Specialization within a PP group

[seinfeld]

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Curious how other groups are handling the increased specialization in anesthesia. IE how are groups handling the recent rec's from the ASA regarding TEE use during cardiac, separate cardiac call? How about regional for Ortho, is everyone doing it or do you all dabble. How about outpt anesthesia? Being an ICU trained guy who does 40% ICU i rarely go to the outpt centers, is it really the best model for pt care to send me out there once every 3-4 months?

Thoughts on what the best best direction anesthesiology should take and how PP groups are managing the increased specialization for TEE, Regional, Ambulatory etc.

 

[urge]

Ambulatory and regional specialization? Wut?

 

[IlDestriero]

Curious how other groups are handling the increased specialization in anesthesia. IE how are groups handling the recent rec's from the ASA regarding TEE use during cardiac, separate cardiac call? How about regional for Ortho, is everyone doing it or do you all dabble. How about outpt anesthesia? Being an ICU trained guy who does 40% ICU i rarely go to the outpt centers, is it really the best model for pt care to send me out there once every 3-4 months?

Thoughts on what the best best direction anesthesiology should take and how PP groups are managing the increased specialization for TEE, Regional, Ambulatory etc.

Funny story about a group I almost joined. The new chairman was a great guy and we hit it off right away. When he took over, from being chair elsewhere, there was a group of 3 partners that only did Neuro. Nothing else. He told them that was going to end and that they would have to go into the call pool, or buy out, and do all cases. They said, in writing, that they were Pediatric Neuroanesthesiologists, and had been for several years. His reply was that there is no such thing, so get with the program or get out. One stayed. I guess they thought it really existed.
I work at a big specialty hospital. We have teams for Fetal, liver tx, ASCs, craniofacial, blocks/pain and cardiac. We also have loose teams for offsights (gi, rads, IR). From my experience, the icu guys usually want to do the trainwrecks. There's talk of possible teams for neuro and Ortho spine. Lots of overlap.

 

[seinfeld]

Ambulatory and regional specialization? Wut?

Considering there exist sub-societies within the ASA for specifically these arenas i am not alone.

From a practical standpoint (whether a board certified anesthesiologist should be able to perform certain things is a completely different thread) not everyone can do regional, TEE, or be smooth at the nuances of outpt surgery and the anesthesia required.

Getting back to my original question. Urge would your group run more efficiently and would the regional/Cardiac cases go more smoothly if you had a dedicated group of anesthesiologists? If you were a patient would you want a guy who does a femoral nerve block once every six months or 15 a week?

I ask this in all earnest. Should anesthesia practice continue to be a "family practice" type field were we know a little about a lot or should we start trying to be specialists within our filed and know more about a little?

 

[aredoubleyou]

The real underlying question is how are people paid. Chair time, then maybe the icu guy likes trainwrecks when in the or. Units, the icu guy likes total knees with fem caths in each. Am i wrong?

 

[Planktonmd]

The recent trend of creating imaginary sub-specialties in anesthesiology is another step towards the demise of this field.
Why on earth do you need to be a specialist to do regional???
Or to do ambulatory anesthesia?
Or Neuroanesthesia?
Or even pediatric anesthesia?
None of these things is rocket science and 3 years residency should be more than enough to master all of them (assuming one has no missing chromosomes and an IQ above 70%).

 

[IN2B8R]

The recent trend of creating imaginary sub-specialties in anesthesiology is another step towards the demise of this field.
Why on earth do you need to be a specialist to do regional???
Or to do ambulatory anesthesia?
Or Neuroanesthesia?
Or even pediatric anesthesia?
None of these things is rocket science and 3 years residency should be more than enough to master all of them (assuming one has no missing chromosomes and an IQ above 70%).

Could not agree more.... Becoming proficient at something is key, be that TEE or regional, etc.... So it all depends on the practice that you are in: if you are in a "do it all" type of practice, then there needs to be no subspecialists, period.

 

[G-Man82]

The recent trend of creating imaginary sub-specialties in anesthesiology is another step towards the demise of this field.
Why on earth do you need to be a specialist to do regional???
Or to do ambulatory anesthesia?
Or Neuroanesthesia?
Or even pediatric anesthesia?
None of these things is rocket science and 3 years residency should be more than enough to master all of them (assuming one has no missing chromosomes and an IQ above 70%).

It was the "generalist" aspect of anesthesiology that drew me to this specialty in the first place. The same anesthesiologist could in one day theoretically do an emergent OB case, a routine neuro case, take the transplant that turned up, and later participate in trauma resuscitation. Unlike a lot of the medical and surgical specialties, anesthesiologists did not have to become body-part specialists. I was always under the impression that fellowships were taken if the resident either wanted more exposure to a certain field (e.g. neuro, OB, peds, regional), or wanted to spend time practicing outside the OR (pain and CCM). It'll be interesting to see if that changes during the course of my residency, especially since I finish as the Obamacare changes take full force in 2014.

 

[Jay K]

Would your group run more efficiently and would the regional/Cardiac cases go more smoothly if you had a dedicated group of anesthesiologists?

Plank and Urge's responses are spot-on.

These sub-specialist societies have their roles, but a lot of it has to do with academics and innovation/progress within those fields. In private practice, as you have inquired, this would not be efficient (cause you asked); Unless you're a Children's hospital or Texas Heart Institute - maybe having subspecialists would be more efficient. Every partner should ideally be able to do everything - and do it well. I can tell you if I couldn't do blocks, peds, OB, cardiac, ambulatory or anything else "subspecial" well, I probably wouldn't have stayed a partner for very long.

On the flip-side: Our general surgeons do AV fistula's/grafts. Our cardiac surgeons do CEA's and AAA's. There's nothing that says a vascular surgeon has to do them. Do we have vascular surgeons? Sure. But the GS and CV guys get the referrals... why? One reason is they're better - even if they aren't sub-specialized in the field.

 

[Masseter Spasm]

I think that the sub-specialization that one sees within academics is driven by several factors.

Academic hospitals tend to be large, requiring a large anesthesia group. Some surgeons prefer to work with a small group of anesthesiologists. ("I am sick of having to work with 50 different anesthesiologists. We need to form a cataract team, so that I get a consistent anesthesia.")
Also sub-specialization is also influenced by call. (It is not really possible to be responsible for a cardiac case, transplant, general OR cases, and/or OB simultaneously.) For this reason academic groups create entities like OB, cardiac, transplant, pain, general, and/or pediatric call to balance off hours clinical demands. (Private Practice usually just assigns "backup call" so that the primary attending has additional help if needed.)

I think that one unintended consequence of this subspecialization is political division within the anesthesia department. ("The cardiac guys have it easy, the general call people do not have to take as much call as me, etc...") One of the benefits of joining a reasonably-sized private practice group should be that transparency increases. If everybody has roughly the same responsibilities, call obligations and compensation decisions should seem more equitable.

 

[seinfeld]

Every partner should ideally be able to do everything - and do it well. .

I agree but not the reality in life. Most people just want to get by and get a check.

I appreciate everyone replies.

Although i wish i could be the best at everything i feel the technology will continue to evolve and certain arenas of anesthesiology will require specialization.

If patients wanted doctors who handled all comers than family practitioners would be the most sought after by the public and internists, pediatricians, and obstetricians would only be used as consultants.

Some states are starting to link the anesthesiologist (along with the surgeon) to outcome in cardiac surgery. Wonder where that will take us as specialty?

 

[proman]

Just speaking as a resident with a bit of exposure to some private practices, it seems that only the high-volume private practices would benefit from the subspecialist anesthesiologists. I spent a month at a place that did 1000 hearts a year, and had the best outcomes in the state. It was 1 private group but only fellowship trained cardiac anesthesiologists did the hearts. I see peds as the same. Only the pediatric hospitals are really interested in fellowship trained, with some exceptions. Peds seems to either be a marketing scheme for the healthy ones, or really needed for the young (<1 year) or really sick kids. Regional/ambulatory/neuro/ortho?/spine etc only really seems important in the academic centers, where you'd expect the advancement of the specialty to occur.

 

[deleted126335]

Curious how other groups are handling the increased specialization in anesthesia. IE how are groups handling the recent rec's from the ASA regarding TEE use during cardiac, separate cardiac call? How about regional for Ortho, is everyone doing it or do you all dabble. How about outpt anesthesia? Being an ICU trained guy who does 40% ICU i rarely go to the outpt centers, is it really the best model for pt care to send me out there once every 3-4 months?

Thoughts on what the best best direction anesthesiology should take and how PP groups are managing the increased specialization for TEE, Regional, Ambulatory etc.

These can be big issues of contention in small-mid size groups. In my last group, a core subset of the group did hearts during the day, but there was no separate cardiac call. The surgeons pushed for it, but there was no way we could work it out amongst ourselves.

 

[Voodoo]

I think subspecialization should probably be dictated by the nature of your practice. For example, I work in a group of approx 40 anesthesiologists. We have about 600 deliveries/month and our hospital contract requires in-house coverage. But the OB department wants us to limit the number of providers so that we stay in practice (I don't necessarily agree with this) and can move relatively quickly. Our solution is to allow about half of us to be in the OB call pool (separate from OR call).

We have a heart call pool of about 9 providers who take OR call but also get called back for pump bring backs. We have a peds call pool for kids < 2. I wasn't happy about the peds thing because unless you're grandfathered in, they want you to have a peds fellowship. But then again when I see 2 day olds coming in for omphalocele surgery I cringe and thank my lucky stars that I don't have to do that.

Is that laziness or complacency? I don't know. My residency didn't give me the strongest training in really young kids so I'm ok with that.

There seems to be an alarming trend of making special "ambulatory" subspecialties. Give me a break. In our practice, we have a couple surgeons who only want a couple providers they are "comfortable" with. To me, that's the strength of the group - the ability to say "screw you" to such ludicrous requests.