On-call staffing with residents/CRNAs

[psychbender]

Another issue with this is that these big cases have sometimes been assigned to CRNAs because the CA2 is stuck in said PEG tube when the trauma rolls in (and the CRNAs/SRNAs want to do these big cases as well).

This is the real problem, and likely the second reason the CRNAs are complaining (after wanting to get paid immensely for doing less work). If you start throwing the CA2 into ditzel cases between larger ones, you're committing an asset prematurely, so it is no longer available when it's designated task actually rolls in. This is a lesson in basic triage/resource management. Hold some assets in reserve for the big emergencies, and utilize the shift workers for the bulk of the night work. That is, literally, what they are there for.


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[Psai]

Thanks everyone for your input. Its clear that I should have provided more context.

On a given night, there are usually at least 1-2 'big cases' (traumas, septic ICU patients, kids, etc), so it's not like the CA2s are sleeping the entire time. It's more like they're getting a 2-3 hour break between cases.

The question boils down to: should they be put in a PEG tube at 3 AM after doing a trauma because it's 'their turn' again? Often times two other cases will have started and finished before a long case is finished, so after finishing a big one, you're up again. This is what the CRNAs are pushing for.

Another issue with this is that these big cases have sometimes been assigned to CRNAs because the CA2 is stuck in said PEG tube when the trauma rolls in (and the CRNAs/SRNAs want to do these big cases as well).

There is no such thing as turns. They are there to support residents. They are there to relieve the residents for big cases and that means starting or finishing the routine ones.

Big cases should never go to crnas if there are residents there. And leadership shouldn't be promoting this idea of equivalence between nurses and residents because there is none. It's not a round robin, they are support staff.

 

[GravelRider]

This sounds more like a case of whiney CRNAs as opposed to whiney residents. The issue here boils down to CRNAs continuing to try to blur the lines and be seen as equals. It’s also human nature to want to get paid more for less work.

It sounds like your place is busy enough to support keeping residents in reserve for higher acuity cases. I had a similar setup in residency. I rarely did a lap chole at night, but I also rarely slept. It would be a shame for the resident to miss the trauma or ruptured aneurysm case just so they maintain their spot in the “rotation.” There is no rotation with CRNAs, period. If the triaging attending or CA3 sees an educational opportunity with the 20yr old appy then call the resident. Otherwise let them rest for the crani that is sure to roll through the door. I don’t blame the CRNAs for trying, but I would actually take it a step further and formalize a policy for roles at night.

 

[deleted162650]

This, ladies and gentlemen, is why you shouldn't go to a residency program with an SRNA program.

 

[Psai]

This, ladies and gentlemen, is why you shouldn't go to a residency program with an SRNA program.

Yeah that's why I didn't want to go to the Brigham. Because they have srnas.

 

[dchz]

This, ladies and gentlemen, is why you shouldn't go to a residency program with an SRNA program.

What if the SRNA program is 2nd to none? Like I don't have to worry about putting in central lines ever because the CRNA will do it for me.

 

[deleted162650]

What if the SRNA program is 2nd to none? Like I don't have to worry about putting in central lines ever because the CRNA will do it for me.

Well that's different. I guess I should have been more specific.

 

[Ronin786]

I went to a program where the residents did all the work. We never had the luxury of CRNAs overnight.

However, the program in question clearly has that luxury. I wholeheartedly disagree with anybody saying that doing the 3AM lap chole is a badge of honor or that it should be considered educational. The CRNAs are there as a shift worker. They're not there to sleep. Any non-senior level case should go to them even if it means they're working all night long. This sort of complaining needs to be stamped out. The residents are there to learn, not to work for the sake of working. There should be clear cut rules as to what is considered educational and what is not, with the understanding that overflow needs to be taken care of regardless.

 

[Mman]

This sounds more like a case of whiney CRNAs as opposed to whiney residents. The issue here boils down to CRNAs continuing to try to blur the lines and be seen as equals. It’s also human nature to want to get paid more for less work.

It sounds like your place is busy enough to support keeping residents in reserve for higher acuity cases. I had a similar setup in residency. I rarely did a lap chole at night, but I also rarely slept. It would be a shame for the resident to miss the trauma or ruptured aneurysm case just so they maintain their spot in the “rotation.” There is no rotation with CRNAs, period. If the triaging attending or CA3 sees an educational opportunity with the 20yr old appy then call the resident. Otherwise let them rest for the crani that is sure to roll through the door. I don’t blame the CRNAs for trying, but I would actually take it a step further and formalize a policy for roles at night.

See we had a rotation at night and it didn't prevent a resident from ever doing a great case. Why? Because if the resident was doing the lap appy and a AAA got posted, then the CRNA took over the lap appy and the resident went and did the AAA. But having the resident sleep just in case a "real" case comes in is pretty stupid IMHO.

 

[GravelRider]

See we had a rotation at night and it didn't prevent a resident from ever doing a great case. Why? Because if the resident was doing the lap appy and a AAA got posted, then the CRNA took over the lap appy and the resident went and did the AAA. But having the resident sleep just in case a "real" case comes in is pretty stupid IMHO.

Paying a CRNA to sleep is also pretty stupid IMHO.

 

[Ronin786]

See we had a rotation at night and it didn't prevent a resident from ever doing a great case. Why? Because if the resident was doing the lap appy and a AAA got posted, then the CRNA took over the lap appy and the resident went and did the AAA. But having the resident sleep just in case a "real" case comes in is pretty stupid IMHO.

How is that stupid?

This is the problem with a lot of academic centers. Residents shouldn't be cheap labor you use to get your cases done. If it's a real case with educational value, put the resident in there. If it's a BS case, put the CRNA who is getting paid a lot more and is on a night float system in there. It's what the CRNAs are there for.

Spineless academic centers though are so afraid of angering their precious CRNAs and would rather abuse their residents who have nowhere else to go.

 

[Mman]

How is that stupid?

This is the problem with a lot of academic centers. Residents shouldn't be cheap labor you use to get your cases done. If it's a real case with educational value, put the resident in there. If it's a BS case, put the CRNA who is getting paid a lot more and is on a night float system in there. It's what the CRNAs are there for.

Spineless academic centers though are so afraid of angering their precious CRNAs and would rather abuse their residents who have nowhere else to go.

Because learning how to work while tired and stressed is valuable. Residents these days have pretty strict work hour limits. Complaining that it is too tough and they shouldn't have to do boring cases at night when they are tired is whiny to me. It has literally nothing to do with CRNAs. It's principle. You are either there to work/learn or you aren't. Every case is a learning opportunity. Man (or woman) up and do it.

When I'm working overnight as an attending and get a BS case I don't get to say it's too boring and roll over and go back to bed.

 

[psychbender]

See we had a rotation at night and it didn't prevent a resident from ever doing a great case. Why? Because if the resident was doing the lap appy and a AAA got posted, then the CRNA took over the lap appy and the resident went and did the AAA. But having the resident sleep just in case a "real" case comes in is pretty stupid IMHO.

It depends on how frequently big cases come in the middle of the night. If one can realistically expect to be up all night doing these cases, then it's not unreasonable to hold the CA2 in reserve, awaiting the transplant, big trauma, or aortic dissection to come in. If those things are rare, and the CRNAs will actually listen and get the resident out to do the better case, then there's less of a reason to have the CA2 kept out of the OR as a 'just in case.' Although, if they're not that common, then I find it hard to understand why the hospital is even paying a CRNA to be in-house overnight.

My residency was resident and attending only overnight, so we did all of the cases. My only complaint at the time was that the 3-11pm staff would cry if they weren't being relieved by the call team (who had been in house all day) by 6pm, so they could go home. Getting dinner and signout from the Acute Pain resident (routinely had a 30+ pt list we managed that kept you up most nights), who was waiting to leave until the ORs started to die down, was apparently a secondary concern to getting out the people who were being paid to be there for eight hours in the evening.

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[Shimmy8]

I do 24 hour shifts q3-4 days when I’m on. I can definitely be up all night. It is 10000% a mental and physical skill to be able to function efficiently and safely with little sleep.

I’m not saying if there’s a CRNA there and ready they shouldn’t do any cases, as it’s a complicated issue, but it’s nonsense there’s no value to the residents to do the BS cases.

On the other hand, of course, residents also have academic and didactic and research responsibilities so a night of sleep on call was always a blessing. But it’s got to be a balance of some kind. Hard to have a “right” answer IMO.

 

[Ronin786]

Because learning how to work while tired and stressed is valuable. Residents these days have pretty strict work hour limits. Complaining that it is too tough and they shouldn't have to do boring cases at night when they are tired is whiny to me. It has literally nothing to do with CRNAs. It's principle. You are either there to work/learn or you aren't. Every case is a learning opportunity. Man (or woman) up and do it.

When I'm working overnight as an attending and get a BS case I don't get to say it's too boring and roll over and go back to bed.

That's bull****. It's the problem with seemingly most academic centers across all residencies. As if being on-call for 24 hours straight, 5-7 times a month doesn't teach you enough about doing work. Or working 80 hour weeks regularly. Or sacrificing your time with your family to get the ORs finished. But sure, the 3AM lap appy or incarcerated hernia is what's really holding back residents from knowing how to do hard work.

Medical students and residents have literally spent hundreds of thousands of dollars trying to become physicians. Yet there's this antiquated idea that they need to buy into the privilege of sacrificing themselves to prove something. Guess what, you can graduate competent residents without working them to death in bull**** cases.

There's a giant difference between working and learning. Residents should be learners. Especially if you have the resources to ensure that. As I said before, I went to a residency where I did the majority of the work. As a CA-3 I was lucky if I saw an attending all day long. I did the work and didn't complain, but the prevalence of this attitude that residents are there to do labor is pervasive across all medical specialties and is especially sickening.

 

[anbuitachi]

I do 24 hour shifts q3-4 days when I’m on. I can definitely be up all night. It is 10000% a mental and physical skill to be able to function efficiently and safely with little sleep.

I’m not saying if there’s a CRNA there and ready they shouldn’t do any cases, as it’s a complicated issue, but it’s nonsense there’s no value to the residents to do the BS cases.

On the other hand, of course, residents also have academic and didactic and research responsibilities so a night of sleep on call was always a blessing. But it’s got to be a balance of some kind. Hard to have a “right” answer IMO.

there are literally studies showing working sleep deprived is similar to working while under influence of alcohol. i know many people on here are super anesthesiologists and can do everything efficiently and safely with little sleep. 24 hours is nothing, im sure many people here can spend a week without sleep and still do great.

 

[deleted162650]

there are literally studies showing working sleep deprived is similar to working while under influence of alcohol

If you can't do the job buzzed, you shouldn't be doing it.

 

[Psai]

If you can't do the job buzzed, you shouldn't be doing it.

This is basically my motto

 

[anbuitachi]

If you can't do the job buzzed, you shouldn't be doing it.

i am 100% confident i can do the job drunk and high

 

[Mr.S]

The residents are there to learn, not to work for the sake of working. There should be clear cut rules as to what is considered educational and what is not, with the understanding that overflow needs to be taken care of regardless.

Hint! Hint!
1) In my opinion, every case you do in residency is a learning case. I dont care how big or small you deem it to be as a resident. Period.

You want rules: read previous sentence.
In other words, every single case is a learning case. You dont get to decline cases. Who are you?

 

[anbuitachi]

Hint! Hint!
1) In my opinion, every case you do in residency is a learning case. I dont care how big or small you deem it to be as a resident. Period.

You want rules: read previous sentence.
In other words, every single case is a learning case.

well actually every case is a learning case for attendings as well. just do all cases

but anyway, seriously, every case CAN be a learning case. doesn't mean it will be or was a learning case. i can 100% safely say i learned NOTHING from the last 10 cataracts i did

 

[Mman]

That's bull****. It's the problem with seemingly most academic centers across all residencies. As if being on-call for 24 hours straight, 5-7 times a month doesn't teach you enough about doing work. Or working 80 hour weeks regularly. Or sacrificing your time with your family to get the ORs finished. But sure, the 3AM lap appy or incarcerated hernia is what's really holding back residents from knowing how to do hard work.

Medical students and residents have literally spent hundreds of thousands of dollars trying to become physicians. Yet there's this antiquated idea that they need to buy into the privilege of sacrificing themselves to prove something. Guess what, you can graduate competent residents without working them to death in bull**** cases.

There's a giant difference between working and learning. Residents should be learners. Especially if you have the resources to ensure that. As I said before, I went to a residency where I did the majority of the work. As a CA-3 I was lucky if I saw an attending all day long. I did the work and didn't complain, but the prevalence of this attitude that residents are there to do labor is pervasive across all medical specialties and is especially sickening.

I worked about 60 hours per week as a resident. I never exceeded 24 straight hours. I rarely ever exceeded 15 hours straight (yay for night float). And I did all kinds of BS cases in the middle of the night as a junior resident flipping with the CRNA that was there. If somebody whines about not sleeping while at work, they wouldn't fit in at a strong residency program. And if they don't like it I'd wish them luck in the real world for the next 30 years.

 

[dchz]

i can 100% safely say i learned NOTHING from the last 10 cataracts i did

You SHOULD be learning how to talk the ophthalmologist into letting you do the retrobulbar blocks...

 

[Southpaw]

I rarely if ever worked 80 during residency. No CRNAs to help at night or weekends. I look back on those days as some of the best years of my life. Definitely some entitlement issues in this thread.

 

[anbuitachi]

I worked about 60 hours per week as a resident. I never exceeded 24 straight hours. I rarely ever exceeded 15 hours straight (yay for night float). And I did all kinds of BS cases in the middle of the night as a junior resident flipping with the CRNA that was there. If somebody whines about not sleeping while at work, they wouldn't fit in at a strong residency program. And if they don't like it I'd wish them luck in the real world for the next 30 years.

wow that's a real chill residency

 

[MoMoGesiologist]

Every case is a learning opportunity. For example, when a lap apply comes in and the CRNA tells you you're gonna do it while they sleep, you learned who's your real boss. Now stop complaining and be a "real doctor"!

 

[GravelRider]

First of all, no CRNA should have a say in how residents are educated. This is being driven by CRNA whining, not resident whining. If the education committee decides resident experience is lacking in some way then fine, but that’s not what is happening here. Allowing CRNAs to get a say in how attendings choose to triage cases is wrong no matter what. What’s next? The SRNA is in the “rotation” for the big heart cases or in the “rotation” for the blocks? There’s no rotation with CRNAs and CRNAs don’t get a say in how residents are trained. Period. End of discussion.

 

[Mr.S]

but anyway, seriously, every case CAN be a learning case. doesn't mean it will be or was a learning case. i can 100% safely say i learned NOTHING from the last 10 cataracts i did

Lots of bad things can happen in a cataract.
didnt they do a block ? If they did, talk the patient through it or give medication. Monitor for Oculo cardiac reflex.
ease the patients anxiety via verbal anesthesia.
Establish rapport with the staff, and surgeons,

make sure the patient is comfortable.
work on your speed.
etc etc etc..
Lots of things. Look for them.
and it is NOT uncommon to convert to ga. Not common either. But you cant convert if you are not even there.
every case is a learning case. Look for the learning opportunity.

I hate to sound haughty.. I am as lazy as the rest of them.. but in retrospect this is what ive learned.

 

[anbuitachi]

Lots of bad things can happen in a cataract.
didnt they do a block ? If they did, talk the patient through it or give medication. Monitor for Oculo cardiac reflex.
ease the patients anxiety via verbal anesthesia.
Establish rapport with the staff, and surgeons,

make sure the patient is comfortable.
work on your speed.
etc etc etc..
Lots of things. Look for them.
and it is NOT uncommon to convert to ga. Not common either. But you cant convert if you are not even there.
every case is a learning case. Look for the learning opportunity.

I hate to sound haughty.. I am as lazy as the rest of them.. but in retrospect this is what ive learned.

Like i said , every case CAN be a learning case. most of those apply for maybe your FIRST couple cataracts. i guess i could have turned those into learning cases. instead of bolusing prop or giving fent/midaz for their block, i couldve bolused ketamine and see how that goes. maybe id learn something.

We monitor for OCR for every cataract. if it didn't happen... did you learn something from it not happening?

 

[dhb]

i learned NOTHING from the last 10 cataracts i did

That's because you don't do bad as.s cataracts.

Ps: i did my fist eye blocks last month

 

[jwk]

That's because you don't do bad as.s cataracts.

Ps: i did my fist eye blocks last month

That's a whole different thread t0 discuss . Why would anyone want to be doing eye blocks for the ophthalmologist in this day and age?

 

[anbuitachi]

That's a whole different thread t0 discuss . Why would anyone want to be doing eye blocks for the ophthalmologist in this day and age?

That's because you don't do bad as.s cataracts.

Ps: i did my fist eye blocks last month

sounded like dhb just punched the patient in the eye and blocked it

 

[deleted171991]

(This is the kind of thread that pisses me off enough to post. So here goes my rant about cases with "low or no educational value", possibly off-topic.)

To the Millennials: stop whining! You are already the most pampered generation in history, and pampering means (by definition) less learning. Accordingly, you are probably the weakest generation in a long time. Our surgeons complain that their recent Ivy League grad new hires can't function as independent attendings, especially in case of unexpected complications. We see bad judgment all the time from "top program" CA-3 residents, even about things that one would call common sense (newsflash: it's not common). There is SO MUCH to learn, SO MUCH to see, especially in anesthesia where every GOOD attending should know many different ways to skin the cat.

Most of quality learning happens during stressful situations. Your tendency to avoid anything uncomfortable ("safe spaces", "hurting feelings", only doing cases with "educational value", and other BS) hurts your education BIG TIME. You will learn the most when you are tired, stressed, working with unpleasant or incompetent attendings, rushed etc., because that's when mistakes and complications happen, and also that's when the strongest memories develop. You need to be pushed outside of your comfort zone to learn and to grow. If your program doesn't (because they are afraid of your sensitive skins), do it yourselves. Volunteer for that case when you are so tired you can barely think, even if it's "just" a lap appy. Trust me, your adrenaline will kick in and you will learn something extremely valuable: how to do a case after not having slept for 24 hours. You think you won't have insomnia as attendings? Or that you will never have to stay/round post-call? You think you will have the luxury to just call in sick? You won't last 6 months in your PP jobs with this mentality. NOW is the time to learn how to face all the demons, while you still have the safety net.

When one of my residents has a crappy night-call in the ICU, I always tell them to appreciate that. As an attending, you will NEVER regret having been exposed to stuff during residency, and badness has a tendency to happen after "business hours". A lot of the art of medicine is based on deja vu, that's why your attendings run circles around you, even as CA-3s with senioritis. During residency, you'll want to be the black cloud who's known as the **** magnet. When you're an attending, and there is nobody else to hold your hand and tell you "everything will be fine, mommy is here", you will fall back onto your residency EXPERIENCE. Not knowledge, EXPERIENCE. And experience in anesthesia is gained in an unpredictable fashion, the same way the brownie hits the fan. EVERY case has educational value, even if nothing bad happens. Why? Because every single hour of practice makes you a better anesthesiologist. Decades from now, you will still learn something new every week (if you're a good doctor). And, as I said, you cannot predict when a learning experience will happen, but you can be damn sure it won't if you're not there.

If you're wise, you will want to maximize your learning during residency. That means working as much as you can physically resist, with the meanest mofos you have in your department, with the worst equipment, the laziest techs, at the most inconvenient hours, you name it. During your training years, everything that doesn't kill you will make you stronger, and the deeper the pool of **** you climb out from, the more you will have learned. You will NOT remember the cushy afternoon tea called "conference", regardless what world class genius is teaching it. It's worthless. Medical knowledge comes mostly from self-education; any CRNA can read the same books, learn the same monkey skills, but where you can beat them is stamina, both in gaining knowledge (read MEDICINE at least for one hour EVERY DAY) and experience (aka DEJA VU).

As anesthesiology residents, IF YOU'RE NOT IN THE OR, YOU'RE WASTING YOUR TIME! Find the meanest and best arsehole in your department (preferably one with PP experience) and learn everything you can from him/her, even if it's a lap appy at 3 AM. (It's up to you to convince your airway expert attending to let you intubate that Mallampati 1 with a fiberoptic, or do a case under epidural if he's a regional guy etc.) These are the guys whose teachings you will remember, because the memory is coupled with a strong feeling of discomfort. Every attending/program who's treating you like a precious Faberge egg (which is slowly becoming the norm) is doing you a disservice.

You can sleep when you're attendings. You're welcome, babies. I wish somebody had told me all this back when I used to whine about my lack of sleep.

 

[anbuitachi]

(This is the kind of thread that pisses me off enough to post.)

To the Millennials: stop whining! You are already the most pampered generation in history, and pampering means (by definition) less learning. Accordingly, you are probably the weakest generation in a long time. Our surgeons complain that their recent Ivy League grad new hires can't function as independent attendings, especially in case of unexpected complications. We see bad judgment all the time from "top 10 program" CA-3 residents. There is SO MUCH to learn, SO MUCH to see.

Most of quality learning happens during stressful situations. Your tendency to avoid anything uncomfortable ("safe spaces", "hurting feelings", only doing cases with "educational value", and other BS) hurts your education BIG TIME. You will learn the most when you are tired, stressed, working with unpleasant (but competent) attendings, rushed etc., because that's when mistakes and complications happen, and also that's when the strongest memories develop. You need to be pushed outside of your comfort zone to learn and to grow. If your program doesn't (because they are afraid of your sensitive skins), do it yourselves. Volunteer for that case when you are so tired you can barely think, even if it's "just" a lap appy. Trust me, your adrenaline will kick in and you will learn something extremely valuable: how to do a case after not having slept for 24 hours. You think you won't have insomnia as attendings? Or that you will never have to stay/round post-call? You think you will have the luxury to just call in sick? You won't last 6 months in your PP jobs with this mentality. NOW is the time to learn how to face all the demons, while you still have the safety net.

When one of my residents has a crappy night-call in the ICU, I always tell them to appreciate that. As an attending, you will NEVER regret having been exposed to stuff during residency, and badness has a tendency to happen after "business hours". A lot of the art of medicine is based on deja vu, that's why your attendings run circles around you, even as CA-3s with senioritis. During residency, you'll want to be the black cloud who's known as the **** magnet. When you're an attending, and there is nobody else to hold your hand and tell you "everything will be fine, mommy is here", you will fall back onto your residency EXPERIENCE. Not knowledge, EXPERIENCE. And experience in anesthesia is gained in an unpredictable fashion, the same way the brownie hits the fan. EVERY case has educational value, even if nothing bad happens. Why? Because every single hour of practice makes you a better anesthesiologist. Decades from now, you will still learn something new every week (if you're a good doctor). And, as I said, you cannot predict when a learning experience will happen, but you can be damn sure it won't if you're not there.

If you're wise, you will want to maximize your learning during residency. That means working as much as you can physically resist, with the meanest mofos you have in your department, with the worst equipment, the laziest techs, at the most inconvenient hours, you name it. During your training years, everything that doesn't kill you will make you stronger, and the deeper the pool of **** you climb out from, the more you have learned. You will NOT remember the cushy afternoon tea called "conference", regardless what world class genius is teaching it. It's worthless. Medical knowledge comes mostly from self-education; any CRNA can read the same books, learn the same monkey skills, but where you can beat them is stamina, both in gaining knowledge (read MEDICINE at least for one hour EVERY DAY) and experience (aka DEJA VU).

As anesthesiology residents, IF YOU'RE NOT IN THE OR, YOU'RE WASTING YOUR TIME! Find the meanest and best arsehole in your department and learn everything you can from him/her, even if it's a lap appy at 3 AM. (It's up to you to convince your airway expert attending to let you intubate that Mallampati 1 with a fiberoptic, or do a case under epidural if he's a regional guy etc.) These are the guys whose teachings you will remember, especially if the memory is coupled with a strong feeling of discomfort. You will be surprised how much you can learn just by watching them help you (btw, you will be stealing tricks from your partners all your life).

You can sleep when you're attendings. You're welcome, babies.

Funny because here the young attendings are the good ones, and the old ones are the ones that dont remember how to do stuff. Your group should stop hiring from those ivy league institutions if they've had such a bad experience. Or perhaps the older attendings are doing a bad job at educating =)

I think you seriously got it wrong for your second point. We are doctors who take care of patients in the OR, and keep them safe. that is literally our #1 job. we SHOULD be doing things in a safe environment not put ourselves in a dangerous environment so complications can happen so we can learn better by forming a stronger memory. we should NOT be putting patients at risk for the sake of our learning. it's like what i mentioned about the ED. things fall thru the cracks and poor care gets delivered due to short staffing of the ED, etc. it doesn't mean the department should keep the ED short staffed for the purpose of their learning. Yes attendings dont have work hour restrictions, but if your PP is making you work 85 hours in a row or constantly rushing you so they can make some extra money, while increasing the risk of complications, i cant say for other people but i wouldnt want to work for a PP like that in the first place. If i were the patient, i would NOT want my anesthesiologist to be someone who just did a 24 hour shift, or is rushed, tired or stressed.

 

[deleted171991]

Funny because here the young attendings are the good ones, and the old ones are the ones that dont remember how to do stuff. Your group should stop hiring from those ivy league institutions if they've had such a bad experience. Or perhaps the older attendings are doing a bad job at educating =)

I think you seriously got it wrong for your second point. We are doctors who take care of patients in the OR, and keep them safe. that is literally our #1 job. we SHOULD be doing things in a safe environment not put ourselves in a dangerous environment so complications can happen so we can learn better by forming a stronger memory. we should NOT be putting patients at risk for the sake of our learning. it's like what i mentioned about the ED. things fall thru the cracks and poor care gets delivered due to short staffing of the ED, etc. it doesn't mean the department should keep the ED short staffed for the purpose of their learning. Yes attendings dont have work hour restrictions, but if your PP is making you work 85 hours in a row or constantly rushing you so they can make some extra money, while increasing the risk of complications, i cant say for other people but i wouldnt want to work for a PP like that in the first place. If i were the patient, i would NOT want my anesthesiologist to be someone who just did a 24 hour shift, or is rushed, tired or stressed.

Because, in the real world, everybody is the most rested and competent person who could do the case, and the best interests of the patient come first, second and third. And the patients themselves would want only doctors who have never done a case in an "unsafe" situation during their training.

It's not your job, as residents, to worry about "patient safety"; that one belongs to the attending. Your job is to worry about your education. Let me put it this way: SEAL training doesn't have duty hour limits.

I completely agree that, in an ideal world, we should all work 3 shifts, and be as rested as possible. But that's not what one should train for.

 

[anbuitachi]

Because, in the real world, everybody is the most rested and competent person who could do the case, and the best interests of the patient come first, second and third.

It's not your job, as residents, to worry about "patient safety"; that one belongs to the attending. Your job is to worry about your education. One doesn't become a SEAL by playing it safe.

it may not always happen, but we try to be, but i'm at an academic center so its not 100% money focused. but that's different from hey i'm tired as hell, i can barely think, havent slept in days, let me do some more cases so i can learn something from my complications..

the good thing about being an attending is getting much more of a choice of what type of environment to work in.

 

[deleted171991]

it may not always happen, but we try to be, but i'm at an academic center so its not 100% money focused. but that's different from hey i'm tired as hell, i can barely think, havent slept in days, let me do some more cases so i can learn something from my complications..

That's not what I meant. Obviously, if one is that tired, one should recuse oneself, if possible. First do no harm (to the patient).

What I meant is that there is a silver lining even when one HAS TO do a case after almost 24 hours of work, especially when there is help around and a safety net (i.e. a CRNA that can be woken up to take over from the exhausted resident). Training is for pushing one's limits (you'd be surprised what adrenaline does to people - hence they give amphetamines to pilots in wars), and it's ONLY 3 years (I am not being sarcastic). One gets to be an anesthesiology resident only once.

The more healthcare becomes an assembly lane-business, the more tired and burned out physicians will be. This is the "patient safety" environment you are training for, I am sorry to say.

I have seen many places which educate attendings in mindfulness (to avoid burnout), and sleep deprivation management, but I still have to encounter one which offers part-time jobs (or other real solutions) to fix all that. Money is king, and bureaucracy its queen.

 

[244913]

If you're paying night shift workers- crna's- beaucoup bucks to work...then work them long and hard and put them away wet.

For residents, the night shift is hour 16-24 of a call in which they are making less than minimum wage.

Maybe programs could get rid of crna's for these "shifts" and pay OT to the residents

 

[GravelRider]

(This is the kind of thread that pisses me off enough to post.)

To the Millennials: stop whining! You are already the most pampered generation in history, and pampering means (by definition) less learning. Accordingly, you are probably the weakest generation in a long time. Our surgeons complain that their recent Ivy League grad new hires can't function as independent attendings, especially in case of unexpected complications. We see bad judgment all the time from "top 10 program" CA-3 residents, even about things that one would call common sense (newsflash: it's not common). There is SO MUCH to learn, SO MUCH to see, especially in anesthesia where every GOOD attending should know many different ways to skin the cat.

Most of quality learning happens during stressful situations. Your tendency to avoid anything uncomfortable ("safe spaces", "hurting feelings", only doing cases with "educational value", and other BS) hurts your education BIG TIME. You will learn the most when you are tired, stressed, working with unpleasant or incompetent attendings, rushed etc., because that's when mistakes and complications happen, and also that's when the strongest memories develop. You need to be pushed outside of your comfort zone to learn and to grow. If your program doesn't (because they are afraid of your sensitive skins), do it yourselves. Volunteer for that case when you are so tired you can barely think, even if it's "just" a lap appy. Trust me, your adrenaline will kick in and you will learn something extremely valuable: how to do a case after not having slept for 24 hours. You think you won't have insomnia as attendings? Or that you will never have to stay/round post-call? You think you will have the luxury to just call in sick? You won't last 6 months in your PP jobs with this mentality. NOW is the time to learn how to face all the demons, while you still have the safety net.

When one of my residents has a crappy night-call in the ICU, I always tell them to appreciate that. As an attending, you will NEVER regret having been exposed to stuff during residency, and badness has a tendency to happen after "business hours". A lot of the art of medicine is based on deja vu, that's why your attendings run circles around you, even as CA-3s with senioritis. During residency, you'll want to be the black cloud who's known as the **** magnet. When you're an attending, and there is nobody else to hold your hand and tell you "everything will be fine, mommy is here", you will fall back onto your residency EXPERIENCE. Not knowledge, EXPERIENCE. And experience in anesthesia is gained in an unpredictable fashion, the same way the brownie hits the fan. EVERY case has educational value, even if nothing bad happens. Why? Because every single hour of practice makes you a better anesthesiologist. Decades from now, you will still learn something new every week (if you're a good doctor). And, as I said, you cannot predict when a learning experience will happen, but you can be damn sure it won't if you're not there.

If you're wise, you will want to maximize your learning during residency. That means working as much as you can physically resist, with the meanest mofos you have in your department, with the worst equipment, the laziest techs, at the most inconvenient hours, you name it. During your training years, everything that doesn't kill you will make you stronger, and the deeper the pool of **** you climb out from, the more you will have learned. You will NOT remember the cushy afternoon tea called "conference", regardless what world class genius is teaching it. It's worthless. Medical knowledge comes mostly from self-education; any CRNA can read the same books, learn the same monkey skills, but where you can beat them is stamina, both in gaining knowledge (read MEDICINE at least for one hour EVERY DAY) and experience (aka DEJA VU).

As anesthesiology residents, IF YOU'RE NOT IN THE OR, YOU'RE WASTING YOUR TIME! Find the meanest and best arsehole in your department (preferably one with PP experience) and learn everything you can from him/her, even if it's a lap appy at 3 AM. (It's up to you to convince your airway expert attending to let you intubate that Mallampati 1 with a fiberoptic, or do a case under epidural if he's a regional guy etc.) These are the guys whose teachings you will remember, because the memory is coupled with a strong feeling of discomfort. Every attending/program who's treating you like a precious Faberge egg (which is slowly becoming the norm) is doing you a disservice.

You can sleep when you're attendings. You're welcome, babies. I wish somebody has told me all this back when I used to whine about my lack of sleep.

Residents weren’t whining. CRNAs were whining. Sleeping 2 out of 24 hours while a CRNA does an appy is not exactly being pampered, IMHO. Pay moonlighting wages to residents slightly less than you are paying CRNAs and you have a lot less whining, you save some money, and a have big selling point for the residency program.

 

[2Fast2Des]

Funny because here the young attendings are the good ones, and the old ones are the ones that dont remember how to do stuff. Your group should stop hiring from those ivy league institutions if they've had such a bad experience. Or perhaps the older attendings are doing a bad job at educating =)

I think you seriously got it wrong for your second point. We are doctors who take care of patients in the OR, and keep them safe. that is literally our #1 job. we SHOULD be doing things in a safe environment not put ourselves in a dangerous environment so complications can happen so we can learn better by forming a stronger memory. we should NOT be putting patients at risk for the sake of our learning. it's like what i mentioned about the ED. things fall thru the cracks and poor care gets delivered due to short staffing of the ED, etc. it doesn't mean the department should keep the ED short staffed for the purpose of their learning. Yes attendings dont have work hour restrictions, but if your PP is making you work 85 hours in a row or constantly rushing you so they can make some extra money, while increasing the risk of complications, i cant say for other people but i wouldnt want to work for a PP like that in the first place. If i were the patient, i would NOT want my anesthesiologist to be someone who just did a 24 hour shift, or is rushed, tired or stressed.

I've noticed that younger attendings practice a bit less cowboy style and follow modern practices, and the old guys a bit cavalier, more old school, not really willing to change their practice or learn new skills. That being said I agree that my cohorts in residency are a bunch of pansies that need to be coaxed to work. God forbid they were in a room past 5pm and relief didn't show up, or didn't get their morning break, or got lunch an hour or 2 late. In PP no breaks or lunch, just chow down or pee break in between cases, and I don't mind at all! Safety shouldn't be a concern for a "tired" resident if the attending is there appropriately, and hell, gets involved in a case in a supportive manner.

 

[ketadex]

(This is the kind of thread that pisses me off enough to post.)

To the Millennials: stop whining! You are already the most pampered generation in history, and pampering means (by definition) less learning. Accordingly, you are probably the weakest generation in a long time. Our surgeons complain that their recent Ivy League grad new hires can't function as independent attendings, especially in case of unexpected complications. We see bad judgment all the time from "top 10 program" CA-3 residents, even about things that one would call common sense (newsflash: it's not common). There is SO MUCH to learn, SO MUCH to see, especially in anesthesia where every GOOD attending should know many different ways to skin the cat.

Most of quality learning happens during stressful situations. Your tendency to avoid anything uncomfortable ("safe spaces", "hurting feelings", only doing cases with "educational value", and other BS) hurts your education BIG TIME. You will learn the most when you are tired, stressed, working with unpleasant or incompetent attendings, rushed etc., because that's when mistakes and complications happen, and also that's when the strongest memories develop. You need to be pushed outside of your comfort zone to learn and to grow. If your program doesn't (because they are afraid of your sensitive skins), do it yourselves. Volunteer for that case when you are so tired you can barely think, even if it's "just" a lap appy. Trust me, your adrenaline will kick in and you will learn something extremely valuable: how to do a case after not having slept for 24 hours. You think you won't have insomnia as attendings? Or that you will never have to stay/round post-call? You think you will have the luxury to just call in sick? You won't last 6 months in your PP jobs with this mentality. NOW is the time to learn how to face all the demons, while you still have the safety net.

When one of my residents has a crappy night-call in the ICU, I always tell them to appreciate that. As an attending, you will NEVER regret having been exposed to stuff during residency, and badness has a tendency to happen after "business hours". A lot of the art of medicine is based on deja vu, that's why your attendings run circles around you, even as CA-3s with senioritis. During residency, you'll want to be the black cloud who's known as the **** magnet. When you're an attending, and there is nobody else to hold your hand and tell you "everything will be fine, mommy is here", you will fall back onto your residency EXPERIENCE. Not knowledge, EXPERIENCE. And experience in anesthesia is gained in an unpredictable fashion, the same way the brownie hits the fan. EVERY case has educational value, even if nothing bad happens. Why? Because every single hour of practice makes you a better anesthesiologist. Decades from now, you will still learn something new every week (if you're a good doctor). And, as I said, you cannot predict when a learning experience will happen, but you can be damn sure it won't if you're not there.

If you're wise, you will want to maximize your learning during residency. That means working as much as you can physically resist, with the meanest mofos you have in your department, with the worst equipment, the laziest techs, at the most inconvenient hours, you name it. During your training years, everything that doesn't kill you will make you stronger, and the deeper the pool of **** you climb out from, the more you will have learned. You will NOT remember the cushy afternoon tea called "conference", regardless what world class genius is teaching it. It's worthless. Medical knowledge comes mostly from self-education; any CRNA can read the same books, learn the same monkey skills, but where you can beat them is stamina, both in gaining knowledge (read MEDICINE at least for one hour EVERY DAY) and experience (aka DEJA VU).

As anesthesiology residents, IF YOU'RE NOT IN THE OR, YOU'RE WASTING YOUR TIME! Find the meanest and best arsehole in your department (preferably one with PP experience) and learn everything you can from him/her, even if it's a lap appy at 3 AM. (It's up to you to convince your airway expert attending to let you intubate that Mallampati 1 with a fiberoptic, or do a case under epidural if he's a regional guy etc.) These are the guys whose teachings you will remember, because the memory is coupled with a strong feeling of discomfort. Every attending/program who's treating you like a precious Faberge egg (which is slowly becoming the norm) is doing you a disservice.

You can sleep when you're attendings. You're welcome, babies. I wish somebody had told me all this back when I used to whine about my lack of sleep.

I have to say, this thread has been a welcome reminder of the bigger picture and what's at stake. Thank you to everyone who shared your perspectives.

I agree that there is something to be learned from every case. I can appreciate the utility in practicing perfection when you're tired and stressed.

This situation with our program has such a sour taste though, because its not as if our attendings got together and decided that the residents would benefit from additional cases on long calls. This situation only became an issue because of the complaints of CRNAs. There was no sit-down pep talk from the program director like what FFP or Mman or others have expressed. Rather, the message from our PD was tail-between-the-legs "We need to all work together". And by 'we', of course he meant residents and CRNAs. So now our chair and PD had a meeting with us to inform us that 'we' are all the same workforce on call, and while senior residents should get pulled out of cases for bigger ones (we'll see how often this actually occurs), we are in rotation with CRNAs.

That said, I'll keep my head down and grind it out.

 

[2Fast2Des]

If you're paying night shift workers- crna's- beaucoup bucks to work...then work them long and hard and put them away wet.

For residents, the night shift is hour 16-24 of a call in which they are making less than minimum wage.

Maybe programs could get rid of crna's for these "shifts" and pay OT to the residents

That would make too much sense. It's like NCAA, the fat cats keep the money and let the kids work. However administrators would rather pay CRNAs more than pay less to have residents get paid

 

[MoMoGesiologist]

"The creatures outside looked from pig to man, and from man to pig, and from pig to man again: but already it was impossible to say which was which." -Animal Farm, George Orwell

In the end, no one will really be able to tell the difference between CRNA and anesthesiologist

 

[Robotic Wis-Hipple]

I have to say, this thread has been a welcome reminder of the bigger picture and what's at stake. Thank you to everyone who shared your perspectives.

I agree that there is something to be learned from every case. I can appreciate the utility in practicing perfection when you're tired and stressed.

This situation with our program has such a sour taste though, because its not as if our attendings got together and decided that the residents would benefit from additional cases on long calls. This situation only became an issue because of the complaints of CRNAs. There was no sit-down pep talk from the program director like what FFP or Mman or others have expressed. Rather, the message from our PD was tail-between-the-legs "We need to all work together". And by 'we', of course he meant residents and CRNAs. So now our chair and PD had a meeting with us to inform us that 'we' are all the same workforce on call, and while senior residents should get pulled out of cases for bigger ones (we'll see how often this actually occurs), we are in rotation with CRNAs.

That said, I'll keep my head down and grind it out.

I hate that answer and how it was dictated to you by your leadership. Chalk that program up as another one lost.

Unreal. Your leadership is weak. Mark my words, the next “ask” won’t be too far away.

 

[Psai]

I have to say, this thread has been a welcome reminder of the bigger picture and what's at stake. Thank you to everyone who shared your perspectives.

I agree that there is something to be learned from every case. I can appreciate the utility in practicing perfection when you're tired and stressed.

This situation with our program has such a sour taste though, because its not as if our attendings got together and decided that the residents would benefit from additional cases on long calls. This situation only became an issue because of the complaints of CRNAs. There was no sit-down pep talk from the program director like what FFP or Mman or others have expressed. Rather, the message from our PD was tail-between-the-legs "We need to all work together". And by 'we', of course he meant residents and CRNAs. So now our chair and PD had a meeting with us to inform us that 'we' are all the same workforce on call, and while senior residents should get pulled out of cases for bigger ones (we'll see how often this actually occurs), we are in rotation with CRNAs.

That said, I'll keep my head down and grind it out.

That is an embarrassment. I wouldn't play that game. Your leadership needs to be outed, embarrassed and replaced.

 

[Man o War]

"The creatures outside looked from pig to man, and from man to pig, and from pig to man again: but already it was impossible to say which was which." -Animal Farm, George Orwell

In the end, no one will really be able to tell the difference between CRNA and anesthesiologist

I’ve worked with enough to know there’s a huge difference though.
Unless residents start approaching residency as how little work they can get away with. Then they will be just as average in the OR as a CRNA.
The whole basis of CRNA training is cutting corners to be frank, not doing the volume of cases a resident does. The minimum case numbers are a joke at our local program, and I have been told there are SRNAs observing cardiac cases for instance and counting them toward their already low case requirements.
My view is these were always meant to be supervised technicians, and not independent practitioners. The AANA has since changed their war cry but didn’t change the corresponding case requirements accordingly.
In short, don’t have a CRNA mentality. I agree with @FFP completely.

 

[Man o War]

Also, I’m already in my golden years but sure I have a few decades left in me. Please young residents and attendings, keep fighting hard for your education and profession. I never ever want to be wheeled back to an OR with a nurse solely in charge of my anesthesia.

 

[GravelRider]

I have to say, this thread has been a welcome reminder of the bigger picture and what's at stake. Thank you to everyone who shared your perspectives.

I agree that there is something to be learned from every case. I can appreciate the utility in practicing perfection when you're tired and stressed.

This situation with our program has such a sour taste though, because its not as if our attendings got together and decided that the residents would benefit from additional cases on long calls. This situation only became an issue because of the complaints of CRNAs. There was no sit-down pep talk from the program director like what FFP or Mman or others have expressed. Rather, the message from our PD was tail-between-the-legs "We need to all work together". And by 'we', of course he meant residents and CRNAs. So now our chair and PD had a meeting with us to inform us that 'we' are all the same workforce on call, and while senior residents should get pulled out of cases for bigger ones (we'll see how often this actually occurs), we are in rotation with CRNAs.

That said, I'll keep my head down and grind it out.

I don’t blame you for keeping your head down...that’s how I approach this career. I’ll put in my time and hopefully jump off before the entire ship sinks. However, this sets a terrible precedent in your program where the CRNAs essentially forced a management level decision and are dictating the education and workforce considerations of the residency program. For all the ridiculous peacocking in this thread about how good of an anesthesiologist you are because you did an extra lap chole at 3am, this was all about the CRNAs exerting their power.

 

[Robotic Wis-Hipple]

I don’t blame you for keeping your head down...that’s how I approach this career. I’ll put in my time and hopefully jump off before the entire ship sinks. However, this sets a terrible precedent in your program where the CRNAs essentially forced a management level decision and are dictating the education and workforce considerations of the residency program. For all the ridiculous peacocking in this thread about how good of an anesthesiologist you are because you did an extra lap chole at 3am, this was all about the CRNAs exerting their power.

This x1000

 

[deleted592694]

I’m not looking for a job, but really want to know which program this is.

I hate that answer and how it was dictated to you by your leadership. Chalk that program up as another one lost.

Unreal. Your leadership is weak. Mark my words, the next “ask” won’t be too far away.