I agree with 1-8, but the problem is that every specialty in medicine has this going on in some form or fashion. Some to a greater extent, but everyone is dealing with this. The question shouldn't be whether anesthesia is suffering from increasing administrative pressures, CRNA encroachment, decreasing reimbursement, etc. The question should be whether anesthesia, when compared to the other options in medicine, is a better option than IM+fellowship, EM, surgery sub specialty, derm, family, psych...
From the outside looking in, most of you guys make it sound like anesthesia is completely screwed and no intelligent medical student with other options would be wise to get into the field. My question to all the residents/attendings here is are you really worse off than the other fields of medicine? Because a superficial review of the data shows a field with hours that are about average for most physicians and an income that is among the highest for physicians. The only ding I can find is that job openings aren't as plentiful as they used to be.
I kind of promised myself not to get into this kind of discussions anymore, so I'll make one exception just t0 point out what you seem to be missing here: in most other specialties, you are the man, not his servant.
If this were not a service specialty, one could stand out by just being a great physician, and patients would sooner or later follow. As an anesthesiologist, it's mostly about artistic impression. If you do a great job technically, nobody will know about it (except for you). But have even the slightest expected complication (PONV, sore throat, lip cut etc.), and everybody will. As long as the patient survives unharmed and happy, all that matters is basically how much the surgeon and your boss like you.
One can be a genius technically, but it won't matter unless one has the right (read
sales-type) personality to go with it (and most doctors just don't, whatever they lie to themselves or others about it). It's not about being friendly; it's about bending over backwards, and
convincing the surgeons about your greatness. Success in this specialty is about keeping the surgeons happy, not (just) the patients. And even when the surgeons are happy, it's like when the upstairs masters were happy 100 years ago; if you open your mouth and want a bigger slice of the pie, your masters will just find another (no)body to take your place, regardless of your anesthetic genius. Why? Because
you have zero pull with the patients. I actually had an educated middle-aged patient ask me in the PACU, after a perfect GA, just a few days ago, what exactly I did except for sitting on my butt watching monitors, because it seemed to him that it was no big deal.
New grads are getting pretty bad offers, and it's not just about being exploited as a junior attending. It's the reality of a market where being an employee is the future, where competing with CRNAs for basically the same job is the future, where being just a (no)body is the future. With anesthesia residency mills and CRNA diploma mills producing graduates at a higher rate than what the market can absorb, it's becoming a dog eat dog environment, unless one goes to a BFE location (which will not make one popular with one's family). And there is no sign or hope for improvement. Where do you think this entire delirium with the PSH is coming from? In many places around the country, there are just too many anesthesiologists; either they will either learn how to do some other non-anesthesia crap, or they will move away to a place where almost no man has gone before, or they will eat **** every day, or they will be unemployed. Period. And very few, if any, fellowships will change that outlook, now when every ***** and his grandmother has one. It won't happen tomorrow, maybe not even in 10 years, but I wouldn't bet against it, especially with my career.
Also, if you want lazy administrators taking 40% of what you make and dictating how you practice (including many unsafe ways), then this is for you. Bean counters simply don't care about malpractice risks, because it's included in their budget for "business losses". They will take risks on your license, they will skim all the profits resulting from those risks, but you will be the bad guy in court, and you will be the one on the hook for whatever damages are beyond your coverage limits (not to speak about just having your career destroyed). It's such a joy to be legally responsible for all the crap a bunch of midlevels can do in your absence and without your knowledge. (It's not like they have a well-documented plan to follow, as in internal medicine.) So, if you love playing Russian roulette with your career every single week (if not day) of your life, then this is for you. (See the threads about malpractice in GI procedures, about how one would not survive a day in those jobs without cutting corners. They will apply to more and more anesthesiologists, in more and more clinical settings. You will be told to either get it done, even if risky for the patient, or find another job.)
People love comparing this to what happened to lawyers in the last decades, and how nobody starts as a partner in a law firm, and how one works one's way up to success, but they are missing the big point: we are not like lawyers, we are like paralegals. We are not the rainmakers, the surgeons are. We are (more and more) easily replaceable. The reason we have made a ton of money during the past decades was the anesthesia provider shortage. That's now gone, and it will stay like that. There is absolutely no reason to believe otherwise. Every single year will be worse than the previous, until we stop churning out providers. (Like that will ever happen, with independent CRNAs everywhere, literally specializing to take our place, including getting "doctorates" to smoke and mirror the general public.)
Btw, I do love a bunch of stuff about my job (otherwise I wouldn't keep doing it). But it's like eating grapefruit with sugar, except that there is more and more fruit, and less and less sugar.
Blade is pretty level-headed, and with his hand on the pulse of the (Florida?) market, so if you don't believe me, believe him.