There are a lot of other possibilities than the above scenario, but you have to come to terms with that cold hard possibility before you go into this job.
Nice how you conveniently ignore this second paragraph of my post. There are a lot of threats to our career and if you cannot accept the very real possibility that you will not be doing
intraoperative cardiac anesthesia in 5-10 years, I think you need to reconsider. The OP specifically asked about a career in cardiac anesthesia, and it sounds like he hasn't even started down the anesthesia path yet. My advice in this thread is mostly to those who are in his situation.
No I don't think Obamacare is the death knell of anesthesia or of surgical careers. In fact, there was a good chance that surgery numbers would have gone up while reimbursement went down keeping our incomes somewhat buoyed at a lower level under his full plan. The plan that ultimately went through will, IMHO, set in motion the most painful possible path to a single payer system. Ultimately everyone gets sick of paying the insurance companies for minimal coverage, has to pay out of pocket for real care, and realizes how much of their health care dollar is increasingly going to insurance administrative costs, then they will scream for a single payer system. In the meantime, the majority of the fiscal pain will be carried by physicians and patients, not hospital admins, insurance folks or politicians.
Political thoughts aside, lets look at the real threats to cardiac anesthesia careers.
1 - Percutaneous procedures. Despite the data supporting superior longevity of CABG in certain circumstances, it is hard to talk a patient into getting a full anesthetic with their chest opened several days hence when they can be stented right now with some sedation and can be out of the ICU in short fashion. Surgeons have, in large part, compensated for this by taking older and sicker patients to the OR. I believe we have pretty much hit our max for older sicker patients. Valves have been the (almost) exclusive domain of the surgeon, but perc valves are coming of age. As tissue modeling, stem cell research, etc improves the valves that can be placed percutaneously, we will see a large segment of cardiac surgical procedures eliminated. Smaller VADs are on the near horizon. These will be placed/ exchanged in the cath lab, and will be attached to the subclavian vessels reducing the need for open chest VAD procedures and transplants. There will be a reduced need for cardiac anesthesia.
2 - Economic reality. The biggest threat. Right now we still live in a country with tremendous economic unreality. Insurance has divorced us from reality to the point that the cost of healthcare is not tangible for the patient or the physician. There is little hope that the overall economy will recover to a point that will allow us to continue spending at current levels for more than a few years. At some point, utilization of health care resources is likely to decrease. This will either come at the behest of government mandate or by individual choice.
Further, these patients are mostly covered by medicare with reimbursement values that are terrible for anesthesiologists. We have artificially propped up salaries through stipends, redistribution of group incomes, supplementing with non-cardiac cases etc, but that can only go so far. In this era of huge budget cuts, it would be surprising if we did not see a significant reduction in the salary of those who practice cardiac anesthesia full-time.
3 - CRNA's
Susan Parry McMullan, CRNA, MSN, chief nurse anesthetist at Hinsdale Anesthesia Associates, Hinsdale, Illinois, uses trans esophageal echocardiography to evaluate pre*operative heart function in a patient scheduled for coronary artery bypass graft surgery.
I think that image/ quote pretty much says all that needs to be said about this threat.
I am sure that there are other threats.
I believe the market will contract from both ends (fewer cases being done with more of them done without anesthesiologist involvement) while incomes will drop with the result being that many of us will not be doing a significant amount of cardiac anesthesia. How dramatic an effect we will see is yet to be determined. As it currently is, how many anesthesiologists are doing strictly cardiac anesthesia? I would guess only slightly more than the number of CRNA's who currently do hearts part-time.
There are, of course, other possibilities. The Supreme Court could declare the bill unconstitutional, congress could stop deficit spending, housing prices could return to 2008 levels, and the AANA could decide that they actually were wrong all along and echocardiography and cardiac anesthesia are really the practice of medicine and should thus be left to fellowship-trained anesthesiologists. Which scenario do you think is more likely.
Our skill set will still be valuable and hopefully we can adapt it to other areas of medicine. Certainly, we can be valuable for non-cardiac surgery in patients with cardiac disease (especially structural cardiac disease), but I doubt that cardiac anesthesia will look the same 5-10 years hence.
Of course the proceduralists are going to see a drop in income, but it is likely that 10 years hence their business will have picked up dramatically as more and more surgical repair is done in a transcatheter fashion. If you are looking for income stability get a job in primary care, the only field who's income is pretty much guaranteed to not go down. If you want to make more money, you have to take more risk of losing that income down the road.
- pod