Starting as an attending

[SDF1]

Hey everyone,

Currently an ACTA fellow at a large academic center in the Northeast. I am joining an academic group starting August, a week after I finish fellowship. Will be doing 50/50 cardiac and other stuff (general, regional team, ambulatory). Will be supervising residents/CRNAs.

Was just forwarded my login information for QGenda which the group uses for scheduling and reality hit that I no longer will be a trainee. A bit nervous/scared/imposter syndrome setting in.

The next few months will be busy, taking my advanced PTE July 2021, starting real job August 2021, oral boards October 2021.

Any advice to quell my uneasiness?

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[GassYous]

You'll be okay. We all get through it.

Run complicated cases by senior attendings. There are always people around to help, especially in academics.

 

[Mman]

Any advice to quell my uneasiness?

Anesthesia is anesthesia.

You already know how to do that. Ask for help learning the details of which surgeons are good/bad/fast/slow and as a general rule of thumb start off doing things the way everybody else does them there for a given case. You might have some super cool new technique nobody there knows about but when you are first starting out it's best to not rock the boat too much. Because if you do something different and it doesn't go perfect, it doesn't look great. If you do it the same way everyone else does at the start and it doesn't go perfect, well they are already used to whatever particular problem comes up and they won't blame you personally.

Eventually as you build up some respect from everyone you can enlighten them on why you want to try doing something differently.

 

[ProwlerturnGas]

Don’t forget to turn on the vaporizer!

 

[DocMcCoy]

There is a famous JET thread that is pretty applicable.

Are You Ready For Private Practice?

(ADDENDUM: I wrote this a cuppla years ago. Its got alotta useful information in it for you. I'm bumping it for the benefit of my CA-3 colleagues who may have missed it and are gonna be on their own in a few months.) I'm starting a thread that I hope will be useful for the current and future...

forums.studentdoctor.net

 

[GaseousClay]

Work hard and challenge yourself in the beginning. Once you start becoming complacent and dare I say lazy, its hard to go back. Plus you want to obtain a good reputation to start with the CRNAs and fellow MD/DOs.

 

[AnesRunner]

If you are going to be covering Regional at an academic center, you are going to need to brush up on your Regional skills since you are relying on your residency experience for that. Find a Regional attending that can help you out (if it's a place with a strong Regional division). As someone else said, anesthesia is anesthesia though. Wouldn't worry about the rest.

 

[abolt18]

Remember the things you hated most about some of your attendings and don't do those things.

 

[Wolverines83]

Be conservative and run stuff by your colleagues. The group as a whole will probably be relieved to realize you're cautious and are willing to ask for help. I don't hesitate if something is out of my comfort zone. Weird valve pathology? Why wouldn't I ask the CT guys? Even if it's a quick "I'm gonna do this. Does that seem reasonable?"

Also, don't be a pushover. I mean, be humble because you're new but that doesn't mean being a pushover. Especially for the CRNAs and surgeons.

And don't be a dick

 

[dabears505]

Also don't do things you know are wrong because of pressure. Dude had a small meal 4 hours ago, can we just go now please? Obvious things that in the rare chance things go wrong you have no defense for, avoid for now.

 

[Wolverines83]

Also don't do things you know are wrong because of pressure. Dude had a small meal 4 hours ago, can we just go now please? Obvious things that in the rare chance things go wrong you have no defense for, avoid for now.

this is exactly what i mean by don't be a pushover. They'll try.

 

[Planktonmd]

Be flexible...But since it's an "academic" group you probably don't have to... you will find academic types who are very talented at making simple stuff seem dramatic and it's up to you if you want to be like them.

 

[Volatile]

A healthy dose of nerves is a good thing, it means you care. Your partners will/should help you. The biggest obstacles in the beginning will be politics/logistics, not your ability to provide an anesthetic. You’ll be fine, enjoy the new journey.

 

[zizzer]

Strike a good balance between confident but willing to run things by people for advice. Be nice to everybody (more important than you might think). Prepare for your cases as best you can before when you get a chance. If you have resources such as Jaffe's book or whatever, put them on PDF on your phone for quick reference. Check out the PDF reader Xodo for this. It works well for books on Android (unsure if it's on iPhones but I'm sure they have something). You usually won't regret doing a little more work to be safer, such as writing in an order to give premedication for reversible bronchoconstriction or aspiration prophylaxis, even if you might not need it.

I'm first-year generalist attending in MD only high acuity practice, so I don't have much advice about working with the CRNAs, sorry.

EDIT: Another thing. If you're continually doing high-acuity cases, eventually somebody's not going to have a good outcome. To an extent it's unavoidable, but it feels very different as an attending. Even if you did everything more or less right, you're going to be second guessing yourself afterwards a bit. All the more reason to take extra steps to be as careful as possible from the beginning when you can. Does that small bowel obstruction patient with a distended abdomen need an NGT pre-induction? Most likely not with a standard RSI. Could you try to place one though and should you? Absolutely.

 

[Simba1711]

I agree with everything but the last part is puzzling. I would argue it’s standard of care to put an ng tube preinduction for patient with sbo. You want to decompress them before induction.

Strike a good balance between confident but willing to run things by people for advice. Be nice to everybody (more important than you might think). Prepare for your cases as best you can before when you get a chance. If you have resources such as Jaffe's book or whatever, put them on PDF on your phone for quick reference. Check out the PDF reader Xodo for this. It works well for books on Android (unsure if it's on iPhones but I'm sure they have something). You usually won't regret doing a little more work to be safer, such as writing in an order to give premedication for reversible bronchoconstriction or aspiration prophylaxis, even if you might not need it.

I'm first-year generalist attending in MD only high acuity practice, so I don't have much advice about working with the CRNAs, sorry.

EDIT: Another thing. If you're continually doing high-acuity cases, eventually somebody's not going to have a good outcome. To an extent it's unavoidable, but it feels very different as an attending. Even if you did everything more or less right, you're going to be second guessing yourself afterwards a bit. All the more reason to take extra steps to be as careful as possible from the beginning when you can. Does that small bowel obstruction patient with a distended abdomen need an NGT pre-induction? Most likely not with a standard RSI. Could you try to place one though and should you? Absolutely.

 

[Mman]

I agree with everything but the last part is puzzling. I would argue it’s standard of care to put an ng tube preinduction for patient with sbo. You want to decompress them before induction.

most SBO patients I take to the OR have already had an NG placed either in the ED or on the floor. Quite rare to see them get to the OR without having had one. I did have a surgeon one time tell me the patient had a very full stomach (and they didn't have an NG) so I had the nurses place one in preop holding for me. I was kind enough to anesthetize their nares so it wasn't quite as painful of a process but I felt with the surgeon warning me that it had to be done.

 

[zizzer]

I usually see it that way too, but I've been the one to put it in or ask the surgeons to multiple times both in residency and at my current job. Either way, it was just an example of something you can do to be safer (maybe not the best example).

 

[Simba1711]

Yeah it’s annoying that happened to me both in residency and at my job in private practice. At my current job , surgeon told me to just do rsi and I had to tell him I’m not doing the case unless we put an ng first.

 

[zizzer]

Yeah just a couple weeks ago we got an OSH transfer where it was documented that multiple nurses couldn't place an NGT, so the surgeon at my hospital was not even going to try until I asked. She placed it successfully on her first try.

 

[deleted697535]

Hookers and coke

 

[nimbus]

Hookers and coke

Nah. Save that for when you’re the dean.

An overdose, a young companion, drug-fueled parties: The secret life of a USC med school dean

Photos and video show then-head of Keck School of Medicine partying with criminals and drug-users.

www.latimes.com

 

[Guillemot]

Just like in training, the most neurotic anesthesiologists are generally the weaker ones. Try to sniff this out fairly quickly and avoid asking this/these individuals(s) for advice.

Additionally, try avoid asking advice from the old guy/gal that excessively pontificates about the old days, how long they have been practicing, and how they are board certified(passed the lowest bar necessary to practice). This type of posturing is generally done to hide weaknesses.

Also the phrase “trust but verify” is a particularly apt one when it comes to being the new guy. Even in relatively benign environments some people will try to take advantage of the newbie.

 

[ChiDO]

Remember, blame anesthesia is the #1 rule of surgeons. 😜

 

[nimbus]

Don’t do this.

"St. Louis man awake during surgery"

I would say that's not a fair comparison. Those are dynamic factors that are usually inconsequential and fixable. This was an all or nothing phenomenon. I would say a fair comparison would be if the patient got a bad surgical site infection and it turns out the anesthesiologist didn't give the...

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