Anesthesia, CRNAs and Future Prospects

[RDB]

Hi all, I have a few questions regarding job prospects of anesthesia looking forward. I'm in 2nd year and this whole process of starting to pick a specialty is very daunting given so many uncertainties in job prospects for many subspecialties all across the board in Canada.

 

While an older thread adressed that CRNAs won't be a threat, is this likely to change? Is anyone aware of how strong the nursing assocations are fighting for this and how strongly the CMA is lobbying against this? With the up and coming massive flux of aging baby boomers, I'm really afraid that the government will try all sorts of tactics to "keep costs manageable."

 

My second question is, given that many anesthesiologists(at least from what I hear) are now doing fellowships to land jobs, it really seems like the health care situation in Canada has just about saturated. An anesthesiologist doing an ICU fellowship today will still have problems landing an ICU job due to lack of hospital beds(at least in Ontario from what I know but i'd be curious about other provinces). Will this change in the future if we project say 7 years forward to around the time I become fully licensed? I keep hearing about doctors not retiring being the problem but I do question how likely it is for a person who's been a lifelong Type A to just up and quit if they've already decided to postpone retirement for a few years.

 

Thanks for any input. It just seems like primary care really is where it's at these days and while I definitely don't mind doing family medicine, it's disheartening that a lot of things I was considering just don't seem viable. I know we should all do what we really are interested in but it is very disheartening and I even think foolhardy to be so time and effort invested in something that you once thought would guarantee you a job not work out.

[Guest copacetic]

I think the job market will open up somwhat across all specialties in the coming years, though not nearly as much as alot of people think. Sure people will be retiring, but there are alot of people doing multiple fellowships waiting on the sidelines for positions to open up. Canada is not like the united states. Here everything is centralized to a few centres, and resources are finite with physicians seens as cost generators. In the US physicians and their services are seen as a source of revenue hence the massive decentralization and the plethora of opportunities.

 

while physicians services in many specialties are badly needed, and there are infact enough physicians, there are simply not enough resources to support the activities of these physicians.

http://www.theglobeandmail.com/news/national/canadian-surgeons-face-flat-lining-job-market/article1920006/

 

to get a job in a major centre, you need a second degree or fellowship to even be looked at, and this is also becoming true of smaller centres...which is ridiculous in my opinion. There is not alot of freedom and flexibility in medicine these days in terms of where you want to practice if youre a specialist.

 

While I intend to practice in canada, I am seriously keeping my options for US employment open. Im also seriously considering family medicine.

[moo]

The US also has its share of problems. I was just in the US and met up with a few of my old classmates. One is a cardiology fellow, his wife is a peds cardiology fellow (both in Chicago) and my other friend is a pediatric nephrology fellow (at UCSF). They are all worried about landing a job after they are done, at least in a major city. My one general pediatrics friend is working for Kaiser, albeit not making that much money (80K a year as a pediatrician). It seems, like in Canada, that all the major cities are saturated with specialists and while jobs are available in mid-sized US cities, nobody seems to want to go there, but if those are the only jobs available, they may fill quickly too.

 

As for anestheisa, I don't see CRNAs being a problem here due to the strong Canadian medical lobby BUT with all the encroachment from NPs, PAs, and other mid-levels (pharmacists) I wouldn't be surprised if in a few years, CRNAs start appearing in Canada too. Right now, it's hard enough to get a job as an anesthesiologist, especially in a place like Vancouver. Imagine what that would be like with CRNAs. However, they've been a threat for a couple decades now, and they haven't encroached into the OR--yet.

 

However, as with all specialties, things go in cycles. Family medicine will probably get more popular over the next few years as stories about difficulties getting jobs abound. Then more specialty jobs will open up and students will start specializing again and family med will decrease in popularity.

 

As the above poster said, there simply isn't enough resources to sustain physician activities. Surgeons need an OR to operate. Anesthesiologists--same thing. Radiologists need their imaging equipment, etc. Unless you are in a specialty where you can easily either open up your own practice or join one where you don't need a lot of equipment for procedures, you're at the mercy of others. That's why you'll always find jobs in things like derm, psych, general peds/IM, and family med.

 

The bottom line is you have to think what's most important to you. If location/family are important, there's nothing more flexible than family medicine (or something general like general peds, general IM, or general psych). If you don't care about location, then you'll in all honestly likely get a job somewhere as a specialist.

[thebouque]

i hope they bring CRNA's here

 

putting people to sleep.....doesn't seem like something you NEED to have an MD to do, obviously its good to have one in the building for more complicated scenarios, but for 90% of the anesthesia seems like we could have someone else doing it. i'm fine with having nurses trained at the doctorate level (as of 2015) putting people to sleep. what is it like 2% of med graduates go into anesthesiology? the ones who are working are working over 60 hours a week? this won't last, we need CRNA's here.

 

This is the impression you had on your anesthesia rotation? From your point of view, what are the acts for which we absolutely need an MD ?

 

By the way anesthesia isn't about simply '' putting people to sleep''. Many people use oral benzos in their own home to fall asleep.

 

The simple act of intubating is very invasive and risky. If you haven't done your anesthesia rotation yet, I suggest you read a bit about the specialty, because it's a wonderful and very complex field.

[NLengr]

I am pretty sure this kids a troll.

[leviathan]

This is the impression you had on your anesthesia rotation? From your point of view, what are the acts for which we absolutely need an MD ?

 

By the way anesthesia isn't about simply '' putting people to sleep''. Many people use oral benzos in their own home to fall asleep.

 

The simple act of intubating is very invasive and risky. If you haven't done your anesthesia rotation yet, I suggest you read a bit about the specialty, because it's a wonderful and very complex field.

Intubation is just a skill that anyone, including a CRNA, can master. The things where you really need an MD in anesthesiology is everything else requiring your brain: the pre-op assessment, management of the patient intraoperatively, and post-op care. It's true that CRNAs can probably handle most basic cases, but even for simple cases there are rare complications when sh#t hits the fan we all know that we would want an MD taking care of us and not a mid-level provider. When it comes to higher ASA level cases those complications start occurring much more frequently and there's no way the average CRNA has the knowledge to know how to manage them.

[rswim]

i hope they bring CRNA's here

 

putting people to sleep.....doesn't seem like something you NEED to have an MD to do, obviously its good to have one in the building for more complicated scenarios, but for 90% of the anesthesia seems like we could have someone else doing it. i'm fine with having nurses trained at the doctorate level (as of 2015) putting people to sleep. what is it like 2% of med graduates go into anesthesiology? the ones who are working are working over 60 hours a week? this won't last, we need CRNA's here.

 

CRNAs can be beneficial if they have the correct attitude. Like nurses in other fields, they should be there to assist the anesthesiologist. Things get dangerous when people think they can do more than they are trained for.

 

A good CRNA will know that he/she is not an anesthesiologist, the same way a ER nurse knows they are not the same as an emergency doctor, a dental hygienist is not the same as a dentist, and a flight attendant is not the same as a pilot.

 

Flying an airplane and Anesthesia are often compared. 99% of the time it is smooth sailings and things are on autopilot. Does this mean that we can turf the pilot and let the flight attendants run the show? Perhaps on sunny days with a calm forecast we should forgo having a pilot? Good luck operating an airline on that premise.

 

Anesthesia is the same way, 99% of the time there isn't that much to it, but you need to have a fellowship trained anesthetist (13 years of post graduate education 9 since starting medical school) there for that 1%. Furthermore, we don't merely want patients to survive their surgery, we want them to have the best possible experience and highly trained specialists with thorough understanding of physiology and pharmacology are required to get the best possible results.

 

CRNAs shouldn't threaten anesthesiologists, and should be seen as a welcome addition to the team to assist the anesthetist the same way scrub nurses assist the surgeons. What scares me is this attitude that a CRNA is any different from any other specialized mid level provider.

[NLengr]

Anesthesia is the same way, 99% of the time there isn't that much to it, but you need to have a fellowship trained anesthetist (13 years of post graduate education 9 since starting medical school) there for that 1%.

 

If we anesthesiologists require a fellowship training to be competent of handling 1% of the situations encountered in most OR's, then our anes residencies have failed.

 

Fellowship training should only be necessary if you are doing extremely complicated cases (ex. high risk cardiac) or want to spend a major portion of your time researching.

[A-Stark]

I agree. Fellowships in anesthesia are pretty sub-specialized, e.g. peds, cardiac, neuro, pain. About the closest that might come to "generalist" fellowships are things like obs and regional.

[rswim]

If we anesthesiologists require a fellowship training to be competent of handling 1% of the situations encountered in most OR's, then our anes residencies have failed.

 

Fellowship training should only be necessary if you are doing extremely complicated cases (ex. high risk cardiac) or want to spend a major portion of your time researching.

 

Im sorry that was a misprint/understanding. By fellowship trained - I was referring to FRCP anesthetists (Fellows of the Royal College) - not necessarily sub specialists. This is in contrast to GPAs and nurse anesthetists (which we do not have in Canada at the moment).

[TimmyMax]

CRNAs can be beneficial if they have the correct attitude. Like nurses in other fields, they should be there to assist the anesthesiologist. Things get dangerous when people think they can do more than they are trained for.

 

A good CRNA will know that he/she is not an anesthesiologist, the same way a ER nurse knows they are not the same as an emergency doctor, a dental hygienist is not the same as a dentist, and a flight attendant is not the same as a pilot.

 

Flying an airplane and Anesthesia are often compared. 99% of the time it is smooth sailings and things are on autopilot. Does this mean that we can turf the pilot and let the flight attendants run the show? Perhaps on sunny days with a calm forecast we should forgo having a pilot? Good luck operating an airline on that premise.

 

Anesthesia is the same way, 99% of the time there isn't that much to it, but you need to have a fellowship trained anesthetist (13 years of post graduate education 9 since starting medical school) there for that 1%. Furthermore, we don't merely want patients to survive their surgery, we want them to have the best possible experience and highly trained specialists with thorough understanding of physiology and pharmacology are required to get the best possible results.

 

CRNAs shouldn't threaten anesthesiologists, and should be seen as a welcome addition to the team to assist the anesthetist the same way scrub nurses assist the surgeons. What scares me is this attitude that a CRNA is any different from any other specialized mid level provider.

 

Well put, rswim! Especially on the pilot analogy. Cheers!

 

Having a colleague who is actively making the switch from providing anesthesia in Canada to providing anesthesia in the US, and hearing his rants about CRNAs who figure that they know better than he does (despite his FRCPC, an additional fellowship training year and 8 years' independent practice experience but it's all Canadian experience, so it's clearly inferior to the US- psssht!) and do whatever they want, and then him having to come and bail them out when they almost invariably do something idiotic, it doesn't sound like the best anesthesia care model to me. That said, there are good CRNAs who know their role and stick to the program, but there are always a one or two on any staff, it seems, who figure that they know better and end up giving the rest a bad name.

 

I remember a few months ago, I was on call and had a really sick train wreck of a patient who was coming for a BKA. Her son was an anesthetist in Texas. She wanted me to speak to her son on the phone and we talked about what I was going to do. I could hear the relief in his voice when he realized that the anesthetic plan he had in mind was the same as what I had already decided that I was going to do with her. I remember that I did have to choke down the urge to ask him if he would have let a CRNA do his mother's case, as I had a pretty good idea of what the answer would have been!

[futureGP]

 

CRNAs can be beneficial if they have the correct attitude. Like nurses in other fields, they should be there to assist the anesthesiologist. Things get dangerous when people think they can do more than they are trained for.

 

A good CRNA will know that he/she is not an anesthesiologist, the same way a ER nurse knows they are not the same as an emergency doctor, a dental hygienist is not the same as a dentist, and a flight attendant is not the same as a pilot.

 

Flying an airplane and Anesthesia are often compared. 99% of the time it is smooth sailings and things are on autopilot. Does this mean that we can turf the pilot and let the flight attendants run the show? Perhaps on sunny days with a calm forecast we should forgo having a pilot? Good luck operating an airline on that premise.

 

Anesthesia is the same way, 99% of the time there isn't that much to it, but you need to have a fellowship trained anesthetist (13 years of post graduate education 9 since starting medical school) there for that 1%. Furthermore, we don't merely want patients to survive their surgery, we want them to have the best possible experience and highly trained specialists with thorough understanding of physiology and pharmacology are required to get the best possible results.

 

CRNAs shouldn't threaten anesthesiologists, and should be seen as a welcome addition to the team to assist the anesthetist the same way scrub nurses assist the surgeons. What scares me is this attitude that a CRNA is any different from any other specialized mid level provider.

 

so FRCPs are the ones flying the Boeing 747/777 super huge jet engine planes

 

FMAs are the ones flying propeller-engine short-distance flights?

 

and the CRNAs are the first officers?

[TimmyMax]

Precisely. But the patients don't like it when you refer to them as Boeing 747/777 super huge jet engine planes, so we'll keep that on the DL!

[rswim]

Currently doing an obstetrics rotation and it made me think about the CRNA issue in anesthesia.

 

Allowing Midwives and other mid level providers deliver low risk routine patients has most certainly not alleviated the need for obstetricians nor has it reduced their earning power. In fact, OB/GYN remuneration has increased substantially in the years since midwives have been given more freedom and responsibility. Would CRNAs to anesthesiologists not be the equivalent of a midwife to an obstetrician?

 

Don't get me wrong, I am not at all in favour of CRNAs or empty threats gov't makes without any real knowledge of what anesthesiologists do, but it is an interesting comparison don't you think?

[futureGP]

Currently doing an obstetrics rotation and it made me think about the CRNA issue in anesthesia.

 

Allowing Midwives and other mid level providers deliver low risk routine patients has most certainly not alleviated the need for obstetricians nor has it reduced their earning power. In fact, OB/GYN remuneration has increased substantially in the years since midwives have been given more freedom and responsibility. Would CRNAs to anesthesiologists not be the equivalent of a midwife to an obstetrician?

 

Don't get me wrong, I am not at all in favour of CRNAs or empty threats gov't makes without any real knowledge of what anesthesiologists do, but it is an interesting comparison don't you think?

 

the midlevels at this point in time, dont pose any threats

[rswim]

the midlevels at this point in time, dont pose any threats

 

Any attendings or senior residents out there with some insight into the future of anesthesia? Do you think it is a wise career choice at this time? From a job availability, flexibility, monetary, continuing evolving and remain interesting ad challenging, perspective?