Interesting perspective by ASA president, Dr. Lema

[johankriek]

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.

the light is on but nobody is home and nobody has been home but cobwebs... I wont even get into how ridiculous the above post is..

why dont flight attendants fly planes? and have the pilots just sitting in the back to be called only when something serious happens. How do you think that sounds?

---

Members don't see this ad.

 

[militarymd]

the light is on but nobody is home and nobody has been home but cobwebs... I wont even get into how ridiculous the above post is..

why dont flight attendants fly planes? and have the pilots just sitting in the back to be called only when something serious happens. How do you think that sounds?

I'm glad you used that analogy.

The latest generation of commercial aircrafts pretty much fly themselves.

The pilot just programs the destination...and punches a button.

Anymore insightful analogies.......I recommend pulling your head out of the sand....or ass....where ever you have it planted.

 

[cowboy71]

And if pilots could go between aircrafts to be there for take-off, landing and when something out of the ordinary occurs then there wouldn't need to be pilots in every aircraft.

In the next 15-20 years anesthesia machines will have closed-loop control systems that will monitor effect sight concentration of all drugs and keep the patient at a much safer level of sedation than we will ever be able too. Using similar concepts tot he way airplanes fly. The need to have someone in the room for ASA 1 or ASA 2 cases will go by the wayside. The technology is almost there today. Soon you will start seeing it.

The future for anesthesiologists is still very bright, just different than what it is today or has been in the past. We will need to truly become the perioperative physician. As the population ages, we will need to optimize them medically for surgery, take care of the sickest in the OR and be able to manage their complicated medical (not surgical) problems post-op, while in the hospital. We will need to have a strong understanding of the medical/surgical interface. Echo will become a tool much like ECG is now for managing cardiac and non-cardiac surgery both pre, peri and postoperative in the patient with a cardiac history. We are in the best position to adapt to this change and take advantage of it, but if we continue to fight against it and try to stop change we will feel a hard squeeze from midlevels and hospitalists. Instead of our role expanding it will drastically diminish.

 

[johankriek]

I'm glad you used that analogy.

The latest generation of commercial aircrafts pretty much fly themselves.

The pilot just programs the destination...and punches a button.

Anymore insightful analogies.......I recommend pulling your head out of the sand....or ass....where ever you have it planted.

you did not answer the question!! in typical "I know everything" Military md fashion

 

[toughlife]

And if pilots could go between aircrafts to be there for take-off, landing and when something out of the ordinary occurs then there wouldn't need to be pilots in every aircraft.

In the next 15-20 years anesthesia machines will have closed-loop control systems that will monitor effect sight concentration of all drugs and keep the patient at a much safer level of sedation than we will ever be able too. Using similar concepts tot he way airplanes fly. The need to have someone in the room for ASA 1 or ASA 2 cases will go by the wayside. The technology is almost there today. Soon you will start seeing it.

The future for anesthesiologists is still very bright, just different than what it is today or has been in the past. We will need to truly become the perioperative physician. As the population ages, we will need to optimize them medically for surgery, take care of the sickest in the OR and be able to manage their complicated medical (not surgical) problems post-op, while in the hospital. We will need to have a strong understanding of the medical/surgical interface. Echo will become a tool much like ECG is now for managing cardiac and non-cardiac surgery both pre, peri and postoperative in the patient with a cardiac history. We are in the best position to adapt to this change and take advantage of it, but if we continue to fight against it and try to stop change we will feel a hard squeeze from midlevels and hospitalists. Instead of our role expanding it will drastically diminish.

I agree. I say we need to go with the flow. Become an expert in perioperative medicine, be comfortable in the ICU managing patients, learn echo and bronchoscopy and you will fare well.

ASA 1 and 2 cases in the future may be done with sedation nurses with an anesthesiologist managing several patients from a control room with monitors. Even CRNAs will be superfluous and overpriced when those systems come into regular use.

I personally do not want to be looking at a monitor charting vitals. I rather look at them for a second to make a decision and move on. I want to be like the ICU docs who dictate how the patient is cared for but does not hang the drip he just ordered.

 

[militarymd]

you did not answer the question!! in typical "I know everything" Military md fashion

because the question is non sequitur.

I/we are talking about and comparing physicians and physician extenders...in the various care team models.

You...are talking about and using an analogy that is equivalent to comparing an OR tech or Janitor to what a physician does.

NON SEQUITUR....and therefore not deserving of an answer.

where in my posts do I imply I know everything.....the only person here who claims to know it all....by first insulting some one else....is......YOU

 

[EtherMD]

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.

My point exactly. By reducing the number of programs to 90 (the strongest 90 programs) and expanding your LEGAL Board Certification to include Critical Care and Peri-Operative Medicine greatly increases the chances you will get a good job after Residency. Hospitals will need you and the importance you bring to the table. It will be better for everyone once the Programs realize this and reduce the number of spots.

Ironically, by not passing the two Resident Supervision reimbursement law Medicare is doing all of us a favor. Programs will eventually be forced to close and reduce the number of graduates. Too bad it takes Medicare to make these decisions for us. The leadership of Anesthesia has failed us.
They are so focused on research and slave labor (Residents) that they fail to grasp the big economic picture. A picture Dermatology and Plastic Surgery understand well: The law of supply and demand. Our leaders need to scale back the number of entering Residents immediately. The ASA President should support this position based on the facts of his own lecture. Each Program Chairperson and Director should act next year.

 

[powermd]

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.

Military is right. If you don't see this, your ego is obscuring the view.

 

[nutmegs]

I'm glad you used that analogy.

The latest generation of commercial aircrafts pretty much fly themselves.

The pilot just programs the destination...and punches a button.

Anymore insightful analogies.......I recommend pulling your head out of the sand....or ass....where ever you have it planted.

haven't flow up front lately, have you?

pilots might not move their hands the entire flight, but they are engaged in the same mental vigilance that anesthesiologist should. they know the plane and its normal and abnormal functioning inside and out, and they monitor the weather, engine status, navigation equipment, etc continuously. the pilot can't just come up front when something goes wrong- there's no time to catch up on that data in an emergency.

if you insist that modern day pilots are mere button pushers (wrong...) how about the MD supervising CRNAs as an air traffic controller? how many planes in the air can you keep track of- their position, destination, fuel level, emergency needs?

 

[nutmegs]

My point exactly. By reducing the number of programs to 90 (the strongest 90 programs) and expanding your LEGAL Board Certification to include Critical Care and Peri-Operative Medicine greatly increases the chances you will get a good job after Residency. Hospitals will need you and the importance you bring to the table. It will be better for everyone once the Programs realize this and reduce the number of spots.

Ironically, by not passing the two Resident Supervision reimbursement law Medicare is doing all of us a favor. Programs will eventually be forced to close and reduce the number of graduates. Too bad it takes Medicare to make these decisions for us. The leadership of Anesthesia has failed us.
They are so focused on research and slave labor (Residents) that they fail to grasp the big economic picture. A picture Dermatology and Plastic Surgery understand well: The law of supply and demand. Our leaders need to scale back the number of entering Residents immediately. The ASA President should support this position based on the facts of his own lecture. Each Program Chairperson and Director should act next year.

why would you be so confident comparing anesthesia to derm, ortho, etc in what should happen to the program size when there really are no mid-level providers moving in en masse on their practices?

 

[johankriek]

Military is right. .

If military were right, women would be home barefoot and pregnant and all minorities would still be slave. And all asians,........ well I wont go there. There would be no progress. So i say HE isn't right.

 

[deleted50478]

If military were right, women would be home barefoot and pregnant and all minorities would still be slave. And all asians,........ well I wont go there. There would be no progress. So i say HE isn't right.

The misrepresentation of statements is getting old. Mil never said all minorities shouldn't do anything. To shorten a very long argument as I recall it, he said something like only those who earn their spots should get them. That isn't quite the same as an evil plan to hold anyone down. I'm sure he'd welcome as many qualified minorities as are available.

Next, you can scroll up and easily see that he didn't says that women should be pregnant, etc. He only agreed with the undeniable fact that women get pregnant, take time off of work, and their co-workers are required to make up for their absence. To act like this isn't true is absurd, so you just attack him instead.

It's a real problem in this country that we choose to ignore the facts if they have any potential of hurting anyone's feelings. Don't deny reality. Propose a positive way of dealing with it.

Sorry if my paraphrasing isn't 100% accurate, but I felt like commenting on this nonsense.

 

[jwk]

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.

FMLA applies to employers and employees, but a partner in a partnership is not an employee. I don't know for sure, but I'll bet it wouldn't apply to partners.

 

[EtherMD]

why would you be so confident comparing anesthesia to derm, ortho, etc in what should happen to the program size when there really are no mid-level providers moving in en masse on their practices?

Experience. The AANA's propoganda is a long way from fact. CRNA's are competent Mid-Level Providers but your "average" CRNA has his/her hands full with an ASA 1 or 2 patient. That is, a "solo" CRNA would not be able to handle most complicated cases and advanced Regional. In addition, turn-over time would increase dramatically as some CRNA"s struggle to get cases started, do spinals, lines, etc. I can't count the number of times I had to intubate for a CRNA, deal with a comlicaton from a CRNA, do the Block for a CRNA, etc., not to mention making the medical/anesthetic decision about the case.

Surgeons and administrators would not put up with the delays and complications for very long. Not to mention the lawyers and increased risk from Anesthesia. Yes, I know there is no data to back up my claims but I am telling you after supervising more than 30,000 anesthetics the "average" CRNA really needs supervision at a major medical center. I am willing to bet my entire career on this fact as I have seen the limits of what CRNA's can do "solo". Even the very best CRNA can not do every case at a major medical center "solo". Despite the AANA rhetoric most CRNA's know this and would be reluctant to do the big ASA 3 and ASA 4 cases solo.

Thus, the supervisory ratio will increase to 5-7 per one MDA. This allows at least some level (100% at 5 with a decrease to 60-70% at 8) of supervision depending on the ratio. AT least the ASA 4 cases would be supervised and the advanced Regional would be performed. The CRNA could do the ASA 1 and 2 case solo leaving the MDA free to be more involved with the bigger cases and sicker patients.

In short, CRNA's can not and do not perform at the same level as an Anesthesiologist. The propoganda and rhetoric about CRNA equivalence is simply not true. But, CRNA's can handle the simple cases and healthy patients. The day is coming when MDA's will be compelled to let them.
Therefore, logic dictates we will need fewer supervisors in the future.
Our future is secure IF we prepare properly: Cut the number of spots and increase the "legal" value of your Board Certification. Major Medical Centers can not function well without you and the ASA 4 patient needs you!

 

[nutmegs]

Experience. The AANA's propoganda is a long way from fact. CRNA's are competent Mid-Level Providers but your "average" CRNA has his/her hands full with an ASA 1 or 2 patient. That is, a "solo" CRNA would not be able to handle most complicated cases and advanced Regional. In addition, turn-over time would increase dramatically as some CRNA"s struggle to get cases started, do spinals, lines, etc. I can't count the number of times I had to intubate for a CRNA, deal with a comlicaton from a CRNA, do the Block for a CRNA, etc., not to mention making the medical/anesthetic decision about the case.

Surgeons and administrators would not put up with the delays and complications for very long. Not to mention the lawyers and increased risk from Anesthesia. Yes, I know there is no data to back up my claims but I am telling you after supervising more than 30,000 anesthetics the "average" CRNA really needs supervision at a major medical center. I am willing to bet my entire career on this fact as I have seen the limits of what CRNA's can do "solo". Even the very best CRNA can not do every case at a major medical center "solo". Despite the AANA rhetoric most CRNA's know this and would be reluctant to do the big ASA 3 and ASA 4 cases solo.

Thus, the supervisory ratio will increase to 5-7 per one MDA. This allows at least some level (100% at 5 with a decrease to 60-70% at 8) of supervision depending on the ratio. AT least the ASA 4 cases would be supervised and the advanced Regional would be performed. The CRNA could do the ASA 1 and 2 case solo leaving the MDA free to be more involved with the bigger cases and sicker patients.

In short, CRNA's can not and do not perform at the same level as an Anesthesiologist. The propoganda and rhetoric about CRNA equivalence is simply not true. But, CRNA's can handle the simple cases and healthy patients. The day is coming when MDA's will be compelled to let them.
Therefore, logic dictates we will need fewer supervisors in the future.
Our future is secure IF we prepare properly: Cut the number of spots and increase the "legal" value of your Board Certification. Major Medical Centers can not function well without you and the ASA 4 patient needs you!

how do you propose cutting slots when your ASA 3/4 population is set to continue increasing dramatically?

 

[proman]

Experience.

In short, CRNA's can not and do not perform at the same level as an Anesthesiologist. Major Medical Centers can not function well without you and the ASA 4 patient needs you!

Finally the voice of reason.

 

[EtherMD]

why would you be so confident comparing anesthesia to derm, ortho, etc in what should happen to the program size when there really are no mid-level providers moving in en masse on their practices?

PLEASE READ THIS POST SLOWLY:


Imagine the year is 2015 (only 8 years from now). Congress/CMS has passed a new rule allowing Anesthesiologists to supervise as many CRNA's/AA's as he/she "feels comfortable doing without jeopardizing the care of the surgical patient." Medicare has slashed reimbursement 20% from today's levels. Hospitals are now the major source of funding for most Groups.

In other words, CEO's and CFO's call the shots and determine which Group/Providers get the contract and the subsidy. AMC's and CRNA Groups are everywhere. With this new law the Administrators expect fewer MDA's and more CRNA's or they will go with the AMC. At this time they do not want CRNA "only" for their hospital because even they recognize the limitations of a Nurse in the operating room. But, they do expect 6-7 CRNA's per MDA.
They will DEMAND a leaner, more cost-effective Anesthesia team.

Now, if OUR leadership has acted properly and predicted this scenario, we will have a few less Anesthesiologists out there in 2015. However, if the leadership failed to act in 2008 then there may be a "glut" of supervisors/MDA's in the marketplace in 2015. This means the AMC's can get all the MDA's they need at a lower price! The hospitals will demand that current Groups BEAT the AMC's bid or lose the contract. This will force MDA wages down significantly and create less opportunity for employment.

BY 2015 the Anesthesiology Residency Programs will be in chaos. They will be forced to close programs and look "weak" to the AANA. American Medical Graduates will stop choosing Anesthesiology as a career choice. THe AANA will have final victory in its site.

The alternative to this scenario is the following:

1. The leadership recognizes the future role of Anesthesiologists as Supervisors, Perioperative Physicians and Pain Specialists. They reduce the number of programs and spots immediately. This ensures current and future Anesthesiologists job security. This "proactive" stance maintains the demand for good Anesthesiologists to find work in the USA. MDA wages are "stable" as hospitals (academic and private practice) must maintain fair salaries or risk losing a "valuable" member of the team. The AANA can not claim victory as the ASA "spins" this reduction as necessary for "quality control" in the field.

2. The leadership "ramps-up" the vaule of your certificate and Board Certification immediately. EVery Resident graduates as a Consultant, Perioperative Physician and Critical Care Specialist. By 2010 a CA-4 year is required which results in additional eligibility for certification in Pediatrics, Pain Management, Neuro or Cardiac Anesthesia. Now, new graduates have the "legal" certification as much, much more than a glorified CRNA.

For your sake I hope this happens. If not, the specialty is finished.

 

[EtherMD]

how do you propose cutting slots when your ASA 3/4 population is set to continue increasing dramatically?

Remember, in the very near future the supervisory rule will change to 5 or 6:1
All MDA Groups will be forced to hire CRNA/AA's or suffer the economic consequences. The death of the "solo" MDA model means many more Anesthesiologists are now available to supervise. This translates into thousands of Anesthesiologists going from "doing" to supervising cases.

Even with a reduction in the number of spots and programs by 2008 there still may be a surplus of supervisors looking for work. The programs need to make sure their graduates have work in 2015. The only way to do this for them is to reduce the number of spots ASAP.

CRNA programs continue to pump out new graduates at record setting paces. Every year more CRNA programs open and more CRNA's graduate.
By 2015 they will cearly dominate the marketplace. Let them. Use economics against them to drive their wages down while maintaining MDA pay.
The only way to reliably do this is by REDUCING the number of spots.

Dermatology gets this concept. Plastic Surgery gets this concept. Why can't you?

As for more ASA 3 and ASA 4 patients in the future this is good for us. It justifies our usefulness in the ACT model. We supervise these cases and leave the ASA 1 and 2 for the CRNA. Currently, we must supervise EVERY case so by reducing 20-30% of cases in a major medical center (year 2015)
this leaves the ASA 3 and 4 (70-80%) of cases for us. Hence, we do not need more MDA's because of the 20% reduction in workload and the large number of former "solo" MDA's now in the ACT model.

 

[nutmegs]

PLEASE READ THIS POST SLOWLY:


Imagine the year is 2015 (only 8 years from now). Congress/CMS has passed a new rule allowing Anesthesiologists to supervise as many CRNA's/AA's as he/she "feels comfortable doing without jeopardizing the care of the surgical patient." Medicare has slashed reimbursement 20% from today's levels. Hospitals are now the major source of funding for most Groups.

In other words, CEO's and CFO's call the shots and determine which Group/Providers get the contract and the subsidy. AMC's and CRNA Groups are everywhere. With this new law the Administrators expect fewer MDA's and more CRNA's or they will go with the AMC. At this time they do not want CRNA "only" for their hospital because even they recognize the limitations of a Nurse in the operating room. But, they do expect 6-7 CRNA's per MDA.
They will DEMAND a leaner, more cost-effective Anesthesia team.

Now, if OUR leadership has acted properly and predicted this scenario, we will have a few less Anesthesiologists out there in 2015. However, if the leadership failed to act in 2008 then there may be a "glut" of supervisors/MDA's in the marketplace in 2015. This means the AMC's can get all the MDA's they need at a lower price! The hospitals will demand that current Groups BEAT the AMC's bid or lose the contract. This will force MDA wages down significantly and create less opportunity for employment.

BY 2015 the Anesthesiology Residency Programs will be in chaos. They will be forced to close programs and look "weak" to the AANA. American Medical Graduates will stop choosing Anesthesiology as a career choice. THe AANA will have final victory in its site.

The alternative to this scenario is the following:

1. The leadership recognizes the future role of Anesthesiologists as Supervisors, Perioperative Physicians and Pain Specialists. They reduce the number of programs and spots immediately. This ensures current and future Anesthesiologists job security. This "proactive" stance maintains the demand for good Anesthesiologists to find work in the USA. MDA wages are "stable" as hospitals (academic and private practice) must maintain fair salaries or risk losing a "valuable" member of the team. The AANA can not claim victory as the ASA "spins" this reduction as necessary for "quality control" in the field.

2. The leadership "ramps-up" the vaule of your certificate and Board Certification immediately. EVery Resident graduates as a Consultant, Perioperative Physician and Critical Care Specialist. By 2010 a CA-4 year is required which results in additional eligibility for certification in Pediatrics, Pain Management, Neuro or Cardiac Anesthesia. Now, new graduates have the "legal" certification as much, much more than a glorified CRNA.

For your sake I hope this happens. If not, the specialty is finished.

I understand your point. I just hope you don't undershoot, or they will be forced to find another way around the supervision problem entirely.

 

[rn29306]

Experience. The AANA's propoganda is a long way from fact. CRNA's are competent Mid-Level Providers but your "average" CRNA has his/her hands full with an ASA 1 or 2 patient.

You've got to be kidding me. That or you've been around some sucky CRNAs.

If this were true, then there would be clear studies and research supporting this. But then again the data isn't there and you are blowing smoke on this one.

 

[nutmegs]

Dermatology gets this concept. Plastic Surgery gets this concept. Why can't you?

no need to be a d*ck

 

[nutmegs]

You've got to be kidding me. That or you've been around some sucky CRNAs.

the CRNAs I've dealt with were above this.

 

[Monty Python]

CRNA programs continue to pump out new graduates at record setting paces. Every year more CRNA programs open and more CRNA's graduate.
By 2015 they will cearly dominate the marketplace. .

I would beg to differ. Current models shows an oncoming wave of CRNA retirements in the very near future. The largest segment of CRNAs are 55-59 years old, trained by the military for Vietnam. The nationwide graduation rate is still falling behind the retirement rate by ~50 per year. The projected increase in graduation rates will barely stay even with the increased retirement rate - it will be a wash.

This, with increased demand for services as the Baby Boomers age.

 

[mille125]

who knows??? by 2015 the mighty CRNA's may be anesthetists and surgeons!!!

 

[jwk]

I would beg to differ. Current models shows an oncoming wave of CRNA retirements in the very near future. The largest segment of CRNAs are 55-59 years old, trained by the military for Vietnam. The nationwide graduation rate is still falling behind the retirement rate by ~50 per year. The projected increase in graduation rates will barely stay even with the increased retirement rate - it will be a wash.

This, with increased demand for services as the Baby Boomers age.

That's what I like to see - facts - as opposed to opinions being touted as facts.

 

[militarymd]

Sorry if my paraphrasing isn't 100% accurate, .

97.5%

 

[EtherMD]

That's what I like to see - facts - as opposed to opinions being touted as facts.

FACT: In my State alone at least THREE new programs have opened in the past 24 months.

Fact: My Group has an offer to start a CRNA program.

Fact: The number of new CRNA Graduates is at an all time high. Each year new records are set.

Fact: Nurses are "flocking" to CRNA school because they can make 3-4 times as much money. Ten years ago the multiple was two.

Fact: More AA Programs will open soon and more are in the works. There are only four as of today but one new one is scheduled to open next year.

Fact: It has never been easier to hire CRNA's than it is today. There are many more "new" graduates each year to recruit. I know because I recruit for my Group.


AANA Propoganda is so prevalent that even their members believe it. The AANA wants to increase its membership dramatically over the next ten years and is willing to tolerate more CRNA's in the work place. This means a leveling off of CRNA salary for a few years but a lot more dues paying members.

Yes, we will need more Mid-Level Providers in the future. Thus, the AANA is gearing-up to meet this demand or risk losing market share to AA's. The last thing the AANA wants is dozens of more AA programs opening up.

I have worked with about a hundred CRNA's in my career. I still stand by my statement that they can not handle more than an ASA 1 or ASA 2 "solo"

 

[EtherMD]

You've got to be kidding me. That or you've been around some sucky CRNAs.

If this were true, then there would be clear studies and research supporting this. But then again the data isn't there and you are blowing smoke on this one.

More AANA propoganda. The "average" (this means 50th percentile) CRNA can handle the ASA 1 and ASA 2 patient "solo". But, they lack the knowledge and skills to do many of the "biggest cases" without an Anesthesiologist.

I have nothing against CRNA's. I work with them daily and have supervised more than 30,0000 anesthetics. I know what they can really do "independently" and what their limitations are. I work with a few who are at the 95th percentile and these CRNA's can handle more than the average; but, even they have their limitations and NONE of them can do all the cases at a major medical center "solo."

I worked with a CRNA who performed at the 99th percentile (in my opinion).
He has three decades of experience and is the best CRNA I have ever worked with; but, even he told me their are a "few cases" at my Major Hospital that he would not want to do "solo". Examples of these include Complicated Pediatrics, Re-do Double Valves with TEE, Complicated Brain Aneurysms and extremely difficult intubations.

This CRNA now runs his own Group (CRNA Only) and earns more than $350,000 per year. I asked him about the likelihood of CRNA "only" practice at my hospital. Do you know how he responded?
Then he told me that it would take a large Group of CRNA's who all perform at the 90th percentile or better to run the place. In addition, he still thought a few MDA's may be needed as back-up. The CRNA's who perform at the 90th percentile or better DEMAND more money and are alawys looking for a better deal. Overall, he thought that a 5-6 CRNA to MDA ratio with CRNA's at the 40-70th percentile would be more cost effective. These statements are coming from a CRNA!

I do not want to go off topic and discuss CRNA vs. MDA. The fact is CRNA's are Mid-Level Providers who do a good job. I appreciate them and work with them. But, they are not Physicians and they are not Anesthesiologists. Most can handle the ASA 1 and ASA 2 patient. But, beyond these level of cases the average CRNA begins to need more input. Most want help from an MDA and want input about case management. Most like having "back-up" for intubations, spinals, central lines, codes, etc. I know our surgeons want MDA's around which is why my hospital pays us a large subsidy. Even our MBA administrators know the limits of CRNA practice. But, they would LOVE the 5-6 CRNA to MDA ratio if we would agree to it.

 

[EtherMD]

I understand your point. I just hope you don't undershoot, or they will be forced to find another way around the supervision problem entirely.

The specialty needs to make a choice. You can contrinue to ignore the most likely scenario where CRNA's and/or AA's do the cases in the near future while MDA's function as Medical Suprervisor; or, you can deal with this scenario by making sure each new graduate is in high demand after training.

The alternative is to ignore the gains the AANA continues to make in the field. You can ignore that Medicare is going to CUT payment to MDA's over the next 5 years significantly. You can ignore that private payers will eventually STOP paying three times Medicare for Anesthesia services very soon.

But, you will NOT be able to ignore the fact you will earn a LOT less money in 2015 if there is a "glut" of Anesthesiologists. It only takes CRNA programs 28 months to "ramp-up" new graduates. That is, the AANA and CRNA programs can react to market forces fairly rapidly. If the demand is there then each CRNA program can increase the number of students. Thus, they could produce an extra 25-50% more CRNA's per year in a short time.

Compare this fact with MDA. It takes a minimum of 48 months to ramp-up MDA's. This assumes you can convince Medical Students to go into the field.
So, if we need more MDA's in 2015 then you will be in "high demand"

 

[EtherMD]

Finally the voice of reason.

A wise man said that if you do not learn from history you are bound to repeat it. That said, let me give you a history lesson.

In the Mid-1990's the number of new graduates (MDA's) hit an all time high.
Do you know what this meant for those graduates? Low starting Pay and LONG partnership tracks. During this period of time finding a good job was difficult. Private Groups took advantage of this glut (and so did academic programs) by paying new MDA graduates a very low wage. The average new graduate made 1/5 what a Partner made. Similarly, the Chairman made about 4-5 times what a new Instructor earned per year.

In the late 1990's/early 00 the number of graduates had declined. By '02-'4 starting salaries had risen dramatically and the average partnership track decreased by about 30-40%. Recruiting a new graduate was "difficult" for private Groups and Academia. Now a new graduate made 1/2 what a partner made per year. The Chairman only earns 2 times what an instructor earns.

This is your history lesson. Don't let the greedy Academic Programs make the same mistake of the Mid-1990's. Your career and your income depend on it.
In short, better to under-estimate our need for MDA services in the future then continue to produce large numbers like we are doing today.

 

[rufio173]

I agree alot with what EtherMD and Mil are saying. It will apply less to me as I will be going into academics (although it will still affect me in terms of more dependence on research funds for my salary), but everything is pointing in the very direction they are speaking of. It's just plain economics. The U.S. government (both republicans and democrats) wants to streamline and decrease healthcare costs (just look at what Bush tried to recently pull). This means less money to go around for everybody and finding ways to cut costs (i.e. using CRNAs to do the bulk of anesthesia monitoring). It will become more and more rare to see a lone Anesthesiologist doing everything in the OR. You will probably only see these things happening in extremely specialized centers or boutique centers catering to the rich and/or famous after the next decade.

As with all things, medicare sets the lower limit of medical spending and as always private insurance always follows in time. We are a world driven by economic forces. Now, if CRNAs start bombing cases and killing people, then that'll be a different story, but given that they are still required to be supervised, not likely to happen with an MDA there.

Unless every MDA wants to go on a huge strike for a month (ethically and morally wrong, as well as financially detrimental) and let moderate to complicated cases be bombed by CRNAs, then this will most likely be what the future holds for the specialty. The one way to sustain current graduate levels is to expand our responsibilities outside of the OR (the so called "perioperative" specialist). The best institutions are gearing up for this, less reputable institutions are not... so choose your residency carefully.

I personally think that as reimbursement rates go down, there will be less qualified medical students being accepted and less going into the anesthesiology field, so forces outside our control will naturally curb the specialty, but the question is whether this will be too late or not...

Cheers,
John

 

[Monty Python]

.....in 2015 ..... It only takes CRNA programs 28 months to "ramp-up" new graduates. That is, the AANA and CRNA programs can react to market forces fairly rapidly. If the demand is there then each CRNA program can increase the number of students. Thus, they could produce an extra 25-50% more CRNA's per year in a short time.

"

The above quote is taken slightly out of context to demonstrate the danger of prognosticating the future, overlooking the Laws of Unintendended Consequences.

As discussed ad nauseum in a separate thread, the AANA decided to mandate all CRNA programs move to the doctoral level by 2015. Some have moved the implementation date earlier. That change will add another year to the current 36 month curriculum.

An additional fly in the ointment: only doctoral-prepared faculty can teach doctoral students. The vast majority of CRNA faculty today have master's degrees. There isn't a flood of PhD-wannabe CRNAs knocking down the walls of academia to further their own education. So where are all these requisite PhD-level CRNAs going to sprout from, being a necessary component to teach PhD SRNA candidates? I forecast a huge traffic jam in CRNA education in the next decade unless they overturn the idea of PhD as the entry-level degree for CRNA practice.

I would be interested to see the results of any study (which to my knowledge hasn't yet been performed) investigating the potential effect on CRNA school applications due to the time and expense of this increased education burden.

 

[jwk]

FACT: In my State alone at least THREE new programs have opened in the past 24 months.

Fact: My Group has an offer to start a CRNA program.

Fact: The number of new CRNA Graduates is at an all time high. Each year new records are set.

Fact: Nurses are "flocking" to CRNA school because they can make 3-4 times as much money. Ten years ago the multiple was two.

Fact: More AA Programs will open soon and more are in the works. There are only four as of today but one new one is scheduled to open next year.

Fact: It has never been easier to hire CRNA's than it is today. There are many more "new" graduates each year to recruit. I know because I recruit for my Group.


AANA Propoganda is so prevalent that even their members believe it. The AANA wants to increase its membership dramatically over the next ten years and is willing to tolerate more CRNA's in the work place. This means a leveling off of CRNA salary for a few years but a lot more dues paying members.

Yes, we will need more Mid-Level Providers in the future. Thus, the AANA is gearing-up to meet this demand or risk losing market share to AA's. The last thing the AANA wants is dozens of more AA programs opening up.

I have worked with about a hundred CRNA's in my career. I still stand by my statement that they can not handle more than an ASA 1 or ASA 2 "solo"

Of course I'm all for more AA programs.

Fact from my area of the country - it's never been HARDER to hire anesthetists (AA or CRNA) than it is right now. Every student graduating from all the AA programs had their choice of jobs - 100% job placement - with large sign-on bonuses and tuition reimbursements as incentives to join a group. I know because I recruit and hire for my group as well.

Graduating CRNA's levels are on the upswing, but not at an all-time high. Those days were back in the late 70's and early 80's before dozens of certificate-only CRNA programs were forced to close. Sure there are more schools opening, but that looming DNP issue will be a BIG problem on the education side. And they face some of the same issues as anesthesia residencies - programs cost money to run and require faculty to teach, and both are in short supply.

And BTW, if your group has an offer to start a CRNA program, then I'd suggest that you have become part of the problem.

 

[EtherMD]

Of course I'm all for more AA programs.

Fact from my area of the country - it's never been HARDER to hire anesthetists (AA or CRNA) than it is right now. Every student graduating from all the AA programs had their choice of jobs - 100% job placement - with large sign-on bonuses and tuition reimbursements as incentives to join a group. I know because I recruit and hire for my group as well.

Graduating CRNA's levels are on the upswing, but not at an all-time high. Those days were back in the late 70's and early 80's before dozens of certificate-only CRNA programs were forced to close. Sure there are more schools opening, but that looming DNP issue will be a BIG problem on the education side. And they face some of the same issues as anesthesia residencies - programs cost money to run and require faculty to teach, and both are in short supply.

And BTW, if your group has an offer to start a CRNA program, then I'd suggest that you have become part of the problem.

Or part of the solution depending on your viewpoint. The PhD issue remains to be seen; in other words, the theory of PhD sounds interesting to the AANA as they work for full "equivalence" with MDA's. But, I believe they will delay this requirement for several years more (2020).

As for CRNA recruitment in Atlanta and other "hot" areas of the USA I am sure it is more difficult than most cities. But, check the real numbers of graduating students at programs. They are on the rise (over the past 10 years) and will continue to increase. As for the AA's they have not stepped up to the plate and produced enough graduates. Hence, Medical Centers will look for opportunities to staff their operating rooms with AVAILABLE Mid-Level Providers.

The time has come to stop worrying about the CRNA problem. Just admit they can do the ASA 1 and 2 case and move on. Prepare for the future as PERIOPERATIVE PHYSICIAN and MEDICAL SUPERVISOR. Convert Residency Programs to AA programs if the academic centers need cheap lablor. Most of all, reduce the number of programs and spots.

 

[The_Sensei]

For the record........the AANA are a bunch of militant idiots. Anyone disagree? If so, get a lobotomy.....

 

[Gern Blansten]

For the record........the AANA are a bunch of militant idiots. Anyone disagree? If so, get a lobotomy.....

It is strange, I like almost all CRNAs I have met and have never heard any of them espouse the beliefs put forth by the AANA. Do they secretly plot against us or is their leadership that far removed from its core membership's beliefs?

 

[jwk]

It is strange, I like almost all CRNAs I have met and have never heard any of them espouse the beliefs put forth by the AANA. Do they secretly plot against us or is their leadership that far removed from its core membership's beliefs?

Their "leadership" is what is pushing all of this. A majority of CRNA's actually work in care team practices with and/or for an anesthesiologist. I have a practice with 35 CRNA's - none of them are asking to toss out the docs.

 

[EtherMD]

Back to Lema's lecture. Do you think the message will get out to the Chairpersons and Program directors? How will the academic leadership respond?

If the President of the ASA is predicting a large increase in the supervisory ratio shouldn't that warrant a response from the Residency Programs?

We accuse the AANA of propoganda and mistruth. Yet, what are the academic programs telling future Residents? Are they telling the whole story about the future of the specialty? What about the large number of Programs and New Graduates? Why have so many spots? Is this for the benefit of the Student or the Program (read very cheap labor)?

These questions need answers and the leadership needs to LEAD. It is not business as usual in Anesthesia as many Programs pretend. There is still time to make some effective, strategic moves to secure the Specialty of Anesthesiology.

 

[Planktonmd]

It is strange, I like almost all CRNAs I have met and have never heard any of them espouse the beliefs put forth by the AANA. Do they secretly plot against us or is their leadership that far removed from its core membership's beliefs?

There is 2 kinds of CRNA's: The old ones, who were trained to follow a plan and help the "Doctor" give anesthesia. These are great CRNA's, Most of them are very skilled and don't give you headaches!
The second kind is the new grads who were infused with grandiose ideas of being as good or even better than us, they are the ones who I enjoy to take the laryngoscop from their hand and intubate the patient as effortlessly as possible after their third failed try.
The good news is that most of the second group get humbled after a while in practice, when they start to know how much they don't know!

 

[EtherMD]

AA PROGRAMS: The Solution?

I an curious to read opinions about Academic Centers starting AA programs at the National Level. In other words, mobilize academia to train 80% of the current level of Residents and train many more AA's. The marketplace could easily absorb the extra Mid-Level Provider and AA's work under the supervision of an Anesthesiologist.

AA's are happy at the Master's level and are not seeking DNP/PhD to work in the ACT model. On the other hand, the militant AANA wants full equivalence for its members and complete, Independent Practice. Thus, the push for all CRNA's to have a DNP/PhD.

Again, it seems like a large surge of new AA Programs by Academia over the next 2-3 years would help the ASA. It would provide large numbers of qualified providers for the operating room. The ASA could effectively bring the AANA to its knees with such a surge. This may result in the AANA re-evaluating its position about CRNA's "solo" practice for certain types of cases and centers.

If not, it would only take 5-10 years for enough AA graduates to reach the Private Practice level to have a major impact on the field. As usual, the ASA has a viable solution right in view and chooses not to act. Well, the time has come for some MAJOR action on behalf of its membership.

 

[morpheus md]

The specialty needs to make a choice. You can contrinue to ignore the most likely scenario where CRNA's and/or AA's do the cases in the near future while MDA's function as Medical Suprervisor; or, you can deal with this scenario by making sure each new graduate is in high demand after training.

The alternative is to ignore the gains the AANA continues to make in the field. You can ignore that Medicare is going to CUT payment to MDA's over the next 5 years significantly. You can ignore that private payers will eventually STOP paying three times Medicare for Anesthesia services very soon.

But, you will NOT be able to ignore the fact you will earn a LOT less money in 2015 if there is a "glut" of Anesthesiologists. It only takes CRNA programs 28 months to "ramp-up" new graduates. That is, the AANA and CRNA programs can react to market forces fairly rapidly. If the demand is there then each CRNA program can increase the number of students. Thus, they could produce an extra 25-50% more CRNA's per year in a short time.

Compare this fact with MDA. It takes a minimum of 48 months to ramp-up MDA's. This assumes you can convince Medical Students to go into the field.
So, if we need more MDA's in 2015 then you will be in "high demand"

How does a newly minted attending keep their skills up if they go straight to supervising CRNAs out of residency. If you are back up for 5-6 rooms, your skills should be bullet proof, but if you are routinely supervising from the day after CA3 year, wouldn't you lose your edge?

 

[militarymd]

How does a newly minted attending keep their skills up if they go straight to supervising CRNAs out of residency. If you are back up for 5-6 rooms, your skills should be bullet proof, but if you are routinely supervising from the day after CA3 year, wouldn't you lose your edge?

you do cases by yourself at night...the Emergencies.

 

[EtherMD]

How does a newly minted attending keep their skills up if they go straight to supervising CRNAs out of residency. If you are back up for 5-6 rooms, your skills should be bullet proof, but if you are routinely supervising from the day after CA3 year, wouldn't you lose your edge?

Valid Concern. MilitaryMD suggest doing cases at night and on the weekend.
That would work. But, it does help to get a few thousand "solo" cases under your belt prior to supervising 5-6 rooms. This represents one or two years of MDA Solo practice. I was fortunate enough to do about 6-8,000 anesthetics prior to supervising CRNA's. It reall does help.

But, even without a few thousand cases you will be dealing with all the difficult intubations, make all the medical decisions, do the Advanced Regional and get those tough Neuraxial Blocks. You should be pretty sharp in a few years as you will supervise up to 5,000 cases per year (if 6 to 1 ratio).
That is a lot cases to see and problems to deal with.

Groups like mine would allow you to do 30% or so of your cases solo the first couple of years. This would allow you to get to know the surgeons better,
polish your own skills and relate to what the CRNA's are putting up with day to day. A leader who knows what its like and stays in the "front lines" has much more support/admiration from his troops. Thus, getting to do the 400lb. ERCP (ASA 4) builds character. Another example is working with the super-fast ENT doctor (10 cases in 3 hours) and the Ass-hole Surgeons (certain Ortho guy, General guy, etc.). This will build your fortitude and make you a better supervisor.

In short, I agree with you that hands on experience (a few thousand cases) is important particularly for the new graduate.

 

[Noyac]

It is strange, I like almost all CRNAs I have met and have never heard any of them espouse the beliefs put forth by the AANA. Do they secretly plot against us or is their leadership that far removed from its core membership's beliefs?

Yes

 

[Monty Python]

AA PROGRAMS: The Solution?

I an curious to read opinions about Academic Centers starting AA programs at the National Level. .

This is a straightforward question, not an editorial: did I miss it, or did Dr. Lema not cover AAs in the powerpoint (find link in the first post of this thread)?

 

[FaceReality]

i heard about this post from a friend. gotta say that im really sorry anesthesiology has to go through so much bul*****. the good news is that Lema is putting the smackdown on what needs to happen. Lets hope things get better for the future.

But you all have to admit, anesthesiologists are pretty damn overpaid for what they do!

 

[powermd]

i heard about this post from a friend. gotta say that im really sorry anesthesiology has to go through so much bul*****. the good news is that Lema is putting the smackdown on what needs to happen. Lets hope things get better for the future.

But you all have to admit, anesthesiologists are pretty damn overpaid for what they do!

I smell fresh troll....

But I would disagree. All doctors are vastly underpaid for what they do. As are teachers.

Hedge fund managers, professional athletes, and entertainers are pretty damn overpaid for what they do. But that's how it is in a free market.

 

[The_Sensei]

But you all have to admit, anesthesiologists are pretty damn overpaid for what they do!

I and many others would WHOLEHEARTEDLY disagree.

 

[CremeSickle]

Johan

you are the Archie Bunker of sdn

That, my friend, is BY FAR the best quote EVER. I almost fell off my chair laughing. too bad the reference will be lost of the majority of the ppl here.

 

[Bertelman]

I've loosely caught up to this thread. Here's my concern. There is a fair amount of conjecture about what is *going* to happen. The few facts I can grasp onto include the need for more surgeries in the future, and the decreased training time for CRNAs, v. MDs. So, if residency programs across the country are cut, and in the near future it is determined that there is now a woeful shortage of MDs, who do you think will pick up the slack? Of course the mid-levels. To me, we would have thus put the nails in our own coffins. I know this will be seen as short-sighted, but I feel that the AANA only gains power when there are less anesthesiologists to fight.

It seems a little early to me to resign ourselves to mid-level supervisors. I understand we've been losing a long PR battle, but I just feel like bad things have been done in the past in the name of "job security"