On-call staffing with residents/CRNAs

[ketadex]

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

I'm not comfortable outing it yet, but a program in the NE.

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[anbuitachi]

I'm not comfortable outing it yet, but a program in the NE.

yea definitely give us more info. we need to watch out for this program with weak leadership

 

[Psai]

I'm not comfortable outing it yet, but a program in the NE.

Maybe you'll be comfortable outing it when you have no job because your weak leadership decided to spend their time educating CRNAs instead of residents.

All I know is that it sure as hell ain't my program thank god.

 

[chocomorsel]

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.

Do you work alone at night? Or with a CRNA?

 

[chocomorsel]

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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Why the hell did you agree to relieve them by 6 pm if they were scheduled AND PAID till 11pm? Better yet, why did the attendings allow crap like this? I totally would have been chilling till 1045pm and then gone in at 1055pm for sign out. Are you kidding me?

 

[chocomorsel]

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.

So you, having hardly ever done more than 15 hours straight in residency due to night float, are here telling the OP that the residents should't bitch about being up 24 hours straight for possibly BS cases that could be handled by CRNAs. Yeah... right.

 

[psychbender]

Why the hell did you agree to relieve them by 6 pm if they were scheduled AND PAID till 11pm? Better yet, why did the attendings allow crap like this? I totally would have been chilling till 1045pm and then gone in at 1055pm for sign out. Are you kidding me?

Military. Because we were ordered to do it. Attendings were often without a lot of backbone, didn't want to rock the boat with their sweet gig, doing little to no work, with low call frequency, regular hours, and civilian moonlighting opportunities. Pushing back against the nurses could result in someone bringing attention to the fact that there were too many docs there, leaving to reassignments, backfilling, or deployments.

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[chocomorsel]

Military. Because we were ordered to do it. Attendings were often without a lot of backbone, didn't want to rock the boat with their sweet gig, doing little to no work, with low call frequency, regular hours, and civilian moonlighting opportunities. Pushing back against the nurses could result in someone bringing attention to the fact that there were too many docs there, leaving to reassignments, backfilling, or deployments.

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Well this sounds like some real arsenine government ****. Sorry you had to go through that. Totally sucks.

 

[Psai]

(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.

It's funny that you're trying to blame our generation for poorly trained physicians. Who are the risk adverse ones who are always claiming that it's their license so they don't want to give up the procedures or operations? I see surgeons and anesthesiologists refusing to let their trainees try things because they are afraid of the liability and don't want to put in the time that it takes to teach. People are forced into meaningless fellowships wasting years of their lives, learning things that they should have mastered in residency. Maybe try giving your trainees space to grow and make decisions and then you won't be seeing them with poor decision making skills because you didn't allow for it.

And now this nonsense with CRNAs. I'm sure it's the residents' fault that they're being given more and more responsibility with their incessant complaining, not the spineless leadership that kowtow to all of their demands. Pathetic.

 

[Mman]

So you, having hardly ever done more than 15 hours straight in residency due to night float, are here telling the OP that the residents should't bitch about being up 24 hours straight for possibly BS cases that could be handled by CRNAs. Yeah... right.

Yes. I did plenty of 36 hour shifts as an intern and in med school. I do plenty of 24 hour shifts now. I did 24 hour shifts in residency (though not often). I feel I am fairly well qualified to comment on it.

I'm in my 40s. If someone in their 20s (like 90% of residents) is complaining about doing a case in the middle of the night because they are tired, maybe OR anesthesia isn't the career for them.

 

[Mman]

Do you work alone at night? Or with a CRNA?

I medically direct AAs and CRNAs most of the time. I have had situations where s&^% hit the fan where I have had to my own emergency case in the middle of the night until further help could arrive from home.

 

[Southpaw]

Cliff notes version:

Working with CRNAs can be difficult. If you don’t want to deal with all the difficulty go find a MD only practice.

 

[MoMoGesiologist]

Cliff notes version:

Working with CRNAs can be difficult. If you don’t want to deal with all the difficulty go find a MD only practice.

Or (at certain places)... become a CRNA and tell doctors what to do while working less, sleeping more, holding more administrative authority, having no liability, garnering more respect, and making more money.

Does that summarize things as well?

 

[chocomorsel]

Yes. I did plenty of 36 hour shifts as an intern and in med school. I do plenty of 24 hour shifts now. I did 24 hour shifts in residency (though not often). I feel I am fairly well qualified to comment on it.

I'm in my 40s. If someone in their 20s (like 90% of residents) is complaining about doing a case in the middle of the night because they are tired, maybe OR anesthesia isn't the career for them.

Those people are well suited for "mommy track" positions. Otherwise known as "no call" positions to be less sexist.
20's, 40's. Whatever age, being up 24 hours working sucks and is inhumane. Not to mention potentially dangerous. I don't know when we in the medical community will realize that. But we do like abusing ourselves and each other. Such is medicine. Who else in the hospital does 24 hour shifts besides us? So the people who make the most critical, life and death decisions are the ones who are the most deprived. Yeah, that's real smart. Yes, it's been done for centuries. Doesn't mean it's good and doesn't mean we shouldn't strive to find better ways.

 

[deleted171991]

Those people are well suited for "mommy track" positions. Otherwise known as "no call" positions to be less sexist.
20's, 40's. Whatever age, being up 24 hours working sucks and is inhumane. Not to mention potentially dangerous. I don't know when we in the medical community will realize that. But we do like abusing ourselves and each other. Such is medicine. Who else in the hospital does 24 hour shifts besides us? So the people who make the most critical, life and death decisions are the ones who are the most deprived. Yeah, that's real smart. Yes, it's been done for centuries. Doesn't mean it's good and doesn't mean we shouldn't strive to find better ways.

Except not during training. I am all for night float and 12 hour-shifts, but that's where I stop. Why? Because, for example, in critical care, tell me how many solo (as in "look, ma, no in-house attending!") night calls (with triage, consults etc.) you did during fellowship, and I'll tell you how good you actually are.

**** has a tendency to happen after hours, when people don't expect it, not when there are a lot of helpers around. And that's how the best doctors are made, not by leaving at 5 pm. "After hours" is when the trainee gets the closest to playing attending.

 

[chocomorsel]

Except not during training. I am all for night float and 12 hour-shifts, but that's where I stop. Why? Because, for example, in critical care, tell me how many solo (as in "look, ma, no in-house attending!") night calls (with triage, consults etc.) you did during fellowship, and I'll tell you how good you actually are.

**** has a tendency to happen after hours, when people don't expect it, not when there are a lot of helpers around. And that's how the best doctors are made, not by leaving at 5 pm. "After hours" is when the trainee gets the closest to playing attending.

Well then, why not do a night float system in residency as well? @Mman had that at his program. Instead of an entire 24hours. When **** is happening at night, why not do it while one's mind and body is fresh?

 

[Guillemot]

I'm curious to see how other programs handle the distribution of cases between residents and CRNAs while on call. Our program has experienced some friction over this issue recently and we are in the process of formalizing a policy about this.

We have a 24-hour call, where residents are scheduled in normal cases as usual from 6AM-5PM and then emergent/add-on cases from 5PM-6AM. We have a large pool of CRNAs at this program who provide morning breaks, lunch breaks, and relieve residents in the afternoon for lectures. We have CRNAs that come in for a 7PM-6AM overnight shift.

While on call, the CA3 supervises 3-4 rooms of CRNAs and junior residents, and is in charge of distributing cases.

Typically the CA3 has protected the CA2s from being stuck in non-educational cases when there are CRNAs available to do them (such as butt puss, lap choleys, etc). The unsaid rule has been that CA2s are woken up to do only Peds/Traumas/Cranis. (The CA1s are treated like a CRNA and do whatever comes up).

However the CRNAs are arguing to the leadership that this isn't fair, and that the CA2 should be in the rotation with the CRNAs to do whatever cases are scheduled. Due to increasing surgical volumes, every night there is a list of add-on cases (mostly non emergent) that go all night until 6AM running 2-3 rooms.

At your programs, are CA2s stuck doing BS cases on call or are they protected for more educational cases?

I didnt read the thread aside from your post that I quoted, but Ill state my opinion:

The way it works at your program now is the way it should work. It did work that way where I trained. On the other hand if there happens to be a night of educational cases with nothing else going on, then the CA2 should be up all night doing them while the CRNA(s) sleep.

Edit: Let me just modify my post by adding that educational cases are not exclusive to the examples above I that quoted. Additional types of cases and patient comorbidities can make the case educational.

 

[Echo33]

(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.

I would probably be considered a Millennial by some, so here are my thoughts.

Agree completely with you on the training perspective. Experience is the best teacher. I believe every case and every hour in the OR has something to offer. I’m a few years into a private practice gig and I can tell you my residency pampered us too much at times. Nobody is here in the middle of the night to tell me to not worry about this ‘uneducational’ lap chole who happens to have end stage copd, LVEF 15 percent and difficult airway. Not to mention I have a stat section going on at the same time and I’ve been working all day - you need that experience. No surgeon or patient cares that you can quote some chapter in Barish or that you published some BS article in last months issue of xyz anesthesia journal. They care that you can get the case done safely and efficiently, with confidence, like you’ve been there before.

In this situation, the ideal result would be if the administration fully staffed the CA-2 and laid off one of the CRNAs. Sounds like from a staffing perspective this could save a significant amount of money.

In defense of us “millennials”. I wasn’t the one who made these rules who pampered us. I believe that was the baby boomers and gen X-ers. We got a raw deal, having been dealt ridiculous work restrictions that require us to persue additional fellowship training to catch up, all while being crushed with debt that no generation before me has ever experienced, debt that continues accumulate interest during that additional training.

Stop with the millennial bashing already

 

[anbuitachi]

I would probably be considered a Millennial by some, so here are my thoughts.

Agree completely with you on the training perspective. Experience is the best teacher. I believe every case and every hour in the OR has something to offer. I’m a few years into a private practice gig and I can tell you my residency pampered us too much at times. Nobody is here in the middle of the night to tell me to not worry about this ‘uneducational’ lap chole who happens to have end stage copd, LVEF 15 percent and difficult airway. Not to mention I have a stat section going on at the same time and I’ve been working all day - you need that experience. No surgeon or patient cares that you can quote some chapter in Barish or that you published some BS article in last months issue of xyz anesthesia journal. They care that you can get the case done safely and efficiently, with confidence, like you’ve been there before.

In this situation, the ideal result would be if the administration fully staffed the CA-2 and laid off one of the CRNAs. Sounds like from a staffing perspective this could save a significant amount of money.

In defense of us “millennials”. I wasn’t the one who made these rules who pampered us. I believe that was the baby boomers and gen X-ers. We got a raw deal, having been dealt ridiculous work restrictions that require us to persue additional fellowship training to catch up, all while being crushed with debt that no generation before me has ever experienced, debt that continues accumulate interest during that additional training.

Stop with the millennial bashing already

Pretty unfair imo to compare residency with Pp job. They serve different purposes. In residency you work long hours and barely get paid. In PP you work long hours and get paid 7x. If you are complaining constantly about a Pp job perhaps quit and get another one . You can't exactly just easily quit and pick up where you left off elsewhere. And residency is more about safety and Pp is about money. Different values.

 

[deleted171991]

Pretty unfair imo to compare residency with Pp job. They serve different purposes. In residency you work long hours and barely get paid. In PP you work long hours and get paid 7x. If you are complaining constantly about a Pp job perhaps quit and get another one . You can't exactly just easily quit and pick up where you left off elsewhere. And residency is more about safety and Pp is about money. Different values.

Respectfully, you're not getting it. One of the main purposes of residency is to prepare you for real life. And real life, everywhere, is beginning to mirror that PP model. It's about money EVERYWHERE. That's why graduate medical education sucks more and more (and so do the lives of academic attendings). There is a reason people say that academia were the first anesthesia management companies, and why the ASA (run mostly by head-honcho academics) sucks.

Don't fool yourself. Everywhere, even at some VA hospitals, anesthesiologists are being squeezed like lemons, despite "patient safety" concerns (up to a point). It's all about "OR utilization", turnovers, productivity, and indices, and especially surgeon satisfaction (they bring the patients, and surgical patients make the most money for a hospital). Anesthesiologists are being spread micron-thin, because the bean counters have figured out that it's cheaper to deal with the occasional malpractice suit than preventing it by doing all the right things to avoid physician burnout. (And we haven't even gotten to CRNA "independence", and 1:5-8 "supervision", which your generation will have to deal with at some point.)

So NOW is the time to prepare for the world outside your residency womb, that's what I am trying to tell you. If you think you have it bad now, as a resident, you ain't seen nothing yet. If you're concerned about your patients' safety now, wait till you're the only one who truly cares about it. We are not only doing surgeries on people who wouldn't have even been considered a decade or two ago, even in an academic center, we are doing them in ambulatory surgicenters or community hospitals (see the case discussions on this forum).

And the way to prepare for that outside world is to gain as much EXPERIENCE as possible. Looking back, I only regret the cases I slept through in residency, the ones I didn't do, the bad stuff I didn't encounter. It's a once in a lifetime opportunity (that's what tired residents tend to forget); getting paid for it is just the frosting on the cake. I know that life is short, that you are sacrificing your youth, that there is so much happening in your lives outside your training, but you HAVE TO ignore all that if you want to get the most out of your training. That's why my initial rant was addressed to Millennials, because you guys are the generation who has difficulties accepting the sacrifices medicine and medical education require. I totally understand, and I'm being a hypocrite here, but only because I don't want others to make the same mistakes I did.

 

[Southpaw]

I abhor that every time I read these discussions it evolves into anesthesiology residents saying 'I don't get this or I don't get that...I barely make money...so and so makes more than I do...so and so works more than I do...' Do you not see how entitled this sounds? Every time someone strolls into the surgery forums to complain about residency the chorus from attendings is basically 'you knew how this would be. you volunteered. you can leave. someone WILL replace you'. Why can't you kids just shut up and work? Remember, they can make it painful but they can't stop the clock. Keep your eye on the ball.

 

[Echo33]

Pretty unfair imo to compare residency with Pp job. They serve different purposes. In residency you work long hours and barely get paid. In PP you work long hours and get paid 7x. If you are complaining constantly about a Pp job perhaps quit and get another one . You can't exactly just easily quit and pick up where you left off elsewhere. And residency is more about safety and Pp is about money. Different values.

To clarify, I love my job.

Also, every job you take is 100 percent about patient safety, including private practice.

What I was trying get across is that residency, in the grand scheme of things, is such a short period of time and you are GIFTED with a safety blanket the entire time. You have to take advantage of that. Do as many cases as possible. Work harder and longer and let people see that. Presence is key (I am a believer that we need to be more present to help show how valuable we are). I think it’s particularly important to work harder than the CRNAs. Residents at my program were basically seen as equal to CRNAs (I need to be relieved now I’ve been working too long!) and that was very frustrating. It sets a bad precedent early on.

I know errors can happen with sleep deprivation and I’m not advocating practicing while impaired. But there are scenarios in this job where you will absolutely be sleep deprived. The OB doc with a STAT section in the middle of the night is not going to wait for you to wake up more.

I’m just trying to give you the perspective from someone who has recently graduated (past 5 years) and can see how we have, in my opinion, lost valuable training experience that the generations before us had

 

[GravelRider]

I abhor that every time I read these discussions it evolves into anesthesiology residents saying 'I don't get this or I don't get that...I barely make money...so and so makes more than I do...so and so works more than I do...' Do you not see how entitled this sounds? Every time someone strolls into the surgery forums to complain about residency the chorus from attendings is basically 'you knew how this would be. you volunteered. you can leave. someone WILL replace you'. Why can't you kids just shut up and work? Remember, they can make it painful but they can't stop the clock. Keep your eye on the ball.

Someone is replacing them...the CRNAs who just put their foot down and made a management decision. I don’t view this argument as a question of wimpy residents. I view this as wimpy attendings who kowtow to CRNA demands. It’s been the story in anesthesia for years now. If you want to go into a field where midlevels tell you how to run things then anesthesia is the field for you. Tuck your ballz, and come on in.

 

[Mr.S]

If you want to go into a field where midlevels tell you how to run things then anesthesia is the field for you. Tuck your ballz, and come on in.

I will add to that. If you want to go into a field where midlevels, administrators, surgeons tell you how to run and do things then anesthesia is the field fo you.

 

[anbuitachi]

I abhor that every time I read these discussions it evolves into anesthesiology residents saying 'I don't get this or I don't get that...I barely make money...so and so makes more than I do...so and so works more than I do...' Do you not see how entitled this sounds? Every time someone strolls into the surgery forums to complain about residency the chorus from attendings is basically 'you knew how this would be. you volunteered. you can leave. someone WILL replace you'. Why can't you kids just shut up and work? Remember, they can make it painful but they can't stop the clock. Keep your eye on the ball.

like i said before, this is the attitude that got us here in the place. the put your head down, work really hard, people will see our value, if you dont like it you shouldn't be here and should leave. that is simply NOT true. you want to work hard? well the administrators want to work you even harder, make things leaner, and get a bigger paycheck. where does the game stop? when you group together and complain. you can play your internal game in your 3 person private practice or whatever but you are missing the bigger picture. your 2 surgeons might in your little group may appreciate you but thats nothing in the grand scheme of things. if you go keep up with the ASAs and PGAs and whatnot recently, you'll see theres a trend, that if you really dont want to be replaced, its not about your puny skills, because hospitals dont realy care, but in the big picture, whether you can put lines in a little faster or diagnose things a little faster means nothing them. you want to be different? then you need to start COMPLAINING, be dissatisfied, advocate for your beliefs on a higher level, otherwise CRNAs will just be sitting in there high chairs drinking wine while work our face off in our own little corners. every year CRNAs try to push for more power, more independence, and equality to doctors. the people who defeats these bills year after year are not those who keep their head down and work all day and night in the OR

 

[nimbus]

like i said before, this is the attitude that got us here in the place. the put your head down, work really hard, people will see our value, if you dont like it you shouldn't be here and should leave. that is simply NOT true. you want to work hard? well the administrators want to work you even harder, make things leaner, and get a bigger paycheck. where does the game stop? when you group together and complain. you can play your internal game in your 3 person private practice or whatever but you are missing the bigger picture. your 2 surgeons might in your little group may appreciate you but thats nothing in the grand scheme of things. if you go keep up with the ASAs and PGAs and whatnot recently, you'll see theres a trend, that if you really dont want to be replaced, its not about your puny skills, because hospitals dont realy care, but in the big picture, whether you can put lines in a little faster or diagnose things a little faster means nothing them. you want to be different? then you need to start COMPLAINING, be dissatisfied, advocate for your beliefs on a higher level, otherwise CRNAs will just be sitting in there high chairs drinking wine while work our face off in our own little corners. every year CRNAs try to push for more power, more independence, and equality to doctors. the people who defeats these bills year after year are not those who keep their head down and work all day and night in the OR

Actually no. You don’t gain power by complaining. Surgeons can do that because they bring business to the hospital but unless you are in a shortage area, anesthesiologists cannot do that. More often than not, people will ignore you. If your complaints become too annoying, they will get rid of you. You gain power by solving problems and meeting the needs of other parties, namely surgeons and administrators. They need to be convinced that you are providing them the best possible deal. In fact, you need to give them a good deal. We are a service industry. That’s why we put our heads down and work. If there was a shortage of willing providers, it would be a different story. But in most places there is no shortage.

 

[Psai]

Actually no. You don’t gain power by complaining. More often than not, people will ignore you. If your complaints become too annoying, they will get rid of you. You gain power by solving problems and meeting the needs of other parties, namely surgeons and administrators. They need to be convinced that you are providing them the best possible deal. In fact, you need to give them a good deal. We are a service industry. That’s why we put our heads down and work. If there was a shortage of willing providers, it would be a different story. But in most places there is no shortage.

Then why do we have people bowing down to nonsense crna complaints when they pump out more graduates than ever? I don't see them getting ignored and removed.

 

[nimbus]

Then why do we have people bowing down to nonsense crna complaints when they pump out more graduates than ever? I don't see them getting ignored and removed.

Maybe that particular department has problems recruiting and retaining CRNAs. Excessive turnover is expensive and disruptive.

That also brings up another issue. By definition, most residents are transient members of the department while the staff CRNAs are probably long term employees. The department leadership needs to balance the issues that are important to both groups. The chairperson serves the faculty, staff, and residents. They need to consider all their interests, not just the residents’.

 

[Man o War]

Then why do we have people bowing down to nonsense crna complaints when they pump out more graduates than ever? I don't see them getting ignored and removed.

They don’t for the most part that I’ve seen. Maybe a hospital here and there,but they have no leverage in most PPs, AMCs, and academic institutions. As AAs gain traction, they will have even less pull than they may appear to now.
Like I said in a previous post, this isn’t the 90s anymore, their demands mostly fall on deaf ears.

 

[dannyboy1]

Maybe that particular department has problems recruiting and retaining CRNAs. Excessive turnover is expensive and disruptive.

That also brings up another issue. By definition, most residents are transient members of the department while the staff CRNAs are probably long term employees. The department leadership needs to balance the issues that are important to both groups. The chairperson serves the faculty, staff, and residents. They need to consider all their interests, not just the residents’.

THIS. Residents have no choice but to suck it up. CRNA’s can leave and find a new job down the block .....

 

[Southpaw]

like i said before, this is the attitude that got us here in the place. the put your head down, work really hard, people will see our value, if you dont like it you shouldn't be here and should leave. that is simply NOT true. you want to work hard? well the administrators want to work you even harder, make things leaner, and get a bigger paycheck. where does the game stop? when you group together and complain. you can play your internal game in your 3 person private practice or whatever but you are missing the bigger picture. your 2 surgeons might in your little group may appreciate you but thats nothing in the grand scheme of things. if you go keep up with the ASAs and PGAs and whatnot recently, you'll see theres a trend, that if you really dont want to be replaced, its not about your puny skills, because hospitals dont realy care, but in the big picture, whether you can put lines in a little faster or diagnose things a little faster means nothing them. you want to be different? then you need to start COMPLAINING, be dissatisfied, advocate for your beliefs on a higher level, otherwise CRNAs will just be sitting in there high chairs drinking wine while work our face off in our own little corners. every year CRNAs try to push for more power, more independence, and equality to doctors. the people who defeats these bills year after year are not those who keep their head down and work all day and night in the OR

I couldn't disagree with this more. I've been in two private practices. No administrative oversight outside of our MD leadership. My opinion on what gains respect and stability is solving problems for the hospital, creating new avenues of success in areas where the hospital wants help (ERAS, improving pain control to decrease length of stay, multi-modal to help decrease opioids, etc.), sitting on committees, being seen as a group that helps as opposed to one that constantly causes headaches, and importantly, a group that does its best to minimize and hopefully avoid a stipend unless its warranted by all parties involved in the negotiation.

I've actually witnessed surgical groups that were headaches, complained, couldn't recruit new talent, and the administration was constantly having to intervene. I watched that group of SURGEONS get replaced and become hospital employed, not voluntarily.

 

[dannyboy1]

Actually no. You don’t gain power by complaining. Surgeons can do that because they bring business to the hospital but unless you are in a shortage area, anesthesiologists cannot do that. More often than not, people will ignore you. If your complaints become too annoying, they will get rid of you. You gain power by solving problems and meeting the needs of other parties, namely surgeons and administrators. They need to be convinced that you are providing them the best possible deal. In fact, you need to give them a good deal. We are a service industry. That’s why we put our heads down and work. If there was a shortage of willing providers, it would be a different story. But in most places there is no shortage.

Exactly. The hospital, AMC, and most surgeons don’t know ( or care) what we do. They just want patients to do to sleep, have their surgery, and wake up intact. And to get it done quickly and without drama. That’s it. Your job satisfaction will come in the form of a paycheck in this field

 

[Southpaw]

Then why do we have people bowing down to nonsense crna complaints when they pump out more graduates than ever? I don't see them getting ignored and removed.

Where? I don't see that. In my experience CRNAs keep their heads down and work. Do they want independence? Yes. Is it happening? Extremely slowly. This board takes everything to the extreme. If you're in an area that can't recruit CRNAs, then ask yourself why? It's either low paying or poor location. CRNAs, in my opinion, rarely look at a strong benefit package. They care about hours worked (when do I clock in? when do I clock out?) and dollars earned. You wanna do that? You know the pathway, and yes, as a CRNA you will become more replaceable overtime as your leadership continues to flood the market and more groups push for AAs because of the headaches CRNAs have historically caused.

 

[Man o War]

I couldn't disagree with this more. I've been in two private practices. No administrative oversight outside of our MD leadership. My opinion on what gains respect and stability is solving problems for the hospital, creating new avenues of success in areas where the hospital wants help (ERAS, improving pain control to decrease length of stay, multi-modal to help decrease opioids, etc.), sitting on committees, being seen as a group that helps as opposed to one that constantly causes headaches, and importantly, a group that does its best to minimize and hopefully avoid a stipend unless its warranted by all parties involved in the negotiation.

I've actually witnessed surgical groups that were headaches, complained, couldn't recruit new talent, and the administration was constantly having to intervene. I watched that group of SURGEONS get replaced and become hospital employed, not voluntarily.

Same, 2 different surgical subs in our case. Nobody is really safe anymore. A 3rd surgical sub recently got screwed during their most recent contract negotiations, they are very unhappy.

 

[dannyboy1]

CRNAs, in my opinion, rarely look at a strong benefit package. They care about hours worked (when do I clock in? when do I clock out?) and dollars earned. You wanna do that? You know the pathway.

That’s all we docs should be looking at as well. I work for an AMC. I understand that I am a cog in the wheel and I will act like it. Leadership?committees? Not for this doc. Just gonna sign the charts and get paid for as long as this racket can continue....

 

[anbuitachi]

I couldn't disagree with this more. I've been in two private practices. No administrative oversight outside of our MD leadership. My opinion on what gains respect and stability is solving problems for the hospital, creating new avenues of success in areas where the hospital wants help (ERAS, improving pain control to decrease length of stay, multi-modal to help decrease opioids, etc.), sitting on committees, being seen as a group that helps as opposed to one that constantly causes headaches, and importantly, a group that does its best to minimize and hopefully avoid a stipend unless its warranted by all parties involved in the negotiation.

I've actually witnessed surgical groups that were headaches, complained, couldn't recruit new talent, and the administration was constantly having to intervene. I watched that group of SURGEONS get replaced and become hospital employed, not voluntarily.

how big were those private practices?

Maybe that particular department has problems recruiting and retaining CRNAs. Excessive turnover is expensive and disruptive.

That also brings up another issue. By definition, most residents are transient members of the department while the staff CRNAs are probably long term employees. The department leadership needs to balance the issues that are important to both groups. The chairperson serves the faculty, staff, and residents. They need to consider all their interests, not just the residents’.

i problem IMO is that they are bypassing the attending on call. it should be the overnight attendings decision. if the overnight attending doesnt want CRNA working and prefers residents do all the cases, then thats that. but i think its a weak department when the CRNA is going directly to admin and bypassing overnight attendings power. these are people he/she is supervising, he/she should be deciding

 

[deleted171991]

Where? I don't see that. In my experience CRNAs keep their heads down and work. Do they want independence? Yes. Is it happening? Extremely slowly. This board takes everything to the extreme.

Extreme, my behind. The VA has already given complete independence to APRNs, with no physician oversight. They can admit, discharge etc., all on their own. That was also something many physicians thought would not happen soon, especially in a sick population. CRNAs are next. My money is on less than 10 years till it happens (more like 5).

 

[Southpaw]

Extreme, my behind. The VA has already given complete independence to APRNs, with no physician oversight. They can admit, discharge etc., all on their own. That was also something many physicians thought would not happen soon, especially in a sick population. CRNAs are next. My money is on less than 10 years till it happens (more like 5).

I actually want them all to be independent. All of them. I don't want to train them. I don't want to supervise them. I don't want to bill for supervision of them. The EM forum says the same. I want them all completely independent the second they finish their training. No different than me with regard to independence when I finished training. I want the chips to fall where they may. I am confident I'll have a job in this game as long as I want one. I also can't handle the argument of 'but what about what's best for the patient...'. I assure you, it'll sort itself out. Anyway, just my opinion.

 

[Southpaw]

how big were those private practices?

Why does that matter?

 

[Southpaw]

That’s all we docs should be looking at as well. I work for an AMC. I understand that I am a cog in the wheel and I will act like it. Leadership?committees? Not for this doc. Just gonna sign the charts and get paid for as long as this racket can continue....

Great. In so many jobs no one would even think to ask you to do unpaid work. And yet it's commonplace in medicine. You don't want to do it? Fine. Amazingly, you will with basically 100% certainty always have an extremely well paying job as long as you show up on time, don't prove to be dangerous, and are somewhat able to get along with people.

 

[Ronin786]

Most groups like to talk a big game about proving their value to a hospital by sitting on committees and quality improvement. Yet most groups won’t even consider hiring somebody to their group that would also staff an ICU where you can clearly prove your worth to a hospital and make it more difficult to be replaced.

 

[Mman]

Most groups like to talk a big game about proving their value to a hospital by sitting on committees and quality improvement. Yet most groups won’t even consider hiring somebody to their group that would also staff an ICU where you can clearly prove your worth to a hospital and make it more difficult to be replaced.

that's because covering the ICU is a relative money loser for them.

 

[Southpaw]

Most groups like to talk a big game about proving their value to a hospital by sitting on committees and quality improvement. Yet most groups won’t even consider hiring somebody to their group that would also staff an ICU where you can clearly prove your worth to a hospital and make it more difficult to be replaced.

I don't disagree with you. There'd be logistical difficulties to work out, the largest of which would be ensuring the current ICU staff is willing to bring in a new anesthesiology-trained intensivist. But I absolutely agree with you in that it would prove value to the hospital and be of great value to the group beyond any degree of $$ won/lost. Like it or not, most anesthesiology private practice groups are only able to see growth or contraction in terms of $$. Certain things, like expanding to cover the ICU, go beyond $$.

 

[Mman]

I don't disagree with you. There'd be logistical difficulties to work out, the largest of which would be ensuring the current ICU staff is willing to bring in a new anesthesiology-trained intensivist. But I absolutely agree with you in that it would prove value to the hospital and be of great value to the group beyond any degree of $$ won/lost. Like it or not, most anesthesiology private practice groups are only able to see growth or contraction in terms of $$. Certain things, like expanding to cover the ICU, go beyond $$.

If it was such a slam dunk of value, you'd see it more commonly across the country. In any well run business, it's about the return on investment. While having an anesthesiologist in an ICU provides some level of value, that's hard to quantify. And if it's only one doc, that doesn't really provide much value at all to a hospital IMHO. Now if it was complete staffing of an ICU, that would be different, but that would also have exponentially higher costs.

 

[Southpaw]

If it was such a slam dunk of value, you'd see it more commonly across the country. In any well run business, it's about the return on investment. While having an anesthesiologist in an ICU provides some level of value, that's hard to quantify. And if it's only one doc, that doesn't really provide much value at all to a hospital IMHO. Now if it was complete staffing of an ICU, that would be different, but that would also have exponentially higher costs.

Most are staffed IM/CC of course. That doesn’t make it impossible. If your group staffs the ICU, even partially, you just got harder to replace. Not all of Amazon’s moves have been profitable in the short. They’re in it for the long run. Most anesthesiologists I know can’t see beyond the month to month.

 

[shepardsun]

Millennials- arriving on the scene to find the building on fire and being yelled at by the arsonists for not working harder to put it out.

Every case is educational. You should work harder than everyone else. Don't have kids during residency- they take up too much time when you have your safety net and family and personal lifeshould come secondary to your training. Thinking about binging that new Netflix series? Don't. Every episode is 30 minutes of time that you could have been reading Miller.

 

[Mman]

Most are staffed IM/CC of course. That doesn’t make it impossible. If your group staffs the ICU, even partially, you just got harder to replace. Not all of Amazon’s moves have been profitable in the short. They’re in it for the long run. Most anesthesiologists I know can’t see beyond the month to month.

replacing a doc or two from an ICU rotation is very easy. Replacing an entire staff is much tougher.

 

[GravelRider]

Millennials- arriving on the scene to find the building on fire and being yelled at by the arsonists for not working harder to put it out.

Every case is educational. You should work harder than everyone else. Don't have kids during residency- they take up too much time when you have your safety net and family and personal lifeshould come secondary to your training. Thinking about binging that new Netflix series? Don't. Every episode is 30 minutes of time that you could have been reading Miller.

Why should a resident strive for excellence only to be a hardworking cog in the AMC machine? Strive for mediocrity and have a happy life instead. The return on investment in watching 30 minutes of Netflix is probably much higher for your overall happiness than 30 minutes of reading boring Miller. Shoot for the bare minimum, not for the stars. We work in a field where excellence is not rewarded, so why bother?

 

[Ronin786]

replacing a doc or two from an ICU rotation is very easy. Replacing an entire staff is much tougher.

It’s arguable about how easy it would be to replace 1-2 ICU staff, but it’s definitely more expensive for any AMC/hospital taking over a contract. If your ICU is staffed by your anesthesiologists, they’re not being paid a full time FTE for their ICU time. You’d have to hire two full time pulmonologists to cover the same amount of time.

Like Southpaw mentioned though, most groups can’t look past the $$$ in and out and would rather rely on nebulous ideas of sitting on committees or creating ERAS pathways.

 

[Mr.S]

We work in a field where excellence is not rewarded, so why bother?

It is not only not rewarded but discouraged. They punish you for striving for excellence.
Mediocrity is where everyone wants you!!
It took me a bit to figure that out.
It was tough for me and still is because my whole backround, our whole backround is excellence.