Are we really training our residents right?

[Noyac]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's? When a resident finishes his/her training are they any different than the CRNA's trained in the same program?
Residents, are you being trained to use your judgement? Are you given the liberty to act as you may see fit when it comes to pt care? Or are you being encouraged to use protocols?
Are you dropping pts off in the pacu expecting someone else to manage their pain and hemodynamics like a CRNA would or are you thinking beyond this part? A very experienced partner of mine and I were talking the other day. We noticed that younger more recently trained physicians are not doing this. Our approach is to have the pt ready to be sent to the floor basically when we bring them to the pacu. I don't expect the nurses there to have to do much other than record vitals for 15-30 min. Pain, hemodynamics and anything else should be taken care of by the time they get there. PONV does not exist.
Are your attendings training you this way? If not, then ask yourself and them, WHY NOT?

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[deleted171991]

Noyac, many senior academic attendings would DIE in private practice. Some don't even have the skills to do an entire case on their own anymore, without a resident or CRNA. And you want these guys to actually teach residents how to survive in the real world, when they are the reason why the ivory towers are the way they are in the first place?

 

[Stank811]

Noyac do you have specific examples? The program I graduate from ensured that all the index cases or complex patients were assigned to a residents and overflow index cases were assigned to a CRNA. I do not feel that I could have been more prepared to enter PP and hit the ground running while at the same time training in a academic center. My program did a really nice job I feel of letting you have autonomy when it was deserved. The majority of my CA-3 year was me performing the induction, maintenance, and wake up as I wanted….the only times that I did not get such great autonomy was when I was assigned a newer attending or when a senior attending wanted to teach a concept...which I encouraged.

One thing that I notice going from a large academic center to a community hospital was the resources are less and the support staff is much less comfortable with more complex care. For example, I am much more liberal with my extubations than I would be in an academic center b/c my current hospital does not have the appropriate RT or nursing resources to wean patients from the vent in the PACU as was the case in the center I trained…can it be done….yes, but I am not sure if it is safer for the patient for me to leave them vented in the PACU.

I am assuming your offering a competitive package to attract strong residents. Some of the packages being mentioned on this forum are terrible and any resident with a sliver of insight would run like hell from them. In my area the same groups are always mentioned when it comes to being considered strong and that is because they always have been offering fair and more than competitive packages and thus are always able to pull in strong residents.

 

[RK.md]

I've covered our PACU for two weeks this month and had plenty of flexibility given by the attendings to do whatever I needed to with regards to post-operative management (PONV, pain, hemodynamics, labs, etc). I only request a final sign out once I'm convinced a patient is stable for transfer or discharge. Additionally, I'm also in charge of out-of-O.R. airways and codes (the role of a consultant), another wonderful aspect of my early training which I've come to enjoy. As protocol-driven everything has become in medicine, I feel like my training has been centered more around clinical intuition backed by evidence and experience.

 

[8ball]

We are not training residents right. We focus on stupid esoteric **** with no real bearing on clinical practice when we should be hammering on the one topic that could potentially separate us from the nurses in the eyes of everyone else in the hospital - crisis management and OR/PACU critical care. I personally think its embarassing how uncomfortable my co-residents appear in crisis situations (i'm not great either, i admit it and im actively working on it) and I can't blame others for their perception of our specialty when 90% of the time the routine stool-sitting looks so simple and then we go and get a cardiology consult for a simple SVT.

 

[Colba55o]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's? When a resident finishes his/her training are they any different than the CRNA's trained in the same program?
Residents, are you being trained to use your judgement? Are you given the liberty to act as you may see fit when it comes to pt care? Or are you being encouraged to use protocols?
Are you dropping pts off in the pacu expecting someone else to manage their pain and hemodynamics like a CRNA would or are you thinking beyond this part? A very experienced partner of mine and I were talking the other day. We noticed that younger more recently trained physicians are not doing this. Our approach is to have the pt ready to be sent to the floor basically when we bring them to the pacu. I don't expect the nurses there to have to do much other than record vitals for 15-30 min. Pain, hemodynamics and anything else should be taken care of by the time they get there. PONV does not exist.
Are your attendings training you this way? If not, then ask yourself and them, WHY NOT?

Of course different residency programs train residents differently so it's hard to say if "we" are training residents appropriately.
Residency is only 3 years long, how long have your experienced partner and you been in practice? I have been in pp for 1 year and I consider the learning curve to have been as steep as 3 years of residency. Even at the best programs, I think a new grad is not going to be as good as a 10+ year veteran. Cut the new folks some slack, they will get the hang of it with time

 

[pgg]

We are not training residents right. We focus on stupid esoteric **** with no real bearing on clinical practice when we should be hammering on the one topic that could potentially separate us from the nurses in the eyes of everyone else in the hospital - crisis management and OR/PACU critical care. I personally think its embarassing how uncomfortable my co-residents appear in crisis situations (i'm not great either, i admit it and im actively working on it) and I can't blame others for their perception of our specialty when 90% of the time the routine stool-sitting looks so simple and then we go and get a cardiology consult for a simple SVT.

One difficulty is that a genuine crisis is a rare event in anesthesia. It's totally possible for a resident to go weeks or (much) longer between them ... and as they gain experience and learn how to intervene early or avoid them altogether, they get even rarer. It's hard to practice a rare event.

Simulation can help with that, but it's expensive and very labor intensive and it takes residents away from real patients in the OR. The next best thing is probably ordinary pimping (not necessarily malignant) and and scenario discussion (ie mini mock orals) from a motivated attending during other cases. THIS is where I think training residents right or wrong enters into the equation.

Now you add in the absurdity of the work hour restrictions progressively instituted over the last decade, which are about one step away from requiring afternoon nap time with milk and cookie refreshments, and current residents just aren't in the hospital as much. Med students, interns, and residents have less autonomy and much shorter leashes now. (When was the last time you saw a med student put in a central line? I did lots as a MS4. Now the interns and even residents need the numbers.) Three years of residency now is less experience than it was a decade ago. Should we be surprised that senior residents and new grads are lagging on some things that require experience to master?


Anxiety goes away with experience ... and especially preparation. For example, a person who doesn't know ACLS cold is going to be uncertain and uncomfortable during a code. I've been teaching ACLS for many years now and man, there are a lot of doctors who struggle with it and are really uncomfortable during the mock codes. They're not dumb and they don't have anxiety disorders - they're just unprepared. There's nothing else to say there.

One last comment. It's easy to blame a teacher for not teaching, and I don't deny that there are plenty of attendings out there who are ultraconcerned with not missing their next q30min scheduled dose of coffee, but in residency we're past the high school spoon feeding. Residency is the finale academic stage in preparing people to be completely independent self-learners. Some fault usually lies with the learner who isn't learning. (Before anyone gripes at me, I'm not at all absolving the teachers of their responsibility to adjust the teaching to the needs of individual learners.)


All that said ...

I have been in pp for 1 year and I consider the learning curve to have been as steep as 3 years of residency.

Absolute truth there. As a new grad I benefited tremendously from a couple of more experienced anesthesiologists who took the time to help me navigate the people, environment, and culture. I could do a safe anesthetic on day 1. Doing it efficiently in their system took some time.

 

[floridaboy18]

Currently a CA-2. I feel like I get a ton of autonomy. I get to decide on the anesthetic plan, and unless my attending doesn't think that's the best plan (which they will gladly let me know) I get to carry out said plan. Residents run the PACU. Each of us does a month doing sign outs and management. Attendings are involved if something is there we are having trouble managing or haven't seen. Additionally, every CA-3 call you are supervising rooms (induction, maintenance, and emergence) while at the same time running the PACU for sign outs and management. In addition you carry the airway/code pager. Attendings are there for help if needed but only if needed. You get as much autonomy as you want.

Even as a CA-1 on hearts doing a robotic thoracic case on a myasthenia patient I was able to make and perform my own plan. Avoided NDNMB's all together with a narcotic infusion. Patient woke up taking 700 cc TV's with an easy extubation in the OR. No prolonged ICU stay. My plan, great autonomy, and great learning experience. As a CA-1.

I agree with the above sentiment regarding spoon feeding. Take charge of your training. Demand autonomy. Ask for help when necessary. Ask questions to learn. We are all adults here. Take charge of your learning, and execute a well thought out plan.

 

[Ignatius J]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's? When a resident finishes his/her training are they any different than the CRNA's trained in the same program?
Residents, are you being trained to use your judgement? Are you given the liberty to act as you may see fit when it comes to pt care? Or are you being encouraged to use protocols?
Are you dropping pts off in the pacu expecting someone else to manage their pain and hemodynamics like a CRNA would or are you thinking beyond this part? A very experienced partner of mine and I were talking the other day. We noticed that younger more recently trained physicians are not doing this. Our approach is to have the pt ready to be sent to the floor basically when we bring them to the pacu. I don't expect the nurses there to have to do much other than record vitals for 15-30 min. Pain, hemodynamics and anything else should be taken care of by the time they get there. PONV does not exist.
Are your attendings training you this way? If not, then ask yourself and them, WHY NOT?

Out at PONV doesn't exist. A little self-righteous.

 

[Depakote]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's? When a resident finishes his/her training are they any different than the CRNA's trained in the same program?
Residents, are you being trained to use your judgement? Are you given the liberty to act as you may see fit when it comes to pt care? Or are you being encouraged to use protocols?
Are you dropping pts off in the pacu expecting someone else to manage their pain and hemodynamics like a CRNA would or are you thinking beyond this part? A very experienced partner of mine and I were talking the other day. We noticed that younger more recently trained physicians are not doing this. Our approach is to have the pt ready to be sent to the floor basically when we bring them to the pacu. I don't expect the nurses there to have to do much other than record vitals for 15-30 min. Pain, hemodynamics and anything else should be taken care of by the time they get there. PONV does not exist.
Are your attendings training you this way? If not, then ask yourself and them, WHY NOT?

I'm a CA-3 and at this stage in the game I own the patient from pre-op through PACU. I tell my attending which lines I feel are indicated and why (they usually agree, but will respectfully tell they want to do something different). At induction, it's somewhat attending dependent but I often get to push my own drugs with the attending standing by, unless they feel that the airway or the line is the more pressing issue. I'll do the major positioning with the help of the attending. I'll extubate and bring the patient to PACU at which point I'll write their post-op orders and manage any PACU issues. I will say that I feel like my program is doing a good job prepping my for the outside world.

 

[urge]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's? When a resident finishes his/her training are they any different than the CRNA's trained in the same program?
Residents, are you being trained to use your judgement? Are you given the liberty to act as you may see fit when it comes to pt care? Or are you being encouraged to use protocols?
Are you dropping pts off in the pacu expecting someone else to manage their pain and hemodynamics like a CRNA would or are you thinking beyond this part? A very experienced partner of mine and I were talking the other day. We noticed that younger more recently trained physicians are not doing this. Our approach is to have the pt ready to be sent to the floor basically when we bring them to the pacu. I don't expect the nurses there to have to do much other than record vitals for 15-30 min. Pain, hemodynamics and anything else should be taken care of by the time they get there. PONV does not exist.
Are your attendings training you this way? If not, then ask yourself and them, WHY NOT?

Makes me wonder what kind of conversations the younger guys are having regarding the older guys.

 

[Noyac]

It appears that I have struck a cord with more than a few people here.

 

[Noyac]

Makes me wonder what kind of conversations the younger guys are having regarding the older guys.

They area probably saying that the older guys are difficult at times. What they don't understand is why these older guys are difficult at times.

 

[Noyac]

Out at PONV doesn't exist. A little self-righteous.

Ok, I'll give you that one. It was stated this way to give the impression of how rare PONV is. There may be some nausea but I can't remember my pt or any of my partners pt's puking in a long time.

 

[chocomorsel]

Just because they aren't puking, doesn't mean they aren't nauseated. I don't see too much vomiting, but I see plenty of nausea. I am the youngest in the group and the only female, so I assure you that I medicate all my patients for PONV in the OR, unlike most of my older male colleagues who may think I overmedicate for it.

Please forgive me, but I was under the impression that the reason for the PACU was to take care of Post anesthesia/surgical issues, such as neuro/cardiac/respiratory stability as well as pain and nausea. Are we really paying nurses just to chart vitals? Might as well drop the patients of in their respective hospital beds or call for immediate wheelchair assistance then to get them into the cars directly from the ORs.

When patients wake up more from their drug induced sleep, inevitably they will start feeling more pain, and once they start moving around inevitably they will start feeling nauseated. Not all patients, but plenty of them. That is why we take them to PACU for further care.

It's no measure of how good an anesthesiologist is or isn't.

 

[Noyac]

Choco, you are not following my discussion. I agree with anything you are saying but what I'm talking about is planning your anesthetic beyond the immediate recovery period. For example, if you choose to use Remi, are you planning for pain after you turn it off? That's just one example.
Also, I would be in the camp of your older male colleagues. I don't think every single pt needs antiemetics. That's a crna practice style IMO.
Also, I'm not saying newly trained physicians are wrong or that they are no good. I'm just asking the question, are we training them differently than we are training our CRNA's? As physicians we have the knowledge that CRNA's don't have and we need to act on it. We need to take more ownership of our pt's. Don't just drop a diabetic off in pacu without checking a BS for 3 hrs and expect the nurses to do this. Why can't w check it intra-op and treat it there? This is an example again, I don't want to talk about diabetes in the OR here. Start a new thread for that one.

 

[Noyac]

Ok, I have a bit more time to reply and provide some clarification.
Admittedly, I am not in academics and I'm sure some things have changed since I was. I'm simply asking the question, Are we training our future anesthesiologist to be peri-operative physicians? Are we considering the overall pt and taking into account all that comes with that pt? CRNA's provide a good product at a somewhat lesser cost. We will be asked to compete with this more and more. When a crna performs an anesthestic, they are just treating the pt and the pts response to surgical stimulation. They then wake the pt up and drop them off in pacu for someone else to take over. The pt immediately becomes the surgeon's ( or hospitalist's) problem from there on. My discussion with my partner touched on this some but mostly it got me thinking deeper into the issue. What are we as anesthesiologists required to do? Not much more than a crna if you ask most others. But if we continue to just perform like these CRNA's then we will be treated like one and ultimately employed like one.
So, do you guys round on pt's post-op? I don't round on every pt but if my pt's are admitted post -op I make every effort to go see them the next day. If they are doing fine then no need to see them again. If they are not fully recovered from their pathology or anything related to it then I continue to see them and provide input from my perspective to those managing the pt. Are our residents being trained this way? I have some exceptionally good younger partners. So don't think I'm talking about my group per-se. We choose very carefully and we have made some mistakes along the way but this is not about my group.

Also, when you are wrapping up the surgerical procedure are you planning beyond pacu? What issues might this pt have in the next 24hrs? Are your attendings discussing these types of things with you? We should know our pt's as well or better than our surgeons and definitely better than the hospitalists. So why then are we not still following the pts after surgery? Maybe I'm talking about anesthesiologists as post surgical hospitalists, I don't really know at this point but I can see how this will benefit our profession.

I hope this clears up the discussion some.

 

[Noyac]

Please forgive me, but I was under the impression that the reason for the PACU was to take care of Post anesthesia/surgical issues, such as neuro/cardiac/respiratory stability as well as pain and nausea. Are we really paying nurses just to chart vitals? Might as well drop the patients of in their respective hospital beds or call for immediate wheelchair assistance then to get them into the cars directly from the ORs.

When patients wake up more from their drug induced sleep, inevitably they will start feeling more pain, and once they start moving around inevitably they will start feeling nauseated. Not all patients, but plenty of them. That is why we take them to PACU for further care.

It's no measure of how good an anesthesiologist is or isn't.

This is part of what I'm talking about. Why would you expect the nurses in pacu to take over for you?
In my practice, if I perform my anesthestic correctly, then yes we are paying the nurses to chart vitals.
So IMO, it is a measure of how good an anesthesiologist is.

 

[pgg]

It's no measure of how good an anesthesiologist is or isn't.

At places with high outpatient volume/throughput and limited PACU staff, a good anesthesiologist and a well-planned well-executed anesthetic is the difference between a rapid discharge, and PACU gridlock backing up the ORs.

I've worked places where every minute the PACU nurse is giving PRN hypertension, pain, and nausea meds (or simply waiting for a patient to wake up) is a minute I'm phase-1 recovering my own patient in the OR, because the PACU is full.

 

[chocomorsel]

Well I am just an average anesthesiologist. I don't work in a fast paced environment, thankfully so no backup in PACU unless the hospital is full. Anyway, gotta go back to work. yeh call. I round on my ICU patients and patients that had a difficult time in the OR.

 

[Noyac]

Well I am just an average anesthesiologist. I don't work in a fast paced environment, thankfully so no backup in PACU unless the hospital is full. Anyway, gotta go back to work. yeh call. I round on my ICU patients and patients that had a difficult time in the OR.

I don't follow this statement. We are talkng about doing more and you are content with average? And you take a shot at your "older male colleagues" but then again call yourself average. I'm confused (not really).

 

[BuzzPhreed]

I'm with Noyac on this one. You should be constantly trying to improve your practice. The slicker you get, the better your patients' peri-operative course, the more you will be viewed as an excellent provider by the people who will ask.

I too rarely have uncomfortable nauseated patients in the PACU. That has to do with not overmedicating with nausea-inducing substances as much as it does with recognizing who is likely to be a puker in the PACU. I usually bring my patients warm, awake, and comfortable to the PACU. I frequently here, "I doesn't even look like you had anesthesia" from the PACU nurses. That is SUCCESS in my book. Of course that's for the chipshot outpatient cases. When I do a lung resection or a big complex vascular case sometimes I'm happy if I can just get them extubated at the end.

It's all a matter of perspective. Never strive to be "average".

 

[BuzzPhreed]

The real question is, are we training our residents to be good physicians or are we training them just like the crna's?

You can train them to be cookie-cutter and follow a recipe. Or you can train them to think. I believe that's the crux of what you're getting at.

The only cookie-cutter anesthesia I do is in the endo unit. And it's still well thought out and ready to adapt if something changes. When you start to get into the "this is the way we do that case" then you're no different than a CRNA. That's how they think. Most of them.

 

[dhb]

Something to consider is the breadth of knowledge is always expanding and elements older anesthesiologists have picked up over the years need to be crammed in a short 3y residency. I had a 5y residency and wasn't able to accomplish everything i was set to do: not enough TEE skills namely.

 

[chocomorsel]

I don't follow this statement. We are talkng about doing more and you are content with average? And you take a shot at your "older male colleagues" but then again call yourself average. I'm confused (not really).

I am not striving to be average. And I did not take a shot at the older male colleagues. I simply stated a fact. Take it as you may. I medicate all my patients, with different drugs but at least they all get zofran for a GA. Some more, some less. Call it CRNA thinking, but that is how I was taught and that is what the texts showed me. I am only two years out and still have plenty to learn.

As far as being content as an average anesthesiologist, well, that is something that I am accepting at this point in my career, being that I work in a small community hospital, don't run into many emergencies or crazy situations as frequently as you would in a bigger hospital. Some of my skills have deteriorated due to lack of use, but hopefully that will change as I move to a new hospital setting in the near future with more variety of cases. I have had difficult cases where patient outcomes where poor and I went back over the scenarios in my head and thought that maybe these patients would have been better off served at bigger hospitals where these type of difficult cases were common place. I go home and read and research the scenarios, go over them with colleagues and hope to learn from my mistakes. So I don't pretend to be the superstar that some on SDN tend to think and say they are, as I know I have limitations and there are some cases that are challenging to me in my the small community hospital.

I could sit here and say that I can intubate anyone at anytime, under any circumstances, save every life or limb at 2 am by dropping lines, TEE, depleting the blood bank, working out crazy equations and calculations in my head and patients who came in dead with a ruptured AAA walk out of the hospital in 5 days without any deficits like some of ya'll claim to do. However, I am a realist and know that I do what I can, know my limits, make mistakes and strive to improve. I am no superstar like some of ya'll claim to be. There are a lot of egos in medicine, and mine is not one of those. My situation will be improved by going back to a bigger facility and getting exposed and re-exposed to more. There is plenty I haven't seen or done even though I trained at a level 1 trauma center. Even my little hospital exposes me to stuff and I continue learning.
Take it as you may.

 

[Triple AAA]

Truth be told, there are very few instances in which any trainee really has a chance to practice their own anesthetic. This was true for me both as a resident and as a fellow. Residency is not about thinking for yourself. Residency is about looking up your room assignment for the next day and trying to figure out what Attending X wants to do, whether or not you would do it yourself. God forbid you try thinking outside the box, you can expect a reaming from Attending X. As someone mentioned earlier, your learning curve during the first year at private practice is just as large as 3 years of residency, and far more valuable.

 

[gasdoc77]

You can train them to be cookie-cutter and follow a recipe. Or you can train them to think. I believe that's the crux of what you're getting at.

The only cookie-cutter anesthesia I do is in the endo unit. And it's still well thought out and ready to adapt if something changes. When you start to get into the "this is the way we do that case" then you're no different than a CRNA. That's how they think. Most of them.

This is an important point. One of my pet peeves is the "we do this for this surgeon/case (nevermind the patient)" culture of PP. I realize that it is part of the game, but completely submitting to this mentality simply validates those that argue against the importance of our role. There is some truth that the further and further removed one is from training/academia, the greater the likelihood that they have subscribed to this approach.