CRNA vs. Anesthesiologist Surgery Help

[jope]

What are your reasons for not wanting a CRNA?

You also mention "your" field's training as a reference to MD/DO training. The first professional group to provide anesthesia in the US was nurses. So what do you mean by "your" field?

The saying goes that the person who graduated last in Medical School is still an MD. Would it be fair for me to request care from only those who graduated in the top 25%, 5%? As smart as those top notch students are, how does that translate to clinical practice? Most residents require the guidance and direction of the nursing staff regardless of whichever top tier medical school and class ranking they bring to the table.

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

By all means continue to believe that your white coat colleagues are better, that is your right. As a CRNA I get paid less to do the same cases, whilst able to work better hours and "have a life." I also don't compare myself to MD's because I value the background and training that everyone brings. So instead of sitting here lambasting CRNA's, get educated and realize that we all work together for patients.

Yes there are exceptional nurses as well. However, medical school is a smaller pool and the barrier to get into it is much higher than nursing school. You cannot compare the two. Residency is also much more intense than nursing training. Your DNP might help you with administration or research, but it cannot be compared to the clinical experience of residency.

Secondly, several years of caring for patients as a nurse in the ICU under the direction of an MD does not prepare you to critically think for yourself either. The foundation of knowledge that the typical MD possesses cannot be replaced just by a few years of nursing.

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[deleted171991]

What are your reasons for not wanting a CRNA?

You also mention "your" field's training as a reference to MD/DO training. The first professional group to provide anesthesia in the US was nurses. So what do you mean by "your" field?

According to your logic, surgery is a barber field.

The saying goes that the person who graduated last in Medical School is still an MD. Would it be fair for me to request care from only those who graduated in the top 25%, 5%? As smart as those top notch students are, how does that translate to clinical practice? Most residents require the guidance and direction of the nursing staff regardless of whichever top tier medical school and class ranking they bring to the table.

That applies to nurses, too. The CRNA who graduates last is still a CRNA. And most residents don't require the guidance of nurses, but of other doctors. One cannot "guide" somebody in something one doesn't really know. What an experienced nurse knows is just pattern recognition, not medicine.

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.

The military uses CRNAs because they are cheap. They barely find docs to work for $270K at the VA, while the active military salaries are actually lower than that. Plus the patients in the military are overwhelmingly ASA 1s and 2s.

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

It's not the quantity, it's the quality and intensity of education. Medicine is not just monkey skills, so one cannot measure it just by the hours spent on it. What do nurses bring extra special to the table? The specialized skill in emptying the Foley?

By all means continue to believe that your white coat colleagues are better, that is your right. As a CRNA I get paid less to do the same cases, whilst able to work better hours and "have a life." I also don't compare myself to MD's because I value the background and training that everyone brings. So instead of sitting here lambasting CRNA's, get educated and realize that we all work together for patients.

You don't value anything. That's why you are so high and mighty. You don't want to work together for patients. You consider yourself to be our professional equal, or even better, so I don't see you following the instructions of an "inferior" MD for the good of the patients. If you were so concerned about patients, you would recognize and respect your limits.

 

[kjamess]

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

lol what a joke.

 

[Mman]

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

I'm curious why you count your undergrad degree but not a physician's undergrad degree? Also why do you leave out a year of internship for physicians which is one of the most intense learning experiences possible? Why do you pretend like all CRNAs have a DNAP or DNP? Almost none do nationally. But then again, perhaps you could talk about what part of the DNP or DNAP is relevant to clinical care? Because none of it is.

As far as you are concerned a nurse might bring far more to the table, but you'd be wrong and you don't have the education to the know the difference. Fortunately we actually have CRNAs that went to medical school and became physicians that can accurately comment on how much they didn't know.

CRNAs have about 18 months of clinical anesthesia training. During this 18 months, they work an average of about 30-40 hours per week. You think this is comparable to being a resident for 4 years and working an average of 60+ hours per week? I mean really? Perhaps you could comment on the extremely minimal case requirements CRNAs must do to graduate. Did you know you can become a CRNA without having ever put a central line in a patient? Did you know you they may have never done a fiberoptic intubation on a patient? Did you know they may have never floated a PA catheter? Did you know they may have never done an echo? Did you know they may have never done an epidural on a patient? Should we also talk about the comical case minimums? Really?

I'm guessing you have no interest in talking about actual real issues with CRNA training because you are a troll. You will tell me how well trained you personally are, but you won't be willing to talk about so many of your colleagues that aren't.

 

[Man o War]

What are your reasons for not wanting a CRNA?

You also mention "your" field's training as a reference to MD/DO training. The first professional group to provide anesthesia in the US was nurses. So what do you mean by "your" field?

The saying goes that the person who graduated last in Medical School is still an MD. Would it be fair for me to request care from only those who graduated in the top 25%, 5%? As smart as those top notch students are, how does that translate to clinical practice? Most residents require the guidance and direction of the nursing staff regardless of whichever top tier medical school and class ranking they bring to the table.

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

By all means continue to believe that your white coat colleagues are better, that is your right. As a CRNA I get paid less to do the same cases, whilst able to work better hours and "have a life." I also don't compare myself to MD's because I value the background and training that everyone brings. So instead of sitting here lambasting CRNA's, get educated and realize that we all work together for patients.

If any of this were true, hospitals would get rid of their MDs today. The fact is, even in the many states where all legal barriers for you to practice independently have been lifted, hospitals still choose to have MDs supervise you. The only ones that don't are so desperate they can't recruit an MD and would rather give substandard care than none at all. They then ship any sick patients to the cities with MDs because you can't handle them.
I know tons of CRNAs who cant put in CVLs or any other lines for that matter. They've never done an anesthetic for a cardiac or peds case. Can't do nerve blocks proficiently or at all. They watched a fiberoptic intubation or nerve block as a student and then counted those toward their case counts because those are the low standards allowed by your schools.
Patients are the ones harmed by your dangerous lack of self awareness, not me. But as long as you all get to feed your ego, it's all good right? The inferiority complex/delusions of grandeur are real.

 

[psychbender]

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.
.

LOL wut?! The military uses CRNAs so heavily because they're cheap, and there are more nurses than doctors. They care nothing about 'quality' and just need a warm body to fill a billet and get cases done. Cases, I might add, done on young, healthy patients, that are really hard to mess up. As for downrange, have you noticed that the CRNAs tend to be at the smaller facilities that barely see casualties, while the anesthesiologists are concentrated at the CSH level? And at LRMC? And WRNMMC and SAMC? You know, where the critically injured soldiers show up. Depending on when and where one deployed, plenty of CRNAs saw actual trauma, but the bulk of the trauma care was still shouldered by the physicians at those facilities.

As for years of training, you're conflating years with actual time spent taking care of patients and making medical decisions. None of your time in nursing school or in the ICU was spent making medical diagnoses and coming up with a plan of action. Even your time in the OR had limited decision-making, and limited hours. When I was in and had to train SRNAs, the program changed to a DNAP-granting program, with the clinical portion becoming two years. However, the students were in the OR only three days a week, and were mandated to be out by 1500. No call, no weekends, no holidays. They had the simple cases you'd expect from a military hospital, and when they'd be assigned to an anesthesiologist in a room with complicated patients, they simply followed the instructions and plan of said anesthesiologist, still never making a plan of their own.

CRNAs have a place in medicine as force multipliers, and you're right, have a really sweet gig. However, they are hardly clinically superior to anesthesiologists.


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[Southpaw]

And MDs train them every day, even as I type. I'll never understand.

 

[HIPAAHasOneP]

What are your reasons for not wanting a CRNA?

You also mention "your" field's training as a reference to MD/DO training. The first professional group to provide anesthesia in the US was nurses. So what do you mean by "your" field?

The saying goes that the person who graduated last in Medical School is still an MD. Would it be fair for me to request care from only those who graduated in the top 25%, 5%? As smart as those top notch students are, how does that translate to clinical practice? Most residents require the guidance and direction of the nursing staff regardless of whichever top tier medical school and class ranking they bring to the table.

While I 100% agree with being able to "choose" MD or CRNA, I think the reasoning behind your choice stems from the ego that comes from your white coat and thinking you actually make the most difference. The military prefers to use CRNA's because of their prior nursing experience at the bedside.

MD's have 4 years of medical school and as far as I know 3 years of residency. CRNA's have 4 years of nursing school, X number of working years at the bedside in an ICU and 3 years of advanced training as a DNP or DNAP. As far as I am concerned, nurses bring far more to the table than MD's do.

By all means continue to believe that your white coat colleagues are better, that is your right. As a CRNA I get paid less to do the same cases, whilst able to work better hours and "have a life." I also don't compare myself to MD's because I value the background and training that everyone brings. So instead of sitting here lambasting CRNA's, get educated and realize that we all work together for patients.

Wow, I do not understand all of this hostility toward patients for preferring an anesthesiologist. I preferred a particular surgeon over other surgeons. That doesn't mean I thought the other surgeons suck, it just meant I had a preference for a particular surgeon. I'm a nurse, so I'm definitely a fan of nurses but my preference was to have an anesthesiologist. My decision was not a slam against CRNAs.

The problem I had with the 1:4 model was that no one would answer my questions about how it worked or who would be taking care of me. I asked 3 questions and tried to be very careful about how I asked the questions because I knew it was such a touchy issue. I asked if the anesthesiologist would be present for intubation and emergence, how often the anesthesiologist would check in, and if there was an emergency how long would it take for her to get there. I didn't get an answer to any of those questions. The anesthesiologist was really uncomfortable and wouldn't make eye contact, and just said, "Well, I don't even know if I will be the one taking care of you." Apparently the anesthesiologist then told the CRNA I asked questions, and she was very aloof and unfriendly when she came in to give me the Versed. She didn't even introduce herself. The last thing I wanted to do was to ruffle the feathers of the people taking care of me. Knowing that people were displeased with me created unnecessary stress that I didn't need. I think they should have answered my questions without taking things personally. It wasn't personal.

So, now I politely request an anesthesiologist and everyone has been very nice about it. I may not always have that option, but if it's available I'll take it. I know who is taking care of me, and it's drama free.

 

[HIPAAHasOneP]

Duplicate

 

[deleted171991]

And MDs train them every day, even as I type. I'll never understand.

Oh, I do. You see, there are two situations:

1. The MD is an employee of a group that trains SRNAs. In certain markets, the MD has no choice but train those SRNAs, otherwise he'll lose his job. Actually, it's not the MD training the SRNAs, it's the CRNAs who are training the SRNAs on the anesthesiologist's license.
2. The MD is an owner of such a group. He gets paid for training SRNAs, which can be also used as cheap workforce. Not only that, but the MD is pretty wealthy already and will probably be able to retire once an AMC buys his practice, so he couldn't care less about the damage he does to the profession and future generations.

 

[DrCommonSense]

So I'm not so delusional to think that I am any better at this profession than anyone else on this site. I just have a bit more experience than many here and I wish to share it. You can accept that as rhetoric or as experience, I don't care other than I believe that there is no better anesthetic than an anesthetic delivery solely by an anesthesiologist. However, I am not so delusional to think that this is possible in our country. There just isn't enough of us. And I don't disagree with anyone that claims that there are some fantastic nurses or AA's doing this job as well. I have worked with some ( an AA actually taught me how to do an axillary block). And yes I would let them perform my anesthestic in a pinch but by no means would I take them over a personally chosen anesthesiologist.
So what I'm getting at is that if "we" want to maintain the physician basis of this specialty then we need to come together and support as much physician delivered anesthesia as we can possibly manage. I get it that some practices can't manage even the slightest bit of this. That saddens me but I understand the constraints. I also wonder if this is financially driven more than anything. Don't tell me that you can't recruit physicians when your senior partners are making more than the national average though. This is bullsh*t. If you live in an area that can't support hiring physicians then your cost of living is more than likely extremely lower than the national average and this argument holds no water.
So stop saying that the ACT model is the best. Instead, say it's the best you can do and live with it.

The ACT model is the best model for the older anesthesiologists to get rich, especially when AMCs and Venture Capitalists get into the game.

Ergo, you won't end it and it will expand.

You really think the older dudes care enough to not sell the younger ones out? Money talks, BS walks.

 

[Noyac]

The ACT model is the best model for the older anesthesiologists to get rich, especially when AMCs and Venture Capitalists get into the game.

Ergo, you won't end it and it will expand.

You really think the older dudes care enough to not sell the younger ones out? Money talks, BS walks.

So you agree with me!

 

[sevoflurane]

The ACT model is the best model for the older anesthesiologists to get rich, especially when AMCs and Venture Capitalists get into the game.

Ergo, you won't end it and it will expand.

You really think the older dudes care enough to not sell the younger ones out? Money talks, BS walks.

Not sure I follow. How rich are we talking here? Pretty sure an MD only practice can do pretty well compared to an ACT model-
With or without AMCs/Venture capitalists.

Psychologically an MD model will always be a better way to deliver superior anesthesia. One patient at a time with minimal fires to put out.
I'm sure people with have issues with this.

Monetarily... well it depends on your group and your contracts. Don't underestimate the power of a well run MD only group.

One thing I am pretty sure about with regards to my own personal life is that I feel a lot better not working with CRNAs.
I can focus on one patient, have a reasonable daily experience and still do fairly well without all the BS.
The AANA are not our friends. Can't be trusted, so I choose not to deal with any of them.

I boycott the ACT model on principle alone.

 

[DrCommonSense]

Not sure I follow. How rich are we talking here? Pretty sure an MD only practice can do pretty well compared to an ACT model-
With or without AMCs/Venture capitalists.

Psychologically an MD model will always be a better way to deliver superior anesthesia. One patient at a time with minimal fires to put out.
I'm sure people with have issues with this.

Monetarily... well it depends on your group and your contracts. Don't underestimate the power of a well run MD only group.

One thing I am pretty sure about with regards to my own personal life is that I feel a lot better not working with CRNAs.
I can focus on one patient, have a reasonable daily experience and still do fairly well without all the BS.
The AANA are not our friends. Can't be trusted, so I choose not to deal with any of them.

I boycott the ACT model on principle alone.

The ACT model is vastly superior to the finances of both AMCs/VCs and older anesthesiologists who can profit off the revenue.

The MD only model can possibly be decent for younger docs but hard to sustain in many geographies due to the aforementioned reasons coupled with further CRNA encroachment due to the militant AANA.

Considering the monetary benefit for older docs/AMCS/VCS, money talks and BS walks.

Ergo, those big forces will work against the MD model.

I never said the AANA are friends. They are clear enemies of Anesthesiologists and will reduce their salaries to slightly above nurse levels if they get sufficient independence.

However, greed is the name of the game and it works against the younger generation of anesthesiologists or those that want to work >10 years more.

 

[sevoflurane]

The ACT model is vastly superior to the finances of both AMCs/VCs and older anesthesiologists who can profit off the revenue.

The MD only model can possibly be decent for younger docs but hard to sustain in many geographies due to the aforementioned reasons coupled with further CRNA encroachment due to the militant AANA.

Considering the monetary benefit for older docs/AMCS/VCS, money talks and BS walks.

Vastly superior? Again... depends on your contracts and the group.
ACT will loose out to MD only groups with 1:3 most of the time once you take into account CRNA benefits and scheduling inefficinecies. 1:4 is just not my cup of tea and is NOT vastly superior. Many factors involved. Blanket statements don't fit.
I'm not going to divulge numbers here, but I've been in MD only groups and have done very well compared to MGMA averages.
I provide great anesthesia care to my patients and my happiness factor is sitting around 150%. My days range from chill to very, very busy. Still take about one weekend call every 2 months... and we are currently understaffed. Not bad for an MD only group.

 

[Man o War]

Vastly superior? Again... depends on your contracts and the group.
ACT will loose out to MD only groups with 1:3 most of the time once you take into account CRNA benefits and scheduling inefficinecies. 1:4 is just not my cup of tea and is NOT vastly superior. Many factors involved. Blanket statements don't fit.
I'm not going to divulge numbers here, but I've been in MD only groups and have done very well compared to MGMA averages.
I provide great anesthesia care to my patients and my happiness factor is sitting around 150%. My days range from chill to very, very busy. Still take about one weekend call every 2 months... and we are currently understaffed. Not bad for an MD only group.

The biggest advantage of doc only- LESS CALL. My life is infinitely better now taking half the call I did in ACT model. I'm so much less tired. Those nights wear on old farts like myself.

 

[aneftp]

Vastly superior? Again... depends on your contracts and the group.
ACT will loose out to MD only groups with 1:3 most of the time once you take into account CRNA benefits and scheduling inefficinecies. 1:4 is just not my cup of tea and is NOT vastly superior. Many factors involved. Blanket statements don't fit.
I'm not going to divulge numbers here, but I've been in MD only groups and have done very well compared to MGMA averages.
I provide great anesthesia care to my patients and my happiness factor is sitting around 150%. My days range from chill to very, very busy. Still take about one weekend call every 2 months... and we are currently understaffed. Not bad for an MD only group.

I think a modification to the statement "act model is vastly superior to MD model"

If the payer mix is more than 50% commercial, than the act model is vastly superior than MD only model.

I think a mostly Medicare or Medicaid model, the act model loses its attractiveness.

 

[DrCommonSense]

Vastly superior? Again... depends on your contracts and the group.
ACT will loose out to MD only groups with 1:3 most of the time once you take into account CRNA benefits and scheduling inefficinecies. 1:4 is just not my cup of tea and is NOT vastly superior. Many factors involved. Blanket statements don't fit.
I'm not going to divulge numbers here, but I've been in MD only groups and have done very well compared to MGMA averages.
I provide great anesthesia care to my patients and my happiness factor is sitting around 150%. My days range from chill to very, very busy. Still take about one weekend call every 2 months... and we are currently understaffed. Not bad for an MD only group.

Why is the ACT model moving into the Western states that were traditionally only MD if this is so "efficient"?

Here are the CRNA studies showing that "CRNA only" is the most cost effective followed by the ACT model:

Study Shows CRNA-Only Anesthesia Delivery Most Cost Effective

With MANY older docs making money off the ACT coupled with AMCS/VCs, do you honestly think MD only models will hold with a MILITANT AANA?

Good luck.

 

[DrCommonSense]

Vastly superior? Again... depends on your contracts and the group.
ACT will loose out to MD only groups with 1:3 most of the time once you take into account CRNA benefits and scheduling inefficinecies. 1:4 is just not my cup of tea and is NOT vastly superior. Many factors involved. Blanket statements don't fit.
I'm not going to divulge numbers here, but I've been in MD only groups and have done very well compared to MGMA averages.
I provide great anesthesia care to my patients and my happiness factor is sitting around 150%. My days range from chill to very, very busy. Still take about one weekend call every 2 months... and we are currently understaffed. Not bad for an MD only group.

Here's the full article for analysis:

http://www.fsahq.org/wp-content/upl...tiveness-Analysis-of-Anesthesia-Providers.pdf

From a purely dollar/cents perspective, this makes sense.

You can only argue against it if the CRNAs become far more costly due to lawsuits. I am unconvinced of that argument for ASA 1-3s in B+B cases which are the vast majority of anesthetics given in this country.

In high acuity cases, CRNAs would be problematic. However, the GLUT of physicians that would train to take those "high acuity cases", which are a very small percentage of anesthetics given, due to an attempt to maintain their previous income, would decrease their salaries as well.

Ergo, the salaries would all decrease to nursing level, which would decrease further due to increased supply of CRNAs, if this really gets off the groud.

Unless you can show from an actuarial basis that CRNA lawsuits are so severe that they negate the "savings" that are provided in the economic analysis provided above, its going to be hard to argue for "MD" only models going forward.

 

[Man o War]

Here's the full article for analysis:

http://www.fsahq.org/wp-content/upl...tiveness-Analysis-of-Anesthesia-Providers.pdf

From a purely dollar/cents perspective, this makes sense.

You can only argue against it if the CRNAs become far more costly due to lawsuits. I am unconvinced of that argument for ASA 1-3s in B+B cases which are the vast majority of anesthetics given in this country.

In high acuity cases, CRNAs would be problematic. However, the GLUT of physicians that would train to take those "high acuity cases", which are a very small percentage of anesthetics given, due to an attempt to maintain their previous income, would decrease their salaries as well.

Ergo, the salaries would all decrease to nursing level, which would decrease further due to increased supply of CRNAs, if this really gets off the groud.

Unless you can show from an actuarial basis that CRNA lawsuits are so severe that they negate the "savings" that are provided in the economic analysis provided above, its going to be hard to argue for "MD" only models going forward.

Would you have surgery with an unsupervised CRNA? I'm healthy, ASA 1. So are my kids and wife. I still wouldn't even consider going under without a doc available. I've seen enough to know that even for my healthy family, there's no way. Keep in mind, patients don't get to pick these folks. You might get the 3 months out of training CRNA mill nurse, or you might get the 25 years of experience ex military nurse. Their competency is so much more varied than a doctor's.

 

[DrCommonSense]

Would you have surgery with an unsupervised CRNA? I'm healthy, ASA 1. So are my kids and wife. I still wouldn't even consider going under without a doc available. I've seen enough to know that even for my healthy family, there's no way. Keep in mind, patients don't get to pick these folks. You might get the 3 months out of training CRNA mill nurse, or you might get the 25 years of experience ex military nurse. Their competency is so much more varied than a doctor's.

Doesn't matter what I would do.

Matters what the bean counters determine coupled with the public's willingness to go along with it.

Do you honestly think the public will fight for MD only anesthesia? The public doesn't know much and think anesthesiologists are mostly nurses anyway. If its sold to the public as "cheaper", it will most likely fly. Kind've like the airlines. Most people complain about the smaller economy seats but are NOT willing to pay for even an upgrade to comfort plus much less first class.

The bean counters will ONLY care if the costs of lawsuits far exceed the cost savings from using far more CRNAs. I am not convinced the lawsuits will be sufficient to overcome the cost differences.

 

[Man o War]

Doesn't matter what I would do.

Matters what the bean counters determine coupled with the public's willingness to go along with it.

Do you honestly think the public will fight for MD only anesthesia? The public doesn't know much and think anesthesiologists are mostly nurses anyway. If its sold to the public as "cheaper", it will most likely fly. Kind've like the airlines. Most people complain about the smaller economy seats but are NOT willing to pay for even an upgrade to comfort plus much less first class.

The bean counters will ONLY care if the costs of lawsuits far exceed the cost savings from using far more CRNAs. I am not convinced the lawsuits will be sufficient to overcome the cost differences.

You and I are patients too, so yes it matters. This is where the ASA is missing the boat. I'm convinced the vast majority of patients wouldn't want an unsupervised CRNA if they were educated and knew the differences like we do. So our job is to educate the public.
I'm also unconvinced that CRNAs are cheaper. Right now most don't take call and expect overtime over 40. The cost difference would be minimal if all of the sudden they take on independent status and are expected to cover what a doc does. I personally know 2 CRNAs who do locums who won't work for less than $200/hour, 40 hour max and then differential kicks in....and they get hired for that. That's not cheaper.

 

[sevoflurane]

Why is the ACT model moving into the Western states that were traditionally only MD if this is so "efficient"?

Here are the CRNA studies showing that "CRNA only" is the most cost effective followed by the ACT model:

Study Shows CRNA-Only Anesthesia Delivery Most Cost Effective

With MANY older docs making money off the ACT coupled with AMCS/VCs, do you honestly think MD only models will hold with a MILITANT AANA?

Good luck.

Did you really just quote an AANA article? Look at the references for both articles = AANA.
As for your other article... you do realize it comes from the JOURNAL OF NURSING ECONOMICS.
Now I have my suspicions about you.

That is the biggest load of crap I have ever seen- and both studies you quoted is old propaganda news. Let me be very clear as an attempt to inform you:

1. One of the articles says that CRNA only anesthesia is cheaper than MD only Anesthesia = Complete BS. Both models bill the same- nurses prolly order more preop tests.
2. 1:1 and 1:2 would NOT save any costs regarding services rendered. In fact, they would loose. 1:3 is a washout. Again, you need to keep in mind CRNA 7-3 schedules, their benefits (now you are paying for a lot more benefits for theses day workers) and then there is scheduling inefficiencies that you typically don't see with an MD only group.
3. This article claims that CRNAs can do the same job as MDs including open heart, pediatrics, etc. So what you are telling me is that you believe a CRNA can sit in a hybrid OR and guide a mitral clip procedure, correctly measure annulus areas or effectively place CVL in a 800 gm premie or complex trauma with major coagulopathy? I call BS on that too. Student nurses just don't get that training. Capiche?
4. The West Coast still is mostly MD model. I don't know where you are getting this idea. In my previous job (midwest), we actually KICKED OUT the CRNAs to transition to MD only practice. The last straw was a FM doc who was getting a fusion that was getting taken care of by a CRNA. Code was called for hypoxia (late) and we immediately found a circuit that was disconnected- patient did fine, but would have died if we did not get there in time. Do these cases get reported on these amazing articles you are quoting? the answer is NO.

Believe what you want. But those AANA articles either have washed out your senses or you are playing for the other team.

Here is a rebuttal from the ASA president at the time.

http://www.fsahq.org/wp-content/upl...Containment-Study-_-Anesthesia-_-Channels.pdf

And I will add that nurse anesthesia would drive up costs due to their inability to have the proper background to know what tests to order and why.

Have fun running 4 rooms all night. When I'm working all night, at least I am doing one case at a time which is infinitely more palatable. Remember, you need to be running at least 1:3-1:4 in order to realize real savings. At 1:1 or 1:2 you are not saving any money whatsoever, especially when you have 2 more available CRNAs that are sitting around doing nothing... you are still paying them salary and benefits.

Just shedding some light here... not being aggressive. But it's this belief system that is getting us all into trouble.

 

[Onefellswoop87]

Doesn't matter what I would do.

Matters what the bean counters determine coupled with the public's willingness to go along with it.

Do you honestly think the public will fight for MD only anesthesia? The public doesn't know much and think anesthesiologists are mostly nurses anyway. If its sold to the public as "cheaper", it will most likely fly. Kind've like the airlines. Most people complain about the smaller economy seats but are NOT willing to pay for even an upgrade to comfort plus much less first class.

The bean counters will ONLY care if the costs of lawsuits far exceed the cost savings from using far more CRNAs. I am not convinced the lawsuits will be sufficient to overcome the cost differences.

Your airline analogy doesn't work. It's easily an extra 50% to my ticket to get another 3 inches of leg room or seat width. But MD or CRNA (or FP vs NP) doesn't change a copay/how much of a deductible people are charged. If the ASA had a better PR campaign that for the same anesthesia fee passed on to most patients from their insurance, would you prefer a doc vs CRNA? Then I bet you'd see a change.

 

[sevoflurane]

My opinion for any new grad?

1) Go to an MD only group and stool sit for some time. Go as a locums even.
2) If you join an ACT model make sure you join a group that owns the CRNAs.
3) Don't ever join a practice where CRNAs work side by side with MDs.

 

[Man o War]

Did you really just quote an AANA article? Look at the references for both articles = AANA.
As for your other article... you do realize it comes from the JOURNAL OF NURSING ECONOMICS.
Now I have my suspicions about you.

That is the biggest load of crap I have ever seen- and both studies you quoted is old propaganda news. Let me be very clear as an attempt to inform you:

1. One of the articles says that CRNA only anesthesia is cheaper than MD only Anesthesia = Complete BS. Both models bill the same- nurses prolly order more preop tests.
2. 1:1 and 1:2 would NOT save any costs regarding services rendered. In fact, they would loose. 1:3 is a washout. Again, you need to keep in mind CRNA 7-3 schedules, their benefits (now you are paying for a lot more benefits for theses day workers) and then there is scheduling inefficiencies that you typically don't see with an MD only group.
3. This article claims that CRNAs can do the same job as MDs including open heart, pediatrics, etc. So what you are telling me is that you believe a CRNA can sit in a hybrid OR and guide a mitral clip procedure, correctly measure annulus areas or effectively place CVL in a 800 gm premie or complex trauma with major coagulopathy? I call BS on that too. Student nurses just don't get that training. Capiche?
4. The West Coast still is mostly MD model. I don't know where you are getting this idea. In my previous job (midwest), we actually KICKED OUT the CRNAs to transition to MD only practice. The last straw was a FM doc who was getting a fusion that was getting taken care of by a CRNA. Code was called for hypoxia (late) and we immediately found a circuit that was disconnected- patient did fine, but would have died if we did not get there in time. Do these cases get reported on these amazing articles you are quoting? the answer is NO.

Believe what you want. But those AANA articles either have washed out your senses or you are playing for the other team.

Here is a rebuttal from the ASA president at the time.

http://www.fsahq.org/wp-content/upl...Containment-Study-_-Anesthesia-_-Channels.pdf

And I will add that nurse anesthesia would drive up costs due to their inability to have the proper background to know what tests to order and why.

Have fun running 4 rooms all night. When I'm working all night, at least I am doing one case at a time which is infinitely more palatable. Remember, you need to be running at least 1:3-1:4 in order to realize real savings. At 1:1 or 1:2 you are not saving any money whatsoever, especially when you have 2 more available CRNAs that are sitting around doing nothing... you are still paying them salary and benefits.

Just shedding some light here... not being aggressive. But it's this belief system that is getting us all into trouble.

Our surgeons here would crap a brick if admin tried to bring CRNAs in. They won't even allow an SRNA training program.
They get what they want, so not a nurse in sight.

 

[DrCommonSense]

Did you really just quote an AANA article? Look at the references for both articles = AANA.
As for your other article... you do realize it comes from the JOURNAL OF NURSING ECONOMICS.
Now I have my suspicions about you.

That is the biggest load of crap I have ever seen- and both studies you quoted is old propaganda news. Let me be very clear as an attempt to inform you:

1. One of the articles says that CRNA only anesthesia is cheaper than MD only Anesthesia = Complete BS. Both models bill the same- nurses prolly order more preop tests.
2. 1:1 and 1:2 would NOT save any costs regarding services rendered. In fact, they would loose. 1:3 is a washout. Again, you need to keep in mind CRNA 7-3 schedules, their benefits (now you are paying for a lot more benefits for theses day workers) and then there is scheduling inefficiencies that you typically don't see with an MD only group.
3. This article claims that CRNAs can do the same job as MDs including open heart, pediatrics, etc. So what you are telling me is that you believe a CRNA can sit in a hybrid OR and guide a mitral clip procedure, correctly measure annulus areas or effectively place CVL in a 800 gm premie or complex trauma with major coagulopathy? I call BS on that too. Student nurses just don't get that training. Capiche?
4. The West Coast still is mostly MD model. I don't know where you are getting this idea. In my previous job (midwest), we actually KICKED OUT the CRNAs to transition to MD only practice. The last straw was a FM doc who was getting a fusion that was getting taken care of by a CRNA. Code was called for hypoxia (late) and we immediately found a circuit that was disconnected- patient did fine, but would have died if we did not get there in time. Do these cases get reported on these amazing articles you are quoting? the answer is NO.

Believe what you want. But those AANA articles either have washed out your senses or you are playing for the other team.

Here is a rebuttal from the ASA president at the time.

http://www.fsahq.org/wp-content/upl...Containment-Study-_-Anesthesia-_-Channels.pdf

And I will add that nurse anesthesia would drive up costs due to their inability to have the proper background to know what tests to order and why.

Have fun running 4 rooms all night. When I'm working all night, at least I am doing one case at a time which is infinitely more palatable. Remember, you need to be running at least 1:3-1:4 in order to realize real savings. At 1:1 or 1:2 you are not saving any money whatsoever, especially when you have 2 more available CRNAs that are sitting around doing nothing... you are still paying them salary and benefits.

Just shedding some light here... not being aggressive. But it's this belief system that is getting us all into trouble.

Sounds like ASA is "endorsing" the care model as well. Here is an article from a prominent anesthesiologist saying that an "MD only model is becoming financially untenable"

The only difference is that ASA wants the CRNAs to be "supervised" under an anesthesiologist specifically while CRNAs want to be independent.

Is there any hope for physician-only anesthesia groups?

I quote the CRNA article because they are using that stuff to sway opinions on the economics of anesthesia. These are being backed by big "consultant" groups and they are pushing this through their PACS relentlessly.

Rebuttals include:

1) CRNA independent model allows AMCs to obtain much of the billing revenue for their "profit" and avoid subsidies for the hospital to pay to maintain anesthesiologist salaries. So CRNAS, AMCS and Hospital CEOs have strong motives to push that.

2) They are not advocating for a 1:1 or 1:2 model, so this point is moot.

3) Those complex cases are less than 5% of total cases. I have already addressed this in previous post. If for >95% the CRNAs can show they can lower the costs after insurance/malpractice risk, they are economically viable

4) I don't do anecdotal discussions. I am speaking about the changing statistical reality throughout the country. MD only models are dying off more than they are growing.

 

[DrCommonSense]

Our surgeons here would crap a brick if admin tried to bring CRNAs in. They won't even allow an SRNA training program.
They get what they want, so not a nurse in sight.

Most places aren't like that

 

[DrCommonSense]

Your airline analogy doesn't work. It's easily an extra 50% to my ticket to get another 3 inches of leg room or seat width. But MD or CRNA (or FP vs NP) doesn't change a copay/how much of a deductible people are charged. If the ASA had a better PR campaign that for the same anesthesia fee passed on to most patients from their insurance, would you prefer a doc vs CRNA? Then I bet you'd see a change.

Good point on pushing that angle.

However, AMCS/Hospital CEOs/VCs and militant CRNAs are all in collusion for their own reasons to push a more CRNA based model for their own profitability benefits.

I wouldn't count on the general public being up in arms if a hospital had 1:8 anesthesiologist to CRNA ratios compared to MD only models if they were told they had no choice. I highly doubt they will travel 500 miles to get a surgery to obtain an MD only anesthetic vs huge coverage ratios in any significant numbers to worry hospital CEOs.

 

[DrCommonSense]

Did you really just quote an AANA article? Look at the references for both articles = AANA.
As for your other article... you do realize it comes from the JOURNAL OF NURSING ECONOMICS.
Now I have my suspicions about you.

That is the biggest load of crap I have ever seen- and both studies you quoted is old propaganda news. Let me be very clear as an attempt to inform you:

1. One of the articles says that CRNA only anesthesia is cheaper than MD only Anesthesia = Complete BS. Both models bill the same- nurses prolly order more preop tests.
2. 1:1 and 1:2 would NOT save any costs regarding services rendered. In fact, they would loose. 1:3 is a washout. Again, you need to keep in mind CRNA 7-3 schedules, their benefits (now you are paying for a lot more benefits for theses day workers) and then there is scheduling inefficiencies that you typically don't see with an MD only group.
3. This article claims that CRNAs can do the same job as MDs including open heart, pediatrics, etc. So what you are telling me is that you believe a CRNA can sit in a hybrid OR and guide a mitral clip procedure, correctly measure annulus areas or effectively place CVL in a 800 gm premie or complex trauma with major coagulopathy? I call BS on that too. Student nurses just don't get that training. Capiche?
4. The West Coast still is mostly MD model. I don't know where you are getting this idea. In my previous job (midwest), we actually KICKED OUT the CRNAs to transition to MD only practice. The last straw was a FM doc who was getting a fusion that was getting taken care of by a CRNA. Code was called for hypoxia (late) and we immediately found a circuit that was disconnected- patient did fine, but would have died if we did not get there in time. Do these cases get reported on these amazing articles you are quoting? the answer is NO.

Believe what you want. But those AANA articles either have washed out your senses or you are playing for the other team.

Here is a rebuttal from the ASA president at the time.

http://www.fsahq.org/wp-content/upl...Containment-Study-_-Anesthesia-_-Channels.pdf

And I will add that nurse anesthesia would drive up costs due to their inability to have the proper background to know what tests to order and why.

Have fun running 4 rooms all night. When I'm working all night, at least I am doing one case at a time which is infinitely more palatable. Remember, you need to be running at least 1:3-1:4 in order to realize real savings. At 1:1 or 1:2 you are not saving any money whatsoever, especially when you have 2 more available CRNAs that are sitting around doing nothing... you are still paying them salary and benefits.

Just shedding some light here... not being aggressive. But it's this belief system that is getting us all into trouble.

Another article for you to read by a Stanford Anesthesiologist:

10 TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

I agree with most of this except that other specialties have it even worse so Anesthesia will remain popular. Not sure about that one.

Also, the notion to take high risk cases that are high malpractice risks for a still lower salary doesn't sound like a great prospect compared to an Internal Medicine Doc that takes care of chronic patients in a clinic if the gradient in salaries isn't much.

 

[deleted171991]

The moment CRNAs gain independence in most states, anesthesia as a medical specialty is done/cooked/toast. We will go from 1:3 to 1:8-10 in 5-10 years, mostly as preop monkeys and firefighters. As long as there is a doc around to bail them out when they do something stupid and to run the hard cases by, they will do just fine as stool sitters. Would I want my brain under their care? I wouldn't, but I am the exception. Does 99% of the population care about their own? Nope. When I tell them their general anesthetic will be under the care of a nurse anesthetist, and I will be present only for the important moments, 99% don't even blink.

There will be a handful of us doing solo cases on ASA 4+ patients, the kind that belong in the ICU not the OR. We will still do most of the procedures for a while, and we will do the highly specialized cases (cardiac, liver transplant etc.). Some of us will work at CRNA hourly rates just to have a job (already happening on the East Coast). In time, fewer and fewer *****s will go into this specialty, and those who do will have the lives of family docs and hospitalists. That won't be a problem, because of technological advances that will supplant us.

It's all about the money. Whatever model will allow the bean counters to make the most money, that's the one that will survive. As tort reform progresses, and malpractice damages become more predictable (because of the caps), there will be less and less incentive to use docs where one could use nurses, while suffering predictable malpractice losses that can be budgeted for (not the many millions of dollars of non-economical damages of the past). That's why the ASA, also known as the American Society of AMCs (academic and for-profit), pushes the ACT model and not the solo anesthesiologist model. But don't forget that ACT can mean even 1:10 in the future.

 

[Carbocation1]

PSH competes for work with Hospitalists who are more ingrained in hospital systems and better at medicine than anesthesiologists. Sad. I was set on gas for a long time, but after several gas rotations and following this forum in depth, I am dropping it in favor of IM/Hospital medicine. MD anesthesia is no longer viable. At least hospitalized patients will always demand a physician, and Hospitalists will stand to benefit with the shift away from FFS towards value/bundled care. Anesthesia has gotten so safe that the nurses are good enough at it in this era of Walmart medicine.

 

[aneftp]

PSH competes for work with Hospitalists who are more ingrained in hospital systems and better at medicine than anesthesiologists. Sad. I was set on gas for a long time, but after several gas rotations and following this forum in depth, I am dropping it in favor of IM/Hospital medicine. MD anesthesia is no longer viable. At least hospitalized patients will always demand a physician, and Hospitalists will stand to benefit with the shift away from FFS towards value/bundled care. Anesthesia has gotten so safe that the nurses are good enough at it in this era of Walmart medicine.

Hmm. U do realize NPs are essentially practice solo at many hospitals. Even the "hospitalist/IM" docs are competing with mid tiers.

Be careful what you say about one speciality.

One hospital got tired of negotiations with private group for night call stipend. Administration just decided to hire their own employed NPs to cover at night. Sure they have to call the MD (who's at home) to "consult" with. But sooner or later those Nps are gonna to go completely solo as well.

So they can't do lines? So what the hospital will have anesthesia or surgeon whoever is on call do the lines for the NPs if they can't do it.

Don't be foolish that IM/hospital medicine is immune from encroachment of mid levels.

 

[Man o War]

PSH competes for work with Hospitalists who are more ingrained in hospital systems and better at medicine than anesthesiologists. Sad. I was set on gas for a long time, but after several gas rotations and following this forum in depth, I am dropping it in favor of IM/Hospital medicine. MD anesthesia is no longer viable. At least hospitalized patients will always demand a physician, and Hospitalists will stand to benefit with the shift away from FFS towards value/bundled care. Anesthesia has gotten so safe that the nurses are good enough at it in this era of Walmart medicine.

So you're afraid of midlevels but are going into hospitalist medicine?
That makes no sense.

 

[DrCommonSense]

The moment CRNAs gain independence in most states, anesthesia as a medical specialty is done/cooked/toast. We will go from 1:3 to 1:8-10 in 5-10 years, mostly as preop monkeys and firefighters. As long as there is a doc around to bail them out when they do something stupid and to run the hard cases by, they will do just fine as stool sitters. Would I want my brain under their care? I wouldn't, but I am the exception. Does 99% of the population care about their own? Nope. When I tell them their general anesthetic will be under the care of a nurse anesthetist, and I will be present only for the important moments, 99% don't even blink.

There will be a handful of us doing solo cases on ASA 4+ patients, the kind that belong in the ICU not the OR. We will still do most of the procedures for a while, and we will do the highly specialized cases (cardiac, liver transplant etc.). Some of us will work at CRNA hourly rates just to have a job (already happening on the East Coast). In time, fewer and fewer *****s will go into this specialty, and those who do will have the lives of family docs and hospitalists. That won't be a problem, because of technological advances that will supplant us.

It's all about the money. Whatever model will allow the bean counters to make the most money, that's the one that will survive. As tort reform progresses, and malpractice damages become more predictable (because of the caps), there will be less and less incentive to use docs where one could use nurses, while suffering predictable malpractice losses that can be budgeted for (not the many millions of dollars of non-economical damages of the past). That's why the ASA, also known as the American Society of AMCs (academic and for-profit), pushes the ACT model and not the solo anesthesiologist model. But don't forget that ACT can mean even 1:10 in the future.

So damn true.

But who the f would want to take the tough cases for a slight premium above nursing salaries with huge increases in risk/stress?

 

[BLADEMDA]

PSH competes for work with Hospitalists who are more ingrained in hospital systems and better at medicine than anesthesiologists. Sad. I was set on gas for a long time, but after several gas rotations and following this forum in depth, I am dropping it in favor of IM/Hospital medicine. MD anesthesia is no longer viable. At least hospitalized patients will always demand a physician, and Hospitalists will stand to benefit with the shift away from FFS towards value/bundled care. Anesthesia has gotten so safe that the nurses are good enough at it in this era of Walmart medicine.

I'm not a big fan of Anesthesiology as a specialty for med students but it is still better than being a hospitalist IMHO.

 

[deleted171991]

Hmm. U do realize NPs are essentially practice solo at many hospitals. Even the "hospitalist/IM" docs are competing with mid tiers.

Be careful what you say about one speciality.

One hospital got tired of negotiations with private group for night call stipend. Administration just decided to hire their own employed NPs to cover at night. Sure they have to call the MD (who's at home) to "consult" with. But sooner or later those Nps are gonna to go completely solo as well.

So they can't do lines? So what the hospital will have anesthesia or surgeon whoever is on call do the lines for the NPs if they can't do it.

Don't be foolish that IM/hospital medicine is immune from encroachment of mid levels.

They do lines. Monkey see, monkey do; it's not rocket science. And even the rocket science can be looked up in a book. Except when moments matter, or extremely complex cases, cookie-cutter medicine will do for most patients (90+%). Dr. APRN + Dr. Google + Dr. Uptodate.

Expect physician salaries and lifestyle to drop in all the specialties where a midlevel can mimic doing the same job. Plus midlevels are getting cheekier in most places, inspired by CRNAs and FNPs, and demand having the same privileges as physicians. And the docs give in, even teach them how to insert lines etc., because most hospitals are either downright run by nurses and/or very protective of them, God forbid to upset anybody with a nursing credential.

 

[DrCommonSense]

They do lines. Monkey see, monkey do; it's not rocket science. And even the rocket science can be looked up in a book. Except when moments matter, or extremely complex cases, cookie-cutter medicine will do for most patients (90+%). Dr. APRN + Dr. Google + Dr. Uptodate.

Expect physician salaries and lifestyle to drop in all the specialties where a midlevel can mimic doing the same job. Plus midlevels are getting cheekier in most places, inspired by CRNAs and FNPs, and demand having the same privileges as physicians. And the docs give in, even teach them how to insert lines etc., because most hospitals are either downright run by nurses and/or very protective of them, God forbid to upset anybody with a nursing credential.

Doctors spend more time trying to attack other specialties/salaries than sticking together too. That is why I have little faith in them sticking together as well as the nurses.

Doctors get jealous of each other and have big egos. This is a terrible combination to form a team approach towards fighting back.

So if some other specialty or sub-specialty gets crushed, they will be on board.

You honestly think the surgeons or IM guys care if the Anesthesiologists get crushed?

Hell, half the Anesthesiologists will screw each other over and attack each other on top of it.

 

[sevoflurane]

Another article for you to read by a Stanford Anesthesiologist:

10 TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

I agree with most of this except that other specialties have it even worse so Anesthesia will remain popular. Not sure about that one.

Also, the notion to take high risk cases that are high malpractice risks for a still lower salary doesn't sound like a great prospect compared to an Internal Medicine Doc that takes care of chronic patients in a clinic if the gradient in salaries isn't much.

I've read this article in the past. Because it's written by an academic anesthesiologist, it really doesn't mean anything to me.
In fact, they have the worst view of the actual landscape as they sit in their academic departments and continue to oversupply the market with both anesthesiologists and CRNAs.

I will say that I like the baby boomers and the demand for anesthesia angle.

The whole suggamadex being cost prohibitive is absolutely false. I don't even use glyco/neo for 90% of my cases. It costs just about the same.

Anyways, sorry you all are so unhappy with your jobs.

 

[sevoflurane]

The sky has been falling for the last 20 years... and yet... here we are.

Do what makes you happy and the rest will follow.

 

[deleted171991]

The sky has been falling for the last 20 years... and yet... here we are.

Do what makes you happy and the rest will follow.

Absolutely agree with the latter.

When I interviewed for anesthesiology residency about 10 years ago, I remember being asked about the CRNA "danger". I was totally uninformed back then, plus I couldn't care less. Anesthesia was the best thing since sliced bread and I was excited just thinking about practicing it, like most wide-eyed applicants here.

When I started my residency, there were maybe 5 CRNAs in our department, plus a few travelers. By the time I graduated, the number had swollen to about 50. Now there are like 100+.

When I started my residency, most cases were done by residents, and a few by solo docs or medically directed CRNAs. By the time I finished, solo docs were extremely rare, mostly 1:2 CRNA coverage (the hospital had grown). Nowadays, I hear they are pushing for 1:3 for financial reasons (that's in academia, not PP).

Where I did my residency, some attendings' attitude was "if the CRNA doesn't like the plan, she can just f off". In many current PP jobs (in my area), the attitude is "if the CRNAs don't like you, you can f off".

Back when I started work after residency, I was paid better on an hourly basis in an academic job than I am today in PP. Same market. Both jobs/pays considered standard for the area.

The list can continue. One thing is certain: the sky is falling. It's happening slowly, but steadily (and visibly accelerating). Please stop implying that we are whining idiots. Let's talk in 3-5 years, once your AMC honeymoon is over.

 

[Southpaw]

No doubt the practice environment can and will change. Departments that stretch docs farther and farther for the sake of more CRNAs are inherently inefficient. I believe they made that choice long ago, and are likely blind to their own reality of inefficiency. CRNAs are very expensive regardless of what the AANA would have you believe. Consider the salary and benefits package for a set schedule of 40 hours. Want them to work more? Pay them overtime rates. It's a really nice job considering their training and years of input.

While the bean counters may be short sighted and dismissive, the reality is that you can get MD only care cheaper than a fat, inefficient department full of CRNAs.

My practice is MD only with no stipend from the hospital. We cost them nothing. No salaries, no benefits, no headaches. Is my practice rare? Yes, but it doesn't have to be.

 

[Southpaw]

@Carbocation1 i have no problem with you not choosing this field out of midlevel fear. But choosing IM/hospital medicine is incredibly short sighted. If you don't want to worry about midlevel creep, ever, choose surgery. Far as I can tell, surgery is the only field of medicine that has protected itself against the onslaught of midlevels.

 

[sevoflurane]

Absolutely agree with the latter.

When I interviewed for anesthesiology residency about 10 years ago, I remember being asked about the CRNA "danger". I was totally uninformed back then, plus I couldn't care less. Anesthesia was the best thing since sliced bread and I was excited just thinking about practicing it, like most wide-eyed applicants here.

When I started my residency, there were maybe 5 CRNAs in our department, plus a few travelers. By the time I graduated, the number had swollen to about 50. Now there are like 100+.

When I started my residency, most cases were done by residents, and a few by solo docs or medically directed CRNAs. By the time I finished, solo docs were extremely rare, mostly 1:2 CRNA coverage (the hospital had grown). Nowadays, I hear they are pushing for 1:3 for financial reasons (that's in academia, not PP).

Where I did my residency, some attending' attitude was "if the CRNA doesn't like the plan, she can just f off". In many current PP jobs (in my area), the attitude is "if the CRNAs don't like you, you can f off".

Back when I started work after residency, I was paid better on an hourly basis in an academic job than I am today in PP. Same market. Both jobs/pays considered standard for the area.

The list can continue. One thing is certain: the sky is falling. It's happening slowly, but steadily (and visibly accelerating). Please stop implying that we are whining idiots. Let's talk in 3-5 years, once your AMC honeymoon is over.

I don't think you or anyone else is a whining idiot- those are your words. You def. sing the far side of the discussion though and that's fine.
Good context to hear everyones perspective. This forum has always been an open mic... so go for it.
You do sound angry. Probably angry at your current situation I would imagine. Probably had a bad set of cards dealt to you and it has left a bad taste in your life. IDK. So question...?

Why don't you move out? It sounds grinding. You might find that your outlook isn't as caustic if you tried something else.

The changes that are happening to all of us isn't just in anesthesia. You know this. It's the entire health care field that is morphing.

And honestly, you are def. looking at the wrong groups if this is what you are getting ---> "if the CRNAs don't like you, you can F' off"
I mean really? Do you really think CRNAs are THAT powerful? Forget THAT. That is the weakest sauce I've heard in a while. Why even bother with something like that? Just find an MD practice and don't worry about that crap.

Here is the deal and why I still have a positive outlook on anesthesiology:

I left the midwest and looked all over the West Coast- this was just 3 years ago.
Found tons of great gigs. Offered jobs at all of them.
All were MD-only. And heck, I was interviewing for an anesthesia position. It was fun meeting all these groups of great set of dudes-- that were happy.
I know a lot of people out here that have amazing jobs in great places. No CRNAs. This is fact and I'm not talking about a handful of groups.

If you are not happy get out man. It's that simple and all I can really tell you.
The Sky isn't crashing down despite what you may think. The landscape is ALWAYS going to be changing- always has (today, 5 years ago, 15 years ago, 20 years ago- always changing).

Rise above it. Change with it and figure it out.
Try something new. You'll never know any different otherwise.
No need to waste this life. It's here for the taking.

Been on this forum for 14 years. These discussions are not new.

 

[Southpaw]

Great post, Sevo. I understand that life can lock you into to certain locales (wife, kids, etc.). But no one should be miserable with their career. Everyone has worked
too hard for too long to be here. Some of you who deal with the CRNA nonsense sound absolutely miserable. Come on, don't live like that. Make a change.

 

[deleted171991]

@sevoflurane:
I am not angry at all. I am disillusioned. I only get angry when people treat me like some idiot.

My opinions may sound on the far side to you, and that's fine. I just live next to Mordor and I am telling you that I can see from here that Sauron is back, and sooner or later his armies will reach your beautiful Shire, too. My area went from no AMC to 50+% AMC (for non-academic jobs) in less than 5 years.

Thank you for the advice and the long post.

 

[sevoflurane]

@sevoflurane:
I am not angry at all. I am disillusioned. I only get angry when people treat me like some idiot.

My opinions may sound on the far side to you, and that's fine. I just live next to Mordor and I am telling you that I can see from here that Sauron is back, and sooner or later his armies will reach your beautiful Shire, too. My area went from no AMC to 50+% AMC (for non-academic jobs) in less than 5 years.

Thank you for the advice and the long post.

I feel you man. You are a smart dude no doubt. Remember I'm on YOUR side 100% of the time.
Work with me on this CRNA issue and get to safe haven.
Slowly but surely we will defend our fortress.

 

[sevoflurane]

It's really a pitty. I honestly wouldn't mind working with the non-millitant ones.

The problem for me isn't specific CRNAs but the AANA and their propaganda machine. The cat is out of the box.

They have literally shut out a lot of good potential CRNAs that don't share their millitant beliefs from great practices. Shame on the AANA.

Therefore, they have shot themselves in the foot and we are now all proping up AA's as much as possible.

 

[GravelRider]

PSH competes for work with Hospitalists who are more ingrained in hospital systems and better at medicine than anesthesiologists. Sad. I was set on gas for a long time, but after several gas rotations and following this forum in depth, I am dropping it in favor of IM/Hospital medicine. MD anesthesia is no longer viable. At least hospitalized patients will always demand a physician, and Hospitalists will stand to benefit with the shift away from FFS towards value/bundled care. Anesthesia has gotten so safe that the nurses are good enough at it in this era of Walmart medicine.

As someone who was an internist/hospitalist before anesthesia, I would tell you to be careful about planning for the hospitalist route. I think internal medicine is a better option than anesthesia, but you need to do subspecialty training as well. Internal medicine opens up a lot more doors than anesthesia, but the hospitalist route leads to a lot of burnout. There is also plenty of midlevel encroachment in hospitalist medicine. Most of the people I know who became hospitalists saw it as a stepping stone to something non-clinical...administration, teaching, etc. There is also a lot of turnover in many hospitalist departments. Most are staffed by people who will eventually do a fellowship. I can go on and on and on about all of the problems with hospitalist medicine. I think primary care is a better option these days compared to hospitalist medicine. I have a couple of friends from residency who are pretty happy in their primary care practices.

There are challenges in almost every specialty of medicine now. Internal medicine is a good option because of all of the doors it opens for you, but go into it knowing that it's not all rainbows and sunshine either.

 

[GravelRider]

Something doesn't quite add up in these discussions of MD only anesthesia vs ACT model. If the MD model can be more cost effective and more efficient than an ACT model then why is the overwhelming majority of practices in the population centers of the east coast the ACT model? We keep talking about the fact that part of the reason for lower compensation on the east coast is the fact that there is essentially an oversupply of anesthesiologists who want to live and work there? Then why not go to all MD models on the east coast if it is so efficient?

All things being equal in terms of workload, call schedule, etc...I know for a fact that I would prefer to do my own cases over supervising CRNAs. It is my honest opinion that a big factor in CRNA spread is frankly laziness and skill atrophy. I saw it in attendings during residency and I see it in older anesthesiologists now. There are plenty of exceptions, of course. However, there is a significant portion of anesthesiologists who would rather be watching Fox News in the lounge than "stool sitting." There are plenty of anesthesiologists who defer clinical judgment to CRNAs or give them a wide range of latitude in clinical decision making. Essentially, there are a lot of anesthesiologists who take a pretty "hands-off" approach to working with CRNAs. I think our specialty needs to take a hard look at itself if it wants to put up any sort of significant fight against the AANA or to simply justify its existence if it comes to that in the future.

I know the majority of the people reading this or participating in the discussions on this board likely do not fall into the previously mentioned category. The simple fact that you read and participate in discussions about anesthesia in your spare time likely means that you care about your career and the direction of this profession more than some others. There are constant discussions on here about lesser trained professions claiming similar expertise and lack of respect from physicians, patients, and administrators. Unfortunately, I think that some of those troubles have been "earned," so to speak.