Why are we training more anesthesiologists than surgeons?

[echod]

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Why are we training more anesthesiologists than surgeons every year? There are more residency positions for anesthesia than surgery per NRMP. Shouldn't this ratio be 1:1 or less because of the nurse anesthetists?

 

[Endee]

Is that just general surgery, or does that include orthopedic surgery, neurosurgery, urology, plastic surgery, etc?

 

[ecCA1]

Do anesthesiologists work only with surgeons?

I hear some run ICUs, pain clinics, etc.

 

[Bertelman]

Someone needs to pick up the slack when I start taking 11 weeks vacation.

 

[Ignatius J]

I don't think there are more anesthesiologists than surgeons.

If you lump together general surgery, neurosurgery, plastics, ortho, optho, ENT, urology, ob/gyn, interventional radiology, oral surgeons, some podiatrists, some cardiologists, and some GI docs, I think you will find that anesthesiologists are still far outnumbered by their colleagues doing surgeries/procedures.

 

[BLADEMDA]

I don't think there are more anesthesiologists than surgeons.

If you lump together general surgery, neurosurgery, plastics, ortho, optho, ENT, urology, ob/gyn, interventional radiology, oral surgeons, some podiatrists, some cardiologists, and some GI docs, I think you will find that anesthesiologists are still far outnumbered by their colleagues doing surgeries/procedures.

Correct. But,do we need so many Anesthesiologists to supervise 6:1 or work in opt-out states? Can a mid-level provider do the job "good enough" for Gi, Cardioversions, Labor Epidurals, etc. at half the cost?

 

[pgg]

To further muddy the waters, we don't need a 1:1 surgeon:anesthesiologist/CRNA ratios. We're in the OR every day. They spend days in the clinic.

 

[naus]

Says a lot more about the upcoming general surgery shortage.

 

[Whiskeypunch]

Why are we training more anesthesiologists than surgeons every year? There are more residency positions for anesthesia than surgery per NRMP. Shouldn't this ratio be 1:1 or less because of the nurse anesthetists?

There are way more surgeons than anesthesiologists being trained every year.

Just doing some quick math from http://www.nrmp.org/data/resultsanddata2012.pdf for the spots that filled.

Anesthesia Total: 1437

General Surgery: 1143
Neurosurgery: 194
Ortho: 682
ENT: 283
Plastics: 117
Thoracic: 20
Vascular: 41
OBGYN: 1223

Surgery Total: 3703

Surgery : Anesthesia = 2.6 : 1

(edit**: Forgot Urology and Optho as they are SF match. Too busy to look them up now but you get the picture.)

Then as someone mentioned you've got IR/OMFS/Pod/Cards/GI contributing to case volume too. Plus you've got ~300 or so AOA surgeons and only like ~20 AOA anesthesiologists. I can't find anything more current but here is data from 2009 http://data.aacom.org/media/DO_GME_match_2009.pdf. Oh and there is always the wildcard of foreign surgeons who do residency elsewhere and then come to the US for fellowship, something which I don't think is replicated in anesthesia. For some reason I though this wasn't possible. I thought that you had to repeat a residency in the US to get a license and get priviliges, but clearly there is a way around it. There are two surgeons at the hospital close to me, one in neurosurgery and another in general surgery who both did residency abroad at some well known European places and then just did a fellowship in the U.S.

So the actual ratio is more like 3-3.5:1.

Obviously there are some mitigating factors.

Some anesthesiologists will go on to do critical care and opt for less OR time, and others will go on to do pain medicine and do very little to no OR time.

Surgery has a higher dropout rate in residency (~30% for general surgery?), but that is somewhat mitigated by the number of prelims that take the spots of those who drop.

Surgeons also tend to have a shorter career/higher burnout rate. Anesthesiologists have a higher rate of getting their licenses pulled for diversion.

Surgeons aren't operating every day and have clinic, as someone pointed out.

Personally I found anesthesia to be pretty interesting shadowing, but as I start school I plan on looking at everything else first. Anesthesiology seems like it is in an awesome position in terms of the future if states continue to mandate that CRNA's have oversight.

However, the trend seems to be away from that, and I think that is a bad sign for the field. Especially with capitated payment models in vogue again, I can see hospitals pushing for as many cases as possible being done by unsupervised CRNA's so the surgeons/hospitals can pocket more of the money.

 

[naus]

There are way more surgeons than anesthesiologists being trained every year.

Just doing some quick math from http://www.nrmp.org/data/resultsanddata2012.pdf for the spots that filled.

Anesthesia Total: 1437

General Surgery: 1143
Neurosurgery: 194
Ortho: 682
ENT: 283
Plastics: 117
Thoracic: 20
Vascular: 41
OBGYN: 1223

It's kind of crazy how many orthopods are being trained, 2/3rds that of general surgery. Always thought it was a smaller specialty.

You left out urology too.

 

[Magnus67]

Someone needs to pick up the slack when I start taking 11 weeks vacation.

Agreed,
God I'll be 35 by then, need the young gunz to pick up the slack.😀

 

[Whiskeypunch]

It's kind of crazy how many orthopods are being trained, 2/3rds that of general surgery. Always thought it was a smaller specialty.

You left out urology too.

Yeah Uro and Optho are the SF match forgot about it. I'll edit my post to reflect that.

 

[cchoukal]

Can a mid-level provider do the job "good enough" for Gi, Cardioversions, Labor Epidurals, etc. at half the cost?

Remember, though, that "half the cost" is only because most of them work on salary. If they worked independently and billed for themselves (or if the hospital bills on their behalf), the cost is the same since they bill the same codes for the same work, right?

 

[Ignatius J]

Remember, though, that "half the cost" is only because most of them work on salary. If they worked independently and billed for themselves (or if the hospital bills on their behalf), the cost is the same since they bill the same codes for the same work, right?

Correct. cRNAs on their own won't settle for lower reimbursement rates from insurance and medicare/medicaid. No way. They would just come on back to the care team model if they did.

 

[imfrankie]

cchoukal, how come the VA Spa is hiring?

 

[lushmd]

Remember, though, that "half the cost" is only because most of them work on salary. If they worked independently and billed for themselves (or if the hospital bills on their behalf), the cost is the same since they bill the same codes for the same work, right?

This is true of medicare and many private insurances. However, I'm told that there are some private insurance companies that pay solo CRNAs less (I don't have any details re specific insurance companies, etc...).

 

[cchoukal]

cchoukal, how come the VA Spa is hiring?

Didn't know our ads were out yet. Hiring because we're doing more cases and expanded the OR block times.

 

[imfrankie]

Didn't know our ads were out yet. Hiring because we're doing more cases and expanded the OR block times.

Remember some long deserted weekends out there as a resident.

 

[DrAwsome]

Correct. cRNAs on their own won't settle for lower reimbursement rates from insurance and medicare/medicaid. No way. They would just come on back to the care team model if they did.

So if CRNA don't get any lower reimbursement, they are basically getting anesthesiologist salaries at nurse training. How is this a cost savings? I thought the whole point of having CRNAs is for them to cost less? why would a hospital hire a CRNA vs an MD if it costs the same? That makes no sense, someone please educate me on this.

 

[foxtrot]

Someone needs to pick up the slack when I start taking 11 weeks vacation.

Dude, you rock!! You have to fess up and tell us where you work.

 

[EtherBunny]

Most hospitals subsidize the income of anesthesiologists. If the subsidies are eliminated then, you're right, there is no reason to hire CRNAs over anesthesiologists (if anything, there is a compelling reason to NOT hire the CRNAs because of the obvious differences in education between the two groups). If you're going to pay a CRNA or an anesthesiologist the same amount of money, any reasonable person would hire the physician, for obvious reasons.

 

[gasattack3]

Most hospitals subsidize the income of anesthesiologists. If the subsidies are eliminated then, you're right, there is no reason to hire CRNAs over anesthesiologists (if anything, there is a compelling reason to NOT hire the CRNAs because of the obvious differences in education between the two groups). If you're going to pay a CRNA or an anesthesiologist the same amount of money, any reasonable person would hire the physician, for obvious reasons.

Then the attendings out there that don't know how to set up an infusion pump or run basic OR technologies better get a move on because right now, if you had to compete head to head with a CRNA, TOMORROW, many couldn't run a room. This is a fact.

Some resident colleagues of mine were just saying the other day how it's ridiculous, and obvious, that far too many attendings have become so hands off to the point where they really, simply, could not run a room tomorrow if they needed to.

**I am not a disgruntled resident. I love my job as a resident, and respect most of our attendings a great deal. Most are excellent and I hope to emulate them in the future. This is a warning cry more than an insult.

Seriously, if you don't know how to use simple (we've agreed on previous posts that they ARE simple) technologies in the OR, then make it your business to know. Have your card set up to scan (thus be able to operate) the ACT machine. Know it's basic function. For god's sake, go to the frigging work room and run through an infusion pump set up even if you need to spike a bag, review the standard infusions available and already preprogrammed. When you need these things in a hurry you need them, and it's often when you need an extra set of hands or two. So, it DOES matter.

The less connected (however you want to justify it to yourself) you become with the OR, the MORE competitive CRNA's become to you. It's very simple, and just don't give them that power.

 

[saratoga733]

Then the attendings out there that don't know how to set up an infusion pump or run basic OR technologies better get a move on because right now, if you had to compete head to head with a CRNA, TOMORROW, many couldn't run a room. This is a fact.

Some resident colleagues of mine were just saying the other day how it's ridiculous, and obvious, that far too many attendings have become so hands off to the point where they really, simply, could not run a room tomorrow if they needed to.

**I am not a disgruntled resident. I love my job as a resident, and respect most of our attendings a great deal. Most are excellent and I hope to emulate them in the future. This is a warning cry more than an insult.

Seriously, if you don't know how to use simple (we've agreed on previous posts that they ARE simple) technologies in the OR, then make it your business to know. Have your card set up to scan (thus be able to operate) the ACT machine. Know it's basic function. For god's sake, go to the frigging work room and run through an infusion pump set up even if you need to spike a bag, review the standard infusions available and already preprogrammed. When you need these things in a hurry you need them, and it's often when you need an extra set of hands or two. So, it DOES matter.

The less connected (however you want to justify it to yourself) you become with the OR, the MORE competitive CRNA's become to you. It's very simple, and just don't give them that power.

buddy, what kind of 3rd rate residency program are you training at?? if even a hand full of your attendings don't understand the function of an ACT machine you must have picked/got stuck at the most backward institution in the country.

i understand a COUPLE of lazy/disengaged idiots (as with any specialty) but to harp on this all the time is ridiculous. academic anesthesiologists are some of the most knowledgeable and well informed folks out there by virtue of their teaching commitments and exposure to year round conferences, lectures, and high case complexity. i am inclined to think this 'problem' is more a function of your specific institution.

 

[IlDestriero]

We do our own cases all the time. Not knowing where things are or how they work is not an option for any of our faculty.
And if there are some dudes who can't get off their duff and program a pump that a monkey could program, they can learn in about 5 minutes. CRNAs aren't gaining any ground because the real experts forgot some monkey skill. Please stop posting this drivel.
When the stool hits the fan, the lazy ass who's all thumbs comes in for the big win. The surgeons know this, even if you don't recognize it. Watch what happens when you're struggling to get some dude off pump on your own, who's the surgeon going to ask the circulator to overhead? The CRNA? 🙄
No the attending who can't program the pump. My bet is he has the diagnosis and plan of action before he hits the door.👍
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Il D

 

[gasattack3]

buddy, what kind of 3rd rate residency program are you training at?? if even a hand full of your attendings don't understand the function of an ACT machine you must have picked/got stuck at the most backward institution in the country.

i understand a COUPLE of lazy/disengaged idiots (as with any specialty) but to harp on this all the time is ridiculous. academic anesthesiologists are some of the most knowledgeable and well informed folks out there by virtue of their teaching commitments and exposure to year round conferences, lectures, and high case complexity. i am inclined to think this 'problem' is more a function of your specific institution.

The truth hurts doesn't it?

Like many programs, ours is a mixture of academic and non-academic attendings whom don't regularly work with residents. Those not working with residents on a regular basis are stil able to supervise us during off hours and call (thus we get to know their capabilities). Those not regularly working with residents regularly supervise CRNA's.

It is blatantly obvious that far too many of the attendings whom mostly supervise CRNA's would fumble around if they needed to do a case themselves tomorrow. I am sorry that you clearly take offense to this aspect of our specialty, but it's the reality.

Now, moving on, let's forget about residency, and academia for a second. Forget I'm a resident. If I'm seeing this at our institution (first rate for sure, but let's forego that arguement as it's a distractor from the real point of this post), then what do you think is happening at other institutions or practices??

Few attendings reading this are going to admit, openly, that they would look rather sloppy self-performing an anesthetic tomorrow (those in ACT models). Hopefully, they will take a few short steps in mitigating this, agreeably silly, issue in the coming weeks and stop empowering the CRNA's whom they are supervising with silly sh.t like fumbling around with standard OR equipment.

The easiest way to convey the fact that if push comes to shove, any given attending at any given institution can run a case, start to finish, solo (not including subspecialty cases which commonly require more advanced training/focus/interest such as complex cardiac, transplant, complex peds etc etc. but rather GENERAL cases, to include complicated general cases such as vascular and thoracic and major abdominal etc.), is to DISempower CRNA's with the fact that you don't really NEED them. Currently, they are embrazened/emboldened by the fact that all too often, you do need them, and this is contributing to their political stand that they don't need you.

The truth is sometimes a little uncomfortable, but let's be realistic. This is an easy fix. I'm not saying this is the end-all be-all of solutions, but it's a REALLY simple fix with a lot of psychological bang.

 

[gasattack3]

We do our own cases all the time. Not knowing where things are or how they work is not an option for any of our faculty.
And if there are some dudes who can't get off their duff and program a pump that a monkey could program, they can learn in about 5 minutes. CRNAs aren't gaining any ground because the real experts forgot some monkey skill. Please stop posting this drivel.
When the stool hits the fan, the lazy ass who's all thumbs comes in for the big win. The surgeons know this, even if you don't recognize it. Watch what happens when you're struggling to get some dude off pump on your own, who's the surgeon going to ask the circulator to overhead? The CRNA? 🙄
No the attending who can't program the pump. My bet is he has the diagnosis and plan of action before he hits the door.👍
-
Il D

I agree mostly. But, when he/she comes in with guns blazing, asks the CRNA to step aside, resets pumps to a different drip rate, scoffs at the dobutamine bag hanging on the pump, reaches into the drawer and grabs the milrinone, spikes it, boluses it, shouts out a few orders to the CRNA to hang some plasmanate, all the while positioning the TEE probe to a TG SAX of the LV and asks for another 100 ml of volume from the perfusionist, then grabbing another plasmanate (for example) from the drawer, putting a needle in it and hanging it themselves etc etc. THEN, you really know who needs whom and what's what.

Perception is reality, and TOO OFTEN we are misperceived. CRNA's capitalize on this misperception to our detriment, and a reluctance to recognize (or admit to) this is dangerous to our profession (not you IlDestriero, I'm speaking in general terms). We are on the same team, I assure you of this.

SMALL things can make a difference, and it doesn't need to be a cardiac case going south......

We have a publicity problem in my opinion. SOME of this can be easily remedied and some can not. But, we can do some very simple things to combat a perception/image problem that if we were honest with ourselves, does in fact exist, all too often.