The only "skills" that you may not get to practice in an outpatient setting are central lines, epidurals and running drips. My theory on invasive procedures is that once you reach a certain threshold of experience it becomes as reflexive (if thats the word) as riding a bicycle. As a matter of fact I would say that watching the pain docs do thousands of epidurals under flouro has been the single best training tool for labor epidurals since I Ieft residency. As far as placing lines goes, as long I have access to some sort of ultrasound device I can place an IJ in even the most challenging patient and even without one my knowledge of basic anatomy and the hundreds of lines I placed as a resident have given me enough of a skill set to keep from embarrassing myself in front of nurses and surgeons. The rest of it really does come down to basic knowledge - do you really need to "practice" running pressors or an insulin drip?
Having worked in a few difference private practice and academic settings it seems to me that the people who have "lost" their ability to do complex cases and invasive procedures probably weren't any good at those procedures to begin with. Our 25 physician group only has 5 people who are able to do basic blocks and probably 15 of us who are proficient at placing lines. According to the L&D nurses about 1/3 of the group "suck" at placing epidurals and the director of our group will occasionally pull one of us aside and discretely ask us to go take over a room when one of out colleagues is clearly overwhelmed by a case. Now we have all had basically the same training, passed the same board exams and hold the same position but those who barely scraped by in residency and never took the initiative to do challenging cases and learn blocks are very easy to spot.
I'm with you on the "riding a bicycle" monkey skills and "some lazy people just suck" bits ...
I guess what I'm trying to say is that you really need to do as much learning as possible during residency because you will never have a chance to hone skills you never learned when you are an attending.
... but I don't agree with this.
Not just because many skills CAN be learned after residency (look at all the SDN readers here posting about teaching themselves new blocks, or learning TEE and taking the testamur exam) ... but mainly because it's not "skills" per se that are the issue.
There's a lot of learning after residency - maybe less of the "skills" side, but absolutely the "judgment" side. If you don't go to a practice where you have to do complex cases in borderline patients, judgment can't mature.
The hard part of anesthesia isn't sticking in a line or setting up a pressor drip, it's judgment, anticipation and pre-emption of problems, OR flow management, people/staff management - these may or may not be perishible skills, but I think FEW new graduates have really mastered them. I certainly hadn't and I was a very strong resident. I'm still working to improve myself 3 years later, and I have specific plans to keep improving. If you exit residency and go straight to a cushy outpatient practice or (dare I say it) mommy track job ... no matter how good you were as a senior CA3, you'll not reach your full potential.
I know this, because I stared into that abyss of atrophy and stagnation when the Navy parked me at a tiny hospital right out of residency. And I know that if not for the extra 40-60 hours per month I spend moonlighting (sometimes more if I take vacation time from the Navy to go work at the local civilian joint), I wouldn't be as good as I am now.
I'm still a youngin' relatively speaking. I believe that residency makes us safe and even good, but only challenging independent practice can make us excellent.
Keeping a surgicenter running efficiently is a skill and you have to be deft and efficient, but right after residency, filling your days with knee scopes and butt scopes is a dodgy plan.
