Poll for the residents regarding periop teaching

[propofabulous]

Hey all,

Question for the residents out there. Are there actually programs out there where the attendings teach in the OR? My institution is a quick check in at induction and emergence, essentially starting at the beginning of CA-1 year. I can count on two hands the number of times over the last year that an attending has volunteered to teach me something (instead of me asking for information) - not that there's anything inherently wrong with that (have to be proactive about our own education after all). But I'm just curious what it's like out there for the rest of you! Is my experience pretty much the norm? Thanks!

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[IlDestriero]

If you’re really getting near zero intraop teaching, and your attendings are real faculty at a university, you can annihilate them by giving them horrendous faculty evaluations. You can’t even be considered for promotion with a 2/5 teaching score, 3/5 for non research faculty, not that they’d promote you at that level anyway. I don’t think the residents understand how much power they have with the faculty evaluations. Comments like “worked with them 6 times in the last 2 months, all day, 20+ cases. Had 5 minutes of teaching total at best.” A few of these kinds of comments are promoting ending, a portfolio full is career ending. Unless they’re a multimillion dollar research grant recipient kind of faculty.

 

[dhb]

If you’re really getting near zero intraop teaching, and your attendings are real faculty at a university, you can annihilate them by giving them horrendous faculty evaluations. You can’t even be considered for promotion with a 2/5 teaching score, 3/5 for non research faculty, not that they’d promote you at that level anyway. I don’t think the residents understand how much power they have with the faculty evaluations. Comments like “worked with them 6 times in the last 2 months, all day, 20+ cases. Had 5 minutes of teaching total at best.” A few of these kinds of comments are promoting ending, a portfolio full is career ending. Unless they’re a multimillion dollar research grant recipient kind of faculty.

From what the OP stated it's not just a couple of attendings but the whole department. Are they going to fire everyone based on a resident's evaluation?

 

[DocVapor]

So I'm not doing the poll because it's publicly visible, but at my program it's variable day to day based on the attending as well as the case complexity. Also whether I take some initiative and speak up to ask questions or suggest trying something out of the norm, whether for a medical reason or because I just want to try something different.

Certainly some days I would have liked a little more in-room teaching, especially as a newer resident, but then there are other days where the opposite is true too - the attending decides they're going to spend time with you in the room discussing things but you'd rather not.

I've decided it's a good balance.

 

[deleted875186]

I’m with you, my program has little if any intraop teaching. And the little teaching I do get from many attendings is not useful.

While I agree all us residents can always be more proactive at education, it certainly gets hard when you start a bunch of cystos or lap cases and there’s little to discuss. Anyone have any suggestions on how thy make these days educational?

 

[DrZzZz]

I’m with you, my program has little if any intraop teaching. And the little teaching I do get from many attendings is not useful.

While I agree all us residents can always be more proactive at education, it certainly gets hard when you start a bunch of cystos or lap cases and there’s little to discuss. Anyone have any suggestions on how thy make these days educational?

Your discussion doesn't always have to be related to the cases you're doing or the patients you're taking care of. Figure out what each attending's strong areas are and determine a topic within their realm you want to know more about. Many (certainly not all) are more engaged when you show interest and initiative in your education.

 

[PieOHmy]

I’m with you, my program has little if any intraop teaching. And the little teaching I do get from many attendings is not useful.

While I agree all us residents can always be more proactive at education, it certainly gets hard when you start a bunch of cystos or lap cases and there’s little to discuss. Anyone have any suggestions on how thy make these days educational?

do you not talk about the case?
I can think of dozens of issues on each case that i can go on and on about if i worked with residents.
even if its a straightforward foot case.
and im not even talking about reading the book to the resident. Im talking practical things.

 

[urge]

There is nothing the attending can teach you that is not better explained in a book.

The people asking for teaching are too lazy to read a book.

What you need to learn from the attending is how to actually do the cases, which is often not in the books. Just follow his/her lead and read the theory on your own.

 

[shepardsun]

There is nothing the attending can teach you that is not better explained in a book.

You've clearly never worked with a great teacher.

 

[deleted171991]

do you not talk about the case?
I can think of dozens of issues on each case that i can go on and on about if i worked with residents.
even if its a straightforward foot case.
and im not even talking about reading the book to the resident. Im talking practical things.

This is a two-way street. This generation has been way too coddled. Some of the CA-3s are almost like CRNAs, they only know and like to do stuff one way (theirs). Btw, I remember being a CA-1 and one of my attendings making that kind of remark about me, behind my back. It didn't really slap me in the face back then, but it's something I have been actively working on since the day I became an attending.

And when they make mistakes, and get a stronger reaction from the attending, designed both to protect the patient and anchor the memory for years to come, they report you.

I don't remember almost anything the nice guys taught me during residency. But I remember everything the nasty ones did. Back then, I used to hate them; how stupid I was. I bet they got the worst reviews from the residents. In the current world, I bet they stopped teaching passionately. I did too. Why would I open my mouth if anything I say may be held against me, because I didn't kiss the resident butt properly? I have become as careful around residents as with nurses. The medical world has become too "progressive" for my tastes.

And why the heck should one become great at teaching, if nobody cares? Great teaching doesn't bring grants or papers or fame for the institution, so nobody becomes a tenured professor because of it. Most of the time, residents can't recognize it even when they see it. They are taught about their rights since diaper age, instead of being taught to shut up and listen. Also, many times, the real experts are not great teachers, so one needs to "steal" the craft, like an apprentice, not expect it to be handed over on a silver plate and with Powerpoint slides and handholding.

 

[Guillemot]

I remember declining relief by a call resident from a case at the end of the day on a sick patient because was not a good case to hand off. Since the call resident was free I had him see my inpatient for the next day instead since I was already going to be getting out of there quite late. Got bitched out by the attending for not seeing the patient myself because that was his pet peeve apparently. Hypocritically he also did not see the patient. I was pretty apathetic about the whole thing as I think I was like in like my last month of residency, and I think he was taken aback that I didn't care that he was mad. lol

I tell this story to illustrate that its not just residents that can be whiny bitches.

 

[deleted171991]

I remember declining relief by a call resident from a case at the end of the day on a sick patient because was not a good case to hand off. Since the call resident was free I had him see my inpatient for the next day instead since I was already going to be getting out of there quite late. Got bitched out by the attending for not seeing the patient myself because that was his pet peeve apparently. Hypocritically he also did not see the patient. I was pretty apathetic about the whole thing as I think I was like in like my last month of residency, and I think he was taken aback that I didn't care that he was mad. lol

I tell this story to illustrate that its not just residents that can be whiny bitches.

No doubt the anesthesia world is full of mediocre teachers. I may be one of them. I believe in tough love, tiger mothers, not the BS they call teaching in America.

Btw, you should have asked your co-resident to do the preop, then go talk to the patient yourself before leaving. One doesn't drop the quality of care just because it's late, or it's the end of day etc. That's not what doctors do. You applied that concept for one patient, then failed to do the same for the next one. I am only commenting on this for the residents, not giving lessons to another attending.

Anesthesiologists should definitely preop their own patients whenever possible. To the day, even if my patient has an existing preop, I run everything by the patient, as if I were doing the preop from zero. Best way to remember the patient's data I have found.

 

[2Fast2Des]

I remember declining relief by a call resident from a case at the end of the day on a sick patient because was not a good case to hand off. Since the call resident was free I had him see my inpatient for the next day instead since I was already going to be getting out of there quite late. Got bitched out by the attending for not seeing the patient myself because that was his pet peeve apparently. Hypocritically he also did not see the patient. I was pretty apathetic about the whole thing as I think I was like in like my last month of residency, and I think he was taken aback that I didn't care that he was mad. lol

I tell this story to illustrate that its not just residents that can be whiny bitches.

I still don't understand what seeing the patient the night before really achieves... In PP nobody looks up their history the night before, as what can be learned is learned before the case. Unless the surgeon is wildly incompetent and put a completely in appropriate patient on the board, all the time..

 

[Guillemot]

No doubt the anesthesia world is full of mediocre teachers. I may be one of them. I believe in tough love, tiger mothers, not the BS they call teaching in America.

Btw, you should have asked your co-resident to do the preop, then go talk to the patient yourself before leaving. One doesn't drop the quality of care just because it's late, or it's the end of day etc. That's not what doctors do.

I agree, but I don't believe that having my colleague see them instead of me impacted the quality of their care. That's why I didn't bother. Handing off a sick patient to my colleague would potentially be deleterious to quality of care. That's why I did not hand off. I therefore utilized time efficiently and also provided good care.

No idea what your teaching quality is and not trying to imply anything. I do think though that you often have insightful posts on this forum. Just wanted to point out that residents aren't always the ones with the cliche millennial type issues.

 

[deleted171991]

I still don't understand what seeing the patient the night before really achieves... In PP nobody looks up their history the night before, as what can be learned is learned before the case. Unless the surgeon is wildly incompetent and put a completely in appropriate patient on the board, all the time..

It doesn't achieve anything for an attending who can look up stuff he doesn't quite remember in 5 minutes. For residents, it's essential to read up on their cases for the next day; that's 50% of their residency training.

 

[2Fast2Des]

It doesn't achieve anything for an attending who can look up stuff he doesn't quite remember in 5 minutes. For residents, it's essential to read up on their cases for the next day; that's 50% of their residency training.

They should read about the next day case. I just don't understand why the patient has to be physically seen rather than just do a chart review

 

[deleted171991]

They should read about the next day case. I just don't understand why the patient has to be physically seen rather than just do a chart review

Because it's good for both patient and resident to meet the day before.

 

[2Fast2Des]

Because it's good for both patient and resident to meet the day before.

Is it really?

 

[shepardsun]

The only time I see or contact patients the night before is if they are in house and I can get the consent done and save ten minutes on a case I anticipate will have a significant amount of set up in the morning. I don't at all understand the concept of early trainees contacting patients, especially before talking with the attending about the case. Read about the case, sure, but what do you gain in bothering some poor person the night before?

"Hello Mrs. Smith, I'm a CA1 that has been doing this for six weeks. Let's talk about your case. We might be doing a general anesthetic tomorrow, and you might get a breathing tube, but maybe we'll do an LMA instead. I'm going to consent you for a nerve block, although I don't know exactly which nerve we'll be blocking and you might not need it if the surgeon who I've never met uses a lot of local. You're probably really nervous, so I'll give you some Midazolam or something when I meet you in the morning. Have a great night and don't worry about the surgery, I'm sure it'll all be fine!"

By the time that you know enough to know what you're doing, you can get all the information you need and build the report you need in about ten minutes in pre-op.

 

[deleted875186]

I’m a resident. If I have an inpatient I will see them, only because I do think it’s good for the patient to see a familiar face other than just the surgeon for about 2 minutes in preop on the day of surgery. I don’t think it adds anything to my training though.

I preop and see other people’s inpatients for the next day when on call for the same reason, I imagine as a patient I would want to see an anesthesiologist the night before my surgery. I can’t say I’ve ever found much information that I didn’t already know from a chart review.

 

[pgg]

I think this poll is mostly meaningless, and I'll get to why at the end of this long post.

Teaching is hard. It's always struck me as bizarre and stupid that every one of us gets 4 years of science-heavy yet well-rounded undergraduate education, 4 years of science-only medical school, and 4 years of internship/residency, before we're expected to effectively teach.

You can't get a job as a substitute teacher at a junior high school without SOME kind of teaching credentials. Not necessarily a master's degree in education, but SOMETHING that involved being explicitly taught how to teach. My son just finished his sophomore year of college. He's a music major, plan A is to be a rock star, plan B is to be a high school music teacher, so he's on a track that will lead to teaching credentials. He's already had more hours of education instruction and OJT/internship teaching than I've had in my entire career. He'll probably end up going to grad school for more of it before going to work as a teacher.

Physicians generally have no formal training on education theory, how to evaluate people, how to give feedback, how to remediate people who are struggling, etc. It's no wonder that teaching during residency is so hit or miss. Where I am now, a couple times a year our affiliated university comes through with a day or two of seminars on how to teach. These are very good but they're a band-aid for what's really a huge hole in our training.

Everyone at this level really needs to have figured out the "adult lifelong learner" thing, and should be getting 90%+ of their foundation facts on their own. That doesn't mean that one-on-one teaching in the OR should NEVER be about the differences between type 1 2 and 3 protamine reactions, but ideally we aren't using that time to present facts.

When I think back to the best teachers I had as a resident, I'd say that the best ones didn't spend a lot of time giving me information. Rather, they were excellent clinicians with good judgment who corrected my plans when they had to (with reasoned explanations) and let me execute an OK plan when it was safe to do so, and then smirked as I struggled. I felt secure that they could bail me out of trouble I or the surgeon caused (within reason). I could ask questions and get answers that were better than appeals to habit or dogma.

Residency is more apprenticeship than traditional didactic education. I'm not sure I even agree that residents need "teachers" so much as role models and someone skilled to help them get the work done. I don't think this is something that can be assessed by quantifying the number of minutes spent "teaching" in the OR. I didn't vote in the poll because I honestly don't remember how often or how long my attendings gave me "teaching" in the OR.

 

[deleted171991]

The only time I see or contact patients the night before is if they are in house and I can get the consent done and save ten minutes on a case I anticipate will have a significant amount of set up in the morning. I don't at all understand the concept of early trainees contacting patients, especially before talking with the attending about the case. Read about the case, sure, but what do you gain in bothering some poor person the night before?

"Hello Mrs. Smith, I'm a CA1 that has been doing this for six weeks. Let's talk about your case. We might be doing a general anesthetic tomorrow, and you might get a breathing tube, but maybe we'll do an LMA instead. I'm going to consent you for a nerve block, although I don't know exactly which nerve we'll be blocking and you might not need it if the surgeon who I've never met uses a lot of local. You're probably really nervous, so I'll give you some Midazolam or something when I meet you in the morning. Have a great night and don't worry about the surgery, I'm sure it'll all be fine!"

By the time that you know enough to know what you're doing, you can get all the information you need and build the report you need in about ten minutes in pre-op.

It's about getting good at both H&P. That won't happen under time pressure, on the morning of surgery. Residents shouldn't get into the habit of just believing whatever they read in the preop/medical record; they should run the important things by the patient, and actively question the meaningful details.

That's why they should talk to the patient the day before, for the H&P part, and use the morning of the surgery for the detailed anesthetic plan and consent. The second chat will be much easier, both for resident and patient. Also, when done properly, each chat will take less than 10 minutes. Being able to obtain a good preop fast is one of the major skills an anesthesiologist should have; we are not just people with letters after our name.

Of course, one also has to learn how to do with less, if needed, but that shouldn't be the default setting. I cringe every time I see my residents arrive late and dedicate just a minimal time to talking to the patient. A pertinently detailed H&P (especially if based on previous chart autopsy), while sitting down at the bedside, is where the doctor-patient relationship is born. As in "this is Dr. FFP, my anesthesiologist".

 

[deleted171991]

I think this poll is mostly meaningless, and I'll get to why at the end of this long post.

Teaching is hard. It's always struck me as bizarre and stupid that every one of us gets 4 years of science-heavy yet well-rounded undergraduate education, 4 years of science-only medical school, and 4 years of internship/residency, before we're expected to effectively teach.

You can't get a job as a substitute teacher at a junior high school without SOME kind of teaching credentials. Not necessarily a master's degree in education, but SOMETHING that involved being explicitly taught how to teach. My son just finished his sophomore year of college. He's a music major, plan A is to be a rock star, plan B is to be a high school music teacher, so he's on a track that will lead to teaching credentials. He's already had more hours of education instruction and OJT/internship teaching than I've had in my entire career. He'll probably end up going to grad school for more of it before going to work as a teacher.

Physicians generally have no formal training on education theory, how to evaluate people, how to give feedback, how to remediate people who are struggling, etc. It's no wonder that teaching during residency is so hit or miss. Where I am now, a couple times a year our affiliated university comes through with a day or two of seminars on how to teach. These are very good but they're a band-aid for what's really a huge hole in our training.

Everyone at this level really needs to have figured out the "adult lifelong learner" thing, and should be getting 90%+ of their foundation facts on their own. That doesn't mean that one-on-one teaching in the OR should NEVER be about the differences between type 1 2 and 3 protamine reactions, but ideally we aren't using that time to present facts.

When I think back to the best teachers I had as a resident, I'd say that the best ones didn't spend a lot of time giving me information. Rather, they were excellent clinicians with good judgment who corrected my plans when they had to (with reasoned explanations) and let me execute an OK plan when it was safe to do so, and then smirked as I struggled. I felt secure that they could bail me out of trouble I or the surgeon caused (within reason). I could ask questions and get answers that were better than appeals to habit or dogma.

Residency is more apprenticeship than traditional didactic education. I'm not sure I even agree that residents need "teachers" so much as role models and someone skilled to help them get the work done. I don't think this is something that can be assessed by quantifying the number of minutes spent "teaching" in the OR. I didn't vote in the poll because I honestly don't remember how often or how long my attendings gave me "teaching" in the OR.

Darn beautiful (and articulate) mind. Makes me jealous all the time.

 

[MoMoGesiologist]

I always start off with “if there’s anything you’re interested in learning or have questions about anything, please let me know and we can talk about it” to juniors. The number of people who actually ask me questions or bring up a teaching topic is minimal. You can’t complain about lack of teaching when you don’t show some initiative...