The future of anesthesiology

[BlackScorpion]

To anesthesiology attendings and residents ONLY.

What do you think will be the future of our specialty? During the interview trail, many of the programs I interviewed with were stressing greater incorporation of perioperative medicine, critical care, etc. into their respective training curriculum. To those in the know, what data were these programs analyzing to come to this conclusion?

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[militarymd]

there is only one thing that is for sure.....you WILL make less $$$$$.


Everything else is a big maybe.

 

[VolatileAgent]

To anesthesiology attendings and residents ONLY.

good luck with that one.

(p.s. i don't have a crystal ball. i know what i think will happen if trends continue the way they are now. but i've learned it's pretty worthless trying to play hypothetical games, especially on this forum.)

 

[EtherMD]

Military MD is correct that we will make less money in the future. Medicare Cuts are substantial and more of our patients will fall into this category in the future (graying of America).

Do you realize that an Anesthesiologist working 40 hours per week doing just Medicare cases will make the same pay as a CRNA? This is based on cases done in 2007 at Medicare rates.

In my opinion, Anesthesiology is one of the lowest reimbursed specialties by Medicare (lowest?). This means some of us will make a lot less money in the future.

 

[Noyac]

In my opinion, Anesthesiology is one of the lowest reimbursed specialties by Medicare (lowest?). This means some of us will make a lot less money in the future.

Thank You ASA!

 

[threepeas]

i am sure that reimbursement rates have been declining on some level for a number of years, yet salaries for anesthesiologists are at a peak. if this is true there must be other forces at work besides medicare pay rates which means we dont have to be so gloom about future salaries.

any thoughts on above?
thanks

 

[gaspasser2004]

One of the best days in high school for me was an economics lesson where we had to "bid" on buying donuts. It was a lesson in free market economics where basically we were given a sheet and asked how many donuts we would be willing to buy at a given price. If donuts cost a penny each, I would buy a hundred. If they cost a dollar each, I would buy one. If they cost 25 cents each, I would buy four.

I'm a big believer in the free market inherently solving problems. Look, we all think we are worth about $300,000 plus in the private practice sector and a little less for the academic world. The training is tough, the actual practice is tough and we are worth every penny. The market currently reflects this.

Going back to the first paragraph, there are roughly "X" (current number of anesthesiologists practicing) of us who are willing to work for current pay. If the pay was miraculously doubled, then there would be a mad rush to go into anesthesia and the current people doing anesthesia would work even harder because there was more money to be made. However, if the pay is cut in half, then guess what, a lot of us would not be willing to do anesthesia. Some of us would retire, some of us would find other work, some of us would find more efficient ways to practice (read cutthroat). Also, the medical students would see that anesthesiologists are yet again getting a raw deal and would again not apply to anesthesiology. Supply would go down and demand would go up, thus eventually re-creating an equilibrium.

In America, society values certain things more than others. For instance, public education isn't really valued that much - that's why teacher's salaries are so low and why you don't necessarily have the "best and brightest" going into education (although you have the altruistic). American society has always valued healthcare to the point that we have the best system in the world for those who can afford it (and the "best and brightest" go into it). If healthcare becomes less rewarding financially, then less "best and brightest" will go into it (it has already happened to some degree).

I'm a CA-2, so I am under "communism" now. But out in practice, as long as my services are valued, I will provide them for a particular dollar amount. If my services become less valued, I will either find a more efficient way to practice or another line of work.

 

[cfdavid]

One of the best days in high school for me was an economics lesson where we had to "bid" on buying donuts. It was a lesson in free market economics where basically we were given a sheet and asked how many donuts we would be willing to buy at a given price. If donuts cost a penny each, I would buy a hundred. If they cost a dollar each, I would buy one. If they cost 25 cents each, I would buy four.

I'm a big believer in the free market inherently solving problems. Look, we all think we are worth about $300,000 plus in the private practice sector and a little less for the academic world. The training is tough, the actual practice is tough and we are worth every penny. The market currently reflects this.

Going back to the first paragraph, there are roughly "X" (current number of anesthesiologists practicing) of us who are willing to work for current pay. If the pay was miraculously doubled, then there would be a mad rush to go into anesthesia and the current people doing anesthesia would work even harder because there was more money to be made. However, if the pay is cut in half, then guess what, a lot of us would not be willing to do anesthesia. Some of us would retire, some of us would find other work, some of us would find more efficient ways to practice (read cutthroat). Also, the medical students would see that anesthesiologists are yet again getting a raw deal and would again not apply to anesthesiology. Supply would go down and demand would go up, thus eventually re-creating an equilibrium.

In America, society values certain things more than others. For instance, public education isn't really valued that much - that's why teacher's salaries are so low and why you don't necessarily have the "best and brightest" going into education (although you have the altruistic). American society has always valued healthcare to the point that we have the best system in the world for those who can afford it (and the "best and brightest" go into it). If healthcare becomes less rewarding financially, then less "best and brightest" will go into it (it has already happened to some degree).

I'm a CA-2, so I am under "communism" now. But out in practice, as long as my services are valued, I will provide them for a particular dollar amount. If my services become less valued, I will either find a more efficient way to practice or another line of work.

The problem with that is what would you end up doing??? At least, what else could you do that came close to the financial opportunities of medicine. It's not like you'll go right into investment banking as a 45 y.o. anesthesiologist with little to no financial training.

Sure, there are many entrepreneurial opportunities that exist out there. But, the reality for most is that there will be an acceptance of terms as long as it's viewed that very little can be done about it. That's why it's important for us to lobby HARD for our interests in Washington, as a preemptive measure against continued cuts.

I value your position. I just don't know how realistic it is. However, many of us feel as strongly. So, the best thing to do is to unite against this BS.

Also, (and this applies to ANY field) with the constant of change proving ever resilient, anesthesiology should be (and could be) finding ways to continually ADD VALUE. I know it sounds cliche, but perhaps this is where more value in the critical care and perioperative setting could prove advantages to the field. Regardless, any field will need to constantly strive to reinvent itself and to continue adding value to the chain. This NEEDS to be looked at as an opportunity, rather than something to fear, necessarily. It's the best shot we'll have to advance the field, as well as to ensure a prosperous future.

 

[TheMightyAngus]

there is only one thing that is for sure.....you WILL make less $$$$$.


Everything else is a big maybe.

How much less would you guys anticipate? Salaries cut in third/half? I know you cant predict this sort of thing, but still...

 

[militarymd]

How much less would you guys anticipate? Salaries cut in third/half? I know you cant predict this sort of thing, but still...

depends on how many new anesthesiologists there will be....if the supply is double....expect half the pay.

 

[cfdavid]

depends on how many new anesthesiologists there will be....if the supply is double....expect half the pay.

how would that be? i know you're just using that as an example, but are most programs doubling in size? if not, is there any data comparing number of residency slots from year to year? has there been a major increase over the past few years?

i know at least one program that has expanded in the last 2 years. but, IF this isn't the norm, then increased interest alone wouldn't do anything to supply.

 

[EtherMD]

My best guess (and it is just that) is about a 1/3 reduction in pay over the next ten years. This is based on Medicare reductions, increased % of Medicare cases and more practicing Anesthesiologists.

In addition, CRNA income is fast approaching MD income. In fact, many CRNA's make more money than academic attendings today. CRNA income has doubled over the past ten years while MD income has stayed the same or declined a bit. In fact, more and more hospitals are providing MD anesthesiologists subsidies to maintain the level of current services. At some point, the hospital subsidy model may break as well.

But, the real kicker is that we are the only specialty that gets 3-5 times Medicare from our commercial carriers on a routine basis. The reason is because Medicare pays our specialty very poorly (on par with CRNA only care). Most other specialties get 1.5-2 times Medicare from their commercial carriers.

If we fail as a specialty it is because we do not "branch out" into the peri-operative arena and include advanced skills/training as part of the core program. For example, all Anesthesiologists should be able to do Critical Care and basic TEE. WE really do need to become the "Internists" of the operating room and take on the burden of complete perioperative care.

We must distinguish ourselves from the Nurse Anesthetists by providing services and care they are unable to; this provides justification for Physician Anesthesiologists besides basic anesthesia services.

 

[chicamedica]

My best guess (and it is just that) is about a 1/3 reduction in pay over the next ten years. This is based on Medicare reductions, increased % of Medicare cases and more practicing Anesthesiologists.

In addition, CRNA income is fast approaching MD income. In fact, many CRNA's make more money than academic attendings today. CRNA income has doubled over the past ten years while MD income has stayed the same or declined a bit. In fact, more and more hospitals are providing MD anesthesiologists subsidies to maintain the level of current services. At some point, the hospital subsidy model may break as well.

But, the real kicker is that we are the only specialty that gets 3-5 times Medicare from our commercial carriers on a routine basis. The reason is because Medicare pays our specialty very poorly (on par with CRNA only care). Most other specialties get 1.5-2 times Medicare from their commercial carriers.

If we fail as a specialty it is because we do not "branch out" into the peri-operative arena and include advanced skills/training as part of the core program. For example, all Anesthesiologists should be able to do Critical Care and basic TEE. WE really do need to become the "Internists" of the operating room and take on the burden of complete perioperative care.

We must distinguish ourselves from the Nurse Anesthetists by providing services and care they are unable to; this provides justification for Physician Anesthesiologists besides basic anesthesia services.

Agree 200%. I think this direction is a good thing for our specialty, even if it means lower pay for less time in the OR. Our training prepares us for more than just being technicians and we should live up to that.

 

[GasDaddy]

there is a chart that is available through the NRMP that shows the number of available residency positions there are for each specialty. for anesthesiology, in the 2005 match, there were a little less than 1300. the numbers have been increasing, but only to previous highs from before residency programs began closing down in the mid 90's.

dr. miller from UCSF wrote an article that is online via the ASA's website where he states that the plan should be to bring back perioerative medicine and critical care in order to keep the field alive. this is the plan, and it will happen, it will just take some time. i think the field will survive, there is no question. programs are increasing the amount of critical care you get in the residencies right now. the plan is to add an extra year of residency eventually... making it almost pure extra year of critical care added to the curriculum.

to go into this field for financial or lifestyle reasons is a HUGE mistake. every field is going to have its ups and downs. this field more so than others. a lot of us have major loans to pay, and i hope they will eventually be payed off, but you gotta see which field intrigues you enough to wake up everyday and be good for 30+ years, and which will motivate you to be good at what you do.

that being said, i don't think anesthesiology will take that big of a paycut in the future. anesthesiology residencies aren't pumping out anesthesiologists like crazy. as far as I know, crna programs aren't pumping out crna's like crazy either, but i have no stat to back that up. demand for surgeries is going higher as the population is aging, and we will need more intraoperative specialists. the problem lies in the fact that crna's can do a lot of the intraoperative stuff at a lower cost. so its natural to rely on the crna a lot more. so i dont see how a crna is making as much as an anestheisologist for the same amount of work.... if that were teh case, it would defeat the purpose of even having a crna completely.

anesthesiologists are maintaining their dominance over crna's through a few different methods in my opinion: 1) tough board exams 2) expansion back into critical care and perioperative medicine.

the board exams for anesthesiology are one of the toughest out there. its an important exam not only in terms of keeping people up to date with respect to knowledge and management decisions. but also, in my opinion, and i could be wrong, tells the crna's, "there is no way you're going to pass this test, so don't even try." it keeps MDAs and CRNAs at two completely different levels. CRNA's may be practicing independently in certain states but if they truly want to make that leap, they are goin to have to take that oral and written board exam. i dont see that happening for two reasons... you have to have an MD and have gone through MDA residency. Number two, even if they were to take, i dont think they would do as well.

another thing to consider is that one day the anesthesiology machine will be so advanced that it pretty much does ALL if not A LOT of the work. the bp is down, it will automatically deliver some ephedrine or whatever.... but there will still need to be someone there monitoring the machine. who do you think that will be? MDA's or CRNA's? this is way into the future, but it's interesting to see how things play out.

my final point is this... to make a true comparison of cnra vs mda is the following... who is better equipped at doing what they do right when they graduate? a lot of crna's are good at what they do, but they have also been practing for 15+ years.

 

[GasDaddy]

the real final point........... MONEY DOES NOT BUY HAPPINESS!! its all about intrinsic ways to find happiness. looking outside yourself to be content won't get you anything.....

 

[matt1234321]

It might not buy happiness, but it is sure nice to have when u throw a rod on interstate-45 or when you want to hop in the hot tub and watch hdtv at the same time.

 

[matt1234321]

double post

 

[VolatileAgent]

It might not buy happiness, but it is sure nice to have when u throw a rod on interstate-45...

that's how my wife got pregnant with our first child.

or when you want to hop in the hot tub and watch hdtv at the same time.

and that's how she got pregnant with our second.

 

[TheMightyAngus]

My best guess (and it is just that) is about a 1/3 reduction in pay over the next ten years. This is based on Medicare reductions, increased % of Medicare cases and more practicing Anesthesiologists.

In addition, CRNA income is fast approaching MD income. In fact, many CRNA's make more money than academic attendings today. CRNA income has doubled over the past ten years while MD income has stayed the same or declined a bit. In fact, more and more hospitals are providing MD anesthesiologists subsidies to maintain the level of current services. At some point, the hospital subsidy model may break as well.

But, the real kicker is that we are the only specialty that gets 3-5 times Medicare from our commercial carriers on a routine basis. The reason is because Medicare pays our specialty very poorly (on par with CRNA only care). Most other specialties get 1.5-2 times Medicare from their commercial carriers.

If we fail as a specialty it is because we do not "branch out" into the peri-operative arena and include advanced skills/training as part of the core program. For example, all Anesthesiologists should be able to do Critical Care and basic TEE. WE really do need to become the "Internists" of the operating room and take on the burden of complete perioperative care.

We must distinguish ourselves from the Nurse Anesthetists by providing services and care they are unable to; this provides justification for Physician Anesthesiologists besides basic anesthesia services.

With physician salaries on the decline, are anesthesiologists going to be hit harder than docs in other specialties?

 

[EtherMD]

Look, I realize many of you are young and new to the field. I too had no idea that after Medical School, Residency and 13 years of Private Practice that my biggest problem would be CRNA competition. Medicare is a close second; but, let me elaborate a bit more.

Right now, many of you are in Residency or fresh out. You may not realize the AANA has been waging a successful campaign at the state and National level to obtain CRNA's more "independent practice" rights than ever before.

In fact, 16 states have "opt-out" laws that allow CRNA's to practice completely independently. The AANA is lobbying hard to get more states to do the same. The AANA lobby (more like a union) is much better than the ASA in getting their voice heard by politicians. The AANA has been successful in defeating their competitors (the Anesthesia Assistants) at the state level. Just recently, the AANA got the state of North Carolina to refuse legislation allowing AA's to practice in that state. This despite the efforts of the ASA and the AAAA (AA's parent group) efforts. Even though AA's have been working in Georgia for the past 30 years with an excellent safety record (equal to CRNA) the AANA defeated the bill to allow AA's to practice under the direct supervision of a board certified Anesthesiologist.
Meanwhile, CRNA's with the same level of education as an AA have the right to practice under the "direction" of a Dentist.

I disagree that salaries are going to remain at 2007 levels. Competition from lower level providers (the AANA states that CRNA's can do everything an Anesthesiologist does for half the price) and Medicare cuts are going to sting the profession pretty hard. In my opinion, much harder than Cardiology and Radiology because they have not helped train the competition.

The answer is not to increase the years in Residency. This is academic slavery for another year. The training is long enough at 4 years. The answer is to restructure the training so it is completely clinical in nature or 4 plus 1 for academically oriented Physicians. The PGY-5 year could be research oriented with additional certification in Bronchoscopy, advanced TEE and Transthoracic Echo, U/S use for diagnosis and blocks, EEG interpretation and Nerve conduction studies. We need to include in the core program certification in critical care and perioperative medicine. Basic TEE should be included as well.

The academic elite do not realize the AANA was banging at the door a few years ago and now they are in our house. The answer is not more security (e.g. add another year and pretend we are winning) but shoot now and secure your home (e.g. add more qualifications/certifications to your core program now). Then, your 4 years after medical school will have some real differences from the CRNA. CRNA's only do 27 months of training some of which is non-clinical. Yet, the law treats them as "equal to Physician Anesthesiologists" in 16 states. Being a good Anesthestist is no longer enough; the 48 months of Post-Graduate training must SHOW on paper you are a good Physician. This means Critical Care, Perioperative Medicine, basic TEE, etc. is included in your Consultant certificate.

As usual, our academic leaders and ASA are out of touch with 80% of the market place. Those of us in private practice need the ASA and the academic community to step-up to the plate now. Again, the answer is not more time "in the hole" but better use of the existing four years.

Those of you who get stuck with 5 years of Post-Graduate training just to get the same reimburesment level as a CRNA with 24-27 months of training are being sold down the river by Chairman who want cheap labor. After all, a CRNA costs $160,000-$180,000 for 40 hours a week. You cost 1/3 that amount and they get 60 hours a week. What do you get out of this? A government that pays you the same amount of money as a CRNA for doing a Medicare Case. You don't see the lawyers making these same mistakes or letting their paralegals practice "solo" do you?

One last thing to those of you who actually give a damn and are in a Residency program: get the word out to your fellow Residents over wings and beer. Also, let your program director and chaiperson know you deserve a better piece of paper when you finish: Consultant in Anesthesiology does not suffice anymore. You all deserve better.

 

[foxtrot]

This is one of the best posts I have read on this forum. These are the kind of people we need as chairman of anesthesia programs and heads of the ASA because I have to say, you are really hitting the nail on the head when you say that they are out of touch. For example, I have a real interest in pain and my chairman acts like it is ridiculous that residents want to do pain or critical care fellowships. I will be lucky to get 2 months of pain during my total residency because heaven forbid they lose a warm body from the OR. Our chairman has even told residents that he cannot understand why anyone would want to do anything outside of the OR. This is such an antiquated attitude. Unfortunately we as residents are going to pay for this type of attitude by not having a "better piece of paper" when we finish. I am not saying that all programs are like this but the reality is that many of them are. I know my program is. I have to say, if they added another year to the already exhausting anesthesia residency, I don't think I would do it just so I can go out and get paid a little more than a CRNA and be in constant competition with someone who has 24 months of training who didn't have to take grueling written and oral boards or accumulate $100,000 of debt. What is also amazing is how we train our competition so that they can go out and practice solo or join CRNA groups in rural areas and band together so that a regular anesthesiologist wanting to come into a small town essentially is black balled because they are not in with the CRNA run group. And yes, I actually know an anesthesiologist who this happened to and he now is doing pain in that same rural town where he had trouble contracting with the hospital because there was already a CRNA group in place. The surgeons knew the CRNA's and really had no desire to work with someone new (ie the anesthesiologist). And of course the CRNA's didn't want the hospital to hire an anesthesiologist. The bottom line is that changes in the field of anesthesia have to stem from residency programs and the ASA. Academic anesthesia programs have to wake up from their state of denial before this profession is stung very hard. I am not saying that CRNA's are bad nor do I expect them to go away but I think that EtherMD really made an excellent point when he said that residency programs have to expand their scope of knowledge outside of the OR.

 

[donkeypunch]

EtherMD:

If we fail as a specialty it is because we do not "branch out" into the peri-operative arena and include advanced skills/training as part of the core program. For example, all Anesthesiologists should be able to do Critical Care and basic TEE. WE really do need to become the "Internists" of the operating room and take on the burden of complete perioperative care.

Be careful what you wish for. Having done the whole critical care thing myself as a general surgery resident, I can tell you with absolute certainty that critical care is one of the most labor intensive, $H!tty things that any doctor can ever be subjected to. In fact, not 5 minutes ago I was finishing up a case and the anesthesiologist was bitching ferociously about having to cover the ICU. They have recently "branched out" and started doing a little critical care. I doubt very seriously if many of the anesthesiology trainees of my generation would ever tolerate the workload involved in covering an ICU. Oh the humanity! God save outpatient cosmetic surgery!

 

[ecCA1]

LOL @ taking on critical care as a means of differentiating ourselves from the ****ing CRNAs. The way to handle them is to limit their numbers, which we can do given that we ultimately allow them to be trained.

The solution is very easy: make sure the guys at the top of the profession are not allowed to sell it out from underneath the rest of us.

 

[matt1234321]

LOL @ taking on critical care as a means of differentiating ourselves from the ****ing CRNAs. The way to handle them is to limit their numbers, which we can do given that we ultimately allow them to be trained.

The solution is very easy: make sure the guys at the top of the profession are not allowed to sell it out from underneath the rest of us.

Aren't crnas allowed to teach other crnas. I'm not sure if this alone would work, but it would sure help. To many anesthesiologists will do anything for a buck or 2.

 

[matt1234321]

30 % of physicians say this
30% say that
30% say what
10 % say why

everyone disagrees lol. A kindom divided cannot stand.

 

[amyl]

A kinGdom divided cannot stand.[/QUOTE]

amen

 

[RockLee]

Why doesn't the ASA just target the patient population?

If patients become educated on the fact that it's possible for a non physician to be in charged of their anesthesia, I think they'd have a problem with that.

(i.e. make info/ads describing what's involved in a surgical case. And then telling the patients the pros and cons of having a CRNA vs. MDA, and emphasizing that it's their decision to make and that they have the right to request which they want managing their case.)

If more and more patients begin asking for MDA's only to do their case, I don't care what the law in that state says or what cheap labor the chairman is trying to pull off, things would change.

my two cents.

 

[EtherMD]

Look, many of you are young or new to the field and do not realize the impact the "extra" qualifications means to your career. First, I practiced Critical Care for about 10 years at a Level 2 Trauma Center. I know how labor intensive this is for Anesthesiologists and how much it "hurts" at night and on the weekends. That is why I no longer do it and practice Anesthesiology exclusively.

That said, the "extra" qualifications on your Certificate means a great deal to your credibility by the Surgeons and Medical Staff. You are viewed as a Physician when you do more than just give Anesthesia. Even if you do not practice Critical Care, TEE, Perioperative Medicine, etc. the specilaty of Anesthesiology would be viewed in much more positive fashion. Currently, after four years of Residency you get a certificate in Anesthesiology like a Nurse Anesthetist. You deserve more recognition that just that after 48 months of Post-Graduate training. We need to distinguish ourselves as PHYSICIANS FIRST and then Anesthetists. Legally, your certificate needs to state you are certified in these areas. Whether you decide to use them is up to you. But, you deserve a certificate which clearly distinguishes you as an expert in more than just "Anesthesia."

Unfortunately, many of you don't realize the implicatications that a better certificate could mean to your long term career. What do you have to gain by getting the Chairmen to do this now? Possibly, nothing. What do have to lose by not doing it? Possibly, everything as CRNA's encroach more and more on "full, legal rights to practice Anesthesia Independently." Unlike the AANA which is proactive the ASA and most academic chairmen are "reactive." But, the time has come to recognize what we do as more than just CRNA level work. If we are not willing to state this on our own certificates (which the ABA/ASA and chairman can do) then why should the government pay us more than a CRNA? At least, have the intelligence to list all your qualifications on your certificate in order to justify why you are worth more than a CRNA. After all, having a specialist in perioperative medicine, critical care and basic Echo supervising your Anesthesia and recovery is worth paying for; You deserve these credentials after finishing 48 months of Post-Graduate Training.

Don't let the ABA/ASA and academic Chairmen get away with less. The AANA/CRNA's are smater than you realize and the time has come to list yourself as more than a glorified CRNA. Your certificate after completion of your program and Board Certification needs to clearly delineate these skills.
You deserve it and need to start demanding it. Again, please communicate with you fellow Residents and Attendings whenever possible about this topic.
If we fail to act we have only ourselves to blame.

 

[gaspasser2004]

A couple things...

In America, people get the best government money can buy. Unfortunately us cheapo anesthesiologists haven't been buying enough of it. Did you see in the ASA newsletter this month what the average member contribution to the PAC is? Its about $225. Yep, for guys who make a median of 300,000 +, all they can scrape up to protect the interests of their livelihood is $225. That brings the total PAC budget to about 900,000. 900,000 is what a single good lobbyist makes in a year - it shouldn't be our entire lobbying budget. I'm a CA-2 and I'll admit that I have never contributed, but this year I will contribute the "suggested" $20 resident contribution and when I become an attending, I will contribute 1% of my salary to the PAC. If everyone contrbuted just 1% of their salary, we would all be so much better off.

Like I said before in a previous post, society is willing to overpay for certain things. I think that being put to sleep will continue to be one of them. Think about what is going to happen when the movie "Awake" comes out where the dude is paralyzed and awake and this is illustrated in graphic first person detail for all to see. Do you think the people (lay public) who are about to have surgery are going to want to have the less trained "cheaper" alternative? People will totally be willing to overpay to have a MD "just to be sure" that they won't be awake for surgery, even if there is no proven difference.

For the record, I think the best model for anesthesia is the team approach with MD supervision of CRNA's. One, you have two people thinking about the case and two, you have two sets of hands when things go south. If this model produces a glut of MD anesthesiologists, then we have to correct that glut by decreasing the amount of MD anesthesiologists. There is already talk of cutting the number of residencies in half and creating 50 "centers of excellence" for residency training in anticipation of the MD supervision model. I would prefer this to having to do ICU in a hearbeat.

 

[EtherMD]

30 % of physicians say this
30% say that
30% say what
10 % say why

everyone disagrees lol. A kindom divided cannot stand.

Fact: Everyone agrees that Aneshesiologists' training are far superior to Nurse Anesthetists in terms of quality (College and Medical School) and quantity (more years of clinical training/more cases).

Fact: Nurse Aneshetists via the AANA (www.aana.com) is waging a campaign to equate Nurse Anesthesia as equal to Anesthesiology. The government and states are buying into the propoganda.

Fact: The public is not aware of the CRNA vs. Anesthesiologist issue and sees Nurse Anesthesia as representing the profession.

Conclusion: Your Certificate needs to CLEARLY STATE you are more than a glorified CRNA. A CRNA is an Anesthetist and so are you! But, you are a Physician who did 48 months of Post-Graduate Training so you should have "advanced skills/qualifications" that a CRNA does not; You need to show the Public, Legislators and other Physicians these differences in a "legal manner" like your Certificate/Board Certification. The time has come for your certificate to list these skills: Anesthesia, Critical Care, Peri-Oiperative Medicine, Basic TEE, etc. Or, do you want to be known as a CRNA with an MD degree?

There really are corrrect answers to issues. While 100% agreement is not usually obtainable I believe we approach 90% plus on those listed above.

 

[EtherMD]

A couple things...

In America, people get the best government money can buy. Unfortunately us cheapo anesthesiologists haven't been buying enough of it. Did you see in the ASA newsletter this month what the average member contribution to the PAC is? Its about $225. Yep, for guys who make a median of 300,000 +, all they can scrape up to protect the interests of their livelihood is $225. That brings the total PAC budget to about 900,000. 900,000 is what a single good lobbyist makes in a year - it shouldn't be our entire lobbying budget. I'm a CA-2 and I'll admit that I have never contributed, but this year I will contribute the "suggested" $20 resident contribution and when I become an attending, I will contribute 1% of my salary to the PAC. If everyone contrbuted just 1% of their salary, we would all be so much better off.

Like I said before in a previous post, society is willing to overpay for certain things. I think that being put to sleep will continue to be one of them. Think about what is going to happen when the movie "Awake" comes out where the dude is paralyzed and awake and this is illustrated in graphic first person detail for all to see. Do you think the people (lay public) who are about to have surgery are going to want to have the less trained "cheaper" alternative? People will totally be willing to overpay to have a MD "just to be sure" that they won't be awake for surgery, even if there is no proven difference.

For the record, I think the best model for anesthesia is the team approach with MD supervision of CRNA's. One, you have two people thinking about the case and two, you have two sets of hands when things go south. If this model produces a glut of MD anesthesiologists, then we have to correct that glut by decreasing the amount of MD anesthesiologists. There is already talk of cutting the number of residencies in half and creating 50 "centers of excellence" for residency training in anticipation of the MD supervision model. I would prefer this to having to do ICU in a hearbeat.

Look, you are already doing Critical Care as part of your core program. I am saying that by adding a few months in your PGY-1 year as part of the core requirements that your regular certificate after completion of the program (48 months) woyld list you as "qualified" in this area. The same holds true for peri-operative medicine, basic TEE, etc. Thus, you do not need an "extra" year of ICU nor do you need to practice Critical Care. The advantage of the added "qualifications" is that you are CLEARLY DELINEATED as a Physician expert in Anesthesia and Peri-Operative Care.

What you decide to do with your certificate/certification is up to you. It certainly can't hurt with hospital administrators, third party payers, public perception to have the expertise these other area. Especially, when you ALREADY spent the time getting them during your 48 months of Post-Graduate Training!

 

[cfdavid]

Look, you are already doing Critical Care as part of your core program. I am saying that by adding a few months in your PGY-1 year as part of the core requirements that your regular certificate after completion of the program (48 months) woyld list you as "qualified" in this area. The same holds true for peri-operative medicine, basic TEE, etc. Thus, you do not need an "extra" year of ICU nor do you need to practice Critical Care. The advantage of the added "qualifications" is that you are CLEARLY DELINEATED as a Physician expert in Anesthesia and Peri-Operative Care.

What you decide to do with your certificate/certification is up to you. It certainly can't hurt with hospital administrators, third party payers, public perception to have the expertise these other area. Especially, when you ALREADY spent the time getting them during your 48 months of Post-Graduate Training!

Great posting bro. As a med student not totally familiar with the full extent and training that 4 years of anesthesiology residency provides, your approach seems very logical. I believe you're right on with the suggestion that MD/DO anesthesiologists need to have it formally stated (i.e. certified) the full extent of their qualifications above and beyond anesthesia. So, if existing programs are already providing this "auxilliary" training (and I suspect most are), then it should be FORMALLY recognized. This, as you say WOULD clearly delineate (good term) doctors from nurses in a more substantive way (as if this converstation should be happening in the first place).

 

[Lonestar]

mama sez life is like a box of chocolates.

 

[BlackScorpion]

Wow, with decreasing reimbursements, possible glut of anesthesiologists (from militarymd), and increase competition from technicians, is it possible that our field will experience the lean years of the mid-nineties within the next ten years? Almost makes me want to switch to EM. Damn. Good thing I'm interested in ICU.

 

[BlackScorpion]

And with that Happy New Year to all, even to the CRNAs who troll this forum

 

[GeddyLee]

I doubt extra credentialling on our certificates will make any difference. The bottom line is lobbying and getting the legislation to fall on our side. Physicians seem notoriously uninterested in lobbying to protect their practice and, at least in my program, very interested in educating anesthetists. I'd advise all who are planning careers in anesthesiology to plan their financial future very carefull and not place all you eggs in the anesthesia basket, so to speak.

By the way, for an interesting and probably infuriating read, check out
http://www.anesthesiapatientsafety.com

I'm surprised how CRNA's have made anesthesia so much safer.

 

[EtherMD]

Wow, with decreasing reimbursements, possible glut of anesthesiologists (from militarymd), and increase competition from technicians, is it possible that our field will experience the lean years of the mid-nineties within the next ten years? Almost makes me want to switch to EM. Damn. Good thing I'm interested in ICU.

Wait a minute. I gave you a list of the negatives so you could see the potential problems in the field. Now, let me give you the positives.

Income- Even with a 1/3 reduction in Income the specialty will remain in the upper quartile for pay. The average Anesthesiologist will still make twice the salary of Emergency Medicine Doctors

Job- Being an Anesthesiologist is significantly better than most of the surgical subspecialties except perhaps ENT and Plastics in terms of lifestyle vs. income

CRNA Threat- At major medical centers the surgeons want and demand Anesthesiologists to run the show. CRNA's are just Nurses and your fellow Physicians know that and prefer your services most of the time.

Medicine overall continues to decline as more of our population ages and becomes Medicare based. Our nation wants the best health care but the government does not want to pay for it. I predict in our lifetime the whole system gets altered significantly. Exactly how is anyone's guess.

 

[toughlife]

My best guess (and it is just that) is about a 1/3 reduction in pay over the next ten years. This is based on Medicare reductions, increased % of Medicare cases and more practicing Anesthesiologists.

In addition, CRNA income is fast approaching MD income. In fact, many CRNA's make more money than academic attendings today. CRNA income has doubled over the past ten years while MD income has stayed the same or declined a bit. In fact, more and more hospitals are providing MD anesthesiologists subsidies to maintain the level of current services. At some point, the hospital subsidy model may break as well.

But, the real kicker is that we are the only specialty that gets 3-5 times Medicare from our commercial carriers on a routine basis. The reason is because Medicare pays our specialty very poorly (on par with CRNA only care). Most other specialties get 1.5-2 times Medicare from their commercial carriers.

If we fail as a specialty it is because we do not "branch out" into the peri-operative arena and include advanced skills/training as part of the core program. For example, all Anesthesiologists should be able to do Critical Care and basic TEE. WE really do need to become the "Internists" of the operating room and take on the burden of complete perioperative care.

We must distinguish ourselves from the Nurse Anesthetists by providing services and care they are unable to; this provides justification for Physician Anesthesiologists besides basic anesthesia services.

The other day I was asking myself what would prevent us from providing pre-intra- and post-op care to patients coming to the hospital for a surgical procedure.

Would it be possible to bundle the anesthetic charge as part of a larger perioperative care bill? In other words, if Mrs. Jones is coming in for her cholecystectomy, I would admit her to the hospital, my colleague/group partner who is in the OR that week, would do her anesthetic and, if she required ICU care, my other group partner in the ICU could care for this patient during her ICU stay.

This way, one could not do/bill an anesthetic unless you are qualified and willing to provide complete perioperative care for this patient. Also, the anesthetic could be billed as part of a complete package.

I would argue that a patient would get more streamlined and better care since one group of physicians would be dedicated to caring for this patient since they came into the hospital until they were discharged.

Crnas could be used to do some of the cases but since they cannot provide the entire range of medical services the anesthesiologist could, they would be relegated to a salary since the anesthetic is part of a larger bill which they cannot bill for.

Comments?

 

[toughlife]

Look, I realize many of you are young and new to the field. I too had no idea that after Medical School, Residency and 13 years of Private Practice that my biggest problem would be CRNA competition. Medicare is a close second; but, let me elaborate a bit more.

Right now, many of you are in Residency or fresh out. You may not realize the AANA has been waging a successful campaign at the state and National level to obtain CRNA's more "independent practice" rights than ever before.

In fact, 16 states have "opt-out" laws that allow CRNA's to practice completely independently. The AANA is lobbying hard to get more states to do the same. The AANA lobby (more like a union) is much better than the ASA in getting their voice heard by politicians. The AANA has been successful in defeating their competitors (the Anesthesia Assistants) at the state level. Just recently, the AANA got the state of North Carolina to refuse legislation allowing AA's to practice in that state. This despite the efforts of the ASA and the AAAA (AA's parent group) efforts. Even though AA's have been working in Georgia for the past 30 years with an excellent safety record (equal to CRNA) the AANA defeated the bill to allow AA's to practice under the direct supervision of a board certified Anesthesiologist.
Meanwhile, CRNA's with the same level of education as an AA have the right to practice under the "direction" of a Dentist.

I disagree that salaries are going to remain at 2007 levels. Competition from lower level providers (the AANA states that CRNA's can do everything an Anesthesiologist does for half the price) and Medicare cuts are going to sting the profession pretty hard. In my opinion, much harder than Cardiology and Radiology because they have not helped train the competition.

The answer is not to increase the years in Residency. This is academic slavery for another year. The training is long enough at 4 years. The answer is to restructure the training so it is completely clinical in nature or 4 plus 1 for academically oriented Physicians. The PGY-5 year could be research oriented with additional certification in Bronchoscopy, advanced TEE and Transthoracic Echo, U/S use for diagnosis and blocks, EEG interpretation and Nerve conduction studies. We need to include in the core program certification in critical care and perioperative medicine. Basic TEE should be included as well.

The academic elite do not realize the AANA was banging at the door a few years ago and now they are in our house. The answer is not more security (e.g. add another year and pretend we are winning) but shoot now and secure your home (e.g. add more qualifications/certifications to your core program now). Then, your 4 years after medical school will have some real differences from the CRNA. CRNA's only do 27 months of training some of which is non-clinical. Yet, the law treats them as "equal to Physician Anesthesiologists" in 16 states. Being a good Anesthestist is no longer enough; the 48 months of Post-Graduate training must SHOW on paper you are a good Physician. This means Critical Care, Perioperative Medicine, basic TEE, etc. is included in your Consultant certificate.

As usual, our academic leaders and ASA are out of touch with 80% of the market place. Those of us in private practice need the ASA and the academic community to step-up to the plate now. Again, the answer is not more time "in the hole" but better use of the existing four years.

Those of you who get stuck with 5 years of Post-Graduate training just to get the same reimburesment level as a CRNA with 24-27 months of training are being sold down the river by Chairman who want cheap labor. After all, a CRNA costs $160,000-$180,000 for 40 hours a week. You cost 1/3 that amount and they get 60 hours a week. What do you get out of this? A government that pays you the same amount of money as a CRNA for doing a Medicare Case. You don't see the lawyers making these same mistakes or letting their paralegals practice "solo" do you?

One last thing to those of you who actually give a damn and are in a Residency program: get the word out to your fellow Residents over wings and beer. Also, let your program director and chaiperson know you deserve a better piece of paper when you finish: Consultant in Anesthesiology does not suffice anymore. You all deserve better.

Would you mind if I emailed this post to the ASA?

 

[TIVA]

Become subspecialists in perioperative medicine? Wait a second ... isn't that what we do everyday? Have I missed something here?

I thought that's exactly what we were trained to become: internists of the OR, consultants in anesthesia, perioperative physicians (take whatever label you like). They are all the same thing.

Surely we do more than simply put someone to sleep or render them insensible to pain. When I'm in the OR, I'm the ICU doc who has a census of one. I'm the one taking care of all the "flea details" while the surgeons do what they need to do. I'm the one who systematically and deliberately takes care of their neurological, musculoskeletal, cardiac, respiratory, renal, hematological, endocrine and hepatic functions. I know that what I do on my side of the curtain will have a potent impact on how well the surgery goes and how long the patient will remain in the hospital post-op.

Unless "perioperative medicine" means something else, we don't need further subspecialty training in perioperative care.

Having said that, at this year's ASA conference, Mark Lema seemed to indicate that the future of anesthesiology lies in hospitalist medicine. I'd be interested in hearing what you blokes have to say on that.

Personally, I don't see it happening. We as anesthesiologists went into this field to avoid hospitalist medicine and all that it entails, including crappy admits from the ER, social work, trying to find someone a rehab or nursing home to go to, getting consults for every little thing, from a Cr of 1.3 to a trop of 0.2 to a Hb of 10.9. We entered anesthesiology so we could have fun: working with our brains and our hands, seeing the interplay of physiology with disease and drugs, doing procedures, fixing a patient while they're under the knife, and the satisifaction of a job well done, the satisfaction of having made a difference. Not dictating discharge summaries.

 

[salmonella]

Become subspecialists in perioperative medicine? Wait a second ... isn't that what we do everyday? Have I missed something here?

I thought that's exactly what we were trained to become: internists of the OR, consultants in anesthesia, perioperative physicians (take whatever label you like). They are all the same thing.

Surely we do more than simply put someone to sleep or render them insensible to pain. When I'm in the OR, I'm the ICU doc who has a census of one. I'm the one taking care of all the "flea details" while the surgeons do what they need to do. I'm the one who systematically and deliberately takes care of their neurological, musculoskeletal, cardiac, respiratory, renal, hematological, endocrine and hepatic functions. I know that what I do on my side of the curtain will have a potent impact on how well the surgery goes and how long the patient will remain in the hospital post-op.

Unless "perioperative medicine" means something else, we don't need further subspecialty training in perioperative care.

Having said that, at this year's ASA conference, Mark Lema seemed to indicate that the future of anesthesiology lies in hospitalist medicine. I'd be interested in hearing what you blokes have to say on that.

Personally, I don't see it happening. We as anesthesiologists went into this field to avoid hospitalist medicine and all that it entails, including crappy admits from the ER, social work, trying to find someone a rehab or nursing home to go to, getting consults for every little thing, from a Cr of 1.3 to a trop of 0.2 to a Hb of 10.9. We entered anesthesiology so we could have fun: working with our brains and our hands, seeing the interplay of physiology with disease and drugs, doing procedures, fixing a patient while they're under the knife, and the satisifaction of a job well done, the satisfaction of having made a difference. Not dictating discharge summaries.

Hospitalist medicine is within the realm of internal medicine. Although anesthesiologists are very good at managing surgical patients, their ability to care for medically complex patients on medical wards is limited. It's better leave that for internists. Hospital medicine is not as simple as you guys think.

 

[EtherMD]

Become subspecialists in perioperative medicine? Wait a second ... isn't that what we do everyday? Have I missed something here?

I thought that's exactly what we were trained to become: internists of the OR, consultants in anesthesia, perioperative physicians (take whatever label you like). They are all the same thing.

Surely we do more than simply put someone to sleep or render them insensible to pain. When I'm in the OR, I'm the ICU doc who has a census of one. I'm the one taking care of all the "flea details" while the surgeons do what they need to do. I'm the one who systematically and deliberately takes care of their neurological, musculoskeletal, cardiac, respiratory, renal, hematological, endocrine and hepatic functions. I know that what I do on my side of the curtain will have a potent impact on how well the surgery goes and how long the patient will remain in the hospital post-op.

Unless "perioperative medicine" means something else, we don't need further subspecialty training in perioperative care.

Having said that, at this year's ASA conference, Mark Lema seemed to indicate that the future of anesthesiology lies in hospitalist medicine. I'd be interested in hearing what you blokes have to say on that.

Personally, I don't see it happening. We as anesthesiologists went into this field to avoid hospitalist medicine and all that it entails, including crappy admits from the ER, social work, trying to find someone a rehab or nursing home to go to, getting consults for every little thing, from a Cr of 1.3 to a trop of 0.2 to a Hb of 10.9. We entered anesthesiology so we could have fun: working with our brains and our hands, seeing the interplay of physiology with disease and drugs, doing procedures, fixing a patient while they're under the knife, and the satisifaction of a job well done, the satisfaction of having made a difference. Not dictating discharge summaries.

First of all, to those of you in Residency "semantics" may not mean much right now. But, to the public, administrators, legislators and even the Nurse Anesthetists it is VERY important. What you decide to do AFTER Residency is up to you. But, maintaining a "legal" right to practice in a broad manner by getting a certificate/certification in all the areas you are qualified can only help your career. ASA 3 is the new ASA2 for the specialty. That is, we see sicker patients every day and these people would benefit from an Anesthesiologist vs. a CRNA. How do we convice the public and the legislators of this fact when you do not realize the importance of semantics.
I am not asking you to be an "Internist" but a complete peri-operative Physician will advanced skills in basic PFT interpretation, basic Echo, U/S, Critical Care. Most good Residents can do all of this and more after completing a Residency.

A good Nurse Anesthetist can put someone to sleep and wake them up. Is that all you want your training certificate to show? Or, do you want to be CERTIFIED as a Peri-operative Physician that can CHOOSE to do more for patients. Don't you understand that there is a war going on at the State and National Levels? You are insulated from this battle at the teaching hospitals but the battle continues in rural America, Outpatient Centers and smaller cities.

Many Residents have too much to handle as it is; yet, you can not ignore the value of semantics in this war. You deserve for your certificate/certification to qualify for much more than basic Anesthesia services (glorified CRNA).
I know you posses the skills and knowledge to do all of this now; so do most good, Board Certified Anesthesiologists. Thus, the LEGAL need for your certificate/certification to reflect it. You deserve it. But, first you must understand why you need to fight for it.

 

[EtherMD]

Would you mind if I emailed this post to the ASA?

You may send one, all or none of my posts to anyone you wish. But, I hope you will pass the word to every Resident and every Fellow the importance of this issue. We can not win the Medicare battle until we defeat the CRNA's.
We need certificates/Board Certification in much more than "Anesthesiology."
We need the legal semantics to reflect our training as Physicians. We must clearly delineate our skills as Peri-Operative Physicians in a legal manner so the AANA can not claim "equivalence" to us. Only then do we have a chance to win the Medicare reimbursement battle.

 

[dhb]

Although anesthesiologists are very good at managing surgical patients, their ability to care for medically complex patients on medical wards is limited.

limited by what?

Hospital medicine is not as simple as you guys think.

How would you know?

 

[toughlife]

You may send one, all or none of my posts to anyone you wish. But, I hope you will pass the word to every Resident and every Fellow the importance of this issue. We can not win the Medicare battle until we defeat the CRNA's.
We need certificates/Board Certification in much more than "Anesthesiology."
We need the legal semantics to reflect our training as Physicians. We must clearly delineate our skills as Peri-Operative Physicians in a legal manner so the AANA can not claim "equivalence" to us. Only then do we have a chance to win the Medicare reimbursement battle.

I will bring it up at the next residency meeting with the PD present.

 

[Sevo]

Hospitalist medicine is within the realm of internal medicine. Although anesthesiologists are very good at managing surgical patients, their ability to care for medically complex patients on medical wards is limited. It's better leave that for internists. Hospital medicine is not as simple as you guys think.

The hardest thing about hospital medicine is the almost impossible task of kicking the patient out of the hospital and into a SNF.

As a medical student and as an intern, it was always the same. Patients come in with problem through clinic or ER; course of action essentially determined on hospital day one for 85% of patients; impossible to get them out of the hospital once treatment goals had been met (usually by hospital day three to five) because of deconditioning, personal economics (destitute, can't afford meds), or inability to get them into the proper nursing facility.

I'm not even going to go into lack of follow-up, non-compliance, psych, poor floor nursing, or denial issues.

 

[dhb]

Patients come in with problem through clinic or ER; course of action essentially determined on hospital day one for 85% of patients; impossible to get them out of the hospital once treatment goals had been met (usually by hospital day three to five) because of deconditioning, personal economics (destitute, can't afford meds), or inability to get them into the proper nursing facility.

Exactly i would say a good 50 to 70% of people in hospitals don't need the level of care that is provided and could be d/c to a less expensive facility.

 

[Arch Guillotti]

The hardest thing about hospital medicine is the almost impossible task of kicking the patient out of the hospital and into a SNF.

I don't know... Blocking an admission from the ED can be pretty tough. That is unless you are known as "the brick wall" - one of my favorite residents to work with during my intern year.

 

[Sevo]

I don't know... Blocking an admission from the ED can be pretty tough. That is unless you are known as "the brick wall" - one of my favorite residents to work with during my intern year.

Unfortunately that attitude goes right out the window when you get that residency diploma. Bills have to be paid.

 

[EtherMD]

I will bring it up at the next residency meeting with the PD present.

Thanks. The purpose for posting my statements is to make Residents and senior medical students aware of the situation in the specialty. When I finished my Residency CRNA's were a "minimal" threat to the ASA and practicing Anesthesiologists. As their numbers grew so did the clout of the AANA.

The AANA uses propoganda and lies to convince the public of their "equal stature" as Anesthesia providers. Now, you and a few others know the truth but what about John Q. Public? What about our National and State legislators?

If the ASA and the Academic Program Chairs are not going to "defend" the specialty against the AANA propoganda who will? Thus, I am angry at the Academic Chairpersons for letting us all down (especially the Residents) by not taking immediate action. There is absolutely no reason not to alter your Residency Diploma and Board Certification this year (2007) to reflect your training. Anesthesiologists are not glorified CRNA's; the best place to start proving (legally) this difference is with your diploma/certificate.

If every Resident started to demand change on this issue the wheels will begin to move. The answer is not to increase the mandatory training from
48-60 months as your 'basic" training is more than adequate.