advice for early attending when supervising

[gasman7k]

For those of us who are "forced" into a job with heavy supervision (3:1) of CRNA's (i.e. geographically confined for family & personal reasons), what is your advice for maintaining skills? Also, how much independence do you in general give hands-on-providers? I.e. are you in the room as much as possible?

thanks for input.

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[IMGASMD]

For those of us who are "forced" into a job with heavy supervision (3:1) of CRNA's (i.e. geographically confined for family & personal reasons), what is your advice for maintaining skills? Also, how much independence do you in general give hands-on-providers? I.e. are you in the room as much as possible?

thanks for input.

Depends on your group and CRNA really. We employ our CRNAs, I can see some problems if they’re employed by another entity. As to maintaining skills, do as much as you want. Once in a while I will take an intubation. We don’t really let CRNA do neuroaxial blocks. We let some do A-Lines. So we still maintain some proficiency at some things.

As to in the room as much as possible? 1:3 is pretty tough, especially when you’re running the board. Think about you’re giving 45 mins of breaks in the morning. 1.5 hours during lunch time. You have all the prwops you’re responsible for. Any of those who are sick or anything that’s not “normal” you’re bound to spend some time out of the room to fix it.

I love my current job, I even like some of our CRNAs. But if I say I am not looking for a position that I can be doing my own cases, I’d be lying.

 

[Mman]

For those of us who are "forced" into a job with heavy supervision (3:1) of CRNA's (i.e. geographically confined for family & personal reasons), what is your advice for maintaining skills? Also, how much independence do you in general give hands-on-providers? I.e. are you in the room as much as possible?

thanks for input.

come up with an anesthetic plan for each patient that they can execute (doesn't do the patient any good if you have some super duper awesome way of doing things that requires you to be there every second of the case). Be there for every induction and you can do things like start a 2nd IV or art line while they are managing the airway (or you can jump in and help secure airway if it is difficult). Make sure they understand expectations for sending you FYI pages or calling you back to room and then check back every 30-60 minutes until case finishes.

You don't have to worry about maintaining skills since you should end up doing far more procedures and difficult airways supervising than you ever would doing your own cases.

 

[deleted162650]

Depends on your group and CRNA really. We employ our CRNAs, I can see some problems if they’re employed by another entity. As to maintaining skills, do as much as you want. Once in a while I will take an intubation. We don’t really let CRNA do neuroaxial blocks. We let some do A-Lines. So we still maintain some proficiency at some things.

As to in the room as much as possible? 1:3 is pretty tough, especially when you’re running the board. Think about you’re giving 45 mins of breaks in the morning. 1.5 hours during lunch time. You have all the prwops you’re responsible for. Any of those who are sick or anything that’s not “normal” you’re bound to spend some time out of the room to fix it.

I love my

 

[anbuitachi]

Depends on your group and CRNA really. We employ our CRNAs, I can see some problems if they’re employed by another entity. As to maintaining skills, do as much as you want. Once in a while I will take an intubation. We don’t really let CRNA do neuroaxial blocks. We let some do A-Lines. So we still maintain some proficiency at some things.

As to in the room as much as possible? 1:3 is pretty tough, especially when you’re running the board. Think about you’re giving 45 mins of breaks in the morning. 1.5 hours during lunch time. You have all the prwops you’re responsible for. Any of those who are sick or anything that’s not “normal” you’re bound to spend some time out of the room to fix it.

I love my

15 minutes per CRNA? here they are required to get 1 20 min break in AM, and 1 20 min break in PM. so covering 1:3, just breaks alone is 1 hr in morning, 1 in afternoon... add in lunch.. thats like 2 hours more

 

[Mman]

15 minutes per CRNA? here they are required to get 1 20 min break in AM, and 1 20 min break in PM. so covering 1:3, just breaks alone is 1 hr in morning, 1 in afternoon... add in lunch.. thats like 2 hours more

we have CRNAs to give breaks. I don't give breaks unless their bladder is going to explode and they need me to sit in there for a few minutes while they run out.

 

[Shimmy8]

Echo Mman's comments above.

But I'll add: learn your people. Some are great, some good, some bad. Some you can trust, others you can't. Some will throw you under the bus, some won't call you when trouble is brewing. Doesn't take long to learn the individual habits.

 

[vector2]

For those of us who are "forced" into a job with heavy supervision (3:1) of CRNA's (i.e. geographically confined for family & personal reasons), what is your advice for maintaining skills? Also, how much independence do you in general give hands-on-providers? I.e. are you in the room as much as possible?

thanks for input.

When just starting out, err on the side of being too present as opposed to absent until you get to know which CRNAs are competent and which are duds. Come up with a plan and let them know exactly all the things they must call for. Watch the charts like a hawk if you have an EMR- you'll be surprised by the number of times you see a nurse just let a BP sit in the 70s and 80s post-induction because "stimulation is coming soon."

Best thing to do really is just be polite and friendly but assertive when needed. If you want to intubate for the practice, tell them nicely you're going to intubate. If you want to do the a-line, tell them you're going to do it. That being said, it becomes much easier to be assertive when you've been there for a minute and you've had to bail a number of them out when it comes to a difficult airway, difficult access/a-line, refractory hypotension, hypoxia etc. As silly as it seems since you're a BE/BC anesthesiologist and they're a nurse, respect is earned once they see you're a stud, it's (unfortunately) not automatically given.

 

[anbuitachi]

we have CRNAs to give breaks. I don't give breaks unless their bladder is going to explode and they need me to sit in there for a few minutes while they run out.

So crnas get days where all they do is give breaks???

 

[deleted171991]

FYI: that's the "standard" on the East Coast.

 

[deleted162650]

FYI: that's the "standard" on the East Coast.

I know. Sad. My job satisfaction would drop immensely if that was my life.

 

[IMGASMD]

15 minutes per CRNA? here they are required to get 1 20 min break in AM, and 1 20 min break in PM. so covering 1:3, just breaks alone is 1 hr in morning, 1 in afternoon... add in lunch.. thats like 2 hours more

I love the word “required”.
They bitch and moan if they didn’t get one.....
sigh. I know how sad this is.

 

[pocafx]

So crnas get days where all they do is give breaks???

Yes

 

[2Fast2Des]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

 

[deleted171991]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

Because they are not stupid working machines with MD after their names. I actually do respect them for standing up for their rights, unlike employed anesthesiologists. They don't behave as if they live to work.

 

[vector2]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

Incentives matter. In an MD practice, if you are PP/eat what you kill then you certainly have an incentive to pass on the breaks and increase throughput. If you're some AMC schlub on a 7-5 salary and the only people who see increased revenue from your increased productivity are your bosses, why in god's name wouldn't you demand 20 min in AM, 30 min lunch, 20 min in PM?

 

[deleted171991]

Incentives matter. In an MD practice, if you are PP/eat what you kill then you certainly have an incentive to pass on the breaks and increase throughput. If you're some AMC schlub on a 7-5 salary and the only people who see increased revenue from your increased productivity are your bosses, why in god's name wouldn't you demand 20 min in AM, 30 min lunch, 20 min in PM?

Because it's frowned upon. In America, your employer expects to "own" you (and your life), and if you're not a good puppy they will just get another sucker.

 

[anbuitachi]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

Cause it's not good for you?

 

[nimbus]

90% of stool sitting is just a big break. If only it were warmer.

 

[deleted50478]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

You shouldn’t spend too much time in the OR watching them chart railroad tracks. It’s insulting and a waste of time. You should check in frequently and they should message you with any issues that aren’t totally routine and easily managed. You’ll find a good balance.

About the breaks, it’s nicer for them to have a break to go to the bathroom or have some coffee than to have to text and ask, especially if you are doing mostly long cases. On the other hand, it’s annoying if they sit around outside the OR doing nothing because their break time isn’t over yet, especially at lunch if they’ve finished and you have 3 more lunches to give. They’re mostly hurting each other if they take too long, but that doesn’t seem to register with a lot of them. When I sat the stool my breaks were half as long if I took them at all. I’ve had CRNA’s like that too but it’s the exception to the rule.

 

[narcotics999]

90% of stool sitting is just a big break. If only it were warmer.

Muscle produces the majority of body heat. Muscle up.

 

[chocomorsel]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

Now that I am out of the OR, I immensely enjoy my lunch and bathroom breaks.
They are much needed, don’t matter what nobody says. We aren’t robots.

 

[chocomorsel]

90% of stool sitting is just a big break. If only it were warmer.

Except there are no toilets or eating places inside the ORs.
If only.

 

[2Fast2Des]

Because they are not stupid working machines with MD after their names. I actually do respect them for standing up for their rights, unlike employed anesthesiologists. They don't behave as if they live to work.

Incentives matter. In an MD practice, if you are PP/eat what you kill then you certainly have an incentive to pass on the breaks and increase throughput. If you're some AMC schlub on a 7-5 salary and the only people who see increased revenue from your increased productivity are your bosses, why in god's name wouldn't you demand 20 min in AM, 30 min lunch, 20 min in PM?

Makes sense when you put it that way. I'm in PP where its kill to eat so I can see the AMC perspective, why toil unnecessarily. But usually being a physician never really ingrained that care for oneself attitude lol

Cause it's not good for you?

Not saying to hold back human needs, but calling someone in to give a few minutes here or there isn't that big a deal if you really need to take care of business or get a quick bite. Unless people in the group hate each other that much to offer that. Especially when CRNA works until 1p or 3p, its not exactly a long day that you cannot survive without an hour of total break time... Doing 24 hour calls on cardiac in residency where you work your ass off pretty much every hour and then hear that can't live without a break is kind of weak

90% of stool sitting is just a big break. If only it were warmer.

Even in residency when I would get a break in the morning I would be bored since no one else was usually around and I would just drink water and stare at wall/phone for 15 minutes until I went back so didn't make a hell of a lot of sense when I was doing the same in the room.

 

[nimbus]

Muscle produces the majority of body heat. Muscle up.

If that is true, why do fat people always complain that they are hot?

 

[narcotics999]

If that is true, why do fat people always complain that they are hot?

Because their nice, smooth fat layer is equivalent to three layers of Canada goose.

 

[pgg]

If you're directing multiple rooms, and you personally give a break in one, how are "immediately available" to the other rooms you're allegedly directing?

Every time I've worked in an ACT model, there have been CRNAs on break duty.

 

[Man o War]

Very good advice above.
I would add- watch the young male CRNAs. I’ve found them to be the most scary- ego, they think they know it all and haven’t been humbled yet. They also have the added male
nurse chip on the shoulder which certainly doesn’t help anything. Not all of them, but enough to be a trend IMO

 

[deleted171991]

If that is true, why do fat people always complain that they are hot?

Because it takes a lot of muscle to carry that fat.

 

[anbuitachi]

If you're directing multiple rooms, and you personally give a break in one, how are "immediately available" to the other rooms you're allegedly directing?

Every time I've worked in an ACT model, there have been CRNAs on break duty.

how is that different from residency with attending double covering 2 residents. the attending is still the one giving breaks (unless you guys had a different system), but is still chart marked as immediately available..

 

[Arch Guillotti]

how is that different from residency with attending double covering 2 residents. the attending is still the one giving breaks (unless you guys had a different system), but is still chart marked as immediately available..

The nurses always did the breaks in residency.

 

[vector2]

Very good advice above.
I would add- watch the young male CRNAs. I’ve found them to be the most scary- ego, they think they know it all and haven’t been humbled yet. They also have the added male
nurse chip on the shoulder which certainly doesn’t help anything. Not all of them, but enough to be a trend IMO

In addition to this cohort, keep an eye out for any of the senior nurses who sass you with the “I’ve been doing this for 20 years” line when you ask them to do something, particularly something they’re unfamiliar with. They may have been practicing for 20 years, but inevitably 20 years ago was also the last time they learned anything new about medications, infusions, advanced airway equipment, or best practices for fluids, blood, and vent management.

 

[abolt18]

In addition to this cohort, keep an eye out for any of the senior nurses who sass you with the “I’ve been doing this for 20 years” line when you ask them to do something, particularly something they’re unfamiliar with. They may have been practicing for 20 years, but inevitably 20 years ago was also the last time they learned anything new about medications, infusions, advanced airway equipment, or best practices for fluids, blood, and vent management.

I've taken over more than one case from "old" crnas where my patient is breathing 800cc-1L tidal volumes (10-12 cc/kg).

 

[deleted50478]

I've taken over more than one case from "old" crnas where my patient is breathing 800cc-1L tidal volumes (10-12 cc/kg).

Probably 16 cc/kg IBW

 

[2Fast2Des]

I've taken over more than one case from "old" crnas where my patient is breathing 800cc-1L tidal volumes (10-12 cc/kg).

No more atelectasis for sure

 

[pgg]

how is that different from residency with attending double covering 2 residents. the attending is still the one giving breaks (unless you guys had a different system), but is still chart marked as immediately available..

We're always 1:1 with residents. A luxury of government inefficiency, sure, but it's nice.

I did some away rotations as a resident where my attending had another room, but I honestly don't remember if or how breaks were offered.

 

[Ronin786]

We're always 1:1 with residents. A luxury of government inefficiency, sure, but it's nice.

I did some away rotations as a resident where my attending had another room, but I honestly don't remember if or how breaks were offered.

I think it differs by an institutional basis, but during residency we had an attending come from somewhere that had CRNAs only doing breaks. Refused to give breaks in any of his rooms that weren't 1:1. Obviously turned into an issue, but the company line was that given the staffing availability of an academic center, another attending was always immediately available in case of emergency.

Not sure I necessarily agree with it, but our chairman indicated that CMS was on board with that.

 

[anbuitachi]

The nurses always did the breaks in residency.

very interesting, didn't know this was a thing! attendings job would be so much easier double covering residents if there were CRNAs here to give breaks.. i guess we dont have a budget to hire a full time 200k+/yr break giver

 

[Morzh]

Except there are no toilets or eating places inside the ORs.

Not with that attitude there aren't!

 

[Mman]

In addition to this cohort, keep an eye out for any of the senior nurses who sass you with the “I’ve been doing this for 20 years” line when you ask them to do something, particularly something they’re unfamiliar with. They may have been practicing for 20 years, but inevitably 20 years ago was also the last time they learned anything new about medications, infusions, advanced airway equipment, or best practices for fluids, blood, and vent management.

While I understand what you are saying, it's also important that you come up with an anesthetic plan that can be implemented by that person that has been doing this for 20 years. It doesn't help your other patients if your plan requires you to be in one room for 80% of the case.

 

[AdmiralChz]

Still don't know why they need breaks or why we have a break culture. I pee or eat real quick in between cases and it's not a big deal. People these days cannot function without needing their precious breaks.

I think it’s an employment law that they get at least lunch.

Very good advice above.
I would add- watch the young male CRNAs. I’ve found them to be the most scary- ego, they think they know it all and haven’t been humbled yet. They also have the added male
nurse chip on the shoulder which certainly doesn’t help anything. Not all of them, but enough to be a trend IMO

In my experience, it’s actually the young females with 5-10 years experience - been doing it long enough to be comfortable and (overly) confident they could do it without you but haven’t seen a horrible, unexpected complication for which they were unprepared for. Those very seasoned CRNAs in our group are more astute and love having help as well as talking through a case ahead of time if there’s any issues.

 

[AdmiralChz]

Other pearls I utilize - to save on time and keep skills up for cases that require a-lines I typically allow the CRNA to choose whether they want to a-line or intubate and ideally do both simulaneously. A select few get butt hurt about it and want to do it all but most are happy to to try the a-line while I intubate.

We do 20-30% of our own cases though so I definitely don’t feel any skill atrophy. I usually have to rescue an airway or two a day (while the nurse calls for the glidescope) and several a-lines a week. Plus if the OB CRNA is giving lunches I’ll head up and do epidurals and spinals, as well as step in if needed.

ACT isn’t the monstrous hellscape everyone says it is around here. It has its flaws, but overall I’m very content.

 

[AdmiralChz]

I will say, though, that it was a huge wake up call for me to start supervising. Our CRNAs are fairly independent and didn’t respond well to micro-managing like give this much fluid give that much neostigmine. A few pulled me aside and talked to me about it, and their concerns were fair so instead I keep the discussions big picture unless the management gets dangerous.

 

[Consigliere]

I will say, though, that it was a huge wake up call for me to start supervising. Our CRNAs are fairly independent and didn’t respond well to micro-managing like give this much fluid give that much neostigmine. A few pulled me aside and talked to me about it, and their concerns were fair so instead I keep the discussions big picture unless the management gets dangerous.

Sad that this occurs. I have NEVER had a CRNA "pull me aside" but then again I never worked in an environment that would tolerate that.

 

[deleted171991]

I will say, though, that it was a huge wake up call for me to start supervising. Our CRNAs are fairly independent and didn’t respond well to micro-managing like give this much fluid give that much neostigmine. A few pulled me aside and talked to me about it, and their concerns were fair so instead I keep the discussions big picture unless the management gets dangerous.

Unfortunately they have trouble understanding the concept of "medical direction" (versus true "supervision" - different animal). Those 7 TEFRA rules for medical direction mean that CRNAs shouldn't do anything without our approval, so they should be micromanaged. That's impossible in the real world. But, just FYI, if anything happens, the jury will expect the anesthesiologist to have micromanaged every detail, so one will be responsible for every complication, even those happening clearly because of an independent CRNA decision.

 

[AdmiralChz]

Sad that this occurs. I have NEVER had a CRNA "pull me aside" but then again I never worked in an environment that would tolerate that.

I think you misunderstand. We had a discussion about how to better supervise and be a more effective leader. This was had in conjunction with other partners as well. It was a positive, productive conversation.

I am still very much in charge and if I don’t like the management I’ll ask the CRNA to leave while I fix it. I’m happy with the arrangement.

 

[deleted171991]

Sad that this occurs. I have NEVER had a CRNA "pull me aside" but then again I never worked in an environment that would tolerate that.

Because your CRNAs are your employees. Rule #1 of supervision is: one should have hiring and firing power over one's underlings. Otherwise it's not true supervision. That's why physicians have been having trouble with hospital nurses and midlevels all over America.

I have worked in academia, PP, and as a hospital-employee. Even in PP, in a place where they were employed by the anesthesia group but the market favored the CRNAs, they had an independent streak, and some were even militant and arrogant. This whole BS about physician "leadership" is just another attempt to find a scapegoat. In the military, one doesn't need to prove **** to have one's orders followed by one's underlings; why is it any different in such a high acuity environment as the OR? There shouldn't be any place for debate, unless it involves patient safety.

Unfortunately, American (and, lately, millennial) dumb egalitarianism has been deeply corrupting the system for the last couple of decades, so nowadays the best way to practice medicine is not to make waves as much as possible. And THAT is my advice for new grads.

 

[AdmiralChz]

I’m not sure why I bothered to even respond to this thread, was just trying to help the OP, not argue about the ACT model which I knew would happen .

 

[deleted171991]

I’m not sure why I bothered to even respond to this thread, was just trying to help the OP, not argue about the ACT model which I knew would happen .

Nobody's arguing with you.

More advice for recent grads: Are You Ready For Private Practice?

 

[Consigliere]

Nobody's arguing with you.

Unfortunately, the ACT (and nurse power) model is a ship that has sailed (once the "healthcare workers" stopped being employed by the physician groups, as in the past), so new grads had better adapt fast to CRNA (and other nurse)

....so new grads had better adapt fast to CRNA (and other nurse) butt-kissing.

The wise will heed this advice; the foolish will ignore it.