My Persepective on Fellowships/Academia/Anesthesia

[BLADEMDA]

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IPS and Quality
Mortality rates are significantly lower in hospitals with closed ICUs managed exclusively by board certified intensivists. Dr. Peter Pronovost, an intensivist at the Johns Hopkins Medical Institutions, conducted a systematic review of the existing literature regarding ICU physician staffing and quality. He found that high intensity staffing (ICUs where intensivists manage or co-manage all patients) versus low intensity staffing (where intensivists manage or co-manage some or none of the patients) is associated with a 30% reduction in hospital mortality and a 40% reduction in ICU mortality.
This data suggests that over 54,133 deaths that occur in the ICU could be avoided if The Leapfrog Group IPS Safety Standard were implemented in all urban hospitals with ICUs across the US.1 Studies have also demonstrated a reduced hospital and ICU length of stay with high intensity versus low intensity staffing

 

[BLADEMDA]

What we need is that kind of ICU data for our ASA 3-5 patients. It makes no sense to think that a CRNA would have the same outcome on a sick patient (follow outcomes for 24 hours) as a Board Certified Anesthesiologist. Such Solo CRNA care is likely to be inferior and result in higher morbidity/mortality.

The problem is we don't have that data at this time. Solo CRNAs stick to rural USA and smaller hospitals where it is difficult to get accurate data on the "sicker" patient population. Hence, unless the ASA endoses a real study at large hospitals we won't ever get that data. The stuff that the AANA publishes is bogus, biased and unreliable because it is purely agenda driven data.

So, for the foreseeable future Critical Care, Pain and high risk peds are the areas safe from the Solo CRNA. Cardiac with advanced TEE is safe today but will likely "fall" into the grubby AANA hands over the next ten years.

Blade

 

[ProRealDoc]

You should read this month's ASA Newsletter (Sept. 2009) pages 10 and 11.

Can someone post a link?


"For the present, however, there is a conspicuous and somewhat inexplicable disconnect between the practice of anesthesiology and that of critical care, and anesthesiology critical care today remains a largely academic pursuit confined mostly to university medical centers. Indeed, while 15 percent of academic anesthesiology chairs in this country are members of the American Society of Critical Care Anesthesiologists www.ascca.org, only 2
percent ot the greater ASA physician membership belongs to this group. As the articles in this issue of the NEWSLETTER attest, the achievements of critical care anesthesiologists are substantial, and it is arguable that pur collective contributions have been proportionally greater than our numbers might suggest. Given the likely decline in demands for O.R. services and the unique capacity for our specialty to evolve and fulfill the increasing demand for critical care, now is an opportune time to evaluate anesthesiology's present lack of engagement and to consider ways in which we might become more involved in the future. From the perspective of where we are "going to be," this analysis is particularly relevant for anesthesiology trainess and practitioners who will be active health care providers in 2025 and beyond."

Walter Boyle, MD. FCCM
ASA Newsletter Sept. 2009

Here you go

http://viewer.zmags.com/publication/9960917c#

 

[ProRealDoc]

What we need is that kind of ICU data for our ASA 3-5 patients. It makes no sense to think that a CRNA would have the same outcome on a sick patient (follow outcomes for 24 hours) as a Board Certified Anesthesiologist. Such Solo CRNA care is likely to be inferior and result in higher morbidity/mortality.

The problem is we don't have that data at this time. Solo CRNAs stick to rural USA and smaller hospitals where it is difficult to get accurate data on the "sicker" patient population. Hence, unless the ASA endoses a real study at large hospitals we won't ever get that data. The stuff that the AANA publishes is bogus, biased and unreliable because it is purely agenda driven data.

So, for the foreseeable future Critical Care, Pain and high risk peds are the areas safe from the Solo CRNA. Cardiac with advanced TEE is safe today but will likely "fall" into the grubby AANA hands over the next ten years.

Blade

I agree. The monkey skills that a CRNA has are useless in a critical care environment. Thinkers not technicians is what's needed in that environment.

 

[badasshairday]

So, for the foreseeable future Critical Care, Pain and high risk peds are the areas safe from the Solo CRNA. Cardiac with advanced TEE is safe today but will likely "fall" into the grubby AANA hands over the next ten years.

Blade

When you say that Cardiac is safe today but likely to fall into the AANA territory, do you mean they would be providing the anesthetic solo? It seems unlikely since it seems that cardiac patients would have more risks and be ASA2-4's.

 

[Pilot Doc]

What we need is that kind of ICU data for our ASA 3-5 patients.

Would that really help? What percentage of anesthesia units are generated by ASA III-V patients nationally. It can't be a very big percentage.

Put another way, even if we "save" the ASA III-V patients from low/no supervision CRNA care, the anesthesiologist job market would crater if solo CRNA became std of care for ASA I-II.

 

[BLADEMDA]

Would that really help? What percentage of anesthesia units are generated by ASA III-V patients nationally. It can't be a very big percentage.

Put another way, even if we "save" the ASA III-V patients from low/no supervision CRNA care, the anesthesiologist job market would crater if solo CRNA became std of care for ASA I-II.

Probably True but many more ASA 3 these days. About 50% of my caseload is ASA 3 and 4.

 

[BLADEMDA]

When you say that Cardiac is safe today but likely to fall into the AANA territory, do you mean they would be providing the anesthetic solo? It seems unlikely since it seems that cardiac patients would have more risks and be ASA2-4's.

Cardiac Patients= ASA 4 and some 3's (less than 0.5 percent are a 2)


Yes, eventually the AANA will move into Cardiac/TEE territory and claim equivalency. They are a two week Fellowship away😱

 

[IDBasco]

Probably True but many more ASA 3 these days. About 50% of my caseload is ASA 3 and 4.

As a med student it seems reasonable to assume that with the large baby boomer population and the growing number of obese people with comorbidities that this number would be on the rise, yes?

 

[Pilot Doc]

Probably True but many more ASA 3 these days. About 50% of my caseload is ASA 3 and 4.

Let's assume your caseload is typical of anesthesia as a whole.

If the I-II patients go to solo CRNA, 50% of anesthesiology manpower becomes surplus. You estimate earlier that there are 40K MD's nationwide. That means that 20,000 are now surplus. Assume 10,000 simply leave the job market. Also assume that 50% of residency programs immediately close so that they supply an appropriate number of grads to the market (500/yr or so) If 1000 docs retire each year it takes 40 years for supply and demand to equal.

Lots of unrealistic and forced assumptions above, but the overall point is this: If ASA I & II patients are ceded to CRNA only, the anesthesiology job market crumples. Defending ASA III-V patients as MD turf is not a viable way to stay safe. Perhaps it's useful as part of a greater plan to shift MD's more into CCM, pain, peds, etc, but alone it would make no difference.

 

[chemist157]

Interesting.

However, I wonder how long it will be until we as periop physicians start 'teaching' CRNAs. Then they too will want to have the skill sets we do (TEE, regional,etc). I feel like they will try to 'learn' more....You guys know how it is, they want to advance their 'nursing' skills. Some idiot docs out there are going to train them so that they themselves dont have to come in,etc.

At my home institution it happens all the time. The doc talks the SRNA through what he or the SRNA is doing and explains to them why. And half the time the SRNA and CRNA don't acknowledge the doc or express any gratitude. And the CRNA "teaching" them looks annoyed. It's infuriating.

 

[BLADEMDA]

As a med student it seems reasonable to assume that with the large baby boomer population and the growing number of obese people with comorbidities that this number would be on the rise, yes?

Yes, I expect 70-80% ASA 3 and 4 in the hospital setting with the majority of ASA 1 and 2 patients done at the outpatient centers.

 

[BLADEMDA]

Let's assume your caseload is typical of anesthesia as a whole.

If the I-II patients go to solo CRNA, 50% of anesthesiology manpower becomes surplus. You estimate earlier that there are 40K MD's nationwide. That means that 20,000 are now surplus. Assume 10,000 simply leave the job market. Also assume that 50% of residency programs immediately close so that they supply an appropriate number of grads to the market (500/yr or so) If 1000 docs retire each year it takes 40 years for supply and demand to equal.

Lots of unrealistic and forced assumptions above, but the overall point is this: If ASA I & II patients are ceded to CRNA only, the anesthesiology job market crumples. Defending ASA III-V patients as MD turf is not a viable way to stay safe. Perhaps it's useful as part of a greater plan to shift MD's more into CCM, pain, peds, etc, but alone it would make no difference.

Well I can only post the truth. Anesthesia is extremely safe on ASA 1 and 2 patients and the vast majority of midlevels (AAs included) can handle those cases. While we can provide advanced Regional to those patients the midlevels can SAFELY do the GA. Yes, we provide back-up to the midlevel but that has more to do with the INADEQUACY of the AANA certification/training than us.

However, there are way more ASA 3 patients out there than you can appreciate from DA U. What is a surgeon to do for anesthesia? Schedule ASA 1 and 2 with a CRNA and the rest with us? It makes no sense. If we are needed on more than half the cases then we are needed in the O.R.

 

[BLADEMDA]

1. Electives- The most important part of a fellowship in CC is the option to get an elective in TEE and Echo lab. It is ESSENTIAL that you can pass the ECho Exam and obtain Testamur status. A CC trained MD (A) with Testamur status is VERY VALUABLE in many PP. You will be viewed as having EXTRA SKILLS and bringing something to the table.

2. Do you get Pulmonary/Bronch experience? Again, this is a valuable "billable" procedure in PP that can bring in significant money.

3. Good Experience in the Units- You don't need much ECMO but a month in NeuroICU would be nice. How bad is the call? You don't want to get murdered for those 12 months.

4. Location- Can you tolerate the location? Can you just stay where you are for 12 months? There is a lot to be said for just sucking it up and doing 12 months at your current program. That said, items 1-3 must be heavily weighed against item 4.

Blade

 

[ProRealDoc]

1. Electives- The most important part of a fellowship in CC is the option to get an elective in TEE and Echo lab. It is ESSENTIAL that you can pass the ECho Exam and obtain Testamur status. A CC trained MD (A) with Testamur status is VERY VALUABLE in many PP. You will be viewed as having EXTRA SKILLS and bringing something to the table.

2. Do you get Pulmonary/Bronch experience? Again, this is a valuable "billable" procedure in PP that can bring in significant money.

3. Good Experience in the Units- You don't need much ECMO but a month in NeuroICU would be nice. How bad is the call? You don't want to get murdered for those 12 months.

4. Location- Can you tolerate the location? Can you just stay where you are for 12 months? There is a lot to be said for just sucking it up and doing 12 months at your current program. That said, items 1-3 must be heavily weighed against item 4.

Blade

1) yes, lots! 2 dedicated months of TEE.
2) One month of bronchs with the pulmonary service and practice during regular unit months.
3) One month of CT ICU with ECMO, IABPs, etc and one month of neuro ICU and MICU
4) locations sucks, but it's only a year.

 

[bigdan]

Blade/ProReal -

Awesome thread guys.

Re: the CCM fellowship, which I've been interested in for a while - do you know of programs that meet what Blade listed? I know there was a thread on this; Duke is the ONLY one that goes out to actually say that they'll give you enough heart reads to be able to sit for the exam. I did any away rotation at CCF in their SICU, and they, beyond any shadow of a doubt MUST have enough hearts there to allow fellows to do TEE, but I've never heard that it's something offered there as part of the CCM fellowship. Any other program ideas?

Thanks in advance!

dc

 

[BLADEMDA]

Let's discuss the Tier 1 Fellowships in more detail. As you may surmise I prefer the CC Fellowship over the Cardiac one because it offers MORE for those 12 months. You can become a Testamur and CC certified in 12 months. Even if you don't practice Critical Care you are a TEE Testamur and wel trained for ASA 4-5 cases. Plus, if things change you have another marketable skill.

The Pain Fellowship speaks for itself. The AANA simply won't be a threat to a good Pain MD. Your training is far superior to a CRNA. You should be able to CRUSH any Advanced Practice Nurse in your area. What CRNA is truly qualified to be doing Advanced Pain Medicine?

Peds. Those who think a CRNA can do high risk peds Solo are drinking too much AANA Kool-Aid. These cases are high risk and some recommend Board Certified Anesthesiologists have a one year fellowship prior to doing high risk Peds. Again, the CRNA will not be given the authority to do these cases Solo at Pediatric hospitals; no matter how many Opt-Out states the AANA gets.

Blade

 

[BLADEMDA]

Tier 1 Fellowships move you up the curve. Which end of the market do you want to find yourself in about 10 years?

 

[Jeff05]

i'm doing a pain fellowship. i think that even if one does not transition to 100% chronic pain based practice after, there is still a lot to gain.

you can round with the acute service (out of OR, extra value to dept and hospital/administration/joint commission), you can take care of the difficult pacu pain patient, or just run a solid anesthetic for a chronic pain patient. i have seen many seasoned anesthesiologists get this wrong. sometimes, you can't give enough fentanyl.

in the future, i see an extension of the acute pain service, as many patients develop chronic post surgical pain (CPSP, see Anesthesiology september 2009, p. 461). this will be a bridge between acute pain and true chronic pain.
imagine adding a CPSP service to a thriving acute pain service - patient satisfaction would go through the roof (someone actually cares about my pain a whole 3 weeks after the surgery!?). surgeons would be thrilled, as they would not have to (mis-)manage this condition for several months postop (until they get fed up and send the patient to chronic pain). administrators would love it - another service to bill for that would actually make some money and increase compliance with joint commission standards (pain management initiatives).

just thinking. i do believe that our lucrative days of plopping an LMA into a healthy 23 yo for a knee scope are coming to an end.

 

[ProRealDoc]

Blade/ProReal -

Awesome thread guys.

Re: the CCM fellowship, which I've been interested in for a while - do you know of programs that meet what Blade listed? I know there was a thread on this; Duke is the ONLY one that goes out to actually say that they'll give you enough heart reads to be able to sit for the exam. I did any away rotation at CCF in their SICU, and they, beyond any shadow of a doubt MUST have enough hearts there to allow fellows to do TEE, but I've never heard that it's something offered there as part of the CCM fellowship. Any other program ideas?

Thanks in advance!

dc

It all comes down to what you negotiate.

 

[Mista Suprane]

1) yes, lots! 2 dedicated months of TEE.
2) One month of bronchs with the pulmonary service and practice during regular unit months.
3) One month of CT ICU with ECMO, IABPs, etc and one month of neuro ICU and MICU
4) locations sucks, but it's only a year.

which program is this?