Interesting perspective by ASA president, Dr. Lema

[EtherMD]

This is a straightforward question, not an editorial: did I miss it, or did Dr. Lema not cover AAs in the powerpoint (find link in the first post of this thread)?

NO mention of AA's at all by Lema. Nothing said good or bad. No mention of more AA programs or even the existence of AA's. Clearly an oversight and a major one at that.

In the movie "Field of Dreams" Kevin Costner is told "build it and they will come." This same theory applies to new AA programs and licensure issues in all States. AA's are currently licensed in 16 states but COULD be licensed in many more if the ASA does the following:

1. Encourage at least THREE teaching hospitals and Medical Schools to start an AA program per State. Don't wait any longer- just start them.

2. After they graduate hundreds of new AA's go to the State legislature and demand practice rights. The AA's will have trained right along side Residents and CRNA's. They will gain the support of many of the legislators who were not interested in AA practice rights previously.

3. North Carolina is the perfect test state. UNC, Duke and Wake Forest all have medical schools and teaching hospitals. They could produce 60 new AA's per year each. That is a lot of manpower coming from just three schools. Then, go battle the AANA (again) at the State level. The AANA defeated the bill to allow AA licensure last year.

4. Florida- the ASA/AAAA won a tough battle two years ago for AA licensure. Now is the time for at least 2-3 more programs to open in the State. Along with NOVA University, the Medical Schools ALL need to start AA programs. UF, USF and UM (not to mention FIU and UCF which have new medical schools opening next year) all have medical schools and all need AA programs. UM and USF currently have CRNA programs.

If the ASA can just get the above things going NOW the AANA will realize how serious the ASA is about fighting back. The AANA will finally notice we are doing something constructive about the militant position of "independent" CRNA practice. We could get a Mid-Level Provider without the threat of independent practice and loss of job security.

The current level of AA's inthe USA is a trickle in the marketplace. That could and should change with a massive surge by the ASA. This war with the AANA is "winnable" if we are interested in fighting back. Right now, most of us are content to use the existing structure of CRNA's to staff the operating room. However, the AA model is proven in the State of Georgia and works just as well. Again, the soultion to the CRNA problem can be peaceful by getting the AANA to back of its militant stance about Independent CRNA practice or it can be bloody by backing the creation of DOZENS more AA programs. But, the window of opportunity for fighting the AANA won't remain open forever. So, it comes down to the greed and complacency of our leadership and academic programs: Will they act and will it be soon enough?
Probably not.

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[CremeSickle]

Ahhh you forget a very important part of the equation.

MONEY.

If we increase MD/DO output then not only are the cuts going to decrease our income but so too will competition from our own peers. When Anesthesiology only pays a physician 180-200 will many people enter the specialty? Of course not. Look at family practice as an example of where we would be.

Why?

Cause over 3/4 of the people in my residency program make no bones about the fact that they are in this for the 'Sit on the stool kick back without a pager and rake in the big bucks work easy hours and no holidays' (LIFESTYLE) reputation that anesthesia has been labeled with by OUR OWN PROFESSION. I had a couple of colleagues in other residencies joke with me that Anesthesiologists aren't "real" doctors or are second rate ones at best. Now they may be kidding, but that perception is certainly a reality amongst many physicians.

I had a discussion with a surgeon and he said straight up "You will have it easy, sit on your butt all day and make 300K". Had another tell me he thought i was pretty "bright" so why did i choose to go into anesthesia?

Really, there is alot of fault to be laid at the feet of our own organization and specialty for our current predicament. Reading Dr. Lema's statement I see this translation "We have alot of people who don't care about our specialty but want to reap all the benefits without doing any of the work".

So true.

I've loosely caught up to this thread. Here's my concern. There is a fair amount of conjecture about what is *going* to happen. The few facts I can grasp onto include the need for more surgeries in the future, and the decreased training time for CRNAs, v. MDs. So, if residency programs across the country are cut, and in the near future it is determined that there is now a woeful shortage of MDs, who do you think will pick up the slack? Of course the mid-levels. To me, we would have thus put the nails in our own coffins. I know this will be seen as short-sighted, but I feel that the AANA only gains power when there are less anesthesiologists to fight.

It seems a little early to me to resign ourselves to mid-level supervisors. I understand we've been losing a long PR battle, but I just feel like bad things have been done in the past in the name of "job security"

 

[Bertelman]

Ahhh you forget a very important part of the equation.

MONEY.

If we increase MD/DO output then not only are the cuts going to decrease our income but so too will competition from our own peers. When Anesthesiology only pays a physician 180-200 will many people enter the specialty? Of course not. Look at family practice as an example of where we would be.

I certainly agree that much of the current interest in Anesthesia is from a population that wants to make money w/o work. That's sad, but it is reflelcted in other specialties as well. I'm not necessarily advocating an INCREASE in the number of residency spots, although that seems to have been happening slowly over the last few years. I still see this as

More anesthestics to provide - less MDs to provide them = more CRNA's

 

[EtherMD]

I've loosely caught up to this thread. Here's my concern. There is a fair amount of conjecture about what is *going* to happen. The few facts I can grasp onto include the need for more surgeries in the future, and the decreased training time for CRNAs, v. MDs. So, if residency programs across the country are cut, and in the near future it is determined that there is now a woeful shortage of MDs, who do you think will pick up the slack? Of course the mid-levels. To me, we would have thus put the nails in our own coffins. I know this will be seen as short-sighted, but I feel that the AANA only gains power when there are less anesthesiologists to fight.

It seems a little early to me to resign ourselves to mid-level supervisors. I understand we've been losing a long PR battle, but I just feel like bad things have been done in the past in the name of "job security"

The day of the MDA being able to afford to relax and do one case is coming to an end. The President of the ASA is predicting it and so am I. Economics will force you to supervise 5 or 6 rooms. Economics will dictate that you use a Mid-Level Provider during the day. At night and the weekend (depending on your practice) the MDA will be more involved personally with the delivery of the anesthetic. With Medicare becoming the predominant payer (it already is in my area) you will make $180,000 per year GROSS (40 hours per week) by doing your own Anesthesia. Perhaps, with a hospital subsidy you can make more.

But, what will happen once the Private Payers join in the bloodletting? How will minimal subsidied practices (like the ones in the West) survive as MDA only?

Examine the facts: On Long Island the average private payer reimburses an MDA at SIX times Medicare!! In my practice (SouthEast) private payers reimburse me at THREE and HAlf MEDICARE RATES! However, in my practice the private payers only make up about 10% of the payer mix. So, even a drastic reduction by private payers can be compensated by fighting with my hospital administrators for a SMALL increase in subsidy.

The All MDA model is possible if we are willing to reduce our incomes substantially (about $275,000). This reduction of income does not come with a reduction in work or responsibility as the average work week will remain at 52 hours for this money (private practice). But, at this level of income MDA's are competitive with CRNA's and are a viable alternative.

However, a better approach to the problem is what I have already posted:

1. Reduce the number of programs/positions by 20%

2. Open new AA programs in large numbers

3. Increase the value of Board Certification by listing Perioperative Physician, Critical Care, Basic TEE, etc. Mandate one Fellowship Year with Board Eligibilty in that subspecialty after the year.

With these three changes we can win. We can ensure job security and a shot a good Physician level income. Think about it.

 

[EtherMD]

I certainly agree that much of the current interest in Anesthesia is from a population that wants to make money w/o work. That's sad, but it is reflelcted in other specialties as well. I'm not necessarily advocating an INCREASE in the number of residency spots, although that seems to have been happening slowly over the last few years. I still see this as

More anesthestics to provide - less MDs to provide them = more CRNA's[/QUOTE

Wrong. Check your math. Answer= more AA's which results in MORE job security. See previous posts for description/explanation.

 

[Bertelman]

Somehow I still believe this proposed solution is attemtping to maintain the salary status quo while depending on a circuitous route with too many factors outside our control. Like increasing # of AAs while somehow keeping CRNAs stagnant. Then believing AAs will be content with their position, never trying to wrangle control like CRNAs are doing.

I just feel that increasing the number of midlevels only proves to the public that our services don't require an MD to perform. Once we have ceded that point, I think things go downhill fast. Sure, you'll probably say things are headed in that direction already, but somehow I just believe there is another solution. I'd prefer further discussions on that as opposed to a political rallying cry to change our own training output, since we have clearly failed to control other outside factors. I view it as a sign of weakness.

 

[johankriek]

I certainly agree that much of the current interest in Anesthesia is from a population that wants to make money w/o work. That's sad, but it is reflelcted in other specialties as well. I'm not necessarily advocating an INCREASE in the number of residency spots, although that seems to have been happening slowly over the last few years. I still see this as

More anesthestics to provide - less MDs to provide them = more CRNA's

stop attacking those who are choosing anesthesia now.. they did not create this mess. It is the guyss 10-20 years ago who created this mess. And the residency now is 4 years long, back in the day it was 2 years. So i would submit that the graduates of today have worked harder for what they have, have to assimilate more information and take more rigorous exams and deal with more bureacracy and red tape than ever before. It is not the problem of the graduates today that have created this problem. They inherited it.

 

[johankriek]

The All MDA model is possible if we are willing to reduce our incomes substantially (about $275,000).

you are out of touch.. what do you mean reduce our income? How much do you think the average anesthesiologists makes? the above number is where many many anesthesiologists are year after year..

 

[Darwin]

Ether,

You have undoubdetly spent a lot of time thinking about the issues, and the ASA certainly needs more individuals like you. It is entirely irrelevant if people agree or disagree with what you have to say, the important issue is that you have an opinion and are clearly passionate about it. Please don't take this the wrong way (I appreciate your passionate stance, and I am respectful of your seniority and experience), but do you direct an equal amount of energy towards those in the ASA who can actually make a difference? You may make a difference and elighten a few individuals here, but I fear that by the time the average reader of this forum is practicing (and certainly if your predictions hold true), it will be too late. My questions are...do you hold a leadership position in the ASA? Are you in contact with the leaders? If so, in what ways? What ways have worked for you, and what ways haven't?

I don't intend this line of questioning to be a challenge...just wondering how to effectively become an advocate and play my part in controlling the future of my chosen career.

 

[EtherMD]

Somehow I still believe this proposed solution is attemtping to maintain the salary status quo while depending on a circuitous route with too many factors outside our control. Like increasing # of AAs while somehow keeping CRNAs stagnant. Then believing AAs will be content with their position, never trying to wrangle control like CRNAs are doing.

I just feel that increasing the number of midlevels only proves to the public that our services don't require an MD to perform. Once we have ceded that point, I think things go downhill fast. Sure, you'll probably say things are headed in that direction already, but somehow I just believe there is another solution. I'd prefer further discussions on that as opposed to a political rallying cry to change our own training output, since we have clearly failed to control other outside factors. I view it as a sign of weakness.

I appreciate your opinion. I don't pretend to have all the definitive answers to our (ASA/MDA's) problems but I know one thing: the course we are on is not working. Medicare is telling the specialty we are worth the same as a CRNA. Is this the message you want to hear? I would rather die fighting than sitting on my Anesthetic stool and do nothing.

Please examine my points one by one and look at the "down-side" of each one.

1. Reduction of Spots- This may lead to a shortage of Anesthesiologists in a few years. CRNA's will rise up and fill the shortage. I got news for you. They are already doing that and Lema is predicting more Solo practices. CRNA's are cheaper than MDA's and always will be. We can't compete on price alone and need to emphasize our skills and benefits when dealing with the complex patient. Hence, a few less MDA's doing ASA 1 and ASA 2 patients won't hurt the specialty. I view the risk of a 20% reduction as "low" with the potential benefit as "high." Opinions?

2. Increase the AA Programs- Along with number 1 comes number 2 so not all the additional mid-level providers are CRNA's. There is NO RISK to us from AA's as they work under MDA supervision. You can bet your life savings that the AANA will NEVER allow another MId-Level Provider to practice Independently. The SOLO practice issue is the BIGGEST reason why the ASA and AANA don't get along. The AANA will fight to keep the AA's out of the Anesthesia business altogeher. The AANA views the AAAA as its number one threat. The risk to the ASA/MDA is ZERO on this issue. Unfortunately, our prdecessors did not stand up to the solo practice issue twenty years ago.
The AANA is slowly winning the battle for Independent Practice. We must respond with a surge of AA programs.

3. Increase the value of the Certificate- The risk to the ASA/MDA is zero on this one as well. The only thing a better certificate means to the Physician Anesthesiologist is more opportunity and a legal way of distinguishing oneself from the local Nurse Anesthetist. Advanced training as a Critical Care, Perioperative Physician plus SUBSPECIALIST in one area (Pain, Cardiac, Peds, etc.) only validates the specialty as much, much more than Anesthetists.
This shows the government, hospitals and private payers we have value as Physicians beyond simple dial turners. We really need number THREE badly and right now.

My three points are only suggestions for making an effort to help the specialty. They address Mark Lema's lecture and provide an avenue for us to pursue.

The answer is not business as usual. The answer is not the standard certificate with the same number of graduates. Either cut the spots back as I suggest or ramp-up the numbers by 50% so we have the graduates to provide one on one Anesthesia. I believe that more is not better and will lead to us becoming the Family Practice Doctors of the Anesthesia world.

Apathy is so prevelant among the specialty that we only respond to issues as needed (crisis mode mentality). Well, the crisis really is coming in Anesthesia and I hope you are prepared for it. Our window to do anything meaningful to save the specialty is still open. For how much longer is anyone's guess.

One more thing: Your Program Directors do not spend enough time (if any ) on these issues. Instead, your consultant certificate in Anesthesiology is going to make you an expensive CRNA in ten years. The Nurse Anesthetists and the AANA are whipping our butts while academia discusses only ANESTHESIA CASES with the Residents. Ridiculous and dangerous.
Where are the lessons on economics and the AANA? They do you a great disservice by pretending its business as usual when in ten years the President of the ASA is predicting "doom and gloom" for the specialty.

You must begin to discuss these topics in your Programs. The Chairpersons along with the ASA have the power to save the specialty (or at least try).
As usual, it is up to those with the least power and money (Residents and Fellows) to make the most impact. But, remember you also have the most to lose economically.

 

[EtherMD]

you are out of touch.. what do you mean reduce our income? How much do you think the average anesthesiologists makes? the above number is where many many anesthesiologists are year after year..

Average Private Practice MDA makes around $375,000 plus benefits. Average Academic attending makes $230,000 plus benefits.

I know MDA's who make $100,000 and some who make $850,000. There is a wide range depending on practice and location.

 

[Bertelman]

stop attacking those who are choosing anesthesia now.. they did not create this mess. It is the guyss 10-20 years ago who created this mess. And the residency now is 4 years long, back in the day it was 2 years. So i would submit that the graduates of today have worked harder for what they have, have to assimilate more information and take more rigorous exams and deal with more bureacracy and red tape than ever before. It is not the problem of the graduates today that have created this problem. They inherited it.

I'm not really attacking anyone, and I'm certainly not about to assign blame for a problem I scarcely understand. I'm just saying it is very clear when you hear someone say "I'm thinking Rads, Ophtho or Gas" where their true motivation lies. My point in making the statement is not to blame anyone for anything, certainly not those currently entering the residency (of which I will hopefully be one in 5 weeks). I made the statement to establish some level of agreeance with Ether on his comments.

I'm all for letting the market determine the needs instead of practicing self-mutilation in the hopes that we can regenerate a few limbs down the road. All this talk reminds me of the scene from Holy Grail. "Come back and fight", as we get limbs chopped off in succession, but in this scenario we're the ones doing the chopping. So my salary drops to $250. Boo-Hoo. Maybe then the ones who perceive anesthesia as a cash cow will move on to greener pastures. In my eyes, the quickest (and most foolish) way to ensure the redefinition of our future is to decrease the number of graduates. I'd rather stick around and fight the good fight to ensure the sustenance of our future than to concede the future of anesthesiology to mid-levels. If it eventually happens, fine. The end game is the same. But to be the driving force that makes it happen just seems too Chicken Little.

 

[militarymd]

FMLA applies to employers and employees, but a partner in a partnership is not an employee. I don't know for sure, but I'll bet it wouldn't apply to partners.

Partners are also employees....Depending on what type of corporation your business is....partners ...in general just means that you have part ownership of that corporation.....and usually the partner is also an employee ...if you are going to get paid with a W-2

If you are an owner/partner...but don't have to be paid with a W-2 then.. you could be NOT an employee....

Different depending on the type of corporation/business arrangement you have set up.

But bottom line.....in a small business...trying to provide medical services (covering anesthetizing locations)....if you have a member who stops working...for whatever reason....it becomes a hardship on the remaining workers.........which can lead to breaches of contract....which are reasons that lead hospitals to want to choose AMC's

 

[EtherMD]

I'm not really attacking anyone, and I'm certainly not about to assign blame for a problem I scarcely understand. I'm just saying it is very clear when you hear someone say "I'm thinking Rads, Ophtho or Gas" where their true motivation lies. My point in making the statement is not to blame anyone for anything, certainly not those currently entering the residency (of which I will hopefully be one in 5 weeks). I made the statement to establish some level of agreeance with Ether on his comments.

I'm all for letting the market determine the needs instead of practicing self-mutilation in the hopes that we can regenerate a few limbs down the road. All this talk reminds me of the scene from Holy Grail. "Come back and fight", as we get limbs chopped off in succession, but in this scenario we're the ones doing the chopping. So my salary drops to $250. Boo-Hoo. Maybe then the ones who perceive anesthesia as a cash cow will move on to greener pastures. In my eyes, the quickest (and most foolish) way to ensure the redefinition of our future is to decrease the number of graduates. I'd rather stick around and fight the good fight to ensure the sustenance of our future than to concede the future of anesthesiology to mid-levels. If it eventually happens, fine. The end game is the same. But to be the driving force that makes it happen just seems too Chicken Little.

No problem. This is what I expect will happen as the marketplace always has the final say on the subject. But, you do realize that inaction is a response to a problem. By deciding to do nothing and allowing the status quo you are making a decision. That is, you agree that CRNA's pose no threat to your practice in the future and that current numbers of new graduates is the correct amount.

I respectfully disagree with this approach but do understand it is what the leadership has decided for the response to the AANA: do nothing and hold the line.

Fine. But, even LEMA thinks that this results in our eventual demise as primary solo anesthetists. In the end, the decision to make changes belongs as much to the new batch of MDA's (those in training and just out) as anyone else. Most of the senior guys are protected from market forces to a degree. It is the new generation that will be impacted the most.

So, if you are happy making 20% more than a CRNA so be it. Too bad , because with good leadership and effective changes (like those I have listed) you would do much, much better.

Based on your response future Medical School Graduates will need to choose another specialty to earn real Physician income and believe me they will- in droves.

 

[Bertelman]

Ether,

I can understand how my post was perceived as apathy. That's not what I'm condoning. By "fight the good fight", I was implying we should actually act to maintain our current position. Whatever that takes. Take action so that reimbursements can remain at a reasonable level. Actually DO something in the court of public opinion to ensure we are perceived as the standard of care. I'm not suggesting apathy, just a different course of action.

I have ultimate respect for Dr. Lema and his position, but I'm not sure we should jump on a bandwagon of action merely because it is an action, compared to years of stagnation. I fully appreciate the encroachment of midlevels, and have seen it occur recently at my former employer.

I still don't buy into the last statement that future doctors will have to choose other specialties to make real money. Seriously, from what I have heard a salary of, say, $250 is a 40% cut from what a lot are making. I'd be happy with it, and it is most certainly above the national average for physicians, which is probably closer to $150. I can appreciate that current practicing anesthesiologists will take a substantial hit. Thus, I'm confounded that they refuse to be part of the solution, and instead choose to drastically reduce future colleagues to maintain their own identities.

I respectfully disagree with the assertion that the obligation of ensuring our future should be as dependent on sacrifices made by current grads and soon-to-be residents. I think it's shameful that it has to be that way, and an unfortunately typical attitude in this country, including the current state of Medicare and SS. Govt subsidies for Viagra? Are you effing kidding me? The "I got mine" attitude of this country can be appalling at times. How about the current leaders and elders of the profession step up and act like they care about the future of our profession and give the future leaders some inspiration instead of the burden of change. Let's search for a solution that doesn't include cannibalizing our own.

 

[EtherMD]

Ether,

I can understand how my post was perceived as apathy. That's not what I'm condoning. By "fight the good fight", I was implying we should actually act to maintain our current position. Whatever that takes. Take action so that reimbursements can remain at a reasonable level. Actually DO something in the court of public opinion to ensure we are perceived as the standard of care. I'm not suggesting apathy, just a different course of action.

I have ultimate respect for Dr. Lema and his position, but I'm not sure we should jump on a bandwagon of action merely because it is an action, compared to years of stagnation. I fully appreciate the encroachment of midlevels, and have seen it occur recently at my former employer.

I still don't buy into the last statement that future doctors will have to choose other specialties to make real money. Seriously, from what I have heard a salary of, say, $250 is a 40% cut from what a lot are making. I'd be happy with it, and it is most certainly above the national average for physicians, which is probably closer to $150. I can appreciate that current practicing anesthesiologists will take a substantial hit. Thus, I'm confounded that they refuse to be part of the solution, and instead choose to drastically reduce future colleagues to maintain their own identities.

I respectfully disagree with the assertion that the obligation of ensuring our future should be as dependent on sacrifices made by current grads and soon-to-be residents. I think it's shameful that it has to be that way, and an unfortunately typical attitude in this country, including the current state of Medicare and SS. Govt subsidies for Viagra? Are you effing kidding me? The "I got mine" attitude of this country can be appalling at times. How about the current leaders and elders of the profession step up and act like they care about the future of our profession and give the future leaders some inspiration instead of the burden of change. Let's search for a solution that doesn't include cannibalizing our own.

As a medical student you really don't grasp the full impact of my posts. Nor, do you understand the lesson history has already taught us in Anesthesia about too many providers (read my post about the mid 1990's). LESS IS MORE Sometimes when the law of suppy and demand is in play. Currently, the rate of new graduates is based on a certain percentage doing solo cases in the near future. If this does not happen and the solo market dries up what does that do to supply? Yes, you guessed it. The market place drops everyone's salary. Providers can pick us apart and Academic centers will feast on you.

You don't realize the financial implications of your strategy and the potential impact on new graduates' income levels. The only way to ensure the law of supply vs. demand works in your favor is by limiting the supply. The Mid-Levels are not the number one threat to the specialty: Medicare reimbursement holds that spot.

You have yet to address my points 2 and 3. AA's pose no threat to MDA's and a better certificate means more street credibility. My point three addresses the "public perception" about MDA's with more teeth to your certificate other than "consultant in Anesthesiology" which the AANA claims its membership can do as well. I know Medicare will take care of number one (the number of new graduates) sooner or later: it is simple economics. Your ability to bargain with private payers and hospitals will be severely curtailed by an "abundance" of young, new graduates looking for work.

As for the best and brightest choosing another field I can guarantee that; they always go where the money is- simple economics.

 

[EtherMD]

Anesthesiologists with decades of experience have a lot less to lose than new graduates if Lema's predictions are correct (which I believe they are).

We are well-established in the hospital and have long established relationships with surgeons. Who do you think bears the greatest burden of an over-supply of new graduates? Look to the Mid 1990's for the answer: new graduates.

I am less concerned about my future ability to weather any storm than yours!
New graduates will feel the pain FIRST of the ASA and academic leadership's mistakes. Once the law of Supply vs. Demand is violated and the programs start pumping out too many new gradutes who suffers the most? Who has to suffer the most through the correction? Who has to find work at CRNA pay? Who has to fight with CRNA "only" Groups for contracts that were previously viewed as "poor" by senior MDA's?

So, go ahead and "fight the good fight" and pump out all those new graduates. But, you won't be able to fight the law of supply vs. demand for very long: simple economics.

Medicare has determined what a case is worth regardless of whether an MDA or a CRNA does it. That value is CRNA level pay (maybe 90% of customary CRNA pay). Is this what you are "fighting the good fight" for? If not, then wise up and realize your future value as a Physician is per Dr. Lema's lecture: As a supervisor and Perioperative Consultant.

As for Medicare and the government coming to the rescue of Anesthesiology by "correcting the relative value scale" of our specialty, you must be kidding. The more likely scenario is the one described by Lema: Private Payers refusing to pay more than 120-150%. Who do you think is going to pay the difference so you can earn that $250,000 salary? The hospital provided that there are not hundreds of new graduates who will work for less.

 

[Bertelman]

As a medical student you really don't grasp the full impact of my posts. Nor, do you understand the lesson history has already taught us in Anesthesia about too many providers (read my post about the mid 1990's). LESS IS MORE Sometimes when the law of suppy and demand is in play. Currently, the rate of new graduates is based on a certain percentage doing solo cases in the near future. If this does not happen and the solo market dries up what does that do to supply? Yes, you guessed it. The market place drops everyone's salary. Providers can pick us apart and Academic centers will feast on you.

My main point is that if the solo market does not dry up, we have sealed our fate by decreasing grads while embracing mid-levels. I can't say anyone here can predict the future with accuracy any better than the prognosticators of the 80's, 90's or any other time.

I really do understand your perspective, and I believe that it is a viable solution to the problem. I just don't think it's the only solution. My posts are not meant to challenge each point you present. Much of what you say makes sense economically. I just feel like some of us who are entering the field are tired of hearing about the problems we are inheriting. It seems the attitudes of those who actually have had the power to change this for the last couple decades is to place the burden on us. Thanks, guys.

btw, it may be early, but I plan to complete a fellowship precisely to ensure a little job security and marketability. I acknowledge the problem at hand.

 

[MacGyver]

1) If MDAs are really going to concede 90% of general surgery coverage to CRNAs, you need a much larger slash than 20% to your residency programs. Try more like an 80% cut.

2) I fail to see how all these new certs in "perioperative, TEE, critical care, etc" are going to mitigate the midlevel threat. Is medicare going to start reimbursing you guys at high rates to make up for all the OR business you have conceded to CRNAs?

3) You are naive to assume that CRNAs wont be successful in getting OR coverage for the more complex cases. If you're already giving them all ASA 1/2 right now, then 20 years from now be prepared to start giving up ASA 3/4 cases too.

4) CRNAs already brag about providing 70% of all gas coverage in the states. If you give up all the "routine" cases to them, they'll have even more ammo in their propaganda campaign. When they start putting out ad campaigns claiming that they provide 90% of all gas in the USA, state legislatures will be even more tempted to give them coverage of the remaining 10%. They will effectively own anesthesia if you just give up the bread/butter stuff that makes up the overwhelming majority of cases.

5) I always laugh when i hear people putting out AAs as the solution. You are incredibly naive if you think AAs wont want autonomy just like the CRNAs do. Dont give me that crap that AAs are "controlled" by doctors either. Thats true only because the state legislatures have so far allowed that. But they could very easily strike any "supervisory" language and allow AAs to go solo. Dont think the AAs wont push for it either. Maybe not now, but give it 15 years and then come back and talk to me. I bet you'll see a big push for AA independence.

Every year, the "supervision" rules for PAs get more and more lax. It will be the same for AAs. First it was direct chart review and on-site MD req taken away. Now some states dont require any chart review whatsoever and only a 30 minute meeting with the MD ONCE A FREAKING YEAR! Lets face it guys, PA "supervision" is an absolute sham. It will be the same for AAs over time.

Why do I always have to straighten you guys out around here? THERE IS NO MIDLEVEL GROUP INCLUDING PAS THAT HAS BEEN SATISFIED WITH THEIR CURRENT SCOPE OF PRACTICE AND NOT SOUGHT TO GAIN AUTONOMY.

 

[Bertelman]

I am less concerned about my future ability to weather any storm than yours!
New graduates will feel the pain FIRST of the ASA and academic leadership's mistakes. Once the law of Supply vs. Demand is violated and the programs start pumping out too many new gradutes who suffers the most? Who has to suffer the most through the correction? Who has to find work at CRNA pay? Who has to fight with CRNA "only" Groups for contracts that were previously viewed as "poor" by senior MDA's?

So, go ahead and "fight the good fight" and pump out all those new graduates. But, you won't be able to fight the law of supply vs. demand for very long: simple economics.

Medicare has determined what a case is worth regardless of whether an MDA or a CRNA does it. That value is CRNA level pay (maybe 90% of customary CRNA pay). Is this what you are "fighting the good fight" for? If not, then wise up and realize your future value as a Physician is per Dr. Lema's lecture: As a supervisor and Perioperative Consultant.

As for Medicare and the government coming to the rescue of Anesthesiology by "correcting the relative value scale" of our specialty, you must be kidding. The more likely scenario is the one described by Lema: Private Payers refusing to pay more than 120-150%. Who do you think is going to pay the difference so you can earn that $250,000 salary? The hospital provided that there are not hundreds of new graduates who will work for less.

This is precisely the attitude I am referring to. "I've got mine, you can pick up the scraps!" It seems your main motivation for these changes is to ensure your own future, at our expense. Don't be surprised if we greet this proposal with suspicion.

And the contradiction in your above post is your own job security. If the market is truly flooded with new grads chomping at the bit to make a few bucks, guess whose contract will suffer- yours. If we let the market determine demand, it's the lowest bidder that will win. Right now, it's not the old guard anesthesia groups. It could be the new gen of grads that are willing to work for less because they don't know any better. You'd prefer it be mid-levels. You are actually championing your OWN job security, while directing me to become something your generation has refused to accept.

No thanks. I'd rather take my chances and rely on my own competitive nature for survival.

 

[johankriek]

3. Increase the value of the Certificate- The risk to the ASA/MDA is zero on this one as well. The only thing a better certificate means to the Physician Anesthesiologist is more opportunity and a legal way of distinguishing oneself from the local Nurse Anesthetist. Advanced training as a Critical Care, Perioperative Physician plus SUBSPECIALIST in one area (Pain, Cardiac, Peds, etc.) only validates the specialty as much, much more than Anesthetists.
This shows the government, hospitals and private payers we have value as Physicians beyond simple dial turners. We really need number THREE badly and right now.

.

are you kidding me? are you for real? As if I have to distinguish myself from a CRNA on any level. there is no comparison what i bring to the OR with what a CRNA brings to the OR. If you think you need a cardiac pain or critical care fellowship to distinguish yourself from a crna you need to re evaluate yourself as a physician. so what do you propose.. One more Year of training mandatory. go home my friend.. give it up. go back to your office and think again. more time in indentured servitude. while loans are racking interest. actually the banks would love you..

the answer is ONe anesthesiologist, one patient.. point blank.. simple isnt it? you hire crnas for stuff like what i use my anesthesia tech for( awesome) Put on monitors size up the lma.. tape the ivs, that kind of thing.. pump out more and more anesthesiologists. try to push out the old "****s early to put this specialty back on track..
CRNAs arent as cheap as you think.. I know plenty of physicians who would work for the pay they make..

 

[jwk]

1)

5) I always laugh when i hear people putting out AAs as the solution. You are incredibly naive if you think AAs wont want autonomy just like the CRNAs do. Dont give me that crap that AAs are "controlled" by doctors either. Thats true only because the state legislatures have so far allowed that. But they could very easily strike any "supervisory" language and allow AAs to go solo. Dont think the AAs wont push for it either. Maybe not now, but give it 15 years and then come back and talk to me. I bet you'll see a big push for AA independence.

Every year, the "supervision" rules for PAs get more and more lax. It will be the same for AAs. First it was direct chart review and on-site MD req taken away. Now some states dont require any chart review whatsoever and only a 30 minute meeting with the MD ONCE A FREAKING YEAR! Lets face it guys, PA "supervision" is an absolute sham. It will be the same for AAs over time.

Why do I always have to straighten you guys out around here? THERE IS NO MIDLEVEL GROUP INCLUDING PAS THAT HAS BEEN SATISFIED WITH THEIR CURRENT SCOPE OF PRACTICE AND NOT SOUGHT TO GAIN AUTONOMY.

I've been an AA for almost 30 years. Our profession is committed to the anesthesia care team mode of practice. Always has been - always will. Your assertion that we will seek independent practice is based on a lack of knowledge about AA's. There has never been a proposal at the federal or state level, or within our own professional organization, to seek independent practice.

We have no illusions that we have the breadth of medical knowledge that physicians do. As so many of you are so fond of saying, "if you want to be a doctor, go to medical school".

PA supervision laws may have become more lax over the years, but laws governing AA practice certainly have not. In fact, it's tighter now than it was 25 years ago - a group I rotated through as a student had 2 anesthesiologists directing as many as 16 anesthetists (AA and CRNA) at one time. That doesn't happen anymore.

 

[CremeSickle]

Ok Johan

How are you going to prove what you just said in front of congress when we are defending our turf? Thats correct, you wont be able to. By the way, they wont be taking your 'word for it'.

are you kidding me? are you for real? As if I have to distinguish myself from a CRNA on any level. there is no comparison what i bring to the OR with what a CRNA brings to the OR. If you think you need a cardiac pain or critical care fellowship to distinguish yourself from a crna you need to re evaluate yourself as a physician. so what do you propose.. One more Year of training mandatory. go home my friend.. give it up. go back to your office and think again. more time in indentured servitude. while loans are racking interest. actually the banks would love you..

the answer is ONe anesthesiologist, one patient.. point blank.. simple isnt it? you hire crnas for stuff like what i use my anesthesia tech for( awesome) Put on monitors size up the lma.. tape the ivs, that kind of thing.. pump out more and more anesthesiologists. try to push out the old "****s early to put this specialty back on track..
CRNAs arent as cheap as you think.. I know plenty of physicians who would work for the pay they make..

 

[CremeSickle]

Sorry jwk

As i remember we (the USA) said the same thing to Great Britain.

Just b/c your organization isnt doing it now dosent mean that wont be the direction in the future. I think its a huge possibility then we have TWO organizations to fight.

AAs are not the answer but im not sure what is.

I've been an AA for almost 30 years. Our profession is committed to the anesthesia care team mode of practice. Always has been - always will. Your assertion that we will seek independent practice is based on a lack of knowledge about AA's. There has never been a proposal at the federal or state level, or within our own professional organization, to seek independent practice.

We have no illusions that we have the breadth of medical knowledge that physicians do. As so many of you are so fond of saying, "if you want to be a doctor, go to medical school".

PA supervision laws may have become more lax over the years, but laws governing AA practice certainly have not. In fact, it's tighter now than it was 25 years ago - a group I rotated through as a student had 2 anesthesiologists directing as many as 16 anesthetists (AA and CRNA) at one time. That doesn't happen anymore.

 

[EtherMD]

are you kidding me? are you for real? As if I have to distinguish myself from a CRNA on any level. there is no comparison what i bring to the OR with what a CRNA brings to the OR. If you think you need a cardiac pain or critical care fellowship to distinguish yourself from a crna you need to re evaluate yourself as a physician. so what do you propose.. One more Year of training mandatory. go home my friend.. give it up. go back to your office and think again. more time in indentured servitude. while loans are racking interest. actually the banks would love you..

the answer is ONe anesthesiologist, one patient.. point blank.. simple isnt it? you hire crnas for stuff like what i use my anesthesia tech for( awesome) Put on monitors size up the lma.. tape the ivs, that kind of thing.. pump out more and more anesthesiologists. try to push out the old "****s early to put this specialty back on track..
CRNAs arent as cheap as you think.. I know plenty of physicians who would work for the pay they make..

Legitimate response and opinion. The ASA and Programs are doing just that; pumping out as many new graduates as possible. They are pursuing your strategy but I think it is the wrong approach. In about 5-10 years (maybe less) we will find out who is right.

But, the CRNA's are not going away and are planning a surge of their own. Hopefully, with the aging baby boomers there is room enough for everyone.
Remember, the market place will have the final say on this one and Medicare is a key player here. So, it doesn't look good for the ASA economically.

Your anger towards point three puzzles me. My desire for a better certificate can only help new graduates compete with the old farts and CRNA's. An enhanced certificate with subspecialty certification can only make one look better in front of the surgeons and hospital administrators. It is foolish not to do everything in today's world to legally distinguish one's self from the competition (both older MDA's and CRNA's). I understand your pain about student loans and the desire to end the slavery called Residency as soon as possible but the current certificate is "weak" and should be more substantial.

Currently, Medicare pays a solo CRNA vs. YOU the same amount for doing a case. This means the government dores not VALUE your services more than a Nurse Anesthetist. Uncle Sam is very clear on this issue and if the private payers join this payment level what does that make you? An MDA working for CRNA pay.

The creation of more AA programs would be beneficial. The AANA will never allow AA's to practice independently. The AANA fights to keep AA's from being licensed in each state (recently defeated a bill to allow licensure in North Carolina). There is NO threat for independent practice here.

I would like to remind you that Dr. Lema's lecture started this thread and it was him (The President of the ASA) that predicted the death of "solo" MDA cases. For your sake, I hope he is wrong.

 

[EtherMD]

1) If MDAs are really going to concede 90% of general surgery coverage to CRNAs, you need a much larger slash than 20% to your residency programs. Try more like an 80% cut.

2) I fail to see how all these new certs in "perioperative, TEE, critical care, etc" are going to mitigate the midlevel threat. Is medicare going to start reimbursing you guys at high rates to make up for all the OR business you have conceded to CRNAs?

3) You are naive to assume that CRNAs wont be successful in getting OR coverage for the more complex cases. If you're already giving them all ASA 1/2 right now, then 20 years from now be prepared to start giving up ASA 3/4 cases too.

4) CRNAs already brag about providing 70% of all gas coverage in the states. If you give up all the "routine" cases to them, they'll have even more ammo in their propaganda campaign. When they start putting out ad campaigns claiming that they provide 90% of all gas in the USA, state legislatures will be even more tempted to give them coverage of the remaining 10%. They will effectively own anesthesia if you just give up the bread/butter stuff that makes up the overwhelming majority of cases.

5) I always laugh when i hear people putting out AAs as the solution. You are incredibly naive if you think AAs wont want autonomy just like the CRNAs do. Dont give me that crap that AAs are "controlled" by doctors either. Thats true only because the state legislatures have so far allowed that. But they could very easily strike any "supervisory" language and allow AAs to go solo. Dont think the AAs wont push for it either. Maybe not now, but give it 15 years and then come back and talk to me. I bet you'll see a big push for AA independence.

Every year, the "supervision" rules for PAs get more and more lax. It will be the same for AAs. First it was direct chart review and on-site MD req taken away. Now some states dont require any chart review whatsoever and only a 30 minute meeting with the MD ONCE A FREAKING YEAR! Lets face it guys, PA "supervision" is an absolute sham. It will be the same for AAs over time.

Why do I always have to straighten you guys out around here? THERE IS NO MIDLEVEL GROUP INCLUDING PAS THAT HAS BEEN SATISFIED WITH THEIR CURRENT SCOPE OF PRACTICE AND NOT SOUGHT TO GAIN AUTONOMY.

Anesthesia is very different than Family Practice. CRNA independent practice should never have been allowed and is unfair to the patient. Anesthesia is the practice of Medicine as we use the most potent agents known to man. A hundred years ago Nurses used open drop Ether but things have drastically changed in the modern era.

Because of the Acute nature of the field most CRNA's are glad to have an MDA around for input and help. Most appreciate the problems (including death) that can occur from a routine anesthetic. This is much different than your average office visit.

A 20% Reduction in Graduates should be enough. With the increasing baby boomer population and complexity of cases the law of supply vs, demand would remain in force with this reduction. In the late 1990's the Specialty got the number of new Graduates right. All we have to do is use those numbers as a guide for the next decade.

As for "conceding" cases to the CRNA's I don't beileve that; I believe every patient deserves to have a Physician supervising their care in case anything goes wrong. But, what I did say is that CRNA's can handle the ASA 1 and ASA 2 patient easily. Morally, I firmly believe Anesthesia is the practice of MEdicine and the AANA has used politics to gain through lesgislation what its membership did not earn through education. "Solo" CRNA practice is the main issue I have with the AANA and I oppose it completely. If a CRNA or AA wants to practice ACUTE MEDICINE in the operating room a Medical degree should be required.

However, the AANA has convinced our legislators that a Physician Anesthesiologist is not needed and that CRNA's are "equivalent" providers.
Thus, they have achieved complete Independent Practice rights in 16 states and only need a dentist to supervise them in the others. That said, the ASA must continue to fight this issue each and every time it comes up. Regardless of the outcome, on prinicipal alone the ASA needs to fight Independent CRNA practice until there is no State left to fight for. CRNA's should not practice Independent of an Anesthesiologist; our patients deserve better.

The fact that Mid-Level providers are used in the operating room like surgical technicians are used by surgeons does not mean they should have the right to do the procedure solo. Thus, AA's represent a realstic return to the role of the true Mid-Level Provider in the operating room. By not having enough AA's in the market place MDA's must hire CRNA's to staff the operating rooms.
This feeds the AANA's militant stance even more.

The ASA has a wondow of opportunity to help start more AA programs. This will serve "notice" to the AANA that the ASA is serious about doing battle over the Independent provider issue. The AANA will be furious about new AA programs as they know most of their members work for and/or under an MDA.
This means the 5-10% of their membership that actually works "solo" come secondary to the rest who work in the ACT model.

If the AAAA (AA's political arm) is Great Britain then the AANA is Russia.
Which one do you want to rely on? Which one will turn on you the first chance it gets?

 

[apellous]

Ether,

I think you couldnt be more right on these issues. What we need is plan. How are we going to get these acedemic centers/medical schools to start AA training programs. I am a resident at Indiana and this is the PERFECT place for an AA program. This is a huge program that needs more residents and already has like 80. There are no CRNA programs here(or in the state) and this is the perfect time to act. I have talked with members of the faculty about it, but what really need to happen is to have a someone with much more knowlegde than me come here and pitch the concept to the chair/dean. Have the AAAA come here and pressent all the info to the faculty; how this will help our profession,the department, and residency porgram.

I really think giving us the ability to choose our mid-levels gives us a huge advantage in keeping control of our profession. We are the ones who control the majority of the hospital contracts and the administrators are going to what to keep us around for big cases and emergencies. If CRNAs know we can replace them they are less likely to pi$$ us off politically. When I am in practice I would hire 100% AAs if it was posible. Has an intern I had very bad experiences with Crnas and very good ones with AAs.

Hope it turns out that there is an increase in AA programs. most of my friends in residencies thoughout the country feel similar to me with regard to the CRNAs and would like to see the AA programs expand.

 

[badgas]

I have a question and please forgive me if it is stupid. Why don't physicians in general band together and refuse medicare and insurance all together unless they pay what we bill? Auto insurance pays the full bill to mechanics... why do we settle for taking whatever they feel like paying?

 

[militarymd]

I have a question and please forgive me if it is stupid. Why don't physicians in general band together and refuse medicare and insurance all together unless they pay what we bill? Auto insurance pays the full bill to mechanics... why do we settle for taking whatever they feel like paying?

Auto insurance doesn't always pay the full bill.....Certain insurances require you to go to certain body shops....why? Pre-negotiated rates.

There's always someone who will low bid you....that's business....

or we could go the way of Canada....or U.S.S.R. where everyone bills and gets paid the same.

 

[badgas]

Auto insurance doesn't always pay the full bill.....Certain insurances require you to go to certain body shops....why? Pre-negotiated rates.

There's always someone who will low bid you....that's business....

or we could go the way of Canada....or U.S.S.R. where everyone bills and gets paid the same.

My question was more along the lines of why we can't join together and refuse to let medicare and insurance companies dictate our salaries. They can not force us to practice however they need our services. We have control over the supply, so why don't we use that to increase the demand? In the long run, I think it would force the midlevels to prove how trained they truly are, which would wake the government up a bit. This would increase salaries, improve patient care and put the crnas back where they belong. Just my thought.

 

[militarymd]

My question was more along the lines of why we can't join together and refuse to let medicare and insurance companies dictate our salaries. They can not force us to practice however they need our services. We have control over the supply, so why don't we use that to increase the demand? In the long run, I think it would force the midlevels to prove how trained they truly are, which would wake the government up a bit. This would increase salaries, improve patient care and put the crnas back where they belong. Just my thought.

OK...here is a hypothetical situation for you.

You are a new grad...just wrote a $1,000.00 check to the ABA to enter the board certification process.

You have $400,000 in debt from college, medical school, and residency.

Your 10 year old car just broke down ..needs a new timing beltcost $800.00

Your wife is 8 1/2 month pregnant...cost of health insurance $700.00/month

Rent for your crappy apartment...$600.00/month.

Your choices:

1) hold the high road...work for full reimbursement or not at all.

2) take medicare...

btw...I'm not going to be giving you a loan...the local bank will ..but at prime plus 3 points.

What are you going to do?

 

[badgas]

OK...here is a hypothetical situation for you.

You are a new grad...just wrote a $1,000.00 check to the ABA to enter the board certification process.

You have $400,000 in debt from college, medical school, and residency.

Your 10 year old car just broke down ..needs a new timing beltcost $800.00

Your wife is 8 1/2 month pregnant...cost of health insurance $700.00/month

Rent for your crappy apartment...$600.00/month.

Your choices:

1) hold the high road...work for full reimbursement or not at all.

2) take medicare...

btw...I'm not going to be giving you a loan...the local bank will ..but at prime plus 3 points.

What are you going to do?

I'm not saying just me. I'm saying everyone. A one month hold out would stir things up quite a bit I would think.

 

[militarymd]

I'm not saying just me. I'm saying everyone. A one month hold out would stir things up quite a bit I would think.

and then.......business as usual.

What you propose is EXTREMELY unlikely to happen.

The majority of people live beyond their means. People have expected cash flows....money in....money out....Most people are NOT willing to disrupt this flow of cash.

I know BC physicians who essentially live paycheck to paycheck.....think about that...people making hundreds of thousands of dollars....living paycheck to paycheck....now imagine disrupting that cash flow.....BIG impact

Unions....strikes....stuff like that....will NOT likely work.

 

[apellous]

Rather than argue about unrealistic strikes and union. How can we increase the number of AA programs in this country and allow anesthesiologist the opprotunity to hire a mid-level that is not tring to stab them in the chest.

EtherMD how do we go forward with the plan to increase AA programs. JKW you have been in the AA business for years how do we move forward.

 

[CremeSickle]

Ok here is what I dont get

We add more AAs (whos intentions I dont trust anymore than CRNAs).

Now as we increase the AAs we have a future of 10-1 supervision as seen by lema.

I dont see how that increases anesthesiologists or pay. We are STILL giving up anesthesia to someone else and clearly saying we arent needed to do it.

 

[Bertelman]

Ok here is what I dont get

We add more AAs (whos intentions I dont trust anymore than CRNAs).

Now as we increase the AAs we have a future of 10-1 supervision as seen by lema.

I dont see how that increases anesthesiologists or pay. We are STILL giving up anesthesia to someone else and clearly saying we arent needed to do it.

 

[EtherMD]

Ok here is what I dont get

We add more AAs (whos intentions I dont trust anymore than CRNAs).

Now as we increase the AAs we have a future of 10-1 supervision as seen by lema.

I dont see how that increases anesthesiologists or pay. We are STILL giving up anesthesia to someone else and clearly saying we arent needed to do it.

Lema's 10:1 ratio is absurd. More likely 5 or 6:1 ratio. We have had 4:1 ratio for decades so a move to 5/6 to 1 is a major increase.

THe AAAA is on good terms with the ASA. THe AAAA and AA's would band together on supervision requirements and reimbursement. Not so with the AANA. They prefer to go their own way. The AANA views MDA's as unnecessary and a hinderance to their membership. The AAAA views the ASA and the MDA as Captain of the Anesthesia ship.

With the AAAA you get job security for decades if not longer. With the AANA you get daily battles over INdependent Practice and "equivalence" in the operating room. With the AAAA you get a Master's level assistant. With the AANA you get wannabe Doctors looking to require DNP/PhD for its new members in a few years. This is to confuse the public even more by claiming its members are DOCTORS of Anesthesia.

Clearly, the ASA needs to get moving on new AA programs. The window of opportunity to fight the AANA will only be open so much longer. Sorry, but without a surge of new AA programs SOON the AANA will win the propoganda
battle with the public. Ladies and Gentlemen, we are LOSING the war against the AANA. Our backs are up against the proverbial wall so the AAAA is best option and our only option.

If you want job security or even a job at all your choice is simple:

1. Do nothing- I guarantee the AANA wins the war. MDA's will be too expensive for basic anesthetics. Instead, we will function as back-up in a tertiary care setting. Many of us will be forced to work for CRNA income as there will be too many supervisors looking for work.

2. Fight Back Now- MY points 2 and 3 in a previous post address how. Back the AA's the ONLY Mid-Level Provider who acknowledges OFFICIALLY you are needed in the operating room. THe time has come for a vigorous defense of the specialty against the AANA. The AAAA is the ANSWER to effectively counter the AANA. Point 3 relates to "beefing-up" your basic certificate and requiring one fellowship prior to graduating training. As I have explained every Resident is eligible for certification in at least two subspecialty areas after PGY-5. This makes you much more than a "consultant in basic Anesthesia."

I still believe a reduction in the number of graduates to the level of the late 1990's would be good for you. The market would pay you better and you would remain in demand.

So, how do we get started on these issues? Why not start a web site devoted to the issue? Why not mobilize Residents and Fellows to champion the cause? All you need is someone to start a campaign and get contributions. Someone to make the ASA and academic chairs take notice that the next generation does not want to be the last generation of Anesthesiologists. Perhaps, a senior Resident or ASA member along with the President of the AAAA could get the campaign off the ground.

Lema needs to realize that the AAAA is part of the solution and not part of the problem. Can someone e-mail him and ask him to think about the issue?
One more thing, the issues being discussed are just as important to your career and success (more so in my opinion) than any case you will ever hear about or do.

 

[EtherMD]

Not True. We are saying that Anesthesia is the Practice of Medicine. As such, an Anesthesiologist is required to be the main provider or supervisor of the Anesthetic.

It is the AANA who states YOU are not needed in the O.R. It is the AANA that wants to produce Doctors of Nurse Anesthesia so the lines are blurred even more to the average joe on the street.

Mid-Level Providers are a fact of USA Anesthesia. You will not eliminate the Mid-level Provider but you can CHOOSE which one you prefer. The choice is yours but by doing NOTHING you are choosing the status quo: AANA
I guarantee you will regret that decision.

 

[Duckie24]

Lema needs to realize that the AAAA is part of the solution and not part of the problem. Can someone e-mail him and ask him to think about the issue?

I think you would be a great person to do this. Your posts in this thread have been very intelligent, well-argued, and most of all you seem to be not only passionate about this issue but have also developed an action plan to present to him.

 

[EtherMD]

I think you would be a great person to do this. Your posts in this thread have been very intelligent, well-argued, and most of all you seem to be not only passionate about this issue but have also developed an action plan to present to him.

Is there a Resident or Fellow at his Program that could politely ask him to read these posts? After all, he is Chairman of an Academic Program and President of the ASA so this issue should be of concern to him.

Any Resident or Fellow out there that can ask him?

 

[militarymd]

Is there a Resident or Fellow at his Program that could politely ask him to read these posts? After all, he is Chairman of an Academic Program and President of the ASA so this issue should be of concern to him.

Any Resident or Fellow out there that can ask him?

Here's his e-mail address: [email protected]

Why don't you e-mail him?

 

[johankriek]

Anesthesia is very different than Family Practice. CRNA independent practice should never have been allowed and is unfair to the patient. Anesthesia is the practice of Medicine as we use the most potent agents known to man. A hundred years ago Nurses used open drop Ether but things have drastically changed in the modern era.

Because of the Acute nature of the field most CRNA's are glad to have an MDA around for input and help. Most appreciate the problems (including death) that can occur from a routine anesthetic. This is much different than your average office visit.

A 20% Reduction in Graduates should be enough. With the increasing baby boomer population and complexity of cases the law of supply vs, demand would remain in force with this reduction. In the late 1990's the Specialty got the number of new Graduates right. All we have to do is use those numbers as a guide for the next decade.

As for "conceding" cases to the CRNA's I don't beileve that; I believe every patient deserves to have a Physician supervising their care in case anything goes wrong. But, what I did say is that CRNA's can handle the ASA 1 and ASA 2 patient easily. Morally, I firmly believe Anesthesia is the practice of MEdicine and the AANA has used politics to gain through lesgislation what its membership did not earn through education. "Solo" CRNA practice is the main issue I have with the AANA and I oppose it completely. If a CRNA or AA wants to practice ACUTE MEDICINE in the operating room a Medical degree should be required.

However, the AANA has convinced our legislators that a Physician Anesthesiologist is not needed and that CRNA's are "equivalent" providers.
Thus, they have achieved complete Independent Practice rights in 16 states and only need a dentist to supervise them in the others. That said, the ASA must continue to fight this issue each and every time it comes up. Regardless of the outcome, on prinicipal alone the ASA needs to fight Independent CRNA practice until there is no State left to fight for. CRNA's should not practice Independent of an Anesthesiologist; our patients deserve better.

The fact that Mid-Level providers are used in the operating room like surgical technicians are used by surgeons does not mean they should have the right to do the procedure solo. Thus, AA's represent a realstic return to the role of the true Mid-Level Provider in the operating room. By not having enough AA's in the market place MDA's must hire CRNA's to staff the operating rooms.
This feeds the AANA's militant stance even more.

The ASA has a wondow of opportunity to help start more AA programs. This will serve "notice" to the AANA that the ASA is serious about doing battle over the Independent provider issue. The AANA will be furious about new AA programs as they know most of their members work for and/or under an MDA.
This means the 5-10% of their membership that actually works "solo" come secondary to the rest who work in the ACT model.

If the AAAA (AA's political arm) is Great Britain then the AANA is Russia.
Which one do you want to rely on? Which one will turn on you the first chance it gets?

I agree with you 1000 percent when you say a crna independent practice is unfair to the patient. All the ASA has to do is educate patients about the fact that you may not have an anesthesiologists available to you. Let them make the decision. Just point out the fact that if they went to facility A, they would have a physician directing care, but if you are here ( facility B, there will be NO doctor directing your anesthetic care and let patients make the decision. I know what I would choose. I concur with you when you say that every patient deserves an anesthesiologist directing care. Period.

I think a four year residency is sufficient to train an anesthesiologist. When i finished. with out a fellowship I was at a hospital where I did hearts everyday for about 6 months. I left that place because they wanted me to take call every single day. The point is I did not do a fellowship. I did not do a fellowhip in OB yet I do OB a lot. I dont need a ICU fellowship. I did almost 8 months of ICU between internship and residency.

 

[johankriek]

Here's his e-mail address: [email protected]

Why don't you e-mail him?

you are going to get in trouble for giving his email address out..

cant wait!!!

 

[militarymd]

you are going to get in trouble for giving his email address out..

cant wait!!!

It is public info.

 

[EtherMD]

I agree with you 1000 percent when you say a crna independent practice is unfair to the patient. All the ASA has to do is educate patients about the fact that you may not have an anesthesiologists available to you. Let them make the decision. Just point out the fact that if they went to facility A, they would have a physician directing care, but if you are here ( facility B, there will be NO doctor directing your anesthetic care and let patients make the decision. I know what I would choose. I concur with you when you say that every patient deserves an anesthesiologist directing care. Period.

I think a four year residency is sufficient to train an anesthesiologist. When i finished. with out a fellowship I was at a hospital where I did hearts everyday for about 6 months. I left that place because they wanted me to take call every single day. The point is I did not do a fellowship. I did not do a fellowhip in OB yet I do OB a lot. I dont need a ICU fellowship. I did almost 8 months of ICU between internship and residency.

This issue is not about you and me. I am not questioning the value experience plays in developing an MDA. Do I need a fellowship after ten thousand OB cases? Or, thousands of Hearts? How about twelve thousand Central lines?

My point is the next generation needs a quality certificate that establishes them as Specialists from day one. If we want the government to pay us more than a CRNA we have to show them a LEGAL reason why we are much more than Anesthetists. What does your Certificate Legally say? It says 'Consultant in Anesthesiology.' You are much, much more than that and this what I am refering to when I say Residents deserve a better certificate after training.

One more year of training won't kill the average Resident. But, what it will do is give IMMEDIATE street credibility to the surgeons, administrators and payers that you are extremely qualified in many areas.

5 years of Post-Graduate Training results in the following certificate with Board eligibility:

1. Consultant in Anesthesiology
2. Basic TEE and U/S
3. Perioperative Physician
4. Critical Care Medicine
5. PGY-5 You pick an area like Cardiac, Pediatrics, Pain Medicine, etc.

Number Five is Your Fellowship year. "Lean and Mean" would be the next generation of MDA's. These MDA's would have a certificate with "teeth."
Anesthesiology has been good to me and I would like it to be good for the next generation as well.

We need to adapt to the world of Medicine or be left behind. Being listed as just a Consultant in Anesthesiology is no longer sufficient.

 

[militarymd]

..............All the ASA has to do is educate patients about the fact that you may not have an anesthesiologists available to you. Let them make the decision. Just point out the fact that if they went to facility A, they would have a physician directing care, but if you are here ( facility B, there will be NO doctor directing your anesthetic care and let patients make the decision. I know what I would choose.................

I don't believe it is as simple as that.

There are Anesthesiologists who I would not allow to direct my anesthetic care (2 comes to mind right now....both from Vanderbilt).....

...at the same time there are many CRNA's who I believe are safer than the said anesthesiologists.

The issues are complex.......We as a group need to take the high road...

less spots....higher quality training...higher quality physicians....and drum out folks like the ones I'm talking about.

 

[johankriek]

I don't believe it is as simple as that.

There are Anesthesiologists who I would not allow to direct my anesthetic care (2 comes to mind right now....both from Vanderbilt).....

...at the same time there are many CRNA's who I believe are safer than the said anesthesiologists.

The issues are complex.......We as a group need to take the high road...

less spots....higher quality training...higher quality physicians....and drum out folks like the ones I'm talking about.

Just because there are some careless anesthesiologists out there doesnt damn the whole specialty. thats just like saying.. the surgeon continually nicks the bowel.. let the nurse practicioner do it.. cmon

but why dont you agree the patients need to make the decision..

 

[militarymd]

Just because there are some careless anesthesiologists out there doesnt damn the whole specialty. thats just like saying.. the surgeon continually nicks the bowel.. let the nurse practicioner do it.. cmon

but why dont you agree the patients need to make the decision..

What I'm saying is that our specialty has a LOT of these people in it....and we need to trim the fat.....

and I agree that patients need to make the decision....unfortuantely, patients are known for making notoriusly bad decisions.

 

[CremeSickle]

EtherMD your killing me here.

Here is tha part of the eq your missing.

Increase AAs = Decrease Anesthesiologists.

As AAs increase and grow they WILL look for independance as EVERY Mid Level has in history.

You seem to pretend like what their website and "bylaws" say now is something etched in stone. This can change like the wind and at a whim from their membership. A-la PAs.

My answer = MORE anesthesiologists, MORE PR, MORE politicing

NO reliance on midlevels to support OUR future

 

[toughlife]

It is strange, I like almost all CRNAs I have met and have never heard any of them espouse the beliefs put forth by the AANA. Do they secretly plot against us or is their leadership that far removed from its core membership's beliefs?

Don't be fooled. In your face they are nice and all. Behind you, they are writing their check to the AANA political action commiittee to screw you over.