Thank You ASA

[BLADEMDA]

I started posting on SDN about practice issues with Anesthesiology 5 years ago. At that time I was in the minority. The leadership and SDN had not yet come to recognize the scope and breadth of the problems we face as a specialty. I am glad to post that this is no longer the case.

In this month's ASA Newsletter (January 2012) our leadership has made it crystal clear that the future, if there is one, of this specialty must be different than our past. We must adapt or die. The articles were well written and showed a true grasp of our current threats and future obsolescence unless we adapt to the upcoming health care system.

Dr. kapur must be commended for her excellent understanding of this topic and how we must lead into the future or be left behind. There is no doubt that we must evolve into full perioperative physicians in order to maintain our necessity in the Obama health care system.

I am grateful to SDN for providing a platform to engage in these discussion where others could read and understand about our specialties problems. ASA has heard the message and is now fully on board. All the issues I have posted about are directly or indirectly mentioned in this month's newsletter. Now that we agree on the problems let's work on the solutions.

I propose that the ASA/ABA immediately rework the PGY 1 thru PGY 5 years to include a fellowship in two subspecialties: critical care and another of your choice such as Peds or Cardiac. CCM must be incorporated into our training so every graduate finishes with enough time (12 months) to sit for the Critical Care exam.

For those of us in private practice academia should provide a pathway for CCM certification.
For example, I did 6 months of ICU as a resident and am willing to return to a Training program to finish another 6 months at my own personal cost. Unfortunately, at this time no such option exists for experienced Anesthesiologists There are quite a few of us private practitioners committed to this specialty; we stand ready to help our field evolve out of the OR. Critical Care Medicine in the USA is in need of more good,solid physicians to provide care to our aging population. I stand ready to join the effort.

Dr. Kapur mentions the example of The Kodak company. If we are to avoid becoming the next Kodak then the market place dictates we provide a service to the customer that is both needed and valued at all levels. We must be more than a stool sitter.

Kudos to the ASA leadership for their efforts. Now we must step up to the next level and fundamentally transform this specialty from gas passer to perioperative physician. I for one embrace this essential transformation.

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[ArMed]

Blade, on the interview trail I happened on a program in the tri-state who's PD shared many of your sentiments. In fact, he was very excited about a fellowship program in which he was in the midst of crafting. The details seemed a little vague, but the idea was that the program would be a Perioperative Medicine Fellowship with focuses on postoperative care and patient safety. It seemed heavily academic from its description, but the PD's main goal in its formulation was to further specialize the field in general.

 

[ICUTEEDOC]

as a soon to be certified CC anesthesiologist I can tell you how frustrating it is to see the lack of opportunity to practice my fellowship in PP at least in my area. I look forward to the day where we can compete with pulm/cc on a level playing field.

 

[deleted126335]

I heard Dr. Kapur's talk at the ASA. Trying to read between the lines, everybody in all professions (MD, CRNA, or AA) seek to defend or ideally expand their turf. Given economic realities, IF we put all of our efforts on defending every bit of turf in the realm of the OR, the ASU, the dental office, endo suite, cataract center, podiatrist office, etc. we will be fighting the wrong war at the wrong time and doomed to failure. That we should embrace the perioperative physician concept and not fight and waste resources where we are destined to lose due to economic realities.

Thinking big picture, this is in the long term best interest of the medical specialty of anesthesiology. It is also not in the best interest of many of the current generation of practicing anesthesiologists.

Bitter pill. Regrettably I agree.

 

[scudrunner]

I was at the conference and heard the lecture. I did not care for several aspects of it, especially the hands-off tele-anesthesiologists concept. But, I'm all for the peri-operative physician/surgical home concept. I agreed with Dr. Bacon's article in the Dec Newsletter. Adapt and expand, yes. Get pushed out of the way and give up ground, no

 

[deleted126335]

No one cares for what has happened in medicine over the last 20 years. No one cares for what we think is coming. The question is how to respond.

 

[G0S2]

At my soon to be fellowship institution the PD asked if I was doing CCM or CCM/CT. I told him only CCM and he said of the 2 that was the best choice/bet for the future. We are getting it and applications for CCM spots are up. My bet is we will start (10 yrs) to compete in the PP arena.

 

[Bertelman]

At my soon to be fellowship institution the PD asked if I was doing CCM or CCM/CT. I told him only CCM and he said of the 2 that was the best choice/bet for the future. We are getting it and applications for CCM spots are up. My bet is we will start (10 yrs) to compete in the PP arena.

This wouldn't happen to be the PD of your CCM fellowship, would it?

 

[Doctor4Life1769]

This wouldn't happen to be the PD of your CCM fellowship, would it?

he said it was.

 

[BLADEMDA]

I heard Dr. Kapur's talk at the ASA. Trying to read between the lines, everybody in all professions (MD, CRNA, or AA) seek to defend or ideally expand their turf. Given economic realities, IF we put all of our efforts on defending every bit of turf in the realm of the OR, the ASU, the dental office, endo suite, cataract center, podiatrist office, etc. we will be fighting the wrong war at the wrong time and doomed to failure. That we should embrace the perioperative physician concept and not fight and waste resources where we are destined to lose due to economic realities.

Thinking big picture, this is in the long term best interest of the medical specialty of anesthesiology. It is also not in the best interest of many of the current generation of practicing anesthesiologists.

Bitter pill. Regrettably I agree.

The time has Come to prepare the Anesthesiology Resident of 2012 for his/her future. This means reworking of the Residency itself so the newly minted Anesthesiologist will still be valuable to hospitals circa 2025.

 

[Bertelman]

he said it was.

I assumed so, but maybe he met with another PD at his fellowship institution, like the residency PD or something. There are probably like 50 PDs at WashU.

My implied point is that of course the CCM PD is going to say that CCM is the most valuable.

 

[Doctor4Life1769]

I assumed so, but maybe he met with another PD at his fellowship institution, like the residency PD or something. There are probably like 50 PDs at WashU.

My implied point is that of course the CCM PD is going to say that CCM is the most valuable.

Ah, I hear ya.

As for your point... that is true. It's like being a med student and being told by each attending in their respective field how "they are the best."

 

[Doctor4Life1769]

At the rate everyone's talking, it's as if we're going to turn into Radiology, necessitating a fellowship.

In real life, not so much.

 

[G0S2]

I assumed so, but maybe he met with another PD at his fellowship institution, like the residency PD or something. There are probably like 50 PDs at WashU.

My implied point is that of course the CCM PD is going to say that CCM is the most valuable.

There are many dual-trained CCM attendings at Wash U in the CCM dept. I truly believe he was giving me his honest assessment thinking about the need for more intensivists overall.

Do you need a fellowship to do CT anesthesia? I guess if you want to be TEE boarded. You do need a fellowship to be an attending in the unit.

The combined fellowship, however, is the ultimate in training like my PD at my home institution said, there are more and more people with dual training at CCM meetings.

 

[Bertelman]

There are many dual-trained CCM attendings at Wash U in the CCM dept. I truly believe he was giving me his honest assessment thinking about the need for more intensivists overall.

Do you need a fellowship to do CT anesthesia? I guess if you want to be TEE boarded. You do need a fellowship to be an attending in the unit.

The combined fellowship, however, is the ultimate in training like my PD at my home institution said, there are more and more people with dual training at CCM meetings.

I'm guessing you'll need a CT fellowship to do hearts 10 yrs from now, which is when you predict the CCM market for anesthesia will open up. As it stand today, more than 50% of the jobs I see advertised for any significant cardiac volume are looking for fellowship training or similar TEE certification. Newly trained surgeons are expecting it, groups like to advertise their certs, and hospital admins probably like it, too.

You don't need a fellowship to do Peds, either, but that is often quoted as the most valuable fellowship on this forum.

I'm not saying cardiac is the best fellowship to do- obviously I'm biased, as you are. We all want to know that the decision we have made will pay off in security and cash for the next 30 yrs. I just don't think anyone here is wise enough to tell me with certainty that out of Peds/CCM/Cards one of those will somehow be more valuable in 10 yrs

 

[michigangirl]

I'm guessing you'll need a CT fellowship to do hearts 10 yrs from now, which is when you predict the CCM market for anesthesia will open up. As it stand today, more than 50% of the jobs I see advertised for any significant cardiac volume are looking for fellowship training or similar TEE certification. Newly trained surgeons are expecting it, groups like to advertise their certs, and hospital admins probably like it, too.

You don't need a fellowship to do Peds, either, but that is often quoted as the most valuable fellowship on this forum.

I'm not saying cardiac is the best fellowship to do- obviously I'm biased, as you are. We all want to know that the decision we have made will pay off in security and cash for the next 30 yrs. I just don't think anyone here is wise enough to tell me with certainty that out of Peds/CCM/Cards one of those will somehow be more valuable in 10 yrs

You don't need a fellowship to do routine peds anesthesia but you do need a fellowship to get hired in tertiary care academics where the kids are tiny and sick as #%. The pedi anesthesia jobs for those positions are out there-- and the sick and tiny kids aren't going anywhere-- in fact, with more and more preemies surviving (for better or worse), transplant techniques evovling, the numbers are only increasing for kids with multiple co-morbidities coming in for complex surgery. I don't have numbers to back this up, but anecdotally, it's true. I don't see CRNAs infringing on my NICU/PICU population and cases. I'm not saying its the best fellowship to do, but it's a great option. And of course, I'm biased

 

[BLADEMDA]

You don't need a fellowship to do routine peds anesthesia but you do need a fellowship to get hired in tertiary care academics where the kids are tiny and sick as #%. The pedi anesthesia jobs for those positions are out there-- and the sick and tiny kids aren't going anywhere-- in fact, with more and more preemies surviving (for better or worse), transplant techniques evovling, the numbers are only increasing for kids with multiple co-morbidities coming in for complex surgery. I don't have numbers to back this up, but anecdotally, it's true. I don't see CRNAs infringing on my NICU/PICU population and cases. I'm not saying its the best fellowship to do, but it's a great option. And of course, I'm biased

I agree with you. The best fellowships are Peds, Cardiac, Pain and CCM. Regional, OB and Neuro are fine if you want/need more exposure than you got in CA1-CA3.

 

[BLADEMDA]

I'm guessing you'll need a CT fellowship to do hearts 10 yrs from now, which is when you predict the CCM market for anesthesia will open up. As it stand today, more than 50% of the jobs I see advertised for any significant cardiac volume are looking for fellowship training or similar TEE certification. Newly trained surgeons are expecting it, groups like to advertise their certs, and hospital admins probably like it, too.

You don't need a fellowship to do Peds, either, but that is often quoted as the most valuable fellowship on this forum.

I'm not saying cardiac is the best fellowship to do- obviously I'm biased, as you are. We all want to know that the decision we have made will pay off in security and cash for the next 30 yrs. I just don't think anyone here is wise enough to tell me with certainty that out of Peds/CCM/Cards one of those will somehow be more valuable in 10 yrs

The best fellowship is the one which keeps you employed years 15-30 of your career and not year 1-15. I know that may sound odd but it's the reality you face.

 

[DrRobert]

I wipe my ass with critical care. On the other hand, I love OR anesthesia. The most painful months of my life were spent during my ICU rotations. If anesthesia ever got to the point where critical care was required, I would retire. Thankfully I will be able to live out my career in the OR only.

 

[BLADEMDA]

I wipe my ass with critical care. On the other hand, I love OR anesthesia. The most painful months of my life were spent during my ICU rotations. If anesthesia ever got to the point where critical care was required, I would retire. Thankfully I will be able to live out my career in the OR only.

Yes, many Anesthesiologists feel the exact same way but without the colloquial expression.

However, it may get to the point in 10-15 years that critical care is indeed required and then you are welcome to retire.

 

[DrRobert]

If that's the way this profession is going I would strongly encourage med students to do rotations in both anesthesia and pulm/cc before deciding on anesthesia.

They are entirely different animals. The critical care guys at my hospital are miserable human beings. They work twice as hard as we do, make half as much money, and have to deal with all the family/social/end of life crap. You can see the envy in their eyes when you drop off that ruptured AAA in their unit at 2am after you got to put in all the lines, do the resuscitation, and then wheel the patient to the ICU and move on to the next case. They know that for the next couple days they will have to deal with the loads of complications guaranteed to arise, only to see that patient die in their ICU. Multiply that by several patients each day, and they are literally in hell.

 

[michigangirl]

If that's the way this profession is going I would strongly encourage med students to do rotations in both anesthesia and pulm/cc before deciding on anesthesia.

They are entirely different animals. The critical care guys at my hospital are miserable human beings. They work twice as hard as we do, make half as much money, and have to deal with all the family/social/end of life crap. You can see the envy in their eyes when you drop off that ruptured AAA in their unit at 2am after you got to put in all the lines, do the resuscitation, and then wheel the patient to the ICU and move on to the next case. They know that for the next couple days they will have to deal with the loads of complications guaranteed to arise, only to see that patient die in their ICU. Multiply that by several patients each day, and they are literally in hell.

It's been a few years since I've done any adult critical care, but I think its very important for the medical students to understand there is a big difference between anesthesia/surgical critical care and pulm/med critical care. You couldn't pay me enough to work in a medical ICU. At least in my institution the cardiac surgery ICU and surgical ICU can only be staffed by surgeons or anesthesiologists. These folks don't go anywhere near the medical ICU, the only exception being the neurocritical care unit where you have a mix of post-surgical/TBI/stroke where anesthesiologists and neurologists co-exist.

Pulm/cc will not expose students to high-acuity post-surgical ICU care that is the norm for most large tertiary care centers. I love post-op ICU care in kids and adults-- taking my skills from the OR to peri-op is rewarding. but straight up adult medical ICU I will leave to pulm/cc friends.

 

[BLADEMDA]

If that's the way this profession is going I would strongly encourage med students to do rotations in both anesthesia and pulm/cc before deciding on anesthesia.

They are entirely different animals. The critical care guys at my hospital are miserable human beings. They work twice as hard as we do, make half as much money, and have to deal with all the family/social/end of life crap. You can see the envy in their eyes when you drop off that ruptured AAA in their unit at 2am after you got to put in all the lines, do the resuscitation, and then wheel the patient to the ICU and move on to the next case. They know that for the next couple days they will have to deal with the loads of complications guaranteed to arise, only to see that patient die in their ICU. Multiply that by several patients each day, and they are literally in hell.

Periop Physicians should be able to handle the patient from preop through discharge.
This means ordering the correct tests, assessing patient risk, choose and supervise the anesthestic,direct the ICU stay if needed and be part of the discharge team.

I envision the Resident being QUALIFIED to do Ctritical Care after an anesthesia residency. Whether he or she chooses to do so is another matter entirely.

 

[Doctor4Life1769]

Did a few SICU months as an M4 and enjoyed it. Heck, the MICU wasn't perfect but I enjoyed it too...

I may be heading to an ICU fellowship, or maybe peds. Haven't fully decided as its still too early (not done a peds case) but im pretty sure by the time it's all said and done I'll be looking at one of those two come decision time. I've got no desire to deal with pain patients nor do cardiac cases, so there's that.

Do y'all recommend doing a NICU elective your final year of residency? Or is it utterly useless? Thanks

 

[michigangirl]

Do y'all recommend doing a NICU elective your final year of residency? Or is it utterly useless? Thanks[/QUOTE]

Do NOT do a NICU elective your final year of residency. It will not be of much benefit as an anesthesia resident-- I am telling you this as a former peds resident and anesthesia resident. The exposure you get in the NICU is not a reflection of what you will be dealing with in the OR. i would recommend a PICU elective if you are set on doing peds ICU stuff to get a feel for whether you are going to do peds or not. Our pedi anesthesia fellows rotate through the nicu as part of fellowship (so you will eventually get to do this if you choose peds) and they learn important stuff about nutrition, fluids, but our approach to OR care of these kids is very different from the NICU approach, and you would be better served in an intensive peri-operative care environment for kids. To be clear, this is not a knock on my NICU colleagues-- they run the NICU as it should be run with primary concerns for neonatologists and pediatricians in the care of these babies. The PICU takes on a more anesthesia/surgical approach since there is much more surgical acuity and cases.

If you've already done PICU, then choose something fun that might be of benefit and go for it! good luck.

 

[Doctor4Life1769]

Do NOT do a NICU elective your final year of residency. It will not be of much benefit as an anesthesia resident-- I am telling you this as a former peds resident and anesthesia resident. The exposure you get in the NICU is not a reflection of what you will be dealing with in the OR. i would recommend a PICU elective if you are set on doing peds ICU stuff to get a feel for whether you are going to do peds or not. Our pedi anesthesia fellows rotate through the nicu as part of fellowship (so you will eventually get to do this if you choose peds) and they learn important stuff about nutrition, fluids, but our approach to OR care of these kids is very different from the NICU approach, and you would be better served in an intensive peri-operative care environment for kids. To be clear, this is not a knock on my NICU colleagues-- they run the NICU as it should be run with primary concerns for neonatologists and pediatricians in the care of these babies. The PICU takes on a more anesthesia/surgical approach since there is much more surgical acuity and cases.

If you've already done PICU, then choose something fun that might be of benefit and go for it! good luck.

No there's not a PICU/NICU scheduled but they're options if we so choose our final year. I'll look into PICU if I'm set on peds... if I decide against it then I probably won't. Appreciate the advice!

 

[Stank811]

I agree that the future of anesthesia will be something structured like a "surgical home" or essentially how it is structured in europe from what I understand. We will be responsible for clearing the surgical pt for the OR, we will be responsible for them in the OR, and we will be responsible for them in the surgical ICU while the pulm CC people will be responsible for the medical ICU ("medical home").

From my perspective it seems that in a time when subsidies are being decreased or wiped out it would be in the best interest of PP groups to hire a CC fellow to work in the unit. The new CC staff would providing better outcomes for the surgeon and make the unit more efficient which makes the hospital money giving the PP group significant political power within the hospital. Many ICU units were PP groups work have hospitalist consulted on unit pts...I guarantee a CC anesthesiologist devoted to post surgical unit pt could produce better outcomes in these practice settings.

My question for many of the PP attending's on this forum is why are many of the PP groups out there not willing to take on CC trained anesthesiologist to work part time in the OR and par time in the ICU. Is it to much work to restructure ? Is there concern that the new CC trained anesthesiologist will become aligned with the hospital administration and potential force the group to be incorporated into the hospital system? Is it all economics based?

 

[BLADEMDA]

I agree that the future of anesthesia will be something structured like a "surgical home" or essentially how it is structured in europe from what I understand. We will be responsible for clearing the surgical pt for the OR, we will be responsible for them in the OR, and we will be responsible for them in the surgical ICU while the pulm CC people will be responsible for the medical ICU ("medical home").

From my perspective it seems that in a time when subsidies are being decreased or wiped out it would be in the best interest of PP groups to hire a CC fellow to work in the unit. The new CC staff would providing better outcomes for the surgeon and make the unit more efficient which makes the hospital money giving the PP group significant political power within the hospital. Many ICU units were PP groups work have hospitalist consulted on unit pts...I guarantee a CC anesthesiologist devoted to post surgical unit pt could produce better outcomes in these practice settings.

My question for many of the PP attending's on this forum is why are many of the PP groups out there not willing to take on CC trained anesthesiologist to work part time in the OR and par time in the ICU. Is it to much work to restructure ? Is there concern that the new CC trained anesthesiologist will become aligned with the hospital administration and potential force the group to be incorporated into the hospital system? Is it all economics based?

The future of this field is exactly as you have described above; and, I firmly believe the trend with Obamacare will be to hire more CCM Anesthesiologists to join Groups and improve outcome/shorten hospital stays. Think of the bundled payment systems of the future. What better way to show value than by staffing the surgical ICU, decrease the ordering of unncessary tests and consults and providing preop/intraop and post op care.

The future is the complete perioperative physician and not just a gas passer/stool sitter.

 

[scudrunner]

The future of this field is exactly as you have described above; and, I firmly believe the trend with Obamacare will be to hire more CCM Anesthesiologists to join Groups and improve outcome/shorten hospital stays. Think of the bundled payment systems of the future. What better way to show value than by staffing the surgical ICU, decrease the ordering of unncessary tests and consults and providing preop/intraop and post op care.

The future is the complete perioperative physician and not just a gas passer/stool sitter.

Good!

 

[CrazyJake]

Blade - what will happen to the generalist who just wants to stool sit? There are many who are happy with that. Will they embrace the peri operative physician role? Will they take a huge paycut?

What about the specialists who have the fellowship training and expertise in Cardiac, Peds, OB, whatever. How is this bundled payment thing gonna fair for the fellowship trained folks.

I personally would enjoy cardiac or peds years more than CCM, but maybe the CCM guys are about to be in big demand.

CJ

 

[Doctor4Life1769]

Blade - what will happen to the generalist who just wants to stool sit? There are many who are happy with that. Will they embrace the peri operative physician role? Will they take a huge paycut?

What about the specialists who have the fellowship training and expertise in Cardiac, Peds, OB, whatever. How is this bundled payment thing gonna fair for the fellowship trained folks.

I personally would enjoy cardiac or peds years more than CCM, but maybe the CCM guys are about to be in big demand.

CJ

Looks to be that there's a good demand for cardiac too. I'd think that if u can handle cardiac you can handle ICU, but i could be wrong.

 

[epidural man]

Looks to be that there's a good demand for cardiac too. I'd think that if u can handle cardiac you can handle ICU, but i could be wrong.

Most well trained CCM guys can handle all complex cardiac cases and many are ultrasound trained.

Not sure that equation holds true the other way around.

 

[Doctor4Life1769]

Most well trained CCM guys can handle all complex cardiac cases and many are ultrasound trained.

Not sure that equation holds true the other way around.

That's true. Good point.

 

[bkell101]

The time has Come to prepare the Anesthesiology Resident of 2012 for his/her future. This means reworking of the Residency itself so the newly minted Anesthesiologist will still be valuable to hospitals circa 2025.

Blade (or anybody else), what things would you do to rework the traditional residency curriculum in order to best prepare future grads?

...I've been on the interview trail and have heard several program directors give their two sense on where they think the field is heading. I've heard many different opinions. Some PD's have been talking about TEE months, extra regional months, extra ICU training, PACU months, Pre-op clinic, ect...I've heard some on the other end of the spectrum claiming these extra months are pulling residents out of the OR and take away from intra-operative skills. Should residency be extended? What adds the most value to our training?

This seems to be an era where strong leadership with the willingness to change and adapt is crucial. Should I be looking for a program that has this type of leadership in order to have a training experience in line with the future needs of the field?

 

[learnmore]

Maybe I'm missing something... at the hospital I mainly rotate in, there are no CRNAs in the ORs... but there and many NPs covering the ICUs from medical to neuro to surgical.

I don't really see how spending more time in an ICU is going distinguish physicians from nurses.

 

[BLADEMDA]

NPs running the ICU? Please. ICUs need a Physician Supervisor to run the show. I'd like to see Anesthesiologists take over the Surgical ICU as part of "home base" along with preoperative consults and postop care. This is perfect for the Obamacare USA.

Midlevels can be used in many Medicare/Medicaid hospitals witha mix above 60%. The Anesthesiologist function as part of the IPAB in that hospital and serve as perioperative GATEKEEPERS for the newly, restrictive CMS system.

Fo example, want that elective total knee? But, you weigh 400 pounds, 5'6" with severe sleep apnea, DM, HTN, GERD, etc. You may need to get "clearance" from the local IPAB Perioperative Physician first who must submit the data to CMS.


http://en.wikipedia.org/wiki/Independent_Payment_Advisory_Board

 

[Stank811]

Maybe I'm missing something... at the hospital I mainly rotate in, there are no CRNAs in the ORs... but there and many NPs covering the ICUs from medical to neuro to surgical.

I don't really see how spending more time in an ICU is going distinguish physicians from nurses.

Residents dont need to do a fellowship to distinguish themselves from nurses...they already did that by going to medical school. What all this discussion is about revolves around predicating how the healthcare system/job market will look like in the future. 10 yrs ago a resident could graduate and find a nice job in a surgery center doing "propofol, LMA, paycheck" ten times a day and have a great lifestyle with great pay. Some anesthesiologist still practice like this in certain areas of the country but many on this board feel that these groups will have to expand their role or eventually find themselves getting paid less or without a job in general. If a group of people is able to predict the healthcare environment in 10 yrs and adapt their practice/skill set (evolve) to fit certain foreseen needs they will find themselves in a nice spot in the food chain. And because many on this board predict the same needs, many suggest similar paths which often includes sub specializing (CCM, Hearts, Regional, Peds etc). Who knows we could be wrong. Also all this talk about fellowship I dont think is suggesting that we will be leaving the OR...it is just about evolving and expanding our scope within the healthcare system and I think we as a specialty are in a great position to do so especially in the surgical arena like Blade illustrated above.

 

[Stillwater45]

So with all this talk about moving OUT of the OR - What advantage will a fellowship be that makes you more specialized IN the OR (Peds, Cardiac) ? How will a peds anesthesiologist fit into the "surgical home" scenario.

Also if we have bundled payments will regional get the boot? Say insurance pays $30,000 for a total joint "bundle". Will the orthopods still want to pony up part of that chunk for a block? Will regional be on its way out?

 

[numbmd]

There is a perioperative medicine society on the internal medicine side of the ball, however there is no perioperative medicine society as a subset of the ASA .Medicine? Seriously? I have been interested in this for some time, but was really inspired at the ASA meeting as well. I have investigated this with the ASA and there is nothing preventing US from doing it ourselves. To that end, I have been talking around, and have decided to do something about it...

1. I am trying to establish a Society of Perioperative Medicine as a subset of the ASA. When our membership reaches 400 members, it can be formally recognized by the ASA.

2. I am establishing a Perioperative Medicine fellowship at our institution. We will be looking for fellows to start in July. I am willing to be flexible on the rotations, but think it will have rotations in acute pain, managing our Pre surgical screening program, PACU management, OR anesthesia management, and our Quality Information/ Performance improvement. Maybe some time in Critical Care, but with the emphasis on keeping people OUT of the ICU, and possibly working on further configuring our AIMS program.

3. We need to do better at managing our patient outcomes. I personally think that squeezing the bag alone is self limiting, and the road to unemployment in the long run.

If there is anyone interested in trying to help establish a Perioperative Society, let's do it.

 

[chessknt]

There is a perioperative medicine society on the internal medicine side of the ball, however there is no perioperative medicine society as a subset of the ASA .Medicine? Seriously? I have been interested in this for some time, but was really inspired at the ASA meeting as well. I have investigated this with the ASA and there is nothing preventing US from doing it ourselves. To that end, I have been talking around, and have decided to do something about it...

1. I am trying to establish a Society of Perioperative Medicine as a subset of the ASA. When our membership reaches 400 members, it can be formally recognized by the ASA.

2. I am establishing a Perioperative Medicine fellowship at our institution. We will be looking for fellows to start in July. I am willing to be flexible on the rotations, but think it will have rotations in acute pain, managing our Pre surgical screening program, PACU management, OR anesthesia management, and our Quality Information/ Performance improvement. Maybe some time in Critical Care, but with the emphasis on keeping people OUT of the ICU, and possibly working on further configuring our AIMS program.

3. We need to do better at managing our patient outcomes. I personally think that squeezing the bag alone is self limiting, and the road to unemployment in the long run.

If there is anyone interested in trying to help establish a Perioperative Society, let's do it.

I dont get point #3. What does anesthesia have to do with post-op complications not related to anesthesia? Do you think surgeons are ok with letting the anesthesiologist manage the post-op patient? The ones I have met sure would not be.

 

[numbmd]

At our institution, our surgeons are happy to operate and leave. They don't want to manage their patients if they knew they didn't have to. The real point is to expand the scope of your practice as far as you can, add value to your practice and hospital. Cut down on post op pain, decrease lab costs, keep people out of the ICU, and you'll keep your job. Work at the top of your degree, not the bottom.

Squeezing the bag is like being a toll collector, and the nurses are EZ Pass.

 

[chessknt]

At our institution, our surgeons are happy to operate and leave. They don't want to manage their patients if they knew they didn't have to. The real point is to expand the scope of your practice as far as you can, add value to your practice and hospital. Cut down on post op pain, decrease lab costs, keep people out of the ICU, and you'll keep your job. Work at the top of your degree, not the bottom.

Squeezing the bag is like being a toll collector, and the nurses are EZ Pass.

How is that different from letting pulm/cc handling their post-op patients?

I think the future of anesthesiology is going to be very dependent on the supreme court this summer. Even specializing in multiple areas, which is far from feasible for the majority, wont be able to negate the catastrophically low medicare reimbursement rates.

 

[numbmd]

Maybe it's our place, but our surgeons don't really like the pulm/cc guys to screw up their cases. They really like the CTICU where anesthesia runs the show. Maybe because we are more aggressive in management, maybe because they remember when we saved their rear ends in the OR.

Maybe we need to start thinking outside the box, maybe we need to push ourselves, maybe we need to change things before its too late.

Or maybe we can put our heads in the sand, ride it out for as long as we can, squeeze out every last drop, then leave it to the nurses. Anesthesia is pretty safe, maybe we don't need to improve it anymore. I don't see nurses publishing a whole lot, other than papers saying they are as good as anesthesiologists. Yeah, pent, sux, tube, coffee, I'll take that. A little morphine post op. And a stick to bite on. Give me lots of needless tests. TAP block? No thanks. Fast tracking? Think I'll stay a couple of hours in the PACU, I like the noise. Multimodal pain regimen? Yeah, isn't that called percocet?

I'll stay a few extra days then drive home in my Delta 88.

 

[Quirk11]

If we are talking the future, we need to frame the context of the healthcare system circa 2020.

1) Eventual change change from fee for service to capitation. Very likely to happen. One episode of payment for a certain condition. this changes the game for ALL specialties.

2) PCP's as more gatekeepers at the hospital level. PS, PCP's are penalized for referrals and ordering too many tests. This will decrease the need for specialists of ALL fields per patient at least. The government wants lower use of imaging, specialist procedures etc.

3) Higher enrollment on Medicaid. States like Maine are high at 200 % , Alabama is low. States will be forced to cut medicaid fees by sheer math as they must enroll more. Especially as 40 million immigrants gain citizen ship.

4) Hospital owned practices , much less private practice, already happening to many fields.

5) Rationing via IPAB. Is a laminectomy effective? A CABG in a 70 year old? ESI?

6) Refusal to pay based on illogical criteria. Does the patient get re-admitted within 30 days for the same condition? No one gets paid. Did the patient get admitted more than 3 times in their life to an ED in Washington State, then no ED personel gets paid again...

7) A development for concierge / more personal medicine.

We have the tools to continue to develop anesthesiology in this context. Continue to expand critical care etc...it doesn't take radical new things, just to encourage people to pursue these fellowships as Blade mentioned...We are a hospital specialty, and in 2020, that won't be the worst thing...

The most important thing is to change the field to talk to the PUBLIC. They want us. Stop forcing residents to memorize Mapelson circuits and get them into the real world as Blade has suggested...

Maybe it's our place, but our surgeons don't really like the pulm/cc guys to screw up their cases. They really like the CTICU where anesthesia runs the show. Maybe because we are more aggressive in management, maybe because they remember when we saved their rear ends in the OR.

Maybe we need to start thinking outside the box, maybe we need to push ourselves, maybe we need to change things before its too late.

Or maybe we can put our heads in the sand, ride it out for as long as we can, squeeze out every last drop, then leave it to the nurses. Anesthesia is pretty safe, maybe we don't need to improve it anymore. I don't see nurses publishing a whole lot, other than papers saying they are as good as anesthesiologists. Yeah, pent, sux, tube, coffee, I'll take that. A little morphine post op. And a stick to bite on. Give me lots of needless tests. TAP block? No thanks. Fast tracking? Think I'll stay a couple of hours in the PACU, I like the noise. Multimodal pain regimen? Yeah, isn't that called percocet?

I'll stay a few extra days then drive home in my Delta 88.

 

[kazuma]

I'll stay a few extra days then drive home in my Delta 88.

I like your style man.

 

[michigangirl]

I dont get point #3. What does anesthesia have to do with post-op complications not related to anesthesia? Do you think surgeons are ok with letting the anesthesiologist manage the post-op patient? The ones I have met sure would not be.

How is that different from letting pulm/cc handling their post-op patients?

We understand surgical patients better because we see the surgeries, we have to understand them to provide safe, effective anesthetics for them, and this all translates to the post-op environment and optimal care. Our surgeons respect the anesthesia-icu folks because they often still work with them in the OR, they know they understand the surgeries, and it's a lot more collaborative.

It's not that we are personally "responsible" for post-op complications not related to anesthesia-- unless it's a complication that is reversible by going back to surgery stat, even if its directly related to surgery, we as anesthesiologists know how to deal with every organ system. Renal failure after cardiac surgery, stroke after a craniofacial reconstruction (plastic surgeons, neuro complication), etc. etc-- this is a unique skill we offer that we understand the big picture.