Making the most of residency

[bluebird70]

I wanted to ask the more experienced of you a question. My residency program - which used to have smaller class sizes and good CRNA support - has now become a larger, "resident-run" program where residents are increasingly utilized to cover general ORs, ortho, sometimes eye rooms, etc. And due to the gradual increase in class size, each resident's quality educational caseload has been diluted.

We do have our strengths - excellent trauma, peds, thoracic. Our OB, neuro, cardiac, and regional are ok but not great. No transplant. On the other hand, we do have quite sick patients because we essentially function as a county hospital - so that is a good strength.

Considering all this, what is your advice to make the most of the remainder of my residency? As I start my CA-2 year, what can I do push my learning in the OR when I'm slotted for bread and butter cases? Asking for better cases is not an option given our class size. At the same time, should I just trust that taking care of sick patients even in bread and butter cases will give me good training? Especially considering that I'll be applying for peds this year and will theoretically get plenty of "advanced" cases in fellowship. Thanks everyone.

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[Arch Guillotti]

“Keep your feet on the ground and keep reaching for the stars”

Casey Kasem

 

[nimbus]

As always, seek out opportunities to work on your weaknesses.

 

[zizzer]

If you work hard, you'll learn a lot more than you think in the next two years. I could barely start IVs at the end of CA-1 year and was really concerned, but was determined to not give up a year of income to do a fellowship so I worked hard and took a job doing just about all the challenging cases you could imagine in a physician only, tertiary care practice with trauma, transplant, OB, blocks, and just about everything else.

You don't need to be doing an awake craniotomy every day to be challenged. A typical call shift with pneumoperitoneum or bowel obstruction in a patient with comorbidities is challenging enough, as are bread and butter cases with sick patients. I'm assuming you take care of patients with HFrEF, severe COPD, supermorbid obesity, etc, right? Put some work into learning procedures well: ultrasound-guided arterial lines, CVCs, and PIVs. If you struggle with a patient BMV, DL, or VL, now is the time to figure out why and how you may have done better, if possible. If you learn the skills, you'll be able to do liver transplants with a bit of orientation from a partner in the future about how to be prepared for specific portions of the case even though you don't have them in your program.

Even for ASA 1 straightforward cases, challenge yourself to provide an optimal analgesic plan, quick wakeup, no nausea, etc. Learn from a pharmacokinetic app such as iTIVA. Learn how to read EEG for depth of anesthesia monitoring. If nothing else, use the time during stable cases to start studying for the oral boards, as it's actually really useful stuff to think out and be prepared for.

Most importantly, challenge yourself to decide the plans, even if you're attending wants to do something else. This mental exercise will prepare you best. Otherwise, you're just learning to follow directions.

 

[vector2]

For bread and butter cases as a senior:

Do an asleep fiberoptic with and without a Williams and/or Ovassapian airway
Do a VL assisted FOI
Use a blade which you are uncomfortable with
Intubate without a stylet
Use a non-standard combination of induction drugs
Run a paralytic infusion
Try an opioid free technique
Do elective ultrasound IVs in the upper arm
Try a new block (are you well-versed in 4 pt TAP, rectus sheath, or QL for a laparotomy?)
Drill emergency OR crisis management
Do an oral board stem or grabbag with your staff
Try a deep extubation
Try to perfect awake extubations where the pt doesn't buck or struggle at all

 

[UscGhost]

Do GI, TEE, Mac cases, regional, ultrasound, spinals, etc.

 

[cchoukal]

When I have a senior resident doing a nothing-burger case, my challenge to them is to make everything smooth, from the IV, to lines, to their demeanor. They know how to do the case, but they often don't think about how to do it smoothly as if they were on their own.

 

[GassYous]

Learn how to be fast and efficient. I don't get why it takes some people 20 minutes to get a patient intubated. It takes 5. I guess they can get another unit out of dilly dallying? I'd rather go home and see my kid. Don't take 30 minutes to put in an epidural or a central line.

 

[Lecithin5]

For bread and butter cases as a senior:

Do an asleep fiberoptic with and without a Williams and/or Ovassapian airway
Do a VL assisted FOI
Use a blade which you are uncomfortable with
Intubate without a stylet
Use a non-standard combination of induction drugs
Run a paralytic infusion
Try an opioid free technique
Do elective ultrasound IVs in the upper arm
Try a new block (are you well-versed in 4 pt TAP, rectus sheath, or QL for a laparotomy?)
Drill emergency OR crisis management
Do an oral board stem or grabbag with your staff
Try a deep extubation
Try to perfect awake extubations where the pt doesn't buck or struggle at all

This is great advice. Have your staff pimp you with your asa 1 cases- “what would you do if your peak pressures suddenly increased” etc etc.

 

[Drwine]

Don't wait to be "spoon fed". Lots of good advice here. Seek out a good mentor and master autodidactic learning. When I was born the only treatment for heart failure was mercurial diuretics and digitalis. When I finished residency there was no propofol, sevoflurane, desflurane, LMAs, TEE, ultrasound guided lines. I had to find a way to master the use of all of the above and you will have to do similar.

 

[nimbus]

Don't wait to be "spoon fed". Lots of good advice here. Seek out a good mentor and master autodidactic learning. When I was born the only treatment for heart failure was mercurial diuretics and digitalis. When I finished residency there was no propofol, sevoflurane, desflurane, LMAs, TEE, ultrasound guided lines. I had to find a way to master the use of all of the above and you will have to do similar.

Damn, you’re even older than me

 

[BLADEMDA]

Vector2 gave great advice. My 2 cents is learn to get faster, much faster.