Learning to supervise

Started by NunquamDormio
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NunquamDormio

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I am currently in fellowship but looking at lots of jobs that require supervision. The best job I've found so far requires 3:1 supervision of CRNAs. I entered fellowship straight out of residency, and have zero experience with supervising cases. How do I learn to be good at this?

Should I spend time reading about preoperative evaluation? Or is it just a matter of starting cases with CRNAs to make sure nothing goes wrong on induction, and then leaving once they're underway?
 
Hard to answer this question without more detail. Is it a medical direction or supervision model? Are the CRNAs on average experienced or not? Are your future partners pretty hands on with them? Is the case load bread and butter or do you routinely have sick vascular, thoracic, neuro, ortho, peds?
 
vector2 said:
Hard to answer this question without more detail. Is it a medical direction or supervision model? Are the CRNAs on average experienced or not? Are your future partners pretty hands on with them? Is the case load bread and butter or do you routinely have sick vascular, thoracic, neuro, ortho, peds?
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Those are good questions. Also, can you trust them to call you if something is out of the ordinary? If not, you have to check in a lot more frequently and it’s harder to be comfortable away from the OR.
 
NunquamDormio said:
I am currently in fellowship but looking at lots of jobs that require supervision. The best job I've found so far requires 3:1 supervision of CRNAs. I entered fellowship straight out of residency, and have zero experience with supervising cases. How do I learn to be good at this?

Should I spend time reading about preoperative evaluation? Or is it just a matter of starting cases with CRNAs to make sure nothing goes wrong on induction, and then leaving once they're underway?
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This is completely and totally dependent on the CRNAs. You will need to get to know each one and their weaknesses....then adjust your supervision to that. Some of them have ego issues which is very dangerous. Some are absolutely terrible clinicians. The best CRNAs I’ve worked with are probably at the level of a 2nd year resident on average. The worst ones I’ve worked with were when I was doing moonlighting stints and I was seriously concerned for my license.
My biggest piece of advice is join a group where the docs have hiring and firing power. Incompetent or militant CRNAs are shown the door. Otherwise you are in for a world of stress and angst.
 
Do what the other guys in the practice do. You have to assume that what they are doing is safe. You can basically classify crnas in 4 groups:

1. Competent/takes supervision well
2. Competent but has ego
3. Weak but humble
4. Weak but doesn't know it

Group 1 are our favorites. 2 & 3 can be annoying but you have to take the good with the bad. Group 4 is dangerous. We all have stories about these crnas.

Always keep in mind you can refuse to work with a crna. This is not something you want to do, but it's the nuclear option that you always have. I've use it as a threat a couple of time to get crnas in line.
 
NunquamDormio said:
I am currently in fellowship but looking at lots of jobs that require supervision. The best job I've found so far requires 3:1 supervision of CRNAs. I entered fellowship straight out of residency, and have zero experience with supervising cases. How do I learn to be good at this?

Should I spend time reading about preoperative evaluation? Or is it just a matter of starting cases with CRNAs to make sure nothing goes wrong on induction, and then leaving once they're underway?
Click to expand...
Get a job were you do at least a fair number of your own cases. I think at least 30% should be a good number. You don't want to be a needle and paper monkey. But I hear that's where the money is. You will suffer from skill atrophy though.
 
It's helpful to know the preoperative guidelines, cardiac risk stratification/ MACE, knowing timelines for anticoagulation and neuraxial, guidelines for timing of elective surgery and stents, MI, continuing DAPT, etc. These are the conversations you'll be having outside the OR while scrambling to get your cases started. Best, when possible, to review your schedule and do focused chart reviews the night before and contact surgeons beforehand if you have a concern, as it is a huge PITA to be having these conversations while keeping your cases going, negotiating blocks and breaks, etc. You'll learn to pick your spots with how much you micromanage the CRNA's. Get a sense for the culture, but don't get so wrapped up in it that you start ignoring the important instincts you've begun to develop in training. If it feels unsafe to you, hit the breaks, as some CRNA's will have developed bad/risky habits that they have gotten away with for the last 10+ years.

Good luck!
 
Remember that it is not really your case, especially in 4:1 you cannot give every patient the same care as if you would have done the case solo. So long as the patient is alive and neurologically intact at the end of the case, sign the chart and move on....
 
dannyboy1 said:
Remember that it is not really your case, especially in 4:1 you cannot give every patient the same care as if you would have done the case solo. So long as the patient is alive and neurologically intact at the end of the case, sign the chart and move on....
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I wonder what would have happened if you said this during your medical school interview instead of "my plan is to practice family medicine in an underserved, rural area." Oh how corruptible and flexible our idealism becomes....
 
Consigliere said:
I wonder what would have happened if you said this during your medical school interview instead of "my plan is to practice family medicine in an underserved, rural area." Oh how corruptible and flexible our idealism becomes....
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You cynic you:nono:

Consider some of the idealistic posts on the USAP thread:

"The fact is we have docs with blood on their hands. We need to call them out and hold them responsible to the extent that they have taken their bribes to open the door and let these rent-seeking parasites in. Perhaps there should be a curriculum on professional integrity for all trainees. It could even be a part of the ACGME’s core competencies."

"But, it's hard to understand the level of entitlement that some baby boomers display. Which wouldn't be so bad in itself if some of those same entitled boomers weren't so extremely mediocre from a professional point of view. "


"Most wealth comes from exploitation of others. Selling access to allow useless suits to rob other docs of their income"


"If you realize that you live in a world larger than yourself and have a modicum of integrity, it really is in fact a choice, and the correct choice should be obvious to those who care about the future of the profession."



Idealism is alive and well.😉🤣
 
Consigliere said:
I wonder what would have happened if you said this during your medical school interview instead of "my plan is to practice family medicine in an underserved, rural area." Oh how corruptible and flexible our idealism becomes....
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lol. I never had that much idealism to begin with. To me anesthesia is a job. I just to get through my workday with the least amount of stress, drama, ( and effort) as possible. It’s working out ok so far....
 
dannyboy1 said:
lol. I never had that much idealism to begin with. To me anesthesia is a job. I just to get through my workday with the least amount of stress, drama, ( and effort) as possible. It’s working out ok so far....
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At least you're honest about it and I respect that. FYI I feel the same way.
 
I think the biggest thing with supervision is picking your battles. There are many ways to anesthetize a patient and even though i sometimes feel i would do things differently, i only bring it up if it seems like a major patient safety issue or it is likely to have a considerable impact on post-operative outcome. One thing is for sure though: the minute anything goes wrong (ie: patient arrives in PACU hypothermic, too much narcotic is given, there is a positional related nerve praxia) YOU are the one who is responsible even if you were only around for induction. You get all the lovely emails and criticism that follows. I would advocate to be very direct/clear if you want things done a certain way but allow as much autonomy as possible when permitted. I think the majority of anesthetists in our group fall into group 1 or 2. Our partners really take the time to find skilled people that care about learning and doing a nice job for patients.

I must say that not having to "set up the room" every day is nice. While i don't always love bouncing between pre-op, the OR, and PACU i much prefer it to sitting in a room for several hours every day.
 
caveat87 said:
I think the biggest thing with supervision is picking your battles. There are many ways to anesthetize a patient and even though i sometimes feel i would do things differently, i only bring it up if it seems like a major patient safety issue or it is likely to have a considerable impact on post-operative outcome. One thing is for sure though: the minute anything goes wrong (ie: patient arrives in PACU hypothermic, too much narcotic is given, there is a positional related nerve praxia) YOU are the one who is responsible even if you were only around for induction. You get all the lovely emails and criticism that follows. I would advocate to be very direct/clear if you want things done a certain way but allow as much autonomy as possible when permitted. I think the majority of anesthetists in our group fall into group 1 or 2. Our partners really take the time to find skilled people that care about learning and doing a nice job for patients.

I must say that not having to "set up the room" every day is nice. While i don't always love bouncing between pre-op, the OR, and PACU i much prefer it to sitting in a room for several hours every day.
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Pretty common sense response. We work in a heavily medically directed ACT practice. We want our anesthetists to take initiative, but at the same time, follow directions as needed. Cowboys will not be here long. There is mutual respect going both ways - we all have a job to do. The docs expect me to do my job to the best of my ability, and I in turn expect the same from them. I'm more than happy to ask for help when things are not going as they should - but if I have a problem and ask for help, I expect them to be there immediately. We take this anesthesia care "team" concept seriously and expectations are clear all around.
 
I supervise the majority of the time. I still do my own cases maybe 10% of the time depending on manpower/scheduling. I'm in my 5th year PP.

The system favors an ACT model. If that is the system/model in your place then all you can do is make the best of it. Mutual respect is key as are getting to know the nuances, personalities, and skill levels of the CRNA's. I would nip any blatant militancy in the bud in whatever way possible however, and this can be a headache. But, I think it's important to do.

That said, most mid-levels just want to be treated like a decent human being and to get the job done. Make sure you hold up to your end of the bargain, and see patients on time, get orders in, get to the OR in time to start cases without delay. Communicate with them, and take a team approach to things. They are not your enemy in spite of the rhetoric we hear and coming from national PAC's etc. In the group, you are there to be professionals (all of you) and to get the job done smoothly.

There are a myriad of ways (indeed you won't be able to avoid them) to stay hands on in an ACT model. Sometimes this depends on the culture within your department, and the rigidity to which you adhere to certain criteria. But, there are usually ample opportunities to start cases solo, wake up patients and take to PACU, and of course there is nothing that says they do all intubations. Indeed I encourage you to do maybe 2 out of, say, 6 intubations (for a busy gen surg room for example). This won't rub them the wrong way as if you are "stealing" all the fun, or come off that you don't trust them to do a good job. In fact, they will respect you for wanting to maintain your skills.

Do all known difficult intubations yourself. You just have to do that and draw the line that that is your role. Of course that applies to difficult airway gear. That is, however, not to say you can't let them try for cases you are not truly that concerned about. For sure docs get better advanced airway experience in training.

It's hard to explain until you've been in an ACT model, but there are plenty of ways for docs to stay exceptionally relevant in the hospital system. 5 years out and I am less worried about a CRNA taking my job that I was in med school or residency. Maybe I'm in a bubble, but I don't think so. Stay active in the department, engage in committees, and be the professional you trained to be. This will solve 80% of your problems.

Again, take a team approach because then you always have the moral and professional high ground. Any bad apples will either weed themselves out or be universally recognized as such..

Good luck.
 
As a CRNA turned MD, having been blessed with great CRNAs, I agree that picking your battles is most important. If the in-room provider wants to use Oxy instead of Dilaudid, and you can’t see why not, let them. This goes for residents as well.

It can be as simple as saying, “How do you want to do this case?”, rather than,”Do it this way.” It doesn’t take that much more psychic energy, but then the CRNA gets to think, and feel like their opinions matter to you (maybe they don’t). If you have a better way, and you explain your rationale, the CRNA might learn something. Rembering that you are the decider though, if medical circumstances demand a particular regime.

Also, after seeing the pt preop, call the in-room guy, and tell them what is heading their way. Then they can set up for the next case more tailored to what’s about to happen. That may save you some aggravation.
 
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