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"This is exactly what I envisioned doing when I became a doctor!" said no one ever.
I'm just breaking your balls, Admiral...
advice for early attending when supervising
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"This is exactly what I envisioned doing when I became a doctor!" said no one ever.
I'm just breaking your balls, Admiral...
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Pulled aside, aka cart pulling the horse? Fluid management and your particulars should be accepted by those administering an anesthetic under your supervision and license, I would think. Or atleast I don't know how I'd explain in court that the CRNA flooded the patient or overdosed and I had no idea but on the record its my name.
D
deleted171991
That's called "micromanagement" in nurse lingo. As I said, it's frowned upon even in some PPs. Why? Because it's easier to replace an anesthesiologist (than multiple CRNAs).
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I found supervision easier than expected as an attending. Our setup is a mix of CRNAs and Residents, we are usually 1:2 regardless of the combination but will be 1:3 generally on call (CRNAs) and rarely 1:4. We are not responsible for breaks as it would make us no longer "immediately available" unless we are 1:1 covering (generally only occurs on call at night or often with liver transplants, etc.).
My approach has generally been to ask the CRNA how they typically do or would like to do the case. If I agree with it I basically leave it at that. If I disagree with it I will start talking about other ways I have seen it done as well and the advantages and make it pretty clear that in my opinion it's better, so far I have never had anyone argue with me and either they quietly went along with my version of the plan while mentally cursing me, or, as is my intention, they do the case my way thinking that they made the decision. I also fully recognize that a hallmark of anesthesia is there are about 0 "right" ways to do a case so I am very open to anything that makes sense and sounds safe so I may just be more flexible on average.
Regarding the act of actually supervising. A lot of it I titrate to the particular person I am supervising. If it is someone I am less confident in I "recommend" a lot of criteria for vitals and various ways to achieve this. I've found that some of the more extreme Dunning-Krugers still react well to this because the parameters provide a sense of familiarity and comfort and by giving multiple options there is still an illusion of constrained autonomy. Other than this, I basically set a timer on my watch for ~30 minutes and I just poke my head into the rooms or peek through the window each time it goes off. I haven't had an issue of note with this method yet.
As a side note, I highly recommend reading Thinking Fast and Slow by Daniel Kahneman, it definitely influenced a lot of how I interact with people when I am trying to "encourage" a specific decision.
My approach has generally been to ask the CRNA how they typically do or would like to do the case. If I agree with it I basically leave it at that. If I disagree with it I will start talking about other ways I have seen it done as well and the advantages and make it pretty clear that in my opinion it's better, so far I have never had anyone argue with me and either they quietly went along with my version of the plan while mentally cursing me, or, as is my intention, they do the case my way thinking that they made the decision. I also fully recognize that a hallmark of anesthesia is there are about 0 "right" ways to do a case so I am very open to anything that makes sense and sounds safe so I may just be more flexible on average.
Regarding the act of actually supervising. A lot of it I titrate to the particular person I am supervising. If it is someone I am less confident in I "recommend" a lot of criteria for vitals and various ways to achieve this. I've found that some of the more extreme Dunning-Krugers still react well to this because the parameters provide a sense of familiarity and comfort and by giving multiple options there is still an illusion of constrained autonomy. Other than this, I basically set a timer on my watch for ~30 minutes and I just poke my head into the rooms or peek through the window each time it goes off. I haven't had an issue of note with this method yet.
As a side note, I highly recommend reading Thinking Fast and Slow by Daniel Kahneman, it definitely influenced a lot of how I interact with people when I am trying to "encourage" a specific decision.
If it won’t put the patient in the mourge you keep your mouth shut. Also drink a lot of coffee, find a comfortable seat in the lounge, and have an unlimited data plan on your cell phone. This is the proper way to “supervise”
D
deleted171991
New grads, please note that, while this advice is very practical, it's also illegal. TEFRA means much more than this.
Also, exchanging medical information over SMS exposes one to federal HIPAA penalties.
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I usually just have them FaceTime me for induction and emergence? Am I not doing it right?!
At end of the day, I will always resent my license is on the line for someone’s actions. I find those jobs which CRNA is practice independently and physicians do their own cases laughable. But I digress, this is not the thread debating supervision vs direction vs ACT vs MD only models.
Love it or hate it this is modern medicine. I am an employee and my employer (the AMC) wants to make as much money as possible. In an efficient reasonably predictable practice it is orders of magnitudes cheaper to run CRNA’s who typically work set hours in 4:1 coverage. And don’t kid yourself, they would run a lot leaner than 4:1 if the rules allowed it. They would also find plenty of people willing to sign the chart if the price was right.....
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deleted171991
Also, don't fool yourselves. At some point, a disgruntled CRNA in these 4:1 places will blow a whistle and there will be a lot of felony charges for Medicare fraud. There is NO way to both respect TEFRA with 4:1 and be efficient at the same time.
To be honest, I can hardly wait till Medicare turns a group into an example for all the greedy bastards.
To be honest, I can hardly wait till Medicare turns a group into an example for all the greedy bastards.
It's called being a doctor. Everybody works with nurses and techs and NAs and people that touch and interact with patients on our behalf and under our orders and we end up being responsible for much of what they do.
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deleted171991
You must be kidding me! Last time I checked, if I put in an order and an ICU nurse refuses to execute it (for reasons other than patient safety) she's in trouble.
The same scenario with a CRNA (probably) will not result even in a slap on the wrist, for the simple reason that there is no paper trail (one cannot document in detail the anesthetic plan, especially when covering 3-4 rooms), and the physician will get branded as "difficult" and put on the (CRNAs' and administrators') blacklist. God forbid one "micromanages" (i.e does one's job as a supervising physician).
So it's not called "being a doctor". It's called "being a scapegoat". And every single person who likes the ACT model I've met is either lazy and/or incompetent and/or making serious money as a partner/chief. ACT does not make one a better anesthesiologist (au contraire), so any self-respecting anesthesiologist would stay away if given the chance (except for the few complicated cases which would clearly benefit from 2 sets of hands).
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I accept ultimately I am the one who is responsible, if I actually give the orders.
There is no way when you’re 1:4 and/or give breaks and to dictate every action of your CRNAs. How do you make sure they call you for every decision that they make? You can’t. And handle some of them with kid gloves is the part that eek me greatly. I will be the first one to admit, I will never be a good politician.
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So as i understand this micromanagement issue: you have to do a halfass anesthetic because ultimately the nurse is going to do it her way right?
I’ve said it before and I’ll say it again. ACT is not about ideal anesthesia. It is about “good enough“ anesthesia. All I hear about on this board are about incompetent and dangerous CRNA’s and the selling out of the profession. Ect. Yet I have never seen anyone so against it that they volunteer to only work solo and to take a similar salary to a CRNA (minus the cost of supervision). apparently everything has its price....
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Just a couple thoughts...
If your CRNAs need micromanagement, then you might give some thought to hiring better quality CRNAs - or perhaps try some CAAs.
Our group typically runs 3:1 or sometimes 4:1, depending on pt. acuity. It can be done, and it can be done well, and it can be done within the confines of TEFRA.
And if a group has docs giving the morning and lunch breaks, that's clearly operating outside the TEFRA requirements.
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I was tired of it and went MD only out west. My salary was much better than a CRNA.
Just cuz you are MD or DO only doesn’t mean you make CRNA wages.
There are a few of us on this board who used to supervise and now don’t. Or had the option to supervise but passed it up to do solo care.
@Man o War is one I can think of at this tipsy Friday night moment. Yeah he does hearts but there are plenty of people who do hearts with CRNAs. Clearly that’s not his case and as he’d said before he loves going at it it alone.
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How can you be happy knowing that "your" patients, (actually an AA and ICU nurse told me that we don't actually take care of patients, they do, I digress) aren't getting the best anesthetic, on a daily basis... I luckily have the opportunity to give my patients the ideal anesthetic according to what I think may be best. No way would a CRNA be accepting to do multimodal infusions/therapy, techniques or anything outside the prop/roc/tube/way too much narcs box.
Yep, you got it all right.
Supervising AAs is definitely better than CRNAs if one can find that gig.
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I voted with my feet and have only worked for practices where I do my own cases. Sure the pay is much less than in a 1:4 practice but still ends up being higher than CRNA level pay. The quality of (work)life and stress level can't be beat. There are still enough physician only/ physician run practices out west and job openings do exist.
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I’m sure it’s already been noted above but don’t feel bad taking intubations, lines, etc. whenever you want. When it’s all going bad, you are the end of the line, and you need to be able to get it done. If you’re not doing your own cases, don’t get rusty. Ideally find a place where you can do your own cases some of the time.
As for the CRNAs, ask your partners who you need to keep an eye on, who’s a bad communicator, etc. They’ll tell you, and you’ll learn soon enough. Check in, at least remotely, every 1/2 hour or so, so that you see trends, know what’s going down, etc. If you have EPIC or a good EMR, it’s very easy to click on the patient and scan the record.
As for the plan and execution, keep it simple, with a clear plan, reasonable expectations, etc. Make them clear. Call if you’re giving blood, call when coming off pump, etc. Then make sure it’s done that way. Pick your battles carefully about what to demand if the CRNA seems uncomfortable with the plan. LMA vs ETT isn’t a hill worth dying on. I always err on the side of safety and I’m very comfortable with that decision. If some other cowboy would do something different, they’re welcome to pick up the case. 😉
One other thing I will add that many on here regularly disagree with, follow the society guidelines, hospital and departmental policies, etc. There is likely no difference in NPO status at 6 hours, or 8 in a mild trauma patient, Gum on admission, platelet counts, whatever. The guidelines and policies exist amd you should know what they are, and you’re free to ignore them at your peril. However when there is a bad outcome that an ambulance chasing attorney can try to link with your not following policies, they will. The surgeon will be the first one to toss you under the bus and play dumb. That’s the reality. The hospital system and their Brioni suit wearing attorney will soon follow and see this as their possible get out of liability free card and be sitting at another table instead of at your side at the trial. I don’t worry much about this stuff, but I try to protect myself as best I can. If the surgeon wants to go now, and it’s not obviously emergent, they have to say that it is an emergency that can’t wait until, NPO, pregnancy test, whatever, and I take the 20 seconds to document that conversation. Often they won’t say that and suddenly another couple of hours, waiting on a lab, transfusion, etc. is perfectly fine. Then if something happens it’s you who can say that you knowingly did not follow the guideline because you discussed it with the surgeon and he/she said it could not wait and needed to go immediately. Who are you to know what’s a true surgical emergency that can’t wait?
As for the CRNAs, ask your partners who you need to keep an eye on, who’s a bad communicator, etc. They’ll tell you, and you’ll learn soon enough. Check in, at least remotely, every 1/2 hour or so, so that you see trends, know what’s going down, etc. If you have EPIC or a good EMR, it’s very easy to click on the patient and scan the record.
As for the plan and execution, keep it simple, with a clear plan, reasonable expectations, etc. Make them clear. Call if you’re giving blood, call when coming off pump, etc. Then make sure it’s done that way. Pick your battles carefully about what to demand if the CRNA seems uncomfortable with the plan. LMA vs ETT isn’t a hill worth dying on. I always err on the side of safety and I’m very comfortable with that decision. If some other cowboy would do something different, they’re welcome to pick up the case. 😉
One other thing I will add that many on here regularly disagree with, follow the society guidelines, hospital and departmental policies, etc. There is likely no difference in NPO status at 6 hours, or 8 in a mild trauma patient, Gum on admission, platelet counts, whatever. The guidelines and policies exist amd you should know what they are, and you’re free to ignore them at your peril. However when there is a bad outcome that an ambulance chasing attorney can try to link with your not following policies, they will. The surgeon will be the first one to toss you under the bus and play dumb. That’s the reality. The hospital system and their Brioni suit wearing attorney will soon follow and see this as their possible get out of liability free card and be sitting at another table instead of at your side at the trial. I don’t worry much about this stuff, but I try to protect myself as best I can. If the surgeon wants to go now, and it’s not obviously emergent, they have to say that it is an emergency that can’t wait until, NPO, pregnancy test, whatever, and I take the 20 seconds to document that conversation. Often they won’t say that and suddenly another couple of hours, waiting on a lab, transfusion, etc. is perfectly fine. Then if something happens it’s you who can say that you knowingly did not follow the guideline because you discussed it with the surgeon and he/she said it could not wait and needed to go immediately. Who are you to know what’s a true surgical emergency that can’t wait?
well that is obviously not true
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Yep, def not true, they love multimodal- sometimes to their detriment. My colleague a couple months ago went to check in on a hypotensive pt near the end of a cysto/ureter case and he sees the nurse in there pushing sticks of ephedrine. The nurse had recently heard a couple docs recommend giving a little precedex (0.5-1 mcg/kg total incrementally) as a pain adjunct / to smooth out wakeups in spines, big abdominal, young males etc, so of course the nurse thought it would be a good idea to give 80 mcg over 2 min to a 60 kg, 75yo lady who was cruising in a relatively non-stimulating 1.5 hr case. BP finally came up after my colleague gave a little vaso, but unfortunately the lady was so snowed she spent another 2-3 hrs on a wakeup vent in PACU. Naturally the nurse didn't care cause managing the PACU is someone else's problem. All I can say is, it must be nice to be MD only, or barring that, employ your own nurses.
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deleted171991
Only about 25 (counting just my immediate colleagues, and not including my many attendings from residency). 🙂
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Hmm no judgement or consultation with the attending by the CRNA deciding to be dumb? Oh wait they can f up but it's all good because someone has their back.
Multimodal has a time and a place as well... Simple cases should get simple anesthesia, or atleast time it properly if you are going to do it. And if you take over a case and things are going well, leave it alone!
MD only is the way to go if its an option for you. On average the quality of the anesthesia will probably be better. Lets not pretend though that there aren't many MDs out there that provide cringe-worthy care.
I don’t know about that...
There’s bad doctors in all specialties....we have all sat and shook our head watching a crappy surgeon do their thing.
I’ve seen far more bad CRNAs though- not even a contest. The bar is so much lower.
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From my limited experience:
Have a plan everyone is comfortable with, including yourself. Don't let yourself get pushed into something you don't think is safe. Also, don't push the CRNA into doing something they don't think is safe. If they or you have concerns, be more available, or maybe put in an aline, etc.
If you are nice and listen and are competent and recognize there are many ways to do an anesthetic, you can have a good relationship with your CRNAs and provide quality anesthesia.
Have a plan everyone is comfortable with, including yourself. Don't let yourself get pushed into something you don't think is safe. Also, don't push the CRNA into doing something they don't think is safe. If they or you have concerns, be more available, or maybe put in an aline, etc.
If you are nice and listen and are competent and recognize there are many ways to do an anesthetic, you can have a good relationship with your CRNAs and provide quality anesthesia.
Purposeful or not, subliminal or not, I find it quite fascinating/sad that you not only listed having a good relationship with the CRNA in the same breath as providing a quality anesthetic, but you even listed it before providing a quality anesthetic. Maybe it means nothing and I am reading too much into it, but I think on some level it goes to show how much importance you guys place on having "collegial" relationships with them, and how you guys have to play Dr. Phil while working with these people to not hurt their feelings and get them to like you.
I don't know how you guys do it. MD-only or bust.
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You are correct: it means nothing and you are reading too much into it
I like to have a good relationship with everyone I work with from surgeons to nurses to techs to janitors. Far more fun at work than being the raging a-hole that nobody likes.
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From what I hear you guys, as AAs, are less combative (that may not be the correct word) than CRNAs. CRNAs come from a nursing background which already tends to not like being told what to do by physicians so it gets worse when you have nurses with "advanced degrees" who are still told what to do by a physician.
I don't work with AAs so maybe I'm naive but I've got the impression that AAs sort of know their role in the care team and are cool with it. Again, I could be 100% wrong on this take.
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Great post.
Every group of people gathered together has a “raging dingus.” If you don’t know who it is, it’s probably you.
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When I was a kid, I spent more time and energy trying to get out of doing my chores than it would have taken to just do the job as instructed and move on. This mindset goes along with the whole shift work mentality that seems to be the nursing way of doing things (not surprising since they ARE shift workers). But somehow, they also seem to want to claim to be the ones who do all the heavy lifting and care for the patients the most and know what's best. They care the most...unless their shift is ending soon. Then, they care the least about anything or anyone. Can't have it both ways if you ask me.
I like to have a nice working relationship with people around me at work, too. But when it is in my best interest to care for patients as efficiently as possible, this group of people who claim to be patient advocates transform themselves into an obstacle. Speed and efficiency in the perioperative setting is so much better for everyone, especially the patients. Fast cases = less total anesthesia = fast recovery = less time in PACU = money saved = we all go home quicker = more time outside the hospital = more time with friends and family = more happiness. This can all break down at any level and ideally, the rate determining step should be the speed of the surgeon, not the rest of the process.
I like to have a nice working relationship with people around me at work, too. But when it is in my best interest to care for patients as efficiently as possible, this group of people who claim to be patient advocates transform themselves into an obstacle. Speed and efficiency in the perioperative setting is so much better for everyone, especially the patients. Fast cases = less total anesthesia = fast recovery = less time in PACU = money saved = we all go home quicker = more time outside the hospital = more time with friends and family = more happiness. This can all break down at any level and ideally, the rate determining step should be the speed of the surgeon, not the rest of the process.
100% agree.
But by the sound of some posts on this thread, it sounds like some anesthesiologists feel like the only way you can have a good relationship with certain CRNAs is by “not micromanaging”, not “sweating the small stuff”, letting them do procedures like neuraxial blocks/PNBs, etc....and essentially letting them do what they want short of causing some obvious morbidity. That to me indicates a sad, sad state of affairs. I wonder if surgeons would let the circulator pick what suture they want for them? “I’m sure there’s no outcome difference between 2-0 Vicryl and a 3-0 Vicryl, and I don’t want the circulator to feel bad so I’ll let them choose...”
Again, I don’t supervise so I have never needed to navigate these bizarre relationships. I’m not saying it’s wrong to approach the relationship with CRNAs like above...I’m just reflecting on how it is a symptom of the horrid state of nurse-driven medicine where doctors have to tuck their tails between their legs in fear of getting written up, hurting others’ feelings, etc...sometimes at the cost of a patient’s wellbeing (let me allow the CRNA to give this difficult intubation a shot. Two missing teeth and a hypopharynx full of blood later, I can step in....)
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You can be nice to people and have collegial relationships with subordinates, without ceding any authority. If it was always easy, there wouldn't be a need for anyone to write books on leadership or for military academies to exist to teach new ensigns and 2nd lieutenants how to lead.
Sometimes letting a weak/inflexible/shoulderchippy CRNA do a case the way he usually does it is just the best use of the tool you've got. There are lots of safe ways to do most cases. You don't have to die on every single hill.
There's an art to giving instructions to another person. When I do so with CRNAs I try to phrase things in a way that imply that I knew they already know something, and that I knew they were going to do it that way anyway. Sometimes that's true and they knew and were going to do it. Sometimes they didn't and weren't. In the latter case it's a chance for them to save some face and learn something.
"Since this guy has terribly controlled hypertension we should keep his MAPs above 75. I'll set up a phenylephrine infusion so he doesn't sag before cut time."
works better than
"Keep his MAPs above 75."
which the weak or lazy will interpret as
"Don't let him get too low, except between intubation and incision, or if it's just for a little while."
and the militant turds will hear as
"You're stupid and I'm going to give an arbitrary number because I think you're stupid and can't manage this simple case without me micromanaging you. Stupid."
while they go ahead and do things their way.
Sometimes letting a weak/inflexible/shoulderchippy CRNA do a case the way he usually does it is just the best use of the tool you've got. There are lots of safe ways to do most cases. You don't have to die on every single hill.
There's an art to giving instructions to another person. When I do so with CRNAs I try to phrase things in a way that imply that I knew they already know something, and that I knew they were going to do it that way anyway. Sometimes that's true and they knew and were going to do it. Sometimes they didn't and weren't. In the latter case it's a chance for them to save some face and learn something.
"Since this guy has terribly controlled hypertension we should keep his MAPs above 75. I'll set up a phenylephrine infusion so he doesn't sag before cut time."
works better than
"Keep his MAPs above 75."
which the weak or lazy will interpret as
"Don't let him get too low, except between intubation and incision, or if it's just for a little while."
and the militant turds will hear as
"You're stupid and I'm going to give an arbitrary number because I think you're stupid and can't manage this simple case without me micromanaging you. Stupid."
while they go ahead and do things their way.
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Not necessarily true, precisely for the reason you said. They’re shift workers. The practice can be so busy and just work them until 3 daily. They also don’t have to take calls and can get overtime. They also may be employed by AMC or hospital, I.e. not you, some of them couldn’t give an rat’s ass about when everyone else is going home.
I am still looking for an MD only practice, but cannot say I am naive enough to think such practices will be problem free.
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I think this depends on where you work. Some companies/practices are more notorious than others
