Will CRNAs doom their own job market?

[ERDOC555]

Hello Anesthesiologists!

There have been countless threads on CRNAs, but my question is:

With increasing nursing programs and schools pumping out more and more CRNAs each year, will the market for CRNAs be saturated in 10-15 years? (similar to pharmacy right now)

With CRNAs consistently making almost as much as primary care physicians (150-200k), there is no question that CRNA is a job with the shortest easiest path for the most amount of money and a decent schedule. I personally think this is a bubble that is bound to burst as almost no other job with such little training makes that much money.

I want expert opinions from people in Anesthesia, especially those who have been keeping a close eye on these issues.

Thanks!

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[Chloroform4Life]

Perhaps they will saturate the market which will ultimately drive their salary down. But with more of them, and with independent practice looming over our head, it will likely also drive our salary down. This will especially be true if AMCs are the boss of anesthesiologists and CRNAs. As CRNAs becomes cheaper, AMCs will want to use more supervision and independent nurses models, which means they will need less anesthesiologists. With less demands, there will be a surplus of anesthesiologists vying for the crappy supervision jobs, which the AMCs will offer for a paltry salary.

Unfortunately, private practices won't be able to compete with these AMC models because they will offer hospitals cheaper services (they will need less stipends since they can bill more from insurances). Hospitals will end their contracts with private practice groups and sign with AMCs. It's happening now. I know this cause this is happening at my practice.

So yes, the surplus of CRNAs will hurt them, but it will hurt us more.

 

[ERDOC555]

Perhaps they will saturate the market which will ultimately drive their salary down. But with more of them, and with independent practice looming over our head, it will likely also drive our salary down. This will especially be true if AMCs are the boss of anesthesiologists and CRNAs. As CRNAs becomes cheaper, AMCs will want to use more supervision and independent nurses models, which means they will need less anesthesiologists. With less demands, there will be a surplus of anesthesiologists vying for the crappy supervision jobs, which the AMCs will offer for a paltry salary.

Unfortunately, private practices won't be able to compete with these AMC models because they will offer hospitals cheaper services (they will need less stipends since they can bill more from insurances). Hospitals will end their contracts with private practice groups and sign with AMCs. It's happening now. I know this cause this is happening at my practice.

So yes, the surplus of CRNAs will hurt them, but it will hurt us more.

Rather depressing :/

Are there any situations in which things improve for Anesthesia MDs? I assume the US would need to see enough major torts for CRNA negligence to freak out the public enough for any change.

 

[Doctor4Life1769]

Rather depressing :/

Are there any situations in which things improve for Anesthesia MDs? I assume the US would need to see enough major torts for CRNA negligence to freak out the public enough for any change.

It'll only get worse.
AAs will one day claim equivalency. Just you watch. PAs are already making such claims.

 

[ERDOC555]

It'll only get worse.
AAs will one day claim equivalency. Just you watch. PAs are already making such claims.

Are there any people on this forum who would still recommend anesthesiology to future students? If so for what reasons?

I've read most of the threads on here and see a compelling case for why Anesthesia will be an even riskier, more stressful, and decreasingly compensated field in the future. Regardless of how much you like the work, "supervising" 3-4 CRNAs while risking your reputation doesn't seem like a good way to practice medicine 🙁

 

[Doctor4Life1769]

Are there any people on this forum who would still recommend anesthesiology to future students? If so for what reasons?

I've read most of the threads on here and see a compelling case for why Anesthesia will be an even riskier, more stressful, and decreasingly compensated field in the future. Regardless of how much you like the work, "supervising" 3-4 CRNAs while risking your reputation doesn't seem like a good way to practice medicine 🙁

If you can't see yourself doing anything else, then go with anesthesia.

 

[jwk]

It'll only get worse.
AAs will one day claim equivalency. Just you watch. PAs are already making such claims.

No, we won't. And we've been around just about as long as PAs.

 

[Doctor4Life1769]

No, we won't. And we've been around just about as long as PAs.

I'm sure that's what PAs used to say.

 

[GravelRider]

Rather depressing :/

Are there any situations in which things improve for Anesthesia MDs? I assume the US would need to see enough major torts for CRNA negligence to freak out the public enough for any change.

No. It's happening in all fields of medicine. The procedural fields are somewhat insulated from midlevel encroachment for the time being.

What doomed anesthesia and the practice for all American physicians, in general, was the rampant fee-for-service emphasis on volume that made a lot of doctor's rich in the 80's and 90's. This opened the door for "physician extenders" to help increase volume and thus increase income. Now we've created a monster and that monster wants independent practice. Despite all the problems with the Canadian and European healthcare models, you don't see the kind of midlevel encroachment that you see in the United States. Now the emphasis is still on volume, but instead of making physicians rich, it makes management companies and hospital CEOs rich. Physicians have lost autonomy and are now just worker bees in the medical industrial complex.

 

[Doctor4Life1769]

http://www.comphealth.com/resources...hic-busting-myths-about-physician-assistants/

 

[Chloroform4Life]

You will be lucky if you're "directing" 3-4 CRNAs in the future. If AMCs have their way, you'll be "supervising" 6-10 CRNAs.

 

[jwk]

I'm sure that's what PAs used to say.

Independent AA practice simply isn't an issue. The entire profession has been designed around functioning within the anesthesia care team environment under the direction of an anesthesiologist. It's codified in state laws and federal regulations - it is not something that can be modified at the local level. It's not something that is open to interpretation.

Unlike CRNAs and their professional organizations that minimize and even ridicule the necessity of physician anesthesiologists, AAs have always sought to work with anesthesiologists and the ASA.

https://aaaa.memberclicks.net/assets/aaaa blue brochure lo res.pdf

 

[Planktonmd]

I'm sure that's what PAs used to say.

I gotta say I have never seen a militant AA who claims to be equivalent to physicians!

 

[Planktonmd]

No. It's happening in all fields of medicine. The procedural fields are somewhat insulated from midlevel encroachment for the time being.

What doomed anesthesia and the practice for all American physicians, in general, was the rampant fee-for-service emphasis on volume that made a lot of doctor's rich in the 80's and 90's. This opened the door for "physician extenders" to help increase volume and thus increase income. Now we've created a monster and that monster wants independent practice. Despite all the problems with the Canadian and European healthcare models, you don't see the kind of midlevel encroachment that you see in the United States. Now the emphasis is still on volume, but instead of making physicians rich, it makes management companies and hospital CEOs rich. Physicians have lost autonomy and are now just worker bees in the medical industrial complex.

The reason you don't see this decline in Europe or Canada is because medicine in these countries was never allowed to become a profitable business with only one focus: making money!

 

[drmwvr]

The reason you don't see this decline in Europe or Canada is because medicine in these countries was never allowed to become a profitable business with only one focus: making money!

It's also why there are uniquely talented physicians that Europeans would be benefiting from that are not because those doctors practice in the US. Physician brain drain doesn't seem to be a phenomenon here.

 

[pjl]

#6 on that PA picture was awesome.


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[Mad Jack]

I'm sure that's what PAs used to say.

A fractional minority of PAs are asking for independent practice, you're really blowing things out of proportion.

 

[Mad Jack]

No. It's happening in all fields of medicine. The procedural fields are somewhat insulated from midlevel encroachment for the time being.

What doomed anesthesia and the practice for all American physicians, in general, was the rampant fee-for-service emphasis on volume that made a lot of doctor's rich in the 80's and 90's. This opened the door for "physician extenders" to help increase volume and thus increase income. Now we've created a monster and that monster wants independent practice. Despite all the problems with the Canadian and European healthcare models, you don't see the kind of midlevel encroachment that you see in the United States. Now the emphasis is still on volume, but instead of making physicians rich, it makes management companies and hospital CEOs rich. Physicians have lost autonomy and are now just worker bees in the medical industrial complex.

What will, unfortunately, doom all physicians is the death of FFS. Without it, physicians no longer have the billing codes, and without those, we lose our power to bargain. Ultimately, I think this is the goal for hospitals and insurers- cut out the providers, and deal only with each other via ACOs, then make us justify our incomes despite having no control or view of the billing process or how much revenue we generate...

 

[Doctor4Life1769]

A fractional minority of PAs are asking for independent practice, you're really blowing things out of proportion.

That's how it starts.
Glad to see from jwk's link that it probably won't happen with the AA profession. AANA is trying to squash them.

 

[drmwvr]

A fractional minority of PAs are asking for independent practice, you're really blowing things out of proportion.

Whatever "fractional minority" that exists today didn't 10 years ago. This is the point. An element of accelerated entropy was introduced into the American medical universe some time in the past and did/is doing exactly what a rational observer would predict. It shouldn't come as a surprise to anyone that this is the case. A well intentioned idea, some would say, that has become a viable alternative to actually becoming a physician for individuals that have every bit of the aptitude for medical training and practice.

The incentives that were once available to most US medical graduates no longer exist to the extent they once did and the sacrifice and expense are the same if not greater. So you have students that would at one time be seriously considering medical school or engineering or law now reading the signs of the times and choosing to become PA's or Uber Nurses.

 

[criticalelement]

It's also why there are uniquely talented physicians that Europeans would be benefiting from that are not because those doctors practice in the US. Physician brain drain doesn't seem to be a phenomenon here.

I gotta say... I rarely meet european trained or european physicians here.. I think ive only met 2 or 3 in the past ten years. SO i dont know what you are talking about WIllis

 

[Planktonmd]

It's also why there are uniquely talented physicians that Europeans would be benefiting from that are not because those doctors practice in the US. Physician brain drain doesn't seem to be a phenomenon here.

Once the business of medicine becomes less profitable to physicians, which is what's happening now, you will see the brain drain in action.

 

[bashwell]

It seems to me:

Supervising CRNAs

+

Being an employee of an AMC or hospital

=

99% of the responsibilities and legal liabilities

+

1% of the power, authority, autonomy, or say-so to do anything to improve circumstances if circumstances ever need to be improved, which they almost surely will (e.g., firing a bad CRNA).

 

[WholeLottaGame7]

I gotta say... I rarely meet european trained or european physicians here.. I think ive only met 2 or 3 in the past ten years. SO i dont know what you are talking about WIllis

Bunch of UK or UK-trained anesthesiologists at my training program. They were (mostly) awesome. In general, very chill and confident compared to similar US trained anesthesiologists.

 

[bashwell]

I know in the UK, Ireland, and many Commonwealth nations, it takes a long time to become an attending physician. For example, it takes a minimum of 7 years post-med school to become an anesthesiologist in Australia/New Zealand. Oftentimes it takes 9 or even 10+ years. Not uncommon to be a PGY9 or 10 and finally an attending level anesthesiologist.

The first ~2 years after med school (PGY1-2) are spent doing rotations in core specialties + electives. Then, for example, to become an anesthesia resident, you often have to do another 1-2 years in ICU, because that's what everyone else will have done.

Many people also start a residency (technically "residency programs" don't exist but I'm just using it for convenience) in one specialty, don't like it or whatever, stop, then switch to another specialty. Lots of people from ICU and ED for example who have decided to do anesthesia instead.

Given this background, many physicians in these nations likely have a broader background going into a particular specialty than their American counterparts.

 

[drmwvr]

I gotta say... I rarely meet european trained or european physicians here.. I think ive only met 2 or 3 in the past ten years. SO i dont know what you are talking about WIllis

Your personal experience notwithstanding, it doesn't change the reality of the situation in Europe that exists for the reasons we're talking about. Granted, 'most' of these physicians are immigrating to Australia and even New Zealand from the UK, but the point stands. Given the situation here, the US may just be a second choice.

 

[bashwell]

Your personal experience notwithstanding, it doesn't change the reality of the situation in Europe that exists for the reasons we're talking about. Granted, 'most' of these physicians are immigrating to Australia and even New Zealand from the UK, but the point stands. Given the situation here, the US may just be a second choice.

I can attest to the fact that there are tons of UK, Ireland, and other Commonwealth (e.g., South African) trained physicians in Australia. According to most of the ones I've spoken to (n=10-15), the salaries, work/life balance, and general healthcare system (e.g., Australia's Medicare vs. the UK's NHS) are far better in Australia than their home nations.

To be fair, maybe they're biased because they all did move to Australia after all.

 

[Jimmy Chitwood]

Diploma mill CRNA schools are going to flood the market with ****ty CRNAs, as we are already seeing. These are smart kids, but there really is something to be said for our training. The more they crank these guys out, the worse it will get for them.

Of course, it is also going to get worse for us. We have to supervise these clowns, and when they assassinate someone, our ass is on the line too. I would almost prefer them to just get full independence than me have to worry about some kid who was an ICU nurse 5 minutes ago, and in high school 5 minutes before that.

We all know how it would turn out if they do get full independence. It would be bad for everyone, including them.

And yes, i do believe that they are dooming their own job market.

 

[deleted162650]

Of course, it is also going to get worse for us. We have to supervise these clowns, and when they assassinate someone, our ass is on the line too. I would almost prefer them to just get full independence than me have to worry about some kid who was an ICU nurse 5 minutes ago, and in high school 5 minutes before that.

I was talking to one of our ENT's the other day whose daughter is graduating from college this year. Her plan is to get an NP degree. He said once she starts in the fall, she'll have her RN in 14mo and her NP in 16mo. Think about that. With just 16mo of "education" after a 4 year college degree (in whatever field), she will have the ability to see pts. independently and write Rx's, etc. Even the ENT was scared sheetless at that prospect, and it's his daughter we're talking about.

 

[bashwell]

I was talking to one of our ENT's the other day whose daughter is graduating from college this year. Her plan is to get an NP degree. He said once she starts in the fall, she'll have her RN in 14mo and her NP in 16mo. Think about that. With just 16mo of "education" after a 4 year college degree (in whatever field), she will have the ability to see pts. independently and write Rx's, etc. Even the ENT was scared sheetless at that prospect, and it's his daughter we're talking about.

This kind of thing would be laughed at in a Commonwealth nation like Australia. To be an NP in Australia, you need to be a registered nurse first of all (which you have to get a bachelor's degree specifically in nursing to do so). Then you need a minimum of 5 years full-time experience working as an RN and also concurrently employed in good standing at a hospital. You need the approval of two senior nurses in your dept who have known you for more than a year too. I think you also need the approval of the director of nursing at your hospital or something like that. And a certain number of practice hours in a particular field (for your NP I assume) which need to be fulfilled. Then you can apply to be a NP which is a masters degree and also requires a research component I believe. At least that's my limited understanding from talking to some NPs.

 

[psychbender]

I was talking to one of our ENT's the other day whose daughter is graduating from college this year. Her plan is to get an NP degree. He said once she starts in the fall, she'll have her RN in 14mo and her NP in 16mo. Think about that. With just 16mo of "education" after a 4 year college degree (in whatever field), she will have the ability to see pts. independently and write Rx's, etc. Even the ENT was scared sheetless at that prospect, and it's his daughter we're talking about.

I think you might be misinterpreting the timeline just a touch, in that I think it is 30 months total (14 then another 16), not 16 months total. It sounds like your ENT friend's daughter is doing an accelerated NP program, with includes a BS to BSN component. My wife did something similar, although her nursing school closed the program now. For hers, the BSN was obtained in about 1.5 years after undergraduate (she had a BS in Biology), and classes for the MSN started during the final semester. Then, over the next year, the NP classes and clinicals were finished. Grand total, I believe it was just about two and a half years (so, 30 months) after undergrad. It is still far too short, and only includes 800 clinical hours (the same as every other NP program), which are not standardized at all between students (one student's IM rotation could be with an Endocrinologist, another's could be with a Gastroenterologist, a third might actually be with an internist).

 

[deleted171991]

This kind of thing would be laughed at in a Commonwealth nation like Australia. To be an NP in Australia, you need to be a registered nurse first of all (which you have to get a bachelor's degree specifically in nursing to do so). Then you need a minimum of 5 years full-time experience working as an RN and also concurrently employed in good standing at a hospital. You need the approval of two senior nurses in your dept who have known you for more than a year too. I think you also need the approval of the director of nursing at your hospital or something like that. And a certain number of practice hours in a particular field (for your NP I assume) which need to be fulfilled. Then you can apply to be a NP which is a masters degree and also requires a research component I believe. At least that's my limited understanding from talking to some NPs.

You wanna bet that their NPs are not regulated by the board of nursing?

 

[deleted126335]

"I don't know about CRNAs dooming their own job market".

I do know that healthcare systems have been appalled at their spiraling anesthesia costs over the last fifteen years. Thus they have been doing everything that they can to flood the market with "providers". Plenty of individual CRNAs in academic and clinical teaching positions are happy to go along for the ride.

 

[bashwell]

You wanna bet that their NPs are not regulated by the board of nursing?

Yeah, not suggesting there aren't issues with NPs, but the educational requirements seem more rigorous than in the US if the above is true.

 

[GravelRider]

What will, unfortunately, doom all physicians is the death of FFS. Without it, physicians no longer have the billing codes, and without those, we lose our power to bargain. Ultimately, I think this is the goal for hospitals and insurers- cut out the providers, and deal only with each other via ACOs, then make us justify our incomes despite having no control or view of the billing process or how much revenue we generate

But when private practice physicians ramped up volume by employing "physician extenders" in order to generate more income, is that really any different than what is being pushed on us now by hospitals and management companies? You can't tell me that when anesthesiologists started supervising 4+ rooms they were thinking about the best interests of the patients and filling a community need. They were thinking about their wallets...much like the CEOs currently.

My point is, this is a monster of our own creation. These CRNAs were getting minimal supervision while the anesthesiologist was "supervising" 4 rooms and they thought, hey I can do this myself. The CEOs (being very rich and thus politically influential) agree with them. Now as hospitals continue to build more and more surgicenters and ORs to generate volume and income, the quickest way to staff these places with anesthesia personnel is by pumping out CRNAs (with our training being so long and the limit on anesthesia residency spots). We gave them the roadmap to making ourselves irrelevant.

 

[Mman]

With increasing nursing programs and schools pumping out more and more CRNAs each year, will the market for CRNAs be saturated in 10-15 years? (similar to pharmacy right now)

They already have hurt their job market. We used to lose around 10-15% of CRNAs per year taking higher pay jobs elsewhere. Now we lose well under 5% per year for that reason. Oh, and we've cut their pay.

Way too many CRNAs applying for too few jobs and it will continue to worsen acutely the next several years.

The biggest danger to them is that all these unemployed and underemployed CRNAs are going to start seeing the AANA as not being out to help them.

 

[Ronin2258]

They already have hurt their job market. We used to lose around 10-15% of CRNAs per year taking higher pay jobs elsewhere. Now we lose well under 5% per year for that reason. Oh, and we've cut their pay.

Way too many CRNAs applying for too few jobs and it will continue to worsen acutely the next several years.

The biggest danger to them is that all these unemployed and underemployed CRNAs are going to start seeing the AANA as not being out to help them.

I suspect you're right.

If the Michigan CRNA walkout from a couple of months was an example, all but the ringleaders eventually yielded to the new, lower pay schedule, didn't they?

It's going to get much worse for them, I suspect.

It would give me no small sense of satisfaction to see AANA just get trounced by its own constituents for not truly supporting their recent graduates. The new ones I'm talking to (n=20-30) think the older CRNAs are beyond insane to push for independent practice.

And I did sign the VA petition. Getting my care from there on occasion, I will insist on physician care through all my treatment. Period.