USAP-answer to cheaper labor

[neutro]

Its not good form to publicly discuss an individual and their qualifications and experiences openly on a forum - irrespective if you agree or disagree with them. Unless they are present to answer themselves, these are all suppositions. So not a big fan of this.

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[Arch Guillotti]

Now for the fmg part -
I trained at the Cleveland clinic who does have a program for fmg anesthesiologists to come do a second residency in the USA. I worked next to residents that were the chief of their hospital in China, established anesthesiologist in Egypt or other similar places. While my experience is admittedly anecdotal - the “chief” from China was horrid as a ca1… they started over. I’m sure she was great when they were done with her. Another (from India?) was also terrible and never completed the residency here and was pushed out - they’re out of medicine. There were some from Egypt, India, Italy? And some other places I can’t recall that were good residents and ended up capable doctors. My point is this - and I hope this is what Dutton means - those fmgs have to come here and be trained AGAIN- come be residents…. Not come “fresh off the boat” and be taking care of patients.
I’ve seen lots of bad anesthesiologists that trained in this country too…. Definitely need to up our games.

Sure sounds like "second to none" to me!

 

[Howard888]

I do not think Dutton is talking about bringing foreign grads to train them. I think he is talking bringing in grads directly as attendings.

HCA is also looking and also trying to create residencies (already has-Tampa, Austin, etc).

Again HCA and USAP are doing the EXACT same thing. Trying to maximize short term profits regardless of long term effects

 

[pgg]

we certainly have the clinical volume and would turn out top notch residents who had seen everything (we are a major transplant center, high risk ob, etc.). We would have to send them elsewhere for peds. I think we have elected not to open a residency program at this time as the majority of the partners weren’t interested in it.

These statements are fundamentally incongruent. You just can't handwave away the small detail that residency programs are first and foremost dependent upon the motivation and quality of the faculty. Adequate clinical volume is necessary but not sufficient.

There are many hospitals in the USA that have sufficient clinical volume to train anesthesia residents. But most anesthesiologists at these places don't want to teach. If they wanted to teach ... they wouldn't be there. They'd be at academic hospitals where they could, you know, teach.

My hospital could probably support a small anesthesia residency, if clinical volume was the only criteria. There are about 30 anesthesiologists in my group and I'd wager fairly confidently that approximately zero of us have any interest in being a program director, assistant program director, education coordinator, member of a clinical competency committee, spending hours preparing lectures and rounds, spending hours actually doing lectures and rounds, working with remediation plans for struggling residents, on and on and on. It works out to a few FTEs if you don't want a malignant labor-centric program that's always getting side-eyed from the RRC.

I know you know all this, but I don't know why you think USAP or someone else is just going to stand up a residency program and not suck at it.

 

[aneftp]

These statements are fundamentally incongruent. You just can't handwave away the small detail that residency programs are first and foremost dependent upon the motivation and quality of the faculty. Adequate clinical volume is necessary but not sufficient.

There are many hospitals in the USA that have sufficient clinical volume to train anesthesia residents. But most anesthesiologists at these places don't want to teach. If they wanted to teach ... they wouldn't be there. They'd be at academic hospitals where they could, you know, teach.

My hospital could probably support a small anesthesia residency, if clinical volume was the only criteria. There are about 30 anesthesiologists in my group and I'd wager fairly confidently that approximately zero of us have any interest in being a program director, assistant program director, education coordinator, member of a clinical competency committee, spending hours preparing lectures and rounds, spending hours actually doing lectures and rounds, working with remediation plans for struggling residents, on and on and on. It works out to a few FTEs if you don't want a malignant labor-centric program that's always getting side-eyed from the RRC.

I know you know all this, but I don't know why you think USAP or someone else is just going to stand up a residency program and not suck at it.

The only way community private quasi future or potential training programs can function is this
1. Program director 3 non clinical days off each week mandatory plus stipend 80k
2. Assistant program director gets 2 non clinical days off and each week plus stipend 60k
Other anesthesiologists get 50k teaching stipend

The cost savings for these future training programs go out the window.

 

[pgg]

The only way community private quasi future or potential training programs can function is this
1. Program director 3 non clinical days off each week mandatory plus stipend 80k
2. Assistant program director gets 2 non clinical days off and each week plus stipend 60k
Other anesthesiologists get 50k teaching stipend

The cost savings for these future training programs go out the window.

That sounds about right.

It's a massively complex and time consuming endeavor.

Only a ****ing suit would think you could conjure a residency program and solve a labor problem.

 

[voxveritatisetlucis]

Im sure FMGs would put a lot more pressure on salaries then more residency programs. At least a residency program requires some infrastructure. What’s preventing them from just allowing 30,000 anesthesiologists from foreign countries to get licensed?

 

[amyl]

These statements are fundamentally incongruent. You just can't handwave away the small detail that residency programs are first and foremost dependent upon the motivation and quality of the faculty. Adequate clinical volume is necessary but not sufficient.

There are many hospitals in the USA that have sufficient clinical volume to train anesthesia residents. But most anesthesiologists at these places don't want to teach. If they wanted to teach ... they wouldn't be there. They'd be at academic hospitals where they could, you know, teach.

My hospital could probably support a small anesthesia residency, if clinical volume was the only criteria. There are about 30 anesthesiologists in my group and I'd wager fairly confidently that approximately zero of us have any interest in being a program director, assistant program director, education coordinator, member of a clinical competency committee, spending hours preparing lectures and rounds, spending hours actually doing lectures and rounds, working with remediation plans for struggling residents, on and on and on. It works out to a few FTEs if you don't want a malignant labor-centric program that's always getting side-eyed from the RRC.

I know you know all this, but I don't know why you think USAP or someone else is just going to stand up a residency program and not suck at it.

You missed the point where I said we were NOT going to do it because we didn’t think we had enthusiastic enough buy in from the partners. A few of us really invested was not enough. Please be clear I am talking specifically about the spots they wanted to open with my division at my hospital. I have no first hand idea about any other USAP residency programs.

 

[amyl]

Im sure FMGs would put a lot more pressure on salaries then more residency programs. At least a residency program requires some infrastructure. What’s preventing them from just allowing 30,000 anesthesiologists from foreign countries to get licensed?

Because the training in most foreign countries sucks compared to ours. I’m advocating that highly qualified anesthesiologists trained in other countries come repeat a residency in the USA - not come take care of people.

 

[pgg]

You missed the point where I said we were NOT going to do it because we didn’t think we had enthusiastic enough buy in from the partners. A few of us really invested was not enough. Please be clear I am talking specifically about the spots they wanted to open with my division at my hospital. I have no first hand idea about any other USAP residency programs.

Fair enough, though I think my comments apply to about 98% of the hospitals out there that "could" have a residency program but presently don't.

I don't know the first thing about the other USAP locations but I'd bet money that if any try to start residency programs, they'll do a shoddy job of it.

Because the training in most foreign countries sucks compared to ours. I’m advocating that highly qualified anesthesiologists trained in other countries come repeat a residency in the USA - not come take care of people.

Agreed

UK, western Europe, Japan, Korea, etc - the floor of their care is likely on par with ours and maybe there ought to be an expedited path for people here and there to move to each others' systems.

But it's surprising how quickly the bell curve widens when you stray into eastern Europe and southeast Asia. Don't have any experience in South America but I'm going to guess it's the same there.

 

[circleK]

Because the training in most foreign countries sucks compared to ours. I’m advocating that highly qualified anesthesiologists trained in other countries come repeat a residency in the USA - not come take care of people.

Fair enough but that is not what is implied in Dr Dutton’s response in the OP, and he is representing USAP’s strategy in that statement.

 

[lane]

Fair enough but that is not what is implied in Dr Dutton’s response in the OP, and he is representing USAP’s strategy in that statement.

“Expedited pathways” does not mean opening floodgates for unvetted foreign physicians to practice immediately.
That’s a huge jump to assume that coming from a physician whose entire career has been built upon quality.

 

[circleK]

I never mentioned “opening floodgates for unvetted foreign physicians to practice immediately”.
I think you’re quoting someone else.
But what exactly does expedited pathways mean in your estimation?

 

[Dr. Rude]

I never mentioned “opening floodgates for unvetted foreign physicians to practice immediately”.
I think you’re quoting someone else.
But what exactly does expedited pathways mean in your estimation?

Something like this:

New Law Allows International Graduates to Skip US Residency

One state is fighting its physician shortage by creating a new pathway for experienced IMGs to practice in the US; the AMA has taken steps to ease the path to licensing for other IMGs.

www.medscape.com

 

[Gern Blansten]

That sounds about right.

It's a massively complex and time consuming endeavor.

Only a ****ing suit would think you could conjure a residency program and solve a labor problem.

I agree with that assessment, but it typically takes the RRC about 5-7 years to gather data that the residency program is out of compliance. So, some may see it as a short term solution, knowing that they can skirt the rules for a few years before they get shut down. Seems like some of the private equity residencies over the past decade have followed that track, whether intentional or unintentional.

 

[DazedWanderer]

Because the training in most foreign countries sucks compared to ours. I’m advocating that highly qualified anesthesiologists trained in other countries come repeat a residency in the USA - not come take care of people.

That's not really the debate though. Most first world countries have very similar quality of training, most under-developed countries have inferior training. There is not much dissent from this consensus, just as there is not much dissent that anesthesiologists receive superior training to CRNAs. The argument is that there will come a point where the demand for more anesthesia care applies enough pressure on politicians that they will lower the bar for standard of care in order to expand coverage and appease the public demand. This is exactly what they did when they granted CRNAs independent practice rights in many states already. Upholding the quality metric eventually was surpassed by the demand for quantity. It is not a far stretch to see the same thing happening with foreign trained anesthesiologists within reason. In a hypothetical where the anesthesia staffing crisis became stark enough (we are headed in this direction) they'll start off with granting practice rights to those from only western countries with similar quality of training and demonstrable english proficiency, slowly expanding the countries that qualify as necessary. Not hard to imagine at all. Politicians' priority is appeasing the public, not physicians or our interests. They would gladly throw our profession under the bus if they thought it would allow them to win some cheap votes and clutch onto power just a little bit longer.

 

[narcotics999]

“Expedited pathways” does not mean opening floodgates for unvetted foreign physicians to practice immediately.
That’s a huge jump to assume that coming from a physician whose entire career has been built upon quality.

People change, especially when $$$ are involved. These early anesthesiologists who sold their groups to Teamhealth, Somnia, USAP etc were not bad clinicians either.

I am not really judging Dr. Dutton this way. Just say that past track record does not predict the future.

 

[centdoc]

From Richard Dutton himself on dealing with staffing issues. At least admitting they’re looking for cheap labor. Again, these models crack with no surprises act and increasing labor cost (for both private equity and the pyramid MDs)


How is USAP addressing the continually growing anesthesiologist shortages in the U.S.?

RD: We are continuously investing in recruiting and retention efforts. I'm most proud of our work establishing anesthesia residencies in four of our cities and are exploring expedited pathways to bring non-U.S. anesthesiologists into practice here.

Why this U.S. Anesthesia Partners exec is excited about AI in the operating room

"Discover the top concerns facing the U.S. anesthesia industry in 2024, from declining reimbursements to staffing shortages and the impact of weight loss medica

www.beckersasc.com

USAP starting a residency program is laughable... Given the REAL residency training I had, the USAP program would be a joke; all they want are warm bodies to fill stools. There would never be enough variety of cases, and definitely no one teaching them the didactics needed. I feel sorry for any medical students who are forced to do residnecy at a USAP "program" because they couldn't match elsewhere. What a complete tragedy.

 

[centdoc]

Well on the plus side, at least the solution wasn’t to open CRNA schools and lobby for independent practice

USAP has indeed opened its own srNa training program.

 

[amyl]

USAP has indeed opened its own srNa training program.

Where?

 

[kidthor]

USAP starting a residency program is laughable... Given the REAL residency training I had, the USAP program would be a joke; all they want are warm bodies to fill stools. There would never be enough variety of cases, and definitely no one teaching them the didactics needed. I feel sorry for any medical students who are forced to do residnecy at a USAP "program" because they couldn't match elsewhere. What a complete tragedy.

Also HCA has so many residency programs now. I really worry about the residents they’re exploiting.

 

[JoelJoel84]

We won’t hire any HCA grads for our PP, even when we were getting desperate for a bit like many other groups and working extra. I’m sure many other groups are similar , regarding the HCA and now USAP pseudo- residencies.

 

[nimbus]

We won’t hire any HCA grads for our PP, even when we were getting desperate for a bit like many other groups and working extra. I’m sure many other groups are similar , regarding the HCA and now USAP pseudo- residencies.

They’re trying to create their own supply of anesthesiologists. It works to the advantage of USAP and HCA if other practices won’t hire their graduates.

 

[dannyboy1]

We won’t hire any HCA grads for our PP, even when we were getting desperate for a bit like many other groups and working extra. I’m sure many other groups are similar , regarding the HCA and now USAP pseudo- residencies.

What are you smoking. Even if you won’t, many will. Certainly the AMC and hospital employed positions. It will affect the market for all of us.

 

[NightyNight]

What are you smoking. Even if you won’t, many will. Certainly the AMC and hospital employed positions. It will affect the market for all of us.

I can see AMCs hiring. But depending on the hospital, I assume not as easy if the initial grads are deemed incompetent.

 

[ProwlerturnGas]

Devils advocate…Are graduates of these programs incompetent? Anyone with first hand experience?

 

[ambiturner]

Devils advocate…Are graduates of these programs incompetent? Anyone with first hand experience?

I have never worked specifically with residents from these programs but in my experience, weaker programs tend to have much larger standard deviations of quality than the best programs. Thus, they will produce the occasional resident that is as good as any you will ever see (maybe someone who got an advanced spot after narrowly failing to match ortho or ENT) but will also produce some that are unfathomably bad.

 

[Beeftenderloin]

I have never worked specifically with residents from these programs but in my experience, weaker programs tend to have much larger standard deviations of quality than the best programs. Thus, they will produce the occasional resident that is as good as any you will ever see (maybe someone who got an advanced spot after narrowly failing to match ortho or ENT) but will also produce some that are unfathomably bad.

This. An absolutely terrible program can still have a couple diamonds in the rough and top tier programs can produce some absolute duds. But on average, the former will produce worse anesthesiologists than the latter. As someone who went to a ****ty (albeit non HCA) program and now work almost exclusively with people who didn’t, this has been my experience.

 

[nimbus]

So yeah, in the end, I’m not worried about immigrants taking our jobs.

Well I’m an immigrant and I took an “American” job. BTW aren’t you an immigrant too?

 

[nimbus]

https://www.nrmp.org/wp-content/uploads/2024/03/Advance-Data-Tables-2024.pdf

Latest NRMP results say…..

 

[aneftp]

Devils advocate…Are graduates of these programs incompetent? Anyone with first hand experience?

Some of these hca grads are pretty bad. I said some. Not all. I have encountered a few on locums trail. The full time staff at the facilities that need locums will figure it out very early on when they arrive within the first couple of days. But they need the bodies especially daytime help so will take any one they can get.

There is a thin line between showing a lack of confidence as a new grad and lack of skill with these new grads. That’s why I advise new grads to get a full time job for a year or possibly two. The appeal of locums money is incredible.

But u are behind the 8 ball when you are a community hospital new grad (in my minds of many) when you step into a facility.

In my opinion. Usap, hca, envision wanting to start community residency programs are doing prospective residents and our profession a disservice. Because many attendings aren’t interested in teaching at the community level. Some practices are too busy as well and can’t offer the same services to residents (protected teaching time). So these residents who graduate come out poorly train. Than they end up playing catch up as attendings to fill in the gaps.

We don’t want to become like some srna puppy mills programs I know in the 2000s churning out new anesthesiologists not prepared.

 

[Arantius]

Some of these hca grads are pretty bad. I said some. Not all. I have encountered a few on locums trail. The full time staff at the facilities that need locums will figure it out very early on when they arrive within the first couple of days. But they need the bodies especially daytime help so will take any one they can get.

There is a thin line between showing a lack of confidence as a new grad and lack of skill with these new grads. That’s why I advise new grads to get a full time job for a year or possibly two. The appeal of locums money is incredible.

But u are behind the 8 ball when you are a community hospital new grad (in my minds of many) when you step into a facility.

In my opinion. Usap, hca, envision wanting to start community residency programs are doing prospective residents and our profession a disservice. Because many attendings aren’t interested in teaching at the community level. Some practices are too busy as well and can’t offer the same services to residents (protected teaching time). So these residents who graduate come out poorly train. Than they end up playing catch up as attendings to fill in the gaps.

We don’t want to become like some srna puppy mills programs I know in the 2000s churning out new anesthesiologists not prepared.

This is short sighted seeing as we need thousands of anesthesiologists and getting more Medicare $$ for residencies is going to be impossible… so let corporations run residencies with their own dollars. What’s so wrong with that? We can’t be taken seriously when we say we need more of us but then say we DONT want more residencies, and a solution for training until the .gov can catch up

 

[NightyNight]

Well, it’s different if they are training people to sign charts or meeting the basics of a decent academic program. We don’t need Hollywood Upstairs Anesthesia Program (maybe someone gets the reference) producing shams which doesn’t help a group have a call team taker.

We certainly need more docs so we ain’t doin Q4 call. It’s not like CRNAs in ACT model wanna stay until 5-7pm anyway.

 

[aneftp]

This is short sighted seeing as we need thousands of anesthesiologists and getting more Medicare $$ for residencies is going to be impossible… so let corporations run residencies with their own dollars. What’s so wrong with that? We can’t be taken seriously when we say we need more of us but then say we DONT want more residencies, and a solution for training until the .gov can catch up

Since unmatched people are desperate for ANY RESIDENCY. Corporations are fine running anesthesia programs and not offer to pay. How about that? Just like srna programs.

I’m sure every unmatched anesthesia applicant if given a chance would even work for free for 4 years if there is attending 400-500k a year pot at the of the road.

The rate of return say every unmatched resident would borrow an equivalent of 60k a year during residency for living expenses and work for free if their choice is no job no training. Or work for free but be board eligibility for anesthesia board certification.

 

[aneftp]

Can 1 crna be on at night with 1 srna or 2 srna?

That would be the cheapest solution?

One MD with one crna and 2 free labor srna?

Theoretically can cover ob
And 2 OR at the same time.

 

[kidthor]

Can 1 crna be on at night with 1 srna or 2 srna?

That would be the cheapest solution?

One MD with one crna and 2 free labor srna?

Theoretically can cover ob
And 2 OR at the same time.

Or they could just have RTs intubate the patients, plug them into an anesthesia machine, and have the surgeons run the anesthesia part. Even cheaper.

 

[nimbus]

Since unmatched people are desperate for ANY RESIDENCY. Corporations are fine running anesthesia programs and not offer to pay. How about that? Just like srna programs.

I’m sure every unmatched anesthesia applicant if given a chance would even work for free for 4 years if there is attending 400-500k a year pot at the of the road.

The rate of return say every unmatched resident would borrow an equivalent of 60k a year during residency for living expenses and work for free if their choice is no job no training. Or work for free but be board eligibility for anesthesia board certification.

This has not happened yet. Hopefully ACGME has some rule to prevent this from ever happening.

However, there are some orthodontic and endodontic residencies that actually charge tuition and don’t offer any pay. I can only imagine these spots are taken by children of wealthy orthodontists preparing to inherit mommy or daddy’s practice.


Penn charges about $550k over 4 years.

School of Dental Medicine Costs

Dental Medicine D.M.D Year 1 10 months Year 2 9 months Year 3 12 months Year 4 9 months

srfs.upenn.edu

USC charges about $320k over 3 years.

Paying for Dental School - Herman Ostrow School of Dentistry of USC

A dental education is a significant financial investment. The Herman Ostrow School of Dentistry of USC is committed to ensuring that all eligible students have access to the financial aid programs they need to achieve their educational goals.

dentistry.usc.edu

 

[Hoya11]

Can 1 crna be on at night with 1 srna or 2 srna?

That would be the cheapest solution?

One MD with one crna and 2 free labor srna?

Theoretically can cover ob
And 2 OR at the same time.

Unfortunately I know from experience..

1 MD can cover 1 CRNA and 1 SRNA or 2 SRNAs..

We had the SRNA on call for Main OR and the CRNA upstairs in OB and one MD in house, one MD on backup beeper if need 3 rooms..

 

[Dr. Rude]

Unfortunately I know from experience..

1 MD can cover 1 CRNA and 1 SRNA or 2 SRNAs..

We had the SRNA on call for Main OR and the CRNA upstairs in OB and one MD in house, one MD on backup beeper if need 3 rooms..

The obvious management would be to pull the CRNA from OB if it was quiet to do the main OR case.

 

[Gern Blansten]

The private equity group residency model is a set up for failure. It happens over and over. The issue is, these are not the established and most competitive programs, so the top candidates steer clear. They end up with lower tier candidates with fourth quartile class ranks and low step scores (these are the candidates most at risk for failing the boards). The program is typically a bunch of private practice physicians pressured by administrators to cut costs. Production pressure exists. No infrastructure for education exists so it is created from scratch with a physician group that did not “sign up” to be a teacher. The physicians are all likely good friends with the established CRNA group who they are friends with outside the hospital. Maybe their kids are growing up together. The CRNA group present wants to continue their practice unimpeded by the residency program. This means that they want to do the cases that they like. The schedule will be made to accommodate those who are outspoken and know how to navigate the system. So residents get leftovers. Same with lunch breaks. Residents will be last to get breaks.
Eventually, it will be recognized that the system is stacked against the residents and they will complain. So, the surveys begin to reflect the discontent (perhaps three to four years in as the residents figure it out). The RRC will send a notice to shape up about a year later. A stern warning will follow the next year. Meanwhile, a couple of classes have graduated and done terribly on written and oral board giving the program a 50% pass rate. Another strong look at the program occurs, this time, for academic purposes. They are given a year to shape up. They don’t. Now the program is 5-7 years into the process. The RRC puts them on probation. Nothing improves. In fact, it gets worse because the candidates are now even lower quality because who wants to join a program on probation except those who have no other choice. Another year passes and the RRC decides to shut them down 7-8 years into the process. The residents (who are not top candidates) are forced to beg for a spot as orphans from a closed program. The hospital and private equity group, meanwhile, move on with life after the residency having just had seven to eight years of very affordable labor to staff their OR services. The physicians who did care about education are burned out and frustrated. Everyone moves on and the private equity firm got several years of bargain basement labor costs, which helped the profitability of the shareholders. No harm done, right?
I’m old enough that I’ve seen how this movie ends. However, the sheer number of new private equity residencies is something I’ve not seen. Overall, I think it’s bad for the specialty.

 

[Arantius]

The private equity group residency model is a set up for failure. It happens over and over. The issue is, these are not the established and most competitive programs, so the top candidates steer clear. They end up with lower tier candidates with fourth quartile class ranks and low step scores (these are the candidates most at risk for failing the boards). The program is typically a bunch of private practice physicians pressured by administrators to cut costs. Production pressure exists. No infrastructure for education exists so it is created from scratch with a physician group that did not “sign up” to be a teacher. The physicians are all likely good friends with the established CRNA group who they are friends with outside the hospital. Maybe their kids are growing up together. The CRNA group present wants to continue their practice unimpeded by the residency program. This means that they want to do the cases that they like. The schedule will be made to accommodate those who are outspoken and know how to navigate the system. So residents get leftovers. Same with lunch breaks. Residents will be last to get breaks.
Eventually, it will be recognized that the system is stacked against the residents and they will complain. So, the surveys begin to reflect the discontent (perhaps three to four years in as the residents figure it out). The RRC will send a notice to shape up about a year later. A stern warning will follow the next year. Meanwhile, a couple of classes have graduated and done terribly on written and oral board giving the program a 50% pass rate. Another strong look at the program occurs, this time, for academic purposes. They are given a year to shape up. They don’t. Now the program is 5-7 years into the process. The RRC puts them on probation. Nothing improves. In fact, it gets worse because the candidates are now even lower quality because who wants to join a program on probation except those who have no other choice. Another year passes and the RRC decides to shut them down 7-8 years into the process. The residents (who are not top candidates) are forced to beg for a spot as orphans from a closed program. The hospital and private equity group, meanwhile, move on with life after the residency having just had seven to eight years of very affordable labor to staff their OR services. The physicians who did care about education are burned out and frustrated. Everyone moves on and the private equity firm got several years of bargain basement labor costs, which helped the profitability of the shareholders. No harm done, right?
I’m old enough that I’ve seen how this movie ends. However, the sheer number of new private equity residencies is something I’ve not seen. Overall, I think it’s bad for the specialty.

Agree PE is a problem, I dont see hospital based programs a problem whether they are for profit or non profit…

 

[aneftp]

The private equity group residency model is a set up for failure. It happens over and over. The issue is, these are not the established and most competitive programs, so the top candidates steer clear. They end up with lower tier candidates with fourth quartile class ranks and low step scores (these are the candidates most at risk for failing the boards). The program is typically a bunch of private practice physicians pressured by administrators to cut costs. Production pressure exists. No infrastructure for education exists so it is created from scratch with a physician group that did not “sign up” to be a teacher. The physicians are all likely good friends with the established CRNA group who they are friends with outside the hospital. Maybe their kids are growing up together. The CRNA group present wants to continue their practice unimpeded by the residency program. This means that they want to do the cases that they like. The schedule will be made to accommodate those who are outspoken and know how to navigate the system. So residents get leftovers. Same with lunch breaks. Residents will be last to get breaks.
Eventually, it will be recognized that the system is stacked against the residents and they will complain. So, the surveys begin to reflect the discontent (perhaps three to four years in as the residents figure it out). The RRC will send a notice to shape up about a year later. A stern warning will follow the next year. Meanwhile, a couple of classes have graduated and done terribly on written and oral board giving the program a 50% pass rate. Another strong look at the program occurs, this time, for academic purposes. They are given a year to shape up. They don’t. Now the program is 5-7 years into the process. The RRC puts them on probation. Nothing improves. In fact, it gets worse because the candidates are now even lower quality because who wants to join a program on probation except those who have no other choice. Another year passes and the RRC decides to shut them down 7-8 years into the process. The residents (who are not top candidates) are forced to beg for a spot as orphans from a closed program. The hospital and private equity group, meanwhile, move on with life after the residency having just had seven to eight years of very affordable labor to staff their OR services. The physicians who did care about education are burned out and frustrated. Everyone moves on and the private equity firm got several years of bargain basement labor costs, which helped the profitability of the shareholders. No harm done, right?
I’m old enough that I’ve seen how this movie ends. However, the sheer number of new private equity residencies is something I’ve not seen. Overall, I think it’s bad for the specialty.

The issue is students with scores as high as 290s were being matched to these bottom programs THIS YEAR.

These are bright students. Upper 1/3 is their class. My friend is the program director

It’s due to lots of factors (locations, marriage etc)

Like I said. This year match feels like the 1990/1991 match years (for those of u guys old enough to remember). Extremely competitive. The top of the top students went into same (they are turning 59-60 this year). The best of the best med students got matched into lower programs those years. We all know what happen when they finished in 1994/1995. No jobs. Or very low paying jobs.

 

[ambiturner]

The issue is students with scores as high as 290s were being matched to these bottom programs THIS YEAR.

These are bright students. Upper 1/3 is their class. My friend is the program director

It’s due to lots of factors (locations, marriage etc)

Like I said. This year match feels like the 1990/1991 match years (for those of u guys old enough to remember). Extremely competitive. The top of the top students went into same (they are turning 59-60 this year). The best of the best med students got matched into lower programs those years. We all know what happen when they finished in 1994/1995. No jobs. Or very low paying jobs.

I see the comparison but what’s going to happen between now and then to make the market tank? Bill Clinton gets blamed for the last market souring but it also could have been simple supply and demand dynamics too.

 

[Maverikk]

What made the market tank then?

 

[aneftp]

I see the comparison but what’s going to happen between now and then to make the market tank? Bill Clinton gets blamed for the last market souring but it also could have been simple supply and demand dynamics too.

No one knows.

It’s will boil down if hospitals continue to merge and simply collude (yes I use the word collude) together to form essentially duopolies in many mid major cities where 2-3 major hospital systems exist and keep salaries lot.

I’m in Florida and south Florida is Notoriously low balling and has continue to due to supply and demand. Even the Dallas area where my buddy lives continues to be very saturated. Very saturated equals lot balling. Supply and demand.

Now if hospitals take over entire anesthesia contracts. They can easily dictate salaries. But so far hospital admin have been pretty dumb. I use dumb wording. Seriously.

You would think they would hire consultants to know how to run anesthesia but that’s not part of their playbook. If I were a hospital in a mid major city (metro less than 3 million) which pretty much covers 90% of the country. I’d reach out to my other ceos and collude on price/compensation. It would work.

 

[nimbus]

What made the market tank then?

Managed care sky is falling fears.

And Medicare balance billing was banned. Before this, if you had a large patient base of wealthy retirees on Medicare, you could bill them up to your “usual and customary” rates. Then Medicare changed the rules so that if you wanted to participate in Medicare, you had to accept Medicare assignment and could not balance bill Medicare patients. I don’t know the exact dates but it happened in the early 1990s. Anesthesia and EM were 2 of the specialties that were hit the hardest because of the way Medicare reimbursements were calculated. While we can opt out of Medicare participation, it is practically impossible to do so if you see working in a hospital or surgicenter.

 

[nimbus]

Wisconsin Legislature: AB954: Bill Text

docs.legis.wisconsin.gov

“Analysis by the Legislative Reference Bureau

This bill creates provisional licenses for certain internationally trained
physicians to practice as a physician in this state and provides that certain physician
assistants or physician associates who are licensed to practice in certain qualifying
countries may apply for and receive a license to practice as a physician assistant in
this state without having to satisfy certain educational requirements provided under
current law. Under the bill, provisional licenses to practice as a physician are
automatically converted into permanent licenses after the provisional license holder
practices in this state and maintains good standing for three consecutive years.
Under current law, the Medical Examining Board licenses and regulates
physicians. This bill provides that the Medical Examining Board may issue a
provisional license to practice as a physician to an applicant who meets certain
requirements, including: (1) the applicant has an offer for employment as a physician
in this state; (2) the applicant has been granted a medical doctorate or a substantially
similar degree by an international medical program; (3) the applicant has completed
a residency program or a postgraduate medical training program that is

---

substantially similar to a residency program; (4) the applicant has practiced as a
fully licensed physician in his or her country of practice for at least five years after
completing a residency program or a postgraduate medical training program that is
substantially similar to a residency program; (5) the applicant has been in good
standing with the medical licensing or regulatory agency of his or her country of
practice for the five years preceding the individual's application and does not have
any pending disciplinary action before the medical licensing or regulatory agency;
(6) the applicant has passed all steps of the United States Medical Licensing
Examination administered by the National Board of Medical Examiners and the
Federation of State Medical Boards, or their successor organizations; (7) the
applicant has, or will have prior to working as a physician in this state, a federal
immigration status and employment authorization that enables the applicant to
work as a physician in this state; and (8) the applicant possesses basic fluency in the
English language. Under the bill, “international medical program” is defined to
mean any medical school, residency program, medical internship program, or other
program that is approved by the Educational Commission for Foreign Medical
Graduates or provides individuals with a medical education or training outside the
United States that is substantially similar to the training required to qualify to
practice medicine and surgery in this state.“

 

[pgg]

This is short sighted seeing as we need thousands of anesthesiologists and getting more Medicare $$ for residencies is going to be impossible… so let corporations run residencies with their own dollars. What’s so wrong with that?

Agree PE is a problem, I dont see hospital based programs a problem whether they are for profit or non profit…

So how many residents are, uh, being educated by your corporat---I mean hospital?