Advice for new grads

[Noyac]

I know what most of you are thinking, " here we go again, Noy wants to give advice."
But seriously, if you could give a new grad "one" piece of advice, what would it be?

Mine would be, go to a group where you actually do cases. You have so much more to learn. Supervising nurses will not improve your skills nearly as well as actually sitting on a stool.

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[deleted171991]

My first piece of advice would have been the same.

Another one: find a job that makes you happy. Not only your spouse, or your family.

 

[Mman]

Supervising nurses will not improve your skills nearly as well as actually sitting on a stool.

What skill is that? Supervising allows me to preop more patients (see more pathology and come up with more anesthetic plans and see how they play out), manage more difficult airways, place more arterial lines, place more central lines, place more epidurals, place more spinals, manage more PACU issues, etc.

Do I get as good at turning down the Iso dial at the precise instant to extubate as the dressing is going on? No way. Then again I'd argue that's one of the least important things I could ever do.

 

[Wiscoblue]

You do make a very good point Mman. My experience does not support that. I've mostly done all my own cases all my life. But I must say, when I was a faculty member supervising residents and sometimes CRNAs 20 years ago, I did notice that many other faculty had become incapable of doing an anesthetic by themselves. If they had a VIP request case, they made sure they had a good CA3 with them. And they always shied away from difficult cases. They would cancel, postpone or dump the case on to someone else. I myself saw a decline in my skills.

 

[BuzzPhreed]

What skill is that? Supervising allows me to preop more patients (see more pathology and come up with more anesthetic plans and see how they play out), manage more difficult airways, place more arterial lines, place more central lines, place more epidurals, place more spinals, manage more PACU issues, etc.

Do I get as good at turning down the Iso dial at the precise instant to extubate as the dressing is going on? No way. Then again I'd argue that's one of the least important things I could ever do.

You think you are doing a good job. What you are actually doing is juggling a bunch of cases, not being able to give your full attention to any one of them, and "deferring" a lot of management to someone who may not have the depth or breadth of understanding about the nuances of a particular case.

I don't think anyone would disagree that you might use these skills you describe in this environment after a few years of experience and learning how the real world works. I think what Noyac is saying is don't jump out of residency into this type of job. Learn to be an independent anesthesiologist at least for a little while first. Supervision/direction right out of residency may afford you one day a week of doing your own cases, if you're lucky. You're not going to become a rock star doing that.

 

[sevoflurane]

Just think of a fresh grad coming out of residency and then supervising 4 CRNAs at a community hospital that does general surg, ortho, plastics and urology....
What happens when this grad starts looking for his next gig with higher acuity? Better keep looking at the ACT model cuz he'll need the extra hands. No thank you.

I have no issues with the ACT model. However, I will 100% agree with Noy in that starting out it behooves you develop a lot of confidence being solo at the head of the bed.

You get a couple of good years of solo practice at a medium to high acuity hospital and you will be able to build on that. Later, if you supervise, you can carry that confidence into the ACT model.

Having never done a solo AAA rupture or GSW with 15 holes through various organs doesn't really push the limits of what you can do as an anesthesiologist. IMO, you'll never get there supervising.

Not once have I called in one of my partners for help with a case while on primary call. Not once. If we were to hire someone that started to call out the 2nd call/backup person because they needed help... well we'd extend that help of course but we may question the abilities of said person if it was a consistent phenomena.

Not dogging anyone here. Just saying.

 

[sevoflurane]

BTW/ Noy has a lot of experience with CRNA's... and he did tons of hearts SOLO back in the day. He knows what he's talking aobut.

 

[gasdoc77]

You think you are doing a good job. What you are actually doing is juggling a bunch of cases, not being able to give your full attention to any one of them, and "deferring" a lot of management to someone who may not have the depth or breadth of understanding about the nuances of a particular case.

I don't think anyone would disagree that you might use these skills you describe in this environment after a few years of experience and learning how the real world works. I think what Noyac is saying is don't jump out of residency into this type of job. Learn to be an independent anesthesiologist at least for a little while first. Supervision/direction right out of residency may afford you one day a week of doing your own cases, if you're lucky. You're not going to become a rock star doing that.

I suppose we all are biased, but I will say that my current practice is 2/3 super and 1/3 solo. There is absolutely no comparison for me which days are more laborious. My super days are almost always 4:1 and the acuity is higher than our local "academic" institution, since they don't do heads and hearts and we are a regional referral center for both. Starting a day where 2 of the 4 rooms are hearts (in the room lined up by 7 am) and one of the other two could require a block if not a catheter doesn't compare to doing my own case. Just to throw salt in the wound, our group culture is that we provide ALL our own breaks. Try giving 4 lunches (2 hours) in the middle of the day while still doing your lines and echos. The logistics can be quite overwhelming.
I will concur that the supervision in academics was quite different and, without question, skills become eroded.

 

[sevoflurane]

Besides what has already been mentioned, I would say that starting out you should really try not to be a "know it all". Try to learn the institutional culture, be flexible, and be a team player. Be a nice person and befriend your nursing and surgical staff. It will make your life and work environment much easier.

 

[chocomorsel]

Gasdoc77, how are you able to give your CRNAs lunches while at the same time being responsible for the other three rooms? My practice tells me I can't do that in a medical directed model. Which I know is different technically than supervision. The only time I can do that is when I am down to one room in between cases as our turnovers are at least 30min.

Personally I agree with Sevo and Urge. Supervising sucks in general and doing it right out of residency is not smart. I am in a practice that's about 60/40 supervision vs. solo cases. Want to be in a place where supervision is minimal or non-existent.

 

[BobBarker]

Nm

 

[RedAnesthesia]

I agree that new grads should be doing solo practice straight out of residency. However, I feel those practices are becoming less and less. Our current healthcare model is in favor of ACT model and I expect it continue to proliferate. I will be curious to see how many MDs are doing solo practice in 10 years.

Red

 

[gasdoc77]

Gasdoc77, how are you able to give your CRNAs lunches while at the same time being responsible for the other three rooms? My practice tells me I can't do that in a medical directed model. Which I know is different technically than supervision. The only time I can do that is when I am down to one room in between cases as our turnovers are at least 30min.

Personally I agree with Sevo and Urge. Supervising sucks in general and doing it right out of residency is not smart. I am in a practice that's about 60/40 supervision vs. solo cases. Want to be in a place where supervision is minimal or non-existent.

I basically start at 11 and if another room needs to induce that nurse comes and finishes the lunch I began so that I can pop over and induce, intubate, etc. I have to be sure to be ahead on all preops, lines, and blocks since we do them all ourselves. It is unnecessarily complicated but, as the new guy, my pointing out the obvious inefficiency and it's impact on workflow/productivity is not welcome. It has become a machismo thing, which always carries some kind of price tag (life lesson there).
If anyone knows of an ASA link or statement that suggests this conflicts with "immediately available" please share, since logic has so far proven an inadequate arguement.

 

[B-Bone]

I basically start at 11 and if another room needs to induce that nurse comes and finishes the lunch I began so that I can pop over and induce, intubate, etc. I have to be sure to be ahead on all preops, lines, and blocks since we do them all ourselves. It is unnecessarily complicated but, as the new guy, my pointing out the obvious inefficiency and it's impact on workflow/productivity is not welcome. It has become a machismo thing, which always carries some kind of price tag (life lesson there).
If anyone knows of an ASA link or statement that suggests this conflicts with "immediately available" please share, since logic has so far proven an inadequate arguement.

This 100% conflicts with the "immediately available" portion of TERFA. Ask your billing company. If you are signed in as the primary provider for a case, you are not immediately available for another room. Your group must have literally thousands of TEFRA violations racked up. If you are not signed in as the primary provider for a case, but are the only anesthesia provider in the room, then this is fraud. Note that if you were ever audited by CMS, you would have payments retroactively cancelled and would be assessed a fine for triple the fraudulent billing amounts. They can look back for years. Sounds like a huge risk (and just bad medicine, as well).

https://www.nashvillepost.com/news/...s_allege_vast_vumc_medicare_billing_deception
http://www.whistleblowerlawyerblawg...histleblowers-under-the-false-claims-act.html
http://anesth.utmb.edu/Faculty/Billing/CompliancePlan.pdf see page 3

 

[Mman]

You think you are doing a good job. What you are actually doing is juggling a bunch of cases, not being able to give your full attention to any one of them, and "deferring" a lot of management to someone who may not have the depth or breadth of understanding about the nuances of a particular case.

Having done both, I'm going to disagree. I don't "think I'm doing a good job", I know I am. The management I defer is trivial. Covering more rooms has given me more experience and made me far slicker and more confident with sick patients than I ever got sitting on a stool for 6 hours.

Every job is different. Are there anesthesiologists supervising rooms that just show up to sign a chart and occasionally bail somebody out? Of course. Does that mean that every job is like that? Of course not.


The single most important than for a new grad is to join a group with plenty of experienced partners willing and able to help you learn the ropes and that can support you in tough decisions.

 

[GA8314]

First, there is no perfect job. Is it better to supervise pediatrics and cardiac than to go to a place that doesn't do em at all?? Or that only has the fellowship folks doing them? How would your skills fair then?

Is it IDEAL to go do your own cases for 5 or 10 years right out of the gate? Perhaps, but what is available to a new grad is entirely another matter. Move to a place where you have zero ties or isn't desirable to you for that solo job? Not sure that's the answer.

Tomorrow I'm running 4 CRNAS rooms at a very busy orthopedic hospital. Didn't look at the cases but suffice it to say that the regional/neuraxial activity is going to far surpass that had I been doing my own room solo. Ill be leaving the CRNA with essentially a MAC/LMA case. Is that the best use of my time? Doing those cases?

I myself get hung up on the very issues brought up by Noy. But MY advice is to control what you can. Realize that there is no perfect gig as far as cases go but you need to ensure no matter what gig you are in, to maintain your skills. Hard to do if your hospital does all the hearts but the guys down the street does most of the ortho/regional, or say Peds work? You bet it is. Not sure it's worth getting hung up on, but take every chance to bring any weaknesses back up to speed.

It's true, one needs to stay extra vigilant when supervising so as to not let skills erode. This is why I tubed 2 of 2 patients requiring it last week with my CRNA.

Is the solo job doing ALL cases solo? What are you giving up for it? Again, there are no perfect scenarios. All one can do is find the best job given each persons criteria.

 

[deleted171991]

I think the idea of working solo a good amount of time is that it makes you a much better supervisor. How can you medically direct experienced CRNAs in cases that you wouldn't know how to do properly solo? Also, when you work solo, you learn your limits; there is basically nobody else to bail you out, you sleep in the bed you made. You learn how far you can go in critical situations, so you become much less jumpy when you supervise, and let the CRNA try first: "If there is a problem, I could still fix it... I could still fix it... NOW it's the time to take over", instead of taking over too early or too late.

CRNAs can very easily and fast make a difference between an experienced doctor and a paper monkey. The latter is the one that creates militant CRNAs. Nobody should supervise/direct right out of residency (except for simple cases). I don't care how good you think you are.

 

[Urzuz]

As someone who is fresh out of residency and who has been doing my own cases for the past 1.5 months, I can confidently say that being able to develop an anesthetic plan and see it through from preop to recovery is markedly different now versus when I was a CA-3. The stakes are different. And despite how confident I may have been as a CA-3 last year in doing some of the bread-and-butter cases that float my way in practice now, there is something different about managing a patient intraoperatively when it is all on me. I have also seen things go awry intraop, and I have learned how to best troubleshoot and deal with these problems. Afterwards, I was able to reflect on my plan and reflect on the development of these problems (how did they come about? What was the surgeon doing at the time? What were the patient's vital signs? Were there any red flags before it developed?), and in the future I will be better prepared. I don't think I would have had the same insight had I been running into the room after getting called by a CRNA and retrospectively trying to piece together what happened.

I feel like I have learned and matured a lot since starting by myself, and this is just the beginning. As mentioned earlier, it also helps that I am surrounded by people that have a wealth of experience to offer and are more than willing to lend a helping hand.

 

[BuzzPhreed]

Having done both, I'm going to disagree. I don't "think I'm doing a good job", I know I am. (snip)

Let me clarify and expand.

First, you've done both. That's the point. It behooves a new residency grad to go out and "cut their teeth" on their own. Maybe they can find a practice where they do their own cases like a doc only practice. Maybe the do locums for a while. Who knows? Jumping straight into a supervision/direction-only model is not in their best interest.

Secondly, I am currently in a practice where I do about 70% solo, 30% supervised. I ran three rooms this past Friday with 3 seasoned CRNAs. They know the drill. They know when to call. They don't do anything without clarifying. They don't come up with stuff on their own. This is ideal. They always wait to induce, and always call before extubation. Part of this is having done it (in most of their cases) for over 30 years. The other part of it is our group defining the scope of their practice and hospital management backing us 100%.

Lastly, I've been in the situation that Noyac is admonishing new residency grads to avoid. The ones who've been there have gotten so used to the CRNAs doing everything and them being nothing more than paper jocks, I wouldn't trust them to bail me out if I needed help. I wouldn't trust a lot of them to give me - me personally - anesthesia if I needed it. It's not that they couldn't do it. It would just be sloppy, which is a lot of what I saw. Why is this? Because there are 'ologists who've been in that practice 8, 9, 10 years who joined coming fresh out of residency immediately into a high-ratio medical direction environment and who probably haven't done a solo case in 4-5 years. That's the 100% truth. And I saw the rustiness first hand.

So, you have the advantage of practicing in both environments. Me, too. And that's the point.

 

[seinfeld]

I have found that attending who prefer do their own cases tend to be more inflexible supervising physicians (always and never statements regarding minutia). I do both my own hearts solo, and also supervise 3:1. My supervising days are more stressful but at least I go to the bathroom within normal timeframe from the onset of micturition and get lunch before the end of a case.


Advice:
1. Dont ask your partners "how should I do this". Tell them how you are planning to do it and then ask if this is standard at that institution and if the surgeon has any preferences. If you ask to many open ended questions of your new colleagues you could start getting a bad reputation (notice I did not say that asking for help is bad but make sure you do it in a way that gives your partners confidence in your knowledge and skills).

2. When supervising be clear on what is important with the CRNA and then also realize that some things are preferences and not gospel. Set goals for the patients care, like Keep MAP over 70, low or high narcotics. Be clear to communicate your absolute preference which are not negotiable. IE if you want an RSI thats your call,communicate with CRNA. IF you want an ETT vs LMA that your call. But dont start telling CRNA how to tape the tube, how much ephedrine or neo to give etc. It also works in reverese like if a CRNA asks for an ETT when you were thinking LMA. Unless you have a compelling reason for a less secure airway (RAD, concern about reversal of NMB) I usually go with it.

3. Surgeons will tell you all the time that case X can be done with MAC or LMA. Remember at the deposition no one will believe that the surgical preference should have impacted the anesthetic choice. I tend to be nice and conversational about the reasons for my choice with the surgeon. When i first started, if I really felt uncomfortable with the surgeons request I asked an older partner to talk with the surgeon and if they felt the surgeon was right I would push the case off to them.

4. Be a DOCTOR. Be interested in the patient and the case. Dont sit down but watch and discuss the findings as they evolve. Ask the surgeon next day how their patient is recovering. When a patient is following outside the normal pathway in the recovery room call the surgeon yourself and discuss you findings and concerns.

 

[GA8314]

Consider also, like Seinfelds situation, that some ACT models are structured that the MDs sit their own hearts, thoracic, and major vascular. The rest is supervision.

Still some others have it where the Physicians DO their own cases from time to time. So, what's the ideal ratio?? 30/70%. 70% your own that is?

What if your solo only group doesn't even do hearts? How about very little Peds?? Again, there is no perfect group.

Other ACT groups have the late MD sitting their own if only running one late room. Same for weekends. There is plenty of flexibility in order to maintain that finesse in an ACT model. And I can say that supervising has allowed me to put more OR time in the cases and during the times I see fit, and requiring more of my time.

What you can not do in an ACT model is rely on CRNAs to the point where you cant do the case yourself. This includes knowing how to set up and operate pumps and other equipment. And I submit that when they KNOW you can take over and run solo on any given case, then respect will come. But you don't need to do it every day I think.

 

[urge]

It is forbidden in my place to give lunches when covering 2 rooms or more. I believe that is standard but people tend to ignore it. Basically you cannot be immediately available. You have to call one CRNA back to help the other.

As to supervision vs solo, I believe you get more procedural skills in solo practice but you gain experience a lot faster supervising.

It boils down to what you want as a new grad. Do you want to be super slick early on , building up experience slowly, or do you want to see stuff coming before it has happened but giving up some procedural skills along the way?

I basically start at 11 and if another room needs to induce that nurse comes and finishes the lunch I began so that I can pop over and induce, intubate, etc. I have to be sure to be ahead on all preops, lines, and blocks since we do them all ourselves. It is unnecessarily complicated but, as the new guy, my pointing out the obvious inefficiency and it's impact on workflow/productivity is not welcome. It has become a machismo thing, which always carries some kind of price tag (life lesson there).
If anyone knows of an ASA link or statement that suggests this conflicts with "immediately available" please share, since logic has so far proven an inadequate arguement.[/QUOTE
forbidden

 

[Noyac]

All good points everyone. GA8314 makes very good points and I agree with many of them.

My pov is more like this. Supervising gives you certain skills that are valuable. One of those skills not to be overlooked is efficient time management which wasn't mentioned directly here but eluded to for sure. Seeing more pathology and devolving plans is also important but I would argue that not managing these pathologies continuously would be difficult for me personally to learn to mange these pts and more importantly keep them out of trouble. When supervising you don't necessarily get this because if the crna is good they do it for you and if not they call when the trouble has already occurred. Resolving the problem is not to be minimized at all. Another point, running around doing lines and blocks etc all day is taxing. I get it. But these are (In the words of an infamous sdn'er) monkey skills that everyone should be able to do.

So I will concede that there are some circumstances and jobs that make a supervisory gig right for someone. However, if you were to go to one of these as a new grad I think it would be smart to do as many of your own cases as possible.

 

[pjl]

Our group is 70:30 supervise to solo. MD solo for whatever the 2-3 "hardest" rooms are whether it is hearts, aneurysms, or just a bunch of kids. I feel this balances my hatred of sitting eye cases myself (supervise those) and lack of OR experience.
The skills required are completely different, and the is no doubt in my mind I work harder on supervision days. Solo days are a breeze, even on fairly bad days. I absolutely don't feel as smooth as I would if I had been solo since graduating, but I have seen a lot more pathology than I would have without the supervision component.

If forced by geography or whatever to pick solo vs straight supervision right out I would (and did) choose a group where you do at least some of your own cases. There is good and bad to all jobs and situations, pick a job that grows your comfort zone. The surgicenter gig sounds nice, but you are unlikely to stay in that setting for 30 years, and don't want to limit future too much.

 

[GA8314]

Running 4 CRNA rooms today gave me 6 spinals (partner did 1 as I was starting a room), 3 interscalenes (partner did one as I was launching multiple rooms in the a.m.), 1 fem/pop, and 3 adductor canals.......

Had I personally been in any of those rooms myself would, IMHO, not have been as benefitial as my day today. It's not black and white, I get it. I do feel there's a "slickness" that comes with running tough rooms on one's own.

I think you need to assess what is important to you. Take the best opportunity which meets your personal and professional goals. That's all a person can do.

We've all seen the attending who's lost touch with the OR. I strongly believe this is a death nail in one's career. So, if you find yourself in an ACT practice sooner than later, you WILL need to pay attention to skill attrition (or certain aspects of it). That being said, there are advantages to the ACT model also, as per above. It's not black and white though.

I think no matter what practice setting your find yourself, it's important to NOT get complacent. But, there are PLENTY of opportunities to make sure that doesn't happen. It just takes more discipline in some settings...

 

[BuzzPhreed]

Running 4 CRNA rooms today gave me 6 spinals (partner did 1 as I was starting a room), 3 interscalenes (partner did one as I was launching multiple rooms in the a.m.), 1 fem/pop, and 3 adductor canals.......

All of that is predicated of course on the practice not only not allowing CRNAs to do these procedures, but also not creating an environment where they are encouraged to do them. There are supervision-predominate practices where this is the case. I know firsthand. One of the docs I worked with literally did nothing but sign charts. I don't think I ever saw him in a room. Certainly I never saw him actually touch a patient.

"That's just the way we do it here."

If you ever hear that, run.

 

[Noyac]

Running 4 CRNA rooms today gave me 6 spinals (partner did 1 as I was starting a room), 3 interscalenes (partner did one as I was launching multiple rooms in the a.m.), 1 fem/pop, and 3 adductor canals.......

I seriously mean no disrespect here, but if this were my day it would be the easiest day I've had in a long time. And my job ain't that hard.

 

[GA8314]

I seriously mean no disrespect here, but if this were my day it would be the easiest day I've had in a long time. And my job ain't that hard.

I respect your experience but come on......

Edit. I realize you are talking about supervising. Had I been solo in any of those rooms would have meant many missed opportunities.

 

[GA8314]

All of that is predicated of course on the practice not only not allowing CRNAs to do these procedures, but also not creating an environment where they are encouraged to do them. There are supervision-predominate practices where this is the case. I know firsthand. One of the docs I worked with literally did nothing but sign charts. I don't think I ever saw him in a room. Certainly I never saw him actually touch a patient.

"That's just the way we do it here."

If you ever hear that, run.

Such people are the scourge of our profession. I have heard of this happening as well. It's sickening.

 

[Noyac]

I respect your experience but come on......

Edit. I realize you are talking about supervising. Had I been solo in any of those rooms would have meant many missed opportunities.

All I am saying here is that regional anesthesia is the simplest part of our job, especially spinals. Now add having someone else sit for the case and you can't get any simpler.

 

[Yangkower]

Another major benefit of doing your own cases is that surgeons get to know you. If you are good they will respect your opinions. Just the other day I was talking to a surgeon over the drape and he changed the surgery he was doing based on a suggestion I made. I also can discuss upcoming cases if necessary.

In my MD only practice surgeons are frightened by the idea of working with nurse anesthetists which of course is a fear I promote.

 

[Noyac]

Another major benefit of doing your own cases is that surgeons get to know you. If you are good they will respect your opinions. Just the other day I was talking to a surgeon over the drape and he changed the surgery he was doing based on a suggestion I made. I also can discuss upcoming cases if necessary.

In my MD only practice surgeons are frightened by the idea of working with nurse anesthetists which of course is a fear I promote.

So true.

 

[deleted171991]

This is from another thread, where some of us were advocating LMAs:

I have no idea what the literature shows but I see plenty of LMA patients with sore throats and I see a far higher incidence (albeit still low) of pharyngeal injury from an LMA compared to an ETT. Uvula's 3x the size they were preop from getting squished by the LMA for an hour+ or pharyngeal injury from the LMA sitting incorrectly or having too much pressure inflated.

LMAs make our life easier at times. I rarely see a patient that was glad they had an LMA postop with the exception of perhaps a bad reactive airway patient. Patient's don't feel any better postop.

I don't want to resuscitate the issue. I just want to point out that, for me, this has a much higher chance to happen with supervision, because not every CRNA is good at certain things, the same way we are not either. And proper care of the LMA is just the tip of the iceberg; one doesn't know what else is (not) happening while one is not in the room.

I'd rather be responsible for only my own mistakes.

 

[BuzzPhreed]

I'd rather be responsible for only my own mistakes.