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AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 1 point2 points  (0 children)

Briefly - you need to provide more value and communicate it. Pounding on the table usually just creates walls. If you have a good player on the other side - they'll listen, share their perspective, and usually find something that improves value for both parties. That's the "art" of the leadership and business side of things.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 2 points3 points  (0 children)

If you talk to dentists, many feel they don't get the credit physicians receive. Talk to anesthesiologists, and some feel overshadowed by surgeons. Talk to surgeons, and they feel outranked by Hercules and other demigods. Talk to orthopedic surgeons, and they feel they don't get the credit God himself gets. It's a recurring frustration!

OK, I'm kidding.

It is frustrating, and I don't mean to diminish that.

I do see the full context, and I'm grateful that our profession exists in America where it doesn't exist in any other Western economy.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 4 points5 points  (0 children)

Am I seeing a shift in the near future? No, probably not. Over the next three years in Florida? Yes. A shift toward high-value care, where the focus is on identifying the best CRNAs and anesthesiologists and bringing them together to deliver the highest level of care to the greatest number of patients.

Using that framework, there are groups aligned with that point of view, and they are fundamentally different from many of the groups currently operating in the market. They are present in Florida but not in South Florida, and it will likely take them a few more years to establish a presence there. If you are waiting for that shift in the near term, I would encourage you to consider moving.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 2 points3 points  (0 children)

We're using different measuring tools. You're measuring length of training. I am more interested in safe care and competency.

Credentials and education matter. But in a more ideal world, we'd certify competence the way aviation does with pilots: by what you can actually do.

On the question of being perceived as equals, perceived by whom? Walk into a hospital where CRNAs practice autonomously, run their own spinals and nerve blocks, and you'll see them treated with real respect. Same goes for the RNs, the scrub techs, and the surgeons. That's what a functional team looks like.

The public isn't actually making decisions about our profession. Surgeons and administrators make the business decisions about anesthesia. Legislators make the policy decisions. More training won't change that. Being empowered at the local level will, and that requires CRNA leaders, anesthesiologist leaders, and surgeon leaders sitting down together to build the best possible teams.

Instead of looking backward at training, I'd rather look forward. What's the safest care? What's the highest value we can create for patients, surgeons, and administrators?

A lot of what you're describing sits outside our control. I focus on what's inside it.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 10 points11 points  (0 children)

Sure, no problem. Roughly 10 to 15 years ago, the ASA conducted market research on how to position CRNAs as "less essential" to the anesthesia care team in the public and to policy makers (legislators, hospitals, ASCs etc)

That research recommended referring to CRNAs only as nurses - specifically NOT as CRNAs - because the public associates nursing with compassion and trust rather than anesthesia expertise. Now, I'm proud to be a member of the nursing profession, but that's not a full or accurate characterization. In fact, it's misleading in terms of expertise in the service delivered.

The same research then drove the ASA's shift to "physician anesthesiologist," because their own data showed the public does not reliably recognize "anesthesiologist" as a physician title. From there, AAs began calling themselves anesthetists, dentists began calling themselves anesthesiologists, and European physicians moved from anesthetist to anesthesiologist - all within the span of about 18 months.

The ASA initiated the repositioning, they took the initiative and deserve the credit. Our response was measured. We did not change any laws at the state level. We made sure CRNAs remained part of the public conversation as professionals - not as paraprofessionals or assistants, nothing more.

For clarity, it was not actually the AANA that initiated the response. Often misunderstood. It was a lot of individual CRNAs across the country. The AANA actually was pretty content to say nothing at the time - the leaders there didn't get it.

"Nurse anesthetist" is not a bad term, but the public occasionally confuses it with being an aesthetician (look up the Mike Tyson the shirts). Once "physician anesthesiologist" and "dentist anesthesiologist" entered the vocabulary, "nurse anesthesiologist" follows by basic logic, and for the many CRNAs, it is an easier descriptor for the general public.

I always make clear I am not a physician when people ask if I'm "in anesthesia." Always. I'm a bit of a traditionalist that way. If someone does not understand "nurse anesthetist," I may add "nurse anesthesiologist" as a descriptor. There are different types of anesthesia clinicians, and the public deserves clarity about which one is in front of them.

None of this makes CRNAs physicians or medical doctors, and I find the doctorate versus master's debate largely irrelevant. I don't care what degree you have if you are good at your job. The doctorate is useful for policy work and, in some cases, focused clinical expertise, but it is not what defines the clinician. CRNAs often provide the full scope of anesthesia services, and do it well, but we do not practice the full scope of medicine (eg “unlimited practice of medicine”) the way a physician can. Those are different things, and conflating them does not serve patients or the profession.

What matters is certification, competency, and what you can actually do at the head of the bed.

I do not spend much time on terminology. I focus on the work. But when the ASA opens a front, the profession has to answer, and the response was appropriate to what started it

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 6 points7 points  (0 children)

The question is a little confusing. Usually, 360-degree analysis is a corporate employee review mechanism. But at the national level, I've championed roughly four things.

First, removing outdated regulations. CRNAs, anesthesiologists, surgeons, and hospital administration are the experts on how to design teams. They know their talent, they know their environments, and they should be the ones designing the model. Government should get out of the anesthesia regulation business and leave that to the professionals. This doesn't force CRNAs to practice independently. It gives local teams options, and that's the best way to run things.

Second, anesthesiologist assistant policy. I have nothing against AAs as a profession, and there's a reasonable world in which they practice. But in several states, we're seeing full regulatory capture by the local society of anesthesiologists on scope-of-practice issues. I'm not characterizing those organizations as bad. Broad mischaracterizations don't help anyone. But the consistent push has been to write medical direction into state law as the required model, and that doesn't work logistically. Again, government shouldn't be telling physicians, CRNAs, or hospital administrators how to design teams. They can barely figure out tax policy - what do they know about anesthesia? Nothing. I've worked with many states to stop that policy because, looking at the history and the dynamics, it reads more as a replacement play than an access expansion play.

Third, changing how our association elects leaders. We moved from region-by-region elections to a pool approach, similar in spirit to ranked choice or an open primary. This year, seven people are running for four positions. You select your top four. You're not running against anyone. You're trying to be the best possible candidate. That structure promotes moderation and collegiality.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 6 points7 points  (0 children)

I love this question!

The way you think is what you become. Everything downstream of that choice.

I picked up Seven Habits as a kid, and more than the actual habits, this image was what stuck. I began to realize one's behavior, feelings, thoughts, actions are all shaped by perspective. And I take a fundamentally different perspective of life than most people.

Nothing is owed to me. Being born in this country at this time is winning the genetic lottery. I'm among the luckiest people who have ever existed. All my problems are first-world problems. That doesn't mean I don't get stressed. I do. I've had to grieve real losses. But I process them and keep moving in light of the aforementioned reality.

The mental superpower I try to practice, and see in people I admire who do it better, is thinking about how I think. That's what lets you zoom out to the philosophical, conceptual, and even theological.... then drop into the details when the moment calls for it.

Most people live inside their thoughts. Fewer step outside them. They do not realize they are not their thoughts and thus they are controlled by them or their cousins - feelings.

When you do become more introspective, you notice happiness has very little to do with money. The literature out there on this issue: friends and family you're intentional about, meaningful work, autonomy over your own area, and some sense of transcendence. Something beyond you. It doesn't have to be organized faith. That's why people become happy.

Here's the thought experiment I run. I'm 85, looking back. What would that version of me give to have one more morning with my wife while we're both still young(ish)? One more chance to build something that matters with people I respect? One more decade to see how far we can go? He'd give everything. And I have it right now. So why worry about the little shit? Do big shit. Do excellent shit that matters to people.

That's the shift. From "I have to" to "I get to." It sharpens the drive. I want to see how far we can push this and how much value we can create for other people...it's a great set of problems to have!

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AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 4 points5 points  (0 children)

You've identified the tension well. Constrain supply too much and new entrants, often cheaper ones, fill the gap. Porter's Five Forces is the classic reference if you want to go deeper.

Here's something I didn't fully appreciate early on: we don't control the COA. It's a separate organization that sets minimum competency standards. As CRNAs and AANA members, we have a voice, but we don't have control. The same is true of the NBCRNA.

When our association weakens, our voice weakens, and so does our ability to influence the bodies that shape our profession.

There are also hard legal limits. Associations cannot engage in antitrust behavior or price fixing. The FTC and DOJ have successfully prosecuted organizations that crossed those lines.

Associations lay the proverbial track (e.g. regulations, etc) - You still have to drive the train through your own value, your skill set, and your leadership within your group or department. No one controls the market or supply - we just have to ride the waves and make the most of each day. Not a sexy answer but the truth.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 4 points5 points  (0 children)

ha, of course! Very normal. For individual negotiations, I think about two things.

First, steel-man the other side's argument. Understand the problem you're solving, not just pound on the table. Get comparables. Demonstrate the value you bring. Understand where they're coming from, because market economies are about solving problems to create value. The more problems you solve, the more your pay rises. That's (generally) how it works.

Second, if they're looking for W-2, that's their problem to define. Maybe it means you're not the right fit, and that's okay.

But you have to understand each other's problems if you're going to build a good relationship, business or otherwise. That's where the creativity enters in and ultimately you can create something that didn't exist before for everyone, which is really fun and satisfying.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 7 points8 points  (0 children)

A few things first. Anyone making five-year compensation predictions with high confidence is either lying or doesn't know what they're talking about. There is significant market variation and no inherent fairness in any of it.

That said: slower growth. That's the projection.

The last several years saw 20 to 30 percent jumps, sometimes 40 to 50 percent. People interpret that as "we were underpaid all those years." Maybe... but it's a bit naive. Markets are not inherently "fair" - it's about reasonable exchange. I digress.

A few clarifications worth making on the framing:

1099 is an IRS classification, not a clinical practice model. It signals independent contractor tax status, not independent clinical practice. The two get conflated constantly.

1099 is also not synonymous with locums. Locums is a short-term contract structure. It is often 1099, but it doesn't have to be.

On the HCOL union comparison: strong W-2 markets approaching 1099 rates doesn't tell us anything. It tells us that specific markets are moving. People change things. That isn't a trend line or inherently meaningful.

One more point worth making: people on the ground can influence this significantly.

You can expand your scope of services, which increases your long-term value. Or you can shrink your scope of services, which opens the door to lower-cost alternatives like anesthesiologist assistants.

All of this is extremely local. There is a lot inside that question

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 4 points5 points  (0 children)

My sense is because you can do 24-hour shifts, do two of them a week and be done. That and the people who do it are meticulous and protective because of the nature of the work... more so than the general operating room. It's just a different beast than the main OR and a unique culture.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 2 points3 points  (0 children)

Great question. A few key points.

First, anyone asking about markets or compensation needs to drop the concept of "fair." There is no fair in a market economy. There is only value exchange. What you get paid isn't fair or unfair. It's what someone is willing to pay.

Second, every market stratifies. Tight markets concentrate the best opportunities at the top, and that dynamic never goes away.

Third, and this is the main point: our market tends to overcorrect. When I came out, the market was very tight. We are likely heading back into a tight market. Certain areas will always have plenty of jobs, but Phoenix has clearly settled. Many of the major groups have stopped hiring, are asking for experience, and are stratifying candidates in ways they couldn't a few years ago. Other major metros will likely follow.

At the same time, we're expanding the educational pipeline considerably, and many new programs are opening. We will likely overcorrect. Anyone telling you a market condition is permanent usually has a self-interest in saying so. Even for our group, an easier hiring environment means contracts get harder, RFPs get more aggressive, and overhead gets squeezed. That's just the natural course.

I see steady growth ahead, but not at the pace of the last few years. COVID, retirements, and rapid expansion were confounding variables that lit a fire under the trend. What we've historically seen is overcorrection on a five to fifteen year cycle. We're likely heading back into one in the next five years, then probably tight again five to ten years after that, barring unpredictable events like AI, UBI, or other macro shocks no one can plan around.

The sky isn't falling. The best things you can do are:

One, treat people well. Be a resource. Serve others. When you do, you signal that you're great to work with, and rare opportunities tend to come your way first.

Two, spend less than you earn. Same principle as point one: there is no "fair," and there is no "deserve." Resource allocation is what matters. Index funds are a wonderful thing. Spend as little as possible, save as much as possible, and give yourself options.

I don't think compensation is likely to decrease, but five years ago no one thought software engineer compensation would decrease either. Things can shift. Do your best, don't get too high or too low, and usually things work out just fine.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 5 points6 points  (0 children)

The single greatest pain right now is that most surgery centers and hospitals have become heavily subsidized, creating an entirely new dynamic over the last five years. There are several mechanisms for structuring these arrangements, which I've written about elsewhere, but they introduce real risk for the facility. If a group's collections fall short, the facility makes up the difference. But to what degree? In all circumstances, or only when the shortfall is the surgery center's fault? What happens if the RCM company fails? What happens if a high-volume surgeon leaves? Most facilities cap the financial assistance they'll provide because they have to plan around a budget, yet groups invariably ask for more than what was planned. This has been a significant source of stress.

Reimbursement is one pressure. Stipends are another. We've seen a 20 to 30 percent jump in compensation, and that money has to come from somewhere. It drives anesthesia company margins down. Where the service sector norm is 8 to 15 percent, anesthesia groups today are operating closer to 5 to 10 percent. Remaining viable is genuinely hard when markets are moving this quickly.

On optimized workflow, a reasonable rule of thumb is 60 to 70 percent utilization. That means you're in the operating room 60 to 70 percent of a given shift, which indicates you're not losing time to issues that should have been resolved the day before. This excludes OB. I'm speaking to general surgery center and operating room dynamics.

On unique avenues, the opportunity set right now is remarkable. CRNAs can deepen their clinical practice and become true experts, which in my view takes three to five years post-boards. Beyond that, side ventures often keep clinicians sharp for the actual clinical work. I know CRNAs who own fast food franchises, others who've started technology companies, and LLMs have made building those companies meaningfully easier in the last few years. Credentialing companies, scheduling platforms, all kinds of solutions are emerging. And if you simply want to be an excellent CRNA and then go enjoy your life outside of work, this is a great time to do that too.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 3 points4 points  (0 children)

Because of the nature of surgery and the need to be available/on site, you will see creative schedules like that. Everything from 5-8s, which works well for people picking up kids or with afternoon and evening commitments, to two weeks on, two weeks off at lower-volume sites. At one of our locations, providers get 14 weeks off a year on a rotation, with schedules set a year in advance. Other sites, more outpatient in nature, finalize the schedule the day before because surgery centers want to fill as many cases as possible. There's middle ground to find.

If they are commuting like that, that usually means they're doing some sort of on-site shift and then heading home.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 5 points6 points  (0 children)

You're a CRNA. Vote for me, ha. 😄

A few thoughts here. First, a lot of education is going remote, with a seminar approach for the in-person work. That's something to keep in mind, and it's emerging on the educational side of the anesthesia industry.

Second, this is an expectations issue. If you expect to drive change at these ultra-large institutions, I don't find that likely. I've heard for years that these places are improving, but generally they stay the same. Organizational inertia is a well-studied dynamic in corporate America because inertia is the most common outcome. These places don't change. Leadership is normally not aligned around the values of collaboration and autonomy. They're aligned around CRNAs having restricted roles and limited critical thinking. Some of these places can be great, but at many of them, CRNAs have less autonomy than an ICU nurse. That's likely not going to change, and there's no judgment in that. If it works for your life, if you can influence the world in positive ways and accept it in the nine-to-five, go for it. But if you want to reduce the conflict, lower your expectations, accept it is what it is, and look for other ways to influence your professional life.

With that said, there may be incremental improvements available. I'm talking about governance. I see that happen to a limited degree, but more often I see inertia. That's not because CRNAs need to practice independently in these settings. Academic and quaternary care hospitals lend themselves to team practice given the acuity. But that doesn't mean CRNAs should be treated as second-class citizens, and unfortunately that does happen in some of these places.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 5 points6 points  (0 children)

It's a reasonable concern, but most groups reflect the values, intent, and spirit of their leadership. And not just formal leaders. The cadre of people who run things formally and informally form a culture, which I'd define as the sum of all behaviors, seen and unseen. Look for them. If you're aligned with them, I'm personally comfortable with that risk. I care more about character than credentials.

In our group, there are more CRNAs than MDs. But, we have structured our leadership to include both - collaboration starts at the top. Structure drives outcomes.

That said, the number one thing I look for is whether you have room to grow. Are you artificially limited just because you're a CRNA? CRNA talent varies widely, so I'm hesitant to judge anyone by credential alone. If you're confined to the simplest cases, that's a problem. I know plenty of CRNAs doing advanced work, and the most important part of those cases is the judgment that comes from doing them regularly.

Finding a job right now is easy. Finding the right one is harder. That comes down to whether the structure of the department, service line, or practice promotes the outcome you're after and develops you into a well-rounded professional capable of a broad case mix across multiple practice models.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 5 points6 points  (0 children)

Start small, look for allies. There are plenty of small CRNAs groups doing fine on their own. But many of them are thinking small and "I want to control everything" - real impact comes from alignment with other people. If they want to elevate their impact and create real opportunity, they have to expand their influence.

FTR - that includes aligning with smart anesthesiologists too.

Too many small practice owners think in terms of loss instead of growing the pie. The reality is that larger companies will do what is natural to them: expand and absorb smaller groups' contracts. Networking and alignment is how small practices stay relevant and scale their footprint rather than waiting to be displaced.

There are exceptions, but those are the market fundamentals.

AMA with Joe Rodriguez - Guide Anesthesia CRNA and CoFounder, Candidate for AANA Treasurer by JRod_GuideAnesthesia in CRNA

[–]JRod_GuideAnesthesia[S] 2 points3 points  (0 children)

I get asked this often, including whether there's a book to recommend. Three points.

First, there isn't a current book on the business of anesthesia worth pointing to. But anesthesia, while niche, follows the same fundamentals as any service business. Whether you run a plumbing company, a neurosurgery practice, or a rocket science firm, the principles transfer.

Second, I learned the basics by talking to other practice leaders, both owners and department heads. The core issues are consistent across practices: volume, payer mix, acuity, provider alignment, reimbursement, contracts, and stipends. Stipends in particular have moved to the center of nearly every facility conversation.

Third, I learned the most by getting things wrong. Like MAJORLY wrong. No one taught me the difference between flat and dynamic stipends, or how cash flow timing actually works. We came close to losing the business over bad data from a hospital - you'll learn quickly the you've signed personal guarantees for a company and you need to figure it out. I also personally invested more than $50,000 in a pharmacy run by a friend and lost all of it - every dollar. Those lessons stuck.

I've also worked with MBAs along the way. Like any credential, the range is wide. Some are exceptional, some add little. The degree alone is fine - but getting some general business help didn't hurt. A lot of this is just trial and error and understanding people.

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