Dental Anesthetists?

[FutureGasDoc2014]

I am an OMS3 hoping to match anesthesia at a west-coast program in a year. A few months ago I did an away in southern california at an AOA program where I met a "dental anesthetist". I am from the midwest and had never heard of this group.

For those of you like myself, a dental anesthetist is a dentist who trains for 1 or 2 years and can then apparently legally practice full general anesthesia, but usually will go into other dentists' office and do deep sedation or general anesthesia for their patients. These patients are typically 2-5 year olds! This dental anesthetist fellow told me that most of them will graduate and make between 400-600k annually with a very cushy work schedule. I assumed that the salary was inflated as from what I understand most anesthesiologist start at 350k with a fair amount of hours at the hospital.

Flash-forward to two months later, my sister tells me that my 4 year old nephew had anesthesia from a dental anesthetist in an office for some caps and filling. I asked her some basic questions...apparently he charges $750 per hour...his appointment ran over an hour and she owed him just over $1000. She said there were 4 other patients there to see him that day, and that my nephew was the shortest case. I did some quick calculations and found that this dentist could feasibly be pulling in $5-6k in a single day!!!!!

So I called him up, pretending first to be a potential customer...but then began asking questions as if I were interested in the field (which wasn't a lie). He told me that most days he sees between 4-6 patients. He says that he makes at least 800 dollars per patient...usually right around $1000-1100. He told me that his overhead is extremely low because he does Complete Intravenous Anesthesia with propofol and remifentanyl, and rarely intubates!!!!!!! He says that his overhead with driving is about 10-15% and that the rest is all profit.

He told me that typically he starts work at 630am and is done with cases by 1-2pm...he then makes phone calls for the following day until about 4pm while he drives home. He says most days he's home and done by 3pm if not earlier.

I mean run the numbers...this guy is profiting at least 3500k per day...profit. And I have no reason to not believe him because the day he saw my nephew he made a lot more than that!

My question now becomes...why don't anesthesiologists do this? I haven't done a residency, so maybe I will fall in love with the more complex cases that usually land in a med center...but my plan as it stands was to end up at a Surgery Center that does ortho cases as I think I would enjoy more straight forward cases done at an efficient pace...but could I just do this? Why don't anesthesiologists do this? And if they do, why don't more of them? It seems like anesthesiologists could provide a safer service while making a great living.

Please help me to understand this, as I am sure I've missed something. Thank you.

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[Silent Cool]

I am an OMS3 hoping to match anesthesia at a west-coast program in a year. A few months ago I did an away in southern california at an AOA program where I met a "dental anesthetist". I am from the midwest and had never heard of this group.

For those of you like myself, a dental anesthetist is a dentist who trains for 1 or 2 years and can then apparently legally practice full general anesthesia, but usually will go into other dentists' office and do deep sedation or general anesthesia for their patients. These patients are typically 2-5 year olds! This dental anesthetist fellow told me that most of them will graduate and make between 400-600k annually with a very cushy work schedule. I assumed that the salary was inflated as from what I understand most anesthesiologist start at 350k with a fair amount of hours at the hospital.

Flash-forward to two months later, my sister tells me that my 4 year old nephew had anesthesia from a dental anesthetist in an office for some caps and filling. I asked her some basic questions...apparently he charges $750 per hour...his appointment ran over an hour and she owed him just over $1000. She said there were 4 other patients there to see him that day, and that my nephew was the shortest case. I did some quick calculations and found that this dentist could feasibly be pulling in $5-6k in a single day!!!!!

So I called him up, pretending first to be a potential customer...but then began asking questions as if I were interested in the field (which wasn't a lie). He told me that most days he sees between 4-6 patients. He says that he makes at least 800 dollars per patient...usually right around $1000-1100. He told me that his overhead is extremely low because he does Complete Intravenous Anesthesia with propofol and remifentanyl, and rarely intubates!!!!!!! He says that his overhead with driving is about 10-15% and that the rest is all profit.

He told me that typically he starts work at 630am and is done with cases by 1-2pm...he then makes phone calls for the following day until about 4pm while he drives home. He says most days he's home and done by 3pm if not earlier.

I mean run the numbers...this guy is profiting at least 3500k per day...profit. And I have no reason to not believe him because the day he saw my nephew he made a lot more than that!

My question now becomes...why don't anesthesiologists do this? I haven't done a residency, so maybe I will fall in love with the more complex cases that usually land in a med center...but my plan as it stands was to end up at a Surgery Center that does ortho cases as I think I would enjoy more straight forward cases done at an efficient pace...but could I just do this? Why don't anesthesiologists do this? And if they do, why don't more of them? It seems like anesthesiologists could provide a safer service while making a great living.

Please help me to understand this, as I am sure I've missed something. Thank you.

The demand is not consistent. There is a great anesthesiologist in the Palo Alto area by the name of Alex Targ. He does mostly peds dental cases. Keep in mind however that many peds dental cases are under medicaid, which means you cannot charge the patient cash--you have to take what medicaid pays you, which paltry compared to the cash-pay figures you quoted above. Private patients you can charge cash.
I know of a dental anesthesiologist up near Boston (who used to work in CA). He told me he makes about 200K working 6 days per week and used to make over 300K in CA working 5 days. I think the deal with mobile anesthesia is that demand is very spotty. You might have a full week here and there; other weeks are dead. Also keep in mind that if you are performing mobile, office-based anesthesia you should bring an EMT with you. If you are interested, check out:

http://www.drtarg.com/
http://m2anesthesia.com/
http://www.zzzdmd.com/

Also contact @Sublimazing

good luck

 

[Sublimazing]

Yes, thank you for tagging me to this...lol...I think OP wants to hear from an anesthesiologist not a dental anesthetist but to clarify:

-2 years training, next year 3 years
-almost all of it is cash business
-750-1100/hour are pretty normal rates (a little less in socal...650)
-consistency is a problem. Filling your schedule with 5 pts per day is the toughest part, but once you get to that point it is one of the best hourly wages in healthcare...6am-2pm is very realistic...2500-3500 is very realistic
-overhead is closer to 15-20%...some cases are tubed...depends on the provider...some people do tiva some do volatile...tiva is cheaper by a longshot

And I have no idea why more anesthesia groups don't extend into the dental world. I think in a few years it will be more common. Someone I know got approached by a physician group looking to tranisition to dental. There are a few solo MDs out there...but an existing MD group could easily establish an Office Based Presence (like a restaurant that also has a food truck or does catering )

But ya, I'm curious too why the anesthesiologists haven't gotten into this...when the CRNAs really drive them out of hospitals I think it'll happen...who knows.

 

[Spinach Dip]

Anyone know a practice of this kind which will be looking to hire a newly licensed anesthesiologist in...say...10 years?

 

[Sublimazing]

Anyone know a practice of this kind which will be looking to hire a newly licensed anesthesiologist in...say...10 years?

I'm not sure if you're being sarcastic or not, but I am just as curious as the op as to why anesthesiologists haven't made themselves a larger presence in out-patient office based dental anesthesia?

Many of you have voiced that dentists providing sedation is unsafe...so why not make yourself available for these office based procedures? The compensation is great, the hours are great, and you would be providing such a service to these patients while simultaneously bringing the safety that organized anesthesia and your training permits to the world of dentistry.

Have your private groups invest in the portable gas machines and portable carts and send 1-2 anesthesiologists per day out to 2-4 offices.

Start with two providers initially until you feel safe in an isolated environment...or bring a nurse with you.

 

[Spinach Dip]

I'm not sure if you're being sarcastic or not, but I am just as curious as the op as to why anesthesiologists haven't made themselves a larger presence in out-patient office based dental anesthesia?

I was being half serious and half sarcastic.

[serious]

What does the future of this office-based practice look like? Is it something CRNAs (and their team model) will begin to dominate? Or is it something more suited to solo providers?

Also, if one has no attachments to Cali/the east coast, is there a greater number of available jobs? And how does the pay compare?

[/serious]

 

[Trisomy13]

I'm not sure if you're being sarcastic or not, but I am just as curious as the op as to why anesthesiologists haven't made themselves a larger presence in out-patient office based dental anesthesia?.

Off-site anesthesia in a stand alone center doing mostly peds with a dentist in my unsecured airway?

Sounds like a dream job.

 

[Sublimazing]

Off-site anesthesia in a stand alone center doing mostly peds with a dentist in my unsecured airway?

Sounds like a dream job.

Ya i know your residencies don't really train you guys for that environment...but there are at least a handful of physicians who have made the transition. It's really not so bad. And you can intubate whenever you want.

 

[GasEmDee]

Ya i know your residencies don't really train you guys for that environment...but there are at least a handful of physicians who have made the transition. It's really not so bad. And you can intubate whenever you want.

Residency trains us just fine for it. It's not hard, generally speaking. Just annoying and uninteresting to me personally. Most kids are extremely easy to mask ventilate if airway rescue is needed.

 

[Sublimazing]

Residency trains us just fine for it. It's not hard, generally speaking. Just annoying and uninteresting to me personally. Most kids are extremely easy to mask ventilate if airway rescue is needed.

Agreed on the level of difficulty, and certainly your training gives you the foundation...I have just haven't seen the residents at the hospitals we rotate through do IM inductions/Mask Downs independently without an attending or nurse present to help...or emerge their own patient...but i've only seen 3 programs so maybe that stuff is hit at other programs.

I can understand the boredom aspect, these cases are nowhere near the complexity that are fairly commonplace in a med center.

So i guess that's my answer, academic interest trumps money and lifestyle. That makes sense, you got to love what you do.

 

[GasEmDee]

So i guess that's my answer, academic interest trumps money and lifestyle. That makes sense, you got to love what you do.

I was responding to your comment about the training. We learn to do these types of anesthetics for myriad procedures.

You already mentioned what I think is the real answer to your question, which is the consistency of work. I think there are a great number of anesthesiologists who would trade academic interest for money and lifestyle, especially later in their careers. However, I would guess it is simply more lucrative to a full day of cases in a hospital or surgery center than to travel to various dental offices for the occasional case.

 

[PartyROC]

I was responding to your comment about the training. We learn to do these types of anesthetics for myriad procedures.

You already mentioned what I think is the real answer to your question, which is the consistency of work. I think there are a great number of anesthesiologists who would trade academic interest for money and lifestyle, especially later in their careers. However, I would guess it is simply more lucrative to a full day of cases in a hospital or surgery center than to travel to various dental offices for the occasional case.

I think @Sublimazing is located in SoCal where competition is roughest. I'm at a new york program and the DAs have no problem filling their schedules 5 days a week outside of SoCal.

I received job offers from 3 different locations and all of them were better than the med residents at my hospital. The offers were 310k 4 days/w, 325k 5d/w, and 360k for 5.25 d/w

Not urban locations, but these are associate salaries. The guys who branch out on their own are making more than 450k...which isn't as much as the anesthesiologists at the hospital but no way you can compete with the amazing hours. Home by three oclock everyday? No call, no emergencies...yes please

My md friends who were willing discuss numbers were mostly in high 200s or low 300s but that was 5 days a week plus call.

I wouldn't mind having more MDs available because my goals are to start a group with dds and md. There is a dental anesthesiologist in las vegas who has a few physicians who work for him, but he operates a surgery center I am told.

I agree with sub, I think as crnas continue to put a stranglehold on hospitals and drive down salaries both physician anesthesiologists and crnas will start to venture out into office based anesthesia. Like I said, I welcome it.

 

[ProwlerturnGas]

I currently am doing OBA 95% peds dental anesthesia. All secured airways with Nasal RAE tubes and general anesthesia. I am an ABA BC Anesthesiologist and fellowship trained in CCM. Practiced intensive care for 3 years prior to this job. This is waaaayyyy more fun and lucrative. No death, family flogging you to do everything on their 90 y/o father. No clipboard carrying RN's. No CRNA's. (Dentists will always choose physician over CRNA, at least where I am). It is a very nice gig. Oh and no call, no weekends

 

[secants]

How do look for these positions? Just cold calling local dentists to see who's interested? Are you doing your own billing? How much investment is needed for the portable equipment?

 

[ProwlerturnGas]

I never thought in a million years I would do this work! Couldn't find a job as an Intensivist. This almost literally fell into my lap. I work for a group.

 

[Noyac]

I have no doubt that this can be quite lucrative. Currently, we do 6-10 pedi dental restorations 2-3 days a month or about 20 cases a month All via nasal RAE's. I would love to do some of these without the tube but the dentist isn't comfortable with it. Not really his call but I haven't pushed it. Some of these kids are young, 18months. I wouldn't want to do these younger kids in an office but older kids would be fine. Our oldest is occasionally 6 yrs unless they have CP or something.

Last year we did 258 cases. 2/3 were MCAID, 1/3 either insurance or self pay. We averaged $232/case which is $60,000 for the year. We billed $232,000 but adjustments and the sort cut the majority of the collections. So this is $60k for working 2-3 days a month. Pretty good money in my book.

But doing these cases exclusively would suck. Even at $400k/yr.

Also, you can do the math but all this adds up to $2320/day. I currently do better than that in my day to day practice and all with much better cases.

 

[Baller MD]

I have no doubt that this can be quite lucrative. Currently, we do 6-10 pedi dental restorations 2-3 days a month or about 20 cases a month All via nasal RAE's. I would love to do some of these without the tube but the dentist isn't comfortable with it. Not really his call but I haven't pushed it. Some of these kids are young, 18months. I wouldn't want to do these younger kids in an office but older kids would be fine. Our oldest is occasionally 6 yrs unless they have CP or something.

Last year we did 258 cases. 2/3 were MCAID, 1/3 either insurance or self pay. We averaged $232/case which is $60,000 for the year. We billed $232,000 but adjustments and the sort cut the majority of the collections. So this is $60k for working 2-3 days a month. Pretty good money in my book.

But doing these cases exclusively would suck. Even at $400k/yr.

Also, you can do the math but all this adds up to $2320/day. I currently do better than that in my day to day practice and all with much better cases.

What geographical area do you practice in, if you don't mind sharing?

 

[Sublimazing]

Most will start off by cold calling, and then arranging lunches or sit downs....to bring in your brochure or business card. Obviously the ideal practices are pediatric ones with a bunch of peds dentists on staff.

Equipment runs anywhere from 12k to 50k if your buying a mobile vaporizer. It's wayyyyy cheaper to run TIVA...and the you don't have to worry about scavenging or MH.

Most patients are healthy 2-6 year olds. The dentists that are comfortable with open airway are far better because your turnover time is so much better.

It isn't very academically challenging...but there is a certain finesse in trying to get the kiddo meeting discharge criteria in under 10 minutes from surg stop and with a smile on their face.

 

[Noyac]

What geographical area do you practice in, if you don't mind sharing?

Southwest.

 

[ProwlerturnGas]

we do no open airway procedures. why take the chance? The only exception is a quick mask down for tooth extraction, but those are super easy. We run TIVA as well after initial mask induction. We have super quick turnovers. It is not us that slows turnovers by any stretch. I do other things anesthesia wise as well, but peds dental anesthesia is the most fun. We carry all emergency equipment with us and even carry MH supplies should that occur.

 

[PartyROC]

we do no open airway procedures. why take the chance? The only exception is a quick mask down for tooth extraction, but those are super easy. We run TIVA as well after initial mask induction. We have super quick turnovers. It is not us that slows turnovers by any stretch. I do other things anesthesia wise as well, but peds dental anesthesia is the most fun. We carry all emergency equipment with us and even carry MH supplies should that occur.

Sounds like you're at a terrible office if they're "turnover" is more than 5 minutes...I'm not even sure what exactly they're doing...as soon as dentist stands up he's ready for a new one...and it takes 2 min to wipe down chair and open new instruments

And if your open airway isn't significantly faster than your intubation you're doing something wrong.

I guess because we do this stuff so much we get more comfortable with an open airway.

What do you do about scavenging?

How many people do you bring with that you're prepared for MH?

 

[BobBarker]

Sublimating,

How are you getting the IV's in them? Nitrous and emla?

What is your standard tiva mix?

 

[ProwlerturnGas]

Speed not the issue or airway vs no airway…its always been our group policy that kid will be intubated. No exceptions with full restoration work. It's our opinion that it is safer. Many of our cases run 1+ hours. That is just the facts here. Kid is intubated. Throat pack in. We run a portable anesthesia machine with scavenging hookup to dentist vacuum system. Works well. If MH happened, would be busy that is for sure. We do anywhere from 5 kids to my personal max of 12 in a day. Turnovers are indeed fast, my point was that anesthesia was not the delay, even with intubating and extubating. Again, not about speed--although we are fast. IV's go in after mask induction with sevo and nitrous. We are a fast growing group. We must be doing something right, now at 45+ offices

 

[Sublimazing]

@BobBarker

IM injections. We do about 5 a day. If you do it right the kid doesn't cry...2 minutes later he's in a k-hole and ready for monitors and an IV.

 

[Sublimazing]

Speed not the issue or airway vs no airway…its always been our group policy that kid will be intubated. No exceptions with full restoration work. It's our opinion that it is safer. Many of our cases run 1+ hours. That is just the facts here. Kid is intubated. Throat pack in. We run a portable anesthesia machine with scavenging hookup to dentist vacuum system. Works well. If MH happened, would be busy that is for sure. We do anywhere from 5 kids to my personal max of 12 in a day. Turnovers are indeed fast, my point was that anesthesia was not the delay, even with intubating and extubating. Again, not about speed--although we are fast. IV's go in after mask induction with sevo and nitrous. We are a fast growing group. We must be doing something right, now at 45+ offices

That sounds awesome. I'm sure the dentists and patients appreciate the service you provide.

 

[ProwlerturnGas]

Never hit kid with Ketamine for IV start.. Just no need. They are off to sleep in 6-8 breaths or so. I have given low dose ketamine for pain with some procedures. I have not done an open airway dental procedure (other than quick mask down and tooth extraction). Haven't even seen that technique. Does it go well. Do you have to rescue often?

 

[chocomorsel]

Prowler, I believe Sublimaze said, he does only TIVA. No anesthesia machine, just IV/IM drugs. In his case, there's a need.
I personally am very interested in this thread. Something a buddy of mine from residency and I are interested in. Sounds like a great deal, once you iron out all the links. I will PM you guys.

 

[Sublimazing]

Never hit kid with Ketamine for IV start.. Just no need. They are off to sleep in 6-8 breaths or so. I have given low dose ketamine for pain with some procedures. I have not done an open airway dental procedure (other than quick mask down and tooth extraction). Haven't even seen that technique. Does it go well. Do you have to rescue often?

Obviously I'm not masking and darting...

Open airway goes very well. A lot of the kids you see who require GA for dental also have asthma (like a lot a lot)...and the less airway instrumentation the better.

You don't have to worry about blood, or airway edema, you use less meds because there's no tube rubbing their cords the whole procedure, and like I said it is so much faster on the front and backend of what we do. You don't have to worry about paralytic or reversal (if anyone is still paralyzing peds)

Tubes and circuits are expensive if you're using them 5-10x per day.

Now the big risks are laryngospasm, aspiration, and foreign body. The laryngospasms are very rare once you learn how to tell where your patient is on tiva (in the last 600 open cases i've used 10mg of succs).

In terms of aspiration there's no masking so you're not filling the kids belly up with air, and there's no tube so they don't gag.

And foreign body, you just gotta get good at making a throat pack and keep them deep until you've cleaned them up at the end.

Other than that you can run their fiO2 at whatever you want. The npa and your taping prevent obstruction.

 

[Sublimazing]

Sublimating,

How are you getting the IV's in them? Nitrous and emla?

What is your standard tiva mix?

And Remi 7.5 is pretty standard in the industry.

 

[Noyac]

Obviously I'm not masking and darting...

Open airway goes very well. A lot of the kids you see who require GA for dental also have asthma (like a lot a lot)...and the less airway instrumentation the better.

You don't have to worry about blood, or airway edema, you use less meds because there's no tube rubbing their cords the whole procedure, and like I said it is so much faster on the front and backend of what we do. You don't have to worry about paralytic or reversal (if anyone is still paralyzing peds)

Tubes and circuits are expensive if you're using them 5-10x per day.

Now the big risks are laryngospasm, aspiration, and foreign body. The laryngospasms are very rare once you learn how to tell where your patient is on tiva (in the last 600 open cases i've used 10mg of succs).

In terms of aspiration there's no masking so you're not filling the kids belly up with air, and there's no tube so they don't gag.

And foreign body, you just gotta get good at making a throat pack and keep them deep until you've cleaned them up at the end.

Other than that you can run their fiO2 at whatever you want. The npa and your taping prevent obstruction.

Can you give me a run down of the precise approach to your unsecured ( that's what we call open airways) airway? Things like:
what airway devices? Nasal trumpets or what?
Propofol rates?
When do you turn down the propofol?
Do you use any other meds? Glyco? What's Remi "7.5"? No infusion?
How about dental debris? Throat pack? How are they breathing around this?

 

[ProwlerturnGas]

Hey Sublimazing, thanks for the description. I think there are lots of ways to attack this. As long as kid safe, and comfortable that is all that is important. I must say, I do not see any of the problems you present with endotracheal tubes. Not at all. Even the asthma kids tolerate very well. I think what he means by remi 7.5 is concentration, 7.5 mcg/ml (correct me if I'm wrong), run as an infusion in propofol. I use a lower concentration. I have given glyco once, for brief hypotension assoc with bradycardia. Have Sux avail for severe laryngospasm only. We do not paralyze these kids. I also give Toradol, Decadron and Zofran dosed to child's size. Like I said, lots of ways. Depends on culture of your group. We have chosen not to do open airway cases. If it gives perspective, I have worked 17 days this pay period (30 day period). I have done 109 kids and have one more day left. I am telling you this because you can do a large number of cases with secured airway, quickly and efficiently.

 

[Sublimazing]

Hey Sublimazing, thanks for the description. I think there are lots of ways to attack this. As long as kid safe, and comfortable that is all that is important. I must say, I do not see any of the problems you present with endotracheal tubes. Not at all. Even the asthma kids tolerate very well. I think what he means by remi 7.5 is concentration, 7.5 mcg/ml (correct me if I'm wrong), run as an infusion in propofol. I use a lower concentration. I have given glyco once, for brief hypotension assoc with bradycardia. Have Sux avail for severe laryngospasm only. We do not paralyze these kids. I also give Toradol, Decadron and Zofran dosed to child's size. Like I said, lots of ways. Depends on culture of your group. We have chosen not to do open airway cases. If it gives perspective, I have worked 17 days this pay period (30 day period). I have done 109 kids and have one more day left. I am telling you this because you can do a large number of cases with secured airway, quickly and efficiently.

It sounds like a great set up. And maybe I'm coming off anti-intubation when I certainly am not. Not many defend open airway, so sometimes on this board I like to champion it since we used it so much in residency...and I have never seen the residents do it at Loma Linda or our AOA program we rotate through...though maybe it is taught at other programs.

The DA group ASDA has recently teamed up with SAMBA, and as I understand it our next meeting will be a combined one...so I'm just excited for the future of OBA in the dental setting.

 

[ProwlerturnGas]

Didn't think you were anti intubation Just describing our practice style. I believe you do what is most comfortable to you. If you trained open airway style and are good at it, then keep doing it. I didn't run across this in residency, so it seems foreign to me. I am much more comfortable dealing with complications of intubation more so than complications with unsecured airway. I wouldn't mind learning that style actually.

I like this thread Gives light to seldom discussed opportunity in anesthesia. I do believe it's a great job and interesting. Far cry from my previous gig, but hey, you need to be flexible, especially in this medical climate. OBA is its own animal. When I first started, doing children in office setting with no other anesthesia backup seemed daunting. Now it seems natural. Maybe we'll run across each other at a meeting huh?

 

[Silent Cool]

Didn't think you were anti intubation Just describing our practice style. I believe you do what is most comfortable to you. If you trained open airway style and are good at it, then keep doing it. I didn't run across this in residency, so it seems foreign to me. I am much more comfortable dealing with complications of intubation more so than complications with unsecured airway. I wouldn't mind learning that style actually.

I like this thread Gives light to seldom discussed opportunity in anesthesia. I do believe it's a great job and interesting. Far cry from my previous gig, but hey, you need to be flexible, especially in this medical climate. OBA is its own animal. When I first started, doing children in office setting with no other anesthesia backup seemed daunting. Now it seems natural. Maybe we'll run across each other at a meeting huh?

Do you bring with you an EMT?

 

[ProwlerturnGas]

For what Silent Cool?

 

[chocomorsel]

If u don't mind my asking prowler, where are you located? In Utah perhaps? You guys hiring?