Proposed EM/Anesthesiology Combined Program?

[bcmak]

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http://link.springer.com/article/10.1007/s40140-015-0130-9

Has anyone seen this article? It proposed a combined EM/Anes residency and compares it to the IM/Anes and IM/EM combined residencies.
Thoughts? Plausible?

 

[deleted171991]

It would be a genius move. Add a CCM fellowship and the graduate can kick some serious ass.

This is actually the German model, if I am not wrong.

 

[deleted547339]

I see how the anesthesia training adds to the EM training - it would make you a better emergency physician. I don't see how the EM training would significantly add to the practice of anesthesia.

I'm EM going to do a CC fellowship when I finish my residency. Had this been an option, I would have considered it as it would prepare you to be a stellar intensivist.

 

[repititionition]

It would be a genius move. Add a CCM fellowship and the graduate can kick some serious ass.

This is actually the German model, if I am not wrong.

This is the model in most of Europe and the UK. As it was put to me by a UK anesthesiologist, "if it's acute care, anesthesia owns it" (EM/CCM/OR).

Anesthesiology is an incredible and inspiring field, internationally.

 

[partydoc]

Does anesthesia staff the ER? or run traumas that come in?

 

[criticalelement]

2 different fields. wont be many takers.

 

[Magnus67]

"take your place by my side, and together we will rule the Galaxy as father and son!" You would be a near perfect critical care doc , able to handle almost any high level scenario.

 

[repititionition]

Does anesthesia staff the ER? or run traumas that come in?

Varies by country, but EM is a subspecialty of Anesthesiology in many places. To answer your question, anesthesia staffs the OR.

Interesting discussion here: http://www.researchgate.net/post/Sh...lved_in_the_delivery_of_pre-hospital_medicine

 

[Mad Jack]

This is the model in most of Europe and the UK. As it was put to me by a UK anesthesiologist, "if it's acute care, anesthesia owns it" (EM/CCM/OR).

Anesthesiology is an incredible and inspiring field, internationally.

Why did it end up sucking so much in the US compared to internationally, historically? Is it the per-procedure pay structure that incentivized anesthesia just having OR time?

 

[bashwell]

I'm in Australia. Anesthesiology (aka anaesthetics) is indeed awesome here. It's a super competitive specialty to get into though.

 

[cbrons]

Why did it end up sucking so much in the US compared to internationally, historically? Is it the per-procedure pay structure that incentivized anesthesia just having OR time?

CRNAs

 

[cbrons]

http://link.springer.com/article/10.1007/s40140-015-0130-9

Has anyone seen this article? It proposed a combined EM/Anes residency and compares it to the IM/Anes and IM/EM combined residencies.
Thoughts? Plausible?

If this was a 4 year program like it is described in that link, then I would do this in a heart beat.

 

[Mad Jack]

CRNAs

I mean the scope of practice of anesthesiologists compared to other countries. CRNAs didn't kick them out of critical care, CRNAs didn't keep them uninvolved in the ED. Anesthesia evolved down a very, very different path in this country compared to others that boxed anesthesiologists into the OR. That boxing in is precisely why the profession is facing a crisis now that CRNAs are being cranked out in surplus. So I'm just curious why they boxed themselves in in the first place.

 

[bcmak]

If this was a 4 year program like it is described in that link, then I would do this in a heart beat.

I think they mean for it to be a 5 year program.
PGY1 - EM/clinical base year
PGY2- CA1
PG3-5- 6 months of em/anes per year, broken into 3 month blocks

 

[criticalelement]

I think they mean for it to be a 5 year program.
PGY1 - EM/clinical base year
PGY2- CA1
PG3-5- 6 months of em/anes per year, broken into 3 month blocks

BUt then you have to do a fellowship in pain or peds or cardiac turning into at the very minimum a six year residency. For what? To be told what to do by a management group

 

[deleted171991]

I mean the scope of practice of anesthesiologists compared to other countries. CRNAs didn't kick them out of critical care, CRNAs didn't keep them uninvolved in the ED. Anesthesia evolved down a very, very different path in this country compared to others that boxed anesthesiologists into the OR. That boxing in is precisely why the profession is facing a crisis now that CRNAs are being cranked out in surplus. So I'm just curious why they boxed themselves in in the first place.

Lifestyle and greed. OR used to pay better than EM or CCM, and offered a better lifestyle, especially if supervising own CRNAs.

 

[deleted171991]

If this was a 4 year program like it is described in that link, then I would do this in a heart beat.

Even at 5 years, this is gold. A second specialty in just one extra year, especially EM? Are you kidding me? This is a great pathway for somebody interested in the emergency/trauma/CCM side. Unbeatable.

 

[Mad Jack]

Lifestyle and greed. OR used to pay better than EM or CCM, and offered a better lifestyle, especially if supervising own CRNAs.

That's what I figured. They built a ship to be as comfortable as possible, with every amenity but the lifeboats, because what could go wrong, really?

 

[chocomorsel]

This is America. It is always and was always about the money. Hello!!! Except now we are ****ed without any lifeboats.
Thank God I live in a place were anesthesiologists are still independent.

 

[OB1🤙]

I'd rather do a combined anesthesiology/Russian roulette fellowship than anesthesia/EM, but different strokes I guess.

With all due respect to our valued EM colleagues, of course.

If you could filter out the drunks, drug seekers, URIs, nursing home AMS, etc, maybe. I tip my hat to the people with the patience it takes to deal with that s#it, because I don't have it.

 

[deleted547339]

I'd rather do a combined anesthesiology/Russian roulette fellowship than anesthesia/EM, but different strokes I guess.

With all due respect to our valued EM colleagues, of course.

If you could filter out the drunks, drug seekers, URIs, nursing home AMS, etc, maybe. I tip my hat to the people with the patience it takes to deal with that s#it, because I don't have it.

You really don't have that much patience. Obs on pulsox +/- CT, DC +/- security, DC, CT/CXR/UA admit to hospitalist.

 

[teeva]

Anesthesia is nice because you get to deal drugs, namely opiates and benzos, legally and appropriately, and most often on an objective basis. Why would I want to work in the ER and write prescriptions for it, to feed an addiction, to clear the ER, because it's easier to do so than refuse and put up with a belligerent/violent pt, or so grandma can sell the pills to pay for her iphone? That was my experience in the ER when not dealing with vague chest pain, vaginal pain/bleeding, common colds, gomers with UTI, and lower back pain. Not to belittle EM, an awake and talking trauma pt during a trauma code is still too much pt contact for me.

 

[deleted171991]

Lifeboat, my friends, that's why. Insurance policy. And probably a much better one than my CCM fellowship. EM is better paid and much easier to find a job in (than CCM, or anesthesia). Not only that but, in some states, they cannot be sued for malpractice except for egregious errors.

So, for somebody who likes both specialties, it's gold.

 

[Psai]

There's a lot of bull**** in em. Being controlled by your employer based on bull**** press-ganey scores is a huge negative.

 

[deleted171991]

There's a lot of bull**** in em. Being controlled by your employer based on bull**** press-ganey scores is a huge negative.

And where do you think anesthesia is heading? 😉

 

[Nivens]

FFP, I never noticed it before but when I read your posts I do so in Hugo Weaving's voice.

 

[deleted171991]

FFP, I never noticed it before but when I read your posts I do so in Hugo Weaving's voice.

About independent CRNAs: "You hear that Mr. Anderson?... That is the sound of inevitability..." 🙂

 

[repititionition]

So, bringing this thread back around (sort of), why do folks think we still don't see more combined Anesthesiology/CCM residencies? Top of my head I can think of only a half dozen.

Related (for anyone who may know): how competitive are these programs relative to categorical programs at the same institutions?

 

[deleted171991]

Because CCM is still easy to get as a fellowship, hence there is no reason to jump into a combined residency. What if one changes one's mind during residency?

Plus, by doing CCM as a fellowship in another hospital, one can see two different systems, learn from two sets of attendings, not just one.

 

[repititionition]

Because CCM is still easy to get as a fellowship, hence there is no reason to jump into a combined residency. What if one changes one's mind during residency?

Plus, by doing CCM as a fellowship in another hospital, one can see two different systems, learn from two sets of attendings, not just one.

All fair points, but those are from the applicant's perspective, not the program's. It seems like programs would want to create a pipeline (and "lock people in")...

 

[Psai]

And where do you think anesthesia is heading? 😉

Yes I see it coming but they're already deep in it to the point where some of them are climbing out by making urgent care centers

 

[bcmak]

All fair points, but those are from the applicant's perspective, not the program's. It seems like programs would want to create a pipeline (and "lock people in")...

I think a pipeline program would be less appealing to most applicants. People like choices.

 

[Carbocation1]

So in Europe/Australia anesthesiologists are complete acute care physicians and are highly respected, but in the good old US of A they are currently pre-op monkeys and crna babysitters due to the financial incentives? Does anyone expect that with the new payment models and PSH that US anesthesiologists will become more like their European counterparts?

 

[cbrons]

Remember the ASA "surgical home" or whatever it is they were trying/are trying to propose? According to the ASA vision of the future, Where anesthesiologists will basically be the schmucks that answer 2am calls for colace or ambien from nurses the day after surgery?

 

[bcmak]

It would be a genius move. Add a CCM fellowship and the graduate can kick some serious ass.

This is actually the German model, if I am not wrong.

Would they let you split your time between the ED, ICU, and OR like that?
I mean, all three are basically shift models so it would work out but would there be enough overlapping skill sets to approve such a split?

 

[G-Man82]

Isn't this what Anesthesiologists do in Europe? Split their time across these 3 fields?

 

[metsrangers35]

Sort of to take this back to the logistical stuff here... can someone correct me if I'm wrong.

I had been following the ABA and until the last week I don't remember seeing this (but could have definitely just missed it) but it seems like they finally added the first program to officially pick up the combined EM/Anesthesia : Johns Hopkins

Was this always posted there, or did this just happen?
There is no info on Hopkins website yet, but maybe someone on here has the inside scoop

 

[deleted643396]

It would be a genius move. Add a CCM fellowship and the graduate can kick some serious ass.

This is actually the German model, if I am not wrong.

Just wondering if you still felt this way?

I did IM and anesthesia separate from each other and I essentially wasted 2 years of my life (3, if you count my year of IM practice). I think the combined IM/anesthesia residencies are dumb. I probably feel the same way about EM/anesthesia. It becomes a nice talking point on interviews, but beyond occasional moonlighting it would be difficult to find a good integration of both fields as a career. It's hard enough finding good combo anesthesia/ccm jobs...nevermind EM/anesthesia.

 

[deleted171991]

Just wondering if you still felt this way?

I did IM and anesthesia separate from each other and I essentially wasted 2 years of my life (3, if you count my year of IM practice). I think the combined IM/anesthesia residencies are dumb. I probably feel the same way about EM/anesthesia. It becomes a nice talking point on interviews, but beyond occasional moonlighting it would be difficult to find a good integration of both fields as a career. It's hard enough finding good combo anesthesia/ccm jobs...nevermind EM/anesthesia.

Mostly if the graduate is interested in practicing CCM-only. I find that the anesthesia-CCM model is semi-dead outside of academia, and planning for an academic career is dumb, unless the person loooooves research and bull feces. Respectfully.

If one wants to be just the king of ICU, then EM+Gas+CCM will make him the emperor of all critical maladies. If one wants to practice multiple specialties (which most intensivists do to avoid burnout), then the way to go is IM/Pulm-CCM.

The CCM fellowship made me a better doctor and anesthesiologist in many ways. The problem is that most of them matter only to me, and not to a non-academic anesthesia group (unless I want to do all the crappy cases in the OR). Also, let's not forget that there aren't that many (good) combined academic jobs either, especially if one does not have a cardiac anesthesiology fellowship too.

I am probably biased in many ways, one of them being the crappy market in my (and your?) area, the other being my preference for practicing in a MICU (or closed SICU), both of which are rare in academia.

P.S. I don't think your IM residency was a waste. It's a pity that you did not take it further, by doing an anesthesia CCM fellowship (it's just one year, and you'll probably need a fellowship long-term anyway). You would be great and you could work even in an academic MICU, which is enjoyable (and impossible for a non-ABIM boarded intensivist like myself). Unless you feel like pure anesthesiology is your life's calling.

 

[mmag]

Could be a great asset in the future for the large staffing companies/private equity/publically traded companies.
EM is 5-10 years ahead of anesthesiology in terms of consolidation with 25% of physicians working for the above vs 8% of anesthesiologists. So if you are able to staff both the ED and the OR's, you represent double the value in terms of flexibility for a company that has both the ED and the anesthesia contract at a given facility.

source - written by a health care i-banker:
https://s3.amazonaws.com/cdn.trimedmedia.com/digissues/custom/RBJ/2016/rbjaugsept2016/files/12.html

 

[G-Man82]

The CCM fellowship made me a better doctor and anesthesiologist in many ways. The problem is that most of them matter only to me, and not to a non-academic anesthesia group (unless I want to do all the crappy cases in the OR). Also, let's not forget that there aren't that many (good) combined academic jobs either, especially if one does not have a cardiac anesthesiology fellowship too.

So what did you end up doing after fellowship? The place I'm at, though I practice mostly in a cardiothoracic and major vascular surgical ICU, we get about 30% of our patients as medical admits, admitted to me. The usual MICU stuff - GI Bleeds, ARDS, sepsis etc. It is definitely refreshing not having a surgeon "co-managing" sometimes. This is in academic practice. I split my time roughly 50-50 with the ICU and OR


Sent from my iPhone using SDN mobile

 

[deleted87051]

You'd be quite an asset on medical mission trips and MSF type organizations.

 

[deleted643396]

P.S. I don't think your IM residency was a waste. It's a pity that you did not take it further, by doing an anesthesia CCM fellowship (it's just one year, and you'll probably need a fellowship long-term anyway). You would be great and you could work even in an academic MICU, which is enjoyable (and impossible for a non-ABIM boarded intensivist like myself). Unless you feel like pure anesthesiology is your life's calling.

It has crossed my mind since I am in the brutal northeast market, but in the end it is another year of lost income for a not necessarily better income/lifestyle. Despite the layers of nonsense clouding my vision, I do like OR anesthesia and would never want to be a 100% intensivist. I have "shopped around" and did my own market research to see if doing the fellowship would be worth it. There is a growing demand for critical care and I was even offered a job in a desperate rural hospital to provide anesthesia and critical care services without a fellowship. My wife was not excited about living in "coal country" (I wasn't, either). In the higher demand markets, pulm/cc still dominates most community ICUs and the academic places have their own set of well-documented problems. Again, the northeast academic market is pretty terrible with most big name places assuming you should be happy just to have their name on your white coat.

I think the combo residencies are well-intentioned, but I don't really see a market for them...at least not yet. Critical care can make them more useful, but you still have to get creative in your job search because there are not ready-made jobs for EM-anes-ccm or IM-anes-ccm. You almost have to be willing to approach practices and organizations with a "pitch" about the services you can provide.

 

[Cryc_to_the_point]

This looks like a dream to me. Have any programs expressed intent to establish a combined residency? (forgive me if my Google-fu failed me but I could only find announcements of the article)

 

[deleted162650]

Could be a great asset in the future for the large staffing companies/private equity/publically traded companies.
EM is 5-10 years ahead of anesthesiology in terms of consolidation with 25% of physicians working for the above vs 8% of anesthesiologists. So if you are able to staff both the ED and the OR's, you represent double the value in terms of flexibility for a company that has both the ED and the anesthesia contract at a given facility.

source - written by a health care i-banker:
https://s3.amazonaws.com/cdn.trimedmedia.com/digissues/custom/RBJ/2016/rbjaugsept2016/files/12.html

You know things are really effed up when you start looking for ways to make yourself more competitive for an AMC job.

 

[zero0]

I don't really see the appeal. Just do a pain fellowship if you miss those lovable druggies that much.

 

[OxToCA]

I don't really see the appeal. Just do a pain fellowship if you miss those lovable druggies that much.

There's appeal due to what's discussed in a previous thread on the same topic, IMO https://forums.studentdoctor.net/th...sia-combined-residency.1171799/#post-17301013

 

[zero0]

There's appeal due to what's discussed in a previous thread on the same topic, IMO https://forums.studentdoctor.net/th...sia-combined-residency.1171799/#post-17301013

That's just me personally. There's no doubt that this would offer superior ICU training and give you more range, but I personally prefer to stay the heck out of the ED.

 

[deleted162650]

I'm sorry @OxToCA but that avatar will forever be reserved for Ventdependent. You need to change it. Thanks.

 

[OxToCA]

That's just me personally. There's no doubt that this would offer superior ICU training and give you more range, but I personally prefer to stay the heck out of the ED.

It doesn't look like it's for everybody, that's for sure; I might want to do a pain fellowship, too. I also met the last author in 2015 who directs USC's anesthesiology residency, but not about any of the above.