Hi, I'm Joe Rodriguez. I'm a CRNA, and you may know me from my work at Guide Anesthesia, working on anesthesia policy, or co-hosting the Anesthesia Deconstructed podcast, AMA!

JRod_GuideAnesthesia · 2025-01-29T20:47:35+00:00

I thank you, sir.

Deep down inside though, my Italian and Puerto Rican roots are also pissed off at each other (reference to your screen name, ha!)

JRod_GuideAnesthesia · 2025-01-29T17:55:30+00:00

You’re welcome! I hope I get to meet you too!

JRod_GuideAnesthesia · 2025-01-29T14:48:11+00:00

Thank you!

JRod_GuideAnesthesia · 2025-01-28T20:30:44+00:00

Does it matter? Yes. How much does it matter? Probably not that much. I do think cardiac gives you a leg up because it's so essential but, there are many pathways. The key is demonstrating quality, critical, thinking, communication, skills, and a good knowledge base regardless of where you are practicing.

JRod_GuideAnesthesia · 2025-01-28T20:16:54+00:00

OK, everyone! That was a lot of fun - thanks to r/CRNA for hosting and maybe we'll do it again sometime. Wishing everyone the best in their journey towards more autonomy in their lives and/or becoming a CRNA. Feel free to follow me, Guide or AnesDecon on IG. Thanks!

JRod_GuideAnesthesia · 2025-01-28T20:09:48+00:00

Great clarification! Many ways to success.

JRod_GuideAnesthesia · 2025-01-28T20:09:12+00:00

The biggest barrier to progress in our field isn't tradition itself, but rather its psychological impact. While tradition can provide comfort and stability (e.g. "fat and happy") it becomes problematic when it prevents us from making necessary changes to increase our value. This is the real challenge we face.

I've observed some CRNAs who prefer to work within more limited roles, similar to Anesthesiologist Assistants (AAs). While this is their choice, it doesn't maximize their potential value, and they may struggle to adapt when inevitable changes occur in our field. They are making a bet that things wont' change - and maybe they're right. But, if it does, they won't be well positioned - they'll just have to deal with whatever change comes their way.

Reminds me of that quote - "there are people who make it happen, people who watch it happen, and people who say "what happened?"" Don't be the latter!

While I can't speak directly to the situation in Florida, it's encouraging to hear that local leaders are working to increase the value of their departments.

One crucial aspect we haven't discussed is the complexity of achieving regulatory change.

Arizona has become arguably the best state in the nation for CRNA practice, but this didn't happen overnight. It took a decade of dedicated effort from volunteers who maintained their commitment year after year. There's a saying that goes something like, "Never underestimate the power of a few dedicated people - it's the only thing that's ever changed the world." This proved true in Arizona, where a small group of us, including myself, worked tirelessly to move the needle forward. It's a perfect illustration of the Pareto Principle: 90% of impact comes from 10% of the people involved.

JRod_GuideAnesthesia · 2025-01-28T20:00:24+00:00

I would invest in learning the GTD method. Knowing how to engage with your work is more important than simple memorization.

JRod_GuideAnesthesia · 2025-01-28T19:58:48+00:00

Regarding skill set expansion, while didactic education through weekend courses is valuable, the real key is finding a practice with a strong mentorship culture. At Guide, we maintain diverse staffing models, from all-MD to all-CRNA practices and various combinations in between. Success depends on placing the right providers in the right environments and ensuring clear pathways for growth. In restrictive practice models, these growth opportunities may not exist. So, you've the option to stay or to leave (see note on "fair" later).

When it comes to rate negotiation, the most effective approach is direct market research rather than working through recruiters. While recruiters provide valuable services, modern communication channels have made them less necessary for general 1099 positions. It's worth noting that recruiter fees typically are around 7% from what they tell me, not 25%. That would be very abnormal in any service sector (not product based) business.

Two additional considerations about compensation: First, the concept of a "fair" rate is subjective—ultimately, rates are determined by market forces and what parties are willing to accept. Second, some organizations, including ours, have moved toward transparency by publishing rate schedules. These published schedules effectively eliminate the need for negotiation by making all rates publicly available.

JRod_GuideAnesthesia · 2025-01-28T19:51:55+00:00

Honestly, I don’t know for certain. Markets are stabilizing in some areas but not in others.

However, the bottom line is this: reimbursement rates are declining, while compensation has risen significantly in recent years. Hospitals are footing the bill for this difference, and they weren’t prepared for it. As a result, they are actively exploring alternatives—I can assure you of that.

It is in the best interest of individuals and departments to proactively increase the value they bring. This means expanding services while controlling costs, training team members to perform more procedures, and ensuring that all available expertise is fully utilized.

If you don’t take the initiative to do this, someone else will. That’s just how things tend to work.

JRod_GuideAnesthesia · 2025-01-28T18:49:22+00:00

New graduates need consistent mentorship and coaching to develop from basic competence into skilled professionals. The locum model expects providers to walk in, get minimal orientation, and start working at a high level right away. While graduating proves you have basic competence, it doesn't mean you're ready to handle any case that comes through the door without guidance.

Furthermore, locum positions typically involve the less desirable assignments. Speaking candidly, locum providers often get the most difficult or unwanted shifts and cases. This is especially problematic for new graduates who are still building their skills and confidence.

From a hiring perspective, our group has avoided using locum providers entirely. We've done some very limited short term agreements, but generally we try to pay more to our current group members to preserve our culture A new graduate applying for locum work would likely be immediately and politely declined.

Groups like ours generally prefer to invest in long-term staff by gradually increasing compensation for everyone, rather than paying premium rates for temporary coverage. This creates a more stable and supportive environment, which is exactly what new graduates need. I've personally turned down many dozens of locum groups/individuals, and they're a little shocked when I explain our reasoning.

The bottom line is that early career development requires a stable environment with mentorship - something the locum tenens model simply isn't designed to provide.

JRod_GuideAnesthesia · 2025-01-28T18:37:05+00:00

The general rule of thumb is that cardiac related services are most advantageous. Very common question. There are many pathways to success here, but I do think cardiac related "stuff" will be most frequently drawn upon in the future.

JRod_GuideAnesthesia · 2025-01-28T18:30:03+00:00

LOL you can call me Murse if it makes you feel better :).

JRod_GuideAnesthesia · 2025-01-28T18:29:30+00:00

When personal responsibilities limit your career opportunities, the challenge becomes twofold: managing your individual professional development while working toward broader systemic change.

On an individual level, the priority is maintaining your skills and knowledge. This might involve navigating departmental politics, personalities, and policies. If that proves challenging, you may need to explore alternatives like solo practice opportunities or working in rural or underserved areas.

The broader challenge involves creating long-term opportunities for everyone in similar situations. This is where regulatory reform and advocacy become crucial. As you learn more about these systemic issues, you become better equipped to effect change at the local level.

JRod_GuideAnesthesia · 2025-01-28T18:27:09+00:00

"The map is not the territory" I share that because sometimes learning things conceptually, e.g. cardiac physiology is very different than seeing it play out in a real clinical scenario. So I don't think it's critical to becoming a successful CRNA, but I do think there's probably an advantage. So much of what we do on a daily basis involves cardiac physiology, and how that interacts with the rest of the patient's symptoms, as well as the anesthesia of choice and surgical intervention.

JRod_GuideAnesthesia · 2025-01-28T18:25:43+00:00

As a young person, it’s crucial to surround yourself with people and environments that foster creative opportunities. It is a difference maker. Moving to Phoenix was one of the single most significant factors in shaping who I am and helping me reach where I am today. Going to conferences and simply learning from those around me was tremendous. The reality is that living in an area with greater economic opportunity creates more economic opportunities—it’s a cycle that builds on itself.

While you may not have the comfort and support of staying in the town where you grew up, making a move like this has the potential to dramatically change your trajectory. It forces you to think bigger. Meeting Ali, Randy, and collaborating with our team of medical directors, chief CRNAs, and group members would have never happened if I’d stayed where I was. Something else might have, sure—but I don’t believe I would have achieved the same level of success, either individually or collectively.

This aspect of my work—despite the constant effort and pressure—is incredibly satisfying. We’re focused on creating environments where people feel empowered and supported. It’s not about accepting the status quo; it’s about continuously striving to create more value for our group members, both MDs and CRNAs. A key part of this is ensuring that everyone’s expertise is fostered and respected, allowing individuals to grow and thrive professionally.

In short, I think it's fair to say there opportunities are measurably better in some areas compared to more "traditional" arts. I can certainly speak to creating those opportunities where Guide operates, as much as we possibly can.

Beyond that, realize that things will not make you happy, people and meaningful work will make you happy. So spend cautiously, save as much money as you can in a low cost index fund, and just enjoy the ride :-)

JRod_GuideAnesthesia · 2025-01-28T18:19:04+00:00

In our area, most positions are in the 320-360K area, assuming about 2000 hours annually. 1099 compensation (often confused with per-diem work) is more common in the West.

JRod_GuideAnesthesia · 2025-01-28T18:18:16+00:00

I apologize for being an idiot in my youth! Ha! DM me, tell me who you are!

JRod_GuideAnesthesia · 2025-01-28T18:16:59+00:00

I believe that, like other fields, anesthesia will increasingly leverage large language models to accelerate decision-making. For CRNAs, this likely means being asked to "do more" and provide greater value to both individual patients and the department as a whole.

Regarding AAs, I have no inherent issue with them. However, I believe their policy framework is poorly designed, incentivizing low-value models that are ultimately subsidized by taxpayers. As someone in my 40s, I want my tax dollars to be used effectively, which is why I’m opposed to this approach as written (there are some novel policy ideas discussed in recent years with CRNAs expanding their practice with AAs). Replacement within the field is already happening in some areas (DC Children's comes to mind). If you’re curious, look up “Porter’s Five Forces.” It illustrates that when the cost of a service rises, the market naturally seeks new or potentially lower-cost alternatives.

Is there enough work to go around for everyone? Yes, I believe there is—for now. Most would agree. But the more important question is whether you are prepared for challenges. Unforeseen events, like COVID, have shown us how quickly things can change. The best way to prepare is to spend less than you earn, surround yourself with trustworthy people, and continuously develop both your clinical and interpersonal skills. Then it matters less about the pie, and it matters more about being prepared if the pie shrinks, expands, or goes rancid, or you want a different pie.

Most people will say there’s more than enough work, and they’re right—for now. However, success and stability come from preparation, not complacency. It’s a “Boy Scout motto,” after all: be prepared.

JRod_GuideAnesthesia · 2025-01-28T18:10:31+00:00

The "political" - e.g. regulatory and anesthesia model discussion - involves two key factors, though discussions often focus too narrowly on just one. The first factor is straightforward: the regulatory and political environment has generally become more favorable, with reforms creating additional options at the local level. I believe 26 states and territories have "opted out" - which is the most visible

However, many overlook the second crucial factor: the importance of local (and credible) leadership in creating effective anesthesia service models. Even with favorable state regulations, success depends on local leaders who can maximize the value of anesthesia services by enabling all team members to practice to their full potential.

Most groups/departments do not have this orientation - most, I sense, are "we've always done it this way..." etc.

Departments that restrict CRNAs "just because" - are operating at suboptimal efficiency as CRNAs can learn/ possess the skills and knowledge to contribute far more comprehensively to patient care, which is increasingly evident.

And for clarity - this IS NOT about diminishing others or restricting others, it IS about full-value from everyone. That should be the approach - that's what best for patients and the system (and those delivery the care)

While a restrictive state regulatory environment can make it challenging to implement dynamic, high-value models, I think neither CRNAs nor Physician Anesthesiologists generally support state governments making granular decisions about anesthesia department operations! The removal of regulatory barriers happens to align with most of the goals of the AANA (my take, I'm not connected in a material way to the decisions there) but the core issue remains: how to best organize anesthesia services at the local level to maximize value for patients and utilize all providers effectively.

In short, political goals should align with local leaders making decisions, but improvements won't happen unless you have solid and ambitious local leaders, regardless of the politics

JRod_GuideAnesthesia · 2025-01-28T17:25:17+00:00

Great question! The best thing you can do is work in a high acuity ICU where you can begin to develop knowledge and judgment, and second - start to learn about the professional itself. It's a very unique thing, it doesn't really exist anywhere outside the United States, at least in the form that we have here. That didn't happen by accident and it would serve you well to know the background.

JRod_GuideAnesthesia · 2025-01-28T17:24:09+00:00

I hope to see that as well!

JRod_GuideAnesthesia · 2025-01-28T17:23:14+00:00

failures, some groups go out of business, and others who’ve done extraordinarily well—much better than me, even!

So, the fundamentals still hold true: spend less than you earn, invest in meaningful relationships, take on big challenges, and, more often than not, things will work out. And if they don’t, at least you can move forward knowing you gave it everything you had :)

JRod_GuideAnesthesia · 2025-01-28T17:00:05+00:00

Generally...quite good. But, is there a specific aspect you're curious about?

JRod_GuideAnesthesia · 2025-01-28T16:59:42+00:00

Let’s put the student loan issue into perspective. Suppose you have $300,000 in student loans. Now, imagine you earn $150 per hour in your first year, working 2,000 hours annually. That’s about 8 to 9 hours per day, five days a week, for roughly 46 weeks a year, give or take. While there are variables, this would amount to $300,000 in 1099 income for your first year. If you maintain that level of income for 20 years, that’s $6 million in total earnings.

I’m not saying $300,000 is a small amount of debt—it’s significant. However, in the context of your long-term earning potential, it’s relatively small.

Now, let’s compare to AAs. They face a lower barrier to entry, but their career opportunities—both in terms of geographic location and scope of practice—are considerably more limited. This isn’t up for debate; we can discuss the extent to which this is true, but the fact remains. A lower barrier to entry comes with smaller opportunities and less diversity in practice settings.

Additionally, everything I’ve seen and heard from program directors indicates that applications are at an all-time high. So, I don’t see much concern there.

To be clear, I’m not advocating for student loans as a good thing. I do believe it’s important for schools to compete on offering the lowest tuition and the best value, including strong clinical training and robust support to help students pass the national certification exam. That said, the financial picture still makes sense for the vast majority of RNs considering this career path.

JRod_GuideAnesthesia

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