The future of anesthesiology

[EtherMD]

Bill$****!!!!! The argument I'm making here is NOT that the MD's provide better care (I suspect that in most cases, the MD is over-trained to handle most intraoperative anesthesia anyway). My point is ONLY that the MD's are the ones responsible for training and educating all of the mid-level providers, and therefore when push comes to shove the MD's are ABSOLUTELY NOT forced into these market-driven relationships. MD's have a weapon that they are loathe to recognize. Why they keep it quivered is quite beyond me.



That's fine. But what you are intimating is that MD anesthesia has become lazy and entitled. To the extent that is true, they deserve to be replaced by people (whoever they are) that are willing to do the work they are unwilling to do. Is that the explanation for why these management companies are able to make headway into the marketplace? I can't see why a private MD group can't police itself just as well as effectivley as a corporate MD group can. That they are not is one issue. That they are incapable is quite another.



Well, this gets back the question I originally asked you - if the corporations are unable to provide an equal for better service for the same or less amount of money, they have no shot in the marketplace. I wondered then how they could possibly compete if they have (essentially) introduced another level of revenue skim between the hospital and the anesthesiologist. You can crystalize this whole issue by writing here whether or not your contracts with the hospitals have been more favorable or less favorable since the management companies have started to bid. If they are less favorable (which I gather they have been otherwise this whole issue would not warrant an entire thread), the question is "why". One answer is that the management companies could, despite the extra layer of profit-takers, provide a better or same service for less money (presumably by paying their staff much less money). If that is the case, then I am back to my original question - who are these MD's willing to earn so much less money? They are either stupid or bottom or the barrel? They don't do it out of the goodness of their heart.

I'll say something else as well about this as well - my understanding of the management company model suggests to me that they hire more transient, locum, temp . . . whatever, sort of people to staff the OR's and ICU's. You might describe them as anything you like, but "top teir" is not one of them. Top teir people are not willing to work for less money.

The last bit about the hospital MBA agreeing to pay the management company more simply because it has greater top-down expenses is ridiculous. MBA's don't make these sorts of allowances. You pay for service and results.

Judd

JUdd, I answered your questions but you do not like what you read. Thus, you respond in a defensive and speculative manner.

The fact is many hospital administrators prefer to deal with MBA's over Physicians. Simply charging the hospital the same price as the management company is not enough. You must show you are a better value than they are in every way: better care, more services and a lower price. This is the way to show the administration you are doing everything possible to work with them. But, you need to realize the management companies "inflate" the actual costs so they can make a 20% profit on each contract. So, any decent Group should be able to provide more services and beat the overall price.

As far as lazy Anesthesiologists out there I hate to inform you there are many. This is why the management companies can move in and get the contract. Once employed by the company these lazy individuals are forced to work or must find a new job. My understanding is that up to 50% or more of the "old guard" will leave within the first 24 months of being employed by the company.

The hospital gets to clean house with the management company without being bogged down in medical staff and legal issues. When a Physician has been of Staff at a hospital for many years it can be quite difficult to get rid of them (almost impossible). An easy way to get rid of these lazy guys is to have the management company do it. The company reduces their salary and provides clauses in their contracts making a ceratin amount of work mandatory.

Like it or not, there are many 50+ year old Anesthesiologists out there "coasting" on past service and previous work. These guys look to not do cases, avoid call and cancel cases. They have made a great deal of money and will "deal with the consequences" if it happens. In short, they are not "hungry" and concerned about winning the game. Also, it is not easy for the "Group" to get rid of these guys either (legal issues). Thus, the hospital takes the easiest route and starts over with a new company. So, one bad apple really can spoil the whole lot for everyone.

If the hospital grows unhappy with the management company or the Anesthesia Providers all they need to do is replace the company. They have no medical staff or legal issues with the providers because they work for the company. If the company goes so do the providers. This makes cleaning house fast and easy.

However, if the Group providing services is First Tier and proves their worth daily (both with the staff and with the $$bottom line) then the hospital will want to retain them. This is another reason why you want to examine the credentials and work ethic of any Group you join.

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[militarymd]

Military md you are whats wrong with the profession..

Sticks and stones may break my bones, but in the not too distant future...you're going to be working for me....or someone like me.......

 

[juddson]

I am an independent contractor.. If i was looking for a job it certainly would NOT be a partnership track job witha private MD group. I would much rather work for an anesthesia management group.. At least you are not seeing the people who are screwing you on a daily basis.... and they pay more..... but i would never go either..

..

I'm confused by this. Why do you prefer the management company more than a private group? Also, are you suggesting that the management company pays more? I'm not understanding your post.

Judd

 

[EtherMD]

I'm confused by this. Why do you prefer the management company more than a private group? Also, are you suggesting that the management company pays more? I'm not understanding your post.

Judd

Judd,

There a lot of factors in determining what type of practice to join: location, payer mix, Group dynamics, partnership track time and MD qualifications.
The best Groups want the most qualified graduates and that may mean a fellowship these days. There are some Groups out there who start new guys at "low pay" and "string them along" for years. On top of that the partnership income is not good (50%) and they "lie" about the income potential of the job.

If you join a management company the salary should be stated up-front and list the benefits as well (usually the benefits suck). There is no "track" and you can leave the position with short notice. That said, the best Groups out there are still better deals than a "management company" and will come close or beat the management salary by the second year of employment. Partnership income from a well-run Group should always exceed the management company's salary (in a given geographic area). My advice is verify the partnership income of the Group and get a "guarantee of partnership" after 12 months of working for a Group. With these two things in hand your odds are much more favorable of not getting scr#*ed.

 

[johankriek]

I'm confused by this. Why do you prefer the management company more than a private group? Also, are you suggesting that the management company pays more? I'm not understanding your post.

Judd

umm private md groups are very cost concious ( cheap asses). They wanna suck the blood out of the new grads. I disagree with ether mds post above about them looking for the best( well trained) candidates. That has very little to do with the hiring process. what has a lot to do is connections. DO you KNOW THEM personally? do you like to do what THEY Do on your free time/// those such things..

More over, they are more likely to be sneaky, string you along on a partnership track with very low pay witht he hopes of someday being a partner and when partnership time comes. they say well business climate has changed we cant take on a partner.. You leave.. and they get somone new.. THis can only work in highly desirable areas.. but this model works a lot in a lot of places.. Mostly the Northeast is notorious for this.. I heard of a group in NYC offering a 6 year to partner track.. you have to be sniffing glue to accept something like that.. thats my take on private md groups. I interviewed a lot; never accepted an offer before i went out on my own,

 

[UTSouthwestern]

umm private md groups are very cost concious ( cheap asses). They wanna suck the blood out of the new grads. I disagree with ether mds post above about them looking for the best( well trained) candidates. That has very little to do with the hiring process. what has a lot to do is connections. DO you KNOW THEM personally? do you like to do what THEY Do on your free time/// those such things..

More over, they are more likely to be sneaky, string you along on a partnership track with very low pay witht he hopes of someday being a partner and when partnership time comes. they say well business climate has changed we cant take on a partner.. You leave.. and they get somone new.. THis can only work in highly desirable areas.. but this model works a lot in a lot of places.. Mostly the Northeast is notorious for this.. I heard of a group in NYC offering a 6 year to partner track.. you have to be sniffing glue to accept something like that.. thats my take on private md groups. I interviewed a lot; never accepted an offer before i went out on my own,

I'll disagree with you on the first point. If you want to maintain a strong business clientele in just about any business, you are hard pressed to do so when one of your team members is a slovenly, forgetful, unfocused individual. In our hiring process last year, we sifted through more than 100 applications looking for strong candidates.

On the second part, yes the northeast can be brutal. There is one group who's head is chairman of an academic anesthesia department as well as president of the private group who makes $2,000,000/year, but with partnership tracks to young guys as long as 10 years.

 

[toughlife]

So what exactly is considered a strong candidate. This term is thrown around here but it has yet to be defined.

 

[johankriek]

. If you want to maintain a strong business clientele in just about any business, you are hard pressed to do so when one of your team members is a slovenly, forgetful, unfocused individual. In our hiring process last year, we sifted through more than 100 applications looking for strong candidates.

If you are reviewing 100 applications and can't find one suitable candidate in this field threre has got to be something wrong with your standards.. were they ALL slovenly forgetful and unfocused? I mean cmon... pull the other leg it plays jingle bells

to answer tough.. Strong candidate: Board eligible for new grads or board certified ( for 3-4 years out)..... no malpractice history.. personable... willing to work.. no drug history..

you couldnt find those attributes in one person in 100..

 

[EtherMD]

I'm confused by this. Why do you prefer the management company more than a private group? Also, are you suggesting that the management company pays more? I'm not understanding your post.

Judd

Judd,

There are many Groups out there that treat new "hires" fairly. I listed several things to look for in a GRoup:

1. A fair Partnership Track (two years is the norm but if the income is 95th percentile or more you could consider three)

2. A Partner Status agreement after 12 months of employment. This states the Group guarantees your partnership after 12 months of employment but you must complete your agreed partnership track. This prevents any Group from abusing you.

3. A good salary while an "employee" of the Group. An example would be a first year salary of at least $250,000. With a fellowship you should expect $275-$300,000 the first year. Again, this demonstrates "decency" and "fairness" of the Group

4. Validate Partnership Income- Find out what the partnership income is when you join and what it may be in 24 months. Verify the income.

If you find a Group that does items 1-4 for you the odds are very high you will not invest more than a few months time in the Group before being told whether you will make Partner. In addition, most Groups that do items 1-4 for you WANT YOU TO SUCCEED!

 

[militarymd]

"Good" groups aren't going to "guarantee" a "partnership" track. The purpose of NOT letting you be a partner on day one ....is for evaluating the new hiree ....to see if YOU...as the NEW guy will be an asset for the group.

My group does the following:

- equal pay from day one....on the very first day..you get paid the same as the founder of the group.

- 30 DAY partnership track....you MAY be offered "partnership" within 30 days....so far the track is 7 days long.

- HOWEVER, if, after the evaulation period (as determined by the partners) you are found NOT to be an ASSET to the group...you will be let go with a 120 day notice.

 

[cfdavid]

"Good" groups aren't going to "guarantee" a "partnership" track. The purpose of NOT letting you be a partner on day one ....is for evaluating the new hiree ....to see if YOU...as the NEW guy will be an asset for the group.

My group does the following:

- equal pay from day one....on the very first day..you get paid the same as the founder of the group.

- 30 DAY partnership track....you MAY be offered "partnership" within 30 days....so far the track is 7 days long.

- HOWEVER, if, after the evaulation period (as determined by the partners) you are found NOT to be an ASSET to the group...you will be let go with a 120 day notice.

So, what are the top 5 assets that you guys value in a candidate? (try to prioritize them in sequence, if possible) Thanks.

 

[militarymd]

So, what are the top 5 assets that you guys value in a candidate? (try to prioritize them in sequence, if possible) Thanks.

1) hard worker --- believe it or not....most anesthesiologists are NOT...lots of lifestyle pursuers.

2) realize that patients come to the hospital to have surgery...NOT anesthesia.

3) good personality....one that fits in with the rest of us, the surgeons, and the hospital staff.

4) competent.

5) board certified.

 

[UTSouthwestern]

If you are reviewing 100 applications and can't find one suitable candidate in this field threre has got to be something wrong with your standards.. were they ALL slovenly forgetful and unfocused? I mean cmon... pull the other leg it plays jingle bells

to answer tough.. Strong candidate: Board eligible for new grads or board certified ( for 3-4 years out)..... no malpractice history.. personable... willing to work.. no drug history..

you couldnt find those attributes in one person in 100..

You have to realize that we are very thorough. We call your residency program, speak to the references you list, speak to you the candidate at least three times before we even formally interview you to find anything that might make us hesitate so that we avoid wasting your time and ours.

What you have listed above (board eligible, no malpractice hx, personable, etc.) is what we view as an average candidate, as it should be.

 

[EtherMD]

Clarification:

My Group evaluates a new hire at the 12 month interval. We meet and inform the new hire if partnership will be offered at the end of the second year. This way the new hire knows about partnership after 12 months.
The intent is to allow sufficient time to evaluate the new hire and make sure personality, skills and work ethic are up to par.

 

[m3unsure]

What is the call schedule for a decent paying job (near 200K)? I'm thinking if there is anything like q6-7 or better near bigger cities, but not necessarily close or within.

 

[EtherMD]

What is the call schedule for a decent paying job (near 200K)? I'm thinking if there is anything like q6-7 or better near bigger cities, but not necessarily close or within.

Calls for about $200,000 per W-2 should be about 1-2 per month. In fact, you may be able to get a surgicenter position which pays $250,000 plus benefits with no call at all and all holidays off.

 

[EtherMD]

What is the call schedule for a decent paying job (near 200K)? I'm thinking if there is anything like q6-7 or better near bigger cities, but not necessarily close or within.

Those of you out there finishing Residency need to realize the landscape of Anesthesia is changing rapidly. The Groups that used to "use and abuse" new graduates are finding out that "model" does not work anymore.

There are many Groups that are 'fair' and offer good opportunities to new graduates. Do not paint every Group with the same brush; instead, look at the overall picture and decide for yourself if the deal seems fair.

 

[Dawkter]

Curious as to how our perspective on this issue has changed since four years ago. Any thoughts?

 

[BLADEMDA]

The specialty of Anesthesiology will always need good, dedicated people.
I am not trying to "lecture you" on why you shouldn't choose Anesthesiology.
Instead, I am trying to explain the positives and negatives of the specialty.
Also, the value of additional formal training beyond "basic anesthesia."

There are Groups that cover the Operating Rooms and ICU. I know of at least three large, financial successful, Private Practice Groups that have Critical Care Certified Anesthesiologists as an integral part of the practice.
The hospitals usually provide a large "stipend" for the ICU coverage. In addition, Intensive Care Anesthesiologists rotate in the Operating Room and take call.

But, you are a first year Medical Student. Why close your mind to other specialties like Cardiology? Internal Medicine offers Critical Care certification as well Pulmonary Medicine. If your interest is PRIMARILY Critical Care then why choose Anesthesiology without considering the others? That said, the role of Intensivisits in hospitals across the USA is only going to increase over the next ten years. You will never lack job security with Anesthesiology plus fellowships in Critical Care Medicine and Cardiac Anesthesia.

If you were to only pick one fellowship which one would you choose? I ask that question because in today's economic climate Cardiac Anesthesia with Certification in TEE would get you more job offers in the top 10% pay range.
Critical Care Certification is valuable and would get you fewer offers right our of training. However, ten years from now things will be very different and I could easily see Critical Care being the more "valuable" fellowship. One more thing: The "burn-out" factor is higher in Critical Care than Cardiac/Basic Aneshesia in the operating room. Another reason you want to be "cross-trained" in other areas.

I agree with this guy.

 

[Sevo]

The days of the MD/DO only generalist practice are numbered. The anesthesia "team" approach will likely compete against CRNA only practices as the two major models of anesthesia delivery in the United States. You can thank your ivory tower chairmen for that.

If I were starting my CA-3 year and I was looking to stay in the OR, I would strongly recommend doing a pediatrics fellowship. Peds people have always been in short supply; we're always looking for them in my practice. You can literally get a job anywhere and make big bucks right off the bat. Furthermore, few CRNAs can do specialized pediatric cases.

Anesthesia CCM is going the way of the dinosaur and most heart guys are looking to get out of doing hearts. I would only consider doing either if I had a burning desire to do ICU or pump work regularly.

 

[Dawkter]

I know everyone on this forum seems to think the field is changing/in danger but I don't know if I buy it. I am at a large academic institution and none of the attendings seem even the slightest bit worried. One attending told me that this sort of CRNA takeover talk has been going on since the 1980's and nothing has yet to happen. There are simply too many surgeries, too many academic institutions, and too many anesthesiologists are needed to fill these positions. If you graduate from a solid program, you should be able to find work. I was told that people who may struggle to land those 300k+ jobs are people who graduate from programs that just aren't as reputable or known to provide solid training.

Of course I am a medical student so many of you probably have a much better idea of what is actually going on. It just seems like the academic anesthesiologists I encounter are un-phased by any of this.

 

[BLADEMDA]

I know everyone on this forum seems to think the field is changing/in danger but I don't know if I buy it. I am at a large academic institution and none of the attendings seem even the slightest bit worried. One attending told me that this sort of CRNA takeover talk has been going on since the 1980's and nothing has yet to happen. There are simply too many surgeries, too many academic institutions, and too many anesthesiologists are needed to fill these positions. If you graduate from a solid program, you should be able to find work. I was told that people who may struggle to land those 300k+ jobs are people who graduate from programs that just aren't as reputable or known to provide solid training.

Of course I am a medical student so many of you probably have a much better idea of what is actually going on. It just seems like the academic anesthesiologists I encounter are un-phased by any of this.

Change happens slowly over time. The Group to be affected last by any changes will be Academia. But, even they will feel health care change as decided by CMS.

Of course, you will find work after Residency. The question is what kind of work and what will it pay? Yes, there are plenty of $300K jobs out there for new graduates. But, what is the impact of the AANA over the next twenty years?

Here is the sequence of Change:

1. GI Centers- Some already have gone CRNA Only

2. ASCs- A few have gone to the CRNA only model. More are likely to go MD /CRNA with the Doctor doing his/her own case right next door to the CRNA.

3. Rural Hospitals- Many are CRNA only and more may consider it. Even if there is ONE Anesthesiologist the CRNA does his/her own case unsupervised.

4. Community Hospital- They will feel the pressure to save money and reduce stipends. This means fewer Anesthesiologists and more CRNAs. 6:1 ratios are just around the corner.

5. Larger Private Hospitals- Probably a few years behind Community hospitals.

6. ACADEMIA- The Ivory tower will likely be years away from major changes. CRNAs won't be doing cases Solo.

 

[BLADEMDA]

Let me Sum up the Dilemma Anesthesiologists face in the near future with massive budget cuts and millions of new Medicare Recipients:

Is this Field Nursing Level Duty or Physician Specialty? Can an Advanced practice Nurse deliver the same level of care UNSUPERVISED as a Supervised CRNA?

So far, the Data is pretty clear on this issue. Why will CMS continue to pay a Physician's wage for a Nursing Level Function?

 

[BLADEMDA]

http://www.aana.com/WorkArea/DownloadAsset.aspx?id=26339

The Bean Counters in Washington are getting this type of Propaganda from the AANA. Where are our studies showing the value/necessity of Medical Supervision?

The ASA needs a new PAC funded by private practitioners to start studies showing the "added value" of Supervision. You can count on my support.

 

[sevoflurane]

Community hospitals are already affected. A buddy of mine from residency is facing this now. Not a rural hospital. In fact, an extremely nice city in regards to city planning and outdoor beauty.

It started with OB. Lazy MD's that didn't want to do it. So they gave it up to CRNA's. Now they do ALL the OB.

Fast-forward a couple of years. Now the CRNA's have made their way in to the OR's doing the appy's, gallbladders, etc... Working side by side. No supervision. You can help them out when things go bad.... putting your license on the line.

People, it starts with us. With you at YOUR hospital/ASC. Don't let the older guys who don't care sell out OB, ASC's, off site, etc.... so that your call and days could be easier. Push the other way. Even if you have to loose some revenue. How much are you going to loose in revenue when you loose your contract to the CRNA group or management firm or other practice that can do it for less?

Take back these sites and push them out. The cat is already out of the bag, but it doesn't mean you can't do what is right for YOUR profession and those that will follow in your footsteps.

If I wasn't so young in my career, I would be more active. But I can tell you that when CRNA's are discussed at our meetings (including administrative), the idea has been stomped out quickly and decisively. We would take less $$$$ than to proliferate the cancer that is eating up such an exceptional specialty. We refuse to be part of the problem.

THINK ABOUT THIS:

Those that are in their 50's don't have much to loose, so they are relatively safe as they approach retirement. Those that are in their 40's have a lot to loose. Those who are still in residency and medical schools have the most to loose. We are talking about a generation of anesthesiologists that have been some of the brightest medical students entering the profession in years.

Fight the good fight friends.

Not for selfish reasons.

But because it's right.

You want to do solo practice? Go to medical school, grasp a deep understanding of medicine, do a residency that will expose you to everything under the sun and then run solo or supervise. That is how it's done everywhere in the world.

Shortcuts are exactly that... short cuts.

There is no room for shortcuts when it deals with patients and a profession that has rigorous board certification process.

Regards,

Sevo.

 

[sevoflurane]

One more thing. If you are in an ACT model....

PLEASE SEEK OUT QUALIFIED AA'S OVER CRNA'S.

If they don't fit the requirements you are looking for move on to CRNA's.

There is no down side in starting with AA's.

 

[sevoflurane]

From one of the great ones in our profession.

Well you know that the smackdown is coming if I post a reply:

I find it more than a little irritating that anesthesiologists seem to complain about respect issues, lifestyle, pay, nurses, etc. and just stew over it.

I have been in practice six years, do every kind of case known to man, 100% solo/no supervision, work hard but play hard, and only twice can I recall being disrespected/questioned in that time.

Both times, by nurses, a quick, educational, and authoritative response quelled any further insubordination. Surgeons, nurses, and administrators know that when I say something, request something, order something, do something, it has a legitimate purpose and MUST be done. It is a confidence they have in my judgement and more importantly, my compassion.

Conversely, I am told regularly about how some anesthesiologists have little to no ability to make a firm decision, bounce back and forth between totally opposite treatments/decisions, speak/act like scared mice, rush out of the PACU or ICU to make a haircut appointment, talk about anything EXCEPT medicine or THEIR patient, etc.

With that backdrop, it becomes increasingly difficult to keep the lines distinguished.

These are YOUR patients, not just the surgeon's. Take ownership of your patients, your situation, your facility, and be heard. Too many expect that M.D. or D.O. acronyms on their badges will instantly afford respect or authority. With Hollywood medical vomitus on TV and in the movies creating an overgeneralized image of the lazy, incompetent, vain, self-centered, dangerous physician, the deck is stacked against you.

Don't jump up and down on the down side of an overloaded ship, throw the baggage overboard.

Get involved in every phase of every case you do. The more you do that, the faster and easier it becomes and the more indispensible you become. "Dr. CT surgeon, I spoke with your AVR, redo CABG patient last night and he has worsening cervical stenosis with OPLL diagnosed over a year ago. I am recommending full neuromonitoring for this case and will consult with his neurosurgeon on post-op followup and care." In the ICU give a full report and direct the care. "This patient requires Q 4h neurochecks including full upper and lower extremity range of motion and strength exams." Do the first one yourself.

When you walk into an OR, or PACU, or preop holding area, or ICU, your presence should be anxiolytic, not anxiogenic. You can see and hear the difference when different anesthesiologists walk in. We need to make a concerted effort across the specialty to change the attitude of and towards the specialty.

It starts with the medical students. I cannot tell you how many PM's and e-mails I still get from this forum from med students with subpar grades and docile personalities, looking for the high pay, easy lifestyle, no stress field. I no longer respond to those students, because this field does not need foot soldiers. It needs leaders and visionaries to push the boundaries of the field and take ownership of our future. It doesn't need fearmongers, supporting cast members, or the spineless.

Work in a hostile environment? Defuse it. Find out what the issues are and tackle them head on. Do it with zeal, a positive, helpful attitude, but most of all with authority. As I have said multiple times in the past, you have to get involved from the top down to understand and develop all facets of your practice and your facilities. That means spending some off time in administration and rooting out problems before they start to fester. I spend a large portion of my free time in administrative meetings both teaching and learning from administrators about issues they may not even have considered.

Cost considerations are always a concern. This group will do it cheaper, this group uses CRNA's, this group will come out to location X, etc. I have been asked to change my practice by facilities before and each time, I have clearly delineated the pros and cons and emphasized the depth and experience of my group to administrators. I am more than willing to take those assets and develop your competitor. That happened again and two months ago, I was reapproached by the facility I left to come back and resume our practice there. I declined. When they sweetened the deal, I accepted with stipulations.

In the future, we need to develop physician specific, core business concepts that will provide reproducible, sustainable models in all situations. The "cheaper is not better" approach combined with sustainable revenues and proven outcomes starts with the ASA and legislative efforts. It is a comprehensive model that can be used to not only sustain our presence but also redefine our roles as providers, leaders, and business developers.

 

[cfdavid]

Community hospitals are already affected. A buddy of mine from residency is facing this now. Not a rural hospital. In fact, an extremely nice city in regards to city planning and outdoor beauty.

It started with OB. Lazy MD's that didn't want to do it. So they gave it up to CRNA's. Now they do ALL the OB.

Fast-forward a couple of years. Now the CRNA's have made their way in to the OR's doing the appy's, gallbladders, etc... Working side by side. No supervision. You can help them out when things go bad.... putting your license on the line.

People, it starts with us. With you at YOUR hospital/ASC. Don't let the older guys who don't care sell out OB, ASC's, off site, etc.... so that your call and days could be easier. Push the other way. Even if you have to loose some revenue. How much are you going to loose in revenue when you loose your contract to the CRNA group or management firm or other practice that can do it for less?

Take back these sites and push them out. The cat is already out of the bag, but it doesn't mean you can't do what is right for YOUR profession and those that will follow in your footsteps.

If I wasn't so young in my career, I would be more active. But I can tell you that when CRNA's are discussed at our meetings (including administrative), the idea has been stomped out quickly and decisively. We would take less $$$$ than to proliferate the cancer that is eating up such an exceptional specialty. We refuse to be part of the problem.

THINK ABOUT THIS:

Those that are in their 50's don't have much to loose, so they are relatively safe as they approach retirement. Those that are in their 40's have a lot to loose. Those who are still in residency and medical schools have the most to loose. We are talking about a generation of anesthesiologists that have been some of the brightest medical students entering the profession in years.

Fight the good fight friends.

Not for selfish reasons.

But because it's right.

You want to do solo practice? Go to medical school, grasp a deep understanding of medicine, do a residency that will expose you to everything under the sun and then run solo or supervise. That is how it's done everywhere in the world.

Shortcuts are exactly that... short cuts.

There is no room for shortcuts when it deals with patients and a profession that has rigorous board certification process.

Regards,

Sevo.

I'm with you man. 100%. And amen to all of what you just said.

Also, we should take serious stock in what UTSoutwestern's post suggests. Time to get serious and I agree that we should SHUN those passive, lazy, spineless med students from even considering entering this profession.

 

[deleted126335]

Let me Sum up the Dilemma Anesthesiologists face in the near future with massive budget cuts and millions of new Medicare Recipients:

Is this Field Nursing Level Duty or Physician Specialty? Can an Advanced practice Nurse deliver the same level of care UNSUPERVISED as a Supervised CRNA?

So far, the Data is pretty clear on this issue. Why will CMS continue to pay a Physician's wage for a Nursing Level Function?

Productivity, efficiency, value of associate services, cost of unplanned admission or ICU stay, other utilization issues, complications, increased cost or concern of litigation and the effects that has on behavior.

But can we prove it?

OJ and Casey Anthony killed, but it couldn't be proved so they won. CRNAs are a step down, if we can't prove it, we won't win either.

 

[BLADEMDA]

Productivity, efficiency, value of associate services, cost of unplanned admission or ICU stay, other utilization issues, complications, increased cost or concern of litigation and the effects that has on behavior.

But can we prove it?

OJ and Casey Anthony killed, but it couldn't be proved so they won. CRNAs are a step down, if we can't prove it, we won't win either.

I agree with you. Fortunately, the CRNA mills are producing some really awful providers which should make any potential employer greatly concerned at the prospect of a Solo CRNA in their hospital.

 

[prism74]

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.

That plus the fact that many CRNAs do not clarify their exact title when they introduce themselves to patients...patients don't know how to interpret the term 'anesthetist' nor are they inclined to ask, "oh, wait, so does that mean you're a doctor?" The doctor part is usually just assumed.

A thought about the power of patient dissatisfaction -- look at how much Emergency Medicine has changed based on the issue of wait times. True, there were always exceptional cases of unreasonable delays in care that justified overarching change, but now the ED is a place that is driven by the wait time issue (frequently at the expense of the care delivered)...

 

[ccmonopolies]

What I don't understand is that in some countries, anesthesia is practiced solely by nurses. Doctors don't even practice the field. It isn't a medical specialty.

There are a few worries that are keeping me away from the field.

What a previous poster said about being a business developer is spot on. This specialty will only support its salary differential if MD anesthesiologists can somehow drive higher revenue for their hospital partners than CRNAs can.

I honestly don't think this is possible for the entire field as I'm not seeing how anesthesiologists are getting better patient outcomes than the CRNA in the clearly straightforward cases. I do however believe that with the inherent longer training, anesthesiologists who are much better trained to handle complex cases that the CRNAs can't do will survive and maintain their higher salaries.

Basically, I think that future students who are willing to do a fellowship in anesthesia and who are willing to concentrate on complex cases that CRNAs can't do with their limited training can do well.

This way there is a clear delineation in the roles of the anesthesia provider, with the CRNAs providing more straightforward care and the fellowship trained anesthesiologist providing the complex care. I think this is doable when you can simply designate the easier cases to the CRNAs. Any cases with even a hint of complications can be handed to the anesthesiologist.

If this were to happen, it would cause 2 things to play out.

1. The specialty would contract and the number of MD anesthesiologists that we need to train would decrease. The number of CRNAs trained will equilibrate to the number of CRNAs that the country needs.

2. The overall net cost to the taxpayer would also decrease as cheaper CRNAs would replace more expensive MDAs who just practice basic anesthesia.

Our national debt levels compared to GDP are significantly higher than what they were in the 1980s. Back then, we didn't have the impetus to change. The government will do what it has to reign in costs.

 

[dhb]

What I don't understand is that in some countries, anesthesia is practiced solely by nurses. Doctors don't even practice the field. It isn't a medical specialty.

Yeah some countries in Africa

 

[Mman]

What I don't understand is that in some countries, anesthesia is practiced solely by nurses. Doctors don't even practice the field. It isn't a medical specialty.

And what countries are these? I'm having a hard time thinking of a non 3rd world country that you are referring to. As far as I know there is no such thing as a CRNA in Europe. They also can't work in Canada. Pretty sure they aren't in Japan or Australia or New Zealand.

The United States is the only major country that has such a thing as a CRNA.

 

[anynoise]

And what countries are these? I'm having a hard time thinking of a non 3rd world country that you are referring to. As far as I know there is no such thing as a CRNA in Europe. They also can't work in Canada. Pretty sure they aren't in Japan or Australia or New Zealand.

The United States is the only major country that has such a thing as a CRNA.

France has nurse anesthetists and i believe a few other countries in europe.

 

[Mman]

I'm pretty sure that what they call nurse anesthetists in France do not function the same way they do in the US. Sort of similar, but not the same.

 

[ccmonopolies]

I'm pretty sure that what they call nurse anesthetists in France do not function the same way they do in the US. Sort of similar, but not the same.

China, the second largest economy in the world, is a third world country?

You have to think about why the government has allowed the CRNAs to proliferate. Everything happens for a reason. If one thinks about why things are happening and thinks about which variables are more important to those in charge, then somethings become more clear.

 

[Mman]

China, the second largest economy in the world, is a third world country?

You have to think about why the government has allowed the CRNAs to proliferate. Everything happens for a reason. If one thinks about why things are happening and thinks about which variables are more important to those in charge, then somethings become more clear.

The size of the population of China is what makes it the 2nd largest economy in the world, not the standard of living of the population. It's a dump. The healthcare actually being delivered to the vast majority of their population is putrid. There are better situations in Africa.

 

[pgg]

China, the second largest economy in the world, is a third world country?

For the billion or so Chinese peasants, it sure is.

 

[ccmonopolies]

What I don't understand is that in some countries, anesthesia is practiced solely by nurses. Doctors don't even practice the field. It isn't a medical specialty.

There are a few worries that are keeping me away from the field.

What a previous poster said about being a business developer is spot on. This specialty will only support its salary differential if MD anesthesiologists can somehow drive higher revenue for their hospital partners than CRNAs can.

I honestly don't think this is possible for the entire field as I'm not seeing how anesthesiologists are getting better patient outcomes than the CRNA in the clearly straightforward cases. I do however believe that with the inherent longer training, anesthesiologists who are much better trained to handle complex cases that the CRNAs can't do will survive and maintain their higher salaries.

Basically, I think that future students who are willing to do a fellowship in anesthesia and who are willing to concentrate on complex cases that CRNAs can't do with their limited training can do well.

This way there is a clear delineation in the roles of the anesthesia provider, with the CRNAs providing more straightforward care and the fellowship trained anesthesiologist providing the complex care. I think this is doable when you can simply designate the easier cases to the CRNAs. Any cases with even a hint of complications can be handed to the anesthesiologist.

If this were to happen, it would cause 2 things to play out.

1. The specialty would contract and the number of MD anesthesiologists that we need to train would decrease. The number of CRNAs trained will equilibrate to the number of CRNAs that the country needs.

2. The overall net cost to the taxpayer would also decrease as cheaper CRNAs would replace more expensive MDAs who just practice basic anesthesia.

Our national debt levels compared to GDP are significantly higher than what they were in the 1980s. Back then, we didn't have the impetus to change. The government will do what it has to reign in costs.

I like how no one has anything to say about the rest of my thoughts.

 

[mersault]

here's something else about your thoughts: you say, "I honestly don't think this is possible for the entire field as I'm not seeing how anesthesiologists are getting better patient outcomes than the CRNA in the clearly straightforward cases. "

what studies are you referring to that allow you to draw such a conclusion? you surely must have some study comparing "outcomes" between the two groups. I'm not arguing against it, but only because I have no study to back up my argument (otherwise personally I do think without MDs to supervise them things would get out of hand). You, on the other hand, are making a statement and should be able to back it up.

 

[jwk]

I like how no one has anything to say about the rest of my thoughts.

I dunno, maybe because it sounds a tad trollish.

 

[mersault]

Community hospitals are already affected. A buddy of mine from residency is facing this now. Not a rural hospital. In fact, an extremely nice city in regards to city planning and outdoor beauty.

It started with OB. Lazy MD's that didn't want to do it. So they gave it up to CRNA's. Now they do ALL the OB.

Fast-forward a couple of years. Now the CRNA's have made their way in to the OR's doing the appy's, gallbladders, etc... Working side by side. No supervision. You can help them out when things go bad.... putting your license on the line.

People, it starts with us. With you at YOUR hospital/ASC. Don't let the older guys who don't care sell out OB, ASC's, off site, etc.... so that your call and days could be easier. Push the other way. Even if you have to loose some revenue. How much are you going to loose in revenue when you loose your contract to the CRNA group or management firm or other practice that can do it for less?

Take back these sites and push them out. The cat is already out of the bag, but it doesn't mean you can't do what is right for YOUR profession and those that will follow in your footsteps.

If I wasn't so young in my career, I would be more active. But I can tell you that when CRNA's are discussed at our meetings (including administrative), the idea has been stomped out quickly and decisively. We would take less $$$$ than to proliferate the cancer that is eating up such an exceptional specialty. We refuse to be part of the problem.

THINK ABOUT THIS:

Those that are in their 50's don't have much to loose, so they are relatively safe as they approach retirement. Those that are in their 40's have a lot to loose. Those who are still in residency and medical schools have the most to loose. We are talking about a generation of anesthesiologists that have been some of the brightest medical students entering the profession in years.

Fight the good fight friends.

Not for selfish reasons.

But because it's right.

You want to do solo practice? Go to medical school, grasp a deep understanding of medicine, do a residency that will expose you to everything under the sun and then run solo or supervise. That is how it's done everywhere in the world.

Shortcuts are exactly that... short cuts.

There is no room for shortcuts when it deals with patients and a profession that has rigorous board certification process.

Regards,

Sevo.

here here.....it all comes down to physicians themselves. we (well I'm a med student for now) made this mess, and we have to clean it up. I feel like we need more type As in anesthesia. to my fellow med students out there: don't go into anesthesia because you want an "easy' lifestyle, I say f-that, we have to work hard and make up the mess some of these older, and with all due respect in my opinion straight up lazy/greedy, anesthesiologists have made for us.
there is more on the line here than money. much, much more. the dignity of the field is at stake. the value of all those late night study sessions, sleepless calls, panic/anxiety attacks for boards, residency interview hassles, etc etc going all the way back to high school for some of us are at stake here. again, it's not about money. I would be willing to make what average primary care docs make today, but keep anesthesia's integrity in place.
one day, if I can make something of myself in academia, I will openly try my best to stop academic medical centers from training CRNAs. I don't see why this can't happen. some of these academic centers train almost as many CRNAs a year as they do residents. I think that's so f'ed up. if attendings and residents are willing to work extra hours and take lower pay, I don't see why we can't just shut down these training programs. as far as I know CRNAs can't train CRNAs, they need MD backing/training.
again, to the med students here, we're the future of the field and we can do this. we've overcome bigger challenges during our training, all we have to do is get our head in the game and have the right mindset.

 

[Mman]

I like how no one has anything to say about the rest of my thoughts.

Your thoughts weren't very well thought out or well reasoned and didn't seem to require comment.

Any physician that has worked with nurse anesthetists understands the absolute need for them to be supervised. You claim that the CRNAs can take the easy cases while anything with a hint of being complicated goes to the anesthesiologists. That's just inane. I've yet to see a case that didn't have the potential for going bad. Most of the time when something bad does happen intraoperatively, it's unexpected. You can't cherry pick the easy cases for CRNAs to do on their own because they'd still run into trouble.

As mentioned above, you sound like a troll.

 

[jwk]

as far as I know CRNAs can't train CRNAs, they need MD backing/training.

Actually, I think this is exactly what should be happening. CRNA's should be teaching their own.

 

[anynoise]

here's something else about your thoughts: you say, "I honestly don't think this is possible for the entire field as I'm not seeing how anesthesiologists are getting better patient outcomes than the CRNA in the clearly straightforward cases. "

what studies are you referring to that allow you to draw such a conclusion? you surely must have some study comparing "outcomes" between the two groups. I'm not arguing against it, but only because I have no study to back up my argument (otherwise personally I do think without MDs to supervise them things would get out of hand). You, on the other hand, are making a statement and should be able to back it up.

if youre outcomes are.. "delivering an alive patient" to the recovery room, than yes crnas probably get similar outcomes. But if you measure other variables i bet there is a lot of difference. Crnas ask stupid questions, know very little about the overall medical condition of the patient and their anesthetic discussions are very superficial.. They act like they know more than they do and trust me Ive seen some of these cats in action. deep in my heart I aint worried..

BUt, still, I think it will be tough to reclaim the specialty.

 

[ssmallz]

If you know the future of healthcare or can predict the future with such accuracy start picking stocks and investing in businesses. It's way more profitable than medicine if you are good at it.

If you want to go into another field b/c you think it has a brighter future or for whatever reason just apply to it and go into it. I promise, no one here would be offended. We are not here to hold your hand or tell you the future of anesthesia is all rosy and that everything's going to be OK b/c truthfully, we don't know anything more than you do. We're just guessing like you are. You can make the same arguments for just about any field in medicine or any other job in the country. Go into anesthesia because you enjoy practicing anesthesia and let the rest of the BS sort itself out.

Will we make less money? Probably but who knows? Will we be forced out of the ORs? Don't think so but what do I know? Just remember, know one knows the future and the only thing you can count on is change. If you like what you do you will be OK, if not you'll be miserable. It really is as simple as that. Work hard, keep fighting for the profession, and things will be OK.

 

[cfdavid]

If you know the future of healthcare or can predict the future with such accuracy start picking stocks and investing in businesses. It's way more profitable than medicine if you are good at it.

If you want to go into another field b/c you think it has a brighter future or for whatever reason just apply to it and go into it. I promise, no one here would be offended. We are not here to hold your hand or tell you the future of anesthesia is all rosy and that everything's going to be OK b/c truthfully, we don't know anything more than you do. We're just guessing like you are. You can make the same arguments for just about any field in medicine or any other job in the country. Go into anesthesia because you enjoy practicing anesthesia and let the rest of the BS sort itself out.

Will we make less money? Probably but who knows? Will we be forced out of the ORs? Don't think so but what do I know? Just remember, know one knows the future and the only thing you can count on is change. If you like what you do you will be OK, if not you'll be miserable. It really is as simple as that. Work hard, keep fighting for the profession, and things will be OK.

Agree 100%.

So long as our profession adds value we will be just fine. I think the important thing here is to ramp up the marketing of the value which our profession adds, which is SO very easy to go unnoticed. This is a large part of the problem but it's relatively easy to fix. Once again, it's up to US.

 

[pd4emergence]

What I don't understand is that in some countries, anesthesia is practiced solely by nurses. Doctors don't even practice the field. It isn't a medical specialty.

There are a few worries that are keeping me away from the field.

What a previous poster said about being a business developer is spot on. This specialty will only support its salary differential if MD anesthesiologists can somehow drive higher revenue for their hospital partners than CRNAs can.

I honestly don't think this is possible for the entire field as I'm not seeing how anesthesiologists are getting better patient outcomes than the CRNA in the clearly straightforward cases. I do however believe that with the inherent longer training, anesthesiologists who are much better trained to handle complex cases that the CRNAs can't do will survive and maintain their higher salaries.

Basically, I think that future students who are willing to do a fellowship in anesthesia and who are willing to concentrate on complex cases that CRNAs can't do with their limited training can do well.

This way there is a clear delineation in the roles of the anesthesia provider, with the CRNAs providing more straightforward care and the fellowship trained anesthesiologist providing the complex care. I think this is doable when you can simply designate the easier cases to the CRNAs. Any cases with even a hint of complications can be handed to the anesthesiologist.

If this were to happen, it would cause 2 things to play out.

1. The specialty would contract and the number of MD anesthesiologists that we need to train would decrease. The number of CRNAs trained will equilibrate to the number of CRNAs that the country needs.

2. The overall net cost to the taxpayer would also decrease as cheaper CRNAs would replace more expensive MDAs who just practice basic anesthesia.

Our national debt levels compared to GDP are significantly higher than what they were in the 1980s. Back then, we didn't have the impetus to change. The government will do what it has to reign in costs.

Ok, I'll comment even though this seems pretty trollish, you have touched on one of the many misleading strategies in the AANA's lobbying efforts. Independent CRNA's get paid the same amount of money anestheiologists get paid by CMS for the same case. There is no cost savings to the taxpayer. Read the above sentence again and repeat it in your head over and over. The only cost savings may be to the hospital and I don't see a them sharing their excess profit margins just because they saved a little bit on anesthesia services salaries. There is also no such thing as basic anesthesia. If you are a med student do an anesthesia rotation and see what we do. There is lots of stuff that can go wrong. People die or have some other bad outcome in easy cases. It doesn't happen often but it does happen. Now, remember this fact next time you are on the table for a procedure. Who is at the head of the bed? Is it a well trained anesthesiologist or is it a solo recent graduate of the many CRNA mills popping up all over the country. Just keep telling yourself "its just a knee scope", or "its just an EGD", see if that makes you feel any better.

 

[cfdavid]

Ok, I'll comment even though this seems pretty trollish, you have touched on one of the many misleading strategies in the AANA's lobbying efforts. Independent CRNA's get paid the same amount of money anestheiologists get paid by CMS for the same case. There is no cost savings to the taxpayer. Read the above sentence again and repeat it in your head over and over. The only cost savings may be to the hospital and I don't see a them sharing their excess profit margins just because they saved a little bit on anesthesia services salaries. There is also no such thing as basic anesthesia. If you are a med student do an anesthesia rotation and see what we do. There is lots of stuff that can go wrong. People die or have some other bad outcome in easy cases. It doesn't happen often but it does happen. Now, remember this fact next time you are on the table for a procedure. Who is at the head of the bed? Is it a well trained anesthesiologist or is it a solo recent graduate of the many CRNA mills popping up all over the country. Just keep telling yourself "its just a knee scope", or "its just an EGD", see if that makes you feel any better.

Agreed.

At least in the U.S. we've never taken such old, and sick patients to the OR for any number of interventions. Sure, the intervention may be "benign" but when it's an 88 yo with AS, CAD, COPD, CKD etc etc. , well that's a game changer.

Many have suggested that anesthesiologist will be taking care of the sicker patients, leaving the less sick (ASA 1/2's) to CRNA's. Well, if this happens, do you really think there will be any significant reduction in demand? Look at our demographics and reflect on the overall health of this demographic and the future, frankly, looks bright for those providing high acuity health care.

4 months into my anesthesiology training and I've taken some seriously ill people under my (and my attending ofcourse...) care. The numbers of these types of patients is growing by the day as the baby boomers enter the picture.