I am practising pain physician. I have good hospital based practise and I do 50% anesthesia and pai

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madhi

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I am planning to go for critical care anesthesia fellowship in 2015. I need your suggestion guys. How is the future of critical care anesthesia. Can I practise both anesthesia and critical care? How is the future job market looking out to be? Your suggestions are highly appreciated.
 
I am planning to go for critical care anesthesia fellowship in 2015. I need your suggestion guys. How is the future of critical care anesthesia. Can I practise both anesthesia and critical care? How is the future job market looking out to be? Your suggestions are highly appreciated.
You're kidding, right? Nobody does CCM after pain.
 
Yeah I'm not sure where the pain part fits in. I can see doing Cardiac and CCM. Not after pain. Totally different. I think CCM/cardiac would be a very marketable combination for the foreseeable future.
 
I am planning to go for critical care anesthesia fellowship in 2015. I need your suggestion guys. How is the future of critical care anesthesia. Can I practise both anesthesia and critical care? How is the future job market looking out to be? Your suggestions are highly appreciated.


It's a little interesting that others don't answer your question, but only tell you you aren't interested in what you are interested in. How funny is that?

Anyway, I have two siblings who are ICU trained. They both don't work in an ICU. These jobs are hard to find outside of academia. However, if you search hard enough, there are a few. My sister just left a job she LOVED (for love....) where she was doing anesthesia and ICU at a private practice hospital.
 
It's a little interesting that others don't answer your question, but only tell you you aren't interested in what you are interested in. How funny is that?

Anyway, I have two siblings who are ICU trained. They both don't work in an ICU. These jobs are hard to find outside of academia. However, if you search hard enough, there are a few. My sister just left a job she LOVED (for love....) where she was doing anesthesia and ICU at a private practice hospital.
It's more that I have never heard of someone practicing both pain and ICU
 
I appreciate you guys input. Basically it is a burn out issue. Dealing with pain patients and procedure reimbursements coming down. I dont find the pain medicine exciting not stimulating to tickle your brain. I am able to do 50% anesthesia but CRNAs are another headache.
I want to do Critical care and anesthesia. I am already been accepted in the critical care anesthesia fellowship program. How does the future of combination of anesthesia and ICU looks like?
 
I appreciate you guys input. Basically it is a burn out issue. Dealing with pain patients and procedure reimbursements coming down. I dont find the pain medicine exciting not stimulating to tickle your brain. I am able to do 50% anesthesia but CRNAs are another headache.
I want to do Critical care and anesthesia. I am already been accepted in the critical care anesthesia fellowship program. How does the future of combination of anesthesia and ICU looks like?
Everybody seems to say anesthesia with CCM is mainly academic. PP anesthesia (without CCM) doesn't care a lot about your ICU skills, except if they have sick patients they can use you for, or you get TEE-certified during the fellowship (and they'll use you for cardiac).
 
If I did CCM I think I'd spend most of my time talking to families about being realistic. I think we have WAY too many ICU beds because we treat every patient like we can fix them if we spend enough on them and throw enough technology at them. We can't. Sick beds should be for critically ill people that we CAN make better.
 
anyone do a chronic pain fellowship but not do chronic pain afterwards and going back to OR anesthesia? im in my fellowship but considering going for an acute pain/OR job instead of Private practice pain?
 
anyone do a chronic pain fellowship but not do chronic pain afterwards and going back to OR anesthesia? im in my fellowship but considering going for an acute pain/OR job instead of Private practice pain?

Plenty of people do that....having pain a secondary skill set is great b/c it's almost a complete 180 from anesthesia and gives you a chance to practice in 2 different types of environments with different challenges and patients
 
Plenty of people do that....having pain a secondary skill set is great b/c it's almost a complete 180 from anesthesia and gives you a chance to practice in 2 different types of environments with different challenges and patients

If one does a pain fellowship and then decides to go and practice in the OR with a private group, can one still do a day per week of pain medicine? What if one does a fellowship and ends up just doing OR anesthesia afterwards, how long can one do this without practicing any pain before one starts to lose skills as a pain doctor? Are skills in pain easily lost and is it hard to stay up to date with literature if you aren't practicing everyday?
 
If one does a pain fellowship and then decides to go and practice in the OR with a private group, can one still do a day per week of pain medicine? What if one does a fellowship and ends up just doing OR anesthesia afterwards, how long can one do this without practicing any pain before one starts to lose skills as a pain doctor? Are skills in pain easily lost and is it hard to stay up to date with literature if you aren't practicing everyday?

Very quickly - 6 months maybe.

Most fellows graduating are still on the steep learning part of the curve when they graduate. I think I learned how to be a pain physician the first two years AFTER fellowship. That is an important time to be practicing pain.

Personally, I feel you should practice as pain physician for a while - solidify your skills and decision making. Also, a lot of our fellows towards the end of the fellowship think they don't want to do pain - and I get it - it is a very tough, mentally draining year and by the end, you are DONE. But after they graduate, work as staff in pain for a while, they all realize they really enjoy it once the crap of being a fellow is gone.

You did anesthesia for 3 years. That will take longer to loose and forget.
 
Very quickly - 6 months maybe.

Most fellows graduating are still on the steep learning part of the curve when they graduate. I think I learned how to be a pain physician the first two years AFTER fellowship. That is an important time to be practicing pain.

Personally, I feel you should practice as pain physician for a while - solidify your skills and decision making. Also, a lot of our fellows towards the end of the fellowship think they don't want to do pain - and I get it - Tis a very tough, mentally draining year and by the end, you are DONE. But after they graduate, work as staff in pain for a while, they all realize they really enjoy it once the crap of being a fellow is gone.

You did anesthesia for 3 years. That will take longer to loose and forget.

Is it possible to do pain and do gas moonlighting on the side?
 
private practice pain seems horrible right now honestly and the thought of seeing 30 patients/day in clinic is dreadful to me currently as a fellow.

large/stable academic OR/acute pain vs Private practice chronic pain are two different worlds.....what would you guys think is better in the future?
 
Be prepared to compete with the regional guys for acute pain management in academia. You might end up doing only OR.
 
Be prepared to compete with the regional guys for acute pain management in academia. You might end up doing only OR.


i agree with you on that since regional/acute pain is a good gig in academics....at my institution however, the only fellowship trained person on the acute pain team is a chronic pain trained from many years ago and is the director. everyone else is not regional/acute pain fellowship trained so i would be able to have an active role on the acute pain/regional team.....

my dilemma is do I want to do mainly OR/regional or go PP pain in hospital system, two different worlds i know but i've heard many times how the "Things are always rosier on the other side of the fence" since I have never been an attending in the OR yet, just as a resident.

Any academic OR staff out there?
 
Isnt the trend for even fewer docs on a unit? One hospital I was at had one unit staffed completely by NPs rather than physicians. Id bet on this to the further trend as much as possible. The only staffing requirement for a unit is nurses per patients ratio. As long as a doc admits and discharges ultimately from the hospital. As long as cc physicians and consulting ones are around somewhere, hospitals will decrease labor costs through this method of NPs (who also meet the nurse to patient quota required by CMS and credentialing bodies)
 
Isnt the trend for even fewer docs on a unit? One hospital I was at had one unit staffed completely by NPs rather than physicians. Id bet on this to the further trend as much as possible. The only staffing requirement for a unit is nurses per patients ratio. As long as a doc admits and discharges ultimately from the hospital. As long as cc physicians and consulting ones are around somewhere, hospitals will decrease labor costs through this method of NPs (who also meet the nurse to patient quota required by CMS and credentialing bodies)

False in most areas. The trend is for 24/7 physician coverage in hospitals with beds >15-20 beds. Most hospitals are willing to put out a pretty decent stipend to fund this-the problem is that intensivists are hard to find these days but this is changing.

A hospital nearby me used to run solely with ACNPs, then hired a few intensivists to cover. The ended up firing all the ACNPS and hiring more intensivists to cover the unit 24/7.

Small (<10 beds) low acuity ICU will continue to be run by the admitting physician, consultants, and an ACNP available to put in orders, consults, and place lines. The acuity is low at these hospitals there really no reason to have an intensivist on board.
 
False in most areas. The trend is for 24/7 physician coverage in hospitals with beds >15-20 beds. Most hospitals are willing to put out a pretty decent stipend to fund this-the problem is that intensivists are hard to find these days but this is changing.

A hospital nearby me used to run solely with ACNPs, then hired a few intensivists to cover. The ended up firing all the ACNPS and hiring more intensivists to cover the unit 24/7.

Small (<10 beds) low acuity ICU will continue to be run by the admitting physician, consultants, and an ACNP available to put in orders, consults, and place lines. The acuity is low at these hospitals there really no reason to have an intensivist on board.

Do you know what forces are behind this trend?

The place I matched for fellowship has 24/7 ICU dedicated attendings. They say critical care doesn't end when the sun goes down and I agree. With a day in the ICU costing anywhere from $6000-15,000, getting patients transferred to the floor early can save the hospital a significant sum of money each year. If I was an administrator I would want a physician in house 24/7 managing the care of the critically ill patients, tuning them up for floor status in the shortest amount of time possible.

However, at my current place the 20 bed CV unit is still staffed by NP's at night and the hospital isn't willing to support the idea of having a 24/7 physician in house. Our department has been trying to get the unit closed and staffed 24/7 but the administrators don't care (many of the administrators are nurses without any formal business or administration training/experience). Ironically these are the sickest patients in house and I certainly had my work cut out for me on night call compared to the SICU where I was usually able to catch upwards of 2-3 hours worth of cat naps overnight.
 
The force behind the push for 24/7 coverage in private practice is to save money of course.

Since my group has taken over our ICU, we have dramatically decreased vent days, ICU days, daily medication (abx and others) costs, and radiology costs. We also manage our patients with minimal consults on board. If you look at how some pp ICU are run, pretty much a private medicine attending will admit a patient then consult somebody for each organ system. It's not uncommon to see people who have a neurologist, cardiologist, pulmonologist, GI, nephrologist, ect all on board when all the patient really needs is a palliative care consult. NPs (on the floor or in the ICU) tend to act the same way where it's consult consult consult CT scan MRI and so forth.

We are moving very quickly to a bundled care system-the hospital administrations see that we are able to manage patients at a greatly reduced cost to the whole system which will ensure more profit to them in the future.

The problem though is that the better we do, the less patients we have to bill for which is why CCM groups will almost always require a subsidy (especially for 24/7 coverage). I know of an academic group which is "profitable" and they are clearly committing billing fraud.

I am not sure if CVICU's really require 24/7 inhouse coverage. Bread and butter cardiac really isn't that complicated. NPs are better than physicians at following the protocols that dominate cardiac surgery. Also, most of happens in the cardiac icu is dependent on whatever voodoo the surgeon believes in, not on the literature or common sense.
 
What is the job market like for anesthesiologists trained in CCM? Is it tough to compete with all of the Pulm/CCM physicians? Is it really hard to find places where you can work both in the OR and the ICU? If you end up doing just ICU after fellowship, how quickly do you lose your OR skills? If you end up doing just OR afterwards, how quickly do you lose your ICU skills?
 
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