists and their patients, including the Society's continued strong support for the physician supervision patient safety standard.
ASA will continue to inform the ASA membership of developments as they occur. "

This only applies to patient care where Medicare is paying the bills.

This only applies in states where, by virtue of state law, CRNAs have independent practice. That's approximately 25 states.

The other ~25 states require physician supervision/direction of CRNA practice, as written in their state Nurse Practice Act.

State law trumps Medicare reimbursement regulations.

And even in states which allow independent CRNA practice, hospital by-laws can still mandate physician supervision of CRNA practice. Hospital by-laws can always be more restrictive than state law.




.

 

[Dawkter]

Another medical student here with a strong interest in anesthesiology. In my opinion, there are few other fields that would offer me the variety of procedures, excitement, and intellectual stimulus available in anesthesiology. I have been dead set on this field for awhile and don't know if I can even see myself doing anything else.

As sad as I am to hear all of this, at the same time I understand that a huge pay cut is inevitable. I would still pick anesthesiology if it meant making 150-200k. My concern is that in order for anesthesiologists to compete with the CRNA market, would the salary need to drop down into the 80-100k range? I want to do this field but for all the time and money we have invested so far, it would be difficult to justify doing it for that type of salary. Any thoughts... is there a possibility that all of this will blow over soon enough?

 

[anynoise]

I would tend to agree with you but every patient is different and you cannot predict which patients will be easy or hard and have no complications. Sometimes the most difficult cases and the riskier cases are the ASA 1 and 2. Thats where the politicians are scratching their heads because those patients(asa 1 and 2) die under anesthesia sometimes. Those patients get MH, have allergic reactions, those patients have difficult airways, have full stomachs come in for traumas... So do those patients need an MD expertise?

Commisioning a study like the one you are speaking of would be unethical. DO you need a study saying Letting Ray Charles behind the wheel of a car on the 405 is unsafe?

Anyway, good luck with your quest for a safe residency. Ours is on the forefront in battling mid level encroachment and its gonna get ugly if this thing has legs

 

[dozitgetchahi]

Another medical student here with a strong interest in anesthesiology. In my opinion, there are few other fields that would offer me the variety of procedures, excitement, and intellectual stimulus available in anesthesiology. I have been dead set on this field for awhile and don't know if I can even see myself doing anything else.

As sad as I am to hear all of this, at the same time I understand that a huge pay cut is inevitable. I would still pick anesthesiology if it meant making 150-200k. My concern is that in order for anesthesiologists to compete with the CRNA market, would the salary need to drop down into the 80-100k range? I want to do this field but for all the time and money we have invested so far, it would be difficult to justify doing it for that type of salary. Any thoughts... is there a possibility that all of this will blow over soon enough?

I have many of the same sentiments and am anxiously awaiting an answer to this question.

I'm enthusiastic about anes but I'm not willing to roll the dice on my family's economic future. Anesthesiology is interesting and exciting but it's hardly the only thing in medicine I could see myself doing...especially if a massive pay cut and questions about long-term job stability come as part of the package.

 

[Osteoimperfecta]

Caveat: I'm not involved in anes in any way. I am a Navy GMO shortly going back to Ortho residency. And please understand, I'm not asking these questions to be contentious; I'm asking because I genuinely want to know, both out of curiousity now, and so I can structure my own practice down the road.

Intuitively, I would think surgeons would want anesthesiologists. I don't understand why any surgeon would be happy/comfortable with an independent nurse running an aspect of patient care that the surgeon himself can't step in and take care of if something goes wrong.

My experiences in 10+ civilian hospitals as a med student, intern, and GMO has shown that this is not a common view. The surgeons I have worked under simply do not care. Perhaps my perspective is skewed, but from reading this forum I suspect not.

In my head, it seems like there are only a few possible reasons for this, and I would think these assumptions could be generalizable to any facility regardless of how the anes practices are structured:

(1) The surgeons have no financial downside to CRNAs running their ORs.

(2) The surgeons do not see added value from the expanded perioperative services that anesthesiologists can provide.

(3) The surgeons have not noted any significant difference in outcomes/complications for patients with CRNAs.

If the surgeons cared, it would seem to make your case against expanded CRNA practice a lot easier to get across to the public. No one can make a "sour grapes" argument (as the CRNAs seem to do all the time) if it's the surgeon saying we need an anesthesiologist running the case, or at least overseeing the CRNA. But I have never heard the surgical organizations talk about this, or even indicate that it's on their radar.

This I think is a huge mistake; all physicians need to work together to protect the physician workforce. This attitude is lacking in physicians, and I predict it will lead to the ultimate demise of the entire workforce. Specialists abandoned primary care physicians, and now they are used as an effective weapon against specialists and in the new push for restructuring reimbursements to favour 'prevention' over procedures. Which by the way is now a bipartisan effort. The cash cow ORs is the main thing empowering surgeons, and making this anesthesiologist-CRNA discussion worthwhile. If or when it goes away, discussions like this will be redundant, and we will all be getting as much respect as the system presently gives to FPs. My point is, we need to all collectively protect the entire workforce as a whole by preventing mid-level encroachment wherever present, fighting off politicians and hospital administration, while building public support. A fragmented physician workforce is a sitting duck waiting to be maimed.

 

[BLADEMDA]

Another medical student here with a strong interest in anesthesiology. In my opinion, there are few other fields that would offer me the variety of procedures, excitement, and intellectual stimulus available in anesthesiology. I have been dead set on this field for awhile and don't know if I can even see myself doing anything else.

As sad as I am to hear all of this, at the same time I understand that a huge pay cut is inevitable. I would still pick anesthesiology if it meant making 150-200k. My concern is that in order for anesthesiologists to compete with the CRNA market, would the salary need to drop down into the 80-100k range? I want to do this field but for all the time and money we have invested so far, it would be difficult to justify doing it for that type of salary. Any thoughts... is there a possibility that all of this will blow over soon enough?

No. You are way too low on your estimates. Based on 2011 data the average CRNA income is $168,00 across the USA. This includes overtime and Solo CRNAS. A Solo CRNA earns around $240-280K 1099. Even in a Socialized health system I expect the young, Fellowship trained Anesthesiologist to earn around $250K of depreciated, U.S. Dollars. The problem is the USA is going to a need a lot less Anesthesiologists and a lot more DNP CRNAs ($110K) if things keep going the AANA's way.

http://www.locumtenens.com/media/49..._cid=EMAIL:1-SeptemberNewsletter2-CRNA3-CompS

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=753196


Go ahead and read through the above thread.

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=601010

Solo CRNAs ain't cheap. Click on the thread above.

Want to read more about the AANA and/or CRNAS? I have thousands of posts on SDN about the subject.

 

[Taurus]

This I think is a huge mistake; all physicians need to work together to protect the physician workforce. This attitude is lacking in physicians, and I predict it will lead to the ultimate demise of the entire workforce. Specialists abandoned primary care physicians, and now they are used as an effective weapon against specialists and in the new push for restructuring reimbursements to favour 'prevention' over procedures. Which by the way is now a bipartisan effort. The cash cow ORs is the main thing empowering surgeons, and making this anesthesiologist-CRNA discussion worthwhile. If or when it goes away, discussions like this will be redundant, and we will all be getting as much respect as the system presently gives to FPs. My point is, we need to all collectively protect the entire workforce as a whole by preventing mid-level encroachment wherever present, fighting off politicians and hospital administration, while building public support. A fragmented physician workforce is a sitting duck waiting to be maimed.

Bingo! How long before we have independent midlevel surgeons? England is experimenting with training nurses to do surgery. Surgeons need to get off their inflated egoes and see that they are in the same boat as all physicians.

 

[Mac4]

But surgeons here are not training nurses to do surgery and surgery residents are not leaving the OR at 3 pm sharp. Our anesthesia attendings are actively training SRNAs and our residents are happy to hand over the case to SRNAs/CRNAs to go home. Can you name another speciality doing things like this?

 

[Taurus]

But surgeons here are not training nurses to do surgery and surgery residents are not leaving the OR at 3 pm sharp. Our anesthesia attendings are actively training SRNAs and our residents are happy to hand over the case to SRNAs/CRNAs to go home. Can you name another speciality doing things like this?

PCP's training NP's.

Physicians are digging their own professional graves by training nursing midlevels such as NP's, CRNA's, CNM's.

 

[Osteoimperfecta]

But surgeons here are not training nurses to do surgery and surgery residents are not leaving the OR at 3 pm sharp. Our anesthesia attendings are actively training SRNAs and our residents are happy to hand over the case to SRNAs/CRNAs to go home. Can you name another speciality doing things like this?

My point is that the more the system/politicians/and the public continue to be comfortable with the mid-level option in any specialty (anesthesia, primary care, physical medicine, neurology, hell even hospitalist recently, etc) the less valuable the MD/DO tag will be. This is the real threat to all physicians including surgeons, and it will not be too long before reimbursements across the board start to reflect that perception. That is why we all have to band together, even when it is not a direct threat. So, when you see an article in NY times saying CRNAs = physician anesthesiologist, other physicians should not decieve themselves into thinking that ends with anesthesiologists. The silent message to the layman and politicians is "physicians are not worth as much as we are paying them".

 

[foxtrot]

What makes you think the surgeons are going to come running to our rescue? I work at a couple of hospitals as well as some surgery centers, and the surgeons who own shares in the centers are drooling over the prospect of hiring crna's who will sign over billing rights and earn them extra profits. These are the same guys who pat you on the back in the hospital telling you how they would never let a crna touch their patients and then go off to shareholder meetings planning your demise.

The only end game I see here involves all of us taking a massive cut in pay or finding a new line of work. As far as surgeons and administrators are concerned we are simply another cost center like dietary and housekeeping. Nobody cares how good you are at mopping the floors as long as they get mopped as cheaply as possible.

If you are looking for someone to blame, just look around at the next department meeting you attend. Blame academic anesthesiologists who have grown accustomed to sitting on their ever fattening rear ends while crna's wooed and won over surgeons. Blame department chairs who continue to allow srna training while the same students are actively campaigning to being an end to MD anesthesia. Blame worthless greedy private practices that spend all day trying to F the nurses while crna's are busy doing 100% of the work.

OK thats about the end of my rant.

Bingo. Just take a look at the Anesthesiology Newsletter this month. It is dedicated to technology and Anesthesia, when really it should be about how to save our specialty from midlevel takeover. The ASA needs to start taking a hardline stance now, not after CMS adopts a national opt out.

 

[El Dooderino]

Another medical student here with a strong interest in anesthesiology. In my opinion, there are few other fields that would offer me the variety of procedures, excitement, and intellectual stimulus available in anesthesiology. I have been dead set on this field for awhile and don't know if I can even see myself doing anything else.

As sad as I am to hear all of this, at the same time I understand that a huge pay cut is inevitable. I would still pick anesthesiology if it meant making 150-200k. My concern is that in order for anesthesiologists to compete with the CRNA market, would the salary need to drop down into the 80-100k range? I want to do this field but for all the time and money we have invested so far, it would be difficult to justify doing it for that type of salary. Any thoughts... is there a possibility that all of this will blow over soon enough?

yes, the only way to compete with crna's is to make half of what they make. actually, go for 1/3, then you'll really be a competitive candidate for jobs

 

[Dawkter]

yes, the only way to compete with crna's is to make half of what they make. actually, go for 1/3, then you'll really be a competitive candidate for jobs

I just said that number because I have read on this forum that assuming the number of CRNA schools and graduates increases and their market starts to saturate, they will have to take a paycut as well. CRNAs are paid 150k right now because they are in demand and positions are plentiful. As soon as the supply picks up I think they will be making a salary more around 100k.

 

[cfdavid]

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.

This is what happens when anesthesiologists allow CRNA's to become the "face of anesthesia". Time for the MD/DO's to spend a little more time in the OR, limiting the scope (even locally, in an institution) of CRNA practice (i.e. set hospital policy) to stool sitting. No procedures, no regional, no lines. Over time, SRNA's will not have the experience to feel confident doing such things and we can indeed regain the specialty. This is entirely feasbile. Sure, groups might have to work harder, take more call, whatever. But, does anyone really see any other way moving forward?

Do NP's do lumbar punctures in the ED? Not that I've seen. So, why are we allowing CRNA's to do spinals in some institutions (not ours btw)?? It's ridiculous that it's come to this.

All of that being said, it's time to stop the f.cking whining. We need to seriously "man up" as a profession, get with the program, become more proactive, EARN back the respect of pretty much everybody, and see our profession reap the rewards that WILL come with all of that. It's totally up to us.

Also, JLM, you are allowing a CRNA to get into your head. That CRNA is attempting to minimalize your training as a physician. Apparently it's working because her comments are getting to you. Take faith in your medical training. From medical school to intern year, this separates you from a CRNA for sure. You just need to regain your realization of this.

****Leadership. At my institution, no joke, more often than not, the CRNA board runner (never spring chickens) will come in and refer to ME (a CA1) as Dr. cfdavid. Half the time I'm floored by this. My point is that this is institutional. I don't really know where that comes from, but I'm rather certain that our chairman or PD stated that "you will refer to your residents as Dr. XYZ", and it f.cking happens.

Regardless of this, we need to reflect back on all this BS like "the surgery intern is called Dr. surgicenter this and that". Well, I call BS to that as I've seen OR nurses call colorectal fellows "Eddy" and so on. So, it's not just us poor little anesthesiology residents "suffering" through being "disrespected" all of the time. Stop being so insecure and sensitive.

If you think that some small rural town doesn't need your services as a physician anesthesiologist, then that's the mentality which will limit you. If it's not just your imagination, then you need to strengthen your skills, bring something ELSE to the table, promote that "something else", sell yourself, work harder to offer something more value added to the proposition, and you'll be fine.

 

[cfdavid]

Bingo! How long before we have independent midlevel surgeons? England is experimenting with training nurses to do surgery. Surgeons need to get off their inflated egoes and see that they are in the same boat as all physicians.

I'm sure we've all seen the SCRUB TECHS which have taken "first assist" courses, essentially become the "residents" to the surgeon.

Two days ago, I did 3 bariatric cases with one of our surgeons. His first assist has indeed become a deft mechanic. I wonder when that Scrub Tech with a certificate will start wondering why/how it is that the surgeon makes 8 times what he does, and after all, he's capable of doing the procedure himself. When the surgeon leaves the room, ever earlier and earlier as the years go by.........

So, it's not just anesthesia. Other professions WILL BE seeing higher RATES of the types of problems that we've been dealing with for years. The result willl be that physicians will for sure band together more cohesively as other specialties begin being challenged as has ours over the years. This is inevitable.

 

[Osteoimperfecta]

100% agree with cfdavid, it is the leadership at an institution that determines how the residents get treated by everyone else, and subsequently how the staff get treated and percieved. Some surgery programs allow their residents get treated like crap and they do. Sometimes, anesthesiologists walk around the hospital like they don't belong there. My former institution required all surgery residents outside the OR to wear their white coats especially while rounding, and the chair did not allow anyone even think about disrespecting his residents and that was how it went; the anesthesia residents on the other hand often walked around doing pre-ops in scrubs looking no different from scrub techs, the chair was more concerned with encouraging timid behaviour in his residents and writting them up for any nursing complaint, and guess what? Those residents got disrespected daily, soon enough the attendings got their own share of daily disrespect too.

 

[Josh1]

I would tend to agree with you but every patient is different and you cannot predict which patients will be easy or hard and have no complications. Sometimes the most difficult cases and the riskier cases are the ASA 1 and 2. Thats where the politicians are scratching their heads because those patients(asa 1 and 2) die under anesthesia sometimes. Those patients get MH, have allergic reactions, those patients have difficult airways, have full stomachs come in for traumas... So do those patients need an MD expertise?

Commisioning a study like the one you are speaking of would be unethical. DO you need a study saying Letting Ray Charles behind the wheel of a car on the 405 is unsafe?

It wouldn't be hard, we'd just have to study what's actually happening now!
I don't disagree that it is hard to predict the difficult of the patient, but this is not what is at issue. This is a political issue, some person will check off in their check box '[...] can be handled by a nurse w/o a doctor' and anyone in that classification will be. Politicians aren't scratching their heads about this, they are looking for ways to save money. Read the OP's original attached pdf:

"current regulations, 42 CFR part 482.52(a)(4) requires
unnecessary supervision by an "operating practitioner or an anesthesiologist" upping costs by increasing staff members but not safety. This commenter summed up these particular
concerns by, "suggest[ing] that all regulations and interpretive guidelines issued by CMS be reviewed with the intent of removing restrictions concerning anesthesia services provided by nurse anesthetists."

The key statement in that is that 'did not increase safety,' basically saying anesthesiologists are not needed. There either needs to be a study that this is not true, the CRNA's already have their study that they're just as safe, done by a cardiologist ("Surgical Mortality and Type of Anesthesia Provider.").

The end result will be a lot less job opportunities for anesthesiologists. Even careers handling more complex cases like CT/peds will get more applicants and thus lower salary.
I don't think any of us can guess what the pay cut would be, but if this CMS proposal is passed into law it will be big, anesthesiologists will essentially be competing with nurses for jobs.
These CMS actions come under Deficit Panel guidance, what's scarier is that if the deficit panel doesn't come up with a plan an AUTOMATIC reduction of 1.2 trillion goes into effect, 1/2 from medicare and a few other social service plans and 1/2 from defense (which is what is currently causing a lot of the republicans on the committee to be up in arms about). And oh yeah, it's not from medicare beneficiaries, it's from PROVIDERS, i.e. they will still cover the same things, but just pay less, putting pressure on administrators to cut costs. Guess where they're going to look? Why? Because there is no evidence that it makes a difference who runs anesthesia.

This is why I advocate for a study, we can try to get all the political force we can muster but ultimately this will be small compared to if we have a study and then for every death in the OR we can say: 'there would've been a statistically significant difference, but the hospital chose cost over safety' this would be a much more powerful statement.
The sh.tty part is that it was all anesthesiologists research into safety and efficacy that made doing cases easier and safer that what resulted in the current predicament. As someone mentioned above, I bet if nurses were trained on a really easy surgery they could get data that showed no difference, then we'd see some surgeons up in arms
Just my two cents

Edit: you can just read Blade's posts in his links above, they were dire when they were first posted and it looks like his predictions are becoming reality.

Here is my worst case scenario circa 2020. The DNAP CRNA is doing his/her own cases without supervision. The MD (A) does critical/high acuity cases and helps put out fires in the O.R. Most hospitals cut back on MD providers and utilize the CRNA. MDs cover call or back-up call and do cases along with CRNAS.

CMS declares this field Nursing and slashes reimbursement by 50% from today's already low level. CRNAs take a 40% pay cut and we get the same. Most MDs are employed by the hospital or are co-owners in a surgi-center. Private Insurance(whatever remains) also cuts reimbursement for this nursing field by 50%.

So, this field is viewed by the govt and Insurance companies as a Nursing level duty. Regardless of what your University Attendings think or say the reality is a CRNA can legally perform all the same duties as an Anesthesiologist(except TEE, Bronchoscopy and Pain Management) at half the cost.

Thus, as long as you don't mind end up being a Fireman and/or Glorified Anesthesia Nurse (with a Doctorate) then this field is for you.

 

[joshmir]

It has been alleged that many in charge of the ASA run stables of CRNAs and have no inclination to support a study that will show their care to be inferior

 

[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.

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

1. This is just outright pathetic
2. Don't take it personally, OB's are *****s