Sad state of affairs for EM.

[Southpaw]

I decided not to. I wish more would do the same.

what do you do?

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[GravelRider]

When I was a resident not a single attending could tell me anything about private practice. No one educated me on CRNA issues or value/lack thereof with regard to fellowship. In the entire 4 years I was there, and I really truly loved residency by the way, we had 3 1-hr blocks dedicated to guys actually in private practice coming to talk to us as a group. My academic chair was a great guy and an excellent academician, but absolutely clueless as to what mattered to a community anesthesiologist or how a private group achieved income or derived value in their work.

Out of my entire group of attendings in residency maybe 3-4 donated to ASAPAC. And one could make a solid argument that contributing to the PAC and even the ASA is absolutely worthless, but I'm just making the point that they didn't care.

I'm guessing maybe less than 5% of academic attendings (just a shot in the dark number, admittedly) understand base and time units for our field. Nor do they understand contract negotiations with insurance companies and hospitals. These things matter GREATLY to anesthesiologists in the community.

It's not a stretch at all in my opinion to say that if decisions around expansion of residency spots, or decisions made about the desperate state of EM (which is largely based on what has occurred in community practices as opposed to large tertiary centers), are left to academicians or CMG shills as opposed to guys actually showing up day in/day out to see patients and do the work, then the world of medicine will not get to a better place.

I think you are right, to a degree, but I also think academic departments have their share of production pressure. I’m guessing department budgets aren’t infinite and departmental leadership has to figure out a way to do cases and satisfy the hospital administration. Increasing residency slots is a way to increase available labor cheaply. When anesthesia departments everywhere are short-staffed, even 2 extra residents per year can make a difference.

 

[2Fast2Des]

When I was a resident not a single attending could tell me anything about private practice. No one educated me on CRNA issues or value/lack thereof with regard to fellowship. In the entire 4 years I was there, and I really truly loved residency by the way, we had 3 1-hr blocks dedicated to guys actually in private practice coming to talk to us as a group. My academic chair was a great guy and an excellent academician, but absolutely clueless as to what mattered to a community anesthesiologist or how a private group achieved income or derived value in their work.

Out of my entire group of attendings in residency maybe 3-4 donated to ASAPAC. And one could make a solid argument that contributing to the PAC and even the ASA is absolutely worthless, but I'm just making the point that they didn't care.

I'm guessing maybe less than 5% of academic attendings (just a shot in the dark number, admittedly) understand base and time units for our field. Nor do they understand contract negotiations with insurance companies and hospitals. These things matter GREATLY to anesthesiologists in the community.

It's not a stretch at all in my opinion to say that if decisions around expansion of residency spots, or decisions made about the desperate state of EM (which is largely based on what has occurred in community practices as opposed to large tertiary centers), are left to academicians or CMG shills as opposed to guys actually showing up day in/day out to see patients and do the work, then the world of medicine will not get to a better place.

In my residency (large program and group) one of my attendings was very pro physician and trying to rally fellow colleagues to contribute to the state PAC to fight back the aggressive encroaching of CRNAs. No one wanted to put their name on any petition or contribute because they were afraid of CRNA blowback, since the hospital was an SRNA training headquarters and the CRNAs are uber militant (and I'm sure contributing quite heavily to their lobby and aana), it was quite demoralizing and sad, showed me that this field is beyond F'd. The CRNAs found the names of the docs that put their name on the petitions and made their opinions very known of their disdain for them. Many even called out for days they were assigned to be working with the rallying doc.

So... just make hay while you can right now, there is no fight left

 

[anbuitachi]

This is so short sighted. At our place this was admin’s first thought as well to counter the rise in salaries. “More residents! They’re cheap and will dilute the labor pool!”
Food for thought: I was an ER attending physician from 2008-2011. Moonlighting during my anesthesia residency from 2011-2014. The market was fantastic. Jobs everywhere. Money flying around like a rap video. Now, the market is crap in large part due to huge proliferation of residencies and encroachment from mid levels. Sound familiar?
There may be a need for more anesthesiologists but I would much rather take our cues from derm and OMFS than ER. Contact the ASA if needed but our salaries are increasing based on demand>>supply. We can’t oversupply and expect to maintain fair market value.

a lot of decisions are unfortunately made by people in later stages. they dont really care about the specialty for future generations..

 

[IMGASMD]

Most of us were trying to be the best doctor we can for the patients, (whether that’s bull**** that we were fed or not, that’s another discussion.) and quite frankly, that’s all I have time/energy for. I didn’t mind, and I think most of my classmates don’t mind being “cheap labor” because we honestly believed that the more we do, the more we know, the better doctors we will be.

There’s disconnect from many aspects, oral board exam, crna/mid level encroachment economics of medicine, how much we are actually worth to the hospital/insurance company/system.

I contribute to asapac, I also give money to PPP. If I cannot be there myself, I try to at least give monetary support to some of the causes that I believe in. What they do with they money is anybody’s guess.

 

[GassYous]

In my residency (large program and group) one of my attendings was very pro physician and trying to rally fellow colleagues to contribute to the state PAC to fight back the aggressive encroaching of CRNAs. No one wanted to put their name on any petition or contribute because they were afraid of CRNA blowback, since the hospital was an SRNA training headquarters and the CRNAs are uber militant (and I'm sure contributing quite heavily to their lobby and aana), it was quite demoralizing and sad, showed me that this field is beyond F'd. The CRNAs found the names of the docs that put their name on the petitions and made their opinions very known of their disdain for them. Many even called out for days they were assigned to be working with the rallying doc.

So... just make hay while you can right now, there is no fight left

Ha I know some people who thought that they should let crnas do everything (neuraxial, blocks, lines) because they didn't want to sit in the room. They were terrified that the nurses would leave for higher paying jobs and wanted to incentivize them to stay. But the nurses still left.

 

[Southpaw]

In my residency (large program and group) one of my attendings was very pro physician and trying to rally fellow colleagues to contribute to the state PAC to fight back the aggressive encroaching of CRNAs. No one wanted to put their name on any petition or contribute because they were afraid of CRNA blowback, since the hospital was an SRNA training headquarters and the CRNAs are uber militant (and I'm sure contributing quite heavily to their lobby and aana), it was quite demoralizing and sad, showed me that this field is beyond F'd. The CRNAs found the names of the docs that put their name on the petitions and made their opinions very known of their disdain for them. Many even called out for days they were assigned to be working with the rallying doc.

So... just make hay while you can right now, there is no fight left

I've heard of the CRNA tactic of making names of detractors public. I can't think of a single better reason not to work with them. Or to advocate for MD only practices as an organization, which as far as I can tell the ASA doesn't do. Or to advocate for AAs.

Also, what cowards. So what, the CRNA doesn't like you because you actually believe a patient benefits from physician involvement? Big whup, move on. Geez this specialty is so spineless.

 

[vector2]

Ha I know some people who thought that they should let crnas do everything (neuraxial, blocks, lines) because they didn't want to sit in the room. They were terrified that the nurses would leave for higher paying jobs and wanted to incentivize them to stay. But the nurses still left.

Sad. I pointed to the CRNA exodus we had as precisely the time to advocate for them (and the SRNAs) not being allowed to do any procedures more complicated than an a-line. After all, it really showed they had no deep investment in our department or our OR, so why would we help them expand their scope of practice when their main goal is for us to teach them skills they can take elsewhere?

 

[702]

Yeah but I'm not going to unleash that CA1 onto patients without supervision after the end of that 6 months

You’re not. The 6 months of anesthesia training is the introductory training omfs residents get. they then continue their anesthesia training for the next 3.5 or 5.5 years administering anesthesia to Asa 1 and 2 patients under the direct supervision of an omfs attending.

 

[coffeebythelake]

You’re not. The 6 months of anesthesia training is the introductory training omfs residents get. they then continue their anesthesia training for the next 3.5 or 5.5 years administering anesthesia to Asa 1 and 2 patients under the direct supervision of an omfs attending.

Ok. So 6 months of anesthesia training followed by 3.5 to 5.5 additional years of ofms dentistry with some occasional anesthesia cases interspersed being supervised by someone who apprenticed in exactly the same way. Got it.. 🙄

 

[teacher2md]

You’re not. The 6 months of anesthesia training is the introductory training omfs residents get. they then continue their anesthesia training for the next 3.5 or 5.5 years administering anesthesia to Asa 1 and 2 patients under the direct supervision of an omfs attending.

How many intubations are performed during these 5.5 additional years of ‘anesthesia’ training?

 

[Gasmd98]

This right here sums up every minute of my experience throughout multiple facilities in multiple systems over the past few years. Staffing shortages in the Covid world followed by Covid $$ drying up over the past year have accelerated this decline. I’m content to just milk this cow for another 5 years and retire in peace.

You and I have the luxury of milking the cow knowing that we can retire in peace. I feel for all the younger docs out there who will never know what a great career medicine was 20-30 years ago.

 

[DocVapor]

How many intubations are performed during these 5.5 additional years of ‘anesthesia’ training?

None because they are so damn good at anesthesia, obviously.

 

[nimbus]

a lot of decisions are unfortunately made by people in later stages. they dont really care about the specialty for future generations..

Exactly. That’s why there were so many AMC buyouts. No matter what the buyout amount was, it never made sense for the younger doctors in a given practice. The buyout money would have been recouped in 5-10 yrs.

 

[coffeebythelake]

None because they are so damn good at anesthesia, obviously.

OmFS so damn good at anesthesia, and they know better than anyone how to sedate patients because they have loads of experience dealing with laryngospasm. 🤣🙄🤡

 

[vector2]

Exactly. That’s why there were so many AMC buyouts. No matter what the buyout amount was, it never made sense for the younger doctors in a given practice. The buyout money would have been recouped in 5-10 yrs.

Cracks me up when you think about the ubiquity of buyouts in relation to the interminable whining from some boomers about how lazy millenials and zoomers are. The old guard (in multiple specialties) permanently gave away any chance younger generations had of staking their own claim and being their own boss.... for nothing more than 5 years worth of collections. But yet they're indignant that newer generation docs who are nothing more than employees/cogs in the healthcare industrial complex are aggressively seeking work/life balance.

 

[nimbus]

Cracks me up when you think about the ubiquity of buyouts in relation to the interminable whining from some boomers about how lazy millenials and zoomers are. The old guard (in multiple specialties) permanently gave away any chance younger generations had of staking their own claim and being their own boss.... for nothing more than 5 years worth of collections. But yet they're indignant that newer generation docs who are nothing more than employees/cogs in the healthcare industrial complex are aggressively seeking work/life balance.

Most of the buyouts were much less than 5yrs worth of collections. Some were as little as 20% of 5yrs collections. Most were 20-30% of 7-8 yrs collections.

 

[neutro]

Or they order every test known to man, costing much more than the money saved to avoid paying for that pesky physician.

In residency had a brought a young patient s/p VATS intubated, with plan for extubation in ICU. On way to CVICU pt looking like he wanted to fast track his recovery, so I told the nurse give reversal and just extubate since he met criteria anyway. Instead the ICU NP said they don't reverse patients, and instead put him on a prop drip and cardene infusion for his elevated BP and heart rate and thrashing instead of just pulling the tube. Mismanagement to the max. I have so many stories of much more mismanagement by our top of the license "colleagues"

I'm truly scared to get sick and be in any hospital, and be subject to the "care" they subject patients to

In this situation, respectfully, you should have extubated the patient yourself. Yeah it would have taken a few minutes but it would have been a lottttt better for the patient…

Don’t rely on icu nurses to make this type of determination especially since you did the anesthestic and are aware of clinical course…

What I’ve learned is it is best to take care of the patient yourself as much as possible. Stop depending and relying on nurses and midlevels in the name of “care team model”… they don’t know enough and they will not put themselves in uncomfortable situations to learn and improve.

 

[nimbus]

In this situation, respectfully, you should have extubated the patient yourself. Yeah it would have taken a few minutes but it would have been a lottttt better for the patient…

Don’t rely on icu nurses to make this type of determination especially since you did the anesthestic and are aware of clinical course…

What I’ve learned is it is best to take care of the patient yourself as much as possible. Stop depending and relying on nurses and midlevels in the name of “care team model”… they don’t know enough and they will not put themselves in uncomfortable situations to learn and improve.

Yeah they won’t extubate in our ICUs without an ABG after a spontaneous breathing trial. That’s their protocol which makes sense based on their competency and their patient population. It’s not like the OR where we just whip out the tube if the patient is breathing well at the end of a procedure. We do a lot of VATS and robot VATS and they almost never go to ICU.

 

[IMGASMD]

Yeah they won’t extubate in our ICUs without an ABG after a spontaneous breathing trial. That’s their protocol which makes sense based on their competency and their patient population. It’s not like the OR where we just whip out the tube if the patient is breathing well at the end of a procedure. We do a lot of VATS and robot VATS and they almost never go to ICU.

All your stories reminded me of just the other day, took over a hiatal hernia from a nurse anesthetist. It was a long case throughout the day. At the end three of their names were on the chart.

So the first one told the second one, it’s a long case, most likely the patient will go to icu intubated. The second one told the third one, it’s a long case, the surgeon wants the patient to go to icu. Third one told me, it’s a long case, surgeon and the surgical team did a similar case last week, they just drop off the patient in icu. As soon as I got the report, I just asked the surgeon, without the crna there, (I sort of like the guy as a person, and he did take over the case…).
“Dr. Smith, do you really want me to exchange the tube and take her the icu right after?” “If you think she will fly, I don’t see why not extubate her…” “I am in no hurry, and will give it a good try…”
The glare from everyone in the room was palpable. His PA in particular, who insisted that the surgeon “always” just send the patient to ICU after exchange for a single lumen tube.
The CRNAs are nurses at heart. Protocol and following orders are something they will never be able to get away from.

 

[coffeebythelake]

Yeah they won’t extubate in our ICUs without an ABG after a spontaneous breathing trial. That’s their protocol which makes sense based on their competency and their patient population.

We have this protocol at one of our ICUs and it is mostly anesthesja attending and resident run.

I always thought it was stupid to do an abg before having to extubate in the ICU especially reasonably healthy patients that I wasn't going to put an art line for their surgery. When I was a resident I was berated by my attending for not putting in an art line for this exact scenario. I asked why.. and if concerned why don't we do etco2 monitoring like in the OR

 

[GoBeers]

We have this protocol at one of our ICUs and it is mostly anesthesja attending and resident run.

I always thought it was stupid to do an abg before having to extubate in the ICU especially reasonably healthy patients that I wasn't going to put an art line for their surgery. When I was a resident I was berated by my attending for not putting in an art line for this exact scenario. I asked why.. and if concerned why don't we do etco2 monitoring like in the OR

it would be nice if your attending even pretended to be academic and tell you "well co2 gradient this that blah blah, there can be various scenarios that lead to mismatch in Co2 levels such as low etco2 and higher than expect arterial co2 because of low perfusion, increase deadspace such as PE, etc." But in reality, they were probably just sheep following the institutional herd.

 

[C.elegans]

Probably, but I was told they take a slightly less difficult USMLE step1 version (CBSE) to get into OMFS (MD program) and the average score of the ones who got in is lower than FM residents step1 score. You are comparing different cohort of students.

Based on the dental forum, a 75 (or 223) is a GREAT score. 70 (or 213) is a competitive score.

Many OMFS residencies offer an MD so the pathways converge. It would be interesting to compare average step 2 and step 3 scores of OMFS residents compared to other specialties like….anesthesia.

Studied for CBSE for two months while maintaining a top 5% GPA in dental school (mind you I had to put myself through preclinical medschool while going through dental school). Got a score in the 90s which translates to a score in the 250s for Step1. Step 1 was P/F by the time I took it but I got a score in the 250s for Step 2 after 2-3 weeks of studying. Obviously wasn't motivated like my other classmates to do well. A friend at a different OMFS program scored in the 270s for Step 2 after 2-3 weeks. Another OMFS friend scored in 260s for Step 1. Highest Step 1 score at UMich to date is held by a past OMFS resident who scored in the 270s. You get the point.

 

[C.elegans]

Training and experience comes with time. A 4 month trained OMFS resident might be eager and hardworking but they aren't going to be stellar in anesthesia regardless of their credentials and academic fortitude. Perhaps if you consider the patient population (reasonably healthy) and the type of appropriate anesthesia involved (routine intubation, nasal intubation, conscious sedation), then their skill set learned over this time frame might get them through okay most of the time. What we *do* know from the SDN dental forums is that OMFS really like to talk big about how great their anesthesia training is and how they never have bad outcomes.

With all due respect, I don't think any OMFS believes we are as good as anesthesiologists in anesthesia... We are very aware of our limitations and we have an immense level of respect and gratitude for the anesthesiologists who graciously take us under their wings and train us very well. I think what we want to say is that because we are so aware of how bad anesthesia can go if you are not cautious, we are very very careful about patient selection. ASA 1 or 2 young and relatively healthy patients that have the appropriate body habitus are candidates for in-office deep sedation. Anything outside that, we either elect to do it under local, or it's a one way ticket to the OR where the patient gets intubated and we have an anesthesiologist oversee the anesthesia.

While I understand the concerns you have especially in light of some high profile incidents that involved a couple cowboy surgeons not following the standard of care, OMFS as a field actually has a proven track record of safety and favorable outcomes with our in-office sedations. This isn't something we are making up or just claiming bc of our egos. The data speaks for itself. Again, I understand where you are coming from and I know that you only mean to look out for the safety of patients, but I think some accusations you have made on this forum regarding OMFS are a bit unfair.

 

[teacher2md]

The data speaks for itself.

What do you make of this data, that estimates a shockingly frequent rate of brain damaage and death due to in-office sedation by dentists/OMFS?

How safe is deep sedation or general anesthesia while providing dental care?

Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesio…

www.sciencedirect.com

The former president of the Dental Anesthesiology society (himself a dentist) quoted this study to raise the alarm about dental sedation practices.

Dental News - The fight for improved safety of ...

Anaesthesia policy in dentistry is an increasingly controversial topic. Sedation and anaesthesia failures can lead to patient injury, and deaths have made ...

www.dental-tribune.com

 

[C.elegans]

What do you make of this data, that estimates a shockingly frequent rate of brain damaage and death due to in-office sedation by dentists/OMFS?

How safe is deep sedation or general anesthesia while providing dental care?

Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesio…

www.sciencedirect.com

The former president of the Dental Anesthesiology society (himself a dentist) quoted this study to raise the alarm about dental sedation practices.

Dental News - The fight for improved safety of ...

Anaesthesia policy in dentistry is an increasingly controversial topic. Sedation and anaesthesia failures can lead to patient injury, and deaths have made ...

www.dental-tribune.com

I have not seen this particular article, thanks for pointing me to this. However, it is difficult to hold up just one study and claim that is the end all be all when there are multiple other studies that present evidence to the contrary. Either way, I will be inclined to agree that a more standardized set of guidelines are needed so cowboy practitioners can be held accountable. I also actually agree on having a nurse instead of a DA present for these deep sedations.

 

[Splenda88]

I have not seen this particular article, thanks for pointing me to this. However, it is difficult to hold up just one study and claim that is the end all be all when there are multiple other studies that present evidence to the contrary. Either way, I will be inclined to agree that a more standardized set of guidelines are needed so cowboy practitioners can be held accountable. I also actually agree on having a nurse instead of a DA present for these deep sedations.

Isn't dental anesthesia a 3-yr residency program? Why would a CRNA be better than a DA?

 

[C.elegans]

Isn't dental anesthesia a 3-yr residency program? Why would a CRNA be better than a DA?

Sorry I meant DA as in dental assistant. I think a RN should be there to help with monitoring and resuscitation if needed.

 

[teacher2md]

Sorry I meant DA as in dental assistant. I think a RN should be there to help with monitoring and resuscitation if needed.

Isn’t the entire premise of the single-operator model that the dentist can administer anesthesia, monitor the patient, and perform the procedure at the same time?

How would an RN change this? They’re not trained in anesthesiology or airway management.

Sure, if by ‘resuscitation’, you mean they can do ACLS; but that’s hardly an anesthetic plan…

 

[anaesthetic]

Isn’t the entire premise of the single-operator model that the dentist can administer anesthesia, monitor the patient, and perform the procedure at the same time?

How would an RN change this? They’re not trained in anesthesiology or airway management.

Sure, if by ‘resuscitation’, you mean they can do ACLS; but that’s hardly an anesthetic plan…

They can call 9-1-1 while the dentist calls their two anesthesia buddies for advice.

 

[chessknt]

I am not sure any single provider can safely provide deep sedation and perform a procedure effectively unless that procedure is very brief (like a cardioversion). OMFS sure can trach with the best of them but I sure wouldn't want them trying to manage anaphylaxis or malignant hyperthermia.