Residency Training in Anesthesiology

[BLADEMDA]

I submit to you the current model of training Anesthesiology residents needs an update. I proposed something similar a few years back but I think it deserves another thread:

5 years of Mandatory Residency Training. PGY-1 thru PGY-5 which includes 12 months of Critical Care and a subspecialty. Instead of the current 4 year model plus fellowship we move to a 5 year model which allows every Resident to sit for the following boards:

1. Anesthesiology
2. Critical Care
3. Subspecialty like Pain, Cardiac, Peds, etc

If we are to survive as a specialty then we must evolve into something more than glorified CRNAs. The benefits of a Critical Care expert at your side when things go wrong are obvious to most people with a college degree.

My other proposal is for a 6 year Program which involves the following:

6 years of IM/Anesthesiology and Critical Care plus subspecialty training. At the end of the 6 year program the graduate could sit for the following boards:

1. Anesthesiology
2. IM
3. Critical Care
4. Subspecialty


While I know others on SDN will disagree with my proposal I firmly believe both of these TRACKS are far superior to current model. The health care system of the future needs Physician Anesthesiologists to be in charge of complete perioperative care and our ever increasing ASA 4 population. My proposal gives the private practice Anesthesiologist of the future the street credentials to succeed in a tough environment.
The best Medical care deserves the best Anesthesiologist training in the world.

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Members don't see this ad.

 

[deleted171991]

I would prefer the latter version, minus one year (the subspecialty). Not everybody needs a subspecialty, especially after board certification in IM/CCM.

This will never happen, because nobody will want so well-rounded physicians out on the market. Neither the IM guys, nor the CCM guys, nor the cardiac anesthesia guys, nor the general anesthesia guys.

It's the same reason they basically destroyed the combined Cardiac/CCM track, like 18 months wouldn't have been enough. Whatever they change for the worse, I just love how they always grandfather themselves in. Disgusting human nature...

 

[BLADEMDA]

The goal is to train and graduate a superior Anesthesiologist for a difficult job market where Operating room services are DEVALUED.

The benefit of all these Boards are a true perioperative Physician ready to handle any medical emergency inside or outside the hospital. The ASA touts the "home base model" so my proposal gives the credentials to the Anesthesiologist of 2021 to actually cover the ER, ICU, OR, Preop Clinic, etc.

Imagine a new graduate of the 6 year program:

1. Cardiac Trained with TEE and TTE
2. IM Boarded
3. Critical Care Boarded
4. Anesthesia

Honestly, that type of physician is what we need for hospitals under ObamaCare. This type of Anesthesiologist is the answer to Obamacare and the AANA.
A true "terminator" Anesthesiologist for the 21st Century.

 

[IkeBoy18]

The goal is to train and graduate a superior Anesthesiologist for a difficult job market where Operating room services are DEVALUED.

The benefit of all these Boards are a true perioperative Physician ready to handle any medical emergency inside or outside the hospital. The ASA touts the "home base model" so my proposal gives the credentials to the Anesthesiologist of 2021 to actually cover the ER, ICU, OR, Preop Clinic, etc.

Imagine a new graduate of the 6 year program:

1. Cardiac Trained with TEE and TTE
2. IM Boarded
3. Critical Care Boarded
4. Anesthesia

Honestly, that type of physician is what we need for hospitals under ObamaCare. This type of Anesthesiologist is the answer to Obamacare and the AANA.
A true "terminator" Anesthesiologist for the 21st Century.

I would actually do this 6 yr program. too bad it wont be around as a set and will have to be done a la carte.

 

[BLADEMDA]

http://fc07.deviantart.net/fs71/i/2...se_is_the_terminator__by_xdreamzz-d57bc49.jpg
The AANA wouldn't stand a chance against this new Anesthesiologist.

 

[BLADEMDA]

The AANA has created the DNAP. This new CRNA will be toting his/her "doctor of anesthesia" in just 3-4 years. Programs around me are starting new DNAP classes soon.
We must answer the DNAP with a true Perioperative Physician. Even if you work at a surgicenter the 5 year or 6 year Residency program makes you a true expert in Perioperative medicine. The leaders must make this change while we still control credentialing in the hospitals. The time has come to crush the AANA threat with the new Surgical home Physician whose credentials match the ASA rhetoric.

 

[BLADEMDA]

My answer to the CRNA with DNAP.

 

[deleted171991]

That was approximately the image you created in my mind with your first post. Except it was Robocop. And nowadays I don't like roboanything.

 

[aneftp]

The only way to crush the aana is to simply lead them to have crnas do solo challenging cases instead of cherry picking.

Let the human experiment began. We need to run these human trials. Force these hospitals not to punt sicker patients to tertiary medical centers.

 

[BLADEMDA]

AANA Propaganda:

"There is no difference in the training of CRNAS vs Anesthesiologists. Both are trained exactly the same way" AANA

ASA/ABA Answer:

Anesthesiologist are true perioperative Physicians. Unlike CRNAS with a DNAP whose only qualification is an advanced nursing degree in anesthesia Anesthesiologists are highly trained Professionals boarded in multiple specialties. When an Emergency happens unexpectedly the Perioperative Physician is there to save your life. Qualifications of an Anesthesiologist include:

- Medical Degree
- Critical Care Board Certification
- Anesthesia Board Certification
-Subspecialty Certification-
IM Board Certification

 

[BLADEMDA]

The only way to crush the aana is to simply lead them to have crnas do solo challenging cases instead of cherry picking.

Let the human experiment began. We need to run these human trials. Force these hospitals not to punt sicker patients to tertiary medical centers.

Take the high road. Give the new graduate the credentials needed to succeed in the market place.

 

[ryanjmy]

I agree extra cc and more focus on a subspecialty would be beneficial, but an extra year is not needed. You could easily add 3 months of cc the intern year. You could also have 6 months the ca3 year devoted to one specialty.

An extra 2 years of indentured servitude is not going to be appealing to medical students.

 

[BLADEMDA]

I agree extra cc and more focus on a subspecialty would be beneficial, but an extra year is not needed. You could easily add 3 months of cc the intern year. You could also have 6 months the ca3 year devoted to one specialty.

An extra 2 years of indentured servitude is not going to be appealing to medical students.

The 6 year program is needed to allow the specialty Boards to approve the right to sit for the Boards. While I don't like the 6 year program in terms of length it beats the current model of 4 plus 1 or 4 plus zero which makes you less versatile as a true perioperative Physician. Remember, the Specialty will be enhanced greatly with this 6 year program and a reduction to 1200 positions per year. The potential for moonlighting in the E.R., covering the ICU, doing your own TTEs, Pain Clinic during the week, etc. are all possibilities after a 6 year program.

Med Students are too narrowly focused on the short term. Those extra 2 years guarantee gainful employment for the following 3 decades of your career.

 

[deleted171991]

Those extra 2 years guarantee gainful employment for the following 3 decades of your career.

... without the need to apply, interview and travel again like crazy, just for a one year-spot.

 

[BLADEMDA]

... without the need to apply, interview and travel again like crazy, just for a one year-spot.

Exactly. Decrease the positions to 1200 by making all programs offer the 5 or 6 year training as outlined in this thread. You match at one place and stay there for the entire time (unless they farm you out).

 

[Spinach Dip]

Med Students are too narrowly focused on the short term. Those extra 2 years guarantee gainful employment for the following 3 decades of your career.

Ummmm... Sorry?

I think after the requisite 12 years to become an MDA (4 undergrad, 4 MD, 4 residency), a lot of grads want to get out and practicing ASAP. Others (the majority, IIRC) are fine with doing another year to specialize in peds/pain/whatever.



I would agree with your 5-year plan if students could 'opt-out' of specialty training (thus, making it a 4-year program on par with what exists today, but with a different focus).

I agree with the idea of turning the practice of anesthesia to a different focus. I agree something has to be done to fix the CRNA 'problem'. I don't agree with adding years onto residency without some GUARANTEE of a higher wage/more job security.

 

[deleted171991]

Next thing, we will request a DNA analysis before approving medical education loans. Any bad genes, and you are not likely to live enough to pay them back.

 

[Spinach Dip]

This will never happen, because nobody will want so well-rounded physicians out on the market. Neither the IM guys, nor the CCM guys, nor the cardiac anesthesia guys, nor the general anesthesia guys.

Disgusting human nature...

Yeah...



I am not frightened of CRNAs; we can get along. I am frightened because the ASA seems incapable or unwilling to do anything to preserve the integrity of this specialty.
-An anesthesiologist I know.

 

[Spinach Dip]

Next thing, we will request a DNA analysis before approving medical education loans. Any bad genes, and you are not likely to live enough to pay them back.

Those who are Y-positive live, on average, 10 years less than those who are Y-negative.

Soon they will stop offering loans to all Y-positive persons.

 

[deleted171991]

I am not frightened of CRNAs; we can get along. I am frightened because the ASA seems incapable or unwilling to do anything to preserve the integrity of this specialty.
-An anesthesiologist I know.

The ASA is becoming to Anesthesia as the AMA is to FP/IM.

 

[deleted171991]

Those who are Y-positive live, on average, 10 years less than those who are Y-negative.

Soon they will stop offering loans to all Y-positive persons.

Thank God I am 45,X!

 

[HollATme]

Sounds wonderful. Are the programs going to fund the money for all these certifications? Is this quadruple board certification going to even matter with the evolving nature of the job market??

 

[deleted171991]

About the same as a quadruple jump matters today in ice skating. Remember when a triple was a big deal?

P.S. It's called progress, some say. I am beginning to think that it's smarter to invest in a business degree. The medical professional is a dying breed.

 

[HollATme]

Exactly.

 

[HollATme]

Plus, there are anesthesiologists out there who are CCM+Cardiac boarded and are forced to choose - OR or ICU, and most likely end up in the OR.

 

[Ezekiel2517]

They've been talking about these proposed changes for years...sounds like a good idea, but logistically very difficult to get done

 

[deleted171991]

Let me put it this way: the automotive companies have just decided to replace us with cheaper robots, and they will need much fewer of us - just for supervision/repair. Some of us think that a specialized machinist will survive longer than a generalist. Sure, about 2 years longer, until the companies can get specialized robots.

My advice: think about an alternative career. Very few fellowships qualify, if any.

P.S. I inquired today about a solo outpatient Mon-Fri job. Was quoted $1100/day plus benefits, for a board-certified relatively experienced anesthesiologist. There's the future for you.

 

[HollATme]

They've been talking about these proposed changes for years...sounds like a good idea, but logistically very difficult to get done

I can see residency programs mucking it up big time - all in the name of service obligations. Hell, attendings can't even afford themselves to be available during intraop to teach or for wake-ups (for the CA-1s) and you expect the programs to somehow not muck this up??
Programs are too busy crossing their "T's" and dotting their "i's"... compliance nazis over the case logs and work hr logging, paper work on paper work, etc.
You have to be at a residency program that has the anesthesiology dept. being primo - in the OR, in the ICU, CCU, trauma situations, etc.

I have seen some programs initiate an acute care anesthesiology fellowship.
-TEE, TTE, rotations involving the SICU/Trauma ICU, Neuro ICU, etc. and heavy involvement in the ED. (Of course, the OR, as well...)
-it is NOT ACGME-accredited, perhaps it should be. Hell, now OB is accredited. Seriously?!
-it's 1 year - so 5 years total - there, you want your terminator anesthesiologist? You got it... I guess.

 

[kazuma]

I don't agree with adding years onto residency without some GUARANTEE of a higher wage/more job security.

Unfortunately, I don't think there is anything that can guarantee a higher wage in this new paradigm. At this point it's about damage control and creating more value to remain relevant to hospital bean counters and administrators. A CRNA will have a difficult time competing with an anesthesiologist that offers multiple specialized services including complete pre-op evaluation/optimization/risk assessment, advanced intraoperative skills, and ICU management with TEE/TTE/Bronchoscopy.

 

[deleted171991]

A CRNA will have a difficult time competing with an anesthesiologist that offers multiple specialized services including complete pre-op evaluation/optimization/risk assessment, advanced intraoperative skills, and ICU management with TEE/TTE/Bronchoscopy.

You forget one thing: the patients they would need your skills for get an exquisitely crappy reimbursement from Medicrap. What the bean counters will see is that the CRNA is making much more money on her easy cases than the Terminator anesthesiologist. Guess who will be paid better (or the same)?

I would rather supervise 3 young and healthy ASA 1/2 CRNA rooms than do risky crappy cases solo.I bet my employer thinks the same, but for financial reasons. All the fellowships in the world won't make your crappy patients pay more, and neither will the hospitals. CCM is a fad that will die, like anesthesia, once the hospitals figure out the eICU-type remotely-supervised midlevel system. Of anesthesia and CRNAs it reminds you, hmm?

 

[HollATme]

It's probably best to pursue a specialty where .... you're the boss.
It works in business, and last I checked, medicine .... is a business.

 

[Spinach Dip]

P.S. I inquired today about a solo outpatient Mon-Fri job in the Northeast. Was quoted $1100/day plus benefits, for a board-certified relatively experienced anesthesiologist. There's the future for you.

I assume, being in the NE, this is in a high-supply (lots of job seekers per job) area?

What do those numbers look like if one decides to go to a low-supply small-city? Say Topeka, Boise, Nashville, etc. Mulitiply by 1.25? 1.5? 1.75?

 

[kazuma]

You forget one thing: the patients they would need your skills for get an exquisitely crappy reimbursement from Medicrap. What the bean counters will see is that the CRNA is making much more money on her easy cases than the Terminator anesthesiologist. Guess who will be paid better (or the same)?

I would rather supervise 3 young and healthy ASA 1/2 CRNA rooms than do risky crappy cases solo.I bet my employer thinks the same, but for financial reasons. All the fellowships in the world won't make your crappy patients pay more, and neither will the hospitals. CCM is a fad that will die, like anesthesia, once the hospitals figure out the eICU-type remotely-supervised midlevel system. Of anesthesia and CRNAs it reminds you, hmm?

I agree, CCM isn't going to make you any more money. One could argue that it's the only fellowship that decreases your salary at current reimbursement rates. The ACO model is the wild card. If ACO's are successful, the terminator anesthesiologist would have a better chance of survival in that type of system. Like I said, it's about survival and becoming irreplaceable so that you stand a chance at keeping a job that you can live with. The days of high salaries are over. Perhaps I'm young and naive, but I'd rather do my own ASA4 cases all day long and round on the unit 1-2 weeks a month than "supervise" 4-6 rooms and fill out pre-op forms. Last weekend I was on call with an attending who's been out of residency a couple years and she really isn't happy supervising. She said she didn't go through years of training and honing her skills to become a pre-op monkey and chart signer. I can't say that I signed up for that either.

Of course, another option is to carve out a cash based practice. There's lots of talk about opening up cash based systems, but the reality of it is, if it was so easy and lucrative to do, there would probably be a lot more people doing it. In the future, with declining CMS reimbursement and a larger CMS payer mix, this could tip the balance making cash based practices more feasible. But you would still need a decent sized patient panel with deep pockets that can afford to pay for your services out of pocket.

 

[Baller MD]

DNAP? WTF? I want to throw up...

 

[HollATme]

I agree, CCM isn't going to make you any more money. One could argue that it's the only fellowship that decreases your salary at current reimbursement rates. The ACO model is the wild card. If ACO's are successful, the terminator anesthesiologist would have a better chance of survival in that type of system. Like I said, it's about survival and becoming irreplaceable so that you stand a chance at keeping a job that you can live with. The days of high salaries are over. Perhaps I'm young and naive, but I'd rather do my own ASA4 cases all day long and round on the unit 1-2 weeks a month than "supervise" 4-6 rooms and fill out pre-op forms. Last weekend I was on call with an attending who's been out of residency a couple years and she really isn't happy supervising. She said she didn't go through years of training and honing her skills to become a pre-op monkey and chart signer. I can't say that I signed up for that either.

Of course, another option is to carve out a cash based practice. There's lots of talk about opening up cash based systems, but the reality of it is, if it was so easy and lucrative to do, there would probably be a lot more people doing it. In the future, with declining CMS reimbursement and a larger CMS payer mix, this could tip the balance making cash based practices more feasible. But you would still need a decent sized patient panel with deep pockets that can afford to pay for your services out of pocket.

Most of those attendings who complain about supervising 3-4 rooms are the same attendings who disappear the moment the resident has put the tube through the cords. Those who complain will almost always complain. Those who don't, they're the ones who are too busy actually teaching.

Personally, I don't mind supervising 3-4 ASA 1/2 patients. However, if they want me to supervise multiple ASA 3/4 cases, they can go **** themselves.

 

[BLADEMDA]

Blade and FFP: What are you talking about? Seriously, what the hell are you talking about? You want to add 1-2 years onto a residency in the name of marketability? That is ridiculous. If you think that anesthesia has changed drastically or that residents aren't getting enough cases then fine, you can argue for an extra year of training. But to say that we should add extra years just to market ourselves better? Thats nonsense. First of all, I am an excellent perioperative physician. I learned that from 4 years of residency. I dont need a combined medicine residency. What would I even do with being boarded in IM? Im not going to see patients in clinic. It would be a waste of time. You can make an argument (and I do regularly) that currently fellowships are a waste of time. There are people who finished residency recently who do cardiac cases, and who do peds cases, and even OB cases (seriously why is this a fellowship?). There are even people who do pain procedures, sans fellowship! This is just total nonsense what you are spewing. And for the record for the youngins that are worried: I live in a very saturated area in an opt out state where crnas can practice independently, and had no trouble finding a job making 300K with minimal call. Stop the nonsense. Please.

Nonsense?

A 5 year program with Critical Care and Subspecialty Fellowship is nonsense? FYI, Canada requires FIVE YEARS of training to practice Anesthesiology. The goal isn't marketability but Board Certification as a true perioperative Physician.

I see the extra Certification as an asset to CEOs, Administrators, etc looking to add cross coverage in their hospitals once the reimbursement system changes to a single lump sum. Unfortunately, many will see the plan as crap or unnecessary. The game is changing and we must change with it.

 

[BLADEMDA]

Ummmm... Sorry?

I think after the requisite 12 years to become an MDA (4 undergrad, 4 MD, 4 residency), a lot of grads want to get out and practicing ASAP. Others (the majority, IIRC) are fine with doing another year to specialize in peds/pain/whatever.



I would agree with your 5-year plan if students could 'opt-out' of specialty training (thus, making it a 4-year program on par with what exists today, but with a different focus).

I agree with the idea of turning the practice of anesthesia to a different focus. I agree something has to be done to fix the CRNA 'problem'. I don't agree with adding years onto residency without some GUARANTEE of a higher wage/more job security.

The current system is FIVE YEARS LONG if you do a fellowship. I proposed a 5 year Residency which includes Critical and Subspecialty fellowship built into the program.
How exactly is that adding years onto the training?

 

[urge]

I don't see much difference from Blade's proposed system to the current one. At least now the 5th icu year is voluntary.

I don't think there is a big market to make it worthwhile for everyone of us to expend an extra year training in icu.

I agree with Blade that we should all be eligible to take the CC board after finishing anesthesia. I wouldn't add an extra year though. Do you know how many d&c's I did as a ca3? Eyeballs? My time would have been better spent doing extra icu.

 

[urge]

What is this Bull **** that when you write do the D.O. comes up?

 

[Psai]

More years means more interest on huge loans. What about MOCA requirements? I'm assuming that being board-certified in multiple areas mean getting re-certified every ten years. Who knows what kind of continuing education requirements these terminator anesthesiologist will be burdened with?

 

[postbacpremed87]

Blade, our leader, has spoken and we must listen. Please enact the changes above.

 

[gasdoc77]

Those who are Y-positive live, on average, 10 years less than those who are Y-negative.

Soon they will stop offering loans to all Y-positive persons.

How many more days do those that are Y positive work on average over a lifetime if you factor in the part-timers, leave the workforcers, etc. Surely this must offset the premature death of the Y-positivers.

 

[BobBarker]

I have done nearly enough months of critical care to qualify under Blade's new plan. It would be easy to squeeze a couple more in and get anesthesia/CCM in 4. I think that is the better plan as there are too many programs that couldn't handle adequate subspecialty training in pedes/pain/hearts unless they sent you off anyways.

 

[Dwindlin]

Perhaps I'm young and naive, but I'd rather do my own ASA4 cases all day long and round on the unit 1-2 weeks a month than "supervise" 4-6 rooms and fill out pre-op forms.

This x1000.

 

[RT2MD]

I definitely think that the CCM + spec board in 5 years is an excellent plan. I'm not sure what the value would be with adding on a 6th year for IM boards... although I'm guessing you would be stronger in management of things like diabetes/HTN/etc. Do you really think that this is necessary, though? Do you think that would make you look that much better to bean counters?

I'm seriously looking into CCM and Cardiac because I want to be able to take care of the sickest patients possible. I guess I want to be a terminator anesthesiologist, as Blade put it. With that, I will obviously be in post graduate training for 6 years... and I'm 34 now... and just now graduating med school in a couple of months. It would be nice to knock a year off of that.

Along those lines, two of the things I looked at in residency selection were:
1) How much flexibility they offered during the CA2 and (more so) CA3 years to allow me to get the case types I want.
2) How much does the program depend on the residents for work? I wanted to be able to cherry pick cases, so I'm not stuck doing eyeballs (or whatever) in my last month as a CA3.

I'm extremely happy with where I ended up, but if there was a place that offered the 5 year plan that Blade outlined above - I would have taken that into consideration.

 

[BobBarker]

I haven't met a hearts/CCM anesthesiologist but the CCM ones I have worked with are more Johnny 5 than terminator.

 

[RT2MD]

I haven't met a hearts/CCM anesthesiologist but the CCM ones I have worked with are more Johnny 5 than terminator.

HAHAHA! Well... lets hope that I don't end up in that category...

 

[Laryngophed]

I'm with RT2MD. My plan is to give cardiac + CCM a run, in the thought that I'd be best equipped to care for the sickest of the sick. My hope is really work with patients that are acutely ill and transition from OR to ICU. My only real concern is finding a job that will permit me time for both and not penalize me (financially or otherwise) for stepping out of the OR. I do think that it provides a foothold into this "new" arena of preoperative medicine. But what do I know?

 

[Ignatius J]

IMO, adding more years would be the death of our field as we know it. Avoiding 5-6 year residencies is why many residents go into anesthesiology. You would see a catastrophic drop off in the number of applicants and thus graduates, opening the market to alternative anesthesia personnel.

I love anesthesiology, but if you told me 5-6 years with a year of critical care in medical school, I would have bolted to another field.

 

[IanMcGalt]

IMO, adding more years would be the death of our field as we know it. Avoiding 5-6 year residencies is why many residents go into anesthesiology. You would see a catastrophic drop off in the number of applicants and thus graduates, opening the market to alternative anesthesia personnel.

I love anesthesiology, but if you told me 5-6 years with a year of critical care in medical school, I would have bolted to another field.

1) not all programs are capable of providing fellowship-level training
2) residency quality is diluted by fellows, more fellows->worse residencies all else being equal