So, bottom line... what is the future of anesthesiology for MDs?

[deleted126335]

I had debated between anesthesia, rads and ortho. Ended up going to ortho, but honestly ortho isn't rainbows and unicorns either. The residency is brutal and the job market isn't as great as advertised either (it's great if you like BFE). Sometimes I wonder if I wouldn't have been more happy and balanced if I went into anesthesia. Ultimately it's a job. Doing anesthesia in BFE and doing ortho in BFE, in the end you're still in BFE shopping at Walmart on the weekend.

If I had to do this again, I think I would have a picked a specialty that sacrificed some money but had better demand in the major cities (like psych or ED).

My game plan is to work 10 years in BFE while the kids are still young and would enjoy the outdoors, make bank, pay off all debt and amass enough savings for a nice house in the coast, and then debate if I still want to work fulltime anymore.

the longer you stay in BFE, the longer you'll stay in BFE.

---

Members don't see this ad.

 

[Jonassen]

the longer you stay in BFE, the longer you'll stay in BFE.

I believe it. But crappy schools for kids means I'll have to get out of BFE at some point, no point in shelling hard earned money for private schools.

 

[pjl]

I believe it. But crappy schools for kids means I'll have to get out of BFE at some point, no point in shelling hard earned money for private schools.

Maybe. Cost of private school for kids =? per year x12 vs increased income x12 years. If the income increase is enough it is financially "worth it." However, that assumes you like the other aspects of your area.
Say for anesthesia if you make 100k more in BFE, that is 50k post tax, and you spend 10k for private school for a few kids that 40k/year adds up, not to mention lower cost of living and less bigger city issues.
Some private schools are worth it for the ability to get away from the "teaching for the test" that goes on in public schools. Public schools arent the same public schools you went to. My family of teachers all encourage not attending public schools with the recent changes. Again, highly dependent on the area.

 

[IlDestriero]

It's funny that you think a good private school for a few kids is only $10k/yr.
In my area, private schools run at least $9000/year and the ones I would want to send my kids to are $30k/yr.

 

[Baller MD]

It's funny that you think a good private school for a few kids is only $10k/yr.
In my area, private schools run at least $9000/year and the ones I would want to send my kids to are $30k/yr.

Isn't it better to just move to a nice area with good public schools? Just curious.

 

[chmd]

Isn't it better to just move to a nice area with good public schools? Just curious.

Semirural areas aren't likely to have posh private schools costing 10-15k/year, and while I get the motivation to move to an urban area for improved schools, it's not coming in the form of free public schooling.

Lastly the difference in pay between the 2 locales is likely closer to 100k/year, plus shorter and surer time to partner, plus lower likelihood of being gobbled up by an AMC.

 

[IlDestriero]

I live in the best public school district in be suburbs, but 30% of the parents in this district still send their kids to private schools. Seems silly to me, but it may be the best choice for some of the kids. I have a friend that has 5 kids in 2 private schools that cost... Take a breath... ~$150k/yr!

 

[chmd]

I live in the best public school district in be suburbs, but 30% of the parents in this district still send their kids to private schools. Seems silly to me, but it may be the best choice for some of the kids. I have a friend that has 5 kids in 2 private schools that cost... Take a breath... ~$150k/yr!

Since one is already paying for public schools via property tax, I'm annoyed that private school tuition can't be deducted.

 

[nimbus]

Semirural areas aren't likely to have posh private schools costing 10-15k/year, and while I get the motivation to move to an urban area for improved schools, it's not coming in the form of free public schoolin.

More like $25-30k in my area. And just like IlD, most of the kids are from the best public school districts. Makes no sense to me either.

 

[jwk]

Hyperbole for sure. We have multiple crnas making greater than 215k for 40 hours/week with 6 weeks vacation. I'd rather do that than similar pay for IM.

Is this paid by a group or a hospital? It's absurd regardless.

 

[IlDestriero]

Is this paid by a group or a hospital? It's absurd regardless.

We don't pay close to that, but I think they get 6 weeks vaca.

 

[pjl]

Private school in BFE is probably closer to 5-10 per year (less than 5 per year for the better one in my small city), not the city cost of private school Of course, the school's private stables are nonexistent.

That guy paying 150k/year is insane...that is 300k income, he must be making crazy money. I would argue differently I am sure if that was my option.

It is funny to me how much you guys pay to live in the city, but then again I am an uncultured hick who prefers to live on a lake over going to a fancy restaurant, or out to a club. That 4000 sq foot lake house costs the same as a modest one bedroom apartment in many cities.

 

[jwk]

We don't pay close to that, but I think they get 6 weeks vaca.

6 weeks vacation doesn't bother me - it's the $215k for a 40hr work week that is friggin crazy.

 

[aneftp]

I live in the best public school district in be suburbs, but 30% of the parents in this district still send their kids to private schools. Seems silly to me, but it may be the best choice for some of the kids. I have a friend that has 5 kids in 2 private schools that cost... Take a breath... ~$150k/yr!

Everyone claims they live in the best public school district in the suburbs. Ha ha.

I used to live in the DC area. Potomac Maryland is a very affluent area and my colleagues were sending their kids to Sidwell (same as Obama kids and Clinton) when Potomac has supposedly the best school district in Maryland. But my brother lives in a different place in Maryland called Clarksville and they supposedly have their best school district.

So many best school districts.

 

[chmd]

6 weeks vacation doesn't bother me - it's the $215k for a 40hr work week that is friggin crazy.

There's a wide range of salary. Some crnas have been w the group for 15 years. Hours per weeks is maybe closer to 50 than 40 though. Still loads of cash.

 

[Jonassen]

Semirural areas aren't likely to have posh private schools costing 10-15k/year, and while I get the motivation to move to an urban area for improved schools, it's not coming in the form of free public schooling.

Most of the affluent suburbs of major metro areas have decent schools; good enough for top 20 colleges with some decent effort on the part of the kids. With three kids, it's a huge savings versus private schools. Money that could be better used for college tuitions. Property taxes in these areas aren't low, but $15k a year on property taxes is still a good deal with 3 kids. I don't get the ones who live in these suburbs and still send their kids to private schools, it's basically double paying.

Some of the inner city magnet schools aren't bad either and are a little bit less homogeneous. And being in BFE may actually be advantageous when the kids are applying for colleges, since most college admissions have a geographic and high school quota system.

Ultimately schools don't matter that much IMO. It's ultimately a parental guilt thing if the kids did turn up lame, knowing that I could have afforded better schools or moved to somewhere with better schools.

 

[deleted126335]

Most of the affluent suburbs of major metro areas have decent schools; good enough for top 20 colleges with some decent effort on the part of the kids. With three kids, it's a huge savings versus private schools. Money that could be better used for college tuitions. Property taxes in these areas aren't low, but $15k a year on property taxes is still a good deal with 3 kids. I don't get the ones who live in these suburbs and still send their kids to private schools, it's basically double paying.

Some of the inner city magnet schools aren't bad either and are a little bit less homogeneous. And being in BFE may actually be advantageous when the kids are applying for colleges, since most college admissions have a geographic and high school quota system.

Ultimately schools don't matter that much IMO. It's ultimately a parental guilt thing if the kids did turn up lame, knowing that I could have afforded better schools or moved to somewhere with better schools.

I disagree somewhat with the above post. I have paid up for private school for my kids since pre-K. Best money that I have ever spent.
All teachers are on one year annually renewable contracts. The public school system has a teacher's union that almost makes it impossible to get rid of a weak or unmotivated teacher. In addition Public schools have state mandated curriculum which is more than occasionally politicized. A disproportionate amount of time is spent on teaching for state mandated competency tests. A disproportionate level of resources are dedicated to special needs kids that the private schools just won't/can't do so they don't even try. There are a lot of parents who struggle to pay the tuition at private school because they value academic achievement, a quality that is lacking in my corner of the world. If my kids went to a Boston Latin or Bronx Science or other public school that required an academic test for entry, I might feel differently.

 

[Carbocation1]

The fact that a nurse makes 6 figures of any kind is totally ridiculous. These people don't know any medicine and don't have the ability to solve problems. They are technicians that are glorified baby sitters for the patients. Why anyone would pay them more than 50-75k blows my mind. The fact that people really believe these clowns will replace board certified anesthesiologists is even funnier. Do you people love the drama of creating a crisis where there isn't one?

Word. I think the reason for all the pessimism is that anesthesiologists are wired to think of the worst case scenario at all times. It's almost as if being pessimistic is a job requirement for being a good anesthesiologist.

 

[aneftp]

Just my opinion. Parental involvement

The fact that a nurse makes 6 figures of any kind is totally ridiculous. These people don't know any medicine and don't have the ability to solve problems. They are technicians that are glorified baby sitters for the patients. Why anyone would pay them more than 50-75k blows my mind. The fact that people really believe these clowns will replace board certified anesthesiologists is even funnier. Do you people love the drama of creating a crisis where there isn't one?

There are a lot of govt workers which barely a high school degree (maybe some community college experience) pushing $100k plus federal benefits as well.

Remember Linda Tripp DEpt of defense "executive secretary" during Clinton scandal. She was making like $90k and this was 1998 salary.

So it's all relative who thinks who's overpaid.

 

[criticalelement]

The fact that a nurse makes 6 figures of any kind is totally ridiculous. These people don't know any medicine and don't have the ability to solve problems. They are technicians that are glorified baby sitters for the patients. Why anyone would pay them more than 50-75k blows my mind. The fact that people really believe these clowns will replace board certified anesthesiologists is even funnier. Do you people love the drama of creating a crisis where there isn't one?

Dude, it's happening all over. The future is grim for anesthesiologists. I think there is a place for us but the cat is out of the bag already. The ASA has dropped the ball. This job with its pay is too risky for the pay that is average.

 

[pgg]

We lived in BFE for 5 years. Kids went to a public charter school that was fantastic. No cost. I knew some people who paid for private schools. I didn't get it.

Now we're back in an area that's somewhere between suburb/rural. Mediocre public schools. When we lived here before, the public elementary school lost its accreditation for a year. It was an odd dynamic. Nice school, good teachers, good resources. Our kids did great for the short time they were there. But something like half the kids were from dirt poor and single parent (or grandparent) families. It seems that a school's test scores suffer when 1/4 of the kids aren't getting breakfast at home. Go figure. Does that make the school bad? Maybe, if the disadvantaged kids take too much of the teachers' focus away from your own kids. The high school here had a worse reputation, so when we came back we put our kids in a private school. It's about $7K per kid per year. Money well spent. There's another private school here with somewhat nicer facilities, to the tune of $18K per kid per year. I'm pretty sure most of that money goes into lawn maintenance, tennis courts, athletic fields, etc because their class sizes aren't smaller. I certainly think diminishing returns kick in well before $18K per kid per year for high school.

My oldest graduates this year and since he's got a full ride scholarship to college, my out-of-pocket school costs will actually go down next year.

 

[Back 5]

As someone who is fascinated with Anesthesiology, this thread is very depressing

 

[Consigliere]

The fact that a nurse makes 6 figures of any kind is totally ridiculous. These people don't know any medicine and don't have the ability to solve problems. They are technicians that are glorified baby sitters for the patients. Why anyone would pay them more than 50-75k blows my mind. The fact that people really believe these clowns will replace board certified anesthesiologists is even funnier. Do you people love the drama of creating a crisis where there isn't one?

It's already happening all across the USA. Sticking your head in the sand and pretending like it doesn't exist won't make the problem go away.

 

[deleted171991]

Last time I checked anesthesiologists made on average 358k. Also, last time I checked CRNAs aren't new... they've been around forever and still have yet to "take over". If they took over, people would die as they have been recently at these various hospitals where the anesthesiologist wasn't around. You can't give a bunch of *****s that much responsibility and expect nothing to happen. I'm willing to bet in 5-10 years CRNAs will be out of a job because AAs will be legalized in every state and take all of their jobs. It's not worth the liability to not have a doctor and start killing people because you lose millions every time. Hospitals aren't stupid, they've done a cost benefit analysis and realized it was wiser to keep anesthesiologists around.

Averages don't mean **** if the standard deviation is unknown, and if not even the state-specific data is available. Also, numbers don't mean anything if they are not adjusted to hours worked, at least (not to speak about calls or vacation).

The "average" CRNA lifestyle runs circles around the "average" anesthesiologist lifestyle.

Are you still in medical school?

 

[deleted171991]

1. The average is well within a bell curve distribution
2. With more responsibility comes more money and more demanding hours. There is a reason the average anesthesiologist makes 358k and the average CRNA makes 150k. You can't have it all.
3. Yes, I'm still in medical school.

1. What bell curve? You don't know how skewed that curve may be/is. With enough significant outliers, what they call average might be more than what 80% of anesthesiologists make. Without the StDev we just can't know.
2. I was talking on an hourly basis. Where I work, an employed anesthesiologist makes about 25% more per hour, does not have breaks and other "rights" CRNAs have (there is power in numbers), and has infinite more (legal) responsibility. Way better deal for CRNAs; it's like playing doctor on somebody else's license, for an income that's much closer to a doctor's than to a nurse's.

 

[qwerty89]

All of them suck. Unless you miraculously get into derm, optho, urology, ENT, an established plastic surgery practice, or radiation oncology I would stick with anesthesia. The benefit anesthesia has over all of them is not having to deal with patients and the bull****/baggage that comes with them. Dealing with patients is seriously a pain in the ass and it's almost worth the risk of staying put just for that added benefit alone. If you really want to make a ton of money, I would look into an MBA to go corporate or work for a consulting group running their healthcare policy dept. Also, all the wealthy physicians made their money in the business of medicine (MRI centers, surgery centers, starting insurance companies/HMOs, starting groups, opening ER clinics, etc) rather than what specialty they went into. Anesthesia at least affords you the free time to pursue other business ventures.

Rad Onc has a bad job market. Not to mention their % increase in residency spots make rads and gas look like nothing. That does not bode well for the future.

PGY-2 spots
2001: 81
2005: 128
2010: 142
2015: 176

 

[Wiscoblue]

Last time I checked anesthesiologists made on average 358k. Also, last time I checked CRNAs aren't new... they've been around forever and still have yet to "take over". If they took over, people would die as they have been recently at these various hospitals where the anesthesiologist wasn't around. You can't give a bunch of *****s that much responsibility and expect nothing to happen. I'm willing to bet in 5-10 years CRNAs will be out of a job because AAs will be legalized in every state and take all of their jobs. It's not worth the liability to not have a doctor and start killing people because you lose millions every time. Hospitals aren't stupid, they've done a cost benefit analysis and realized it was wiser to keep anesthesiologists around.

There aren't enough AAs being trained to replace CRNAs in just one state leave alone the entire country. You have no clue what you're talking about. We hired two crnas in the last 5 years. We were offering 200k for 8-4 no weekends or holidays 6 weeks of vacation. Not one AA applied for the position.

 

[jwk]

The fact that a nurse makes 6 figures of any kind is totally ridiculous. These people don't know any medicine and don't have the ability to solve problems. They are technicians that are glorified baby sitters for the patients. Why anyone would pay them more than 50-75k blows my mind. The fact that people really believe these clowns will replace board certified anesthesiologists is even funnier. Do you people love the drama of creating a crisis where there isn't one?

You need to get a little real-world knowledge and experience. ADN nurses at a hospital start at more than $50k. A BSN staff nurse is easily $75k or more. I guess your mind is totally blown since most anesthetists make significantly more than that. I fully agree that the $200k+ numbers being tossed around for a 40hr week are crazy, but those are pretty much outliers. In many markets, those numbers would be little more than a pipe dream.

I'm not sure if you've ever actually seen or worked with a CRNA (or an AA), but they are far more than technicians and glorified baby sitters. Of course they have some medical knowledge and can solve problems. Does that mean they should be practicing independently? No. The difference between AA's and CRNA's is that AA's are perfectly willing to work in an ACT environment, and CRNA's are increasingly pushing the independent practice envelope.

 

[jwk]

There aren't enough AAs being trained to replace CRNAs in just one state leave alone the entire country. You have no clue what you're talking about. We hired two crnas in the last 5 years. We were offering 200k for 8-4 no weekends or holidays 6 weeks of vacation. Not one AA applied for the position.

PM me next time you start looking. If AA's can work in your area, I'll get you some applicants.

 

[Wiscoblue]

Sounds good! Yes they can work in my state.

 

[qwerty89]

Last time I checked the average rad Onc guy makes close to 500k on average so even in a bad job market I guarantee they're still making more than most anesthesiologists.

The combination of huge reduction in reimbursements to independent rad onc facilities + increased supply = more employees rather than partners in the future. Being an employee means there is a middleman. When there is a middleman and oversupply you can bet someone can skim quite a bit off the top.

 

[Carbocation1]

Radonc in practice is not as stressful as anesthesia. One reason why midlevels have not infiltrated radonc is due to the demand not being nearly as high as anesthesia.

 

[Carbocation1]

Keep in in mind that 70% of practicing anesthesiologists are over 45. No other specialty that I know of is this top heavy. When the fat cat grey hairs who sold out this specialty to begin with retire, coupled with the opening of AA schools nationwide, you will be counting your blessings you picked GAS while your buddies in chronic care specialties are busy prescribing HTN meds via mobile or are being sued by a patient who just viewed a video of their spine surgery, and didn't like what he saw on tape.

 

[Mad Jack]

Radonc in practice is not as stressful as anesthesia. One reason why midlevels have not infiltrated radonc is due to the demand not being nearly as high as anesthesia.

Honestly I don't think most midlevels are anywhere close to competent enough to practice in radonc. Their training is just soooooo far from where it needs to be.

 

[Carbocation1]

Honestly I don't think most midlevels are anywhere close to competent enough to practice in radonc. Their training is just soooooo far from where it needs to be.

Read: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093461/

 

[Carbocation1]

J Adv Pract Oncol. 2014 Jan-Feb; 5(1): 42–46.
Published online 2014 Jan 1.

Integrating Nurse Practitioners Into Radiation Oncology: One Institution’s Experience

Genevieve Hollis, MSN, CRNP, ANP-BC, AOCN® and Erin McMenamin, MSN, CRNP, ANP-BC, AOCN®
Author information ► Copyright and License information ►


The demand for cancer-related services is soon expected to exceed the number of available oncologists. Factors contributing to this gap include the aging population and the associated increased incidence of cancer diagnosis, expanding treatment options, a growing number of survivors, changes in reimbursement, and fewer physicians specializing in oncology (Erikson, Salsberg, Gaetano, Bruinooge, & Goldstein, 2007; Institute of Medicine [IOM], 2009; Towle et al., 2011). In radiation oncology in particular, the demand for radiation therapy (RT) is expected to increase 10 times faster from 2010 to 2020 than the supply of radiation oncologists (Smith et al., 2010).

Across all settings, nurse practitioners (NPs) have consistently demonstrated their ability to provide safe, efficient, high-quality, well-received cancer care, and they have been acknowledged as critical in addressing this ever-expanding gap (Cunningham, 2004; Erikson et al., 2007; IOM, 2009; Hinkle et al., 2010; Towle et al., 2011). Barriers to autonomous NP practice persist and include a lack of role clarity, practices limiting independent decision-making, a disproportionate involvement in indirect clinical activities, and physician resistance (Chumbler, Geller, & Weier, 2000; Vogel, 2010; Towle et al., 2011; McCorkle et al., 2012; Moote et al., 2012). There is a need for the thoughtful development of creative collaborative models to address these barriers and facilitate NPs’ ability to practice to the fullest extent of their scope, education, and competence, thereby maximizing their ability to deliver excellent, efficient cancer care (Buswell, Ponte, & Shulman, 2009; IOM, 2009; Moote et al., 2012).

Despite the significant number of patients with cancer who receive RT and the many complex symptoms that these patients experience, until relatively recently, radiation oncology had largely been bereft of NPs. Although some literature has described various clinical activities that can be performed by NPs in radiation oncology, there has been little to guide the effective development and integration of these roles into practice (Carper & Haas, 2006; Moote et al., 2012).

In 2008, the department of radiation oncology at the Hospital of the University of Pennsylvania relocated to the much larger Perelman Center for Advanced Medicine (PCAM). The additional technology available in this new setting—including proton therapy in the Roberts Proton Therapy Center—significantly increased the RT options available to a larger number of patients, treatment planning complexity, and clinical research efforts. To meet the challenges associated with this growth, the department engaged in a thoughtful process that ultimately resulted in multiple successful NP practice models. This article summarizes the key elements of the process and outlines future directions.

Go to:
Shared Expectations of the NP Role
A critical initial step in the process of developing a practice model that included NPs was the development of a clear understanding, as well as shared expectations, regarding the NP role. Physicians and administrators were briefed on NP education, scope of practice, regulation, reimbursement, and potential outcomes. Shared expectations evolved and included having NPs practice to the fullest extent of their scope of practice, with the majority of their clinical activities being performed independently. This would predictably result in an enhanced capability to accommodate increased patient volumes (Towle et al., 2011; Moote et al., 2012). Another expectation was the ability to capitalize on NPs’ unique knowledge and skills, thereby increasing the breadth, depth, and quality of health promotion and supportive care provided to patients and families. The final expectation was the NPs’ advancement of the department’s academic mission through the pursuit of related professional activities.

To ensure sufficient patient volumes capable of supporting full-time NP positions, facilitate productivity, and enable development and dissemination of clinical expertise, each NP position was aligned with a specific team of physicians (usually disease-based) rather than with individual physicians. Recognizing that one NP model would not meet the unique needs of all patients and teams, the lead NP collaborated with physicians on each team to analyze patient needs across the illness continuum, current gaps in care, and emerging trends (Carper & Haas, 2006). They determined which clinical activities were only within the physicians’ scope of practice (e.g., prescription, planning, and oversight of RT) and which were central to quality resident education.

Through this analysis, clinical activities within the NP’s independent scope of practice that would enhance patient capacity, expand the supportive care services available to patients, and provide opportunities for substantive professional activities were identified. This ultimately resulted in tailored job descriptions for each NP role. Potential productivity and quality care metrics, as well as financial feasibility, were explored. The proposed job descriptions were submitted to departmental leadership for potential approval. Verbal scripts and a brochure on the benefit of physician/NP collaboration were developed to facilitate communication with patients and colleagues, and NP biographies were placed on the departmental website.

Go to:
Orientation and Retention
Most oncology NPs are educated in primary care or acute care programs that lack substantive cancer-related didactic and clinical components. They usually acquire cancer-specific knowledge and skills on the job through physician mentoring and self-study. This model results in a significant increase in time until the NPs are competent independent providers (Vogel, 2010; Nevidjon et al., 2010). This approach is inefficient, may inadvertently emphasize a medical model approach to care, and can undermine the NPs’ future credibility with colleagues and patients.

Consequently, the lead NP developed an orientation based upon published oncology NP competencies as well as the knowledge and skill needs of new oncology NPs and radiation oncology nurses (Oncology Nursing Society [ONS], 2007; Rosenzweig et al., 2012; Brunner & Hollis, 2012). The orientation was tailored to each NP’s educational preparation, oncology work experience, and aligned team. Nurse practitioner and physician preceptors established didactic and clinical experiences that facilitated knowledge acquisition and application to a progressively independent clinical practice. New NPs attended selected on-site lectures and completed specific online courses available through the ONS. Although the majority of their clinical time was spent with NP and physician preceptors, new NPs also spent time with other radiation oncology staff (e.g., registered nurses, therapists, dosimetrists, social workers, and dietitians) and colleagues from other departments who frequently refer to radiation oncology (e.g., medical and surgical oncology providers and nurse navigators). The latter were critical for the NPs to establish collegial relationships and learn to navigate the health system.

Given the significant fiscal and human resource investment in NP recruitment and orientation, retention strategies have focused on promoting professional growth and a healthy, respectful work environment. An individualized professional development plan addresses each NP’s ongoing learning needs, formative evaluation and modification of role, and expectations for professional activity. Nurse practitioners are expected to obtain national certification as an Advanced Oncology Certified NP (AOCNP®) through the Oncology Nursing Certification Corporation (ONCC) within 2 years of completing orientation. As appropriate, NPs are encouraged to obtain a post-master’s certificate in oncology nursing and complete ONS’s Radiation Oncology Certificate Program. The lead NP is expected to complete semiannual reviews with input from collaborative physicians, other NPs, registered nurses, and the director of nursing. Monthly NP meetings and faculty meetings with physician colleagues provide opportunities to inform clinical operations. Work schedules are dependent on the needs of the service/department, and clear efforts are made to encourage a healthy work/life balance.

Go to:
Metrics
Assessment of clinical activity generally is based on reimbursement data and resource-value units (RVUs). When patients are receiving RT, reimbursement includes professional fees for weekly treatment management. Due to Medicare regulations, NPs currently are not able to independently perform or bill for these professional services. Additionally, no radiation oncology providers can bill for additional professional evaluation and management services during a course of RT or for follow-ups within 90 days of RT completion. Of note, these are the time periods when patients are likely to be symptomatic and apt to benefit from NP interventions. Consequently, reimbursement and RVU data are inadequate in tracking NP activity in radiation oncology.

In collaboration with information technology experts, an alternative method was developed. Data that track clinical activities performed by NPs in "billable" and "nonbillable" time periods are extracted from the electronic medical record, as well as those completed independently or as part of a shared encounter with a physician. The revenue generated from billable independent NP encounters is tracked. Quality-care measures are tracked, including patient satisfaction and medication reconciliation, pain assessment and management, and smoking assessment and cessation counseling. Lastly, professional activities such as presentations, publications, research involvement, quality-improvement projects, and committee participation are also tracked. This information is reported monthly and used to examine trends, formatively evaluate roles, and stimulate future role development.

Go to:
Current Status
Six robust and increasingly independent NP models have emerged that facilitate accommodation of increased patient volumes and expand services available to diverse patient populations. These models encompass clinical activities ranging from consultation to supportive care on and after treatment, disease surveillance, survivorship care, and coordination of care.

Nurse practitioners aligned with teams treating high volumes of prostate cancer patients primarily provide lifelong disease surveillance, management of late effects, and survivorship care in independent follow-up clinics. They also provide expert symptom management to patients with other genitourinary cancers, such as bladder and metastatic prostate cancers, during and immediately after treatment.

The priority for the NPs aligned with teams treating patients with high acuity—such as head and neck, lung, and gastrointestinal cancers—is to provide time-intensive, expert supportive care to these patients during weekly on-treatment physician visits. They independently manage the supportive care and ad hoc/urgent patient needs that occur during treatment and in NP follow-up clinics in the weeks immediately after treatment, when toxicities are expected to peak. This comprehensive approach to supportive care is particularly critical, as these patients consistently have a high symptom burden that can negatively impact quality-of-life and treatment outcomes, the latter due to treatment interruptions.

The head and neck cancer service NP independently performs procedures such as nasopharyngolaryngoscopies and placement of Dobhoff feeding tubes and is exploring an independent survivorship clinic. Given the high symptom burden of lung cancer patients presenting to radiation oncology, the NPs aligned with the lung services screen incoming consults. Patients with identified risk factors for complex symptoms are seen by the NP during the consultation for more comprehensive symptom assessment and initiation of early supportive care interventions. Patients with early-stage lung cancer and gastrointestinal cancer are increasingly being seen in independent NP follow-up clinics for disease surveillance and survivorship care.

Timely completion of inpatient consults, particularly for urgent treatment of oncologic emergencies, is extremely challenging for radiation oncology teams with busy outpatient practices. Additionally, patients hospitalized while receiving RT require coordination of care with inpatient teams to maximize symptom management, minimize treatment interruptions, and avoid gaps during transitions in care. Based upon the success of the previous NP models, a new NP position focusing on the inpatient population was developed. This NP triages all requests for inpatient consultation, performs the actual consult with direct physician input as medically indicated, and coordinates care for patients admitted while receiving RT.

The department provides RT services for pediatric patients from Children’s Hospital of Pennsylvania. A significant aspect of the pediatric NP’s role is to coordinate care between two separate health systems. This NP provides critical on-site pediatric clinical expertise in a predominantly adult care setting, strengthening the delivery of pediatric supportive care and ad hoc/urgent care provided within the department.

Collectively, patient, colleague, and administrator satisfaction with care provided by these NPs has been high. As individual NPs have gained clinical experience and confidence, the independent aspects of their clinical practice have progressively increased. The NPs have incorporated a variety of evidence-based health promotion and supportive care interventions into the care provided to patients and families. Nurse practitioner professional activities have included becoming department committee members, leading quality improvement initiatives, participating in the planning and delivery of the radiation oncology course for nurses, receiving academic appointments at local schools of nursing, authoring peer-reviewed publications, presenting at local and national conferences, and initiating NP-led clinical research efforts.

Go to:
Future Directions
The process of developing and sustaining creative collaborative models for NPs in radiation oncology continues. The established NP models are continually evaluated, and emerging trends are analyzed to identify further opportunities for independent NP practice. Departmental leadership is pursuing initiatives to address persistent barriers to optimal utilization of NPs, including providing adequate clinical space and decreasing their involvement in indirect clinical activities that can be performed by other staff members. Efforts are under way to expand the tracking of quality-care metrics that capture the NPs’ impact on patient, departmental, and institutional outcomes.

Nurse practitioner retention strategies that support professional development opportunities and a healthy work environment need to be expanded to include formal mentor relationships, protected time for professional activities, and a professional advancement ladder that is tied to compensation. Collaborating with academic institutions and professional organizations in the development of novel education and training programs to ensure ongoing availability of highly qualified NPs in radiation oncology is a long-term imperative of the department as well as the oncology profession as a whole.

Go to:
Conclusion
With strong leadership support, utilization of a content expert, and thoughtful planning, this busy academic radiation oncology department has been successful in establishing a structure for the development and integration of NPs. By empowering NPs to practice to the full scope of their education, licensure, and competency, they have been able to positively impact patient care, increase capacity, expand services available to patients, and become professionally productive. Although challenges exist, so do opportunities to fully implement sophisticated NP roles that positively impact patient, departmental, institutional, and professional outcomes. This process could potentially serve as a model for other practices looking to incorporate NPs into their provider groups.

 

[Mad Jack]

J Adv Pract Oncol. 2014 Jan-Feb; 5(1): 42–46.
Published online 2014 Jan 1.

Integrating Nurse Practitioners Into Radiation Oncology: One Institution’s Experience

Genevieve Hollis, MSN, CRNP, ANP-BC, AOCN® and Erin McMenamin, MSN, CRNP, ANP-BC, AOCN®
Author information ► Copyright and License information ►


The demand for cancer-related services is soon expected to exceed the number of available oncologists. Factors contributing to this gap include the aging population and the associated increased incidence of cancer diagnosis, expanding treatment options, a growing number of survivors, changes in reimbursement, and fewer physicians specializing in oncology (Erikson, Salsberg, Gaetano, Bruinooge, & Goldstein, 2007; Institute of Medicine [IOM], 2009; Towle et al., 2011). In radiation oncology in particular, the demand for radiation therapy (RT) is expected to increase 10 times faster from 2010 to 2020 than the supply of radiation oncologists (Smith et al., 2010).

Across all settings, nurse practitioners (NPs) have consistently demonstrated their ability to provide safe, efficient, high-quality, well-received cancer care, and they have been acknowledged as critical in addressing this ever-expanding gap (Cunningham, 2004; Erikson et al., 2007; IOM, 2009; Hinkle et al., 2010; Towle et al., 2011). Barriers to autonomous NP practice persist and include a lack of role clarity, practices limiting independent decision-making, a disproportionate involvement in indirect clinical activities, and physician resistance (Chumbler, Geller, & Weier, 2000; Vogel, 2010; Towle et al., 2011; McCorkle et al., 2012; Moote et al., 2012). There is a need for the thoughtful development of creative collaborative models to address these barriers and facilitate NPs’ ability to practice to the fullest extent of their scope, education, and competence, thereby maximizing their ability to deliver excellent, efficient cancer care (Buswell, Ponte, & Shulman, 2009; IOM, 2009; Moote et al., 2012).

Despite the significant number of patients with cancer who receive RT and the many complex symptoms that these patients experience, until relatively recently, radiation oncology had largely been bereft of NPs. Although some literature has described various clinical activities that can be performed by NPs in radiation oncology, there has been little to guide the effective development and integration of these roles into practice (Carper & Haas, 2006; Moote et al., 2012).

In 2008, the department of radiation oncology at the Hospital of the University of Pennsylvania relocated to the much larger Perelman Center for Advanced Medicine (PCAM). The additional technology available in this new setting—including proton therapy in the Roberts Proton Therapy Center—significantly increased the RT options available to a larger number of patients, treatment planning complexity, and clinical research efforts. To meet the challenges associated with this growth, the department engaged in a thoughtful process that ultimately resulted in multiple successful NP practice models. This article summarizes the key elements of the process and outlines future directions.

Go to:
Shared Expectations of the NP Role
A critical initial step in the process of developing a practice model that included NPs was the development of a clear understanding, as well as shared expectations, regarding the NP role. Physicians and administrators were briefed on NP education, scope of practice, regulation, reimbursement, and potential outcomes. Shared expectations evolved and included having NPs practice to the fullest extent of their scope of practice, with the majority of their clinical activities being performed independently. This would predictably result in an enhanced capability to accommodate increased patient volumes (Towle et al., 2011; Moote et al., 2012). Another expectation was the ability to capitalize on NPs’ unique knowledge and skills, thereby increasing the breadth, depth, and quality of health promotion and supportive care provided to patients and families. The final expectation was the NPs’ advancement of the department’s academic mission through the pursuit of related professional activities.

To ensure sufficient patient volumes capable of supporting full-time NP positions, facilitate productivity, and enable development and dissemination of clinical expertise, each NP position was aligned with a specific team of physicians (usually disease-based) rather than with individual physicians. Recognizing that one NP model would not meet the unique needs of all patients and teams, the lead NP collaborated with physicians on each team to analyze patient needs across the illness continuum, current gaps in care, and emerging trends (Carper & Haas, 2006). They determined which clinical activities were only within the physicians’ scope of practice (e.g., prescription, planning, and oversight of RT) and which were central to quality resident education.

Through this analysis, clinical activities within the NP’s independent scope of practice that would enhance patient capacity, expand the supportive care services available to patients, and provide opportunities for substantive professional activities were identified. This ultimately resulted in tailored job descriptions for each NP role. Potential productivity and quality care metrics, as well as financial feasibility, were explored. The proposed job descriptions were submitted to departmental leadership for potential approval. Verbal scripts and a brochure on the benefit of physician/NP collaboration were developed to facilitate communication with patients and colleagues, and NP biographies were placed on the departmental website.

Go to:
Orientation and Retention
Most oncology NPs are educated in primary care or acute care programs that lack substantive cancer-related didactic and clinical components. They usually acquire cancer-specific knowledge and skills on the job through physician mentoring and self-study. This model results in a significant increase in time until the NPs are competent independent providers (Vogel, 2010; Nevidjon et al., 2010). This approach is inefficient, may inadvertently emphasize a medical model approach to care, and can undermine the NPs’ future credibility with colleagues and patients.

Consequently, the lead NP developed an orientation based upon published oncology NP competencies as well as the knowledge and skill needs of new oncology NPs and radiation oncology nurses (Oncology Nursing Society [ONS], 2007; Rosenzweig et al., 2012; Brunner & Hollis, 2012). The orientation was tailored to each NP’s educational preparation, oncology work experience, and aligned team. Nurse practitioner and physician preceptors established didactic and clinical experiences that facilitated knowledge acquisition and application to a progressively independent clinical practice. New NPs attended selected on-site lectures and completed specific online courses available through the ONS. Although the majority of their clinical time was spent with NP and physician preceptors, new NPs also spent time with other radiation oncology staff (e.g., registered nurses, therapists, dosimetrists, social workers, and dietitians) and colleagues from other departments who frequently refer to radiation oncology (e.g., medical and surgical oncology providers and nurse navigators). The latter were critical for the NPs to establish collegial relationships and learn to navigate the health system.

Given the significant fiscal and human resource investment in NP recruitment and orientation, retention strategies have focused on promoting professional growth and a healthy, respectful work environment. An individualized professional development plan addresses each NP’s ongoing learning needs, formative evaluation and modification of role, and expectations for professional activity. Nurse practitioners are expected to obtain national certification as an Advanced Oncology Certified NP (AOCNP®) through the Oncology Nursing Certification Corporation (ONCC) within 2 years of completing orientation. As appropriate, NPs are encouraged to obtain a post-master’s certificate in oncology nursing and complete ONS’s Radiation Oncology Certificate Program. The lead NP is expected to complete semiannual reviews with input from collaborative physicians, other NPs, registered nurses, and the director of nursing. Monthly NP meetings and faculty meetings with physician colleagues provide opportunities to inform clinical operations. Work schedules are dependent on the needs of the service/department, and clear efforts are made to encourage a healthy work/life balance.

Go to:
Metrics
Assessment of clinical activity generally is based on reimbursement data and resource-value units (RVUs). When patients are receiving RT, reimbursement includes professional fees for weekly treatment management. Due to Medicare regulations, NPs currently are not able to independently perform or bill for these professional services. Additionally, no radiation oncology providers can bill for additional professional evaluation and management services during a course of RT or for follow-ups within 90 days of RT completion. Of note, these are the time periods when patients are likely to be symptomatic and apt to benefit from NP interventions. Consequently, reimbursement and RVU data are inadequate in tracking NP activity in radiation oncology.

In collaboration with information technology experts, an alternative method was developed. Data that track clinical activities performed by NPs in "billable" and "nonbillable" time periods are extracted from the electronic medical record, as well as those completed independently or as part of a shared encounter with a physician. The revenue generated from billable independent NP encounters is tracked. Quality-care measures are tracked, including patient satisfaction and medication reconciliation, pain assessment and management, and smoking assessment and cessation counseling. Lastly, professional activities such as presentations, publications, research involvement, quality-improvement projects, and committee participation are also tracked. This information is reported monthly and used to examine trends, formatively evaluate roles, and stimulate future role development.

Go to:
Current Status
Six robust and increasingly independent NP models have emerged that facilitate accommodation of increased patient volumes and expand services available to diverse patient populations. These models encompass clinical activities ranging from consultation to supportive care on and after treatment, disease surveillance, survivorship care, and coordination of care.

Nurse practitioners aligned with teams treating high volumes of prostate cancer patients primarily provide lifelong disease surveillance, management of late effects, and survivorship care in independent follow-up clinics. They also provide expert symptom management to patients with other genitourinary cancers, such as bladder and metastatic prostate cancers, during and immediately after treatment.

The priority for the NPs aligned with teams treating patients with high acuity—such as head and neck, lung, and gastrointestinal cancers—is to provide time-intensive, expert supportive care to these patients during weekly on-treatment physician visits. They independently manage the supportive care and ad hoc/urgent patient needs that occur during treatment and in NP follow-up clinics in the weeks immediately after treatment, when toxicities are expected to peak. This comprehensive approach to supportive care is particularly critical, as these patients consistently have a high symptom burden that can negatively impact quality-of-life and treatment outcomes, the latter due to treatment interruptions.

The head and neck cancer service NP independently performs procedures such as nasopharyngolaryngoscopies and placement of Dobhoff feeding tubes and is exploring an independent survivorship clinic. Given the high symptom burden of lung cancer patients presenting to radiation oncology, the NPs aligned with the lung services screen incoming consults. Patients with identified risk factors for complex symptoms are seen by the NP during the consultation for more comprehensive symptom assessment and initiation of early supportive care interventions. Patients with early-stage lung cancer and gastrointestinal cancer are increasingly being seen in independent NP follow-up clinics for disease surveillance and survivorship care.

Timely completion of inpatient consults, particularly for urgent treatment of oncologic emergencies, is extremely challenging for radiation oncology teams with busy outpatient practices. Additionally, patients hospitalized while receiving RT require coordination of care with inpatient teams to maximize symptom management, minimize treatment interruptions, and avoid gaps during transitions in care. Based upon the success of the previous NP models, a new NP position focusing on the inpatient population was developed. This NP triages all requests for inpatient consultation, performs the actual consult with direct physician input as medically indicated, and coordinates care for patients admitted while receiving RT.

The department provides RT services for pediatric patients from Children’s Hospital of Pennsylvania. A significant aspect of the pediatric NP’s role is to coordinate care between two separate health systems. This NP provides critical on-site pediatric clinical expertise in a predominantly adult care setting, strengthening the delivery of pediatric supportive care and ad hoc/urgent care provided within the department.

Collectively, patient, colleague, and administrator satisfaction with care provided by these NPs has been high. As individual NPs have gained clinical experience and confidence, the independent aspects of their clinical practice have progressively increased. The NPs have incorporated a variety of evidence-based health promotion and supportive care interventions into the care provided to patients and families. Nurse practitioner professional activities have included becoming department committee members, leading quality improvement initiatives, participating in the planning and delivery of the radiation oncology course for nurses, receiving academic appointments at local schools of nursing, authoring peer-reviewed publications, presenting at local and national conferences, and initiating NP-led clinical research efforts.

Go to:
Future Directions
The process of developing and sustaining creative collaborative models for NPs in radiation oncology continues. The established NP models are continually evaluated, and emerging trends are analyzed to identify further opportunities for independent NP practice. Departmental leadership is pursuing initiatives to address persistent barriers to optimal utilization of NPs, including providing adequate clinical space and decreasing their involvement in indirect clinical activities that can be performed by other staff members. Efforts are under way to expand the tracking of quality-care metrics that capture the NPs’ impact on patient, departmental, and institutional outcomes.

Nurse practitioner retention strategies that support professional development opportunities and a healthy work environment need to be expanded to include formal mentor relationships, protected time for professional activities, and a professional advancement ladder that is tied to compensation. Collaborating with academic institutions and professional organizations in the development of novel education and training programs to ensure ongoing availability of highly qualified NPs in radiation oncology is a long-term imperative of the department as well as the oncology profession as a whole.

Go to:
Conclusion
With strong leadership support, utilization of a content expert, and thoughtful planning, this busy academic radiation oncology department has been successful in establishing a structure for the development and integration of NPs. By empowering NPs to practice to the full scope of their education, licensure, and competency, they have been able to positively impact patient care, increase capacity, expand services available to patients, and become professionally productive. Although challenges exist, so do opportunities to fully implement sophisticated NP roles that positively impact patient, departmental, institutional, and professional outcomes. This process could potentially serve as a model for other practices looking to incorporate NPs into their provider groups.

I highly doubt they were designing and implementing radonc treatment plans though. They were probably just following through with plans implemented by the physicians, doing follow up work, counseling, etc. They couldn't do as they've done in anesthesia and just practice independently, not with the training the currently receive in an NP program.

 

[deleted171991]

Keep in in mind that 70% of practicing anesthesiologists are over 55.

This deserves exactly one answer:

 

[deleted171991]

1. see graph
2. ANAA is well run even if they're all a bunch of idiots. ASA clearly is poorly run despite being good clinicians. I don't know what to tell you. If I was president of the ASA, I would get AAs in every state and put every CRNA out of a job and market them as a threat to the safety of patients while lobbying in Washington for better overall benefits and reimbursements for anesthesiologists.

1. What's the source for that?
2. I agree.

 

[Carbocation1]

This deserves exactly one answer:

Please see attached image as per CIM.

 

[deleted171991]

Please see attached image as per CIM.

If those numbers are true, only about 40% are over 55 years old. Which is way different than 70% (and much more believable).

Since most anesthesiologists (and other specialist physicians) graduate around 30-35 and practice till about 65 (more or less), I would expect about 33% to be above 55, so 40% is nothing out of the ordinary.

 

[Carbocation1]

If those numbers are true, only about 40% are over 55 years old. Which is way different than 70% (and much more believable).

Since most anesthesiologists (and other specialist physicians) graduate around 30-35 and practice till about 65 (more or less), I would expect about 33% to be above 55, so 40% is nothing out of the ordinary.

I meant over 45, my bad. 70% over age 45 is higher than other specialties I looked at, including longevity specialties such as psych and path.

 

[projectpat]

Please see attached image as per CIM.

In 2006, there were 74 practicing anesthesiologists over the age of 100...
Das crazy

 

[deleted126335]

1. see graph
2. ANAA is well run even if they're all a bunch of idiots. ASA clearly is poorly run despite being good clinicians. I don't know what to tell you. If I was president of the ASA, I would get AAs in every state and put every CRNA out of a job and market them as a threat to the safety of patients while lobbying in Washington for better overall benefits and reimbursements for anesthesiologists.

Do not agree. AANA has a simple, clean, easy to understand message that the overwhelming majority of CRNAs can get behind.
ASA has factions: academic v. private practice, MD only v. ACT supporters, Exploitive practices where the super partners are active in ASA and big donors because they have the time and the money, thus pissing off a large number of younger docs. Those that are pro AA's and those that are not. The people that I have personally known at the highest levels of ASA have been amazingly competent and interested, they are just dealing with competing agendas within the organization. AANA does not have this issue to nearly the same extent.

 

[jwk]

Do not agree. AANA has a simple, clean, easy to understand message that the overwhelming majority of CRNAs can get behind.
ASA has factions: academic v. private practice, MD only v. ACT supporters, Exploitive practices where the super partners are active in ASA and big donors because they have the time and the money, thus pissing off a large number of younger docs. Those that are pro AA's and those that are not. The people that I have personally known at the highest levels of ASA have been amazingly competent and interested, they are just dealing with competing agendas within the organization. AANA does not have this issue to nearly the same extent.

The similarities to Republicans vs Democrats is always quite striking to me. CRNAs and the AANA are pretty much far left Democrats, happy to slurp at the government teat as much as they possibly can and pretty much unified behind a single message. MDs and the ASA are much like the Republicans, with multiple factions and priorities as Dr. Doze has noted, and as a consequence, far less unity.

As far as putting AA's in all 50 states - of course that's our goal and has been for 45 years. Making that a reality is far more difficult, since enabling legislation is necessary in each state, and you-know-who will stop at absolutely nothing to try and stop it.

 

[BLADEMDA]

Please see attached image as per CIM.

38% of Anesthesiologists are over 55 and many of them will work part-time until 65 or even later. These aging Anesthesiologists will take the low hanging fruit back from the CRNAs (IMHO) by accepting lower wages for better hours. Most of my Colleagues plan on working part-time until age 65.

The number of new graduates continues to increase which means AMCs will be able to pick them off as the market tightens. The result is lower wages. No matter how you try to spin that graph the fact is wages will be falling for new graduates and the median wage will drop as more groups sell out to AMCs or senior partners retire (and are NOT replaced by a partner).

Those of you in sweet gigs need to realize that will NOT be the norm going forward so make the most of your situation.

 

[criticalelement]

2. If I was president of the ASA, I would get AAs in every state and put every CRNA out of a job and market them as a threat to the safety of patients while lobbying in Washington for better overall benefits and reimbursements for anesthesiologists.

that is the smartest thing ive heard on this board in a while. I agree. We need AA legislation in every state. Also we need PA s in anesthesia,.

 

[PianoMedic]

I believe AAs are the anesthesia equivalent of PAs. Can't remember where I heard/read that though.

 

[criticalelement]

38% of Anesthesiologists are over 55 and many of them will work part-time until 65 or even later. .

that is presuming one can find a part time job. Part time jobs are hard to come by. It is either full time with call or bust

 

[aneftp]

Do not agree. AANA has a simple, clean, easy to understand message that the overwhelming majority of CRNAs can get behind.
ASA has factions: academic v. private practice, MD only v. ACT supporters, Exploitive practices where the super partners are active in ASA and big donors because they have the time and the money, thus pissing off a large number of younger docs. Those that are pro AA's and those that are not. The people that I have personally known at the highest levels of ASA have been amazingly competent and interested, they are just dealing with competing agendas within the organization. AANA does not have this issue to nearly the same extent.

Agree.

AANA is playing the underdog role with nothing to lose. Their position is easier to promote than the ASA.

Nurses and other non physician providers are always trying to "practice to the fullest extent of their abilities" whatever the heck that means.

Docs are always defending their practices.

Good point always on MDs in anesthesia who are anti AA. We know who those folks are. They have different agenda. Aka. They support crnas so they can bill and collect revenue when crnas are on call themselves so those same MDs sleep at home.

If AA were on call they would physically have to get out of their bed from home and go to the hospital for the case.