Interesting perspective by ASA president, Dr. Lema

[Monty Python]

An interesting powerpoint presentation, given recently by Dr. Lema (ASA president). Gives his opinions on manpower, finances, etc.

http://www.asahq.org/Washington/PM2007-01-DRLEMAUPDATE.pdf

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[EtherMD]

Medical Students need to read Dr. Lema's lecture prior to going into Anesthesia. Lema, an academician, is saying the same thing I have been posting on this site the past few months: The speciality of Anesthesia is in major trouble.

Lema predicts that by 2030 the ratio of supervision will be 10:1. MD's will no longer be "cost-effective" and will not be providing "solo" Anesthesia anymore.
I think this will happen in most areas by 2015 and only the most lucrative practices will remain MD "solo."

Unfortunately, the leadership is not acting fast enough or aggressively enough to help the current Group of Residents. They will be "short-changed" at graduation by not being certified as peri-operative specialists, basic TEE competence and basic Critical care. These "things" need to be part of every Anesthesiology Certificate and Board Certification.

THe writing is on the wall; open your eyes and realize that Consultant in Anesthesiology is NOT ENOUGH any longer. The marketplace will demand more by 2015 and you all better be prepared to deal with it. Alternatively, you can work for the CRNA Group or management company that has the contract.

One more thing: Due to continued DECREASE in reimbursement Residency programs will continue to close while CRNA programs flourish. This should help the current Group of graduates maintain employment but what does it say about the future of our specialty?

 

[militarymd]

Very intriguing.....This is what I see in the future also....however, there are MANY who would disagree....and MORE who don't want it to be true.

 

[gogiants]

Very interesting and definately a good read for all of us entering the field. i first heard about a lot of us when visiting ucsf, dr. miller is a huge proponent of anesthesiologists needing to move into the field of critical care in large numbers to ensure the large scale survival of our specialty.

 

[mille125]

every anesthesiologist/pain practitioner should read this presentation...the time to act is now!!!!

 

[flashgordon]

Do you guys think this will apply to fellowship trained anesthesiologists, like Peds + Cardiac??

 

[EtherMD]

Do you guys think this will apply to fellowship trained anesthesiologists, like Peds + Cardiac??

Yes. You will be forced to supervise more CRNA's/AA's because the hospital/payment level will demand it. Cardiac will be a MONEY LOSER (a real stinker) if the maximum reimbursement by a private payer is 120-150% of Medicare. You will be completely dependent on the hospital subsidy to survive. The hospital will expect 6-7 CRNA's per MDA.

Your best shot at a good career is to realize we are going to lose and how best to deal with the consequences. In other words, how can we as a specialty and individuals survive after the war:

1. Reduce the Residency slots and Programs- The number is 130 and I think we need about 90. I realize this makes each spot more competitive but it ensures each graduate is in HIGH DEMAND following Residency. Even with 6-8CRNA's per MDA the reduction in graduates ENSURES your life long education does not result in your earning a Nurse Anesthetist wage.

2. Mandatory Advanced Certification- Every Resident must complete a fellowship in the area of his/her choice. The CA-3 year qualifies for one Advanced certificate and the CA-4 year qualifies you for the other. This means you get REAL credentials after Residency and not just a glorified CRNA certificate.

3. Get the Message Out to the Public about the value and role an Anesthesiologist plays in the Operating Room. This worked for the plastic surgeons (to a degree) and it may help us.

One more thing. Don't waste time complaining about "MDA" as I intend on using this abreviation in my posts. It includes MD/DO Anesthesiologists as a "catch-all" abreviation. You need to focus on the real issues as stated in Mark Lema's lecture.

 

[nutmegs]

Equal numbers of men and women in medicine plus emphasis on quality of life pursuits will reduce productivity of next generation between 15-25%.

found this comment to be awfully sketchy in terms of relevance or credibility. "anesthesia is failing because we let women in"

 

[militarymd]

found this comment to be awfully sketchy in terms of relevance or credibility. "anesthesia is failing because we let women in"

It is relevant AND credibly BECAUSE it is REALITY.

Do you know that many groups out there won't hire women of reproductive age?

I know it is "illegal", but it is a fact of life when you're running a small business....

I'm giving it to you straight....

now go ahead and FLAME away.

 

[nutmegs]

It is relevant AND credibly BECAUSE it is REALITY.

Do you know that many groups out there won't hire women of reproductive age?

I know it is "illegal", but it is a fact of life when you're running a small business....

I'm giving it to you straight....

now go ahead and FLAME away.

why would I waste my time flaming you? why would I respect someone (or their organization) for their "professional presentation" that includes that kind of bull****? reality isn't blaming things on your future colleagues, and it will come to you- and them- sooner or later. until then, see where the status quo takes you.

 

[militarymd]

why would I waste my time flaming you? why would I respect someone (or their organization) for their "professional presentation" that includes that kind of bull****? reality isn't blaming things on your future colleagues, and it will come to you- and them- sooner or later. until then, see where the status quo takes you.

That's my point....successful small businesses frequently don't want certain groups to be their "future colleagues".....

Why?

Your guess is as good as mine.

I'm just stating the facts...the reality...the way it has always been...and the way it will always be.

The organizations where "females of reproductive age" prospers are:

1) LARGE corporations that can absorb inefficiency....read..the dreaded A.M.C.'s

2) groups that tolerate inefficinecies...where the pay is low...or..if the pay is high....ready to be invaded and taken over by A.M.C.'s


Just the facts...

 

[gogiants]

It is relevant AND credibly BECAUSE it is REALITY.

Do you know that many groups out there won't hire women of reproductive age?

I know it is "illegal", but it is a fact of life when you're running a small business....

I'm giving it to you straight....

now go ahead and FLAME away.

unless there was something i missed i did not take the comment on productivity in the presentation to mean that women should be blamed for problems in the future with anesthesia. advancing technology and pure market forces (cheaper labor wins) are to blame for that. i do believe it is true that with increasing numbers of women in all fields of medicine there is going to be a decreasing all around in productivity given that women of reproductive age will often take time off/work part time. to be fair, though i think people entering medicine as a whole (men and women) in general do not want to work as hard as they once did, quality of life is more important. this is something that medicine is just going to have to adapt to (i.e. larger group practices and women doctors helping women doctors). i am a woman who wants to have children which will likely reduce my career productivity and i don't think this is a bad thing or something that any woman should have to apologize for, but it is a reality we all have to admit to and deal with.

and militarymd: these groups you talk about are going to have to learn to deal with this too. they may not like it but with the large amount of women entering the field they can not simply refuse to hire them all (although they can and may try). there are simply going to be too many of us women to ignore at some point. your beloved facts can only survive long term in a world where non-reproductive age women and male anesthesiologists only want to work at these smaller firms or are limitless.

 

[nutmegs]

That's my point....successful small businesses frequently don't want certain groups to be their "future colleagues".....

Why?

Your guess is as good as mine.

I'm just stating the facts...the reality...the way it has always been...and the way it will always be.

The organizations where "females of reproductive age" prospers are:

1) LARGE corporations that can absorb inefficiency....read..the dreaded A.M.C.'s

2) groups that tolerate inefficinecies...where the pay is low...or..if the pay is high....ready to be invaded and taken over by A.M.C.'s


Just the facts...

it'll be a cold day in hell before I'd want to be your colleague, anyway.

 

[nutmegs]

unless there was something i missed i did not take the comment on productivity in the presentation to mean that women should be blamed for problems in the future with anesthesia.

outright, the comment wasn't saying that. it was placed in such an unusual context though, in the "top 5 reasons anesthesia is in crisis" when things such as "the milmds of the world trying to stuff their pockets with too much for too long" didn't make the list. there are plenty of reasons anesthesia is in trouble besides more people taking family leave, period. and its sketchy inclusion alienated me. no more, no less.

 

[militarymd]

and militarymd: these groups you talk about are going to have to learn to deal with this too. they may not like it but with the large amount of women entering the field they can not simply refuse to hire them all (although they can and may try). there are simply going to be too many of us women to ignore at some point.

First off.....I've been wanting to interview "women of reproductive age" for positions.....and my partners have been giving me the "NO".....

Second off....despite my willingness to look at "women of reproductive age" candidates as partner candidates.....the ONLY partner who is a liability in our group right now is a woman of reproductive age....because of all the things that come from women of reproductive age.

I see the battle lines being drawn.....Groups that will run lean and mean AGAINST women of reproductive age who will work for the dreaded A.M.C.'s.

The winners? we'll have to wait and see.

 

[militarymd]

outright, the comment wasn't saying that. it was placed in such an unusual context though, in the "top 5 reasons anesthesia is in crisis" when things such as "the milmds of the world trying to stuff their pockets with too much for too long" didn't make the list. there are plenty of reasons anesthesia is in trouble besides more people taking family leave, period. and it's sketchy inclusion alienated me. no more, no less.

Aren't you wondering WHY it was placed on the list? I'm not.

btw...I'm not "stuffing" my pockets....ALL of my parterners/employees get paid the same as me.

 

[nutmegs]

First off.....I've been wanting to interview "women of reproductive age" for positions.....and my partners have been giving me the "NO".....

Second off....despite my willingness to look at "women of reproductive age" candidates as partner candidates.....the ONLY partner who is a liability in our group right now is a woman of reproductive age....because of all the things that come from women of reproductive age.

I see the battle lines being drawn.....Groups that will run lean and mean AGAINST women of reproductive age who will work for the dreaded A.M.C.'s.

The winners? we'll have to wait and see.

it's much better to give qualified, competent providers no choice but to staff your opposition. good luck.

 

[militarymd]

it'll be a cold day in hell before I'd want to be your colleague, anyway.

I don't hire medical students.

 

[nutmegs]

Aren't you wondering WHY it was placed on the list? I'm not.

btw...I'm not "stuffing" my pockets....ALL of my parterners/employees get paid the same as me.

you, my dear, were simply representative of a larger group in that analogy. I'm sure you won't mind taking one for the team.

 

[nutmegs]

I don't hire medical students.

or women, so it's a moot point

 

[militarymd]

it's much better to give qualified, competent providers no choice but to staff your opposition. good luck.

Here's something that you won't learn until you start having to deal with the "business" of medicine.

QUALIFIED...and COMPETENT...are frequently things that people don't care about when you run a business.....

It is VERY SAD...but it is also very TRUE.

QUALIFED and COMPETENT are 2 qualities that are a given ....ie....you HAVE to HAVE those qualities.....it's everything else that is evaluated.

 

[militarymd]

or women, so it's a moot point

actually...our last hiree...is a woman...and she has more BALLS than the rest of the guys......

 

[EtherMD]

it's much better to give qualified, competent providers no choice but to staff your opposition. good luck.

Please focus on the main issue which is job security and your future.
Men and Women today want to work less than 20 years ago. Women in particular look at "lifestyle" more than money when choosing a practice. In addition, more women are willing to consider salaried positions in order to raise a family and have a "life" outside the hospital.

A small Group may have difficulty dealing with a female partner of child bearing age because FEDERAL LAW mandates that a women be allowed time off from work (up to 6 weeks?) after each baby. Also, some women can not work at the end of their pregnancy and need additional time off. This means the practice will need to suck-it up for each baby or hire a locums (both are tough choices). If a woman dedices to have three children over 5 years this means a small Group will feel the pain of each pregnancy- a lot.

On a positive note with 50% of graduating Residents being female the average work week should decline over the next ten years. Also, many more women will seek part-time work as their career progresses. This creates more opportunity for the male MDA's to secure work. With the greedy Residency programs graduating too many Anesthesiologists the 50% female ratio may help the employment situation.

The best solution is to maintain the 50% female ratio per class AND reduce the number of programs/slots. This creates more opportunity for EVERYONE.
As you can see per Mark Lema's lecture we may all need that opportunity.

 

[militarymd]

Please focus on the main issue which is job security and your future.
Men and Women today want to work less than 20 years ago. Women in particular look at "lifestyle" more than money when choosing a practice. In addition, more women are willing to consider salaried positions in order to raise a family and have a "life" outside the hospital.

A small Group may have difficulty dealing with a female partner of child bearing age because FEDERAL LAW mandates that a women be allowed time off from work (up to 6 weeks?) after each baby. Also, some women can not work at the end of their pregnancy and need additional time off. This means the practice will need to suck-it up for each baby or hire a locums (both are tough choices). If a woman dedices to have three children over 5 years this means a small Group will feel the pain of each pregnancy- a lot.

On a positive note with 50% of graduating Residents being female the average work week should decline over the next ten years. Also, many more women will seek part-time work as their career progresses. This creates more opportunity for the male MDA's to secure work. With the greedy Residency programs graduating too many Anesthesiologists the 50% female ratio may help the employment situation.

The best solution is to maintain the 50% female ratio per class AND reduce the number of programs/slots. This creates more opportunity for EVERYONE.
As you can see per Mark Lema's lecture we may all need that opportunity.

try 12 weeks...per federal law....
Fine for a big corporation...read AMC...

A f uck ing disaster for a small business.....that is trying to fight off the A.M.C.'s...

You can't have it both ways.....which is what certain people want....both ways....

I just want it one way.

 

[EtherMD]

try 12 weeks...per federal law....
Fine for a big corporation...read AMC...

A f uck ing disaster for a small business.....that is trying to fight off the A.M.C.'s...

You can't have it both ways.....which is what certain people want....both ways....

I just want it one way.

I appreciate the qualification of the Federal law which allows up to 12 weeks.
Fortunately, I have never had a female partner take off more than 4 weeks per delivery. Still, the time off really hurts and DOES affect the practice.

Easy on the profanity as I would hate to see you get banned.

 

[CremeSickle]

Craziness.

Truly, I dont want to supervise anyone, i just want to do anesthesia. 10:1, thats an absolute disaster.

 

[EtherMD]

Craziness.

Truly, I dont want to supervise anyone, i just want to do anesthesia. 10:1, thats an absolute disaster.

I supervise CRNA's all day, every day for decades. The most you can safely supervise is about 6-7 to One. I have supervised about 30-40,000 anesthetics so far and 10:1 is too much. At that level you are simply "back-up" only and do not participate in the care of the patient in any manner.
That said, I prefer a 5 to One ratio as my maximum but realize 6 to One may be coming soon.

Please realize that your very career is in question at this point. With Medicare cutting Anesthesia every year it is only a matter of time before the private payers join in the bloodshed. Once the private payers limit reimbursement to 120-150% of Medicare (as per Mark Lema's prediction) the game is over.

Please examine this sobering statistic: By 2010 Medicare will pay an Anesthesia provider about $160,000 per year for a 40 hour work week. The average CRNA's total cost in 2010 (40 hour work week) will be $200,000 per year (pay plus benefits). This means that even a CRNA doing 100% Medicare cases "solo" needs a hospital subsidy!! Even if you throw in private payers at 150% of Medicare there is NO WAY you can make a good salary.

In other words, Anesthesiologists will be totally dependent on the hospital for support. The CEO's will choose the CRNA "only" model with a few Anesthsiologists for back-up. Alternatively, the hospital will give you the real supervisory ratio expected of you: 7:1

I have some advice for Medical Students and Residents: Work like hell to match at a program. Then, work even harder to reduce the number of slots per program and the number of programs. Otherwise, some of you may end up asking the ultimate question after many years of hard work: "do you want fries with that?"

 

[johankriek]

First off.....I've been wanting to interview "women of reproductive age" for positions.....and my partners have been giving me the "NO".....

Second off....despite my willingness to look at "women of reproductive age" candidates as partner candidates.....the ONLY partner who is a liability in our group right now is a woman of reproductive age....because of all the things that come from women of reproductive age.

I see the battle lines being drawn.....Groups that will run lean and mean AGAINST women of reproductive age who will work for the dreaded A.M.C.'s.

The winners? we'll have to wait and see.

dude

you dont stop do you? you are the Archie Bunker of sdn. A while back you were saying black people dont deserve to be doctors because they are genetically inferior academically to whites.. Now you are saying your group wont hire women of reproductive age. are you for real?
I will have to refer your group in alabama to the EEOC...

 

[johankriek]

Please focus on the main issue which is job security and your future.
Men and Women today want to work less than 20 years ago. Women in particular look at "lifestyle" more than money when choosing a practice. In addition, more women are willing to consider salaried positions in order to raise a family and have a "life" outside the hospital.

A small Group may have difficulty dealing with a female partner of child bearing age because FEDERAL LAW mandates that a women be allowed time off from work (up to 6 weeks?) after each baby. Also, some women can not work at the end of their pregnancy and need additional time off. This means the practice will need to suck-it up for each baby or hire a locums (both are tough choices). If a woman dedices to have three children over 5 years this means a small Group will feel the pain of each pregnancy- a lot.

On a positive note with 50% of graduating Residents being female the average work week should decline over the next ten years. Also, many more women will seek part-time work as their career progresses. This creates more opportunity for the male MDA's to secure work. With the greedy Residency programs graduating too many Anesthesiologists the 50% female ratio may help the employment situation.

The best solution is to maintain the 50% female ratio per class AND reduce the number of programs/slots. This creates more opportunity for EVERYONE.
As you can see per Mark Lema's lecture we may all need that opportunity.

I think you and military MD are the same person..

 

[johankriek]

I supervise CRNA's all day, every day for decades. The most you can safely supervise is about 6-7 to One. I have supervised about 30-40,000 anesthetics so far and 10:1 is too much. At that level you are simply "back-up" only and do not participate in the care of the patient in any manner.
That said, I prefer a 5 to One ratio as my maximum but realize 6 to One may be coming soon.

Please realize that your very career is in question at this point. With Medicare cutting Anesthesia every year it is only a matter of time before the private payers join in the bloodshed. Once the private payers limit reimbursement to 120-150% of Medicare (as per Mark Lema's prediction) the game is over.

Please examine this sobering statistic: By 2010 Medicare will pay an Anesthesia provider about $160,000 per year for a 40 hour work week. The average CRNA's total cost in 2010 (40 hour work week) will be $200,000 per year (pay plus benefits). This means that even a CRNA doing 100% Medicare cases "solo" needs a hospital subsidy!! Even if you throw in private payers at 150% of Medicare there is NO WAY you can make a good salary.

In other words, Anesthesiologists will be totally dependent on the hospital for support. The CEO's will choose the CRNA "only" model with a few Anesthsiologists for back-up. Alternatively, the hospital will give you the real supervisory ratio expected of you: 7:1

I have some advice for Medical Students and Residents: Work like hell to match at a program. Then, work even harder to reduce the number of slots per program and the number of programs. Otherwise, some of you may end up asking the ultimate question after many years of hard work: "do you want fries with that?"

yeah the sky is falling too right?

when you supervise 5 crnas at a time.. you are contributing zero.. and your expertise is being wasted mon ami..

I say train as many anesthesiologist possible and make it one patient, one anesthesiologist..

 

[m3unsure]

Everyone must understand that this presentation has to have some political reasons behind it. How many times have I heard of various specialties dealing with a lot of cr@p and they'll die off if you don't do something about it? It's the same game in non-medicine topics too. Anesthesiology will have to change and so will the rest of medicine. And if the president pumps up the gas society to be more active, then we can keep more of the cake that keeps getting smaller every year. Salaries are gonna drop and they have been.

The bigger problem is the stupid lay public will agree with it of course. However, if we decided to have special tax on pro sports players, these same *****s would think its outrageous since "they go out on the field everyday and work hard." I hate it when stupid useless people in society make lots of money (ex: pro sports, actors, and many CEOs) while teachers, etc. get screwed. And whose fault is it? The average man who doesn't want to invest any time into being intelligent. That's why stuff the electoral college still exist to keep stupid people out of power (except that somehow has not worked for the last 2 elections).

I look back and said I'd never be an elitist, but after seeing everything I have, it's hard to deny it. Next time someone says they deserve $40K for balancing a company's checkbook on the computer and complains about doctors, tell 'em to shove it. I could probably write a computer program to do such a inane job so why aren't you getting paid like $20K. Sorry you'd be on the streets. Welcome to capitalism, take your fair share of the @ss whooping.

Enough of my ranting on forums.

 

[EtherMD]

yeah the sky is falling too right?

when you supervise 5 crnas at a time.. you are contributing zero.. and your expertise is being wasted mon ami..

I say train as many anesthesiologist possible and make it one patient, one anesthesiologist..

Did you get your Medical Degree in the USA? Did you pass Math? Are you able to grasp concepts?

If the answer is "no" then please stop reading this post and go back to your video games. However, if the answer is "yes" the please re-read Mark Lema's lecture several times. You fail to grasp the seriousness of the situation.

Mark Lema is PRESIDENT OF THE ASA. He and I are telling you the sky is falling! The AANA is beating the ASA at the National and State levels. Your certificate is not worth more money than a CRNA's certificate (per the Federal government). The government has DETERMINED that CRNA pay (actually 90% of CRNA pay) is ALL THAT YOU ARE WORTH! Your future depends on supervising Mid-Level Providers as you will not earn more money than a CRNA by actually doing the anesthetic. ARE you there? Do you understand?

Now, if you don't mind being a glorified CRNA then go ahead and keep your head buried in the sand. People like you who ignore the facts will "doom" future graduates to a low salary and limited employment opportuntities.

However, if you want to be in "demand" and "earn" the salary of other highly qualified Physicians (Orthopedics, ENT, Optho, etc.) then the number of spots MUST be reduced! It is the law of supply and demand in the marketplace. CRNA's can not do difficult cases "solo" and need the help of an MDA.

Supervising 5 CRNA's does not diminish one's worth or contribution to the case. At that level you can still see EVERY patient and perform Regional Anesthesia. You can start EVERY case and be readily available for Emergencies. What you Can NOt do is stay in the lounge or avoid work!
Supervising 5 CRNA's is WAY MORE difficult than doing ONE case at a time "solo."

So, Mark Lema and I are telling you the same thing: the day is coming when you will need to work real hard for a good living! I firmly believe the best way to protect current and future Anesthesiologists is by reducing the number of slots immediately. Like it or not, Medicare and the Marketplace will do the same thing over the next ten years: Reduce the number of Programs.
The time for action is NOW!

 

[OB1🤙]

So, I sometimes have trouble with concepts, so please explain this to me like I'm a six year-old.

Why, if the problem is too many CRNAs, would the solution involve cutting residency spots and thereby producing less anesthesiologists?

Are you saying this is a solution to declining salaries or a solution to the "death" of MD anesthesia? Because I can see how less anesthesiologists would lead to higher salary for those that remain in the field, but I sure as hell can't see how having less MDs involved in anesthesia care in any way protects the profession for the future.

Also, I was lucky enough to get to watch Dr. Lema give this talk at MGH, and while he expressed significant concern for the future and delineated strategies necessary to protect the profession, his tone was certainly not that the sky was falling and we should all get out now. Not even close. Just reading the slides gives a much more "doomsday is here" sense than his actual talk does.

I think that, as usual, there are two sides to every story, and the truth probably lies somewhere in the middle. No, MD anesthesia is not a dying field. Yes, the gravy train could very well be over. Will I still have a job coming out of residency? Of course I will. Will I be willing to do that job for less money than anesthesiologists are making today? I still can't even imagine doing anything else.

HB, MS4

 

[Noyac]

Easy on the profanity as I would hate to see you get banned.

Not from me you won't.

 

[Noyac]

Did you get your Medical Degree in the USA?

So what does this have to do with anything? Are we to understand the Medical Schools in the USA teach economics? Are we to understand that medical schools in the USA teach business? Are we to understand that a doctor from a US medical school can grasp these concepts better than one from another country? Thats a pretty bold statement, not to mention a pretty stupid one as well.

 

[militarymd]

yeah the sky is falling too right?

when you supervise 5 crnas at a time.. you are contributing zero.. and your expertise is being wasted mon ami..

I say train as many anesthesiologist possible and make it one patient, one anesthesiologist..

fool

 

[militarymd]

So, I sometimes have trouble with concepts, so please explain this to me like I'm a six year-old.

Why, if the problem is too many CRNAs, would the solution involve cutting residency spots and thereby producing less anesthesiologists?

Are you saying this is a solution to declining salaries or a solution to the "death" of MD anesthesia? Because I can see how less anesthesiologists would lead to higher salary for those that remain in the field, but I sure as hell can't see how having less MDs involved in anesthesia care in any way protects the profession for the future.

Also, I was lucky enough to get to watch Dr. Lema give this talk at MGH, and while he expressed significant concern for the future and delineated strategies necessary to protect the profession, his tone was certainly not that the sky was falling and we should all get out now. Not even close. Just reading the slides gives a much more "doomsday is here" sense than his actual talk does.

I think that, as usual, there are two sides to every story, and the truth probably lies somewhere in the middle. No, MD anesthesia is not a dying field. Yes, the gravy train could very well be over. Will I still have a job coming out of residency? Of course I will. Will I be willing to do that job for less money than anesthesiologists are making today? I still can't even imagine doing anything else.

HB, MS4

The concept is simple.....you don't need ALL THAT TRAINING to sit in a room to chart vital signs on a lap chole.

4 hands are better than 2 hands......the care team model.

 

[nutmegs]

I feel way too often that it's people who actually have interest in the entire future of the field versus people who care only about making as much money as they can for the rest of their career. mommy & daddy weren't docs, I don't have a lifestyle to maintain, and yes, I actually was aware of this stuff when I chose the profession. I'd rather have a job for the next 30 years than be a money grubber for 15, only to find myself unemployed because my predecessors dwindled and priced themselves out of any kind of usefulness.

 

[EtherMD]

So what does this have to do with anything? Are we to understand the Medical Schools in the USA teach economics? Are we to understand that medical schools in the USA teach business? Are we to understand that a doctor from a US medical school can grasp these concepts better than one from another country? Thats a pretty bold statement, not to mention a pretty stupid one as well.

I disagree. If you want to maintain the best and brightest graduates of US MEDICAL SCHOOLS in Anesthesiology then ECONOMICS do matter. My pont is that US GRADUATES have more options in choosing their specialty. If Anesthesiology continues its decline then Programs will be pressured into taking mostly FMG's. Look at Plastic Surgery as an example: Plastic Surgery is the MOST COMPETITIVE RESIDENCY in the USA. Why? How many FMG's get positions? Of the FMG's who do match what is the average person like? The small number of FMG's in Plastic Surgery are way more experienced than the average US Graduate.

In addition, there are many more FMG's willing to work for CRNA pay than American Medical Graduates. Even if Anesthesia deteriorates to the level of MDA pay at 10% more than CRNA pay many FMG's will still want the job. After all, how much does Medical School cost in many countries? How much do Anesthesiologists make in most countries? Compare these facts with the average US graduate who had to pay for 4 years of college and 4 years of medical school. Like it or not, the fact remains that US Graduates are the ones ALL RESIDENCY PROGRAMS want to retain.

 

[EtherMD]

So, I sometimes have trouble with concepts, so please explain this to me like I'm a six year-old.

Why, if the problem is too many CRNAs, would the solution involve cutting residency spots and thereby producing less anesthesiologists?

Are you saying this is a solution to declining salaries or a solution to the "death" of MD anesthesia? Because I can see how less anesthesiologists would lead to higher salary for those that remain in the field, but I sure as hell can't see how having less MDs involved in anesthesia care in any way protects the profession for the future.

Also, I was lucky enough to get to watch Dr. Lema give this talk at MGH, and while he expressed significant concern for the future and delineated strategies necessary to protect the profession, his tone was certainly not that the sky was falling and we should all get out now. Not even close. Just reading the slides gives a much more "doomsday is here" sense than his actual talk does.

I think that, as usual, there are two sides to every story, and the truth probably lies somewhere in the middle. No, MD anesthesia is not a dying field. Yes, the gravy train could very well be over. Will I still have a job coming out of residency? Of course I will. Will I be willing to do that job for less money than anesthesiologists are making today? I still can't even imagine doing anything else.

HB, MS4

Medical Schools need to include Economics 101 as a prerequisite course.
The law of supply and demand has a HUGE impact on both your income and your ability to find employment. If the PRESIDENT of the ASA is predicting a greater supervision ratio in the near future (I agree with this 100%) then we need FEWER Anesthesiologists and not more of them. In addition, Medicare is TELLING the programs very clearly that Anesthesia providers are worth NO MORE THAN CRNA PAY! This means no matter what your credentials (M.D./PhD with Cardiac and Critical Care Fellowship) you will be paid CRNA pay for performing an anesthetic personally. When the Private Payers follow the government example then you are OVER-QUALIFIED for basic Anesthesia delivery. The only way to justify your PHYSICIAN INCOME is to act as MEDICAL SUPERVISOR of many Mid-Level Providers.

Do you understand this? Or, would you like to work for me as a CRNA?
This means we need FEWER PROGRAMS for the specialty to survive and prosper. We need advanced training for every graduate. This way you will have a job at the end of the day. Limiting spots can be GOOD for everyone involved and as shown by the surgical subspecialty of plastic surgery!

Medicare will FORCE the Anesthesia Programs to come to this conclusion sooner rather than later. Once the private payers reduce payment for cases dozens of programs will close. Why not plan for this now? Why not develop a strategy for coping with this fact now? Or, you can pretend the ASA is "winning" the war and do nothing.

 

[EtherMD]

I feel way too often that it's people who actually have interest in the entire future of the field versus people who care only about making as much money as they can for the rest of their career. mommy & daddy weren't docs, I don't have a lifestyle to maintain, and yes, I actually was aware of this stuff when I chose the profession. I'd rather have a job for the next 30 years than be a money grubber for 15, only to find myself unemployed because my predecessors dwindled and priced themselves out of any kind of usefulness.

Naive! The market will dictate what you are worth. What influences the market? There are many factors but the number one influence is supply vs. demand. If CRNA's are going to be the primary provider in the operating room (which Mark Lema is predicting) then Anesthesiologists are supervisors.
Hence, We need fewer supervisors in the specialty; otherwise, the law of supply vs. demand will severely hurt your salary to the level you may work for CRNA pay.

Why go to Medical School and Residency to earn a Nurse Anesthetist wage?
If you want to kill the specialty of Anesthesiology the quickest way to do it is by producing too many graduates. The way to "preserve" the Specialty is by producing fewer, high quality, fellowship trained specialists that every hospital needs to staff its facilities.

But, how has "academia" responded to the new "economic reality" of Anesthesia? By not telling yound Medical Students the stark economic truth about Anesthesia. By not closing the weak, non-academic programs. By not trimming the number of available spots immediately. Instead, our leaders "cry" foul because the government won't pay for supervising two Residents. Guess what? The AANA will NEVER allow Medicare to pay for MDA Residents without getting the same privilege for its students. Guess what else? The government agrees with this argument!

If academia needs "bodies" in the operating room then start more AA programs. Replace slave Residents with AA students (Mid-Level provider) and train our future Physician Anesthesiologists for their ACTUAL ROLE as MEDICAL SUPERVISOR and PERIOPERATIVE PHYSICIAN.

I doubt any academicians will listen to Lema or me about the real world. Instead, these "leaders" of our specialty will wait for Medicare and/or the Private Payers to dictate how they respond. Too bad, because the best defense is a good offense. Ironically, trimming the number of new graduates and making these FEWER new graduates more qualified (at least TWO subspecialty area certifications like Critical Care and Cardiac) is the solution.

 

[johankriek]

The concept is simple.....you don't need ALL THAT TRAINING to sit in a room to chart vital signs on a lap chole.

4 hands are better than 2 hands......the care team model.

you consistently contradict yourself. You are truly the fool. Im not going to even delve into your political stances or shall i say non political stances on minorities and women of reproductive age.

On one breath you are saying we have TOO much training. On the other breath you are saying you need 4 hands.. For a healthy lap chole? YOu do not need four hands.. is it better ?maybe! is physician training better to have.. umm a resounding yes....

Is a gi doctor necessary for a routine screening colonoscopy or will any FP or advanced practice nurse do? its routine and easy.. Is a board certified surgeon necessary for a simple Incision and Drainage. should we train LPNs to provide moderate sedation for colonoscopy.

 

[cfdavid]

found this comment to be awfully sketchy in terms of relevance or credibility. "anesthesia is failing because we let women in"

That's hiding your head in the sand. It's not a discriminatory statement, but rather the truth, as others have already stated.

How does the concept of more women (that get pregnant, take time off, possibly exit the field, or go part time) in the profession and a decrease in productivity NOT make sense to you. And it's not just about women. In the past, people were willing to work many more hours, whereas today, we tend to be more concerned with lifestyle and, therefore (this is market sensitive, but in today's market it applies), groups are forced to hire more people for the same amount of work. Thus, a prediction that productivity levels will go down. Just economics. Productivity is usually measured on a PER CAPITA basis, as it is being measured in the presentation.

 

[nutmegs]

That's hiding your head in the sand. It's not a discriminatory statement, but rather the truth, as others have already stated.

How does the concept of more women (that get pregnant, take time off, possibly exit the field, or go part time) in the profession and a decrease in productivity NOT make sense to you. And it's not just about women. In the past, people were willing to work many more hours, whereas today, we tend to be more concerned with lifestyle and, therefore (this is market sensitive, but in today's market it applies), groups are forced to hire more people for the same amount of work. Thus, a prediction that productivity levels will go down. Just economics. Productivity is usually measured on a PER CAPITA basis, as it is being measured in the presentation.

it's good that you read far enough. I didn't say it wasn't true, I just said I don't think it belongs in the top 5 reasons anesthesia is in crisis, and I don't think it really belonged in the context of that particular presentation, given by the head of the ASA. that's it.

 

[militarymd]

you consistently contradict yourself. You are truly the fool. Im not going to even delve into your political stances or shall i say non political stances on minorities and women of reproductive age.

On one breath you are saying we have TOO much training. On the other breath you are saying you need 4 hands.. For a healthy lap chole? YOu do not need four hands.. is it better ?maybe! is physician training better to have.. umm a resounding yes....

Is a gi doctor necessary for a routine screening colonoscopy or will any FP or advanced practice nurse do? its routine and easy.. Is a board certified surgeon necessary for a simple Incision and Drainage. should we train LPNs to provide moderate sedation for colonoscopy.

Zero contradictions in what I said.....Anyone who is familiar with providing anesthesia knows the following (I'm assuming you know a little about providing anestheisa)

1) 95% of your time is spent charting vitals, watching monitors.
- This DOES NOT require advanced training.....unless you are REALLY dumb.

2) the other 4 % of your time is spent doing things that can potentially be very dangerous for your patient.
- if done properly, also not a big deal
- having 4 hands...can facilitate this process...and improve efficiency
- I like having my patients intubated within 5 minutes of entering the OR

3) the remaining 1% of the time.....when things go wrong...when unexpected things happen.....I like having another pair of hands.
- never let your EGO get in the way of good patient care.
- many CRNAs have this problem
- MORE MDs have this problem

The MD should spend most of their time involved in the 5 % of anesthesia care....

If one wants to spend most of your time in the 95% of doing nothing....then you are wasting resources.

But that's just me.....someone who realizes the economic/business nature of anesthesia and medicine in general.

If one wants to bury their head in the sand, and be inefficient...waste money...waste time....that's fine...but be prepared for eventual economic failure.

 

[Gern Blansten]

Mil,
A few months ago you chastised the anesthesiologist for having a couple of colleagues help get things under way for President Clinton's CABG. I forget the choice words you had for them. Now you reverse that and say that 4 hands are better than 2 for a simple case. Which do you believe? Or do you just thrive on pissing people off. I am pretty sure I already know the answer.

 

[militarymd]

Mil,
A few months ago you chastised the anesthesiologist for having a couple of colleagues help get things under way for President Clinton's CABG. I forget the choice words you had for them. Now you reverse that and say that 4 hands are better than 2 for a simple case. Which do you believe? Or do you just thrive on pissing people off. I am pretty sure I already know the answer.

The statement regarding those CV anesthesiologist stands.

You don't need 4 anesthesiologists to do 1 case..."nitwits", I believe was the term I used....glory hounds who are in the room because it was slick willy.......

per what I have been saying....you don't even need 1 anesthesiologist to do 1 case.

1 anesthesiologist AND multiple physician extenders for multiple cases.

If there IS ONLY one case to do (like the middle of the night)...then one anesthesiologist will do....as in my practice....although i believe that having a second set of hands is still beneficial...but because of financial reasons ....that second set of hands disappear after hours.

Where in what I said....did I reverse anything?

 

[m3unsure]

Zero contradictions in what I said.....Anyone who is familiar with providing anesthesia knows the following (I'm assuming you know a little about providing anestheisa)

1) 95% of your time is spent charting vitals, watching monitors.
- This DOES NOT require advanced training.....unless you are REALLY dumb.

2) the other 4 % of your time is spent doing things that can potentially be very dangerous for your patient.
- if done properly, also not a big deal
- having 4 hands...can facilitate this process...and improve efficiency
- I like having my patients intubated within 5 minutes of entering the OR

3) the remaining 1% of the time.....when things go wrong...when unexpected things happen.....I like having another pair of hands.
- never let your EGO get in the way of good patient care.
- many CRNAs have this problem
- MORE MDs have this problem

The MD should spend most of their time involved in the 5 % of anesthesia care....

If one wants to spend most of your time in the 95% of doing nothing....then you are wasting resources.

But that's just me.....someone who realizes the economic/business nature of anesthesia and medicine in general.

If one wants to bury their head in the sand, and be inefficient...waste money...waste time....that's fine...but be prepared for eventual economic failure.

I agree that charting vitals is dumb, but a lot that can be done electronically now. I assume over the next decade, this switch will occur since everything is ending up being electronic.

That 1% has shown up at various times. I'd like somebody around when someone is doing my surgery. CRNAs can do my cataracts when I'm like 70 (if I get there).

Also, I have noticed that more crazy things happen as more and more patients are older and have multiple med problems. They may be small, but I haven't seen a CRNA show confidence in this regard. Is it that their training was light? Or they haven't had enough years under belt? Some CRNAs have told me that would rather stick to easy cases than even do regular resident cases. So who really is behind this political fiasco?

And if we go to a system where I am involved in 5% of the management. Then, those CRNAs better get sued or be liable for the other 95%. If I'm not in the room and watching, then I don't consider myself actively involved. If they can have the independence that their political faction is asking for, then they can take the other responsibilities too.

Plus, I like doing lines and stuff like that. Though it may be simple, many people in anesthesia and its future like this part of the job. If I have to just interpret, why not do internal medicine?

 

[militarymd]

That's the point....to do the procedures and be involved in the technical AND decision making component of care......not the monitoring.

My practice...I do all the central lines....alines...awake intubations..spinals, epidurals.....etc. etc. etc.


I placed 16 blocks yesterday.....combination of femoral, sciatic, interscalene...popliteal....3 epidurals for labor.......

 

[2ndyear]

Regarding residency spots, we just had a big article in the Boston Globe about wait times to see a dermatologist in Boston. Not a huge city and more than enough physicians per capita. But patients are having their suspicious moles and lumps go months waiting for an appointment with a derm. Why? Look at the residency spots. They've kept the number down and demand up.