Is the future looking brighter?

[bronx43]

I didn't think of the other "proceduralist" because I'm quite literally tired from working all night but yes, IR, interventional cards, etc tend to be protected, especially since there's no history of teaching mid-levels procedures so they can cover multiple spots (ahem...anesthesiology) outside of teaching closures. The later fields you speak of I would argue are ripe for the picking it just hasn't happened as fast as anesthesiology. I argue some aspects of anesthesiology (CV, peds) are more protected than being a Generalist, thus the spike in people doing Cardiac and Peds fellowships

I disagree. I would bet money that an independent PA would be doing routine surgery before a midlevel would be interpreting imaging or reading path. *neither will probably happen, but you get the point.
The other specialties have varying degrees of risk, but honestly not that high.

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[deleted171991]

I’ve witnessed IR guys teaching PAs some of their bread and butter procedures and basically leaving the room after timeout. That’s with procedures where anesthesia is involved, so who knows what’s happening on non-anesthesia cases.

Doctors are cowards who allow their employers to bully them into teaching midlevels how to replace them. Teaching midlevels, and all kinds of non-medical students, is now included in the job requirements in many places.

 

[Steve_Zissou]

Doctors are cowards who allow their employers to bully them into teaching midlevels how to replace them. Teaching midlevels, and all kinds of non-medical students, is now included in the job requirements in many places.

Out of curiosity, do you teach non-docs at your job?

 

[deleted171991]

Out of curiosity, do you teach non-docs at your job?

Yes.

 

[pgg]

I think I'd be a poor fit and/or unhappy in most specialties in medicine. In a very real sense, I feel like I escaped to anesthesiology.

I think I'll be satisfied with the paycheck and lifestyle for the duration of my career.

 

[nimbus]

 

[BLADEMDA]

I think I'd be a poor fit and/or unhappy in most specialties in medicine. In a very real sense, I feel like I escaped to anesthesiology.

I think I'll be satisfied with the paycheck and lifestyle for the duration of my career.

The pace of change in medicine is very slow. That means think in terms of decades rather than years. Since I started posting on SDN over a decade ago things have definitely gotten worse. I predicted Physician salaries will eventually settle in at about 20-25% greater than a CRNA. While that level has not been reached YET, I still see that number as the eventual salary level for many Anesthesiologists. In some markets dominated by AMCs, the Anesthesiologist is earning about 30% more than a CRNA for the same type of job (limited call/no call).

I still enjoy the day to day work of what we do and I like the option of cutting back or going part time without any overhead. There are still positives for this field but in the end you need to find a job that can you do for 30 years.

 

[Dejavu]

Go back 10yrs on this forum and You can find people predicting the specialty would be dead within 5-7 yrs.

Anesthesiologist do not equal CRNAs. Anesthesiologist are far superior in skill set and knowledge coming out of training. Once you understand how we are not a commodity you will have a better understanding why this profession will continue to be great.

Go back 42 years and you found people arguing this very topic, with doomsayers all around.

 

[linkin06]

One of my mentors was an old guy. He’s actually married to a CRNA. When I was vacillating over what to apply for (peds vs anesthesia) he said if a hospital started doing all crna, then the rival hospital could just start advertising “we have doctors do your anesthesia.” I heeded that advice. I know for sure now peds was the wrong choice for me. Will see in my next years if it was the real right choice in long run...

 

[AdmiralChz]

One of my mentors was an old guy. He’s actually married to a CRNA. When I was vacillating over what to apply for (peds vs anesthesia) he said if a hospital started doing all crna, then the rival hospital could just start advertising “we have doctors do your anesthesia.” I heeded that advice. I know for sure now peds was the wrong choice for me. Will see in my next years if it was the real right choice in long run...

Hah, I’ve actually seen a very similar ad campaign for an ER in my precious city - “see an actual doctor for your emergency at X hospital” (rather than NP/PA). I wish I had taken a picture.

 

[anbuitachi]

The pace of change in medicine is very slow. That means think in terms of decades rather than years. Since I started posting on SDN over a decade ago things have definitely gotten worse. I predicted Physician salaries will eventually settle in at about 20-25% greater than a CRNA. While that level has not been reached YET, I still see that number as the eventual salary level for many Anesthesiologists. In some markets dominated by AMCs, the Anesthesiologist is earning about 30% more than a CRNA for the same type of job (limited call/no call).

I still enjoy the day to day work of what we do and I like the option of cutting back or going part time without any overhead. There are still positives for this field but in the end you need to find a job that can you do for 30 years.

Here physicians earn 12% more per hour than CRNAs based on hourly rate

 

[deleted126335]

Out of curiosity, do you teach non-docs at your job?

One person can have multiple approaches to teaching learners. There is a difference between teaching and explaining rationale in detail to resident physicians as opposed to correcting midlevel trainees to keep a patient safe. By doing both one may (mostly) be true to their values while not risking their position.

 

[ProRealDoc]

Anesthesia is a cool specialty that will provide you with a great skillset. It typically attracts two types, the ones who enjoy the work and are truly committed to the preservation and advancement of the specialty and those who see it an as exploit to be devalued and sold to the highest bidder (AMCs, megagroups running CRNA mills and abusive PP groups.).

The reimbursement suppression we see on a constant basis in anesthesia and medicine as a whole, it's not by accident. It's the robber barons' ways of hijacking medicine, forcing us to do more with less, train our own competition under the guise of efficiency and pocketing the savings. It's the biggest racket in healthcare.

In the meantime, the efficiency model (training midlevels to do more and maintain income) is biting us in the rearend. This new economic model of healthcare that is being forced upon us, is not necessarily to make a dent on the GDP or provide cheaper care to the patient. It's designed to allow the maximum extraction of financial resources from the current system into the hands of the puppetmasters.

Best recommendation I have for the younger ones going into this field is don't be afraid to go anywhere and get the highest paying job you can and save 50% of your income. In a few years you'll have enough to walk away or go part time if you so choose.

 

[Twiggidy]

It’s hard to ignore money is this field because medical school is so expensive, but the best advice is always to pursue the field you enjoy.

Having said that, i’d make the unpopular argument that if salaries for anesthesiologists decrease to CRNA levels that would be a BAD thing for CRNAs. They should want our salaries to stay high. If all becomes equal in he future then you’ll have a bunch of physicians making the same
as nurses except the physicians are more skilled. Job offers would be in your inbox left and right. It would suck for the doctors’ bank accounts, sure. So is the future bright? Not financially.

 

[BLADEMDA]

I post the same advice year in and year out: If you choose Anesthesiology do a Fellowship in Cardiac, Peds or Pain. Your options are much better overall. If you plan on academics then Critical Care/Cardiac dual combo would be a smart long term career choice.

 

[Twiggidy]

I post the same advice year in and year out: If you choose Anesthesiology do a Fellowship in Cardiac, Peds or Pain. Your options are much better overall. If you plan on academics then Critical Care/Cardiac dual combo would be a smart long term career choice.

Agree. Even at my current private practice a combo cardiac/critical care fellowship would've been useful to me, my group, and the hospital.

 

[Justice4all]

Not to deviate,Team Health retirement plan? W2 but no matching with 401k. Which bitter poison is easier to swallow with all the AMC's?

 

[nimbus]

I still enjoy the day to day work of what we do and I like the option of cutting back or going part time without any overhead. There are still positives for this field but in the end you need to find a job that can you do for 30 years.

This is a very important point. Recently one of our orthopedists was telling me his weekly overhead is $10k so he needs to think twice before taking time off. However he also has ongoing revenue streams (in house PT and imaging) even when he is not actually working.

 

[BLADEMDA]

Not to deviate,Team Health retirement plan? W2 but no matching with 401k. Which bitter poison is easier to swallow with all the AMC's?

Most AMCs have terrible retirement plans. This is one reason to avoid them. Team Health has a non legally secured executive plan which most avoid. They do not match.

Envision offers a match up to $5300-$5500 per year. Mednax is typically matching $5-$15k per year. USAP is probably the best of the worst AMCs.

 

[drdan4]

I post the same advice year in and year out: If you choose Anesthesiology do a Fellowship in Cardiac, Peds or Pain. Your options are much better overall. If you plan on academics then Critical Care/Cardiac dual combo would be a smart long term career choice.

Poor advice. CLEARLY there is NOT enough subspecialty work to support all the people graduating with these fellowships. What do you accomplish by recommending these fellowships? You will supersaturate these already narrow subspecialties, cause a decrease in their reimbursement and the overspill will be competing for General Anesthesia positions anyway. We have 7 fellowship trained recruits in our PP. Six of them have not spent a DAY doing Cardac/Pain/Pain. Waste of a year. Please don't turn Anesthesia into Radiology..there is not enough upside and there is the additional headache of mid levels.

It's a great field and I do want the best and brightest to take care of me and my family. Last thing anyone wants is a bottom of the barrell MD or even worse, a CRNA delivering Anesthesia to their loved ones.

Best way to save the specialty is for new grads to seek MD only practices or PP groups where Docs are in charge of patient safety. Hiding behind a fellowship won't accomplish much in the long run.

 

[deleted925573]

Most AMCs have terrible retirement plans. This is one reason to avoid them. Team Health has a non legally secured executive plan which most avoid. They do not match.

Envision offers a match up to $5300-$5500 per year. Mednax is typically matching $5-$15k per year. USAP is probably the best of the worst AMCs.

USAP made GHA worse. GHA used to be matching plus profit sharing that worked out as twice as much employer contribution vs USAP (one of the many ways USAP made things worse while making nothing whatsoever better)

 

[Twiggidy]

Poor advice. CLEARLY there is NOT enough subspecialty work to support all the people graduating with these fellowships. What do you accomplish by recommending these fellowships? You will supersaturate these already narrow subspecialties, cause a decrease in their reimbursement and the overspill will be competing for General Anesthesia positions anyway. We have 7 fellowship trained recruits in our PP. Six of them have not spent a DAY during Cardac/Pain/Pain. Waste of year. Please don't turn Anesthesia into Radiology..there is not enough upside and there is the additional headache of mid levels.

It's a great field and I do want the best and brightest to take care of me and my family. Last thing anyone wants is a bottom of the barrell MD or even worse, a CRNA delivering Anesthesia to their loved ones.

Best way to save the specialty is for new grads to seek MD only practices or PP groups where Docs are in charge of patient safety. Hiding behind a fellowship won't accomplish much in the long run.

I argue this isn't true. My cardiac fellowship has opened many doors that otherwise wouldn't be there if I hadn't done the fellowship.

 

[Steve_Zissou]

On a random note, worth joining asa as a med student? Or at all?

 

[drdan4]

I argue this isn't true. My cardiac fellowship has opened many doors that otherwise wouldn't be there if I hadn't done the fellowship.

I guess the point of my post is that with twice the number of current Cardiac Fellows those doors may not exist.

 

[VA Hopeful Dr]

As a medical subspecialist, I would say that there are features of both fields which can both attract and impede complete midlevel take over. As you mentioned, anesthesiology is somewhat protected by the high stakes and rapid pace. However, it is also relatively protocolized. The medical specialist, on the other hand, has time to correct errors or oversights should they occur. However, being a patient facing specialty, we are largely protected simply by patient demand, as the vast majority of people (outside of the ghetto or BFE) won't seek out an independent midlevel for specialty care. Primary care and EM? Sure. But not a specialist. Not yet anyways. Midlevels are starting to show up in my field, but most patients want nothing to do with one.

See I'm seeing the exact opposite. Most PCP offices I've seen have at most a single midlevel who does same day acute stuff mainly.

The local medicine subspecialists typically have roughly equal numbers of docs and midlevels.

 

[Twiggidy]

I guess the point of my post is that with twice the number of current Cardiac Fellows those doors may not exist.

Outside of academics, any gig where you're only doing fellowship specific cases are rare and that's not really exclusive to anesthesiology. I was told that during my fellowship and I did my fellowship almost 10 years ago. So this field isn't really turning into radiology in as much as it already is like radiology. This doesn't need to be another "should I do a fellowship" thread because both sides of that argument have been made to exhaustion on this forum.

 

[BLADEMDA]

I guess the point of my post is that with twice the number of current Cardiac Fellows those doors may not exist.

A review of current job postings shows a NEED for Cardiac and Pain attendings with formal training in those fields. If I was a Resident today I would 100% do a fellowship in Pain or Cardiac (peds isn't my cup of tea).

 

[Twiggidy]

A review of current job postings shows a NEED for Cardiac and Pain attendings with formal training in those fields. If I was a Resident today I would 100% do a fellowship in Pain or Cardiac (peds isn't my cup of tea).

Gaswork is flooded with cardiac and pain jobs, they may not all be in the greatest areas but they're on there, and a handful are actually in nice areas.

 

[Twiggidy]

On a random note, worth joining asa as a med student? Or at all?

I say wait until you're an attending but at that point it's only for discount CME IF you can't make the ASA every year. I think the discount over time adds up to the cost of membership. (Personal opinion)

 

[Psai]

Poor advice. CLEARLY there is NOT enough subspecialty work to support all the people graduating with these fellowships. What do you accomplish by recommending these fellowships? You will supersaturate these already narrow subspecialties, cause a decrease in their reimbursement and the overspill will be competing for General Anesthesia positions anyway. We have 7 fellowship trained recruits in our PP. Six of them have not spent a DAY doing Cardac/Pain/Pain. Waste of a year. Please don't turn Anesthesia into Radiology..there is not enough upside and there is the additional headache of mid levels.

It's a great field and I do want the best and brightest to take care of me and my family. Last thing anyone wants is a bottom of the barrell MD or even worse, a CRNA delivering Anesthesia to their loved ones.

Best way to save the specialty is for new grads to seek MD only practices or PP groups where Docs are in charge of patient safety. Hiding behind a fellowship won't accomplish much in the long run.

I am unfellowship trained hire me

 

[2ndyear]

Most AMCs have terrible retirement plans. This is one reason to avoid them. Team Health has a non legally secured executive plan which most avoid. They do not match.

Envision offers a match up to $5300-$5500 per year. Mednax is typically matching $5-$15k per year. USAP is probably the best of the worst AMCs.

I saw an ad for Team Health with the executive retirement plan advertised. I assumed it was extra for medical director, is this not the case?

 

[pgg]

I guess the point of my post is that with twice the number of current Cardiac Fellows those doors may not exist.

The flip side to that is if you want to do cardiac cases, and don't do the fellowship, odds are high you'll be outta luck. We've already reached the point where many places require adv TEE cert to hire and credential people to do hearts. That trend won't reverse. The fellowship trained guy can still do lap choles, though. Who's got the prettier CV?

180+ ACTA positions are filling every year. That barn door has been open a while. Wishing it closed won't be any more effective than wishing the mills would quit churning out CRNAs.

Confirmation bias caveat - I am CT fellowship trained.

 

[deleted162650]

The flip side to that is if you want to do cardiac cases, and don't do the fellowship, odds are high you'll be outta luck. We've already reached the point where many places require adv TEE cert to hire and credential people to do hearts. That trend won't reverse. The fellowship trained guy can still do lap choles, though. Who's got the prettier CV?

180+ ACTA positions are filling every year. That barn door has been open a while. Wishing it closed won't be any more effective than wishing the mills would quit churning out CRNAs.

Confitmation bias caveat - I am CT fellowship trained.

This is precisely the case at my shop. You ain’t gonna be touching a pump case or a kid under 2 unless you’re fellowship trained. Almost makes me wish I’d done that peds fellowship - but then I go back to sipping my IPA instead of being chained to the hospital on peds call and all is right is with the world.

 

[deleted171991]

There is this concept in investing/business called durable competitive advantage. Basically, a company has it if it can raise its prices above its competitors without losing customers. Typical example is Coca-Cola.

In medicine, one can recognize a specialty WITHOUT durable competitive advantage by the fact that its graduates are getting into various fellowships just to get a decent job. Not a better one, but a DECENT one. Examples include radiology, pathology, and the specialties with midlevel encroachment.

Food for thought.

 

[GravelRider]

I don’t think a fellowship opens up more doors or better doors...just different doors. If you’re cardiac trained then you aren’t even going to consider those non-cardiac jobs because then you will have wasted a year and $350k. If anything, it makes your job prospects smaller because you’ll only be looking at cardiac jobs. Do a fellowship if you like that specialty, but not for any other reason. This nonsense that you need to do a fellowship for job security is just that...nonsense. The best job security is to not need the job you have, so spending a year learning to make wise financial decisions and controlling consumption is much better for job security than doing a fellowship.

 

[deleted126335]

This is precisely the case at my shop. You ain’t gonna be touching a pump case or a kid under 2 unless you’re fellowship trained. Almost makes me wish I’d done that peds fellowship - but then I go back to sipping my IPA instead of being chained to the hospital on peds call and all is right is with the world.

Except the peds and cardiac folks will try to leverage their credentials for a bigger piece of the pie for themselves. Has happened in two groups that I have been part of.

 

[deleted162650]

Except the peds and cardiac folks will try to leverage their credentials for a bigger piece of the pie for themselves. Has happened in two groups that I have been part of.

Our cardiac and peds guys gets compensated for the additional call burden they share. The arrangement is fair for both the specialists and generalists. The system has been in place for many years and everyone is happy.

 

[deleted126335]

Our cardiac and peds guys gets compensated for the additional call burden they share. The arrangement is fair for both the specialists and generalists. The system has been in place for many years and everyone is happy.

In one group I used to be part of, the cardiac guys actually split off and got an extraordinary deal. Quite a bit better than the rest.

 

[drdan4]

This is precisely the case at my shop. You ain’t gonna be touching a pump case or a kid under 2 unless you’re fellowship trained. Almost makes me wish I’d done that peds fellowship - but then I go back to sipping my IPA instead of being chained to the hospital on peds call and all is right is with the world.

I don't have a dog in this fight. If every resident wants a Cards/Peds fellowship then more power to them. But understand that these constitute a FRACTION of the Anesthesia job market. Of the 10+ hospitals in a 30 mile radius only one has a heart group (8 guys). And the same is true for Peds. We hired the fellowship guys not for the fellowship but for where they trained as residents because they were all hired through the alumni network.

 

[deleted162650]

In one group I used to be part of, the cardiac guys actually split off and got an extraordinary deal. Quite a bit better than the rest.

Wow, sounds like a pretty crappy group dynamic to lead to that situation in the first place. It wouldn’t be possible with our exclusive contract and non-compete as it’s currently written. We also don’t have the cardiac volume to support guys doing only hearts. All our sub specialists do considerably more general work than sub specialty specific cases.


I know at Norfolk General they have a separate group that covers hearts.

 

[bronx43]

See I'm seeing the exact opposite. Most PCP offices I've seen have at most a single midlevel who does same day acute stuff mainly.

The local medicine subspecialists typically have roughly equal numbers of docs and midlevels.

It's honestly dependent on geography.
Where I am (30-45 minutes outside of a large city in the South), there are literally hoards of independent primary care clinics OWNED and RUN by mid-levels. They are "supervised" by a physician that may be located 20 miles away and are reachable by phone.

 

[Dr.Jekyll75]

Not to steal the Cards fellowship talk but how is Obstetric and critical care fellowship compensated compared to cards?

 

[Twiggidy]

Not to steal the Cards fellowship talk but how is Obstetric and critical care fellowship compensated compared to cards?

OB depends on the payor mix. If you're doing epidurals in a predominantly Medi-caid population, then you're basically working for free. If you're in Silicon Valley where everyone has tech company health insurance then if the OB service is busy you can make more money hand over fist.

Critical care docs are usually paid a hospital stipend and the anesthesia trained docs will supplement with OR work while the medicine trained do with pulmonary clinic.

 

[psychbender]

Not to steal the Cards fellowship talk but how is Obstetric and critical care fellowship compensated compared to cards?

Straight ICU doesn't pay half bad (I've seen $350-400k in suburban/ruralish areas in the east coast), but the hours can suck. Lots of places doing 12 hour shifts, with 7-on/7-off, mix of days and nights. Big ICUs with lots of procedures and production bonuses can pay more. A mixed practice is highly variable in terms of hours, workflow, and compensation, and difficult to find outside if academics (they exist, I'm in one, but they're not the norm).

Sent from my SM-G930V using SDN mobile

 

[Section31]

I’m really sick of the doom and gloom scenarios. My father is a physician, and I can remember his friend telling me around 1993 that anesthesiology was a “dying field”. I was in grade school at the time.

Well guess what, it’s 25 years later and anesthesiology is still one of the highest paying fields of medicine. I live in a beach town, and if anything we have a SHORTAGE of both anesthesiologists AND CRNAs. This is true in large portions of the country as baby boomers retire. Both MDs and CRNAs continue to command exceptionally high salaries.

The negative outlook is a classic case of “grass is always greener” combined with response bias.

I would be willing to bet anyone on this board $10,000 that in 15 years, the median anesthesiologist salary will be HIGHER than it is today, even adjusting for inflation.

To give you some perspective if you’re a medical student still choosing, I make 33-45% more than my brother who is a very well compensated ophthalmologist.

So all these people can speak of doom and gloom, but it’s reminiscent of the Middle Ages, when scores of false prophets claim the end times were near, only for life to go on.

It’s like that old Seinfeld routine about them constantly making new cars but not making new parking spaces. The US population is expanding at a good clip, but residency class sizes are flat. The population is also aging (making them more surgery prone). Surgery is also the cash cow of all hospitals. Without it, many would go under. Guess what, MDs will always be needed in everything but tiny rural hospitals.

So is the future bright? Does a starting salary of 300-400k sound good? Do you think you can live on that? Are there any major changes coming to healthcare landscape to justify the doom and gloom? Not lately. I’d say if you went into medical school today, over a career of 30 years you will gross pretax $10-15 million. Invest wisely and you’ll have a healthy nest egg by 45.

Don’t let anyone talk you out of anesthesia. It’s the best job there is. It’s very well compensated. Even if it became slightly less compensated it would still be VERY well compensated. No overhead, no advertising, no follow up, only medicine. And then drive home in your Porsche to a wife who is more likely than not absolutely gorgeous. Enjoy getting out of work the same time your kids are getting home from school, so you see them grow up. Your kids will be rich, intelligent, and likely physically attractive given the wife. That’s a recipe for being popular. I was the worlds biggest nerd in high school. My daughter was just selected the Prom Queen.

Anesthesiology is the career most consistent with the American Dream. Just avoid the booze, don’t somehow get addicted to drugs, and don’t have affairs. Those are the only things that will make it fall apart.

 

[Southpaw]

And then you have the overly optimistic....

 

[Section31]

And then you have the overly optimistic....

Cynicism... how boring.

 

[nimbus]

I’ve witnessed IR guys teaching PAs some of their bread and butter procedures and basically leaving the room after timeout. That’s with procedures where anesthesia is involved, so who knows what’s happening on non-anesthesia cases.

What procedures?

 

[GravelRider]

What procedures?

Ports being the most notable.

 

[Southpaw]

Cynicism... how boring.

Anesthesia is great, for a certain mindset. Same for every medical field. As far as jobs go, just about EVERY medical field is a great decision. But it's still a job. We all trade time for money. It ain't pro baseball or golf. Like WCI says, if money weren't a factor any longer, I imagine every poster here would either be working less than they do now or not at all.