the BAD side of FM residency programs

[andwhat]

lets compare apples to apples.

i did a year of internal medicine. saw patients in the clinic, rounded on them on the floors, i get it...

please don't pretend like you have ANY idea what it is we do. last week i managed a sick preemie with a hypoplastic ventricle - pressors/echo, did on pump bypasses/valves, major thoracic cases, desaturating sick floor patients, managed sick OB patients, put in 10 different nerve blocks with catheters under ultrasound, managed unstable patients in PACU, difficult airways, etc...what did you do? prescribe lipitor? think about hyponatremia? the reason we make more money (obviously right now it's purely market driven, but the reason we SHOULD make more money) is because we have a much higher level of immediate responsibility for people's lives, perform invasive procedures, and we make FINAL critical treatment DECISIONS. FPs and internists will consult out most advanced management and NOT make critical decisions - every single day.

i agree, the market is cooling and anesthesiology will not continue to have the competitive reimburs. of today. but, it should ALWAYS have a higher reimbursement than a general specialty. that's only fair.

I think that Anesthesiology in an ICU setting is very valuable, the rest so so. I mean you are literally the Surgeon's coat tail. At least thats how I felt during my rotation as a med student. There just weren't that many clear boundaries. However the Surgeons even cussed out the residents at times.

What do I do? Manage sick unstable Congestive Heart Failure exacerbations, Asthma attacks, Overdoses, DiabeticKetoAcidosis, Chronic Obstructive Pulmonary Disease and Pneumonia management, Hypertensive crisis, Sepsis, huge Fungating Radial abscess, Pulmonary Embolus management, Spinal tapped a 3 month old two weeks ago WITHOUT fluoroscopy, Small Bowel Obstruction, major fluid and electrolyte imbalances, etc.

Save lives basically.

Enjoying watching my interventions save lives, and following them after.

Thats what you do when you truly love a field, and are not in for just the money.

Money follows, if you are smart about it. If you invest money, limit your Medicare / Medicaid patients, and manage Self Pay.

I personally think that is a saddening concept, treating only the person that can pay more efficiently. I would never do it, but yeah could easily net over $200K if someone did that.

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[AwesomO]

Yeah, but managing DKA in the ICU setting will always reimburse more than managing HgbA1C's in an outpatient setting.

Managing emergent airways will always reimburse more than Rx'ing albuterol MDI's.

Why? Fewer people can do the more emergent stuff. The more emergent stuff is more valuable.

Hmm don't know if I agree that things are paid based on urgency. For instance doing an appy gets the surgeon reimbursed 300 for about an hours total work. Mean while a outpatient doc can see 4 cases of the patients in the office at about 75 bucks a piece and it comes out to the same thing.

It just happens to be where payments are now. For instance they could decrease pay for managing airways to a tolerable level then come back and do it again next year. They won't stop until enough Gasers say "Stop decreasing my pay or I'll stop practicing."

 

[Coastie]

And why is that, exactly? Which of us is going to save more lives (and money) in the long run? Where's the real value? I think we all know the answer...we just don't want to pay for it.

Preventative care is important, but the all important missing variable is patient compliance. Additionally, DKA can be caused by things out of our hands other than patient non-compliance. Anyway, why is emergent care more valuable? Come on Kent. Fewer people can do it, therefore it's more valuable. If everyone was trained in ICU care and very few in preventative care, then preventative care guys would win. It would be great if everyone worked out and ate an appropriate diet, but we aren't going to start paying exercise trainers and nutritionists more than MD's, are we?

We also have NP's crashing down the gates of family med. This makes the market much less palatable for physicians, unless they can show that they bring far more to the table (which they do). That's why I say FP can make ALOT of money if they have capitalistic principles and good business sense.

 

[Coastie]

The OR is an ICU setting. It's clear that you don't really "get" what Anesthesiologists do..

I think that Anesthesiology in an ICU setting is very valuable, the rest so so. I mean you are literally the Surgeon's coat tail. At least thats how I felt during my rotation as a med student. There just weren't that many clear boundaries. However the Surgeons even cussed out the residents at times.

What do I do? Manage sick unstable Congestive Heart Failure exacerbations, Asthma attacks, Overdoses, DiabeticKetoAcidosis, Chronic Obstructive Pulmonary Disease and Pneumonia management, Hypertensive crisis, Sepsis, huge Fungating Radial abscess, Pulmonary Embolus management, Spinal tapped a 3 month old two weeks ago WITHOUT fluoroscopy, Small Bowel Obstruction, major fluid and electrolyte imbalances, etc.

Save lives basically.

Enjoying watching my interventions save lives, and following them after.

Thats what you do when you truly love a field, and are not in for just the money.

Money follows, if you are smart about it. If you invest money, limit your Medicare / Medicaid patients, and manage Self Pay.

I personally think that is a saddening concept, treating only the person that can pay more efficiently. I would never do it, but yeah could easily net over $200K if someone did that.

 

[Coastie]

Hmm don't know if I agree that things are paid based on urgency. For instance doing an appy gets the surgeon reimbursed 300 for about an hours total work. Mean while a outpatient doc can see 4 cases of the patients in the office at about 75 bucks a piece and it comes out to the same thing.

It just happens to be where payments are now. For instance they could decrease pay for managing airways to a tolerable level then come back and do it again next year. They won't stop until enough Gasers say "Stop decreasing my pay or I'll stop practicing."

?

Uh.

Well, you can disagree. Like I told Kent, fewer people can do what we do, therefore it's more valuable. Combine complexity and urgency, and you have higher reimbursement.

You FP guys can really rake it in. It's there for the taking. Your office visit example is just a prime one as to why. Now go out there and get it done!

 

[andwhat]

?

Uh.

Well, you can disagree. Like I told Kent, fewer people can do what we do, therefore it's more valuable. Combine complexity and urgency, and you have higher reimbursement.

You FP guys can really rake it in. It's there for the taking. Your office visit example is just a prime one as to why. Now go out there and get it done!

more like fewer people choose to do what you do. It is valuable, but certainly not more valuable than what other docs do, ER, Urgent Care, Family Medicine, etc. Its just that the reimbursements are all out of whack.

Office visits are not really where the money is at. Managing twenty complaints in a guy who has a 15 minute appointment, that ends up taking over an hour. You will go broke doing that on a daily basis.

Outpatient medicine is not nearly as simple as it seems believe me.

It also has its perks however.

I have seen Primary Care residents switch over to Anesthesiology and vice versa.

When a wave is hot, then ride it. Who knows what reimbursements will be in the future?

It is lifestyle and stress, and money is obviously a consideration. I certainly would not want to wait around for a Surgeon to get started on a case, for the rest of my life.

 

[Coastie]

Fewer people are able to do it. The market rewards this. Something is only worth as much as the market will pay for it. Value is solely determined by the market, unless, of course, the government is involved, which is where things go AWRY.

more like fewer people choose to do what you do. It is valuable, but certainly not more valuable than what other docs do, ER, Urgent Care, Family Medicine, etc. Its just that the reimbursements are all out of whack.

Office visits are not really where the money is at. Managing twenty complaints in a guy who has a 15 minute appointment, that ends up taking over an hour. You will go broke doing that on a daily basis.

Outpatient medicine is not nearly as simple as it seems believe me.

It also has its perks however.

I have seen Primary Care residents switch over to Anesthesiology and vice versa.

When a wave is hot, then ride it. Who knows what reimbursements will be in the future?

It is lifestyle and stress, and money is obviously a consideration. I certainly would not want to wait around for a Surgeon to get started on a case, for the rest of my life.

 

[iatrosB]

on this thread.

 

[Jeff05]

nevermind.
thank god it's not the late 90s....

 

[deleted87716]

on this thread.

No kidding. Things must be really slow over in the gas forum.

I remember what it was like for anesthesiology in the late 1990's...new grads couldn't find jobs, residency programs were closing, and practically anyone with a pulse could match into gas.

 

[Coastie]

No kidding. Things must be really slow over in the gas forum.

I remember what it was like for anesthesiology in the late 1990's...new grads couldn't find jobs, residency programs were closing, and practically anyone with a pulse could match into gas.

Wait, we come to encourage you guys, talk about the great potential in FP, and you guys post puke faces? How about more threads on concierge practice, increasing reimbursements, and improving quality of patient care to detract patients away from NP clinics?

 

[sophiejane]

At last, I find myself coming to the same conclusion that I've come to before in similar circular arguments over the past few years on SDN:

All those who say that reimbursement is crap and FPs work way too hard, you know what, you are TOTALLY right! It sucks! Don't even think about going into it!

(It will make me even more desirable in 2 years and 2 months. Hee hee.)

Really, folks. Do what you love. Life is far too short to do anything else. Money and stuff have a way of finding you when you are doing something you are passionate about. And you know what? To me, there is no value possible for job satisfaction, so if I make a decent living and can buy a little land and watch sunsets from my front porch and take care of families from cradle to grave, that's all I really care about.

 

[andwhat]

Fewer people are able to do it. The market rewards this. Something is only worth as much as the market will pay for it. Value is solely determined by the market, unless, of course, the government is involved, which is where things go AWRY.

who would want to work the 12 hour days, wake up and go to work before the sun comes up each and every single day, wait around and work for the surgeon for the rest of your life? Basically live in the OR forever?

Work for the hospital and deal with the hospital's politics forever?

It is you that has to wake up and watch the Emergency Appy, and observe the Exploratory Laparotomy at 3 a.m., not me thankfully. I am wholeheartedly relieved somebody does that for a living.

Guess who is your boss for the rest of your life? The Surgeon and Specialist, not to mention the hospital's governing politics, of which you will have very little say -- through direct observation I see this. I do not agree with it at all, as M.D.s should run Medicine. I loathe the depressing prospects of that.

Is it actually Nurse Anesthetists that will one day in the very near future detract from the Anesthesiologist?

I will take my $200 K, work my 9 to 5 with NO CALL, and go to work after the sun comes up every day.

I agree with Sophie, do what you love.

Remember, for the rest of your life, it is the Surgeon and Specialist that governs your life. Get used to that, and stop blowing up at other specialties.

I went to medical school wanting to be my own boss, not work for someone else. I can make a very comfortable living doing that now. I do not need to work 50 or 60 hours a week in a hospital starving on Cafeteria food like a medical student, and laugh at a Surgeon's bad jokes to do it.

Medical school was the time for observation and boredom at times, my plan was never to do it for a living.

This thread is now officially repulsive.

The money in Anesthesia is great at this very moment, but remember folks, not everybody wants to do it....

 

[Coastie]

To each their own. I'd hate doing diabetic foot checks on medicaid patients anytime of day.

I recommend you check out Anesthesiology a little more. You may be surprised what you find.

FP has great potential which Anesthesiology can't touch. It's just a matter of taking hold of it..

who would want to work the 12 hour days, wake up and go to work before the sun comes, wait around for the surgeon for the rest of your life? Basically live in the OR forever?

Work for the hospital and deal with the hospital's politics forever?

It is you that has to wake up and watch the Emergency Appy at 3 a.m., not me thankfully. I am wholeheartedly relieved.

Guess who is your boss for the rest of your life? The Surgeon and Specialist. I would loathe at the prospects of that.

 

[deleted87716]

Wait, we come to encourage you guys, talk about the great potential in FP, and you guys post puke faces? How about more threads on concierge practice, increasing reimbursements, and improving quality of patient care to detract patients away from NP clinics?

Oh, please. What do you care? For that matter, what does anyone in anesthesia know about family medicine, primary care reimbursement, or outpatient medicine in general? Feel free to enlighten me.

FP has great potential which Anesthesiology can't touch.

Thank you for telling me what I already know.

 

[Coastie]

Oh, please. What do you care? For that matter, what does anyone in anesthesia know about family medicine, primary care reimbursement, or outpatient medicine in general? Feel free to enlighten me.



Thank you for telling me what I already know.

I care plenty. I want to see docs take back medicine, and FP could be on the forefront. It's also one of the specialties on the forefront of where we are losing medicine pretty badly.

Primary care reimbursement and outpatient medicine business practices are not understood by only those who do a FP residency. If only that were the case, we may not be in the trouble we are today..I wouldn't mind opening up a few urgent care centers and employing FP docs someday, actually!

 

[sophiejane]

I wouldn't mind opening up a few urgent care centers and employing FP docs someday, actually!

Not if they don't open them first...

There is a sense of entrepreneurship and creativity that is really emerging among those going into FM now. No offense, but I would rather work with FPs and leave gas to the gas folks.

 

[deleted87716]

I wouldn't mind opening up a few urgent care centers and employing FP docs someday, actually!

In your dreams. More likely, you'd get the retired neurologists, non-boarded FMGs, post-rehab surgeons, burnt-out ER docs, and other types who typically go into salaried urgent care jobs. Urgent care blows. The only people who don't think so are those who have already done something worse.

 

[Coastie]

Not if they don't open them first...

There is a sense of entrepreneurship and creativity that is really emerging among those going into FM now. No offense, but I would rather work with FPs and leave gas to the gas folks.

We can all compete and see how the market goes..

I really hope your assessment of the sense is true. If so,

 

[Coastie]

Seriously, Kent, are you kidding?

With the right business model...sheesh.

But what do I know, I'm just a silly gas guy. They had to check my pulse TWICE before letting me into gas residency.

In your dreams. More likely, you'd get the retired neurologists, non-boarded FMGs, post-rehab surgeons, burnt-out ER docs, and other types who typically go into salaried urgent care jobs. Urgent care blows. The only people who don't think so are those who have already done something worse.

 

[deleted87716]

Seriously, Kent, are you kidding?

No, I'm not. I'm gonna go out on a limb here and guess that you probably have about as much first-hand experience with urgent care as you do with family medicine. Am I wrong?

 

[Coastie]

No, I'm not. I'm gonna go out on a limb here and guess that you probably have about as much first-hand experience with urgent care as you do with family medicine. Am I wrong?

I'm pretty familiar with successful urgent care business models. I'm not saying it's easy as pie, but there are ways of making a really good shot at it. I'm not talking about a shady, back alley "urgent care" shop staffed by less than reputable physicians.

 

[deleted87716]

I'm pretty familiar with successful urgent care business models.

I'll bet you stayed at a Holiday Inn Express last night, too.

 

[Coastie]

I'll bet you stayed at a Holiday Inn Express last night, too.

 

[deleted87716]

Why are you so darn defensive?

Being right doesn't make me defensive.

 

[sophiejane]

I really hope your assessment of the sense is true. If so,

All I know is what I see from being in it and what I see people planning to do after residency.

Why would you go into anesthesia if your goal is to open a chain of urgent care centers? Don't you think someone with firsthand experience as a primary care provider would be better suited to that? Just knowing about business isn't enough. You have to understand primary care, which I don't see how you really could as you are a training to be a specialist.

 

[sophiejane]

I find myself in the very bizarre position of out-ranking Kent on SDN at this point in time, which is kind of freaking me out.

Anyway, kids, play nice.

 

[Coastie]

I love Anesthesiology and Critical Care.

Urgent Care Centers are a viable business with certain models in today's environment. Always good to diversify your portfolio. If the market changes, or I find better ventures, I'll look elsewhere, but I'm always looking to provide the best quality healthcare for the lowest price to the patient.

I'll hire FP's to practice the primary care. The business will simply be an instrument to facilitate better physician-patient interactions.

All I know is what I see from being in it and what I see people planning to do after residency.

Why would you go into anesthesia if your goal is to open a chain of urgent care centers? Don't you think someone with firsthand experience as a primary care provider would be better suited to that? Just knowing about business isn't enough. You have to understand primary care, which I don't see how you really could as you are a training to be a specialist.

 

[sophiejane]

I'll hire FP's to practice the primary care. The business will simply be an instrument to facilitate better physician-patient interactions.

I'm sorry, but that sounds like a sound byte, and and extremely fake one at that.

"Hiring" the FPs to do the "primary care" sounds like a recipe for disaster. First of all, what you'd likely be getting would be recent grads or FMGs, neither of whom would likely too inspired to be very loyal. I cannot imagine an established FP going to work for an anesthesiologist at an urgent care doc-in-the-box. It is a little insulting that you assume we'd be busting down the door to work for you.

The most successful business owners are the ones who understand their product. "Hiring" FPs to do your bidding in a primary care practice (which is what urgent care is) is a bad idea if you don't understand the intricacies of providing good primary care to begin with.

 

[deleted87716]

Success in urgent care isn't about "facilitating better physician-patient relations." It's about volume, accessibility (read: walk-in visits nights, weekends, and holidays) and padding the bill with as many ancillary studies as possible to increase the charges per visit.

 

[Jeff05]

you are clueless about anesthesia. in the real world surgeon/anesthesiologist interaction is very collegiate. we do not work for the surgeon (we are consultants. the cardiologist doesn't work for FP, she's a consultant...), we work WITH the surgeons. we work FOR the hospital or the surgeons work FOR us, as we own an intimidating proportion of all surgery centers (because we are trained in residency to manage ORs and to run surgical locations, which is a very specific skill).

also, i don't OBSERVE/WATCH appy/laparotomy/trauma/whatever - i actively manage the patient. can't see it? not clear to you what i'm doing? that's ok, i'm not doing it for you. that's the difference between you as a medical student in anesthesia, passively watching...what?, and being the anesthesiologist.

enjoy your chosen career. i'm glad you're not in anesthesia, more work that i love for me.

quietly, vigilantly, safely - guiding patients from door to door. i can't wait to go to work tomorrow...

 

[thedman888]

also, i don't OBSERVE/WATCH appy/laparotomy/trauma/whatever - i actively manage the patient. can't see it? not clear to you what i'm doing? that's ok, i'm not doing it for you. that's the difference between you as a medical student in anesthesia, passively watching...what?, and being the anesthesiologist....

i dunno...the gas people that i worked with throughout my time in the OR have always been doing their crossword puzzles and reading newspapers. the only "action" was intubation and extubation, and wheeling the patient to and from the PACU.

 

[Coastie]

To sophie and kent: Thanks for the words of encouragement. I'll guess we'll let the market decide. Good luck with your guys' ventures..

I'm sorry, but that sounds like a sound byte, and and extremely fake one at that.

"Hiring" the FPs to do the "primary care" sounds like a recipe for disaster. First of all, what you'd likely be getting would be recent grads or FMGs, neither of whom would likely too inspired to be very loyal. I cannot imagine an established FP going to work for an anesthesiologist at an urgent care doc-in-the-box. It is a little insulting that you assume we'd be busting down the door to work for you.

The most successful business owners are the ones who understand their product. "Hiring" FPs to do your bidding in a primary care practice (which is what urgent care is) is a bad idea if you don't understand the intricacies of providing good primary care to begin with.

 

[The Janitor]

you are clueless about anesthesia. in the real world surgeon/anesthesiologist interaction is very collegiate.

So, you guys were all in the same fraternity?

 

[Jeff05]

#1. i mean collegial
#2. you're quite the d-bag.

 

[Jeff05]

what you likely observed were easy bread and butter cases done by experienced practitioners. while they were reading the paper they were watching the anesthetics, vital, surgeons, while planning the wakeup. you know, thinking - that work you can't SEE. again, you just had NO idea what they were doing.

 

[andwhat]

you are clueless about anesthesia. in the real world surgeon/anesthesiologist interaction is very collegiate. we do not work for the surgeon (we are consultants. the cardiologist doesn't work for FP, she's a consultant...), we work WITH the surgeons. we work FOR the hospital or the surgeons work FOR us, as we own an intimidating proportion of all surgery centers (because we are trained in residency to manage ORs and to run surgical locations, which is a very specific skill).

also, i don't OBSERVE/WATCH appy/laparotomy/trauma/whatever - i actively manage the patient. can't see it? not clear to you what i'm doing? that's ok, i'm not doing it for you. that's the difference between you as a medical student in anesthesia, passively watching...what?, and being the anesthesiologist.

enjoy your chosen career. i'm glad you're not in anesthesia, more work that i love for me.

quietly, vigilantly, safely - guiding patients from door to door. i can't wait to go to work tomorrow...

quietly, vigilantly, safely transferring the patient from the OR bed to the tranport bed cummon count with me now, 1....... 2....... 3!!.....TRANSFER!

You can teach a junior high student how to intubate and extubate, and primordial monkeys can be trained to push propofol.

Central lines -- as I know from personal experience -- can be learned in less than one day, mastered in less than one week.

So quietly and vigilantly finish that crossword puzzle....................

 

[jetproppilot]

You can teach a junior high student how to intubate and extubate, and primordial monkeys can be trained to push propofol.

Central lines -- as I know from personal experience -- can be learned in less than one day, mastered in less than one week.

.................

Really! You mastered central line placement in a week!

Thats frikkin hilarious.

Additionally, have you and that kent dude ever considered charm school?

 

[andwhat]

Really! You mastered central line placement in a week!

Thats frikkin hilarious.

Additionally, have you and that kent dude ever considered charm school?

that kent "dude" is the moderator here. What is it with the barf icon, why is that so popular.

Why don't you guys quietly, vigilantly, and safely get out of this forum?

 

[jetproppilot]

that kent "dude" is the moderator here. What is it with the barf icon, why is that so popular.

Why don't you guys quietly, vigilantly, and safely get out of this forum?

Just inferring you guys are less than friendly.

And you called me arrogant?

Read your own posts, Slim.

 

[AwesomO]

 

[deleted87716]

Just inferring you guys are less than friendly.

Gee, I can't imagine why.

 

[deleted87716]

Additionally, have you and that kent dude ever considered charm school?

Maybe I should consider highlighting my posts in boldfaced size-7 type, calling everyone "dude" and "slim," including lots of military metaphors and slang, and (of course) plenty of veiled profanity. That'd be charming, wouldn't it?

 

[andwhat]

Maybe I should consider highlighting my posts in boldfaced size-7 type, calling everyone "dude" and "slim," including lots of military metaphors and slang, and (of course) plenty of veiled profanity. That'd be charming, wouldn't it?

Why Make 150k When 450k Is Out There?

cannot understand why this person jetpropilot is allowed to abuse and insult everyone on this board.

 

[NewmansOwn]

If I can be totally honest, it's kind of heartbreaking to see this discussion. Kent, I have long looked up to you in this forum, but you're being out-classed by the gas jockies. While I agree that it was inflammatory of Jet to start that "Why make $150k...?" thread, neither he, Coastie or Jeff are being inappropriate or insulting and don't deserve this lack of manners -- I don't see why physicians can't discuss issues interdisciplinarily, respective of each's particular strengths and knowledge areas. Anesthesiologists and all other specialists have a right to defend their specialty in any forum, to better the general fund of knowledge -- this isn't a members-only club.

Furthermore, isn't it your responsibility as moderators to reign in ignorant talking heads? If so, you need to keep a tighter leash on andwhat. I mean really, I feel like I'm watching Fox News...

Who on earth assumes they understand a specialty by observing it? You see an anesthesiologist doing crossword puzzles and assume he's not running countless scenarios in his/her head in preparation for **** hitting the fan. Pull the string on andwhat's back and he'll say "You work for the surgeons!" again, but news flash, Walter Cronkite -- the surgery doesn't start without the anesthesiologist, either.

 

[deleted87716]

If I can be totally honest, it's kind of heartbreaking to see this discussion. Kent, I have long looked up to you in this forum, but you're being out-classed by the gas jockies.

They've had more practice.

isn't it your responsibility as moderators to reign in ignorant talking heads?

I'm not the moderator here, but you can use the "report post" button if you wish to report a post to the moderators.

 

[sophiejane]

CLOSING.

We are way off topic and resurrecting this thread back to the OP's intention seems hopeless.

Feel free to continue on the other similar thread on this forum, at least if and until it degenerates as well.