Right to practice: CRNA vs Anesthesiologist in a Medical Direction model

[sevoflurane]

Advertisement - Members don't see this ad

The fact is there just aren’t enough of us anesthesiologists to go around. We have to pick the lesser of two evils here.

👍

I’ve been in several practices where they would like to hire AAs but cannot find enough of them (especially if the crnas all threaten to quit. Funny how the AA practices never threaten to quit if they add crnas. I don’t know how crnas can justify not ever wanting AAs - makes them look petty - but they get away with it.)

The double standard is so rich with the militant CRNA's. Pretty sure I read somewhere that the AANA has been proposing legislature for CRNAs to medically direct AA's. Such a laughable double standard. I am not a big fan of united health, but good for them in cutting independent CRNA reimbursement by 15%. CRNAs getting paid the same as MDs is a bit crazy if you ask me.

Midlevels should never practice independently. Period. If you want to practice medicine go to med school.

100%

I am in my last 5 years of practice and there is comfort in that I will set sail into the sun knowing that I helped train AAs and NEVER participated in the ACT model.

 

[IVdoc]

If you look at most of the anesthesiologist jobs in the US, most places are staffed with the anesthesiologist in a care team model, supervision, medical direction, collaborative. There are not that many all-anesthesiologists groups in the country and that's reality. So those who do choose to practice in all physician groups are probably in California, small pockets in western and northeastern states. There's like zero all physician groups in the south (Al, Ga, SC, NC, Miss, TN). There are anesthesiologists who cannot move geographically to be part of an all-physician group plus there aren't enough jobs in those groups for people who want to do all physician (maybe one or two spots advertised in all physician groups). Like it or not "mid-levels" are working independently. As someone wrote, you can scream and lobby all you want that physicians are better trained, most hospitals will look at their bottom line, their cash flow. If hospitals perceive that having 1:4 or 1:8 staffing model is going to increase their profit margins, they will promote that model and if that's the only job you can get in a city where you have roots, young kids in school, some people will take that job. So promoting AAs as a viable and great career to the college kids and lobbying to have all states license AAs would benefit the anesthesiologists, the patients and the staffing shortages. Anesthesiologists with AAs/CRNAs care team model vs independent CRNAs, let that competition play out in the market. Or the other option is having anesthesiologists accept lower salaries to work in all physician groups to compete with independent CRNA model but even then, there aren't enough anesthesiologists to make the whole country have all physician anesthesiologist models. The reality is mid-level nurses (CRNAs, NPs) have lobbied governments and are working independently in the US.

 

[sevoflurane]

If you look at most of the anesthesiologist jobs in the US, most places are staffed with the anesthesiologist in a care team model, supervision, medical direction, collaborative. There are not that many all-anesthesiologists groups in the country and that's reality. So those who do choose to practice in all physician groups are probably in California, small pockets in western and northeastern states. There's like zero all physician groups in the south (Al, Ga, SC, NC, Miss, TN). There are anesthesiologists who cannot move geographically to be part of an all-physician group plus there aren't enough jobs in those groups for people who want to do all physician (maybe one or two spots advertised in all physician groups). Like it or not "mid-levels" are working independently. As someone wrote, you can scream and lobby all you want that physicians are better trained, most hospitals will look at their bottom line, their cash flow. If hospitals perceive that having 1:4 or 1:8 staffing model is going to increase their profit margins, they will promote that model and if that's the only job you can get in a city where you have roots, young kids in school, some people will take that job. So promoting AAs as a viable and great career to the college kids and lobbying to have all states license AAs would benefit the anesthesiologists, the patients and the staffing shortages. Anesthesiologists with AAs/CRNAs care team model vs independent CRNAs, let that competition play out in the market. Or the other option is having anesthesiologists accept lower salaries to work in all physician groups to compete with independent CRNA model but even then, there aren't enough anesthesiologists to make the whole country have all physician anesthesiologist models. The reality is mid-level nurses (CRNAs, NPs) have lobbied governments and are working independently in the US.

Nothing in your post is new as of the last 2 decades. The only difference that I see in 18 years of MD only practice is the following:

1). MD only doesn't automatically mean less money. Our regional average where I live is between 600-800K+ with 10 weeks off all MD.
2). 19 years ago when I interviewed with STAR and TEJAS in San Antonio, the jobs were actually pretty good. I think Texas in general has taken a major hit with both income and supervising rations. You can still make money there, but it can be brutal. Texas used to be a money machine for anesthesiologists 15-20 years ago. Increasing supervision rations is scary and happening more and more.
3). We continue to be in high demand and I don't see that going away anytime soon. I am so happy for all the young rockstars coming out of residency and making a killing from day 1 in pretty much any location they desire.

FWIW, Independent CRNAs doesn't make sense to me IF you can find anesthesiologists to staff said contract.
My first year out of residency was 750K in the middle of an ACT model area. It worked and to this day that practice still is MD only.
There are exceptions and small pockets in the midwest and east exists. West coast is much much easier to find an MD only model.

With regards to CRNAs being let loose because hospitals only care about their bottom line... there is one fine point in that thought and it's safety.
We had a group not too far away from where I live go with a large ratio supervision model. Well, less than one year in a major mistake was made by a CRNA that had no anesthesiologist involvement. The mistake caused a death in a 30 some year old patient. Said hospital ends up having to fork out a big fat paycheck eliminating all the "savings" from implementing such a model. It's not always rosy.

ACT is here to stay. It can work and I know of great groups where anesthesiologists and crnas have great mutual respect for each other as it was designed to be. I 100% support this.

Erosion of the job either by militant CRNAs or increased rations in order to pocket more profit or independent nurse anesthesia practice is where I take issue.

As has been said on this forum for 25+ years... the sky isn't falling. It never has.
If anything, it's one of the best times to be an anesthesiologist. ACT or MD only.

 

[amyl]

Texas is a mess because the AGs official statement on crna supervision left it completely up to the supervising physician to decide what is safe. @neuroride - did you send me this once IRL? Please correct me if I’m wrong.
This puts all the accountability on the anesthesiologist- or I guess the GI/surgeon/pain dr if they’re supervising.
Couple that with production pressure and hospitals or AMCs wanting to run as many ORs as possible and any anesthesiologist is put in a bad position without backup (so 4 partners left…) everyday one doc has at least 7-8 rooms or up to 10!
It’s the AGs statement that allows the grey areas in Texas to be hugely exploited as it suits the hospitals and AMCs purposes.
Symmetry is taking USAP contracts - and they’re WORSE. They don’t want to pay anesthesiologists for call so they’re trying to talk the surgeons into changing the bylaws so they supervise the crnas at night. It’s already happened at one Baylor site in DFW.
I honestly don’t know why anyone puts up with it - DFW isn’t that great.

 

[NPJR]

We hire AAs and CRNAs. We train students of both. I am going to disagree with you. A new hire AA (in general) has a steeper learning curve than a new hire CRNA.

I don't even know what that means. Everyone's learning curve is steep, including yours. Soo.. I've witnessed both AAs and CRNAs. AAs are better.

 

[NPJR]

Let’s play this out. Suppose we train up a whole bunch of AA’s overnight. What do you think will happen to the CRNA’s.

If you trained enough AAs overnight to cover all the current ACT sites, every CRNA would all be fighting for the independent jobs in rural america or go back to doing nursing duties with their R.N. degree. That should be the ASA goal.

 

[IVdoc]

That sound nuts in Texas. The surgeons aren't in an uproar about having their necks on the line for the CRNAs at night? That would be like us being on the hook for a surgical PA that does surgery without the attending surgeon. Maybe it takes dramas or deaths or lawsuits for any common sense for laws/policies to change.

I read an ASA Monitor online article that a Michigan lawmaker is putting out a bill for licensure of AAs in the state of Michigan, trying to join the other 18 states that already have AAs working there. A Reddit commentor said that they are an AA but afraid to go back to their home state of Utah because they didn't want to the potential hostility of being one of the first AAs in the state with CRNAs who could resent them. That's sad and any unprofessionalism should be squashed by the administration. AAs in Missouri who live in Kansas have been trying to have licensure in Kansas but the CRNAs in Kansas keep blocking them, delay tactics, misinformation about AAs and their training/skills that the bill to license AAs in KS didn't pass. I don't have a problem working with CRNAs or AAs as long as everyone is respectful and contributes to patient safety. I do have a problem with being a liability sponge for reckless, cavalier "team members" who don't keep me informed on issues in the OR/OB.

 

[Mman]

I don't even know what that means. Everyone's learning curve is steep, including yours. Soo.. I've witnessed both AAs and CRNAs. AAs are better.

I'll spell it out for you if you don't know what it means. Your median CRNA new grad is going to perform better than your median AA new grad. And I've trained AA students from the majority of programs in the country.

And I'm pro AA. I love 'em. They just don't have the 2+ years of working in an ICU experience prior to school so they have a steeper learning curve coming out of school.

 

[dannyboy1]

I'll spell it out for you if you don't know what it means. Your median CRNA new grad is going to perform better than your median AA new grad. And I've trained AA students from the majority of programs in the country.

And I'm pro AA. I love 'em. They just don't have the 2+ years of working in an ICU experience prior to school so they have a steeper learning curve coming out of school.

Again I ask? Why do we want to train more midlevels? Just as PA’s practice essentially independently the same will eventually be true of AA’s…

 

[amyl]

That sound nuts in Texas. The surgeons aren't in an uproar about having their necks on the line for the CRNAs at night? That would be like us being on the hook for a surgical PA that does surgery without the attending surgeon. Maybe it takes dramas or deaths or lawsuits for any common sense for laws/policies to change.

I read an ASA Monitor online article that a Michigan lawmaker is putting out a bill for licensure of AAs in the state of Michigan, trying to join the other 18 states that already have AAs working there. A Reddit commentor said that they are an AA but afraid to go back to their home state of Utah because they didn't want to the potential hostility of being one of the first AAs in the state with CRNAs who could resent them. That's sad and any unprofessionalism should be squashed by the administration. AAs in Missouri who live in Kansas have been trying to have licensure in Kansas but the CRNAs in Kansas keep blocking them, delay tactics, misinformation about AAs and their training/skills that the bill to license AAs in KS didn't pass. I don't have a problem working with CRNAs or AAs as long as everyone is respectful and contributes to patient safety. I do have a problem with being a liability sponge for reckless, cavalier "team members" who don't keep me informed on issues in the OR/OB.

I only have second hand info from friends. Yes initially the surgeons said no at this Baylor in the outskirts of dallas. But eventually they succumbed to be able to do cases. Lots of surgeons work more on rvu bonuses than salary…. I suppose when they made lots less $ their objections softened. Symmetry is definitely trying to expand this model in ft worth - I spoke directly to one of their site chiefs who said they’re trying to change the bylaws so surgeons supervise the crnas at night. Dfw is a 💩 show. So glad to be gone -
Dominated and ruined by AMCs- idk how metro is doing these days - they are solo MD but I hear are working much harder than they want to. 🤷‍♀️ lol isn’t everyone

 

[abolt18]

I'll spell it out for you if you don't know what it means. Your median CRNA new grad is going to perform better than your median AA new grad. And I've trained AA students from the majority of programs in the country.

And I'm pro AA. I love 'em. They just don't have the 2+ years of working in an ICU experience prior to school so they have a steeper learning curve coming out of school.

You have undoubtedly had a lot more experience with this than me, but between the new grad crnas and the new grad AAs I've worked with (and students), I've found their skills to be similar, but the AAs often have less (over)confidence.

So the new grad AAs are more likely to ask questions and call for help or even just "hey will you come look at this?" I think this can easily be interpreted as "less good" but I interpret it as being cautious while they build their knowledge, skills, and confidence. But their actual clinical decision-making abilities? Same. Knowledge about physiology and pharmacology? Same. Skills placing IVs? Probably less good.

We get a lot of AA students rotating through our hospital, and we have a fair number of new grad AAs. I see the new grads as basically mid-year to late CA-1s.

 

[NPJR]

Your median CRNA new grad is going to perform better than your median AA new grad. And I've trained AA students from the majority of programs in the country.

They just don't have the 2+ years of working in an ICU experience prior to school so they have a steeper learning curve coming out of school.

I STILL don't get it. What do you mean "perform better"? I completely disagree. If better means putting petroleum jelly on patient's lips before inserting an LMA , perhaps you are right. What counts is decision making and AAs are better. And I do not buy the prior ICU (nursing) experience as a marker for being a successful and sound clinician. If that were true graduate physicians would have a "steeper learning curve" when compared to their nurse practitioner counterparts which we know is complete horse hockey. If it were true the unit clerk who worked in the ICU for 15 years could have a "leg up" when going to medical school which we know is ridiculous. Save the ICU trope for politicians who buy it, because I don't with all due respect.

 

[NPJR]

You have undoubtedly had a lot more experience with this than me, but between the new grad crnas and the new grad AAs I've worked with (and students), I've found their skills to be similar, but the AAs often have less (over)confidence.

So the new grad AAs are more likely to ask questions and call for help or even just "hey will you come look at this?" I think this can easily be interpreted as "less good" but I interpret it as being cautious while they build their knowledge, skills, and confidence. But their actual clinical decision-making abilities? Same. Knowledge about physiology and pharmacology? Same. Skills placing IVs? Probably less good.

We get a lot of AA students rotating through our hospital, and we have a fair number of new grad AAs. I see the new grads as basically mid-year to late CA-1s.

agreed. I think I would interpret what you said is they have less experience in typical nursing duties which include venipuncture.

 

[Mman]

I STILL don't get it. What do you mean "perform better"? I completely disagree. If better means putting petroleum jelly on patient's lips before inserting an LMA , perhaps you are right. What counts is decision making and AAs are better. And I do not buy the prior ICU (nursing) experience as a marker for being a successful and sound clinician. If that were true graduate physicians would have a "steeper learning curve" when compared to their nurse practitioner counterparts which we know is complete horse hockey. If it were true the unit clerk who worked in the ICU for 15 years could have a "leg up" when going to medical school which we know is ridiculous. Save the ICU trope for politicians who buy it, because I don't with all due respect.

I see more egregious errors from the student and new AAs than I do from the student and new CRNAs.

You can feel free to disagree if you want. I'm just providing my honest real world feedback based on a lot of experience with both. There are plenty of exceptions on both sides of the equation, but I have worked with a lot of both from a lot of different schools.

 

[Mman]

Again I ask? Why do we want to train more midlevels? Just as PA’s practice essentially independently the same will eventually be true of AA’s…

Does it matter what you or I "want"? It's going to happen no matter any of our personal preferences. There are simply not enough trained professionals to deliver the amount of anesthetic care "demanded" of us. Unless someone when more than quadruple the number of residency graduates per year, you are going to need midlevels forever.

And we have plenty of threads here complaining about how horrific newly opened residency programs are.

 

[deleted87051]

Does it matter what you or I "want"? It's going to happen no matter any of our personal preferences. There are simply not enough trained professionals to deliver the amount of anesthetic care "demanded" of us. Unless someone when more than quadruple the number of residency graduates per year, you are going to need midlevels forever.

And we have plenty of threads here complaining about how horrific newly opened residency programs are.

I think horrific new residency programs are preferable to horrific new midlevel training programs.

 

[abolt18]

I see fewer egregious errors from the student and new AAs than I do from the student and new CRNAs.

You can feel free to disagree if you want. I'm just providing my honest real world feedback based on a lot of experience with both. There are plenty of exceptions on both sides of the equation, but I have worked with a lot of both from a lot of different schools.

I'm assuming you meant to say the opposite of what you said, because what you said is counter to what you stated previously?

 

[aneftp]

I'll spell it out for you if you don't know what it means. Your median CRNA new grad is going to perform better than your median AA new grad. And I've trained AA students from the majority of programs in the country.

And I'm pro AA. I love 'em. They just don't have the 2+ years of working in an ICU experience prior to school so they have a steeper learning curve coming out of school.

I’d agree with u. A new crna is likely better than a new AA.

But the skill level can either diverge or converge very quickly in any direction depending on their first couple of years of practice.

But these days. There are some crnas who have daddy anesthesiologists get them into some programs with 10 months of icu experience when u add in vacation time fresh out of bsn. Yes there are some very inexperienced fresh grad crnas I know. And their dads are anesthesiologists telling their young daughters to go to crna school.

So the myth that crnas go to icu nursing for long periods of time is slowly dwindling. It used to be the average icu nursing experience of a srna student was 7 years. It’s much shorter these days.

https://www.reddit.com/r/srna/s/k9DZHXC0cg

Justr read some of these posts. The kids have figured out the game in anesthesia

 

[Mman]

I'm assuming you meant to say the opposite of what you said, because what you said is counter to what you stated previously?

You are correct, I am confusing myself. I shall edit it.

 

[Mman]

I’d agree with u. A new crna is likely better than a new AA.

But the skill level can either diverge or converge very quickly in any direction depending on their first couple of years of practice.

I completely agree.

 

[centdoc]

Not if you’re not a lazy piece of **** with some integrity - don’t you feel some obligation to make sure YOUR patient is okay. when I’m on call and we have a case going I stalk the chart on epic and check in frequently in person and via text with my crna. I’m directing his/her actions - I’m responsible for that patient - also face time with surgeons and OR teams is important. If the anesthesiologist presence and direction is not needed then you’ve made the case for the CRNAs and we are superfluous

I think all practices should have some amount of solo anesthesiologist cases. At least this shows everyone we know exactly what to do. And not just the easy cases, and not always the hard cases. I think all-direction or all-supervision practices promote the “lazy” anesthesilogist optics, even if it’s not true.

 

[NPJR]

Does it matter what you or I "want"? It's going to happen no matter any of our personal preferences. There are simply not enough trained professionals to deliver the amount of anesthetic care "demanded" of us.

Agreed.

 

[NPJR]

Just as PA’s practice essentially independently the same will eventually be true of AA’s…

Not true if you are smart about it. If you are like the previous generation maybe. You link AA training to residency programs and the physicians administer the program. I would even lump existing PAs into the bunch to throw more wrenches into the CRNA plans. Instead of spending money fighting physicians, they'll have to fight AAs and PAs. They'll run out of money.
Have existing PAs complete 24 months of intensive anesthesia training. Enlist the American Board of ANesthesiology to have them sit for an exam and make them Associate DIplomates or Assistant Diplomates. Charge a fee of course. Cant have the name American in your organization and not make money. Revoke their certifications if they go independent. Lots of things you can do.But I agree with Mman, there aint never gonna be enough docs to sit in all the locations so supervision has to be ALWAYS part of the equation.

 

[deleted87051]

Not true if you are smart about it. If you are like the previous generation maybe. You link AA training to residency programs and the physicians administer the program. I would even lump existing PAs into the bunch to throw more wrenches into the CRNA plans. Instead of spending money fighting physicians, they'll have to fight AAs and PAs. They'll run out of money.
Have existing PAs complete 24 months of intensive anesthesia training. Enlist the American Board of ANesthesiology to have them sit for an exam and make them Associate DIplomates or Assistant Diplomates. Charge a fee of course. Cant have the name American in your organization and not make money. Revoke their certifications if they go independent. Lots of things you can do.But I agree with Mman, there aint never gonna be enough docs to sit in all the locations so supervision has to be ALWAYS part of the equation.

You’re suggesting that we set up a system of control over that workforce. We never had that and likely never will. The problem is that many anesthesia midlevels do exactly the same tasks that anesthesiologists do. After enough reps, eg 5 years of chair time, most CRNAs and AAs likely feel they can get the job done start to finish without you. Surgical specialties do a better job of using midlevels as assistants (retracting, updating H&Ps, rounding, discharges) but their midlevels don’t ever do the bone cuts, drive the screw, deploy the stent, or the sew the anastomosis.

And revoking certification of a long time practitioner for political reasons will not go over well.

 

[deleted87051]

I think all practices should have some amount of solo anesthesiologist cases. At least this shows everyone we know exactly what to do. And not just the easy cases, and not always the hard cases. I think all-direction or all-supervision practices promote the “lazy” anesthesilogist optics, even if it’s not true.

It also lets you build more rapport with surgeons and OR staff. Our local Kaiser had a policy of sitting your own cases 1day/week for decades. I think it’s more often now out of necessity.

 

[Mman]

The problem is that many anesthesia midlevels do exactly the same tasks that anesthesiologists do. After enough reps, eg 5 years of chair time, most CRNAs and AAs likely feel they can get the job done start to finish without you.

the problem with the optics of our specialty is that the overwhelming majority of our value to a patient is not able to be seen in any task that we do. Monkey skills like starting IVs or intubating can be learned by anybody. It is the thought process and decision making that creates the value to the patient and leads to better outcomes. But nobody can see that.

 

[Mman]

I would even lump existing PAs into the bunch to throw more wrenches into the CRNA plans. Instead of spending money fighting physicians, they'll have to fight AAs and PAs. They'll run out of money.

there are more RNs in this country than AAs or PAs. And the RNs are a cartel that all vote and lobby together. CRNA, NP, CNM, RN, etc. They all lobby together.

 

[NPJR]

Surgical specialties do a better job of using midlevels as assistants (retracting, updating H&Ps, rounding, discharges) but their midlevels don’t ever do the bone cuts, drive the screw, deploy the stent, or the sew the anastomosis.

And revoking certification of a long time practitioner for political reasons will not go over well.

That should tell you something. The business end of the job as a physician in anesthesia is NOT sitting in the chair and turnin'up and down the Iso.

Should it be the other way around, the CRNAs do the preop and the docs sit in the room. You would still need WAAAAYYY more docs which you would never achieve.

 

[deleted87051]

That should tell you something. The business end of the job as a physician in anesthesia is NOT sitting in the chair and turnin'up and down the Iso.

I’ve been doing anesthesia for a while now and it is for me.


One of the problems we have as a specialty is that we have so many divergent practice models that we can’t even agree what the job is.

 

[Gern Blansten]

Both work most of the time?😉

“My blocks work 100% of the time in 70% of my patients”
Apologies to Anchorman.

 

[amyl]

One of the problems we have as a specialty is that we have so many divergent practice models that we can’t even agree what the job is.

This is the problem and will be the death of the specialty. No cohesion. Divergent agendas. For every doctor that is for solo practice there’s an old guy that won’t sit his own cases. For every doctor (like me) that drives a hard red line at extended care team, there are 4 that think it’s not that big a deal if the money is right…. Or that it’s not such a big deal to let the surgeons supervise the crnas at night. We could never have a union, we don’t ever agree or work together… to our own detriment.
Unions are priceless - pilots unions have negotiated amazing things for them…. And the ASA is mostly silent

 

[jwk]

This is the problem and will be the death of the specialty. No cohesion. Divergent agendas. For every doctor that is for solo practice there’s an old guy that won’t sit his own cases. For every doctor (like me) that drives a hard red line at extended care team, there are 4 that think it’s not that big a deal if the money is right…. Or that it’s not such a big deal to let the surgeons supervise the crnas at night. We could never have a union, we don’t ever agree or work together… to our own detriment.
Unions are priceless - pilots unions have negotiated amazing things for them…. And the ASA is mostly silent

There's FAR more of an altruistic side to medicine than being an airline pilot. After being around union shops growing up, I figured out long ago that unions exist primarily to serve themselves.

 

[amyl]

There's FAR more of an altruistic side to medicine than being an airline pilot. After being around union shops growing up, I figured out long ago that unions exist primarily to serve themselves.

there may be bad unions out there… but the legacy airlines have the best- ours would be more like them because it takes a long time to make a pilot or a doctor - not the same as regular blue collar unions. You guys wouldn’t believe the benefits they get. 18% of salary in retirement accounts on top of big $. Being a pilot these days is so great it’s like a scam, being a doctor these days is getting scammed. If we got a union like the pilots have I would be first in line to sign up.

Ours would be like theirs not the blue collar unions you may think of

 

[Just D.O. it]

there may be bad unions out there… but the legacy airlines have the best- ours would be more like them because it takes a long time to make a pilot or a doctor - not the same as regular blue collar unions. You guys wouldn’t believe the benefits they get. 18% of salary in retirement accounts on top of big $. Being a pilot these days is so great it’s like a scam, being a doctor these days is getting scammed. If we got a union like the pilots have I would be first in line to sign up.

Ours would be like theirs not the blue collar unions you may think of

Oh my God, More of this "other professional careers have it so much better" line.

First of all these are subset of the best pilot jobs you are describing. They only comprise a small fraction of pilots, and are not available to early career young people. Usually they go to pilots that have "gotten experience" either by working a decade or two across much ****tier jobs or being military.

The "average" anesthesiologist is in extreme demand anywhere across the nation and will be able to live a very comfortable life making half a million or more. The "average" flight school grad is gonna get shafted.

Second, you have to account for constant geographic displacement. Again you might find me anecdotes of pilots that get to reliably choose dates and locations but these are usually very senior pilots or those that have connections with their corporate handler (so again a very small subset). I will personally promise you that if you were willing to be in a different city possibly every other night as a locums anesthesiologist. I will find you work that will pay 3-4x of what these SENIOR pilots make.

Also I may be way off base here, and maybe I need to be further educated but I have never understood the praise of mandatory retirement benefits handled by the employer vs just straight cash in this income bracket. You know with a good accountant you can simply invest part of your higher gross pay in a tax exempt account right?

 

[aneftp]

Oh my God, More of this "other professional careers have it so much better" line.

First of all these are subset of the best pilot jobs you are describing. They only comprise a small fraction of pilots, and are not available to early career young people. Usually they go to pilots that have "gotten experience" either by working a decade or two across much ****tier jobs or being military.

The "average" anesthesiologist is in extreme demand anywhere across the nation and will be able to live a very comfortable life making half a million or more. The "average" flight school grad is gonna get shafted.

Second, you have to account for constant geographic displacement. Again you might find me anecdotes of pilots that get to reliably choose dates and locations but these are usually very senior pilots or those that have connections with their corporate handler (so again a very small subset). I will personally promise you that if you were willing to be in a different city possibly every other night as a locums anesthesiologist. I will find you work that will pay 3-4x of what these SENIOR pilots make.

Also I may be way off base here, and maybe I need to be further educated but I have never understood the praise of mandatory retirement benefits handled by the employer vs just straight cash in this income bracket. You know with a good accountant you can simply invest part of your higher gross pay in a tax exempt account right?

So u don’t believe in social security? “Mandatory benefits “. Right?

Americans really don’t know how “save” for a rainy day

Look at all
Those Americans who make huge profits selling homes 2003-2006. One would think they would “roll over
The profits” to
The next home.

Most didn’t rollover the profits.

The doubled down and put zero down on the next home in 2006. Than cried for help in 2010 claimifn
Their home was under water.

My next door neighbor literally got pissed at me when I said u made 300k on ur other home. So what if ur current home is 300k underwater. Where did the 300k profit go?? Trips, cars , pay off other debt

So these mandatory benefits are dangled for retention plus know people will spend their money away.

While most of us are smart with our money. Believe it or not. There are a lot of people who have no clue how to handle money.

 

[pirate_doc]

The ABA could help with this problem but they won't. Wonder why? Right now a lot of hospitals in the act model don't let MDs do solo cases because of $ or whatever. And we have nothing to push back against that.

The ABA should require all anesthesiologists to do x number of cases solo, per year, to maintain board certification. Way more useful for quality patient care than making them answer a bunch of stupid moca questions about microagressions. And it would force hospitals to allow it if they want to maintain board certified anesthesiologists.

But who are we kidding, you can't even get an article critical of PE anesthesia groups published in ASA Monitor...

 

[kidthor]

This is the problem and will be the death of the specialty. No cohesion. Divergent agendas. For every doctor that is for solo practice there’s an old guy that won’t sit his own cases. For every doctor (like me) that drives a hard red line at extended care team, there are 4 that think it’s not that big a deal if the money is right…. Or that it’s not such a big deal to let the surgeons supervise the crnas at night. We could never have a union, we don’t ever agree or work together… to our own detriment.
Unions are priceless - pilots unions have negotiated amazing things for them…. And the ASA is mostly silent

The lack cohesion is a major issue in organizing for advocacy. There are too many who are complacent with the sketchy/lazy conditions you mentioned. I think those are more common with some of the boomers and also associated with some of the legacy exploitation models of group management (now becoming way less common). One factor of emerging cohesion is that we are all mostly employees at this point, so the conflicted mindsets of group mangers/owners is becoming less of an issue.

There are major downsides in being in a true union - as others mentioned the union can often exist to perpetuate itself and there can be tons of infighting. Cedars unionized which made conditions instantly better compared to before, but now they have tons of infighting I hear.

The ASA can't and shouldn't be a union, but it really should represent our interests as members. So much of their inaction is based on corporate capture, as they want to placate corporate elements of NAPA, Envision, USAP, and the like. Yet they don't want to actually represent its paying members. We should be holding their feet to the fire and as members demand they actually represent anesthesiologists rather than supplicating to corporate overlords.

As an example - I've had a few arguments with ASA leadership on why they don't advocate against noncompete agreements and don't advocate against the corporate practice of medicine or private equity ownership of groups - or why they don't advocate for true workplace physical safety or for safe staffing for direction or supervision (they had a panel advocating for 1:10+ supervision last year!). Each time they try to gaslight me and tell me to give more to the PAC, and that I just don't understand what they ASA does or what the PAC does. Odd to be a membership organization that collects ever-escalating funds from members - yet tells the members that they're to simple-minded to understand the organization?

 

[kidthor]

But who are we kidding, you can't even get an article critical of PE anesthesia groups published in ASA Monitor...

Absolutely. That reminds me of Dr. Answine's article highlighting his experience with a private equity backed corporate takeover at his workplace.

To quote his preface there:

"I penned this editorial, and it was accepted for publication in the ASA Monitor (January 2024). At the last minute, it was pulled because “it raised some objections with ASA [American Society of Anesthesiologists] senior leadership.” It was not created to blame but is a written account of an unfortunate series of events leading to the almost total dismantling of a proud and successful group of anesthesiologists, the placement of a national provider of anesthesia in an improbable situation for success, and a large hospital system pushed to near closure of surgical services."

It's a great article.

 

[aneftp]

The ABA could help with this problem but they won't. Wonder why? Right now a lot of hospitals in the act model don't let MDs do solo cases because of $ or whatever. And we have nothing to push back against that.

The ABA should require all anesthesiologists to do x number of cases solo, per year, to maintain board certification. Way more useful for quality patient care than making them answer a bunch of stupid moca questions about microagressions. And it would force hospitals to allow it if they want to maintain board certified anesthesiologists.

But who are we kidding, you can't even get an article critical of PE anesthesia groups published in ASA Monitor...

MD solo at $350/hr is equivalent to crna at $200/hr plus agency fees. 1099

Except hospitals or amc try to pay MDs $300-hr or even less w2 (in Florida)

Crnas up north like Pittsburgh area get around $250/hr or higher plus travel and agency fees so that’s like paying MD $400/hr w2 solo

So we have a compensation supply and demand issue

 

[psychbender]

MD solo at $350/hr is equivalent to crna at $200/hr plus agency fees. 1099

Except hospitals or amc try to pay MDs $300-hr or even less w2 (in Florida)

Crnas up north like Pittsburgh area get around $250/hr or higher plus travel and agency fees so that’s like paying MD $400/hr w2 solo

So we have a compensation supply and demand issue

Is it an issue with supply and demand, or is it an issue with hospital administrators being ******ed, and not realizing that they pay more for ACT than they would for physician solo?

Now, before anyone starts the "BuT tHeRe'S nOt eNoUgH dOcToRs!" argument, I bet that there are enough to change practices from entirely ACT to a mix of solo and ACT, and just pay the solo docs less than the directing docs. Let people *gasp* make their own decision about how they want to work and get paid.

 

[aneftp]

Is it an issue with supply and demand, or is it an issue with hospital administrators being ******ed, and not realizing that they pay more for ACT than they would for physician solo?

Now, before anyone starts the "BuT tHeRe'S nOt eNoUgH dOcToRs!" argument, I bet that there are enough to change practices from entirely ACT to a mix of solo and ACT, and just pay the solo docs less than the directing docs. Let people *gasp* make their own decision about how they want to work and get paid.

Unfortunately with the way most hospitals (that I go to) it becomes solo after 5-7p.

To answer ur question (more of a non answer ). Hospitals don’t care how the cases get done.

just looking over the schedule tomorrow. 2 docs at each site are solo at 4 of the 10 sites of (6 hospitals and 4 ASC) of coverage. So it’s not all 1:4 model.

 

[kidthor]

Now, before anyone starts the "BuT tHeRe'S nOt eNoUgH dOcToRs!" argument, I bet that there are enough to change practices from entirely ACT to a mix of solo and ACT, and just pay the solo docs less than the directing docs. Let people *gasp* make their own decision about how they want to work and get paid.

Totally. They always claim there aren't enough doctors or nurses, yet during COVID employers went on a healthcare worker firing rampage and some went so far as to blame the healthcare workers for being "overpaid". Yet magically now there's a shortage? Same as how the overlords always claims there aren't enough engineers or computer scientists (and therefore supposedly need to then underpay H1B workers to make up the deficit) - yet magically now all the tech companies are also on a firing spree.

It's all supply and demand - pay people enough and there will be plenty of workers wherever and whenever needed. The there aren't enough doctors (or whatever) argument is really "there aren't enough doctors who'll work for the low amount I will pay under horrible conditions - so it's the doc's fault not mine".

 

[Mman]

It's all supply and demand - pay people enough and there will be plenty of workers wherever and whenever needed. The there aren't enough doctors (or whatever) argument is really "there aren't enough doctors who'll work for the low amount I will pay under horrible conditions - so it's the doc's fault not mine".

It takes 12 years for a high school student to become an anesthesiologist. And we can't open new residency spots fast enough to keep up with the growing demand. Stop pretending normal market forces have anything to do with supply/demand in anesthesia. It isn't a functional free market for services. And many anesthesiologists are financially secure enough that they wouldn't work extra almost no matter what you paid them. There just isn't some large pool of underworked people to pull from.

 

[pgg]

It's a weak medically directed practice if the CRNAs don't take direction.

It's easy to say that, but the reality of the world today is that most care team practices have locums CRNAs breezing through from time to time, and some of them are militant clowns who are accustomed to doing their own thing. The passive aggressive games they play are real. By the time they're identified as problems, their assignment is often up, and another seven bodies are processed in through credentialing.

 

[psychbender]

It takes 12 years for a high school student to become an anesthesiologist. And we can't open new residency spots fast enough to keep up with the growing demand. Stop pretending normal market forces have anything to do with supply/demand in anesthesia. It isn't a functional free market for services. And many anesthesiologists are financially secure enough that they wouldn't work extra almost no matter what you paid them. There just isn't some large pool of underworked people to pull from.

Normal market forces do still apply for anesthesia. If a hospital offers $350k for 55hrs/wk 1:4 direction, and 8 weeks off, and they're not in a highly desirable area, few will apply. The problem for that hospital is not a national lack of supply, it's a local lack of supply caused by inadequate compensation for work expected. Increase compensation and change work conditions, and the effective supply of anesthesiologists to that location will increase.

I also don't think that the majority of anesthesiologists are as financially secure, and not willing to go after extra work, as you claim. We have many on this forum living the money-chasing locums life, many more supplementing their fulltime jobs with locums, I know a ton leaving their fulltime jobs for more control and money elsewhere, and a lot more that are uncertain enough in their financial wellbeing that they put up with an abusive system instead of looking for other work.

 

[Mman]

Normal market forces do still apply for anesthesia. If a hospital offers $350k for 55hrs/wk 1:4 direction, and 8 weeks off, and they're not in a highly desirable area, few will apply.

it's still not a free market, it's severely constrained in supply. If your local diner started offering people $500 an hour to wait tables, there would be a nearly unlimited supply of applicants. If your local hospital offered $500 an hour to be an anesthesiologist, there would be infinitely fewer applicants.

I'm not saying there are no market forces, clearly there are. But we can't just act like simply offering to pay somebody more would fix the supply issues. It wouldn't. And while lots of posters on the internet are living the locums life and supplementing their pay with locums side gigs, I bet there is a near order of magnitude greater number of anesthesiologists not posting online that have less than zero interest in doing so. This isn't exactly a representative sample of the work force.

 

[Gern Blansten]

it's still not a free market, it's severely constrained in supply. If your local diner started offering people $500 an hour to wait tables, there would be a nearly unlimited supply of applicants. If your local hospital offered $500 an hour to be an anesthesiologist, there would be infinitely fewer applicants.

I'm not saying there are no market forces, clearly there are. But we can't just act like simply offering to pay somebody more would fix the supply issues. It wouldn't. And while lots of posters on the internet are living the locums life and supplementing their pay with locums side gigs, I bet there is a near order of magnitude greater number of anesthesiologists not posting online that have less than zero interest in doing so. This isn't exactly a representative sample of the work force.

I think it’s both. The supply is limited and it leads to an arms race of who is willing to pay the rate that is needed to get that limited supply. For instance, a hospital or group may lag behind in compensation and be severely short staffed. If that hospital suddenly gets to market value or higher, people will suddenly become available. However, the hospital they left will be faced with the need to increase their compensation package. The arms race is not sustainable on its current trajectory and its breaking the system. There must be a breaking point in there somewhere. It just hasn’t happened yet. My fear is that CEOs will begin to consider other cheaper options, as they already have. Whether it’s emergency medicine doctors practicing outside their training or CRNAs unsupervised, or RNs doing more aggressive deep sedation. The safety issue will be huge, but I think CEOs will look at the financial bottom line and determine that something has to give to allow the leverage to be back in their favor.

 

[aneftp]

I think it’s both. The supply is limited and it leads to an arms race of who is willing to pay the rate that is needed to get that limited supply. For instance, a hospital or group may lag behind in compensation and be severely short staffed. If that hospital suddenly gets to market value or higher, people will suddenly become available. However, the hospital they left will be faced with the need to increase their compensation package. The arms race is not sustainable on its current trajectory and its breaking the system. There must be a breaking point in there somewhere. It just hasn’t happened yet. My fear is that CEOs will begin to consider other cheaper options, as they already have. Whether it’s emergency medicine doctors practicing outside their training or CRNAs unsupervised, or RNs doing more aggressive deep sedation. The safety issue will be huge, but I think CEOs will look at the financial bottom line and determine that something has to give to allow the leverage to be back in their favor.

I have no fear of crnas taking my job. It’s so funny when I troll the militant ones. I tell them mommy tracks docs are working solo for $250/hr. Than their response is to say. They (the crna) $250/hr. I said fine. But u realize u are costing the hospital $350-hr with ur 1099 gigs. They seem so dumbfounded. I said. Sure offer the offer direct $250/hr w2. They refused lol.

That’s when I realize docs shouldn’t be concerned with these crnas. They have not only become so money hungry (can’t blame them). They wanr and pick and choose when and what days they want to work. And want to leave at 3/5pm whatever. It’s the nurse mentality.

As for alternative cheaper providers like paramedics. Sure let them do it. Pay them $100/hr (which I know from oral max offices have done). If they can get away with it. Great.

 

[Hoya11]

I think it’s both. The supply is limited and it leads to an arms race of who is willing to pay the rate that is needed to get that limited supply. For instance, a hospital or group may lag behind in compensation and be severely short staffed. If that hospital suddenly gets to market value or higher, people will suddenly become available. However, the hospital they left will be faced with the need to increase their compensation package. The arms race is not sustainable on its current trajectory and its breaking the system. There must be a breaking point in there somewhere. It just hasn’t happened yet. My fear is that CEOs will begin to consider other cheaper options, as they already have. Whether it’s emergency medicine doctors practicing outside their training or CRNAs unsupervised, or RNs doing more aggressive deep sedation. The safety issue will be huge, but I think CEOs will look at the financial bottom line and determine that something has to give to allow the leverage to be back in their favor.

Hospitals would have a much easier time with anesthesia staffing if they made their surgical scheduling efficient and not catered to the surgeons.

The idea that surgeons are the top of the pyramid and everyone must bend and cater to them and bring in staff they like and buy equipment they prefer is the root of the problem.

Yes you have to wait. No this isn’t an emergency. I don’t care that your schedule is full at your asc tomorrow. No you don’t get 2 rooms. No that case is cancelled she’s 90 and intubated her hip doesn’t need fixing.

Until we settle those issues , our staffing problems will go on. Good for our bottom line I guess. That’s why I think everyone is quiet about it. But what a tremendous waste for the healthcare system ..

 

[aneftp]

Hospitals would have a much easier time with anesthesia staffing if they made their surgical scheduling efficient and not catered to the surgeons.

The idea that surgeons are the top of the pyramid and everyone must bend and cater to them and bring in staff they like and buy equipment they prefer is the root of the problem.

Yes you have to wait. No this isn’t an emergency. I don’t care that your schedule is full at your asc tomorrow. No you don’t get 2 rooms. No that case is cancelled she’s 90 and intubated her hip doesn’t need fixing.

Until we settle those issues , our staffing problems will go on. Good for our bottom line I guess. That’s why I think everyone is quiet about it. But what a tremendous waste for the healthcare system ..

I used to think that way. But with facilities fees so high. Hospitals don’t care if they need to pay extra for overtime etc. they will complain about coverage with anesthesia if u are third party or independent private practice.

But they will
Cough up
The cash these days.