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To all med students considering anesthesia:

Discussion in 'Anesthesiology' started by logs9, Mar 25, 2007.

  1. logs9

    logs9 Member

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    Mar 25, 2007
    When I was a student, I wanted this question answered. Now that I have it, I'm providing it for all of you. So, if you are a med student who is wondering about the politics of anesthesia and our future, I'd like to give you an update on where we are currently (at least in Texas). Then you make your own decision:

    I'm a CA-2 at the Texas Medical Center. I worked with a guest faculty (McCreath) who sits one of the medical economics committees in Texas and routinely debates with CRNAs. She is responsible for chiming in for anesthesiologists during political hearings on billings and practice rights. At first she told me, don't worry, everything in our profession is fine.

    However after I pressed her, she later conceded that we are in serious trouble but that she didn't want to discourage me as I was in residency.

    In fact, she said that the CRNAs that she's up against in these hearings on CRNA practice rights and billings routinely look at her in the eyes and say, "I can do everything you can." In front of all these politicians who are listening in, there isn't much she can say to defend that because it's true. In fact, I know CRNAs who do CV cases.

    Market forces always rule, and in the end, CRNAs who provide cheaper anethesia care just may have equal practice rights and our salaries will be lower. It's simple to understand: market forces always rule. All it takes is a signature on a new bill. With Edwards, Hillary, etc. as president, it would be that much closer and it’s probably closer than most people realize or want to admit. In fact, look at the quick progression of DNPs, AAs, etc.

    But you just have to love anesthesia because it's actually fun. You are a real perioperative physician. You are needed in emergencies. You can take away all pain. It's amazing really. If you can love anesthesia for what it is fundamentally (instead of lifestyle, salary, etc.), you won't have anything to worry about. If not, you should probably consider path, rads, derm, and maybe ER at this point in time.
     
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  3. swpm

    swpm Now with extra snarkiness 10+ Year Member

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    Derm is hypercompetitive. Rads is on the verge of outsourcing to basements in India over teh internets. ER is also vulnerable to midlevels. Path ... I dunno anything about the future of path, except it seems to be uniquely NON-vulnerable to midlevels, so good for them. Me, I think the only joy I'd get out of path would be putting black ink on the other pathologists' microscope eyepieces.

    I agree with your basic premise though, that happy people are doing what they like to do for its own sake. I openly mock those who chose anesthesia for the "lifestyle" without really understanding how much work and stress it is. I love anesthesia for what it is: me and a patient and sharp needles and cool drugs and physiology and instant gratification and a measurable impact on a patient's life. Bonus points 'cause the patient can't talk during 90% of the encounter. I'm actually rather antisocial, though you wouldn't know it from my winning personality on these forums.

    It irks me that CRNAs, with their inferior education and training, stand to get in the way of me earning $400K while doing what I love. But I'll get by.

    It irks me more, however, that a bunch of nurses stand to get in the way of me doing what I really want: doing cases in the OR, by myself. I don't want to supervise a bunch of guys who couldn't get into medical school, but want to practice anesthesiology anyway. But if bailing their semi-qualified asses out of jams is the price I pay for doing some cases myself, and of never again rounding on a medicine inpatient or setting foot in an outpatient clinic ... that's cool too.

    I have to say I'm very happy as a resident. And once I'm done with residency and all the silly-buggers games and crap I put up with that's residency-specific, I think I'll be positively giddy.
     
  4. VentdependenT

    VentdependenT You didnt build thaT Physician Moderator Emeritus 10+ Year Member

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    So why go to medical school at all? Why don't NP's just run ICU's and do interventional cards? Who the hell needs to go through 4yrs med school and 4yrs residency?

    Folks need to step up to the plate. I'm doing a fellowship. Jobs are good now but I'll be damned if I am going to sit back and get hosed. I WILL differentiate myself from the masses. People know I take my position SERIOUSLY even though I have a playful attitude.

    We don't need to reinvent ourselves but rather make the public known about what we do. How IMPORTANT it is, and why you NEED to go to medical school and be a PHYSICIAN in order to deal with and modify one's self in terms of COMPLETE patient care and safety.

    You don't need an MDA to run a general LMA case for a knee scope but what about grandma with an ef of 30% who is having a whipple done and has RA?

    CRNA's are good folks to work with. They pull plenty of weight. Too bad we had some lazy peeps in the past let things get out of control. Now we need to deal with it. I don't think my job is in danger but I know my salary is. I love what I do and I guess thats all that matters.

    Invest wisely and love what ya do.

    Rant over.
     
  5. Taurus

    Taurus Paul Revere of Medicine 10+ Year Member

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    The only field that is insulated from midlevel expansion is surgery for sure and maybe some of the IM fellowships like cards, hem/onc, or GI. Derm is a prime target for midlevels. As a derm attending once told me, a FM could treat 90% of derm cases. If that's true, then a midlevel can too. Path...eh...you need to go visit the Pathology forum. Pathology graduates are having a really hard time finding jobs these days. One SDNer said that he posted a tech job and got resumes form 5 board-certified pathologists. I don't know much about ER, but it seems like lots of PA's are doing it. Litigation potential is too great to outsource rads. My 2 cents.
     
  6. BDylan

    BDylan Member 10+ Year Member

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    Jan 27, 2006
    So what?

    From what I can tell, the worst thing that can happen is that salaries will go down; thankfully you all do what you love. Now you're just doing it for a couple hundred thousand dollars less (but probably for still more than an average FP).

    Then what happens? Less lifestyle-chasers choose anesthesia, less MDAs, more demand, salary climbs a little, and eventually we're back to where we were/are.

    Sounds fun, sign me up.
     
  7. logs9

    logs9 Member

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    Mar 25, 2007
    "I love anesthesia for what it is: me and a patient and sharp needles and cool drugs and physiology and instant gratification and a measurable impact on a patient's life. Bonus points 'cause the patient can't talk during 90% of the encounter. "

    couldn't agree more without sounding like some cheerleader.
     
  8. logs9

    logs9 Member

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    Mar 25, 2007
    Vent, what fellowship are you doing? CV? I'm thinking about CV too because it's fun except that I'm torn between wanting to get out and start earning before it all goes to crap.

    also, i haven't worked with too many CRNAs. but i would think that the one's with CV experience could handle your 85 y/o with CAD, dm, htn, ef30%, etc. whipple case. why not? i'm sure they know how to put in lines, use pressors, give blood products, etc.

    correct me if i'm wrong.
     
  9. VentdependenT

    VentdependenT You didnt build thaT Physician Moderator Emeritus 10+ Year Member

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    You are probably right.

    But what I'm interested in is who would YOU rather have doing your case and why?
     
  10. Intubate

    Intubate ASA Member 10+ Year Member

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    the safest fellowships (if you're worried about someone stealing your job) are peds and pain (although I agree, cardiac is pretty safe-- CRNAs do cardiac cases supervised, but I doubt they ever do them solo...maybe they do).
     
  11. pgy13

    pgy13 Junior Member 10+ Year Member

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    ...and no one paging me at home at 3am because one of their steristrips came off in the shower.
     
  12. EtherMD

    EtherMD Banned Banned

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    This is covered on another post with the same information. You are just confirming what I have been saying for months about the CRNA issue.
    Imagine the rhetoric in ten years when CRNA schools are pumping out thousands of new CRNA's with DNAP's. Clearly, a response by the ASA And the Academic Chairs is needed soon.

    I have posted ideas which would halt the assault on our specialty by CRNA's.
    We are still in control of our destiny-for now. Each of you must speak out during Residency to each other and your attendings. I believe word of mouth is effective in creating an environment for change. The alternative is that Medical Students will tell the Academic Chairs in the field- "No thanks" pretty soon unless action is taken.
     
  13. urgewrx

    urgewrx 2+ Year Member

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    Mar 16, 2007
    Has any of you whinners contributed to the ASA political action committee?
    You can check who has on the ASA website. There are not too many people, so the likelihood is none of you have.

    Shut your YAP and contribute.
     
  14. Lasvegas

    Lasvegas New Member 5+ Year Member

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    Aug 15, 2006


    I WOULD GIVE THEM TONS OF MONEY IF THEY WOULD ACTULLY FIGHT!!! I have posted this before several times. The single most important thing we need to do as a profession if fund a massive PR campaign educating the public regarding the difference between CRNA’s and MD’s. The difference that exists in training, residency - all of it.

    Every potential patient needs to know about the ACT model and how it works. That their life can be looked after by a doctor, a CRNA with an anesthesiologist supervising, or a CRNA with some surgeon supervising that knows FAR less than the nurse about anesthesia. And the fact is for some reason the ASA does not seem to get involved in this way.

    In my thoughts four things are needed to help save our profession from further erosion.

    1. This type of public awareness campaign is key.

    2. Do not teach CRNA’s in any situation if at all possible.

    3. Do not hire CRNA’s in private practice. M.D. only.

    4. Support AA’s and their schools much as possible to provide future mid-level help to the anesthesiologist. This as long as they stick to the concept of total supervision.

    Surgeons have protected their turf by not allowing even the concept of mid-levels doing the most basic operation. Every text-book appendectomy is done by a surgeon.

    As someone already pointed out we blew when we chose to make more money by not doing our own work and ‘supervising’ two or three CRNA’s instead. Now they want to go it alone and compete with us. We helped create this ‘monster’ and now we’re upset that it wants its freedom. However, if we act quickly and uniformly we can at least improve our situation, and future, by involving the person who ultimately has the most to say – the patient.

    The message is simple: Who do you want taking care of you – a doctor or a nurse???
     
  15. urgewrx

    urgewrx 2+ Year Member

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    Mar 16, 2007

    How can they fight with no money? Don't make excuses. Don't be a stingy bastard. Contribute!!
     
  16. Mman

    Mman Senior Member 10+ Year Member

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    Well, I could do a cardiac cath or repair an inguinal hernia, but I'm not qualified to do it independently.

    Just because somebody physically can do something, does not mean they should be given the medical or legal authority to do so in an unsupervised setting. If somebody wants to practice medicine, there are lots of medical schools out there accepting applications.
     
  17. BDylan

    BDylan Member 10+ Year Member

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    Jan 27, 2006
    Along the same lines, what about all those "Kold case clinical files" that are stickied at the top of this forum? I doubt CRNAs have the intellectual or procedural goods to handle most of that.

    And if they can, why does it take so damn long to train an MD?
     
  18. SexPanther

    SexPanther This could be a problem 10+ Year Member

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    Why not have someone who is reasonably well-spoken (eg EtherMD) put our concerns into a well written letter to the ASA? Perhaps we could put together signatures/names of those who agree before we send it off. Let them know that if they address these issues, they will get our money.
     
  19. Stimulate

    Stimulate 2+ Year Member

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    Nov 9, 2006
    Anesthesiologists are facing a tough battle here because we cannot go out and publish studies casting doubt on CRNAS due to the fact that many many anesthesiologists would be shooting their own practices and institutions in the foot. Think about it....many of the biggest research medical centers are heavily reliant upon CRNAs. So if they fund a study and actually show that CRNAs do not provide quality care, what would they be saying about their own practices? It totally sucks but that is the reality we are in. I think that Emory tried to publish a study showing that CRNAs didn't have as good an outcome in off-pump cabgs, and big-name anesthesiologists wrote letters to the editor against the study (defending the CRNAs). So even if you do try to publish a study you will face this kind of response from "leaders in the field".

    Regarding the Doctor of Nursing programs. Will these DNPs be able to call themselves "doctor x" in front of patients? Well, sadly this is up to each state's specific medical practice act. Yep, that's right, this is a battle that is going to require specific amendments to each state's medical practice act. The American Medical Association has this objective in their sights and is already working on this issue on a state-by-state basis. However, my guess is that it will be a long process and require lots of cash.

    Anesthesiology is still going to be good for another 10 or 15 years at least, however, my prediction is that when the CRNAs get independent practice rights in each state (or physician supervision as opposed to anesthesiologist supervision) the reimbursement for anesthesia services is going to be sharply cut by payors. Once you remove the physician care-team model from anesthesia, we are going to be talking about anesthesia as a nursing service and it will be reimbursed as such.

    The CRNA lobby thinks they are doing themselves a favor by winning these rights but the fact is that they are their own worse enemy. They should be embracing the anesthesia care-team model because anesthesiologist involvement is the ONLY thing keeping the bottom from falling out of payment for anesthesia services (am I the only one noticing that Medicare already only pays about $60/ hour for anethesia care?). Further, having the surgeon/dentist/podiatrist as the supervising physician will NOT suffice as physician involvment...and even if it did, the payors will "bundle" that supervision service into the surgeon's fee just like they did with IV PCA pumps.

    The Doctor of Nursing degree will not justify physician-level reimbursement for anesthesia services. The CRNAs have an easier battle than anesthesiologists because their argument is EXACTLY what the payors want to hear. The payors want to reduce their expenditures and little short of a smoking gun is going to stop them. Who wins in the end? The payors. What can we do? Contribute, contribute, contribute... And strongly consider adding a fellowship in an area where you will be harder to replace by mid-levels.

    So does this mean that anesthesiology is a bad field to pursue if you are a medical student? I don't think so. Many of these issues are not unique to anesthesiology. What worries me most is the potential that the best and brightest may no longer pursue medicine because of the huge over-regulation and declining payment system (payment cut of 10% next year by Medicare on the horizon).

    Anyway, most importantly you want to find a field you enjoy and anesthesiology can be very enjoyable. How does that saying go... if you do what you love, you'll never a work a day in your life? Something like that. :)
     
  20. urgewrx

    urgewrx 2+ Year Member

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    You can read said article on www.anesthesiologynews.com under archives- october issue, and the rebuttal from Roizen on the december issue. Joining is free.
     
  21. urgewrx

    urgewrx 2+ Year Member

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    That's not goign to happen. As soon as there are enough anesthesiologists to supervise the nurses the states will cancel the opt-out. Those were emergency measures because there was no body to take care of patients. If you read the letters the tone is like "we really don't want to do this, but we have no choice."
     
  22. Stimulate

    Stimulate 2+ Year Member

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    I hope you are right but you can be assured that the CRNAs are collecting outcomes data on the states where they are practicing with minimal anesthesiologist involvement. They will use that data to further their agenda and push for additional states.

    The states will not reverse their opt-outs unless it is in their financial or political interest to do so. Assuming that the opt-outs are temporary is unwise.
     
  23. EtherMD

    EtherMD Banned Banned

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    You are clueless to politics. States rarely reverse practice rules because they effect many people negtively. The politics definitely does not favor reversal and if anything, more states will join "opt-out" to keep Anesthesia available and affordable. Once the CRNA with DNAP becomes the norm you can expect the AANA to resume its efforts with zeal to convince lawmakers a DNAP=MD.

    You clearly show no real world experience and definitely have little exposure to CRNA politics. There is a saying that it is better to remain silent on issues that show you are an idiot than open your mouth and remove all doubt.
    From your posts this is good advice to follow. Stick with "cases" as your knowledge on economics, medical politics and CRNA's is pretty much zero.
     
  24. Taurus

    Taurus Paul Revere of Medicine 10+ Year Member

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    It's too bad that most people entering medicine have never had real world experience. If they had, then they may give this issue the urgency it requires. For the old timers in anesthesiology, they're not as worried because they'll be retired soon enough. It's the upcoming generations of anesthesiologists who will be most affected by this. For these people, the wake-up moment probably won't happen until they search for a job and realize just how bad the situation really is.
     
  25. GassiusClay

    GassiusClay PGY-2 2+ Year Member

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    Anesthesia vs. CRNAs
    Optho vs. Optom
    Derm vs. FamMed doing Botox
    Gen Surg vs. Sub spec
    Card vs CT Surg
    ER vs. PAs
    ...blah, blah

    Everybody competes forever. Your value is going down in society while football players get payed more to do more useless stuff. Makes sense. No. Welcome to America.

    I wish I could make it rain! Sorry for ranting.
     
  26. Plead the Fifth

    Plead the Fifth ASA Member 10+ Year Member

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    Any words of wisdom for a 3rd year med student looking seriously at a career in Anesthesiology?

    Are there any good texts for my 4th year home rotations as well as the tryout rotations?

    I've become more alarmed about the competitiveness of Anesthesiology in recent years. My school (WVU) had 17 applicants for Anesthesiology spots and only filled 9 (at least 3 went unmatched completely and had to scramble).

    Am I competitive with just average medical school grades (only honors was in Ethics; near honors in Neuroanatomy, Pharm) and a Step I of 215 in 2006? I have very good evaluations thus far in 3rd year rotations but mediocre shelf scores. I'm not looking at top tier programs, just looking to get back down south.
     
  27. Plead the Fifth

    Plead the Fifth ASA Member 10+ Year Member

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    And yup, I read most of the FAQs. Most seemed slightly outdated and I was just wondering if anyone had a fresh perspective on things.

    (Sorry for the hijack, but I can't start a new thread since I just joined, although I'm a long time member, I just forgot my password and the email retrieval system isn't working)
     
  28. AceGirl

    AceGirl

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    You will be fine! Ace your anesthesiology elective, get great LORs and apply broadly...:)
     
  29. Voodoo

    Voodoo Banana Hammocks Rule 2+ Year Member

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    Apr 30, 2006
    Right behind you
    I sincerely enjoyed reading everyone's replies, and I certainly understand the point here, but keep in mind that there are a ton of practices that utilize MD's exclusively.

    To the OP - I understand your concerns, but after reading it again, I'm not totally convinced that you're not a troll. If you've made it this far (i.e. intern year and then 15 months of anesthesia) and you are still concerned about your knowledge base vs a CRNA's and actually believe that stuff you're writing about your politically-active attending's opinions, I'm not too sure what to say. You should probably know the difference now between your knowledge and skill set vs a CRNA's.

    I remember once a long time ago at the facility I trained at there was a big initiative and all the CRNA's were wearing these ridiculous badges that said, "You can sleep easy. A CRNA is taking care of you." We just laughed our a$$es off thinking how stupid a motto/badge that is. And what if the Anesthesiologists had a badge that said the same thing but substituted Anesthesiologist for CRNA -- can you imagine the outrage that the CRNA's would feel? Needless to say, the badges were taken off after a couple days.

    Don't get your panties in a bunch everyone. Be politically active, and realize the sky is not falling down.
     

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