aka_tigerj

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At my school, they are just there for intubations/extubations/help in most cases and let the CRNAs do the rest. They go to the breakroom and chat & have coffee. The only time they do their "own" case is if they are teaching a resident. Is this true throughout the US?
 

secants

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^ has been my limited experience as well
 

Docuronium

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I don't know if they just chat and have coffee. If they're supervising 4 CRNAs that's a busy day---will also be spending time working on various committees, research, educational things in addition to running multiple rooms. Most attendings tell me they wish somedays they could just stay in a room all day and simply focus on a case.
 

GaseousClay

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A lot of the reason why CRNAs think the way they do is academic attendings. This is particularly true at the VA.
 
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aka_tigerj

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I don't know if they just chat and have coffee. If they're supervising 4 CRNAs that's a busy day---will also be spending time working on various committees, research, educational things in addition to running multiple rooms. Most attendings tell me they wish somedays they could just stay in a room all day and simply focus on a case.
Supervise 3 CRNAs...they will "round" on them every half hour, and will come in if they get a cell phone call. They only have meetings on Thursdays. It's so sad. How do young anesthesiologists get enough solo experience to feel comfortable doing things by themselves?
 

DrLight

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It's easy to assume that supervising 3-4 rooms is easy, unless you have actually done it....that includes pre-ops for 3-4 rooms, being present for induction and emergence, signing out 3-4 rooms worth of patients in the PACU and then helping with breaks.
I'm an academic anesthesiologist and neither myself nor my colleagues are just drinking coffee; in fact most of us are lucky to even have time for a real lunch break .
Also to the OP....writing "MD" and "anesthesiologist' in the same sentence is redundant. All anesthesiologists are physicians.
 

GaseousClay

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It's easy to assume that supervising 3-4 rooms is easy, unless you have actually done it....that includes pre-ops for 3-4 rooms, being present for induction and emergence, signing out 3-4 rooms worth of patients in the PACU and then helping with breaks.
I'm an academic anesthesiologist and neither myself nor my colleagues are just drinking coffee; in fact most of us are lucky to even have time for a real lunch break .
Also to the OP....writing "MD" and "anesthesiologist' in the same sentence is redundant. All anesthesiologists are physicians.
if you are supervising 3-4 rooms in academics then i agree with you, that is real work. a lot of institutions I have heard from my resident friends, the attendings are supervising 1 resident and 1 CRNA. Nothing makes them happier than having a room with 2 CRNAs and they don't have to do anything. preops, being present for induction/emergence is rarely the case, especially with experienced CRNAs.
 

G-Man82

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I'm a new Attending at an academic center. Even with just 2 rooms, in any combination of AA/Resident, I still spend a lot of time running around. If ones a fast room, then I'm in preop a lot getting the next guy ready. If my resident is a new-ish CA-1 doing a Mac case on a lady with a BMI of 67, then you can get I'm in that room 90% of the time.

I like the combo of AA and resident. With the AAs, I check in a few times for routine cases, but I spend more of my time with the resident. It's a nice feeling if you feel you actually taught them something. With anesthetists, that obligation isn't there.
 

aneftp

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I think the complexity of cases and co morbidity or patients matters more than how many rooms one is covering. If you are at academic medical center; most have high risk patients in complicated cases. Covering 4 rooms at academic medical center is not the same as covering 4 rooms at community bread and butter hospital.

Yes, there is the "perception" many academic anesthesiologist sit around and do very little. This may be true especially for those with more seniority. But the young academic faculty usually end up doing most of the work (aka young junior faculty either gets 3-4 crna rooms or 2 CA-1 rooms). Senior faculty cherry pick and take 1 experienced CRNA and 1 CA-3 and just chill the rest of the day.

So to make a blanket statement "young" academic anesthesiologist do very little work and don't gain enough experience is most likely incorrect.
 

urge

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They go to the breakroom and chat & have coffee.
You must spend a good part of your time in the breakroom to know where they actually go.

Classic pot calling the kettle black.
 

pgg

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At my school, they are just there for intubations/extubations/help in most cases and let the CRNAs do the rest. They go to the breakroom and chat & have coffee. The only time they do their "own" case is if they are teaching a resident. Is this true throughout the US?
Supervise 3 CRNAs...they will "round" on them every half hour, and will come in if they get a cell phone call. They only have meetings on Thursdays. It's so sad. How do young anesthesiologists get enough solo experience to feel comfortable doing things by themselves?
That's a moderately concern-trollish debut in our forum, but welcome anyway! :)


First, it's sometimes difficult for students rotating through anesthesia to be able to tell the difference between difficult vs easy parts of the job, or routine vs ordinary events in the OR. Anesthesia done well often looks like we're doing nothing at all. Any hack can look busy and constantly do conspicious hero work to save the day, er, I mean, rescue themselves from self-inflicted crises. (It takes a special kind of hack to be obliviously smug and proud of those rescues.)

Are there lazy anesthesiologists out there who let the CRNAs they're "supervising" run amok? Sure. They're turds and there's not much more to say about them.

However, running multiple ORs, doing preops, blocks, PACU work, jogs over to OB for epidurals, consults, running the board and triaging add-ons, while supervising/directing CRNAs can be very difficult and intense work, depending on the case mix, patient mix, and surgeon mix.


I think between your two posts there was actually a serious question in there ... ah yes, here it is ...

How do young anesthesiologists get enough solo experience to feel comfortable doing things by themselves?
The answer to that is to
1) take a job with a good case load and variety, where you're doing your own cases
2) take a job with a good case load and variety, where you're supervising and be involved

In some cases, I'd argue that the new anesthesiologist who's supervising is getting a better-than-solo experience. More cases, more pathology, more chances for things to go wrong, especially if you've got some retread strip-mall CRNA-puppy-mill grad playing wannabe ninja assassin in room 3 while you're helping out cletus the shoulder-chippy 2-year-"veteran" know-it-all in room 5.

Patients are getting sicker, getting older, and surgeons are constantly doing new stuff and trying to do more old stuff on with less workup and shorter hospital stays. We have pulse oximetry now, but I don't believe the job is easier than it was 40 years ago, because we have CRNAs and coffee breaks too.
 
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loveumms

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I wish I had time to sit and chat, have coffee and relax.

I'm an academic anesthesia attending and when I wear a pedometer, I often hit over 10k steps a day. We typically run two rooms - mix of residents and CRNAs. When I'm not checking on my primaries, I'm doing preops, giving breaks or teaching. The other day I had only eight cases but I didn't sit down for more then 10 minutes for breakfast and 10 for lunch. I think it's incredibly naive to think that attending live the high life and there are many days where I wish I could just sit in the OR and do my own case where I didn't have to put out any fires or say the same thing over and over again.
 
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aka_tigerj

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I wish I had time to sit and chat, have coffee and relax.

I'm an academic anesthesia attending and when I wear a pedometer, I often hit over 10k steps a day. We typically run two rooms - mix of residents and CRNAs. When I'm not checking on my primaries, I'm doing preops, giving breaks or teaching. The other day I had only eight cases but I didn't sit down for more then 10 minutes for breakfast and 10 for lunch. I think it's incredibly naive to think that attending live the high life and there are many days where I wish I could just sit in the OR and do my own case where I didn't have to put out any fires or say the same thing over and over again.
Thank you. Yes, it is likely because I am a med student. I don't really know what it's like. :)
 

DreamLover

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More cases, more pathology, more chances for things to go wrong, especially if you've got some retread strip-mall CRNA-puppy-mill grad playing wannabe ninja assassin in room 3 while you're helping out cletus the shoulder-chippy 2-year-"veteran" know-it-all in room 5.
That's a great description...I've in fact supervised both of them, simultaneously
 

IlDestriero

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if you are supervising 3-4 rooms in academics then i agree with you, that is real work. a lot of institutions I have heard from my resident friends, the attendings are supervising 1 resident and 1 CRNA. Nothing makes them happier than having a room with 2 CRNAs and they don't have to do anything. preops, being present for induction/emergence is rarely the case, especially with experienced CRNAs.
We usually cover 2 rooms, rarely 3, and we perform every pre op, discuss our plan with the CRNAs/trainees, and are present for every induction and extubation, and the critical parts of the case, and of course routine checking in to see what's going on. Some days that's pretty easy, some days you're running all day and trying to make time to teach the residents and fellows.
 
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G-Man82

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A lot of the day's my iPhone step counter passes 10,000 steps when I'm in the OR and it's rare for me to find time to sit down and eat. Quite often I've only had lunch at 3 pm after a Kind bar and coffee for breakfast at 7 am. I'm trying to remedy that. Being a newly-minted attending does have its downside.
 

Urzuz

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As with most things in life, it is all about what someone wants to make of the situation. Yes, many academic attendings must log thousands of steps in a day because they are very involved in preoperative, intraoperative, and postoperative management of their patients. But we all know that there are plenty others that do absolutely nothing other than serve as a name on the chart, have no interest in teaching residents, and sit in the break room drinking coffee and chatting all day long. These attendings have reputations as such. They are happy as long as they continue collecting a paycheck at the end of the month. You don't have to be sitting in the break room constantly to realize that there is a group of individuals who will inevitably be there regardless of what time of day you walk into the room.

One other thing to keep in mind -- most ORs in an academic center will not have 4-5 cases booked in it per day due to the complexity of most surgeries performed. Based on my experience where I trained, you would have to be kidding yourself if you thought preoperative and postoperative management took up a significant portion of an attending's day (most patients were teed up already from the preop clinic, and PACU patients were managed by the PACU resident/attending). Granted this may not be the same setup at every academic center, it just made it all the more inexcusable that we had attendings at our program that would disappear for hours on the end, who you would be lucky to see twice during the days you were working with them.
 
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Docuronium

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Supervise 3 CRNAs...they will "round" on them every half hour, and will come in if they get a cell phone call. They only have meetings on Thursdays. It's so sad. How do young anesthesiologists get enough solo experience to feel comfortable doing things by themselves?
I'm curious what you'd have them do? Sit there and watch over the entire anesthetic---part of the job is also learning to let a junior member perform their own anesthetic.

And believe me, they'll get called when things start going bad---won't only come in if they get a cell phone call.
 

sleepallday

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Supervise 3 CRNAs...they will "round" on them every half hour, and will come in if they get a cell phone call. They only have meetings on Thursdays. It's so sad. How do young anesthesiologists get enough solo experience to feel comfortable doing things by themselves?
Young anesthesiologists are comfortable doing cases solo by the end of residency.
 

Mman

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At my school, they are just there for intubations/extubations/help in most cases and let the CRNAs do the rest. They go to the breakroom and chat & have coffee. The only time they do their "own" case is if they are teaching a resident. Is this true throughout the US?
When I'm supervising a CRNA, I'm only "there" for preopping the patient, induction, every 30-60 minutes during the case, emergence, and again in PACU. If everything is going well it might not look like I'm physically doing much other than perhaps starting an extra IV or a-line during induction. Then again you can't see what I'm actually doing which is processing the progress of the procedure and how the patient is doing and how the anesthetic is going and whether or not changes need to be made. Are we behind on volume? How are the narcotics given looking for wake up? Blood loss acceptable? If everything is fine, I don't have to say anything so it looks like I didn't do anything. But I'm watching. Always watching. In our system I can remotely view all the vital signs and vent settings and gas analyzer data.


To a novice it looks like I might not be doing much. But that's just because you don't know what you are looking at. It's kinda like the pilot of the plane sitting there and letting autopilot steer the plane for 8 hours over the Pacific Ocean. They don't look like they are doing anything, but I can assure you that you are glad they are there.
 

amyl

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To the OP- being a DO in anesthesiology has not shut any doors for me. That being said I wasn't an average DO student - top of the class and took usmles and did well.... It's probably slightly easier via the MD route but if you are a very good DO student doors will open for you too. I went to a DO school for personal proximity reasons at the time and it worked for me. Either route can get you where you want to go.... But be ready to put in the hard work - no slackers in my specialty ;-)
 

GA8314

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When I'm supervising a CRNA, I'm only "there" for preopping the patient, induction, every 30-60 minutes during the case, emergence, and again in PACU. If everything is going well it might not look like I'm physically doing much other than perhaps starting an extra IV or a-line during induction. Then again you can't see what I'm actually doing which is processing the progress of the procedure and how the patient is doing and how the anesthetic is going and whether or not changes need to be made. Are we behind on volume? How are the narcotics given looking for wake up? Blood loss acceptable? If everything is fine, I don't have to say anything so it looks like I didn't do anything. But I'm watching. Always watching. In our system I can remotely view all the vital signs and vent settings and gas analyzer data.


To a novice it looks like I might not be doing much. But that's just because you don't know what you are looking at. It's kinda like the pilot of the plane sitting there and letting autopilot steer the plane for 8 hours over the Pacific Ocean. They don't look like they are doing anything, but I can assure you that you are glad they are there.
Agreed. I'm supervisory with residents and CRNA's. As PPG has eluded, there are times when supervising DOES expose you to multiples more comorbidities as well as more difficulties. I'm not saying supervising is BETTER than sitting your own cases, but it's very different. There are benefits to each practice.

In an ACT model, you need to stay self-motivated and get off your a.ss. Even with residents, look up your own labs, EKG's, Echo's. They should as well, but I always know that information. It is very rare for a CRNA to have beat me to the preop punch. I am thorough. So should we ALL be.

I've come to enjoy supervising. I do a lot more procedures. Lots more difficult airway stuff, and it frees me up to do more intersting things at times. I have time to think. Again, there's no perfect practice. I'm NOT saying it's BETTER than sitting your own cases, either.

There are times when I WISH I was sitting my own cases.....lol

Stay GOOD at what you do, and relevant/current. There will always be a place for those folks (Docs, CRNA's, and AA's alike). Things will change, but the work will be there.
 

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I'm NOT saying it's BETTER than sitting your own cases, either.
I'll be so bold as to say it is definitely better to supervise than "sit your own cases." Once you get a taste of the scam of supervision, there's no going back. I could never sit in a freezing cold OR for hours on end charting vitals and listening to inane conversations. Just couldn't do it. Of course I work a lot harder, but supervising frees me up to do other things.
 
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SaltyDog

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I'll be so bold as to say it is definitely better to supervise than "sit your own cases." Once you get a taste of the scam of supervision, there's no going back. I could never sit in a freezing cold OR for hours on end charting vitals and listening to inane conversations. Just couldn't do it. Of course I work a lot harder, but supervising frees me up to do other things.
Let's not pretend it's about any other than $$$. If you got reimbursed more to sit your own cases you know your ass would be in there freezing with pen in hand, and you'd be on here saying how you couldn't be paid enough to supervise midlevels.
 
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Mman

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Let's not pretend it's about any other than $$$. If you got reimbursed more to sit your own cases you know your ass would be in there freezing with pen in hand, and you'd be on here saying how you couldn't be paid enough to supervise midlevels.
If I got paid more money to do less work in an easier job I'd obviously sign up for it.
 

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I agree that 4:1 (and probably even 3:1) is more work and certainly more hectic that doing your own cases. 2:1 seems like it'd be rather chill unless you're supervising Dipsh!ts. Doing your own cases I think is more rewarding/satisfying though.
 

Consigliere

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Let's not pretend it's about any other than $$$. If you got reimbursed more to sit your own cases you know your ass would be in there freezing with pen in hand, and you'd be on here saying how you couldn't be paid enough to supervise midlevels.
Absolutely true. Anyone who is deluding themselves otherwise is a straight up fool.
 
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Consigliere

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I agree that 4:1 (and probably even 3:1) is more work and certainly more hectic that doing your own cases. 2:1 seems like it'd be rather chill unless you're supervising Dipsh!ts. Doing your own cases I think is more rewarding/satisfying though.
Why? How long (if ever) have you been an attending?
 

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Been an attending for just over 2 years (just a baby I know). I'm still at the point where I enjoy personally delivering an anesthetic and doing it well. I realize I may not always feel this way, and I realize that due to economic pressures I will not likely sit my own cases for the duration of my career so I hope those 2 things dovetail nicely at some point. You can't tell me though that you get the same professional satisfaction out of being a chart monkey as you would doing you own case (take your bank statement out of the equation for a minute).
 

criticalelement

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When supervising you have to be more things to more people. You have to be extremely skilled and savvy. Your skill level has to be higher I think. You have to know when the crna needs help before he/she needs it. You have to know when to intervene on an airway/line. You have to read minds. Give timely breaks, You have to make people do things that you want them to do and make them think they thought of it. Once in a while you have to turn the tables around on the surgeons without them even knowing. You have to do these things on every single case x 4 rooms all while establishing rapport with everyone in the room. On top of that you have to know every single patient and which ones are going to try to end your career. On top of that you have to appear humble.. It is a complete mind fu ck.. BUt when you have mastered the psychological gymnastics that is inherent in the job of supervising, you have arrived. It is hard, thats why most people are bad at it.

Much easier to just sit in the room with one thumb up your a s s and one hand down your pants half asleep listening to beep beep beep beep beep beep beep beep beep all fuc k ing case.
 
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The problem is not supervision. The problem is greed. Anybody could provide safe anesthesia with two rooms running, even with mediocre CRNAs, but no, we do 3 or more. That's like taking care of 5 times more ICU patients: just a subpar quality race to the end of shift.

No truly good doc will enjoy this. Too many balls in the air increase the chances that one won't be caught in time, sooner or later. It's just assembly lane and shift mentality, not quality care. But, hey, we're producing all that profit, so it must be good medicine, right?

Much better to sit in a room and think about how I could improve the care of this patient, or the next, or the one after that, or just read stuff to improve the care of the next thousand. Great docs are not the ones who just do, do, do, but mostly the ones who read, read, read, do, read more. Otherwise one just ends up being like an old CRNA, all monkey skills and experience, pretty much a one/few trick-pony.

I am sorry, but I will never believe that quality of care can happen with 3:1 supervision, except with very long cases, or very good midlevels (at which point it's basically independent practice with a firefighter preop monkey doc as resource).
 
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physicsnerd42

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At my institution, attendings cover up to 2 residents/fellows (we basically have no CRNAs). We have many more rooms running than residents available so most attendings also do their own cases on days they don't have a resident. Some attendings mostly do solo cases and some almost always have a resident or two but most split their time between covering and solo (and research, running the board, administration, etc.).
 

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There you go. Talk to me when you've been doing this for 10 years or more. You're still in your honeymoon phase.
And you're already in the "let's make as much money as we can, and then get out of this business" phase. Not that I disagree... :)

As an employee, I couldn't give a f*ck that my employer rakes in the dough for working my butt off in 3 rooms. What's this, residency for life? Work 10-12 intense hours/day, then go home and sleep, then start again in the morning, while waiting for the weekend?

For the first time in years, I actually look forward to going to work. CCM can be intense, but nothing like anesthesia in a profit-/surgeon-focused setting. I have way more input (as a fellow) in the care of each of my 10 ICU patients than my 3 OR patients (as an attending).
 
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What's your point?
My point is that supervision is enjoyable nowadays mostly just to people who make a lot of money out of it. When supervision vs solo means that my personal business makes 50% more profit, and I can hire and fire my own CRNAs, and even have a better lifestyle, it's a no-brainer.
 
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Urzuz

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When supervising you have to be more things to more people. You have to be extremely skilled and savvy. Your skill level has to be higher I think. You have to know when the crna needs help before he/she needs it. You have to know when to intervene on an airway/line. You have to read minds. Give timely breaks, You have to make people do things that you want them to do and make them think they thought of it. Once in a while you have to turn the tables around on the surgeons without them even knowing. You have to do these things on every single case x 4 rooms all while establishing rapport with everyone in the room. On top of that you have to know every single patient and which ones are going to try to end your career. On top of that you have to appear humble.. It is a complete mind fu ck.. BUt when you have mastered the psychological gymnastics that is inherent in the job of supervising, you have arrived. It is hard, thats why most people are bad at it.

Much easier to just sit in the room with one thumb up your a s s and one hand down your pants half asleep listening to beep beep beep beep beep beep beep beep beep all fuc k ing case.
Are you practicing psychiatry or anesthesiology?
 

criticalelement

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And you're already in the "let's make as much money as we can, and then get out of this business" phase. Not that I disagree... :)

As an employee, I couldn't give a f*ck that my employer rakes in the dough for working my butt off in 3 rooms. What's this, residency for life? Work 10-12 intense hours/day, then go home and sleep, then start again in the morning, while waiting for the weekend?

For the first time in years, I actually look forward to going to work. CCM can be intense, but nothing like anesthesia in a profit-/surgeon-focused setting. I have way more input (as a fellow) in the care of each of my 10 ICU patients than my 3 OR patients (as an attending).
you are a icu fellow?
 
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criticalelement

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. I have way more input (as a fellow) in the care of each of my 10 ICU patients than my 3 OR patients (as an attending).
There usually isnt too much debate on WHAT to do for an anesthetic is there? We dont spend too much time scratching our heads trying to figure out what is going on. We know what's going on and we know what to do. The question is how well is said plan going to be carried out. Spinal vs GA Lma vs tube 1 liter vs 1.5liter of fluid extubate deep or awake. these are not issues that keep me up at night.
 
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Mman

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There usually isnt too much debate on WHAT to do for an anesthetic is there? We dont spend too much time scratching our heads trying to figure out what is going on. We know what's going on and we know what to do. The question is how well is said plan going to be carried out. Spinal vs GA Lma vs tube 1 liter vs 1.5liter of fluid extubate deep or awake. these are not issues that keep me up at night.
There isn't much debate about what to do for an ICU patient either. Feed them, antibiotics, fluids, pulmonary toilet, etc.
 

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There usually isnt too much debate on WHAT to do for an anesthetic is there? We dont spend too much time scratching our heads trying to figure out what is going on. We know what's going on and we know what to do. The question is how well is said plan going to be carried out. Spinal vs GA Lma vs tube 1 liter vs 1.5liter of fluid extubate deep or awake. these are not issues that keep me up at night.
Exactly.

In my previous job, if a CRNA did not follow my plan, intentionally, nothing happened (to her, if I bothered to report it, and hence be labeled as difficult by my own management). If she refused to do a case that I had approved, or refused my plan, nothing happened. If s/he downright mismanaged my patient intraop, without letting me know what was going on, nothing happened. And I bet I am by far not the only one who can report such experiences, on top of the practice being tailored to keeping CRNAs happy.

On the other hand I can see how a well-oiled group of smart people can make supervision enjoyable. I just think it's rare.
 
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FFP

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There isn't much debate about what to do for an ICU patient either. Feed them, antibiotics, fluids, pulmonary toilet, etc.
Is there a CCM vs anesthesia cartoon? :D

Which reminds me of:
 

vector2

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Sweet jesus, that video above ended with a link to this "independent" CRNA addressing a group of pre-health students at UC Davis about anesthesia...there are no words

 

FFP

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Sweet jesus, that video above ended with a link to this "independent" CRNA addressing a group of pre-health students at UC Davis about anesthesia...there are no words

I'm glad you didn't miss that. ;)

First posted by @BLADEMDA, if I remember well.
 
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Mman

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Exactly.

In my previous job, if a CRNA did not follow my plan, intentionally, nothing happened (to her, if I bothered to report it, and hence be labeled as difficult by my own management). If she refused to do a case that I had approved, or refused my plan, nothing happened. If s/he downright mismanaged my patient intraop, without letting me know what was going on, nothing happened. And I bet I am by far not the only one who can report such experiences, on top of the practice being tailored to keeping CRNAs happy.

On the other hand I can see how a well-oiled group of smart people can make supervision enjoyable. I just think it's rare.
Any supervision situation where the CRNAs don't work for the MDs is bound to fail. Just the way it is. When their financial incentive is aligned with the medical direction things run extremely smoothly.
 
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GA8314

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Any supervision situation where the CRNAs don't work for the MDs is bound to fail. Just the way it is. When their financial incentive is aligned with the medical direction things run extremely smoothly.
Totally agree. It's made all the difference in my PP job versus when I was a resident and the CRNA's were employed by the hospital.

Also, for the record, nobody should feel there is ONE best way to practice. If you do solo cases, then that's GREAT. Enjoy the benefits, realize there are drawbacks, and keep taking pride in your field. For those in ACT models, I say the same thing.
 
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DreamLover

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Totally agree. It's made all the difference in my PP job versus when I was a resident and the CRNA's were employed by the hospital.

Also, for the record, nobody should feel there is ONE best way to practice. If you do solo cases, then that's GREAT. Enjoy the benefits, realize there are drawbacks, and keep taking pride in your field. For those in ACT models, I say the same thing.
I agree. The last things we need to do is pick each other apart within our profession. Adaptability is one of the common cores we must demonstrate to become board certified.

There are pros and cons to both situations. There are personal preferences for one over another. No matter why you are in one practice model or another, we all have the same goal: excellent patient care.

I believe the best way to achieve that is via physician anesthesiologist care. Whether it is provided in an ACT or solo model, the physician is ultimately responsible for the success of a good anesthetic.

We battle constant antagonism from midlevel practitioners. I see no good place for it among each other. It seems kind of silly.
 
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