Is Anesthesiology still a good choice for Medical Students?

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Having studied the previous threads on this topic extensively, I am reluctant to yet again bring up essentially the same old debate… however… I feel that amid all the opinions, forecasts, and pontification in this community some important details are still not very clear.

As a 3rd year med student who has always maintained a strong interest in Anesthesiology, I have recently run into a lot of doubt regarding the future job prospects and income potential of MD anesthesiologists outside of academics. Regardless of what manifestation of healthcare reform persists 10-20 years down the road, I feel it is almost certain that a much greater percentage of physician income will in some way be funneled through large bulk payments made to organizations (e.g. ACOs) based on patient outcomes. This would of course supplant the fee-for-service status quo.

There is no question that anesthesiologists are among the greatest beneficiaries of the fee-for-service paradigm. MD anesthesiologists achieve their current outstanding level of income solely because they are in position to provide A LOT of service with very little time and resource overhead. Policymakers have already realized this in the 90’s when they cut Medicare anesthesia reimbursement drastically. In a classic illustration of supply and demand, however, medical students swiftly left the specialty for dead while hospitals were then forced to pony up ever higher subsidies to keep their OR’s… um, operating. This translated into higher anesthesiology reimbursement demands in negotiations with private insurers and eventually to the relative high income of anesthesiologists today.

Low and behold, now everyone wants a piece of the gas pie and the field is being glutted with a marked rebound in medical student interest and a new CRNA/AA school popping up every couple of months. Some are even projecting an OVERSUPPLY of CRNAs in as little as 10 years… just barely long enough for a medical student to finish training and get their foot in the door with the fat cats in the private anesthesiology industry.

What worries me this time around, however, is that while medical students have other options (and much higher debt), CRNAs will continue to compete with each other for business and eventually drive down total annual salaries for anesthesiology to true nursing levels. This will fit nicely into the “new healthcare” as financial incentives switch hospitals’ perspective from “billing” to “cost-cutting.” In that environment, it seems impossible that 1300+ new MD anesthesiologists every year can find a way to carve out a salary anywhere near that of their predecessors.

I love anesthesiology, yet I believe it is foolhardy to run the risk of becoming a cheap commodity when there is still time to specialize in something more rewarding of the sacrifices I have made (and will continue to make) through my formation as a physician.

Someone please throw me a wild card… something that I’ve missed in this dreary picture!
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The future income of physicians in all specialties is up in the air, depending on what happens with healthcare reform. If you are that concerned about anesthesiology in particular, might as well choose something else.
 
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Agree. If you know your goal is to go into private practice and make a poopload of money-- no guarantees in anesthesia in five years. It also tells me you feel you do have other options (i.e. anesthesia isn't your dream specialty or something) so if you think those other specialities are immune, by all means go for them. Many of us have put in 5+ years of training in this specialty because we actually enjoy it and couldn't imagine doing anything else-- and continue to fight for what we believe is right for the MD/DO anesthesiologist. the CRNA/AA debates will continue, health care will continue to change-- if you don't think it's worth it or don't think you'll love it enough to deal with those headaches, don't do it. Noone can predict the future here.
 
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I was thinking about this as well and I also kind of agree.
From a financial point of view it seems hard to beat a system where 1 MD supervises 4 CRNAs. That is a huge money savings, which is what CEOs and policymakers look for. I doubt patient safety is the top priority for them. The model will become even more lucrative when there is an oversupply of CRNAs since their salaries will go down. Having the MD supervise makes it seem "safe" and you can always blame the MD if something goes wrong. Thus, I don't see the malpractice for CRNAs going substantially up.
 
to scudrunner:
Point taken... I'll tone down the rhetoric now that I've gotten a few responses and I know people will at least open the thread... I've edited the original post.

to michigangirl:
I'm really sincere in my plea for another outlook at the end of my post. I may very well still choose anesthesiology, but perhaps what people like you need is exactly for people like me to be scared away. Money is NOT the only issue, but I can't help but believe that the "headaches" are a little easier to bear when you feel as though you're being financially appreciated for your YEARS of training

to JamesBond15:
I'm most concerned about a system wherein the CRNAs need no supervision or the surgeon is the "supervisor"
 
How is a physician anesthesiology group that can contribute in the ICU, run an acute and chronic pain service, and manage and supervise every possible anesthetic in a hospital (ACO) ever going to become a "cheap commodity"
 
There is very little certainty in the world today. Who knows, probably there never really has been, and it just seems that things are so precarious today.
So, it's hard to predict the future in terms of supply/demand. Sure, one can look at statistics, but there are so many variables that can impact any given profession that it's very difficult to gauge opportunities in the longer term.

I feel that anesthesiology is a great career path. I've seen several different ways in which the ACT model is "managed". My conclusion is that much of the future is up to US. It will take leadership to steer things in the right direction, at any given institution, including PP.

I also don't really think it needs to be "anesthsiology or bust". It's perfectly normal to have several medicine career paths which you could see yourself enjoying, and thus being happy. So, if you have LESS concerns with respect to other fields, then so be it. Maybe those would be better choices for you.

I do think, however, that this debate (a fact) has been raging for over a decade, and things are still going pretty well from what I can tell. So, try not to get too bogged down in the rhetoric.

In my opinion, with the right kinds of people continuing to enter our profession, this will produce the necessary leadership which will help gaurantee that our field is best represented, and this can take many forms, perhaps most importantly at the "grass roots" level, right there in any particular hospital. I know this doesn't help you in your search, but for those whom have already commited to the profession, this should offer some reassurance. It's up to us.
 
My experience is that medical students like absolutes and are generally risk averse compared to folks from other professions like sales, finance, etc. Hell, students will freak out during the match process because statistically, they only have enough programs ranked to have a 96% chance of matching. That sort of certainty is almost unheard of outside of a medical career, as is the certainty of ALWAYS having a job that at least will keep you in the top 10% of income earners in the country. I don't see much change in that, but currently the procedure-heavy specialties are giving better return, and I sympathize with your questioning whether that will continue.

Who knows? Very hard to predict even 10-20 years out, much less 30-40 years out to the end of your career. Personally, I'm not that worried about a widespread CRNA-only model becoming the norm in this country. I think those of us who are younger in the field see the reality of what a small minority of CRNAs in Park Ridge, IL, are pushing for, and we're willing to step up to the plate with our time and wallets to keep that from happening. Besides, it's hard to tell as a student, but if you work long enough with CRNAs, you'll learn the following:

1) Most CRNAs really don't WANT any more responsibility than they currently have and are perfectly happy punching the clock and letting the "MDA" take the final responsibility.

2) Hardly any (if any at all) surgeons actually want to take the responsibility of something they know virtually nothing about--that being anesthesia. They may think it sounds like a great cost-saver at first, but once the trial attorneys catch wind of it and they start getting sued for CRNA errors, it won't seem so great.

3) Finally, you'll see that there's a big spread of competence for all providers: physicians and nurses alike. Problem is, the bottom half of the bell curve goes a LOT lower for the CRNAs than it does for physician anesthesiologists. That much is inevitable based upon the initial pool from nursing school, the FAR fewer hours of training in "anesthesia school" vs residency, and the vast differences in background knowledge when it comes to human pathology, physiology, pharmacology, etc. There are definitely some top CRNAs who I would trust handling my anesthesia care alone for a simple case (as I am currently an ASA 1), but these are few and far between--and my pickings would be even slimmer as I move up in the years and develop more comorbidities.

So bottom line is...IF the CRNA-only model (with no anesthesiologists waiting in the wings) were to truly catch on and become the norm, patient morbidity and mortality during surgery WILL increase. There are TONS of out-of-work JDs out there, so it wouldn't take long for them to catch whiff of that and start the lawsuits. And in the end, it just wouldn't be tolerated. The only possible exception would be among the poorest patients if we do develop a formal two-tier medical system in which basically anyone who can't afford insurance gets PA/NP/CRNA care only and everyone else gets MD/DO care.

Now granted, that might be little solace to someone just starting med school, as they could conceivably come out into the practicing world right at the height of CRNA-only ORs and not have a job and so and so forth. Sure, by the time they're 45 everyone will have likely figured out how bad an idea that was, there will be huge demands for anesthesiologists, and they'll be raking in the dough again. But the timing would be less than ideal to pay back huge student loans.

That's where you have to make educated guesses, because I think it really is just a guess--regardless of the conviction of some people on here.

Personally, I'm OK entering a field in which I know the anesthesia care team is likely going to take over (at least that's how I see it). I'm from a part of the country where it's pretty ubiqutous anyhow, so that was really my first exposure to anesthesiology and what I've come to expect. I don't think it's going to be a field like surgery where the average anesthesiologist is sitting in the room with a patient for 2-8 hours straight during the whole case. I know that model still persists in some states, but I just don't see that being tolerated as financial pressures increase.

But then again, that's not too different than virtually every other specialty, in which the minute-by-minute care of patients is executed by nurses, while physicians make the plans, perform the critical procedures, and come for assistance when **** hits the fan. Even surgery is increasingly moving to a model of having more PAs and RN-first assists in the ORs, and I think it will likely continue to move in that direction as the bean counters figure out it doesn't take 10+ years of training to close up fascia layers. But if a vessel gets nicked or the anatomy is different than expected, you'd better believe I want a residency-trained surgeon ready at a moment's notice!

Of course, those are just my opinions, and you know what they say about a-holes... So you'll have to figure out your own opinion based on the best information out there. I think anesthesia is always going to have the pro and con of being a "doctor's doctor" specialty. We don't have to deal with inpatient care, clinic, recruiting patients, etc. But on the flip side, we don't bring patients to the hospital, nobody really knows what we do or why we're necessary, etc. But in the end, we're a necessary evil, and if hospitals want to take out organs and give people new knees, they need anesthesia staff. They can try the CRNA-only thing if they want--and some might, but ultimately it will bite them in the ass by way of lawsuits, patient deaths, increased complications, etc., and they'll have to go back to the drawing board and figure out some way to get the money to pay us.

And sure, I do think anesthesiology is one of those fields that not all med students get much exposure to. And it's very difficult when a student is just watching a case to see what anesthesiologists do and how valuable their services are. It's kind of like explaining to someone who goes to see a movie exactly what a "best boy grip" is or any other behind-the-scenes job that runs along the credits. But once you even get your feet wet in the field, you'll see how much goes into it and that it really isn't just a "commodity" that can be filled by anyone with half a brain and a sudoku book. And that will be even more true as our population gets older and older, turning more and more ASA 1/2 folks into ASA 3/4s.

OK...enough spouting off for now. But those are my two cents anyhow.
 
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cfdavid said:
I do think, however, that this debate (a fact) has been raging for over a decade, and things are still going pretty well from what I can tell. So, try not to get too bogged down in the rhetoric.
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Yes! So true! I have some family in both surgery and anesthesiology, and this debate has been going on for multiple decades...seriously. Problem is, every time people try skimping, the reality that we actually need anesthesiologists comes back to the surface, salaries again climb, and everyone runs into the field. Believe it or not, but radiology has had a very similar history. There was a time not too long ago where any FMG with passing board scores could get into radiology because it was felt there wouldn't be a need for as many in the future, etc., etc. Medical specialties all have their ups and downs and are cyclical in nature.

Another funny thing I was told by a physician who inspired me early in my education. He was a semi-retired pathologists who taught part-time at my undergraduate university. He's now probably in his late 80s, so he's been around for quite some time. When I asked him about the "future of medicine" and such, he told me a story about how when he was a kid and told his primary care doc that he wanted to pursue medicine, the guy responded like this: "Don't do it! They've got this thing called Medicare coming down the pipe, and it's going to turn medicine into an entirely socialist-run system and our salaries are going to tank."

The socialism thing obviously might have some truth to it, but nonetheless, physician salaries soared in the 20-30 years immediately following passage of Medicare. So who knows how things will work out?
 
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jackdaniels2010 said:
Yes! So true! I have some family in both surgery and anesthesiology, and this debate has been going on for multiple decades...seriously. Problem is, every time people try skimping, the reality that we actually need anesthesiologists comes back to the surface, salaries again climb, and everyone runs into the field. Believe it or not, but radiology has had a very similar history. There was a time not too long ago where any FMG with passing board scores could get into radiology because it was felt there wouldn't be a need for as many in the future, etc., etc. Medical specialties all have their ups and downs and are cyclical in nature.

Another funny thing I was told by a physician who inspired me early in my education. He was a semi-retired pathologists who taught part-time at my undergraduate university. He's now probably in his late 80s, so he's been around for quite some time. When I asked him about the "future of medicine" and such, he told me a story about how when he was a kid and told his primary care doc that he wanted to pursue medicine, the guy responded like this: "Don't do it! They've got this thing called Medicare coming down the pipe, and it's going to turn medicine into an entirely socialist-run system and our salaries are going to tank."

The socialism thing obviously might have some truth to it, but nonetheless, physician salaries soared in the 20-30 years immediately following passage of Medicare. So who knows how things will work out?
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Ponzi schemes seems like a good deal at the start. Those who get in early may even make some money. But, in the end it falls apart.

It all comes down to "Timing" just like the stock market. For example, just take a look at JDSU. The stock went from $1 to $99 then back to $1. Now it is $25. Timing. Same thing for Anesthesiology. The question is are we closer to $1 or $99. My hunch is we are at $99 and have a long way to fall. Risk/Reward profile must be performed by the purchaser which in this case is the Medical Student.

Picking a specialty is somewhat similar to choosing which stock you think will be a "winner" over the next 20 years. Look at Fundamentals, Competition, Growth, Necessity, etc.
I would not be a buyer of "Anesthesiology" here. I am not alone in that conclusion as the most lucrative private practices have "cashed out" recently by selling to corporations. There are always two sides to a trade: A buyer and a Seller. Unfortunately, only one of them usually makes money.


http://finance.yahoo.com/echarts?s=...pe=line;crosshair=on;ohlcvalues=0;logscale=on
 
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http://finance.yahoo.com/echarts?s=...=on;ohlcvalues=0;logscale=on;source=undefined

Amazon.com Another Stock that went from $2-3 to $100 then back to $3.
But, Amazon adapted and grew its business. Today it is $180.

Perhaps, you the Medical Student think Anesthesiology is like Amazon? That it can innovate and adapt to the new environment. The decision is yours and yours alone to make.

Commoditization
Movement toward perfect competition; the process by which a good or service thought to be unique or superior becomes like other, similar goods and services in the eyes of the market. Commoditization is the movement toward undifferentiated competition between two or more companies offering the same good or service. This leads to lower prices.
 
BLADEMDA said:
It all comes down to "Timing" just like the stock market. For example, just take a look at JDSU. The stock went from $1 to $99 then back to $1. Now it is $25. Timing. Same thing for Anesthesiology. The question is are we closer to $1 or $99. My hunch is we are at $99 and have a long way to fall. Risk/Reward profile must be performed by the purchaser which in this case is the Medical Student.
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Point taken. With that logic, though, I'd honestly have to think twice about going to medical school at all at this point. A lot of these issues that we're talking about I don't think are exclusive to anesthesia. I think as things are progressing, I would feel more hesitant about recommending medical school at all to anyone unless they have family who can pay their entire tuition.

And what you're suggesting is why I'm going to be damned sure to pay off my loans ASAP upon finishing residency/fellowship. Then let the chips fall where they may.
 
jackdaniels2010 said:
Point taken. With that logic, though, I'd honestly have to think twice about going to medical school at all at this point. A lot of these issues that we're talking about I don't think are exclusive to anesthesia. I think as things are progressing, I would feel more hesitant about recommending medical school at all to anyone unless they have family who can pay their entire tuition.

And what you're suggesting is why I'm going to be damned sure to pay off my loans ASAP upon finishing residency/fellowship. Then let the chips fall where they may.
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Would you still be an anesthesiologist and love your job if you were making 175k a year? if the answer is yes, then do it.
 
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"Low-end consumers of anesthesia services regard the ability to safely produce a deeply sedated or anesthetized patient who is happy at the end of the procedure as a commodity, where the key differentiators—compensation and fit with the procedure area workflow—boil down to cost. "

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


http://www.asahq.org/Washington/PM20...LEMAUPDATE.pdf
 
karizma098 said:
Would you still be an anesthesiologist and love your job if you were making 175k a year? if the answer is yes, then do it.
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Yes, personally. But do I think it's worth the roughly $200k debt load (with accumulating interest on top for most folks) to do it? Probably not. As long as I can at least sneak through and still make a bit more than that for a couple years to pay off my loans, I'd be happy.

And I can't imagine I would EVER recommend anyone to go into primary care or general peds unless they had someone to pay for their med school. It's an indentured servitude system this country has set up, and it's a losing deal for the servants, IMHO. That $150k salary gets dried up pretty quick when you have $2-3k monthly payments to make on your loans.
 


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

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

If the government isn't willing to pay any more money for the HIGH END product vs. the LOW END product who is willing to sell them the high end product? How long can the seller of the high end product stay in business once the PRIVATE BUYERS no longer pay a premium for the high end product?
 
"Anesthesiology is at a crossroads. In some settings compensation outstrips revenue, supported by stipends to anesthesia groups from hospitals"


"If a less expensive, albeit less capable but still sufficient, alternative becomes available, will commodity users of anesthesia care pay extra for the super-capable product? Experiences from other industries say no. Ongoing rising cost of the available high-end product will motivate the search for lower cost alternatives and whet the payers’ appetites for implementation
 
BLADEMDA said:
"If a less expensive, albeit less capable but still sufficient, alternative becomes available, will commodity users of anesthesia care pay extra for the super-capable product? Experiences from other industries say no. Ongoing rising cost of the available high-end product will motivate the search for lower cost alternatives and whet the payers’ appetites for implementation
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I guess what it boils down to is whether the American public (whether that be the government, privately insured individuals, or wherever healthcare goes in this country) considers the "less capable" product "still sufficient."

People are generally scared to death of surgery as it is. All it takes are a few 20/20 specials about people dying at CRNA-only practices to refresh the public memory and make the public NOT consider this alternative sufficient.

Of course, if all health care becomes government-run like a big VA system and is entirely unresponsive to public desires, then I guess that's one thing. But if it comes to that and there truly is NO privately insured base out there, then I think we've got bigger fish to fry and anesthesia is in no different a boat than any other medical specialty.
 
jackdaniels2010 said:
I guess what it boils down to is whether the American public (whether that be the government, privately insured individuals, or wherever healthcare goes in this country) considers the "less capable" product "still sufficient."

People are generally scared to death of surgery as it is. All it takes are a few 20/20 specials about people dying at CRNA-only practices to refresh the public memory and make the public NOT consider this alternative sufficient.

Of course, if all health care becomes government-run like a big VA system and is entirely unresponsive to public desires, then I guess that's one thing. But if it comes to that and there truly is NO privately insured base out there, then I think we've got bigger fish to fry and anesthesia is in no different a boat than any other medical specialty.
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Disagree. Anesthesia has the AANA claiming CRNA=MDA. This may reduce Anesthesia to "Nursing Level Duty" while leaving most other specialties as "Physician level" work.
 
karizma098 said:
Would you still be an anesthesiologist and love your job if you were making 175k a year? if the answer is yes, then do it.
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Agree. But, you won't be satisfied at $175K per year unless you have the following:

1) no debt
2) trust fund or large inheritance
3) spouse who earns over $100K
4) LOW EXPECTATIONS
 
BLADEMDA said:
Disagree. Anesthesia has the AANA claiming CRNA=MDA. This may reduce Anesthesia to "Nursing Level Duty" while leaving most other specialties as "Physician level" work.
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Right, so I guess that goes back to the original question regarding whether the alternative is sufficient. Do you believe the AANA with their claim? Obviously, I can call Gary, Indiana, the Paris of the Midwest all day long if I want. Doesn't mean it actually is.

Do you believe their claim and think there would be absolutely no difference in surgical morbidity and mortality in this country if every anesthetic were provided solely by CRNAs?

If so, then why did you go to med school and slug through residency?

And if you DO think there would be a difference, then the question is whether that would be considered acceptable to the American public?
 
Remember that just like the stock market it takes TWO parties to make a trade: A buyer and a seller.

The Medical Student must decide whether to buy into an Anesthesiology career. Academia is the seller here. The buyer can choose to go elsewhere. However, if enough Medical Students decide to avoid Anesthesiology Academia will simply "lower the price" by importing IMGs to fill their spots.

This will in turn lower quality further enhancing the competition's argument that equivalency has been reached in Anesthesia between MDA and CRNA.
 
jackdaniels2010 said:
Right, so I guess that goes back to the original question regarding whether the alternative is sufficient. Do you believe the AANA with their claim? Obviously, I can call Gary, Indiana, the Paris of the Midwest all day long if I want. Doesn't mean it actually is.

Do you believe their claim and think there would be absolutely no difference in surgical morbidity and mortality in this country if every anesthetic were provided solely by CRNAs?

If so, then why did you go to med school and slug through residency?

And if you DO think there would be a difference, then the question is whether that would be considered acceptable to the American public?
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There are differences between Nursing and Physician providers. Lots of differences.
Proving them is another thing entirely. Up to this point Academia has showed little interest in this research area of Anesthesia.
 
To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration of anesthesia occur at a paltry rate of 1/250,00 cases nowadays. This remarkable improvement can be attributed solely to technical improvements in the monitoring of patients during a procedure. Things like continuous pulse oximetry, end tidal CO2 monitoring, and fiberoptic-based intubation equipment have almost completely eliminated major morbidity from the profession. This is a good thing. But maybe not so good for anesthesiologists. They practice in a very algorithmic, checklist-based manner.
Thus, it was relatively easy to teach their methods to CRNA’s during a period when the exponential rise in operative case loads made it necessary to incorporate “anesthesiology assistants” into a practice, thereby allowing one attending physician to cover multiple rooms. That recent studies have confirmed what everyone else in the OR already knew—that it didn’t really matter who was behind the drape while a cholecystectomy was ongoing—- is hardly a surprise. The less variability in clinical excellence one sees from certain specialists, there seems to be a commensurate decrease in perceived prestige. In other words, one’s individual reputation as a doctor can be paradoxically harmed when the overall complication rate of your chosen specialty is so low. You are seen as a mere “cog in the machine”, a cog that could easily be interchangeable with another doctor or, in this case, a CRNA.




Jeff Parks, MD
 
Blade, if you were a medical student today (with 200K debt), would you go into Anesthesiology? What other fields would you consider?
 
BLADEMDA said:
There are differences between Nursing and Physician providers. Lots of differences.
Proving them is another thing entirely. Up to this point Academia has showed little interest in this research area of Anesthesia.
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True. And as has been discussed ad nauseum, there are a lot of reasons WHY such research is difficult. Though whether it's "impossible" is up for debate.

I guess I'm looking at this from a more risk-accepting standpoint. I'm very early in my career but will at least be making enough in a couple years to start doing some real damage to my loans and quickly pay them off. I'm willing to let more and more institutions move to the CRNA-only model, where there's absolutely no backup. And full-service hospitals, not just outpatient plastic surgery centers and places filled with healthy patients.

Though I would PREFER to find a way to prove this without having people die, I am willing to bet that if this is the way folks go, I may see a salary drop during the whole MD=CRNA experiment, but eventually, the experiment will be dropped as too many people suffer serious consequences during surgery to the point that it becomes unacceptable to the general public.

My hope is that enough of us in the field (as I said, especially those of us currently in residency and recent graduates) get on the ball and see things as they are--preventing the deaths and complications that would inevitably occur.
 
BLADEMDA said:
The Medical Student must decide whether to buy into an Anesthesiology career. Academia is the seller here. The buyer can choose to go elsewhere. However, if enough Medical Students decide to avoid Anesthesiology Academia will simply "lower the price" by importing IMGs to fill their spots.

This will in turn lower quality further enhancing the competition's argument that equivalency has been reached in Anesthesia between MDA and CRNA.
Click to expand...

I think this will be less of an issue moving forward now that med school spots have increased. I believe the recent stats showed even IMGs wanting to go into internal medicine are starting to feel the pinch.
 
BLADEMDA said:
To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration
....
cog that could easily be interchangeable with another doctor or, in this case, a CRNA.

Jeff Parks, MD
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Yeah, I've seen a few other quotes by Dr. Parks, the "Buckeye Surgeon", a private practice general surgeon in Ohio.

Fine, I'm willing to let him be a part of the grand experiment, too, and be the only doctor in the room when **** hits the fan and the cogs don't know what to do.
 
badasshairday said:
Blade, if you were a medical student today (with 200K debt), would you go into Anesthesiology? What other fields would you consider?
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No.

1) Neurosurgery- top income despite bad economy
2) ENT
3) Ortho
4) Interventional Radiology
5) Invasive Cardiology with EPS/Ablation/AICD Fellowship
6) Urology
7) Ob/Gyn
8) Retinal Specialist
9) Dermatology
10) Hand Surgery


Items 7-10 just aren't my cup of tea. I also left off Plastic Surgery because its Plastic Surgery.
 
jackdaniels2010 said:
I think this will be less of an issue moving forward now that med school spots have increased. I believe the recent stats showed even IMGs wanting to go into internal medicine are starting to feel the pinch.
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Another reason why Academia just doesn't care. There will always be another Medical Student to fill that empty spot.
 
badasshairday said:
Blade, if you were a medical student today (with 200K debt), would you go into Anesthesiology? What other fields would you consider?
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The richest doctors I know (who earned their own money) either own a surgical center (at least part owner) or are Neurosurgeons. Funny thing is 4 years ago the richest doctors were Plastic Surgeons.

Ortho guys and Invasive Radiology do very well right now.

Gi Docs are also making a fortune off of Surgicenter fees combined with EGD/Colons all day.
 
BLADEMDA said:
Gi Docs are also making a fortune off of Surgicenter fees combined with EGD/Colons all day.
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What do you think about GI's future with the increasing utilization of the "nurse endoscopist"? I'm sure the "access to care" bean counters will be jumping all over this one soon enough...

http://fightcolorectalcancer.org/re...an_perform_colonoscopy_safely_and_effectively

And very similar to the whole CRNA=MD thing, here's a nice, tidy study that shows there's "no difference":

http://www.springerlink.com/content/44413h4282827310/

That was published in 2009. Obviously, I'm sure the EUS/ERCP guys are safe for the time being, but is it possible that 10 years from now, virtually all screening colonoscopies (which are a HUGE part of the GI business) will be performed by nurse endoscopists? And that eventually they'll be claiming equivalence and opening up their own screening centers, etc.

Oh yeah, that study's already been done, too:

http://www.ncbi.nlm.nih.gov/pubmed/11847716
 
Last edited:
BLADEMDA said:
Agree. But, you won't be satisfied at $175K per year unless you have the following:

1) no debt
2) trust fund or large inheritance
3) spouse who earns over $100K
4) LOW EXPECTATIONS
Click to expand...

Agree entirely--and about medicine in general and not just anesthesiology. I was amazed when talking to third-year students on a recent rotation how much medical school education has risen to even in just the few years since I was starting down that road. And I read somewhere on the AAMC website that it's estimated to be an average of roughly $250,000 in tuition ALONE by 2020--which would push the initial debt load for someone starting residency up to about $360k or so once you factor in living expenses, books, testing fees (which are ridiculous), interview expenses, etc. By the time you finish a 5-year residency/fellowship (just picking an average number), that will be about $500,000+ in debt. At 6.8% (the current fixed government student loan rate last I checked), that's $34,000 in interest each year alone!

Let's see how far that $175k paycheck takes you when you get to keep about $100k after taxes and then have to pay about $45k a year to pay down your debt in a semi-reasonable amount of time.

If medical school costs cannot be contained, the future of medicine is going to be reserved for those with parents wealthy enough to pay for all or most of their children's undergraduate and medical school expenses or for those with absolutely no financial sense whatsoever.

There are already many of the latter among our ranks, and hence the indentured servitude. Doctors--especially primary care--are going to have to work to death until ripe old ages to pay off all these loans.
 
Agree with one of the above posters, CRNAs are mostly happy with punching the clock and going home. They don't want attending level responsibility and don't want to take call. In the end, they are still nurses and use unions to protect their lifestyle unlike physicians (limited duty hours, lunch breaks, etc.).

Also, while hospitals and the government are looking for cheaper options to supply healthcare, one can't forget what the cheapest provider of healthcare is: the resident. A CRNA will get paid 2-4x more than a resident for less hours. Its cheaper to staff attendings and residents with some CRNAs than to have an entire department of CRNAs and attendings. A CRNA will not be teaching anesthesiology to a resident, so certainly after residency there will academic attending jobs remaining. And as for private practice, its unlikely these are suddenly going to become the domain of CRNAs.

The number of residency spots in anesthesiology increases every year because of likely future shortages in the field. This deficit is not going to be plugged in by CRNAs alone.

I think people are concerned about no longer being able to do a residency and then go work at a GIs outpatient office and bank. This may be so. But we are nowhere near anesthesiology becoming a dead specialty. There will be hospital based and private practice for a long time. Its going to become increasingly important to spend that extra year doing a fellowship afterwards: things like pediatrics, regional, cardiac, OB/GYN, pain, critical care are all going to stay relatively safe from CRNAs.
 
xbulletin said:
Agree with one of the above posters, CRNAs are mostly happy with punching the clock and going home. They don't want attending level responsibility and don't want to take call. In the end, they are still nurses and use unions to protect their lifestyle unlike physicians (limited duty hours, lunch breaks, etc.).
Click to expand...

Yep, I'm only a resident, and I've already seen plenty of that. There is a VERY small minority of CRNAs who want to go out to BFE, start their own practice, and run a CRNA-only group for more cash. Granted, they exist, and we can debate whether they should all day long. But by and large, there's more noise about this coming out of Park Ridge than from typical CRNA lounge.

CRNAs are by definition nurses and by the time they are practicing as CRNAs have spent at least 6 years in nursing/CRNA school and a couple years or more in an ICU nursing environment. That's a full decade or more to fully internalize the attitude that work is 40 hours a week, overtime pay if more than that, hand the patient off no more than 5-10 minutes after the end of shift, mandatory morning and lunch break, etc. When you work in the wards during a nursing shift change, try to find one who isn't hurriedly signing out their patient regardless of what's going on. They became nurses because this is EXACTLY what they wanted out of their careers.

Physicians, on the other hand, are professionals who are paid by some combination of salary, bonuses, and profit sharing. Aside from ER docs, none of us has ever worked in a shift environment, and this is foreign to us. We spent four years in med school, where students stayed until they were told to leave. 4-5 years in post-grad training working 60-90 hours per week, frequently staying late and/or not logging hours because there was more work to do and at the end of the day we're the ones who have to do it. You can't change these expectations about career/life balance, professional duty versus punching the clock, etc. overnight. It's a very small minority of nurses who go the CRNA route who want physician hours, lifestyle, and responsibility.

xbulletin said:
I think people are concerned about no longer being able to do a residency and then go work at a GIs outpatient office and bank. This may be so. But we are nowhere near anesthesiology becoming a dead specialty. There will be hospital based and private practice for a long time. Its going to become increasingly important to spend that extra year doing a fellowship afterwards: things like pediatrics, regional, cardiac, OB/GYN, pain, critical care are all going to stay relatively safe from CRNAs.
Click to expand...

Agreed. I think you're right that 10-20 years from now, there are going to be hardly any anesthesiologists (if any) actually sitting on the stool 1:1 performing anesthetics for colonoscopies, cataract surgeries, etc. It just doesn't make financial sense to anyone. I know this HAS been the case in the past, but I think most of us going into the field now have come to expect that we're going to be there either to oversee a number of simpler cases as a supervisor/emergency back-up or we're going to be sitting in the stool or on tighter supervision for the big whacks and with older, more complicated patients.

And I agree that many more of us in training now are consider anesthesiology essentially a "five-year residency" with our future role in mind. Yes, I think it's ridiculous that it's come to all of us having to add a year when there still is such a huge difference in hours of training between the two, but it is what it is.

Getting into this gig, I always assumed to spend most of my time in a hospital setting and not at a 9-4 surgicenter or GI suite.

That said, if it does ultimately come to CRNAs providing anesthesia for these services in an almost exclusive fashion, I can't help but imagine payors are going to take too long to figure this out and reduce compensation accordingly.
 
BLADEMDA said:
No.

1) Neurosurgery- top income despite bad economy
2) ENT
3) Ortho
4) Interventional Radiology
5) Invasive Cardiology with EPS/Ablation/AICD Fellowship
6) Urology
7) Ob/Gyn
8) Retinal Specialist
9) Dermatology
10) Hand Surgery


Items 7-10 just aren't my cup of tea. I also left off Plastic Surgery because its Plastic Surgery.
Click to expand...

Do you see GI listed above?
 
CRNAs taking over our jobs is not the issue. It's the increasing pressure we will face to supervise more and more thereby creating less of a need for supervisors that is the problem. What do we do then?

ProReal January 2009
 
BLADEMDA said:
Do you see GI listed above?
Click to expand...

No, was referring to your comment regarding "some of the richest doctors". Was wondering if you believe there is mid-level encroachment coming soon to the GI world, potentially knocking it off the pedestal a bit of being one of the big internal medicine cash cows--and thus most competitive fellowships?
 
BLADEMDA said:
CRNAs taking over our jobs is not the issue. It's the increasing pressure we will face to supervise more and more thereby creating less of a need for supervisors that is the problem. What do we do then?

ProReal January 2009
Click to expand...

Cut back residency spots, right? The hope would be to time it all correctly, though most likely this won't occur and there will be some hurt in the process.
 
jackdaniels2010 said:
Cut back residency spots, right? The hope would be to time it all correctly, though most likely this won't occur and there will be some hurt in the process.
Click to expand...


Unfortunately the reduction of Residency spots will only put pressure on the market to produce more CRNAs/AAs. Yes, it will help your career and your income but I am not certain it helps the specialty. Regardless, the market forces are likely to drive MD Anesthesiology income down but there is little chance Program Chairs are going to reduce cheap/free labor Anesthesia Residency Positions anytime soon.
 
jackdaniels2010 said:
No, was referring to your comment regarding "some of the richest doctors". Was wondering if you believe there is mid-level encroachment coming soon to the GI world, potentially knocking it off the pedestal a bit of being one of the big internal medicine cash cows--and thus most competitive fellowships?
Click to expand...

You are missing a huge difference between Anesthesia and Gi: Patients choose in advance their Gi doctor. In Anesthesia they show up and they get whoever they get.

Thus, I won't be going to a NP Gi provider anytime in the near future. But, can we say the same when we show up in the O.R for an Emergency operation?


http://www.aanadaily.com/index.php/...esthetist-care-announced-at-business-meeting/
 
There is NO EVIDENCE that there is a safety issue. None, nadda, nix nil. This is nothing more than 'evidence by proclamation'. There have been over 60 studies trying to find some difference in 'safety' between CRNAs and MDAs and none of them have. None. For over 100 years CRNAs have been practicing without MDAs, if there was ever even an inkling that patients were at risk this practice would have ended long ago. However, just the opposite is the case, the practice in expanding and increasing. Hospital admins, surgeons and government are making decisions on the EVIDENCE which shows we are just as good and just as safe doing anesthesia. Continuing to BS about safety just exemplifies the desperation of their group.

As for money. It is 100% about money for the ASA and the MDAs fighting for PAs, AAs and against CRNAs. What else could it be about? They are worried about losing their jobs, being replaced and/or having to actually do anesthesia everyday instead of 'supervise' from an office. The safety issue does not exist so that only leaves one other thing... money. It is no wonder why the ASA and their state groups are the ONLY physician groups really fighting CRNA practice. Surgeons as a group who we work with know full well we do an equivalent job as do our patients.

Militant CRNA
 
BLADEMDA said:
Disagree. Anesthesia has the AANA claiming CRNA=MDA. This may reduce Anesthesia to "Nursing Level Duty" while leaving most other specialties as "Physician level" work.
Click to expand...

Blade I think this is why we will hopefully see many private practice groups start to expand their services they provide to hospitals just as is being seen in academic settings all across the country. By doing this the buyer will clearly see an added value to having a physician anesthesia group. (Pain, cardiac, Regional, critical care, etc..) By doing this it takes the term commodity out of the equation to the buyer.
 
OK, so for all the residents and attendings (other than BLADEMDA) who think that anesthesiology is no longer worth it for someone like me who will be ~$300,000 in debt (before interest) before residency even starts, what other specialties do you recommend?

What do you guys think about psych? Path? Ophtho?

Advice appreciated. Still undecided about my future.

I feel that anesthesiology will eventually rebound, but I have a feeling that we aren't at the nadir yet, and it will take about 15+ years for the "golden years" to return, if they ever will.
 
PistolPete said:
OK, so for all the residents and attendings (other than BLADEMDA) who think that anesthesiology is no longer worth it for someone like me who will be ~$300,000 in debt (before interest) before residency even starts, what other specialties do you recommend?

What do you guys think about psych? Path? Ophtho?

Advice appreciated. Still undecided about my future.

I feel that anesthesiology will eventually rebound, but I have a feeling that we aren't at the nadir yet, and it will take about 15+ years for the "golden years" to return, if they ever will.
Click to expand...

$300k in debt? Wow. Anesthesiology as your career choice with that amount of debt? Maybe Obama will let you work in underserved areas?
Military service?

I could never recommend Anesthesiology in 2017 (your finish date?) owing $300K of debt. You better hope the U.S. Supreme Court overturns Obamacare.

For those with limited resources entering Medical School the Military scholarship route is FINALLY starting to look like a good deal.
 
Flat out the numbers are the average debt that US medical school seniors have at graduation. This includes undergraduate debt (if there is any). This DOES include individuals who have received scholarships, had rich/contributing parents, etc. If you remove students who have had complete or partial aid, then that average would obviously increase. Again, the numbers stated by the original poster, DO include people who borrowed $0 (the denominator in all of these calculations is total graduating US seniors).

Average tuition costs for 4 years (I believe these are 2007 values)
Private: 140,000
Public: 80,000

These two numbers do not include borrowing for living expenses, which can range from 9,000 to 14,000 per year depending upon geography and how the student decides to live.

Here are some more numbers:
Student debt statistics

  • $156,456 – According to the Association of American Medical Colleges (AAMC), the average educational debt of indebted graduates of the class of 2009.
  • 79 percent of graduates have debt of at least $100,000.
  • 58 precent of graduates have debt of at least $150,000.
  • 87 percent of graduating medical students carry outstanding loans.
http://www.ama-assn.org/ama/pub/abou...ent-debt.shtml
 
I didn't have the internet when I was in Medical School. Cell phones didn't exist yet. Hence, I didn't have access to this kind of information when choosing a specialty. You do.

In the real world you need to pay the bills, own a home, drive car, raise a family AND pay back that $300K debt. So, here comes the real FACT checker. Where do you stand in terms of Class Rank? USMLE Board Scores? If you are competitive for those specialties averaging more than $500K per year then the odds favor a good lifestyle even with $300K of debt.

For those that owe less than $100K Anesthesiology isn't going anywhere in the next 20 years and you will earn enough to pay off debt and live comfortably.

Still, if I had know my Medical School Colleague (lower Board Scores and Class Rank) would be earning in excess 1.5 million per year doing Backs/Necks would I still be an Anesthesiologist today? Would you?

Take a look at those Surveys. Choose what you like or what you can at least learn to tolerate for 20 years.
 
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