Tuesday, August 27, 2013

Does The ASA's New Headquarters Signal Peak Anesthesia?

There is a well known theory that when record setting skyscrapers are built, it is a signal that a major economic downturn is about to begin. This has been true throughout the history of skyscrapers. The Empire State Building was finished in 1931, near the onset of the Great Depression of the 1930's. The original World Trade Centers were built as the U.S. was entering into the severe economic malaise of the 1970's. The tallest building in the world, the Burj Khalifa in Dubai, was completed just as the Great Recession of this century took hold. It is thought that the reason skyscrapers and bad economies coincide is because skyscrapers are designed during times of great economic optimism and expansion. By the time it is finally completed years down the road, the economy has usually started on its inevitable down cycle. Thus these giant monuments of human ingenuity open just when it seems most foolhardy to build one.

I was thinking about this when I read my latest copy of the ASA Newsletter. Inside is a large spread reporting glowingly on the ASA's brand new headquarters being constructed in the suburbs of Chicago. There are pictures of smiling people holding shovels and gorgeous architectural renderings of the new building. The 70,000 square foot building will better house ASA's employees, which have doubled in number since 2007. This is all in the name of adding "value to its 50,000 members."

Well how nice for the big honchos at the ASA to get new offices. Is that why my annual membership fee is now over $600 per year? While they are admiring their views from their new corner offices, they also keep raising the cost of the CME's they offer. The ACE program that I use to maintain my CME's and MOCA has risen in price over 50% in the last two years. Why does the ASA need to double its number of employees in the past five years? Membership in the ASA has not doubled in that period. I don't feel any better served by my society by having a larger overhead.

The number of anesthesiologists reached its recent nadir in the mid 1990's when high malpractice premiums and low job availability scared medical students away from the field. Opinions changed when more surgeries began to be moved to surgery centers, necessitating more anesthesiologists. Medical malpractice was also helped by payout caps legislated by multiple states. Since then anesthesiology has become one of the hottest fields in medicine.

But now we may be reaching a peak in the number of anesthesiologists in this country. The ASA is fighting tooth and nail to prevent more states from opting out of physician supervision of CRNA's. Alas it is not having much success as 17 states have already taken that step while others are increasing the scope of practice of the nurses. The lucrative field of anesthesiology is starting to feel mighty crowded. With the advent of Obamacare in two months, more anesthesiologists may start contemplating retirement to avoid having to wrestle a new government bureaucracy to get reimbursed for their services. So there is a real danger that the number of anesthesiologists in practice may start to decline.

We shouldn't be shocked by all this. The number of physicians who train in different specialties are cyclical, just like the economy. Anesthesiologists may currently be peaking. Meanwhile, general surgeons could be hitting a bottom. In the 1990's a good categorical surgery residency was a tough get. Now surgery residencies have trouble filling their spots without hiring foreign medical graduates. Primary care appears to be starting its ascent after years of neglect by the government and insurance companies. So don't be surprised if anesthesiology starts to wane again as a specialty. It wouldn't be the first time. But at least the ASA officers will have new offices in which to cry into their Starbucks.


  1. Thanks for the link to the CO judge's decision to allow CRNA supervision opt-out. So instead of building an industrial park, how about our union leaders issuing a policy statement: no MD anesthesia training of CRNAs if our trainees insist on independent practice. How simple. Where else in America is such professional insubordination tolerated? If we want to participate in CRNA education and certifcation, we must extract an agreement from our trainees that their practice is supervised to our professional satisfaction. That's clear to me. Why not to the ASA/ABA/states/feds?

  2. Honest question: Is it feasible for an anesthesiologist to do what this surgeon did here?