Why I like working with residents

[epidural man]

I know there is a lot of downside to academia - JPP and others used to flame academics with such fervor - and I get it.

However, something happened to me today that reminded me why an academic environment is good for me - and would be good for many physicians.

Here's the background -
At our insitution - we have not abondoned doing Bier Blocks (one can argue this point that they are not useful- this isn't what the thread is about.) BUT what we have abandoned is doing upper arm bier blocks. We place the smaller turniquet on the forearm. This has so many advantages with no downside that I can even imagine. For one, the turniquet is so much better tolerated on the forearm. Second, the dose needed is so little that the turniquet can be let down at ANY time - thus it is a perfect solution to a 10-20 minute procedure like a CTR.

Okay, so at my moonlighting gig - the orthopod who does CTR's will not allow forearm turniquets. He says it gets in his way. In other words, he has no desire to change or do things differently from how he has done it for years. This is just one example. He is like this in MANY things that I try to get him to accept or do - which would benefit him, me, and the patient - but he will have none of it.

Okay - so what does this have to do with academics? I get that people have learned a technique and want to stick with it because it works well - this likely cuts down on adverse outcomes.

HOWEVER, I love that I have learned to not be like that. I personally think that makes me a better physician because I am willing to try new things, do something different, be uncomfortable with something out of my ordinary. This happens because I train residents. Because they bring things to me all the time - and the science does change and new things come up. I could ignore them and do things like I have always done - but to me...this would be very short sided and only hurts me in the end. If I order the same thing on the menu that I know I like every time - true, I will never have a bad meal....but on the other hand, I may be missing out on something that I may like twice as much.

I suspect that if one works in private practice for a long period of time, this idea of never trying something new or changing your practice would deeply engrain itself.

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[sevoflurane]

I think it all depends on your practice environment (academics or PP) and your willingness to try something new.

We have started a TAVR program in my PP setting.

Doing 3D TEE and post acquisition processing on annulus area (not diameter) to guide proper valve size is not what is routinely done in the CT ORs. As medicine evolves so do we.

I still do bier blocks, spinal catheters, PNB catheters tied to onQ pumps that the patient takes home, sux drips, all sorts of different TIVA concoctions, etc, etc.

IMO, willingness to step outside of the bubble is not dictated by academics or PP. It's dictated by the individual practitioner.

 

[epidural man]

Sevo - totally agree.

I just think academics forces your hand a little more in the direction of trying new things. It's harder to get away with sticking with your dogma.

 

[deleted162650]

It's harder to get away with sticking with your dogma

I thought the academic guys invented sticking with your dogma.

 

[Consigliere]

You make less money in academia and that's all that matters to me.

 

[OB1🤙]

I agree with the OP that it's easy to get complacent in private practice- for some.

In my experience, there are 2 kind of PP anesthesiologists. Some are always looking to improve, are open to new ideas and techniques, and take pride in staying current and modern.

Some are content to find "what works," and stick to that happily.

Our group takes pride in being made up almost completely of the first type.

 

[loveumms]

I just like to teach and enjoy seeing a resident go from knowing absolutely nothing and being dangerous to a competent anesthesiologist. Knowing that I play a little part in that is priceless.

 

[criticalelement]

The simpler you make it the better off you are.

If you are constantly changing stuff etc etc.. you will never be good at anything.. I have seen residents constantly changing blades from mil3 to mac4 etc. I tell them. Pick your blade and use it solely for one or 2 full years. Then you can venture out. The blade i use is the blade I use. You give me another blade Im gonna be ****ing pissed. Does that make me close minded and unwilling to try new things?

I hate sux drips.. always have.... wont try it... does that make me unwilling to try new things? I already have, dont like it. I have other things that are better.

I hate precedex.. tried it a few times.. confuses the anesthetic.. dont need it.. wont even listen to someone who considers it.

I hate ketamine.. Dont bring that **** to me. Dont do it or I will ****ing be pissed.. Does that make me a bad person? an inferior practicioner. I have a long track record of excellence and everyone knows it.

The best doctors I know have a narrow subset of things they do.. they do it continuously... they do them well. And most importantly their patients do well. all of the time.

I love the glidescope by verathon. LOVE IT.. DOnt bring me the CMAC. I will fuc ki ng throw you and your cmac out of the room. I dont want something new when it comes down to that. Does that make me rigid? Does that make me an inferior practicioner?

Find what you like.. do it over and over and over and over and over and over.. Dont deviate from what you like or comfortable with.

there is a reason why practicioners are in academics. Because they are blow hards..

 

[chocomorsel]

Critical element, YOU sound like a blowhard. Whatever the heck that is.

 

[Arch Guillotti]

The simpler you make it the better off you are.

If you are constantly changing stuff etc etc.. you will never be good at anything.. I have seen residents constantly changing blades from mil3 to mac4 etc. I tell them. Pick your blade and use it solely for one or 2 full years. Then you can venture out. The blade i use is the blade I use. You give me another blade Im gonna be ****ing pissed. Does that make me close minded and unwilling to try new things?

I hate sux drips.. always have.... wont try it... does that make me unwilling to try new things? I already have, dont like it. I have other things that are better.

I hate precedex.. tried it a few times.. confuses the anesthetic.. dont need it.. wont even listen to someone who considers it.

I hate ketamine.. Dont bring that **** to me. Dont do it or I will ****ing be pissed.. Does that make me a bad person? an inferior practicioner. I have a long track record of excellence and everyone knows it.

The best doctors I know have a narrow subset of things they do.. they do it continuously... they do them well. And most importantly their patients do well. all of the time.

I love the glidescope by verathon. LOVE IT.. DOnt bring me the CMAC. I will fuc ki ng throw you and your cmac out of the room. I dont want something new when it comes down to that. Does that make me rigid? Does that make me an inferior practicioner?

Find what you like.. do it over and over and over and over and over and over.. Dont deviate from what you like or comfortable with.

there is a reason why practicioners are in academics. Because they are blow hards..

You sound very dogmatic.

 

[loveumms]

The simpler you make it the better off you are.

If you are constantly changing stuff etc etc.. you will never be good at anything.. I have seen residents constantly changing blades from mil3 to mac4 etc. I tell them. Pick your blade and use it solely for one or 2 full years. Then you can venture out. The blade i use is the blade I use. You give me another blade Im gonna be ****ing pissed. Does that make me close minded and unwilling to try new things?

I hate sux drips.. always have.... wont try it... does that make me unwilling to try new things? I already have, dont like it. I have other things that are better.

I hate precedex.. tried it a few times.. confuses the anesthetic.. dont need it.. wont even listen to someone who considers it.

I hate ketamine.. Dont bring that **** to me. Dont do it or I will ****ing be pissed.. Does that make me a bad person? an inferior practicioner. I have a long track record of excellence and everyone knows it.

The best doctors I know have a narrow subset of things they do.. they do it continuously... they do them well. And most importantly their patients do well. all of the time.

I love the glidescope by verathon. LOVE IT.. DOnt bring me the CMAC. I will fuc ki ng throw you and your cmac out of the room. I dont want something new when it comes down to that. Does that make me rigid? Does that make me an inferior practicioner?

Find what you like.. do it over and over and over and over and over and over.. Dont deviate from what you like or comfortable with.

there is a reason why practicioners are in academics. Because they are blow hards..

One of my attending during residency was like this. Still used meds that were no longer being used by anyone else (because better ones came out).

I agree with doing things over and over to perfect them but becoming closed minded about new techniques/meds is dangerous.

And no one has good outcomes all the time, no matter how well you perfect your craft and how "good" you are. To think so is naive and unreasonable (or you just don't take care of enough patients).

 

[LivetoTell]

For your forearm bier blocks, how much total local are you using (mls)? How soon will you put the TQ down? For my regular upper arm bier blocks, 40mls of 0.5%
does the trick. That's 200mgs and usually well below the toxic threshold for avg weight patients. I still feel ancy about putting it down before 20 minutes, because some might say the "standard of care" is 20 minutes despite being below toxic threshold values.

 

[Urzuz]

The simpler you make it the better off you are.

If you are constantly changing stuff etc etc.. you will never be good at anything.. I have seen residents constantly changing blades from mil3 to mac4 etc. I tell them. Pick your blade and use it solely for one or 2 full years. Then you can venture out. The blade i use is the blade I use. You give me another blade Im gonna be ****ing pissed. Does that make me close minded and unwilling to try new things?

I hate sux drips.. always have.... wont try it... does that make me unwilling to try new things? I already have, dont like it. I have other things that are better.

I hate precedex.. tried it a few times.. confuses the anesthetic.. dont need it.. wont even listen to someone who considers it.

I hate ketamine.. Dont bring that **** to me. Dont do it or I will ****ing be pissed.. Does that make me a bad person? an inferior practicioner. I have a long track record of excellence and everyone knows it.

The best doctors I know have a narrow subset of things they do.. they do it continuously... they do them well. And most importantly their patients do well. all of the time.

I love the glidescope by verathon. LOVE IT.. DOnt bring me the CMAC. I will fuc ki ng throw you and your cmac out of the room. I dont want something new when it comes down to that. Does that make me rigid? Does that make me an inferior practicioner?

Find what you like.. do it over and over and over and over and over and over.. Dont deviate from what you like or comfortable with.

there is a reason why practicioners are in academics. Because they are blow hards..

If your definition of "doing well" is getting your patients to PACU with a blood pressure and a pulse then I don't doubt it. But you should strive to be better than a monkey who puts a tube in and takes a tube out at the end of the case, and you should have a diverse enough repertoire of anesthetic techniques that you can create individualized treatment plans to fit each specific patient's needs. Maybe you can accomplish that without using a sux drip, Precedex, ketamine, and a C-MAC...but as the above posters have mentioned your post makes you sound extremely dogmatic.

And for the record, the worst offenders of being rigid in their plans, not being able to adapt to each unique situation, not thinking ahead, and reacting rather than anticipating are....you guessed it, CRNAs!

 

[criticalelement]

providing safe anesthesia over long periods of time (however that is defined) is better to me than having a diverse repertoire of anesthetics. If that makes me a CRNA in your mind. Ok. I know what works for me and what doesnt. I know what kind of compaints i can live with post op and which ones I dont want to deal with. And for the record it is not how many drugs you use its how you use them is the mark of a pro.

 

[OB1🤙]

FWIW, I hate precedex. I don't care much for remifentanil. Haven't used either in 3 years. Haven't used etomidate in about 4 years. Use ketamine daily. I almost never use sux. I generally use a Mac 3 as my go-to blade.

Tomorrow, if you told me the pharmacy was out of the stuff I like and that I had to do a remi/precedex/vomidate-based anesthetic, using a sux drip, and had to use a Miller 3, I'd be totally fine with that.

I don't think there's anything wrong with figuring out what works best for you and doing that most times.

But I think it's important to be able to use whatever tools happen to be at your disposal, and use them well.

I am often grateful for that etomidate shortage that happened a few years ago. Otherwise, I might not have learned how to induce a cardiac patient with anything else, and I'd still be using that POS drug on the regular.

 

[pgg]

You give me another blade Im gonna be ****ing pissed.

[...]

I hate ketamine.. Dont bring that **** to me. Dont do it or I will ****ing be pissed.

[...]

DOnt bring me the CMAC. I will fuc ki ng throw you and your cmac out of the room.

[...]

there is a reason why practicioners are in academics. Because they are blow hards..

ell oh ell

You crack me up. You've got Consigliere's cynicism but none of his credibility.


I enjoy my days alone, but I also like working with residents. I try not to impose my will or biases too strongly, though I do talk about them. If their plan is safe, I let them do it, even if I'd do it differently. Every once in a while, they do something someone else taught them and I get some new experience or perspective I might not otherwise have had.

Life's too short to get all blowhardy and $*(&@$#! pissed about this drug or that drug, or this tool or that tool.

 

[sevoflurane]

I just like to teach and enjoy seeing a resident go from knowing absolutely nothing and being dangerous to a competent anesthesiologist. Knowing that I play a little part in that is priceless.

My favorite part of residency was my last call.

Type A dissection came in around 2-3 am. My attending was like "this is yours"- I had gained a lot of trust at that point. He spent a total of 10 minutes in the room + a couple of pager texts. I walked out on my last day that morning thinking wow... I'm so glad I had such an awesome attending tonight... cuz that solo case was kick ass--->

For me, that was the best way to end residency... and to this day, I'm thankful for that--> thankful for the GREAT Docs that CHOOSE to stay in academics.

 

[sevoflurane]

I've had residents, med studs, premeds, flight nurses, etc in my room since I started private practice. The ones I like the most are the interns that are going into anesthesia.

To be honest, I give 100% but can only take one day a month (and I feel kinda selfish about that- but it's the way I roll).

I tip my hats to the good ones who do it on a daily basis with love and devotion for our future practitioners.

 

[sevoflurane]

 

[Planktonmd]

A true private practice anesthesiologist would have a hard time teaching residents because you are conditioned that its all about efficiency and about being an invisible ninja who does what needs to be done quickly and invisibly!
You definitely can change and become the masturbatory academic type but it takes time and patience!

 

[WholeLottaGame7]

A true private practice anesthesiologist would have a hard time teaching residents because you are conditioned that its all about efficiency and about being an invisible ninja who does what needs to be done quickly and invisibly!
You definitely can change and become the masturbatory academic type but it takes time and patience!

I always appreciated attendings with a private-practice mindset, for multiple reasons. You get better and more efficient at procedures. You think differently. Your attitude is different.

It's nice to know that the OR is rarely, if ever, waiting on you. People respect that. And they know that if things aren't going smoothly, it's for a reason.

But you can't not change in academics. Slow residents (both surgical and anesthesia) I can deal with. But the nursing staff, administrative issues that are present at most academic hospitals will just drive you bonkers. So if you keep raging against the machine, you'll burn out much quicker. Some of the best attendings in residency left private practice to come back to academics only to leave again after a few years.

 

[pgg]

You PP guys just wish you could watch med students and interns learn to sew ...


On the days when I'm working alone, I still try to be fast and efficient, but the reward isn't being done earlier, it's 10 or 15 minutes of sitting around between cases waiting for the OR to catch up. It bothered me for a while after I returned to an academic hospital, but it's not a fight that can be won. Now I just find a chair and get comfortable. It's not like my paycheck depends on the units I crank out ...