ONE of the problems of our profession.

[gasattack3]

Is that WAY TOO many of the attendings out there who practice in ACT models have lost touch with the "flow" of the OR.

Don't shoot the messanger on this one, but it's true. Too many attendings have gotten to the point where they simple can't run a room. Sure, this RElearning curve would be about a day per type of surgery, but is this really prudent, to be so out of touch with the functionality of various operating room apparatus etc. etc.?

If this doesn't apply to you, then so be it. If it does, rather than get defensive, maybe ask yourself WHY this is the case? Also, ask yourself if this isn't a HUGE reason why our field faces so many challenges from CRNA's who think they can do it all.

Clearly the theoretical/knowledge base is very different, and some of the same attendings whom are INDEED out of touch in the OR, are some of the smartest (and often still very relavent) people around. But, as a general warning, I personally feel that it's TOTALLY unacceptable to NOT know how an infusion pump works or how to run an ACT or a rapid infusion device etc.

Why is this so important? Because it EMPOWERS mid-levels to think to themselves how YOU would bumble around (as too many attendings do in fact do) if left to your own devices (no pun intended). When they KNOW you have no idea how to start an epi drip (despite knowing the infusion rate and the pharmacodynamics of the drug) on the Alaris pump, do you really think this doesn't EMPOWER them??

If this applies to you don't hate the messanger. It's an easy fix.

The flip side?? The handful of attendings in an ACT model who DON'T lose those critical hands on skills. THAT sends an equally powerful message to any CRNA whom thinks they've become indespensible because Dr. X "doesn't even know how to run our epidural pumps or our infusion pumps or how to set up the room etc etc".

In fact, I've seen the above. Where it's painfully obvious that the CRNA's are INDEED very dispensible (not in the overall workforce/manpower realm but in any one scenario) when they are dealing with an attending who can say "no, I'll get it", or "no don't worry, I'll set up the pump" etc etc. And they DO it.

I realize that an ACT model doesn't facilitate this. I realize that not all cases warrant that level of attending participation. But, in my experience as a resident IN THE ROOM, those attendings whom CAN do those things AND stick around to do them every now and again, DO in fact earn the respect of the CRNA's and surgeons alike.

This has been an observation of mine over the past 7 years as a med student and now as a CA2.

It's an easy fix, and I'm not trying to be inflammatory. Once again, we are our worst enemies. A common theme.

How many of you feel "pushed out" or "marginalized" by CRNA's feeling that aside from induction (and MAYBE emergence if you show up), that the OR is THEIR territory? I can tell you that many do feel that way from frank conversations I've had with CRNA's.

If you DO feel that way, that's tough. F.ck em! What's wrong with sitting right down, grabbing that bag, or EVEN telling the CRNA "hey, why don't you get caught up on some charting while I set up our infusions before I start my next case"??

My opinion is that we need to behave as if one day we will be competing head-to-head with CRNA's. That means NEVER (despite what you think about that statement) losing those critical "you can teach a monkey....." type skills. Again, it also sends a psychological message to CRNA's that indeed they are not NEEDED for certain things.

I'm interested in hearing members' thoughts on this matter. I have a feeling that many of the residents know exactly what I'm talking about.

***And just because this is my first post, I assure you I am no troll. I'm in fact a CA2 resident who cares very much about the future of our profession.

---

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[Mman]

while you make an interesting observation and I know where you are coming from, I think your conclusions aren't relevant.

"some" CRNAs might think they can replace an MD because that MD fumbles with how to program a pump or what not. However, those skills are irrelevant to our actual importance. I don't get paid to program a pump. I'm paid for my knowledge base (mostly) and technical abilities (in terms of placing invasive lines, blocks, monitors, etc). The rest just makes you look good.

And while looking good is important, it's just the icing on the cake, not the cake itself.

We separate ourselves from the CRNAs by our ability to practice medicine competently. Not to program a pump I could teach a janitor how to work in 5 minutes. Because if that's all it takes, we really aren't needed.

And I should point out that I'm in an ACT model but can and will make every piece of equipment in the OR hum. I can usually diagnose their circuit leak cause within seconds of walking into a room they've been struggling in for minutes. But that's just style points.

 

[Stank811]

I agree with the OP....surgeons and OR nurses do not really understand our knowledge base so what they are buying into is the icing on the cake. They do not care initially how good the cake is because their initial thoughts are based on presentation. I agree 100% when staff come in a fumble around with equipment and then have the resident or CRNA do it for them they come off incompetent to everyone else in the OR. What product are you selling a delicious cake without frosting, and terrible cake with frosting or both..why wouldn't you sell both if you could.

 

[btbam]

A lot of my attendings fumble around with infusion pumps or don't know where soft suctions are in the cart but that doesn't make me think any less of their abilities and critical thinking as an anesthesiologist.

 

[Mman]

I agree with the OP....surgeons and OR nurses do not really understand our knowledge base so what they are buying into is the icing on the cake. They do not care initially how good the cake is because their initial thoughts are based on presentation. I agree 100% when staff come in a fumble around with equipment and then have the resident or CRNA do it for them they come off incompetent to everyone else in the OR. What product are you selling a delicious cake without frosting, and terrible cake with frosting or both..why wouldn't you sell both if you could.

No, a competent surgeon really doesn't care about that staff and realizes it's ancillary. It's like me judging the surgeon based on how perfectly they can approximate the facial layers in their closure rather than caring if the patient comes back for bleeding 24 hours postop.


Entertaining the feeble minded in the OR with my prowess at menial skills is merely for show. Half the circulating nurses in the OR would rave about my central line placement skills if I was always fast and clean when I did it, but they wouldn't know the difference if I had a 50% pneumothorax rate on subclavians.

That said, I can put on a good show.

 

[Idiopathic]

thanks for the observation. true information, but certainly most all of us are aware of this deficiency.

 

[BobBarker]

Maybe 2 of my attendings could do a case by themselves on call. Critical failure point is inability to check drugs out of the pyxis!

 

[cincincyreds]

Is that WAY TOO many of the attendings out there who practice in ACT models have lost touch with the "flow" of the OR.

Don't shoot the messanger on this one, but it's true. Too many attendings have gotten to the point where they simple can't run a room. Sure, this RElearning curve would be about a day per type of surgery, but is this really prudent, to be so out of touch with the functionality of various operating room apparatus etc. etc.?

If this doesn't apply to you, then so be it. If it does, rather than get defensive, maybe ask yourself WHY this is the case? Also, ask yourself if this isn't a HUGE reason why our field faces so many challenges from CRNA's who think they can do it all.

Clearly the theoretical/knowledge base is very different, and some of the same attendings whom are INDEED out of touch in the OR, are some of the smartest (and often still very relavent) people around. But, as a general warning, I personally feel that it's TOTALLY unacceptable to NOT know how an infusion pump works or how to run an ACT or a rapid infusion device etc.

Why is this so important? Because it EMPOWERS mid-levels to think to themselves how YOU would bumble around (as too many attendings do in fact do) if left to your own devices (no pun intended). When they KNOW you have no idea how to start an epi drip (despite knowing the infusion rate and the pharmacodynamics of the drug) on the Alaris pump, do you really think this doesn't EMPOWER them??

If this applies to you don't hate the messanger. It's an easy fix.

The flip side?? The handful of attendings in an ACT model who DON'T lose those critical hands on skills. THAT sends an equally powerful message to any CRNA whom thinks they've become indespensible because Dr. X "doesn't even know how to run our epidural pumps or our infusion pumps or how to set up the room etc etc".

In fact, I've seen the above. Where it's painfully obvious that the CRNA's are INDEED very dispensible (not in the overall workforce/manpower realm but in any one scenario) when they are dealing with an attending who can say "no, I'll get it", or "no don't worry, I'll set up the pump" etc etc. And they DO it.

I realize that an ACT model doesn't facilitate this. I realize that not all cases warrant that level of attending participation. But, in my experience as a resident IN THE ROOM, those attendings whom CAN do those things AND stick around to do them every now and again, DO in fact earn the respect of the CRNA's and surgeons alike.

This has been an observation of mine over the past 7 years as a med student and now as a CA2.

It's an easy fix, and I'm not trying to be inflammatory. Once again, we are our worst enemies. A common theme.

How many of you feel "pushed out" or "marginalized" by CRNA's feeling that aside from induction (and MAYBE emergence if you show up), that the OR is THEIR territory? I can tell you that many do feel that way from frank conversations I've had with CRNA's.

If you DO feel that way, that's tough. F.ck em! What's wrong with sitting right down, grabbing that bag, or EVEN telling the CRNA "hey, why don't you get caught up on some charting while I set up our infusions before I start my next case"??

My opinion is that we need to behave as if one day we will be competing head-to-head with CRNA's. That means NEVER (despite what you think about that statement) losing those critical "you can teach a monkey....." type skills. Again, it also sends a psychological message to CRNA's that indeed they are not NEEDED for certain things.

I'm interested in hearing members' thoughts on this matter. I have a feeling that many of the residents know exactly what I'm talking about.

***And just because this is my first post, I assure you I am no troll. I'm in fact a CA2 resident who cares very much about the future of our profession.

I do all my own cases. No residents, no cRNAs at my place. I did have the anesthesia tech pushing the blood during the ruptured AAA today while I charted and pushed pressors. I placed a cordis in the ER when I went to evaluate the patient. Not a big deal. I can use any pump and I can use the rapid transfusor on my own.

 

[gasattack3]

while you make an interesting observation and I know where you are coming from, I think your conclusions aren't relevant.

"some" CRNAs might think they can replace an MD because that MD fumbles with how to program a pump or what not. However, those skills are irrelevant to our actual importance. I don't get paid to program a pump. I'm paid for my knowledge base (mostly) and technical abilities (in terms of placing invasive lines, blocks, monitors, etc). The rest just makes you look good.

And while looking good is important, it's just the icing on the cake, not the cake itself.

We separate ourselves from the CRNAs by our ability to practice medicine competently. Not to program a pump I could teach a janitor how to work in 5 minutes. Because if that's all it takes, we really aren't needed.

And I should point out that I'm in an ACT model but can and will make every piece of equipment in the OR hum. I can usually diagnose their circuit leak cause within seconds of walking into a room they've been struggling in for minutes. But that's just style points.

Mman, with all due respect, this mentality COUPLED with the inability to do important, albeit "menial" functions in the OR (which does not include you as you already stated you can do the "monkey business") or even just show a more competent presence in the OR is AT LEAST one of the reasons that 1) a vocal minority of nurses feel they can do your job and 2) the reason that surgeons are seeing (PERCEIVING????) less value on the part of the anesthesiologist.

******The beauty of this deficiency is that these really are pretty simple functions. Perception is reality and our profession is for sure suffering from a perception problem.
Anyway, I think it would be a step in the right direction to become more visible for sure, and also to brush up on the "mechanics" of operating room equipment as pertains to GIVING anesthesia.

 

[WholeLottaGame7]

Mman, with all due respect, this mentality COUPLED with the inability to do important, albeit "menial" functions in the OR (which does not include you as you already stated you can do the "monkey business") or even just show a more competent presence in the OR is AT LEAST one of the reasons that 1) a vocal minority of nurses feel they can do your job and 2) the reason that surgeons are seeing (PERCEIVING????) less value on the part of the anesthesiologist.

******The beauty of this deficiency is that these really are pretty simple functions. Perception is reality and our profession is for sure suffering from a perception problem.
Anyway, I think it would be a step in the right direction to become more visible for sure, and also to brush up on the "mechanics" of operating room equipment as pertains to GIVING anesthesia.

I see where you're coming from, but I also see the other side. But if you think of anesthesiologists more as "critical care/perioperative physicians," I think the example breaks down. If you're in the ICU and you write an order to titrate the SNP to a MAP of 60-80, the RN is going to be the one pushing the buttons and doing the titrating, not the ICU physician. I see the ACT model as a kind of extension of that, so I can't necessarily criticize the attendings all that much.

That said, the more you know, the more helpful you can be, and the more smoothly things will go, so I always appreciate it when attendings can help out with little things.

 

[gasattack3]

I see where you're coming from, but I also see the other side. But if you think of anesthesiologists more as "critical care/perioperative physicians," I think the example breaks down. If you're in the ICU and you write an order to titrate the SNP to a MAP of 60-80, the RN is going to be the one pushing the buttons and doing the titrating, not the ICU physician. I see the ACT model as a kind of extension of that, so I can't necessarily criticize the attendings all that much.

That said, the more you know, the more helpful you can be, and the more smoothly things will go, so I always appreciate it when attendings can help out with little things.

Yes, but in the ICU it's generally known whom placed the order to make something happen. Also, there's rounding, and so the PERCEPTION of value is there.

My point is that attendings in ACT models need to increase their visibility and maintain their hands on skills IN THIS POLITICAL climate where it very well may be in our future for anesthesiologists to go back to the stool and compete head to head. So, losing those skills as well as losing touch with the "gestalt" of OR flow for any range of procedures as TOO many attendings have indeed, is unwise.

Regarding attending visibility and presence in the OR, I have friends doing any number of functions in the OR and I can tell you that those attendings that DO have a palpable presence are respected and appreciated. Even if it's just being there on extubation to lend an extra hand and make critical decisions at that point (how many attendings DON'T show up for extubation??). Simple things like sticking around for positioning (I realize it's hard when you have an 8:00 strart followed by an 8:15 start) for prone and lateral decubitus cases goes a long way.
The simple ways to increase the perception of value are almost endless. So, are the ways NOT to increase that perception under current circumstances, although I feel that's not ultimately sustainable.

And, again, if you don't think that YOU are empowering/emboldening CRNA's when they AND you both know that you don't have a clue about setting up an infusion in the OR, then you are fooling yourself. If you think this is benign, I think you are not in touch with reality. But, it's an easy fix........

A perfect example is during a complex intrathoracic or even transplant case. I've personally seen our cardiac/transplant trained attendings run almost the entire show except for charting (which IS monkey work). Attendings running infusions, hanging product, pushing drugs, making complex decisions on the fly. BEING there. Those attendings are not only respected, but it's completely obvious that instead of a CRNA "assitant" all they really need is a high school kid in the room to chart. So, instead of BEING marginalized by CRNA's which is happening all too infrequently despite DENIAL by many anesthesiologists, the MD can indeed margianalize the CRNA. There is no better way to cut that group down to size. Most KNOW you have a superior knowledge base, but I'm telling you when they feel you can't run the room, that will go to their head and also to their wallet when it comes to funding AANA agendas to get you out of the room entirely.

The vast majority of cases are NOT intrathoracic or complex transplant, but I'm suggesting that simple, small steps can be taken to have essentially the same effect for some "routine" cases.

 

[hoyden]

gasattack3,

as you progress in your residency training ( and it is obvious that you are either a CA-1 or just starting CA-2) you will find out that it is much more convenient to be on your own for prone/lateral decubitus positioning or emergence. No interference from somebody who does things in a different way and considers that way the only way around ( taping only by this particular tape, by this particular way and so on)

 

[ASA6]

I agree with this. Going prone, or a complicated ICU patient, the attendings just get in the way of my organizing/untangling things.

 

[gasattack3]

gasattack3,

as you progress in your residency training ( and it is obvious that you are either a CA-1 or just starting CA-2) you will find out that it is much more convenient to be on your own for prone/lateral decubitus positioning or emergence. No interference from somebody who does things in a different way and considers that way the only way around ( taping only by this particular tape, by this particular way and so on)

i think you guys are missing the point, and side stepping the real issue. I only used positioning as ONE example.

 

[jwk]

i think you guys are missing the point, and side stepping the real issue. I only used positioning as ONE example.

I think your point is simple and I agree with it - an attending should be able to go into an OR and do a case on their own.

 

[btbam]

One of my attendings tries to get the pt back breathing after induction (and 50 of roc) by putting PSV pro on 25-30 of support and the flow trigger really low to "see where they're at". Then he leaves the room, drives me freaking crazy.

 

[BLADEMDA]

I think your point is simple and I agree with it - an attending should be able to go into an OR and do a case on their own.

Most can do cases and some like myself have personally performed in excess of 10,000 anesthetics from start to finish while still working in an ACT. I do less cases these days personally but still get my hands dirty at least 1-2 times a week.

I'd rather do my own cases than supervise 4 CRNAs any day of the week

 

[ProRealDoc]

Yes, but in the ICU it's generally known whom placed the order to make something happen. Also, there's rounding, and so the PERCEPTION of value is there.

My point is that attendings in ACT models need to increase their visibility and maintain their hands on skills IN THIS POLITICAL climate where it very well may be in our future for anesthesiologists to go back to the stool and compete head to head. So, losing those skills as well as losing touch with the "gestalt" of OR flow for any range of procedures as TOO many attendings have indeed, is unwise.

Regarding attending visibility and presence in the OR, I have friends doing any number of functions in the OR and I can tell you that those attendings that DO have a palpable presence are respected and appreciated. Even if it's just being there on extubation to lend an extra hand and make critical decisions at that point (how many attendings DON'T show up for extubation??). Simple things like sticking around for positioning (I realize it's hard when you have an 8:00 strart followed by an 8:15 start) for prone and lateral decubitus cases goes a long way.
The simple ways to increase the perception of value are almost endless. So, are the ways NOT to increase that perception under current circumstances, although I feel that's not ultimately sustainable.

And, again, if you don't think that YOU are empowering/emboldening CRNA's when they AND you both know that you don't have a clue about setting up an infusion in the OR, then you are fooling yourself. If you think this is benign, I think you are not in touch with reality. But, it's an easy fix........

A perfect example is during a complex intrathoracic or even transplant case. I've personally seen our cardiac/transplant trained attendings run almost the entire show except for charting (which IS monkey work). Attendings running infusions, hanging product, pushing drugs, making complex decisions on the fly. BEING there. Those attendings are not only respected, but it's completely obvious that instead of a CRNA "assitant" all they really need is a high school kid in the room to chart. So, instead of BEING marginalized by CRNA's which is happening all too infrequently despite DENIAL by many anesthesiologists, the MD can indeed margianalize the CRNA. There is no better way to cut that group down to size. Most KNOW you have a superior knowledge base, but I'm telling you when they feel you can't run the room, that will go to their head and also to their wallet when it comes to funding AANA agendas to get you out of the room entirely.

The vast majority of cases are NOT intrathoracic or complex transplant, but I'm suggesting that simple, small steps can be taken to have essentially the same effect for some "routine" cases.

Well said! Perception is reality and many surgeons/OR staff perceive the inability or desire to stick around to help as being useless. For physicians starting 4 rooms at the same time, this is challenging task. Add to that the need to preop, do blocks, place invasive lines, and it almost becomes an impossibility. However, if you're supervising two rooms that's a different story.

 

[Mman]

And, again, if you don't think that YOU are empowering/emboldening CRNA's when they AND you both know that you don't have a clue about setting up an infusion in the OR, then you are fooling yourself. If you think this is benign, I think you are not in touch with reality. But, it's an easy fix........

How many attending surgeons have you had long discussions with this about? I'm guessing zero or very few.

And as to the CRNAs, they aren't feeling empowered because you can't work a pump. That's not what they are gunning for. Their sights are far higher.

A smart surgeon understands what your function is and what the superfluous parts of the job are. A dumb militant CRNA doesn't care what you can or can't do. They want your job regardless and feel like they are trained well enough to do it (as dumb as that sounds).


So back to my original point. I understand your point of view. I know where you are coming from. I'm not long removed from being a resident and I always appreciated attendings that could do all the little stuff to help me out. HOWEVER, your conclusion of that being a root cause of surgeon disrespect and getting CRNAs to want to replace you is wrong. Make all the changes you suggest and it wouldn't change the outcomes you are looking for one bit. None. Not even a little.

 

[pgg]

One of my attendings tries to get the pt back breathing after induction (and 50 of roc) by putting PSV pro on 25-30 of support and the flow trigger really low to "see where they're at". Then he leaves the room, drives me freaking crazy.

Then you can do the case your way, and not play silly games with the vent.

 

[gasattack3]

How many attending surgeons have you had long discussions with this about? I'm guessing zero or very few.

And as to the CRNAs, they aren't feeling empowered because you can't work a pump. That's not what they are gunning for. Their sights are far higher.

A smart surgeon understands what your function is and what the superfluous parts of the job are. A dumb militant CRNA doesn't care what you can or can't do. They want your job regardless and feel like they are trained well enough to do it (as dumb as that sounds).


So back to my original point. I understand your point of view. I know where you are coming from. I'm not long removed from being a resident and I always appreciated attendings that could do all the little stuff to help me out. HOWEVER, your conclusion of that being a root cause of surgeon disrespect and getting CRNAs to want to replace you is wrong. Make all the changes you suggest and it wouldn't change the outcomes you are looking for one bit. None. Not even a little.

No, I haven't had such frank discussions with my attendings. Nothing to gain by sturring up the pot. I HAVE had SIMILAR conversations, however, and many agree that you can/should never lose the ability to run a room on your own.

I'm NOT attacking the ACT model. I think that it can definitely work very well, and probably is the most economic and safe model there is, WHEN it works properly.

I have, however, seen many OPPORTUNITIES when attendings really aren't that busy, yet skate out of the room ASAP. I'm really trying to be constructive here. Like ProRealDoc agrees, our profession most certainly suffers from a perception/image problem and to underestimate the future impact of that is fatal.

Also, as others have pointed out, ofcourse running 4 rooms with 15 minute intervals between start times aren't going to be the time for all of this. But, let's face it, AT LEAST several times per week, if not at least a couple times per day, there are opportunities to improve visibility in the OR.

****I still submit that MUCH of the reason that CRNA's have become AS emboldened is because they feel that so many attendings have lost that touch in the OR. I GET that that's not what you are really paid a premium for. That would your knowledge. But, so many CRNA's don't know what they don't know (and probably never will), and they can be pretty ignorant.

Try having them step aside or chart for a while while you run the better part of a case. Do some of the "monkey" business like running a pump or programming an infusion sometime. You will see, as I have seen personally, how they are taken a bit back by all of that. Mainly this is because they can be SO ignorant of your/our skill set. Not sure, but it puts them in their place.

It's one thing for a CRNA to push for equivalency. It's another for the all too many of their ranks to not only want equivalency, but ALSO believe that they can run a room (i.e. do anesthesia as they view it) better than you, if they even believe you can still run a room at all. Because if they know you can run a room, it will indeed cause them pause since it doesn't take a rocket scientist to think that if they become independent, then the market (for now) will decide whom gets the job etc. or attracts a more lucrative payer mix.

Again, this is simple, yet effective. And, it may be fun for you as well. I know a LOT of attendings who would LOVE to do a one on one case more often than they get a chance to.

 

[Mman]

No, I haven't had such frank discussions with my attendings. Nothing to gain by sturring up the pot. I HAVE had SIMILAR conversations, however, and many agree that you can/should never lose the ability to run a room on your own.

I'm NOT attacking the ACT model. I think that it can definitely work very well, and probably is the most economic and safe model there is, WHEN it works properly.

I have, however, seen many OPPORTUNITIES when attendings really aren't that busy, yet skate out of the room ASAP. I'm really trying to be constructive here. Like ProRealDoc agrees, our profession most certainly suffers from a perception/image problem and to underestimate the future impact of that is fatal.

Also, as others have pointed out, ofcourse running 4 rooms with 15 minute intervals between start times aren't going to be the time for all of this. But, let's face it, AT LEAST several times per week, if not at least a couple times per day, there are opportunities to improve visibility in the OR.

****I still submit that MUCH of the reason that CRNA's have become AS emboldened is because they feel that so many attendings have lost that touch in the OR. I GET that that's not what you are really paid a premium for. That would your knowledge. But, so many CRNA's don't know what they don't know (and probably never will), and they can be pretty ignorant.

Try having them step aside or chart for a while while you run the better part of a case. Do some of the "monkey" business like running a pump or programming an infusion sometime. You will see, as I have seen personally, how they are taken a bit back by all of that. Mainly this is because they can be SO ignorant of your/our skill set. Not sure, but it puts them in their place.

It's one thing for a CRNA to push for equivalency. It's another for the all too many of their ranks to not only want equivalency, but ALSO believe that they can run a room (i.e. do anesthesia as they view it) better than you, if they even believe you can still run a room at all. Because if they know you can run a room, it will indeed cause them pause since it doesn't take a rocket scientist to think that if they become independent, then the market (for now) will decide whom gets the job etc. or attracts a more lucrative payer mix.

Again, this is simple, yet effective. And, it may be fun for you as well. I know a LOT of attendings who would LOVE to do a one on one case more often than they get a chance to.

I've spoken with many surgeons on topics like these. Not residents, the attendings. They couldn't care less if you can get the Alaris pump into anesthesia mode. Doesn't change their impression of your skill set one bit.

As I said, I understand your perception as a resident. I'm telling you it will change over time. It did for me.

But that said, I do everything in the OR so you aren't talking about me. I'm the attending that puts the armboards on the table, hooks up the monitors, and preoxygenates the patient while you struggle to draw up the induction drugs. That's because I'm impatient and would rather do something myself than wait 5 seconds for somebody else to do it. But I have colleagues that struggle with the technical details of some dials and knobs and would rather not help flip the patient prone, but it doesn't change surgeons opinion of them.

And when it comes to the CRNAs, you are 100% incorrect of the viewpoint of the AANA and what the root cause of it is. It's all about power and money to them.

 

[gasattack3]

I've spoken with many surgeons on topics like these. Not residents, the attendings. They couldn't care less if you can get the Alaris pump into anesthesia mode. Doesn't change their impression of your skill set one bit.

As I said, I understand your perception as a resident. I'm telling you it will change over time. It did for me.

But that said, I do everything in the OR so you aren't talking about me. I'm the attending that puts the armboards on the table, hooks up the monitors, and preoxygenates the patient while you struggle to draw up the induction drugs. That's because I'm impatient and would rather do something myself than wait 5 seconds for somebody else to do it. But I have colleagues that struggle with the technical details of some dials and knobs and would rather not help flip the patient prone, but it doesn't change surgeons opinion of them.

And when it comes to the CRNAs, you are 100% incorrect of the viewpoint of the AANA and what the root cause of it is. It's all about power and money to them.

I realize I'm not talking about you. But, I really have to call BS on the fact that an attending surgeon cares less that an anesthesiologist fumbles around with dials and knobs. This all too pervasive arrogance on the part of anesthesiologists is a big part of the problem. You can not just ASSUME that everybody knows you are doing higher level things. Again, this will be a fatal mistake on our part. Perception is our reality. I don't like it any more than you do. But, it is what it is.

And I get that the AANA has a much bigger agenda. However, if they really believed that ALL anesthesiologists could function at least as good as them with "monkey" stuff, AND carried the knowledge and training (and skillset) of a physician, then they'd be a little more careful as they may very well get what they are wishing for. But, they are indeed emboldened by what they see are too many (not all and probably not most) anesthesiologists whom have lost the ability to not JUST preop and come up with an anesthetic plan, but also CARRY OUT that plan IF need be, themselves. This creates a sort of arrogance on their part, and encourages an idea in their heads that things would essentially be just fine if you didn't come to work that day.

Now, what percentage of CRNA's think that way is anybodies guess. I suspect it's higher than you think, however, despite any great relationships you have with them professionally.

 

[Mman]

But, I really have to call BS on the fact that an attending surgeon cares less that an anesthesiologist fumbles around with dials and knobs. This all too pervasive arrogance on the part of anesthesiologists is a big part of the problem. You can not just ASSUME that everybody knows you are doing higher level things. Again, this will be a fatal mistake on our part. Perception is our reality. I don't like it any more than you do. But, it is what it is.



Now, what percentage of CRNA's think that way is anybodies guess. I suspect it's higher than you think, however, despite any great relationships you have with them professionally.

No offense, but you admit to never having had a discussion with an experienced attending surgeon on this matter. How are you calling BS on something you've never even asked about?

As to the CRNAs, I have several very close personal relationships with CRNAs in addition to the ones we employ. As in relatives. I've read more issues of the AANA journal than most CRNAs have. I'm well aware of their thought processes. The majority of CRNAs are not our enemy. They want us around to help them. They have no desire to be sitting in a tough case and not have a lifeline to reach for when things hit the fan. Their professional organization is a separate issue.


I've been in your shoes and I know why you think what you think. But I know your conclusion on this is incorrect.

 

[IlDestriero]

One of the reasons that I took my current job was that I frequently get to do my own cases. I'm flying solo at least 20% of the time. I spent several years doing all of my own cases elsewhere. I tell all the fellows and residents they should try not to go to a 100% supervision job right out of residency. You learn a great deal when you have to do everything yourself with little to no back up available. I know it makes you better in a crisis. I'm very tempted to go back to an all MD job in the future, and keep in touch with friends at several places. It will never be the highest paid job, but a well run group can do just fine.
-
"The truth is incontrovertible, malice may attack it, ignorance may deride it, but in the end; there it is."

 

[saratoga733]

Gasattack3, I find it hard to believe an attending would have a difficult time using everyday OR equipment. Not sure where you're doing your residency but where I trained even the 'lab rat' attendings ie those with clinical days once a week know the OR equipment inside out. Now, attendings who are minimally involved or simply lazy that is another story. There are bad apples in every bunch.

WIth that said, I must admit I like the 'pep' in your posts. It's my sense that there are a lot of young, up and coming trainees out there ready to right the wrongs of those before us. Hard working young guns who will NOT sell out our profession. Fortunately, I trained at an institution where there were no CRNAs and currently work at an all MD practice. But I realize the majority of folks out there have to deal with mid-level providers and I applaud your desire to be vocal regarding what you perceive is a problem. Today you are a CA2, tomorrow who knows... you just might be the leader of the OR setting policy. Keep up the good fight.

 

[Idiopathic]

it takes about 2 weeks/20 cases to get back these skills, so i wouldnt worry too much about i t. whatever is important to your specific situation, that is what you will focus on.

knowing how to set up the fiberoptic scope is not the important part of the job (nor is programming the alaris pump). using/directing the use of those things is. now, if you want to suggest there are attendings that are losing THOSE skills (when to give an inotrope, interpretation of PA numbers, airway skills, etc.), ill agree that there are, and that would be a problem.

 

[gasattack3]

it takes about 2 weeks/20 cases to get back these skills, so i wouldnt worry too much about i t. whatever is important to your specific situation, that is what you will focus on.

knowing how to set up the fiberoptic scope is not the important part of the job (nor is programming the alaris pump). using/directing the use of those things is. now, if you want to suggest there are attendings that are losing THOSE skills (when to give an inotrope, interpretation of PA numbers, airway skills, etc.), ill agree that there are, and that would be a problem.

That's part of my point. It IS super easy to brush up on some of the "newer" technologies in the OR. But, why is it that too many attendings don't know how to "operate" said equipment. It's simple stuff and takes very little time at all to learn/RElearn.

My main arguement is that I feel CRNA's are USING that PERCEPTION of incompetency relative to gagetry as a tool/platform/arguement (whatever you want to call it) that they are indeed NEEDED and necessary.

Also, remember that to THEM (not all as we all agree and probably a minority) these things may be a big deal. Perhaps not knowing how quickly one can learn that stuff since maybe it was difficult for THEM. I'm mostly just suggesting that ANYTHING that can increase your autonomy from relying on a CRNA can indeed send a powerful message that IF push came to shove, you really don't "need" them. I think this message may be valuable in future battles, that's all.

Giving them "breaks" is another way to do it, though I realize that poses accessibility problems in an ACT model (i.e. not being immediately available to other rooms).

 

[Idiopathic]

That's part of my point. It IS super easy to brush up on some of the "newer" technologies in the OR. But, why is it that too many attendings don't know how to "operate" said equipment. It's simple stuff and takes very little time at all to learn/RElearn.

My main arguement is that I feel CRNA's are USING that PERCEPTION of incompetency relative to gagetry as a tool/platform/arguement (whatever you want to call it) that they are indeed NEEDED and necessary.

Also, remember that to THEM (not all as we all agree and probably a minority) these things may be a big deal. Perhaps not knowing how quickly one can learn that stuff since maybe it was difficult for THEM. I'm mostly just suggesting that ANYTHING that can increase your autonomy from relying on a CRNA can indeed send a powerful message that IF push came to shove, you really don't "need" them. I think this message may be valuable in future battles, that's all.

Giving them "breaks" is another way to do it, though I realize that poses accessibility problems in an ACT model (i.e. not being immediately available to other rooms).

alternate thought: you need your in room provider to feel confident and to be able to perform these tasks. you cannot engage the mass politics of the situation from the preop holding area while supervising 4 rooms. you need to trust that your provider can handle certain things, be able to teach them those things, or work solo cases. those are your options. there is no place for filling the midlevel provider with self doubt or withholding skills - it only hurts the care of that patient. on a global scale, its a totally different situation, and you can argue the validity of what others can and cannot and should and should not do, and we can all whip them out and talk about whos is bigger, but i think there is very little place for that in the day to day running of multiple ORs.

trust me, it will be reinforced to you (and everyone else) daily how important you are. i did about 400 days as an attending before fellowship, i was needed to handle significant in-room situations other than induction and emergence on probably 390 of them.

 

[pgg]

The majority of CRNAs are not our enemy. They want us around to help them. They have no desire to be sitting in a tough case and not have a lifeline to reach for when things hit the fan.

Exactly. The militant ones get all the press, but most are just good people who happen to be advanced practice nurses. As much as the AANA pisses me off, I respect and like nearly all of the CRNAs I know.

Their professional organization is a separate issue.

Yeah, ASAPAC is the only answer I have to that. Imagine if every anesthesiologist and resident set up a monthly $20 donation on a credit card.


gasattack3 - are you an ASA member and ASAPAC donor?

 

[gasattack3]

Exactly. The militant ones get all the press, but most are just good people who happen to be advanced practice nurses. As much as the AANA pisses me off, I respect and like nearly all of the CRNAs I know.



Yeah, ASAPAC is the only answer I have to that. Imagine if every anesthesiologist and resident set up a monthly $20 donation on a credit card.


gasattack3 - are you an ASA member and ASAPAC donor?

Yes, I am. Both.

Idiopathic, you make some valid points. And Pgg, perhaps as a resident, CRNA's might speak and behave more frankly/openly with me. I can tell you that a suprising number of CRNA's don't do too much to hide the disdain they apparently feel for anesthesiologists, but you won't get this in YOUR interaction with them. It will be all smiles to be sure.....

That said, it's still a miniority of them, I agree. But, too many nonetheless.

I still stand by my assertion that we suffer from an image problem, as a whole (with plenty of acceptions). There are some very simple ways to improve this image. Very easy, yet not often enough employed. That's what I think.

 

[pgg]

Yes, I am. Both.

And Pgg, perhaps as a resident, CRNA's might speak and behave more frankly/openly with me. I can tell you that a suprising number of CRNA's don't do too much to hide the disdain they apparently feel for anesthesiologists, but you won't get this in YOUR interaction with them. It will be all smiles to be sure.....

My guess is that the disdain you see them express for certain attendings that are lazy/uninvolved is comparable to the way I felt about a couple of attendings who were similarly absent. Less "CRNA vs anesthesiologist" ... more "worker bee vs lazy supervisor".

It's possible I'm misreading the CRNAs I know, but I know the regulars pretty well. I do 100% my own cases so there's none of that lazy-supervision / I-don't-need-direction tension you seem to see a lot of. The only time I'm involved in their cases is when they ask for help.


Regardless, the turf wars are not going to be won or lost on the basis of how friendly or pissy we are in our daily interactions with them.

There are some very simple ways to improve this image. Very easy, yet not often enough employed. That's what I think.

Believe it or not, most surgeons, periop nurses, support staff, and CRNAs know the score.

Simple things: work hard, don't dump cases, be good at what you do, stay current, donate to the ASAPAC & your state PAC, and live your life. Obsessing over what you think CRNAs and SRNAs might think of you is no way to go through life.

 

[Idiopathic]

:Believe it or not, most surgeons, periop nurses, support staff, and CRNAs know the score.

Simple things: work hard, don't dump cases, be good at what you do, stay current, donate to the ASAPAC & your state PAC, and live your life. Obsessing over what you think CRNAs and SRNAs might think of you is no way to go through life.

 

[darby11]

. Imagine if every anesthesiologist and resident set up a monthly $20 donation on a credit card.

yeah i can imagine. Nothing would change. MOre money would go in the pocket of the director of the ASA, they would hire more people to make more tests and more hoops for us to jump through to collect more money, and the cycle would go on.

The ASA is a worthless organization that does not support anesthesiologists who actually work for a living..

 

[pgg]

yeah i can imagine. Nothing would change. MOre money would go in the pocket of the director of the ASA, they would hire more people to make more tests and more hoops for us to jump through to collect more money, and the cycle would go on.

The ASA is a worthless organization that does not support anesthesiologists who actually work for a living..

Yes we know, darby-woe-is-me-maceo, life is horrible and as a profession anesthesiology is on an uninterrupted downward trajectory. There is no escape, no hope.

 

[darby11]

Yes we know, darby-woe-is-me-maceo, life is horrible and as a profession anesthesiology is on an uninterrupted downward trajectory. There is no escape, no hope.

i bet you youre one of the people that would benefit from everyone donating to the asa pac.. stop being a SHILL for the ASA

 

[pgg]

i bet you youre one of the people that would benefit from everyone donating to the asa pac..

I sure would, because I'm an anesthesiologist and I practice in the United States.

stop being a SHILL for the ASA

I think you need to look up that word in a dictionary.

 

[2win]

True.
They changed somehow in the last time - BUT they lost the battle.
This is the time for the young ones and not brainwashed to kick in.
ASA is still the academic anesthesia - with all their faults.
2win

 

[medstudent87]

I'm just a med student, but the perception of the field is very much an issue at my level. Almost every time I tell another student that I want to go into anesthesiology, they kinda laugh. I'm guessing this is because they think anesthesiology isn't a real field and we don't really do anything.
Just the other day, a student asked me "so do you actually like anesthesia, or are you just really really lazy?"

WHAt????

 

[jwk]

i bet you youre one of the people that would benefit from everyone donating to the asa pac.. stop being a SHILL for the ASA

Do you do anything besides bitch and moan and complain? I have yet to see the first constructive post from you since you've been a member, and you're woefully short on ANY facts to support your uninformed opinions.

 

[MD Dreams]

I'm just a med student, but the perception of the field is very much an issue at my level. Almost every time I tell another student that I want to go into anesthesiology, they kinda laugh. I'm guessing this is because they think anesthesiology isn't a real field and we don't really do anything.
Just the other day, a student asked me "so do you actually like anesthesia, or are you just really really lazy?"

WHAt????

Then they don't know what anesthesia is all about. I was one of those people at one time. I didn't really realize the magnitude or the responsibility of the specialty until I was one third into my residency. Having that much responsibility for a patients well being can be a humbling experience. If your good at your job and you do it with integrity and passion they will respect you, although what they think doesn't really matter

 

[MD Dreams]

One more thing. In the past there were a lot of lazy anesthesiologist who didn't care about the specialty. They are the reason why we are in this mess today. But anesthesia is changing and has changed dramatically. We need passionate people who will represent the specialty with pride and dignity. There are a lot of issues going on now with anesthesia and you should not close your eyes to them. You should make an informed decision about your future after you have considered all aspects. Good luck!

 

[Dwindlin]

I'm just a med student, but the perception of the field is very much an issue at my level. Almost every time I tell another student that I want to go into anesthesiology, they kinda laugh. I'm guessing this is because they think anesthesiology isn't a real field and we don't really do anything.
Just the other day, a student asked me "so do you actually like anesthesia, or are you just really really lazy?"

WHAt????

I have experienced the same thing. As an MS1 I was 99% sure I wanted to do EM (extensive Fire/EMS/Police background). MS3 changed my mind and when I tell people about one of the popular comments tends to be "wow, so you want to go from doing everything to nothing." Frustrating, but obviously a statement made out of ignorance. I used to try to explain it, but now I just smile and nod.

 

[Dwindlin]

I'm just a med student, but the perception of the field is very much an issue at my level. Almost every time I tell another student that I want to go into anesthesiology, they kinda laugh. I'm guessing this is because they think anesthesiology isn't a real field and we don't really do anything.
Just the other day, a student asked me "so do you actually like anesthesia, or are you just really really lazy?"

WHAt????

I have experienced the same thing. As an MS1 I was 99% sure I wanted to do EM (extensive Fire/EMS/Police background). MS3 changed my mind and when I tell people one of the popular comments tends to be "wow, so you want to go from doing everything to nothing." Frustrating, but obviously a statement made out of ignorance. I used to try to explain it, but now I just smile and nod.

 

[CambieMD]

Well said! Perception is reality and many surgeons/OR staff perceive the inability or desire to stick around to help as being useless. For physicians starting 4 rooms at the same time, this is challenging task. Add to that the need to preop, do blocks, place invasive lines, and it almost becomes an impossibility. However, if you're supervising two rooms that's a different story.

I agree with the OP. We have to be proactive and involved. The problem with being a great problem solver or thinker is that no one can see you think. The surgeon can see you moving the patient and obtaining access.

Cambie

 

[NavyFlightDoc]

As a new CA3, I can identify with the OP's contention of perception being important. WE know that some of our attendings are weaker than others, but that is not what he is talking about. Some of our very smartest, nationally respected attendings are lost when left in a room by themselves. They know what to do, but have trouble with the mechanics. I've seen surgeons roll their eyes, which can't be a good thing. These men and women are fantastic anesthesiologists, and some of the best teachers we have,

BUT nevertheless, as we start planning our follies for the end of the year, a recurring skit theme is imagining what would happen if Dr. X was left in a room to do a case by themselves. I'm chuckling to myself just thinking about it.

 

[Bertelman]

BUT nevertheless, as we start planning our follies for the end of the year, a recurring skit theme is imagining what would happen if Dr. X was left in a room to do a case by themselves. I'm chuckling to myself just thinking about it.

I wanna see the YouTube link.