Jetpearl Number 18: Surgeon strategies

[jetproppilot]

---

Members do not see this ad.

If you are a new attending, say a year or less in practice, you may, in that first year, come across a case that goes against the grain of "how things are done" in your operating room. Or at least how you thought things were done. As always these controversies come up late at night or in the wee hours when none of your other partners are around.

I'm speaking about the when and where.

Lets say you're the call doc and a vaginal delivery happens at 2am and the OB wants to do a BTL now since "she's got the epidural." You speak with the OB and advice them that isn't your understanding; all BTLs are elective and doing one in the middle of the night is impractical.
The OB rants a bit.
You've got a decision to make. Do you make a rukkus? Refuse? Call a senior partner at 3am?
I'm suggesting you do the case.
Here's the pearl:
Early on in your new private practice group, take the path of least resistance when it comes to soft calls, then bring it up in the morning to a senior partner."
I can assure you it will get ironed out, probably more in stone than previous to your 3AM BTL.

Another example...a 1AM cysto where the urologist wants to do it under local but wants you there for "monitoring only." If locals arent recognized at your institution, its 1AM, take the path of least resistance and discuss it in the morning.

This technique of handling the "wee hour" calls is the most effective IMHO. Politically you did the right thing. Noone was pissed off except for, well, you. And again, this will probably be the last time it happens to you.

There are literally dozens of examples like this.

Your first year in a new practice, take the path of least resistance. Protect your group from a buncha crap that couldve been handled better in the morning by a senior partner.

You'll earn gold stars for your motivation and eloquence.

 

[2win]

If you are a new attending, say a year or less in practice, you may, in that first year, come across a case that goes against the grain of "how things are done" in your operating room. Or at least how you thought things were done. As always these controversies come up late at night or in the wee hours when none of your other partners are around.

I'm speaking about the when and where.

Lets say you're the call doc and a vaginal delivery happens at 2am and the OB wants to do a BTL now since "she's got the epidural." You speak with the OB and advice them that isn't your understanding; all BTLs are elective and doing one in the middle of the night is impractical.
The OB rants a bit.
You've got a decision to make. Do you make a rukkus? Refuse? Call a senior partner at 3am?
I'm suggesting you do the case.
Here's the pearl:
Early on in your new private practice group, take the path of least resistance when it comes to soft calls, then bring it up in the morning to a senior partner."
I can assure you it will get ironed out, probably more in stone than previous to your 3AM BTL.

Another example...a 1AM cysto where the urologist wants to do it under local but wants you there for "monitoring only." If locals arent recognized at your institution, its 1AM, take the path of least resistance and discuss it in the morning.

This technique of handling the "wee hour" calls is the most effective IMHO. Politically you did the right thing. Noone was pissed off except for, well, you. And again, this will probably be the last time it happens to you.

There are literally dozens of examples like this.

Your first year in a new practice, take the path of least resistance. Protect your group from a buncha crap that couldve been handled better in the morning by a senior partner.

You'll earn gold stars for your motivation and eloquence.

I protect my juniors from the first day.
They call me any time - night or day.
Nothing is moving in my business without my knowledge.
I respect them because I know that I was there and I didn't have this chance.
I stand for them for good and bad.
Not in the morning.
Anytime.
2win

 

[gaspasser2004]

I protect my juniors from the first day.
They call me any time - night or day.
Nothing is moving in my business without my knowledge.
I respect them because I know that I was there and I didn't have this chance.
I stand for them for good and bad.
Not in the morning.
Anytime.
2win

Those working in 2win's group are very lucky to have him as a resource. I agree with him that leadership is 24/7/365, not just in the morning after a good night's sleep.

Not to beat Jet's example to death, but there are implications for doing purely elective cases in the middle of the night that go beyond simply inconveniencing the on-call anesthesiologist. If there is no back-up call doc, then you won't be available to do a truly emergent case. If the back-up call doc is a gruff senior partner who hates working in the middle of the night, he won't be too happy when he finds out he is doing a case at 3 am because the junior guy allowed a BTL to go.

Otherwise, I agree with Jet's advice that the new guy shouldn't make big waves and should try to fly under the radar.

 

[Noyac]

I protect my juniors from the first day.
They call me any time - night or day.
Nothing is moving in my business without my knowledge.
I respect them because I know that I was there and I didn't have this chance.
I stand for them for good and bad.
Not in the morning.
Anytime.
2win

I will agree with you 2win. This is an attitude that everyone in my group seems to carry as well. Some of us are more vocal about things but all-in-all we all feel the same way. I, on the otherhand, did get this lack of support from my senior partners when I came out of residency. I learned just about everything I know from my first gig and very little from my residency with the exception of performing anesthesia to an art. And that is what residency is all about, teaching you to perform an artful anesthetic. And then your partners should be there to teach you everything else that residency didn't get around to teaching you.

 

[leaverus]

I understand what you guys are saying, but then how do you protect against establishing yourself as a push-over (or at the least appearing as one) for ever afterwards?

 

[jetproppilot]

Those working in 2win's group are very lucky to have him as a resource. I agree with him that leadership is 24/7/365, not just in the morning after a good night's sleep.

Not to beat Jet's example to death, but there are implications for doing purely elective cases in the middle of the night that go beyond simply inconveniencing the on-call anesthesiologist. If there is no back-up call doc, then you won't be available to do a truly emergent case. If the back-up call doc is a gruff senior partner who hates working in the middle of the night, he won't be too happy when he finds out he is doing a case at 3 am because the junior guy allowed a BTL to go.

Otherwise, I agree with Jet's advice that the new guy shouldn't make big waves and should try to fly under the radar.

I agree with your description of 2win. Great resource and his partners are very lucky.

Humbly disagree with your "what if theres an emergency?" prose, albeit for short cases.
Virtually any emergency takes 45 min to an hour to hit the OR doors. If a short elective case is in process it'll be done before the emergency hits.
More descriptive of what I'm trying to relay (than a middle of the night ridiculous request) is a typical Saturday morning at many hospitals that have elective cases on Saturday. If I have 2 crews and 8 cases to do I'd rather run two rooms for 6-8 hours than one room for 12-16 hours, trying to keep shorter cases in one room so turnover for an emergency can be accomodated. This makes more sense IMHO than keeping one crew idle for the "emergency".
Makes me recall an attending at my residency who refused to let residents go in an efficient manner as he was always prepared for, in his words, "a busload of hemophiliacs in a wreck." 😡
I do understand your thought process. I also believe crews can be utilized for short cases and still accomodate emergencies. Keep in mind also that most emergencies are urgencies rather than emergencies. True "crash" emergencies are uncommon.

 

[Bertelman]

I understand what you guys are saying, but then how do you protect against establishing yourself as a push-over (or at the least appearing as one) for ever afterwards?

I think his point is to make it through the night, then discuss the circumstances with your partners the following day.

Next time surgeon tries to pull some ****, stand up for yourself, knowing your partners have your back.

 

[IlDestriero]

Keep in mind also that most emergencies are urgencies rather than emergencies. True "crash" emergencies are uncommon.

Unless you work in a level 1 trauma center.
Those septic NICU wrecks tend to show up at odd hours as well.🙁

 

[jetproppilot]

Unless you work in a level 1 trauma center.
Those septic NICU wrecks tend to show up at odd hours as well.🙁

Well said. Point taken.

 

[Noyac]

Unless you work in a level 1 trauma center.
Those septic NICU wrecks tend to show up at odd hours as well.🙁

OK, but how often is that? I've worked in a few and I don't recall that many. Sure there is occasionally the true "break down the doors, we're coming in" type emergencies but they still are not that often. I guess you need to look at the track record of the hospital. At the level 1 hospitals I worked at we always had people for these cases and more.

 

[IlDestriero]

OK, but how often is that? I've worked in a few and I don't recall that many. Sure there is occasionally the true "break down the doors, we're coming in" type emergencies but they still are not that often. I guess you need to look at the track record of the hospital. At the level 1 hospitals I worked at we always had people for these cases and more.

More frequently than I would like. GSWs, MVAs, sometimes we have about an hour's notice while they get a CT, US, whatever. Other times, 10 minutes after the pager goes off, there they are at the OR doors. NICU disasters are infrequent, but they usually go the same way. Call comes in, attending surgeon is on the way in (10-30 min out) and wants to operate immediately, usually in the NICU.
Either way, you don't have much time to call in the 2nd call guy (who is rarely there after 9pm). We don't do anything elective overnight.

 

[gaspasser2004]

I heard a funny anecdote about an oral boards exam where the hypothetical patient crashed in the middle of transport from OR to ICU. In the examiner's institution, the ICU was a long way from the OR and he was expecting the examinee to take the patient back to the OR. In the examinee's institution, the ICU was very close to the OR, so when the patient crashed, he thought he was virtually through the doors of the ICU and chose to "go" to the ICU. Somehow these differences in perspective were cleared up and everyone in the room ended up laughing about it.

I can see how in some institutions doing a short elective case afterhours/weekends is no big deal. I can also see how in other institutions (such as level I or II trauma centers), tying up a set of hands to do an elective case can be a very big deal.

The spirit of Jet's pearl was for the new guy to not make trouble and this is a point that is very well taken.