anesthsiologist performing minimally-invasive spine surgery

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There's a pain medicine fellowship-trained anesthesiologist in my city who has a pretty successful practice performing minimally invasive spine procedures such as microscopic disectomy. I am just wondering if that is in the scope of practice for a gas doc and if an interventional pain fellowship includes that type of training...and is his practicing such procedures safe? Thanks.
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srleslie said:
There's a pain medicine fellowship-trained anesthesiologist in my city who has a pretty successful practice performing minimally invasive spine procedures such as microscopic disectomy. I am just wondering if that is in the scope of practice for a gas doc and if an interventional pain fellowship includes that type of training...and is his practicing such procedures safe? Thanks.
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I doubt it. What happens when there is a CSF leak? Does he then call neurosurgery?

If I remember, there was some clown Anesthesiologist doing this who took some course in South Korea. Maybe someone can find that story. He apparently was maiming patients. Hopefully he is rotting in jail next to Dr. Murry and OJ.
 
Where I trained, our pain anesthesiologist doc did these. I didn't think it was weird, but then again wasn't interest in pain enough to do the research. Don't know about the complications, or who took care of them. The previous guy trained him to do that. This was not what he focused on though, as he did a little bit of everything.

I bet it's more common than we think.
 
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cincincyreds said:
I doubt it. What happens when there is a CSF leak? Does he then call neurosurgery?

If I remember, there was some clown Anesthesiologist doing this who took some course in South Korea. Maybe someone can find that story. He apparently was maiming patients. Hopefully he is rotting in jail next to Dr. Murry and OJ.
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The guy I'm referring to did his fellowship at John Hopkins so not exactly a fraud.
 
Bertelman said:
Sounds not unlike the EM doc that calls anesthesia for a blood patch after an LP, or the GYN that calls a surgeon when they hit a ureter.
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Just like the old saying, "you can train a monkey to do surgery". It is a different story whether you get privileges, acceptance by the surgeons that refer patients to you and cover by malpractice.
 
chocomorsel said:
Where I trained, our pain anesthesiologist doc did these. I didn't think it was weird, but then again wasn't interest in pain enough to do the research. Don't know about the complications, or who took care of them. The previous guy trained him to do that. This was not what he focused on though, as he did a little bit of everything.

I bet it's more common than we think.
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Yeah... our cardiologists are doing all sorts of stuff in the hybrid OR's... usually cases that are deligated to vascular surgeons.
 
srleslie said:
There's a pain medicine fellowship-trained anesthesiologist in my city who has a pretty successful practice performing minimally invasive spine procedures such as microscopic disectomy. I am just wondering if that is in the scope of practice for a gas doc and if an interventional pain fellowship includes that type of training...and is his practicing such procedures safe? Thanks.
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Many people doing them. I don't have an issue with it.
 
At my training institution Pain docs would be doing microdiskectomies, balloon kyphoplasty and vertebroplasty. They booked OR time just like any other surgeons.
 
We had a heavy interventional pain clinic and they were always pushing the envelope. We focused on minimally invasive techniques though, not anything like an open microdiscectomy. Anything is possible, that was a while ago.
 
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If they are trained in it and practice safely, it is definitely within scope of practice for fellowship trained pain docs.
 
Where did you train? Do the fellows who train there learn these procedures as well?
 
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I am a pain fellow at a program that provides extensive training in min invasive procedures such as MILD and Kyphoplasty. Being able to do such procedures in the real world seems to depend more on available services at a given institution. If there is a strong neuro group you are less likely to get privileges. These type of procedures are definitely within our scope of practice. Discectomy...I don't know but the idea that you should not be able to do a procedure because of a very rare potential complication is crazy. Should GI stop doing colonoscopy because of possible perforated bowel that would require Gen Surg? Should anesthesiologists stop doing IJ central lines because dilating the carotid would require a vascular surgeon to repair?
 
RickKane said:
I am a pain fellow at a program that provides extensive training in min invasive procedures such as MILD and Kyphoplasty. Being able to do such procedures in the real world seems to depend more on available services at a given institution. If there is a strong neuro group you are less likely to get privileges.
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Yeah, if another group is already providing something similar, you may encounter turf battles.
 
Gern Blansten said:
If they are trained in it and practice safely, it is definitely within scope of practice for fellowship trained pain docs.
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You are assuming that all pain fellowships are created equal. The fellowship where I trained as a resident involved 12 months of running a revolving door clinic and lots of ESI's, facets and the occasional stimulator. I now cover a surgery center where a couple of guys who trained there are using their "korea fellowship" to perform endoscopic discectomies. The only thing stopping them so far has been the difficulty they face getting paid by insurance.

I haven't done a pain fellowship and I am not well versed in their scope of practice, but taking the following points:
1. No neurosurgical backup
2. No spine instruments in the building
3. A whopping 90 minutes of postop monitoring before being sent home
4. Questionable overseas training

and its REALLY hard to call this "practicing safely".
 
Anybody work with family medicine docs that do interventional pain? It is happening out there, and from those who provide anesthesia for it, I have heard it is not pretty.
 
Gasworks said:
You are assuming that all pain fellowships are created equal. The fellowship where I trained as a resident involved 12 months of running a revolving door clinic and lots of ESI's, facets and the occasional stimulator. I now cover a surgery center where a couple of guys who trained there are using their "korea fellowship" to perform endoscopic discectomies. The only thing stopping them so far has been the difficulty they face getting paid by insurance.

I haven't done a pain fellowship and I am not well versed in their scope of practice, but taking the following points:
1. No neurosurgical backup
2. No spine instruments in the building
3. A whopping 90 minutes of postop monitoring before being sent home
4. Questionable overseas training

and its REALLY hard to call this "practicing safely".
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All hospitals have a big problem with credentialing physicians to do newer procedures. Basically, people go and learn some drastically new technique (I'm not talking about small variations in their usual practice), and want to use it on patients and they say they are automatically credentialed for it. It is akin to a non-robotic surgeon just suddenly deciding that they are now a robotic surgeon based on some minimal teaching from a company rep.
With technological advances, this is an issue facing multiple fields and all hospitals as they try to determine what is and is not safe.
 
Gern Blansten said:
All hospitals have a big problem with credentialing physicians to do newer procedures. Basically, people go and learn some drastically new technique (I'm not talking about small variations in their usual practice), and want to use it on patients and they say they are automatically credentialed for it. It is akin to a non-robotic surgeon just suddenly deciding that they are now a robotic surgeon based on some minimal teaching from a company rep.
With technological advances, this is an issue facing multiple fields and all hospitals as they try to determine what is and is not safe.
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On a similar note, how is a pain doc learning an invasive procedure like mild or foraminoplasties any different than a urologist learning robitc prostatectomies post residencey or OB learning robo hysters? At my hospital, we just got a robot last year and none of the docs trained with a robot in residency. After a 2 years, the ob's are pretty good with it b/c they do a high volume of hysters but the uros take while doing their prostates
 
ssmallz said:
On a similar note, how is a pain doc learning an invasive procedure like mild or foraminoplasties any different than a urologist learning robitc prostatectomies post residencey or OB learning robo hysters? At my hospital, we just got a robot last year and none of the docs trained with a robot in residency. After a 2 years, the ob's are pretty good with it b/c they do a high volume of hysters but the uros take while doing their prostates
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This would be more analogous:

Pain doc -> MISS
GI doc -> lap nissen
 
I think the "what if" arguement is rather one sided. What if a TAVI goes wrong? A cardiac surgeon needs to bail the cards interventionalist out.

What if a ureter is cut? Urology fixes OB's mistake. What if Urology nicks a major vessel? Frankly, they may call in the "go to" Trauma/Gen Surg or even Vascular surgeon.

What happens when a general surgeon has a complication from a CEA?

What happens when a TIPS goes bad?

When a neurosurgeon punctures the peritoneum and thinks he/she may have nicked the gut while tunneling a catheter, do they just fix it? Or doe they get Gen Surg in there?

The number of examples is limited only by the breadth of interventions.
 
gasattack3 said:
I think the "what if" arguement is rather one sided. What if a TAVI goes wrong? A cardiac surgeon needs to bail the cards interventionalist out.

What if a ureter is cut? Urology fixes OB's mistake. What if Urology nicks a major vessel? Frankly, they may call in the "go to" Trauma/Gen Surg or even Vascular surgeon.

What happens when a general surgeon has a complication from a CEA?

What happens when a TIPS goes bad?

When a neurosurgeon punctures the peritoneum and thinks he/she may have nicked the gut while tunneling a catheter, do they just fix it? Or doe they get Gen Surg in there?

The number of examples is limited only by the breadth of interventions.
Click to expand...

OK I see the point you are trying to make. I can add to that list a very common scenario, a GI in an outpatient endo center perfs and has to pack some poor idiot into an ambulance and send them to the nearest ER. My point is that all of the scenarios you are giving involve what is essentially a complication within the practitioners primary scope of practice. A pain fellowship trained anesthesiologist who has NEVER inserted anything larger than a 16 gauge needle into a persons back has no business attending a 2 week seminar in korea and then deciding they are going to hammer trochars into a patients spine and rip out pieces of disc.

It's a sad state of affairs when this looks perfectly fine to credentialing committees, medical directors, nurse managers, etc. and it takes a bean counter at some thieving insurance company to put the brakes on this sort of monkey business.
 
gasattack3 said:
I think the "what if" arguement is rather one sided. What if a TAVI goes wrong? A cardiac surgeon needs to bail the cards interventionalist out.

What if a ureter is cut? Urology fixes OB's mistake. What if Urology nicks a major vessel? Frankly, they may call in the "go to" Trauma/Gen Surg or even Vascular surgeon.

What happens when a general surgeon has a complication from a CEA?

What happens when a TIPS goes bad?

When a neurosurgeon punctures the peritoneum and thinks he/she may have nicked the gut while tunneling a catheter, do they just fix it? Or doe they get Gen Surg in there?

The number of examples is limited only by the breadth of interventions.
Click to expand...

What you listed above are rare complications in routine cases while surgeons spent years in training. You are comparing Apples to Oranges. The point is microdiscectomy is a surgical procedure and being taught to fellows maybe only in a few programs in the country. I have seen people coming out of fellowship having a difficult time manuevering a needle, let alone using scalple, bovie, suturing, handling surgical instruments. If there is a lawsuit, it will be next to impossible to defend yourself without your peers support and demonstration of competency.
 
neuropathic said:
What you listed above are rare complications in routine cases while surgeons spent years in training. You are comparing Apples to Oranges. The point is microdiscectomy is a surgical procedure and being taught to fellows maybe only in a few programs in the country. I have seen people coming out of fellowship having a difficult time manuevering a needle, let alone using scalple, bovie, suturing, handling surgical instruments. If there is a lawsuit, it will be next to impossible to defend yourself without your peers support and demonstration of competency.
Click to expand...

The overall point is that while other specialties have been pushing these boundaries for years. our "gentelemenly" conduct had gotten us nowhere.. Medical specialties, cards, GI, even nephro are constantly upping the ante (as is every field)...... Why should our field be any different?
 
Gasworks said:
OK I see the point you are trying to make. I can add to that list a very common scenario, a GI in an outpatient endo center perfs and has to pack some poor idiot into an ambulance and send them to the nearest ER. My point is that all of the scenarios you are giving involve what is essentially a complication within the practitioners primary scope of practice. A pain fellowship trained anesthesiologist who has NEVER inserted anything larger than a 16 gauge needle into a persons back has no business attending a 2 week seminar in korea and then deciding they are going to hammer trochars into a patients spine and rip out pieces of disc.

It's a sad state of affairs when this looks perfectly fine to credentialing committees, medical directors, nurse managers, etc. and it takes a bean counter at some thieving insurance company to put the brakes on this sort of monkey business.
Click to expand...

It's within a cardiologists "primary scope of practice" to rupture a myocardial wall and kill a patient? A risk WHITHIN that person's primary scope of practice?? A "complication within the practitioners primary scope of practice".... hmm... I see....

So, is it not within the "primary scope of practice" for an interventional pain specialist to treat certain conditions, with evolving minimally invasive procedures, which their patients suffer?

Wasn't that the arguement cardiology faced long ago? That it was not "their business" to "intervene". Not without IR or CVS? Come on.
 
gasattack3 said:
The overall point is that while other specialties have been pushing these boundaries for years. our "gentelemenly" conduct had gotten us nowhere.. Medical specialties, cards, GI, even nephro are constantly upping the ante (as is every field)...... Why should our field be any different?
Click to expand...

When we make pain fellowship lasting 2-3 years, then we can advance the scope of procedures and likely more pain docs capable of "cutting" people.
 
neuropathic said:
When we make pain fellowship lasting 2-3 years, then we can advance the scope of procedures and likely more pain docs capable of "cutting" people.
Click to expand...

IMHO, if you have performed a sufficient number of procedures in that area (minimally invasive diskectomy) under proper supervision then you should be allowed to do that procedure in practice. This means you need a fellowship program willing to sign off on your competency in that procedure.

If you want to do that procedure without formal training at a teaching hospital then the bar should be set higher but still permitted after a sufficient number with supervision.
 
neuropathic said:
When we make pain fellowship lasting 2-3 years, then we can advance the scope of procedures and likely more pain docs capable of "cutting" people.
Click to expand...

Agree with blade, what did the general surgeons who graduated residency 10 years before laproscopy came out do? They found a mentor and learned. I'm not talking about taking a weekend course in Korea and saying you're an expert. I'm talking about taking time out of your practice as an attending to scrub in with someone who knows how to do the procedure and learn the ins and outs, then getting proctored and eventually doing it solo. There were many anesthesiologists out here who never did regional or did it minimally as a resident and then got more proficient when the ultrasound came out.
 
ssmallz said:
Agree with blade, what did the general surgeons who graduated residency 10 years before laproscopy came out do? They found a mentor and learned. I'm not talking about taking a weekend course in Korea and saying you're an expert. I'm talking about taking time out of your practice as an attending to scrub in with someone who knows how to do the procedure and learn the ins and outs, then getting proctored and eventually doing it solo. There were many anesthesiologists out here who never did regional or did it minimally as a resident and then got more proficient when the ultrasound came out.
Click to expand...

The difference is it is a big leap for non-surgeons learning to do surgeries vs surgeons learning a new technique. Surgery is not something you can learn from a 1-2 weeks course if you have never done it before. You ask any non-surgeons or pain docs what is a rongeur look like or what it is use for, most of them will reply, "I don't know".
 
neuropathic said:
The difference is it is a big leap for non-surgeons learning to do surgeries vs surgeons learning a new technique. Surgery is not something you can learn from a 1-2 weeks course if you have never done it before. You ask any non-surgeons or pain docs what is a rongeur look like or what it is use for, most of them will reply, "I don't know".
Click to expand...

I agree with you that there is a significant difference between procedures like MILD and SCSs vs MISS but if that's what they are starting to teach at the JHU fellowship and others then why are we ignoring this? How long before this becomes standard for pain docs in the future, maybe not next year but how bout 10? Nacus stated earlier in this thread that at his fellowship they routinely did some of that stuff so we should certainly learn. I've met a few old school pain docs who don't use flouro for any of their blocks, they don't get too many referrals. Before laparoscopy how many surgeons knew what a trochar was? That didn't stop them from learning the latest techniques and changing from open choles to lap choles.

Just to be clear, I'm not referring to some quack who does a weekend course and says "I can do MISS". Those guys are idiots. A weekend course or some course in korea should only be the beginning. I'm more referring to someone willing to put the time and effort in to learn a new procedure from a competent mentor. Taking time out of your clinic every month to work with that mentor, then getting comfortable, and finally being proctored before going at it alone.
 
ssmallz said:
I agree with you that there is a significant difference between procedures like MILD and SCSs vs MISS but if that's what they are starting to teach at the JHU fellowship and others then why are we ignoring this? How long before this becomes standard for pain docs in the future, maybe not next year but how bout 10? Nacus stated earlier in this thread that at his fellowship they routinely did some of that stuff so we should certainly learn. I've met a few old school pain docs who don't use flouro for any of their blocks, they don't get too many referrals. Before laparoscopy how many surgeons knew what a trochar was? That didn't stop them from learning the latest techniques and changing from open choles to lap choles.

Just to be clear, I'm not referring to some quack who does a weekend course and says "I can do MISS". Those guys are idiots. A weekend course or some course in korea should only be the beginning. I'm more referring to someone willing to put the time and effort in to learn a new procedure from a competent mentor. Taking time out of your clinic every month to work with that mentor, then getting comfortable, and finally being proctored before going at it alone.
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Absolutely correct. The great thing about Medicine is that your learning doesn't end after Residency; on the contrary, it takes a solid 10 years in practice to apppreciate all the things you don't know but now have the confidence to learn. This field is a humbling experience but that only makes you want to get better. For pain Docs this means stepping up to the plate and embracing all the new non invasive procedures. For older Anesthesiologists it means picking up that U/S and embracing direct vision nerve blocks.
 
The comparison to a surgeon learning laparoscopy or robotics is not valid. A surgeon already knows how to surgery and thats where the bulk of his training has been. Conceptually the steps to the surgery are exactly the same, as are the indications, and generally the complications. If he gets into trouble, he knows exactly how to fix it by converting to open.

Now I'm not saying you necessarily need 5-9 years of ortho/nsurg training to do some minor spinal procedures, but a year or two after a residency where you receive absolutely no training to do surgery, does not sound appropriate. No fellowship training at all, but some 'mentoring/proctoring' even less so. A general surgeon training to do spinal surgery would make a lot more sense. You can roll your eyes and say turf wars, blah blah blah, but some turf wars are legitimate. What would you guys be saying if internal medicine grads started providing general anesthesia after a training course or a year of fellowship?
 
I've rotated with 2 anesthesia pain docs in the VA who are performing MILD procedures on almost a daily basis. There's supposedly a course you can take to get some kind of certificate. The procedure sounds risky, but the equipment used really prevents the user from poking too far and making terrible mistakes.
 
Solarium said:
I've rotated with 2 anesthesia pain docs in the VA who are performing MILD procedures on almost a daily basis. There's supposedly a course you can take to get some kind of certificate. The procedure sounds risky, but the equipment used really prevents the user from poking too far and making terrible mistakes.
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Sounds like poor patient selection if they are doing that many. And the complications will add up when the numbers come up. The data vertos is suppressing from a researcher in Canada (neurosurgeon) is more concerning/telling than the funded data published.
 
Any EBM studies regarding this type of procedure regardless of the practitioner ( ortho, anesth, neuro)???
Nada
Fraud
2win
 
2win said:
Any EBM studies regarding this type of procedure regardless of the practitioner ( ortho, anesth, neuro)???
Nada
Fraud
2win
Click to expand...

EBM is a useless exercise for new technologies based on purely subjective phenomenon.

You going to get an IRB to approve MILD vs sham MILD? Not a chance. And good luck getting patients to consent to randomize between MILD and placebo control.
 
Comparing an anesthesiologist learning to use u/s for blocks to one who's learning spine surgery is ridiculous.

The hard part of nerve blocks has little to do with driving the needle. The bulk of being competent and safe with nerve blocks is knowing
- when the block is indicated or contraindicated
- which block to do
- which drug to use
- which additives to use or not use
- what dose to use
- what complications can arise
- how to manage those complications

None of this changes when a nerve-stim-guru anesthesiologist picks up an ultrasound probe for the first time.

All of it changes when he picks up a drill or hammer and starts eyeballing spines for the first time.

I think it's nuts and if one of these weekend course superstars booked a case where I work, you wouldn't find me doing the anesthesia for him.
 
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