Anesthesia and diagnosis

[UMMS FMD]

Hey all,

I'm an M3 who's seriously considering applying into Anesthesia next year and was curious whether as a practitioner you get to use your diagnosing skills at all. I'm pretty sure this is what I want to do but this is the last question mark in my mind. I'm debating between Anesthesia and Emergency Medicine but am more drawn towards the former. The only real draw for me to EM is being able to diagnose, but if there's an element of that in Anesthesia, that'd be helpful to know.

Any thoughts?

Thanks!

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[2ndyear]

This is just my take on it as a resident:
You do need to have some diagnostic skill, but the traditional physical exam, labs, history and review of symptoms aren't really used in our field. I mean we do listen to lungs and do an airway exam but we aren't really diagnosing, just assessing readiness for anesthesia. We also review the labs, studies, etc but again aren't diagnosing something. Our patients come in for surgery, so one thing is usually diagnosed. They may have other things that need diagnosis. Say you have an 85 year old with a broken hip. Ortho has diagnosed the broken hip, but they haven't worked up her shortness of breath. Now as an anesthesia provider you need to put the diagnostician hat on and investigate further.

Intraop diagnosis to me is very fast and requires that you have already got your differential diagnosis planned. Hypotension, fluid or pressors. You don't have time to think about it, you just do it. If they have valvular heart disease then you better have read that chapter before the case.

ER diagnosis isn't all it's cracked up to be either. In my ER months as an intern I saw it as a game. First you play sick or not sick. With the sick ones you then play admit or not admit. If you get to admit, then stop. If you stand in the doorway and can see an admit then you're done, call the team and admit. In the meantime you have to be ready for said patient to decompensate and crash, and then it's treating just like in anesthesia. Quick, on your feet. If you have a not sick then it's just what can I do to get the patient home. Maybe a little more diagnosing, but a lot of rule out. The headache has had a negative CT, therefore it's not a SAH, send home. I don't care if it's a migraine or a cluster or a tension they all mean the same thing. Home. ER isn't easy and I don't mean to make it sound so, but the volume can be overwhelming. You need to have some sort of triage in your head to keep sane.

 

[threepeas]

had the same concern. i will try and incorporate critical care to satisfy that desire. the only people that truly make diagnoses are radiologist, and of course pathologist.

i would also add that you do make diagnoses that are specific to anesthesia complications. complications from procedures you do, evaluation of preoperative tests, intraoperative cardiopulmonary problems, PACU problems, etc.

good luck.

 

[militarymd]

Hey all,

I'm an M3 who's seriously considering applying into Anesthesia next year and was curious whether as a practitioner you get to use your diagnosing skills at all. I'm pretty sure this is what I want to do but this is the last question mark in my mind. I'm debating between Anesthesia and Emergency Medicine but am more drawn towards the former. The only real draw for me to EM is being able to diagnose, but if there's an element of that in Anesthesia, that'd be helpful to know.

Any thoughts?

Thanks!

About the only time that good diagnostic skills would come in handy is in the emergency/urgent add ons....patients with broken extremities, hot abdomens, etc....with no prior medical care who need to head to the OR.

A good physician can evaluate the patient...diagnose more common chronic medical conditions....and take them to the OR.....


Does it really matter though?

NO....the vast majority of practices out there just refer to the medical specialist....

What will you do as the gas guy.....prop, sux, tube....chart vital signs....and collect a fat pay check......well, probably a thin pay check by the time the glut of life style oriented anesthesia residents graduate.

 

[LongSnow]

Anethesia invloves plenty of diagnostic skills, especially practical diagnosis. IE - do I think this chest pain is worrisome? What is the degress of cardiac diastolic dysfunction? Risk/benefit proceed/delay? should I and if so anesthetize this patient for carotid endarteretomy with critical cervical stenosis? In short, in anesthesia (as I imagine in EM) you must learn about many fields of medicine. Its not all propofol/sux tube (though I wish it was!!!) And often, this has do be done in a minimal amount of time with incomplete information.

Personally, I have found anesthesia much more fun as a resident that as a medical student.


Never forget that the induction of anesthesia, in untrained hands, is a fatal event.



I am soon graduating from residency, and will join private practice in a mere 6 months and 25 days. I have only grown to love anesthesia more since I started 3+ years ago. Although my practice will be B&b anesthesia + some pain managment, i get the sense that we as anesthesiologists are going to be more and more involved in preoperative care, and even postoperative pain as well.

 

[Conflicted]

hey

I would imagine that the critical care fellowship and pain fellowship Anesthesiologists are diagnosing arent they?

 

[Bertelman]

well, probably a thin pay check by the time the glut of life style oriented anesthesia residents graduate.

I'm not trying to hijack this thread, and I know "the end is near" has been discussed elsewhere, and there is probably some sarcasm in the above, but here goes...

How exactly will the type of resident, i.e. lifestyle-oriented, change your salary in the future? I can appreciate the complexities of reimbursement, insurance, Medicare, etc. I don't see how the motives of residents will determine your salary. Anesthesia isn't exactly the only hideout for those expecting a nice lifestyle. Are the folks in Rads, Derm, ENT, etc. concerned about smaller paychecks?

If you're not in this for the lifestyle, I would think you could run circles around those wanting 7-3 4/wk, no call and 3 months off. That equals $$$$$ for Mil in the right practice.

 

[Trisomy13]

the lifestyle issue amuses me. just yesterday a fellow intern on my team in the MICU commented how i must be looking forward to the nice lifestyle of my future, coming in at 9 and leaving at 3. i asked him when surgeries typically start, and he paused and you could almost see the gears turning. i followed up by asking him what time the PACU closes. i told him if i wanted great hours i would do as he did and enter family medicine. cancel my appts, close the office and go golfing when the weather is nice...

 

[salmonella]

I'm not trying to hijack this thread, and I know "the end is near" has been discussed elsewhere, and there is probably some sarcasm in the above, but here goes...

How exactly will the type of resident, i.e. lifestyle-oriented, change your salary in the future? I can appreciate the complexities of reimbursement, insurance, Medicare, etc. I don't see how the motives of residents will determine your salary. Anesthesia isn't exactly the only hideout for those expecting a nice lifestyle. Are the folks in Rads, Derm, ENT, etc. concerned about smaller paychecks?

If you're not in this for the lifestyle, I would think you could run circles around those wanting 7-3 4/wk, no call and 3 months off. That equals $$$$$ for Mil in the right practice.

The general feeling is that anesthesiology is at higher risk of reimbursement cut and job insecurity compared to specialties such as Rads, Derm and ENT. This is evidenced by the fluctuating job market/salary in the past decade. Also, the CRNA issue is worrisome. More and more states will likely allow CRNAs to give anesthesia independently in the future. The negative public perception regarding the prevalent drug addiction problem in anesthesiology needs to be addressed as well. The current anesthesia salary is probably as high as it could be, without much room to go up, but does have plenty of room to come down. The congress will reduce reimbursement significantly pretty soon.

 

[VolatileAgent]

the lifestyle issue amuses me. just yesterday a fellow intern on my team in the MICU commented how i must be looking forward to the nice lifestyle of my future, coming in at 9 and leaving at 3. i asked him when surgeries typically start, and he paused and you could almost see the gears turning. i followed up by asking him what time the PACU closes. i told him if i wanted great hours i would do as he did and enter family medicine. cancel my appts, close the office and go golfing when the weather is nice...

too true. lately, my days are typically 12+ hours starting usually at 5:45 AM. and, that's not including call days...

 

[Bertelman]

The general feeling is that anesthesiology is at higher risk of reimbursement cut and job insecurity compared to specialties such as Rads, Derm and ENT. This is evidenced by the fluctuating job market/salary in the past decade. Also, the CRNA issue is worrisome. More and more states will likely allow CRNAs to give anesthesia independently in the future. The negative public perception regarding the prevalent drug addiction problem in anesthesiology needs to be addressed as well. The current anesthesia salary is probably as high as it could be, without much room to go up, but does have plenty of room to come down. The congress will reduce reimbursement significantly pretty soon.

I understand those concerns. None of them involve motives of selfish, but ill-informed med students. And I don't think the public's perception of drug use (stimulated by a few recent forgettable articles), which I don't believe is any more prevalent now in anesthesia than it was before, has any chance of affecting your salary. Clearly it isn't affecting the NFL, MLB, etc.

 

[Noyac]

hey

I would imagine that the critical care fellowship and pain fellowship Anesthesiologists are diagnosing arent they?

Not so much.

 

[Conflicted]

Hmm

Why is it that anesthesia is getting cut so much when rads are being farmed out to other countries all over the world ?

Why is rad so special?

 

[ZA_Gasman]

To bring this back onto topic...

You may not do that much diagnosing, but you still need to have those skills. If one assumes that the patient has been completely diagnosed and worked up by the team presenting the patient for surgery, well, then lets just hope that the ol' malpractice insurance is well paid up.

It isn't the 90yr old gomer with a femur fracture and 47 medical diagnoses that will catch you, it is the young asymptomatic undiagnosed Mitral stenosis, or the HOCM that you have to watch out for. You don't want to discover something like this on induction and then have to do fast diagnosis. I like my dopes to have as little need for rapid diagnosis as possible, thank you very much!

 

[iron]

I find myself using quite a few of my diagnostic skills. Partially because of my practice in a county hospital with patients who do not get executive work-ups or walk thru the door very sick. Partially because I'm a physician who uses her training to figure out what's wrong when things don't seem right.

You will see plenty of patients with undiagnosed HTN, DM, OSA, COPD. Most of them you will treat as you need to for that day, that surgery. Occasionally you will have a greater impact. And don't forget smoking cessation counseling.

This week I had an 84 yo come for lap/open chole. 4d in the hospital getting Abx on the medicine service with surgical consult. At admission his CXR was showed poor inspiration and elevated diaphragms. At arrival in OR holding on 2L he didn't look so hot. Rattling cough, productive sputum, sat on floor reportedly 96% on 2L, medicine exam noted clear B/L. My exam rhonci R lung. Sat 78% on 2L, 90% on 100% non-rebreather. A-a gradient huge. CXR - R sided pneumonia.

By implementing your training as a physician, not just a technician, you maintain your credibility and get respect. YOu know what you're about and shows professional pride.

Physicians diagnose and treat.

 

[BubbleHead]

I find myself using quite a few of my diagnostic skills. Partially because of my practice in a county hospital with patients who do not get executive work-ups or walk thru the door very sick. Partially because I'm a physician who uses her training to figure out what's wrong when things don't seem right.

You will see plenty of patients with undiagnosed HTN, DM, OSA, COPD. Most of them you will treat as you need to for that day, that surgery. Occasionally you will have a greater impact. And don't forget smoking cessation counseling.

This week I had an 84 yo come for lap/open chole. 4d in the hospital getting Abx on the medicine service with surgical consult. At admission his CXR was showed poor inspiration and elevated diaphragms. At arrival in OR holding on 2L he didn't look so hot. Rattling cough, productive sputum, sat on floor reportedly 96% on 2L, medicine exam noted clear B/L. My exam rhonci R lung. Sat 78% on 2L, 90% on 100% non-rebreather. A-a gradient huge. CXR - R sided pneumonia.

By implementing your training as a physician, not just a technician, you maintain your credibility and get respect. YOu know what you're about and shows professional pride.

Physicians diagnose and treat.

Thanks to No on Issue 4 and Yes on 5 you'll have a little help with that smoking cessation counseling. Dec 8th the Smoking Ban goes into effect.

 

[militarymd]

I find myself using quite a few of my diagnostic skills. Partially because of my practice in a county hospital with patients who do not get executive work-ups or walk thru the door very sick. Partially because I'm a physician who uses her training to figure out what's wrong when things don't seem right.

You will see plenty of patients with undiagnosed HTN, DM, OSA, COPD. Most of them you will treat as you need to for that day, that surgery. Occasionally you will have a greater impact. And don't forget smoking cessation counseling.

This week I had an 84 yo come for lap/open chole. 4d in the hospital getting Abx on the medicine service with surgical consult. At admission his CXR was showed poor inspiration and elevated diaphragms. At arrival in OR holding on 2L he didn't look so hot. Rattling cough, productive sputum, sat on floor reportedly 96% on 2L, medicine exam noted clear B/L. My exam rhonci R lung. Sat 78% on 2L, 90% on 100% non-rebreather. A-a gradient huge. CXR - R sided pneumonia.

By implementing your training as a physician, not just a technician, you maintain your credibility and get respect. YOu know what you're about and shows professional pride.

Physicians diagnose and treat.

I wouldn't call that diagnosing or treating...and then pat myself on my back for that.

That patient doesn't look good....you assessed the risk of going to surgery....decided whether you go or not....that's it.

You may have identified some abnormal physiology (hypoxia and dysfunctional air exchange)........

You certainly didn't treat anything...Treating pneumonia would involved:

1) ordering inital antibiotics (based on American Thoracic Society's practice guildines for initial treatment of pneumonia...or BTS if you so choose)

2) making a decision to admit for inpatient therapy vs outpatient therapy (not relevant in your example)

3) ordering additional tests to identify the organism

4) and, perhaps most important, follow/up care to evaluate for effectiveness of prescribed therapy.

a) patients who do not respond within 3 to 4 days of therapy require
1) broadening abx
2) evaluation for pulmonary inflammatory disease that is of non-infections origin

5) etc.

6) etc.

Your garden variety anesthesiologist (99.9999% of us) do not do this.

If you do this...or did this for this patient, then I would agree with your self assessment.

 

[VolatileAgent]

Hmm

Why is it that anesthesia is getting cut so much when rads are being farmed out to other countries all over the world ?

Why is rad so special?

the continued demonstration of your inability to even remotely grasp basic facts is astounding.

if you are referring to services such as "nighthawk", those are u.s. trained/licensed radiologists. furthermore, a radiologist doesn't need to personally evaluate a patient to read an x-ray or scan. your attempt to draw a parallel is so off, it can't even be called an apples to oranges comparison.

 

[Conflicted]

Volatile


Your attempts at character assassination are laughable. You know so little about the actual healthcare system it amazes me.

Yes, nighthawk docs are US credentialed. However, the POINT is that these rads cut the costs of service considerably yet the US based radiologist salary isn't cut at all. Juxtaposed to the anesthesia world which CANNOT be farmed out to other countries (for obvious reasons) yet thats where the cuts are.

It makes no sense. If the Nighthawk service is as safe as having an onsite US rad, why isnt their pay being cut near as much as anesthesia who cannot be replaced so easily?

Man, you have to get a life as opposed to spending 3 days AFTER i post something trying to come up with a way to insult me. Your pathetic.

 

[Trisomy13]

nothing to see here, folks. keep moving.

 

[badgas]

Oh wow... I'm shocked. Conflicted is taking us down this road YET AGAIN!

 

[Conflicted]

Badgas

I did not begin with the insults here. In fact, i was simply suggesting there were other places that should be cut besides anesthesia. Volatile began the insults.

 

[DrDre']

Volatile


Your attempts at character assassination are laughable. You know so little about the actual healthcare system it amazes me.

Yes, nighthawk docs are US credentialed. However, the POINT is that these rads cut the costs of service considerably yet the US based radiologist salary isn't cut at all. Juxtaposed to the anesthesia world which CANNOT be farmed out to other countries (for obvious reasons) yet thats where the cuts are.

It makes no sense. If the Nighthawk service is as safe as having an onsite US rad, why isnt their pay being cut near as much as anesthesia who cannot be replaced so easily?

Man, you have to get a life as opposed to spending 3 days AFTER i post something trying to come up with a way to insult me. Your pathetic.

Sorry, on call. I am pathetic for pointing this out but this is my pet peeve, YOU ARE pathetic. You do not own the state of being pathetic (or do you?)


Love these posts. Can't wait to meet ALL you guys at ASA some day!

 

[Conflicted]

DrDre

I stand corrected and will not make the mistake again!

 

[badgas]

Badgas

I did not begin with the insults here. In fact, i was simply suggesting there were other places that should be cut besides anesthesia. Volatile began the insults.

Come on man... all I'm hearing here is "HE started it!" It's funny how you're always involved yet always the victim.

 

[Conflicted]

Oh my

well, his post was first after i said something pro-anesthesia. Would you not defend yourself when your attacked? Its not about "he started it" its about being attacked and defending oneself.

 

[DrDre']

Just bored. Not attacking you per se for the "you are". Just finally felt the desire to post about it (did I mention I am bored?)

Oh my

well, his post was first after i said something pro-anesthesia. Would you not defend yourself when your attacked? Its not about "he started it" its about being attacked and defending oneself.

 

[Conflicted]

hey Dr Dre

N/p i took it as a fun poke at my bad grammer

 

[BlackScorpion]

conflicted, you still here?

 

[burntcrispy]

You guys need to PM each other, find yourselves a hotel room to meet at and get out that pent up frustration of your man love for each other. This is really getting old. I mean, I've had crushes on some of the nurses but this is just a bit too much.

 

[VolatileAgent]

Volatile


Your attempts at character assassination are laughable. You know so little about the actual healthcare system it amazes me.

(see below)

Yes, nighthawk docs are US credentialed. However, the POINT is that these rads cut the costs of service considerably yet the US based radiologist salary isn't cut at all. Juxtaposed to the anesthesia world which CANNOT be farmed out to other countries (for obvious reasons) yet thats where the cuts are.

It makes no sense. If the Nighthawk service is as safe as having an onsite US rad, why isnt their pay being cut near as much as anesthesia who cannot be replaced so easily?

Man, you have to get a life as opposed to spending 3 days AFTER i post something trying to come up with a way to insult me. Your pathetic.

hospital systems - read this carefully - pay a premium (that means they pay more, not less) to have access to that service. this is because there are not enough radiologists to staff hospitals, especially to read critical scans at night. that's because there is a radiologist shortage. so, you are completely wrong in your assessment.

furthermore, this has nothing to do with cutting medicare funding for anesthesiologists. just as the iraq war has nothing to do with cutting medicare funding for anesthesiologists. just as the price of tea in china has nothing to do with cutting medicare funding for anesthesiologists. so, it's your attempted comparison that is laughable.

again, i will state that your lack of a grasp of what really goes on in a hospital, srna, is astounding. why don't you stop posting on this forum, learn how the world really works, graduate from your SRNA school, get a real job, and then come back here once you've grown up and figure a few more things out?

(and, it's "you're pathetic", which you are, and not "your pathetic" which is a possessive pronoun. so, learn grammar while you're at it too. your [which is the proper way to use that word] general lack of intelligence repeatedly demonstrated here illustrates precisely why CRNA's will never get independent practice rights.)

 

[VolatileAgent]

one more thing...

Man, you have to get a life as opposed to spending 3 days AFTER i post something trying to come up with a way to insult me. Your pathetic.

forums are not "real time." contrary to what you may think, i actually do have a wife, children, and a rich existence outside this forum. i do not come here everyday, but i do come back here to read (and respond to) those threads that i feel are worthy of comment and/or criticism. other times, posts are so preposterous or just flat out wrong, like yours, that they can't go unchecked lest someone less inclined to check facts unwittingly gains the wrong impression.

so, the fact that i came back "3 days" after you posted, yet you post almost immediately after i did tells me a lot about which one of us really needs to get a life...

 

[Conflicted]

*sigh*

I had a long post here proving my point then decided this was futile. We have hijacked the thread enough and you are not worth the time. Sufficed to say, im not an SRNA.

 

[BlackScorpion]

Can you please leave these forums now?