This bugs me (question regarding Dental Anesthesiologists)

[FutureDMD1234]

You clearly don't know what you don't know.

How do you know that the infomation I put are not facts? If that what you mean?

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[Planktonmd]

You have obviously given up on everything Good luck

If I expect the organization that represents me to defend my interests this means I gave up on everything?
If I don't agree with the ASA's plan for the future of my profession this makes my ideas hopeless?
I think I am actually the opposite, I am refusing to give up on everything and I still believe that we should never give up OR anesthesia regardless of what your ASA's view of the future might be.
It's funny how you changed your views over such a short period of time and suddenly became an ASA bureaucrat. What happened to you?
If you are going to start your political career by acting and thinking like a bureaucrat I think you actually belong in the ASA they deserve you.

 

[toughlife]

If I expect the organization that represents me to defend my interests this means I gave up on everything?
If I don't agree with the ASA's plan for the future of my profession this makes my ideas hopeless?
I think I am actually the opposite, I am refusing to give up on everything and I still believe that we should never give up OR anesthesia regardless of what your ASA's view of the future might be.
It's funny how you changed your views over such a short period of time and suddenly became an ASA bureaucrat. What happened to you?
If you are going to start your political career by acting and thinking like a bureaucrat I think you actually belong in the ASA they deserve you.

dude, NO ONE is giving up the OR. NO ONE. The whole idea of the existence of the ASA is to ensure adequate presence in the OR and continued fair reimbursement.

What I think you need to understand is that everyone in medicine is at the mercy of the insurers and those who pay your bills. So we must ensure that we are flexible and bring something to the table besides being able to pass gas. It's like your group having fellowship trained dudes who have more to offer than just pass gas because by now, we all know we are not the only ones who can pass gas. Correct?

So what is wrong with being an organization who has a foothold in the OR, the ICU and in pain. I know you like the OR and I am sure you will be there until you retire but expecting that we bank our future on something that we don't have a monopoly on is unrealistic. I won't bank my future on always being a gaspasser.

What will you do the day, you get replaced by a CRNA because you have nothing else to offer? can you say, I can also do TEE or run the ICU if needed? That decision won't be yours to make but it will be up to those who pay you. Granted you can have an exclusive contract but we all know those can disappear in a matter of minutes.

The point of the ASA triying to expand is to bring something else to the table besides passing just gas. How that goal is met is a matter of debate.

What I think needs to be done is to mount an aggressive advertising campaign delineating our qualifications, to spend a lot of resources educating the public and to make sure that graduating residents can do more than just pass gas. I doubt anyone would balk at having more skills. We also need to file lawsuits to keep the CRNAs from expanding their scope of practice and ensure we are represented at hospital commiittees. I have said this many times before. So don't give me that crap about being a bureacrat. I want change so I am getting involved.

 

[Planktonmd]

we all know we are not the only ones who can pass gas. Correct?

Incorrect!
This is what the ASA has already accepted but it is not correct.
We are the only ones who can practice anesthesiology, not pass gas, Practice ANESTHESIOLOGY, which includes administering or supervising every anesthetic, if someone else gives anesthesia that doesn't make it right and there is no reason on earth why we should endorse it.
Above all there is no reason on earth why an organization that represents us should accept the notion that the supervision of anesthesia can be done by any physician.
Do you get it?
We should fight for a simple idea: Only anesthesiologists can supervise the administration of anesthesia, if we don't fight for that we are heading toward disaster.
Can you imagine the surgeons accepting that nurses and PA's can practice surgery under the supervision of any physician?
Why should we have a lower standard?
The professional organization that claims to speak in the name of Anesthesiology should not make compromises and change the definition of the specialty to accommodate a defective health care system and corrupt politicians.
We need to have some dignity.

 

[toughlife]

Incorrect!
This is what the ASA has already accepted but it is not correct.
We are the only ones who can practice anesthesiology, not pass gas, Practice ANESTHESIOLOGY, which includes administering or supervising every anesthetic, if someone else gives anesthesia that doesn't make it right and there is no reason on earth why we should endorse it.
Above all there is no reason on earth why an organization that represents us should accept the notion that the supervision of anesthesia can be done by any physician.
Do you get it?
We should fight for a simple idea: Only anesthesiologists can supervise the administration of anesthesia, if we don't fight for that we are heading toward disaster.
Can you imagine the surgeons accepting that nurses and PA's can practice surgery under the supervision of any physician?
Why should we have a lower standard?
The professional organization that claims to speak in the name of Anesthesiology should not make compromises and change the definition of the specialty to accommodate a defective health care system and corrupt politicians.
We need to have some dignity.

I see your point but it is under the assumption that most anesthesiologists are actually present everytime an anesthetic is administered. How do make sure there's an anesthesiologist every time fentanyl or versed is pushed?

How do we staff every single OR in the USA? What about rural america? How do reign in the independent CRNAs who are out there practicing without an anesthesiologist supervision? The ASA can say an anesthesiologist is required but what if there are no anesthesiologist to provide such service? What do we do then?

I agree that the ASA should not be changing its tune to please a politician, another physician group or an insurer. The question however, is how does the ASA enforce such a rule? Many anesthesiologists are not members and they love to hire CRNAs to fatten their paycheck. A stand by the ASA to not allow unsupervised anesthesia to be delivered falls on deaf ears when it comes to those members who don't choose to follow the rules or those who are not members.

Do you think these cats care what the ASA has to say or what it is fighting for? So yeah, I see your point but it is unenforceable since the ASA can make any proclamation it desires but its members are ultimately responsible for following the rules.

 

[Planktonmd]

I see your point but it is under the assumption that most anesthesiologists are actually present everytime an anesthetic is administered. How do make sure there's an anesthesiologist every time fentanyl or versed is pushed?

How do we staff every single OR in the USA? What about rural america? How do reign in the independent CRNAs who are out there practicing without an anesthesiologist supervision? The ASA can say an anesthesiologist is required but what if there are no anesthesiologist to provide such service? What do we do then?

I agree that the ASA should not be changing its tune to please a politician, another physician group or an insurer. The question however, is how does the ASA enforce such a rule? Many anesthesiologists are not members and they love to hire CRNAs to fatten their paycheck. A stand by the ASA to not allow unsupervised anesthesia to be delivered falls on deaf ears when it comes to those members who don't choose to follow the rules or those who are not members.

Do you think these cats care what the ASA has to say or what it is fighting for? So yeah, I see your point but it is unenforceable since the ASA can make any proclamation it desires but its members are ultimately responsible for following the rules.

The ASA as an organization that represents the specialty of Anesthesiology in this country should never endorse the administration of anesthesia unsupervised or under the supervision of other physicians.
If certain economic or political circumstances are making this practice possible in some parts of the country we should not accept the new standard and change the definition of the specialty to accommodate it.
If a hospital wants to do surgery they must
hire an anesthesiologist to supervise their anesthesia, if they can't find one it means they are not paying enough.
How come they can find Radiologists and Neurosurgeons but they can't find Anesthesiologists?
They need to put more money into it and they won't do that unless we tell them that the presence of an Anesthesiologist is the standard of care.

 

[toughlife]

The ASA as an organization that represents the specialty of Anesthesiology in this country should never endorse the administration of anesthesia unsupervised or under the supervision of other physicians.
If certain economic or political circumstances are making this practice possible in some parts of the country we should not accept the new standard and change the definition of the specialty to accommodate it.
If a hospital wants to do surgery they must higher an anesthesiologist to supervise their anesthesia, if they can't find one it means they are not paying enough.
How come they can find Radiologists and Neurosurgeons but they can't find Anesthesiologists?
They need to put more money into it and they won't do that unless we tell them that the presence of an Anesthesiologist is the standard of care.

I must say you are not alone in that line of thinking and I can point to many people in the ASA who feel just like you do. I think we definitely need to ensure that the anesthesiologist remains as the leader in the anesthesia field.

I don't think anyone can argue that the anesthesiologist is the most educated and best trained individual to ensure proper anesthesia care and to ensure the highest standard for patient safety are met. We need to ensure the public and the politicians know that and know it well. That, I will fight for anyday.

 

[GassiusClay]

Yuck. Anybody here contact there legislators to tell them specifically about the teaching rule. I let my senators know about it, and I specifically mentioned how non-physicians are trying to distort the reality in order to push the agenda. I guess keeping them aware of the other guys' tactics is important.

 

[radslooking]

It doesn't make any sense to not have an anesthesiologist as the supervisor of CRNA's, if you establish that they need supervision. I don't understand why the ASA would say "physician". That's pretty dumb. Of course any physician cannot supervise an OR, it takes an anesthesiologist.

If anesthesiology is to truly beat back the CRNA's in the OR, they will need to show that their presence confers a benefit. If these independently practicing CRNA's are shown to have similar rates of complications, then I don't see what your bargaining tool will be in pushing them out of OR.

What will your argument be? We have more education! Well, so what? If it doesn't impact the quality of the care, it seems you won't have a leg to stand on there.

 

[toughlife]

It doesn't make any sense to not have an anesthesiologist as the supervisor of CRNA's, if you establish that they need supervision. I don't understand why the ASA would say "physician". That's pretty dumb. Of course any physician cannot supervise an OR, it takes an anesthesiologist.

If anesthesiology is to truly beat back the CRNA's in the OR, they will need to show that their presence confers a benefit. If these independently practicing CRNA's are shown to have similar rates of complications, then I don't see what your bargaining tool will be in pushing them out of OR.

What will your argument be? We have more education! Well, so what? If it doesn't impact the quality of the care, it seems you won't have a leg to stand on there.

Complications do not only occur intraoperatively as you may know. Most of the poor management issues that arise when poor care is delivered by a CRNA are seen after surgery in the PACU or in the ICU.

The care provided by an anesthesiologist extends beyond the walls of the OR as opposed to that provided by CRNAs. To think otherwise shows lack of knowledge about the profession.

 

[Dr.Millisevert]

There's a dental anesthesiologist finishing up his training at my program who is flat out boasting about how he's setting up an ambulatory practice, having people (other anesthesiologists) work for him, and of course, taking some off the top. That's fine since that's how many businesses seem to run anyway...you've got the worker bees and the queen bee(s). My issue is this- WHY ARE OUR PROGRAMS TRAINING OTHER PROFESSIONS TO DO WHAT WE DO?? Are we not cheapening ourselves? Moreover, there are no practice restrictions once this sub-group finish their "dental anesthesia" training. Shouldn't we MDAs define our territory? Or better yet, stop training these so called "dental anesthesiologists", and keep our demand up. I'm not trying to start a riot here but it's obvious our / ASA's lack of practice definitions and parameters is making it to loose and continues to add to the threat of our field being viewed as "easy". Maybe I should write this to the ASAPAC but what do you guys/gals think?

Calm down!

Seriously... Ok there are only 3-5 dental anesth residency programs in the entire United States. Each one only accepts 1-3 residents per year. For a grand total of.. wait for it... 5 -15 total dental anesth graduates each year in the entire country!

Even though they do hold a GA license equivalent to MD anesth... 95% of them spend of their time doing IV sedations only for other dentists, pediatric dentists, and maxillofacial surgeons.

Most dentists these days can graduate and work 5 days per week 9-4pm and clear 200k+/yr. Not many are going to really want to go back to do extra years of residency training for this. I mean.. ok, even if it means you can make an extra 100k per year even.. you'd probably have to pay back at least half of that each year in extra malpractice. And do you really think any of these people are going to even attempt to move into cardio or neuro anesth.. hell no!

Basically, there are only a small handful of programs.. and even so, only a small handful of dentists even apply to them out of interest.

I really don't see how this is such a big issue. I think you should be more worried about the many, many, Dr. Nurse CRNA programs out there. Dentists aren't really a threat.



Peace

 

[radslooking]

Complications do not only occur intraoperatively as you may know. Most of the poor management issues that arise when poor care is delivered by a CRNA are seen after surgery in the PACU or in the ICU.

The care provided by an anesthesiologist extends beyond the walls of the OR as opposed to that provided by CRNAs. To think otherwise shows lack of knowledge about the profession.

well, you may be right. but for independently practicing CRNA's out there....somebody must be running the PACU, so who is it? I'm just saying, we are an evidence based profession, so I'm looking for any indication of any stats out there. Are there more complications (intraop or periop) for the independently practicing CRNA's?

 

[toughlife]

well, you may be right. but for independently practicing CRNA's out there....somebody must be running the PACU, so who is it? I'm just saying, we are an evidence based profession, so I'm looking for any indication of any stats out there. Are there more complications (intraop or periop) for the independently practicing CRNA's?

Nobody has conducted such a study to date. I would like to see from an outcomes perspective what the result would be. Are you in radiology?

 

[2win]

well, you may be right. but for independently practicing CRNA's out there....somebody must be running the PACU, so who is it? I'm just saying, we are an evidence based profession, so I'm looking for any indication of any stats out there. Are there more complications (intraop or periop) for the independently practicing CRNA's?

again I have to be on tough side...You say that we're an "evidence based" profession - may I question your statement? Do we have to go in detail in whatever studies we have available? Is this eveidence based "fashion" based on ethical and moral grounds? Or it is a money driven issue? Show me the "great" CRNA or whatever nurse to manage a post op case in PACU in ICU...You deny with your statement the expertise of critical care, IM, and ANESTHESIA MD expertise. Think twice,
regards
2win

 

[radslooking]

again I have to be on tough side...You say that we're an "evidence based" profession - may I question your statement? Do we have to go in detail in whatever studies we have available? Is this eveidence based "fashion" based on ethical and moral grounds? Or it is a money driven issue? Show me the "great" CRNA or whatever nurse to manage a post op case in PACU in ICU...You deny with your statement the expertise of critical care, IM, and ANESTHESIA MD expertise. Think twice,
regards
2win

if you are confident that such experience makes a difference (and I agree with you) then such a study would bolster your case. in fact, it may be the only way to properly put the crna's in their place given their expansion.

 

[toughlife]

if you are confident that such experience makes a difference (and I agree with you) then such a study would bolster your case. in fact, it may be the only way to properly put the crna's in their place given their expansion.

It would be a good way to emphasize differences but I would like to see which IRB would approve such a study and who is willing to take the liability in case of poor outcomes.

 

[radslooking]

It would be a good way to emphasize differences but I would like to see which IRB would approve such a study and who is willing to take the liability in case of poor outcomes.

i suppose this makes sense in a country only like ours. subject millions of people to unsupervised crna's versus doing a decent study with much fewer people and actually figuring out what they should and shouldn't do. oh well.

 

[BruceBanner]

This specialty has been on this self destructive pathway for more than 50 years.
We have historically allowed any one willing to do our job, and even helped them learn our business.
This is why the future isn't bright and this is why we get no respect.
I think that anesthesiologists had inherited low self esteem from the older generation that didn't care if they were treated like doctors as long as they made the big money.
Now, the big money is rapidly disappearing and we are left with this wonderful heritage.
Many of our leaders don't even dare to claim exclusivity to the practice of their own specialty, and this is why you will find the ASA only calling for a "physician" to supervise CRNA's they don't even have the guts to say that the one who supervises CRNA's has to be an ANESTHESIOLOGIST.
I have major doubts that this specialty is even salvageable.
I hate to say this to the new enthusiastic generation but that is the reality and it's not going to get better.
If you don't like it, now is the the time to get out.

Forgive me for chiming in--I'm just a student--but I really want to get into the specialty and these issues are concerning me. What attracts me to the specialty is probably similar to what attracts a lot of people: the responsibility, the advanced knowledge of pharm/physiology, nature of patient interaction, and the ability to have some control over your workload after residency.

However, I work at a major U.S. hospital and when I am in the OR the anesthesiologists are often treated as guys or gals just running a machine...like anyone could do it. Im sure this isnt representative of the entire specialty, but this is a major teaching hospital and I would have thought that the MDA's would garner a bit more respect. They even use CRNA's here for most of the bread and butter cases.

This concerns me because I am really attracted to the specialty but I dont want to go through all of the training only to have some schmuck with a 'tech school' degree be competing with me for work. Do you think it is an professionally unsound choice in terms of stability and competition within the next 10+ years?

 

[Planktonmd]

Forgive me for chiming in--I'm just a student--but I really want to get into the specialty and these issues are concerning me. What attracts me to the specialty is probably similar to what attracts a lot of people: the responsibility, the advanced knowledge of pharm/physiology, nature of patient interaction, and the ability to have some control over your workload after residency.

However, I work at a major U.S. hospital and when I am in the OR the anesthesiologists are often treated as guys or gals just running a machine...like anyone could do it. Im sure this isnt representative of the entire specialty, but this is a major teaching hospital and I would have thought that the MDA's would garner a bit more respect. They even use CRNA's here for most of the bread and butter cases.

This concerns me because I am really attracted to the specialty but I dont want to go through all of the training only to have some schmuck with a 'tech school' degree be competing with me for work. Do you think it is an professionally unsound choice in terms of stability and competition within the next 10+ years?

Your concerns are well justified and my advice to you would be:
Go to anesthesia only if you think this the one and only specialty you want to do, and that no matter what happens you want to be an Anesthesiologist.
If the above does not apply to you then please find another specialty.

 

[skatertudoroga]

Are m.d. anesthesiologists allowed to do anesthesia in dental offices? If it pays so well with so little overhead why don't they do it? Or it doesn't pay much? I mean one of the pluses is that you do anesthesia on relatively healthy patients and outside the hospital...

 

[lushmd]

Some do. For example, one of the attending anesthesiologists at my program splits his time between one of our hospitals and providing ambulatory dental anesthesia. I can't speak as to the economics of this sort of practice though.

 

[skatertudoroga]

Some do. For example, one of the attending anesthesiologists at my program splits his time between one of our hospitals and providing ambulatory dental anesthesia. I can't speak as to the economics of this sort of practice though.

Cool! So if you burn out of hospital anesthesia as an m.d., it is realistic to make a career in dental anesthesia? Or if you don't burn out, but want more variety, you can do as your attending is doing?

 

[lushmd]

Cool! So if you burn out of hospital anesthesia as an m.d., it is realistic to make a career in dental anesthesia? Or if you don't burn out, but want more variety, you can do as your attending is doing?

I suppose you could make a go of it if you were so inclined. Again, I don't know enough about the economics of this sort of practice to properly comment on it. Compensation aside, the appeal of this sort of practice would be the schedule (no nights/weekends). Having said that, don't underestimate the technical difficulty of this sort of anesthesia. You're sharing the airway and often giving very deep sedation, to the point of general anesthesia, usually without an ETT/LMA.

 

[skatertudoroga]

I suppose you could make a go of it if you were so inclined. Again, I don't know enough about the economics of this sort of practice to properly comment on it. Compensation aside, the appeal of this sort of practice would be the schedule (no nights/weekends). Having said that, don't underestimate the technical difficulty of this sort of anesthesia. You're sharing the airway and often giving very deep sedation, to the point of general anesthesia, usually without an ETT/LMA.

Thank you! I just wanted to learn about different careers.

 

[Clemenza]

I'm a dentist.

I'm also in medical school now, and strongly considering anesthesiology. In fact, I'd say it's at the top of my list right now.

Dental anesthesiologists are different than anesthesiologists. Obviously, they do not possess medical degrees. Moreover, their residency is two to three years in duration. Not four.

Furthermore, "dental anesthesiology" is not an ADA-recognized specialty of dentistry. Oral and maxillofacial surgeons want to keep it this way. OMFSs are with little exception the only dentists who have enough anesthesia training to provide IV sedation. Being the sole anesthesia providers within the dental profession helps protect their patient supply. (For example, there are many general dentists who can take out third molars, but patients often want to be sedated for this procedure).

Furthermore, the training requirements are inconsistent. Again, some are two years in duration while others are three. (And just FYI, not too long ago, these programs used to be 12 months in duration!). This lack of standardization, I think, means that it is a long ways off from becoming a specialty.

Another worthwhile point is that there's a dental equivalent to the ASA. It's the ADSA. You know who can gain membership to the ADSA? Dental anesthesiologists, of course. But so can oral surgeons (who have completed no more than 4 to 6 months of anesthesia rotation....plus whatever training in IV sedation they had), as well as general dentists who have become certified to provide oral or IV sedation. Again, not very stringent requirements.

Finally, I'm not even sure if dental anesthesiologists have hospital privileges. That is, I don't think it's possible for them to work in anything but an outpatient setting.

 

[sevoflurane]

Finally, I'm not even sure if dental anesthesiologists have hospital privileges. That is, I don't think it's possible for them to work in anything but an outpatient setting.

Unfortunately, this is not true.

 

[sevoflurane]

.

 

[sevoflurane]

OMFSs are with little exception the only dentists who have enough anesthesia training to provide IV sedation.

Also not true.

 

[W222]

its not an issue really until someone young and healthy turns up brain dead or outright dead from a routine procedure. then people start asking questions. just like what happened in pa with that 18 year old girl who died in a plastic surgeons office

Yup, I have heard of atleast one dentist who has killed someone in his office. I don't know what came about after the death (lawsuit, ect.), but I heard from several reliable sources that a did patient die and dead is dead. If a dentist is performing a teva/GAs in their office on god knows who that is a recipe for disaster. They don't do pre-op evals and they likely won't know how sick some of their patients are because they don't know the disease process. I don't buy that a one year crash course in anything will give you enough to go out into the real world, and that stands for CRNAs also.

 

[Sergio99]

we cannot move to Russia, France,,,maybe Kenya - the ABA diploma and residency is not recognized. There the "anesthesia" still has the ICU, they didn't sell it for nothing.

Hola,

As far as I know, the United States is the only country in the world that has CRNAs, Dental Anesthetists, and all the other mid-level practitioners. What other countries do have (in the third world, not in civilized countries) is surgeons who administer anesthesia themselves and grab any nurse, with special training or not, put them at the head of the table to monitor the patient and they go on with their surgery. We have a surgeon who administers drugs himself in the same fashion, but not for general anesthesia.

Back in 1978, when I was doing a fellowship, there was a dentist doing the residency of anesthesia in the same program as the other residents, and he was very good. I always had misgivings about the guy because he was not a physician, but not because he was not good. Some "dental anesthetists" do general anesthesia of all kinds, including pediatric anesthesia for complex repairs of various congenital abnormalities.

Now, you have to remember that all of these situations have no reciprocity at all. No dentist would let us do dental work of any kind, nor any surgeon would let us perform surgery. They can invade our turf, but we cannot invade theirs. Not that we would want to, but if we did, they wouldn't let us.

I agree with previous posters, there is not much that can be done about this because the government doesn't respect us, other specialties don't respect us, and our own society doesn't respect us.

I am sorry to be so pessimistic, but in the last 30 years I have been in the specialty, I have not seen any progress in this area. Yes, there have been many advances in the science of anesthesia, we are better anesthesiologists today than we used to be in the past, but not better businessmen and we have not advanced in our public relations and public image.

Greetings

 

[Clemenza]

Also not true.

Sevoflurane, no offense, but I think I know what goes on in dentistry more than you....my being a dentist and all....

I said "with little exception", not "with no exception". The overwhelming majority of general dentists, periodontists, pediatric dentists, endodontists, and prosthodontists (i.e. dental professionals whose work is heavily operative in nature) are not trained to perform IV sedations.

There are a few programs here and there who will provide some training in light IV sedation. The dental school I attended had a few cases where the periodontics residents would administer Versed intravenously--which at the time I thought was a big deal until I saw a patient get up in the middle of the procedure to go to the bathroom! I've had patients more sedated from a half milligram of Xanax given for anxiolysis.

Once again, oral surgeons are the only dental professionals who are routinely trained to perform IV sedation. If I'm not mistaken, the ADA stupilates that any dentist who wishes to perform IV sedation needs to have a year of training in it (or have completed an OMFS residency).

 

[Clemenza]

Now, you have to remember that all of these situations have no reciprocity at all. No dentist would let us do dental work of any kind, nor any surgeon would let us perform surgery. They can invade our turf, but we cannot invade theirs. Not that we would want to, but if we did, they wouldn't let us.

If I'm not mistaken, the practice of dentistry falls within the practice of medicine. I believe a physician, technically, is permitted to place a filling or perform a root canal. He'd be out of his mind to attempt this, but he can.

There are certainly physicians who extract teeth in certain circumstances. It's rare, but they're permitted to do it.

On a related note, I should mention that most dental surgeries requiring general anesthesia (e.g. trauma cases, draining infections, orthognathic surgery, bone grafts where bone is harvested from the iliac crest or tibia, as well as patients who are not candidates for IV sedation, etc. etc.) are performed with an anesthesiologist (or CRNA) at the head of the table.

Similarly, there are anesthesiology groups that cater to dental offices needing anesthesia services.

(Just FYI, I use the term "anesthesiologist" in reference to MDs or DOs).