question for attending physicians

[D P356]

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med student here,

question for you attendings...

after residency, how long did it take for you all to become comfortable with your abilities? As an attending, you are the end of the road for your field. So when things go bad, at what point (months/years/etc) does it become "routine?"

I recall being with an anesthesiologist, and a AAA procedure started going south, and this doc looked like he had ice water running through his veins and was not phased at all.

Another instance was when a neurosurgery patient was wearing a C collar, the airway was challenging and after a couple attempts, the attending went through the patients nose to intubate. Probably pretty basic to you guys/gals, but that was my first time ever shadowing an anesthesiologist.

Perhaps on the inside those docs had the adrenaline flowing, but they were both really smooth and composed.

Essentially, how long did it take being out on your own to get the confidence in your abilities to handle whatever happens? From day one, you're on the line, but when do you start to catch your groove?

Thanks

 

[jetproppilot]

med student here,

question for you attendings...

after residency, how long did it take for you all to become comfortable with your abilities? As an attending, you are the end of the road for your field. So when things go bad, at what point (months/years/etc) does it become "routine?"

I recall being with an anesthesiologist, and a AAA procedure started going south, and this doc looked like he had ice water running through his veins and was not phased at all.

Another instance was when a neurosurgery patient was wearing a C collar, the airway was challenging and after a couple attempts, the attending went through the patients nose to intubate. Probably pretty basic to you guys/gals, but that was my first time ever shadowing an anesthesiologist.

Perhaps on the inside those docs had the adrenaline flowing, but they were both really smooth and composed.

Essentially, how long did it take being out on your own to get the confidence in your abilities to handle whatever happens? From day one, you're on the line, but when do you start to catch your groove?

Thanks

A strong resident will transition nicely into private practice fully capable of handling most situations.

There is some anxiety however even if you are competent since there's no

Big Brother (a.k.a. Your academic attending)

backing you up.

To grasp this profession as a whole,

gut wrenching stressful cases, how to control the flow of the OR (which can be stressful), gain complete confidence in your procedural skills, gain complete confidence in your judgement skills,

I'd say it takes about

5 years of a busy private practice

to be able to maintain a

heart rate of 55

regardless of what's going on around you.

 

[Trisomy13]

A strong resident will transition nicely into private practice fully capable of handling most situations.

There is some anxiety however even if you are competent since there's no

Big Brother (a.k.a. Your academic attending)

backing you up.

To grasp this profession as a whole,

gut wrenching stressful cases, how to control the flow of the OR (which can be stressful), gain complete confidence in your procedural skills, gain complete confidence in your judgement skills,

I'd say it takes about

5 years of a busy private practice

to be able to maintain a

heart rate of 55

regardless of what's going on around you.

being only about 1.5 years out of residency, I think this reply is spot on.

to the OP: some days the OR flow is more stressful than any train wreck case that is going on. 5 years seems a little long to me to "get it", but probably appropriate for some. judging by some attendings you will meet, there is no amount of time that will make them into cool characters. if you find yourself at a residency with some weak (or crazy, or lazy, or dysfunctional...) attendings, use your time with them to learn how NOT to be in the OR. nobody likes a spaz. when the patient is crumping, the team shouldn't be distracted by the anesthesiologist losing his sh|t.

 

[IN2B8R]

med student here,

question for you attendings...

after residency, how long did it take for you all to become comfortable with your abilities? As an attending, you are the end of the road for your field. So when things go bad, at what point (months/years/etc) does it become "routine?"

I recall being with an anesthesiologist, and a AAA procedure started going south, and this doc looked like he had ice water running through his veins and was not phased at all.

Another instance was when a neurosurgery patient was wearing a C collar, the airway was challenging and after a couple attempts, the attending went through the patients nose to intubate. Probably pretty basic to you guys/gals, but that was my first time ever shadowing an anesthesiologist.

Perhaps on the inside those docs had the adrenaline flowing, but they were both really smooth and composed.

Essentially, how long did it take being out on your own to get the confidence in your abilities to handle whatever happens? From day one, you're on the line, but when do you start to catch your groove?

Thanks

Once you have done enough cardiac, peds, neonates, pain, OB and all of the other BS in between, including getting shafted by arse-hole hospital administrators, then be it ice or blood that runs through your veins, you are "comfortably numb," while all others are ****ing in their pants.

 

[pgg]

I'm 2.5 years out and some days I feel like the learning curve is still steeper than I thought it would be at this point.

It's the things that aren't taught in residency that were hardest at first - board running, people management, dealing with pissed off surgeons whose soft-urgent cases were getting bumped by actual emergencies. That stuff I still struggle with at times.

I have a lot less anesthesia angst now though. I remember having anesthesia dreams my first year out, which got worse around my oral board date. Instead of the show-up-at-gradeschool-in-underwear nightmare, it was in-the-OR-everything's-going-to-hell nightmare and I forgot to check the laryngoscope battery or turn on the vaporizer.

It gets better though. Then I come in here and read one of periopdoc's posts and start feeling inadequate again.

I believe Jet's 5 years of busy private practice mark is probably pretty accurate.

 

[IlDestriero]

I would say 3 years if you're doing your own cases. I can't say how long in the care team model as that's not how I got started.
I would recommend that all new grads try to go out into 1:1 practice (no supervision). You refine what works for you and what doesn't when it's you getting it done every day. Watching the stool hit the fan when there's nobody but you to fix the problem puts hair on your chest quick. Though I acknowledge that's not an option for everyone, and probably less and less of one each year.
And yes, some people never get there. Ever. Some are always painfully anxious, some waste too much time trying to figure out what's going on instead of doing something, and some crack under pressure. One of the smartest staff I trained with was crap in a true emergency. Not the guy you want when the ruptured AAA is essentially DOA in the ED. 5 star resume, crap in the OR. I hope he chilled out.
There are also micromanaging, pimp heavy, pains in the ass attendings that are suddenly worth their weight in platinum when it all goes to stool. Their blood secretly runs with ice.👍 They can suck to work with, but you can often learn the most from them. They're day trading on their iPad while directing the recussitation from the stool in the corner.

 

[Idiopathic]

i had nightmares off and on for 6 months after starting, and an incapacitating migraine before my first overnight OB call. i still get nervous with things like floor airways and am maybe a little too "hands-on" when things get dicey. that will get better i hope (or rather, my ability to allow my residents to learn from these situations will)

 

[D P356]

thanks for your responses. If you're in an ACT model wouldn't you be likely to be responsible for 4x the potential amount of crap hitting the fan? You could potentially put out more fires? (I'm not saying that is good or bad, just asking the folks who are in the game) Thanks again.

 

[B-Bone]

I've only been out a year and a half, but my attitude regarding stressful,do-or-die situations has completely changed. I used to get really flustered during badness, and did not perform well. I can pinpoint the exact case that changed things for me. Last month of CA-3 year, a bad case rolled my way with no advance notice (not even a phone call!) and a cardiac surgeon straddling the patient doing open cardiac massage in his jeans and a flannel shirt. I had no time to think, only things to do. ACLS. HEPARIN. PUMP. I remember thinking "this dude is already dead, there's nothing I can do to blow this". Once that was in my head, all the jitters melted away and I had no trouble stepping back and focusing on the big picture. I remember some bad-ass total stud anesthesiologist with icewater veins trying to explain to me that most horrific situations were all easy to deal with because it's really just ABC's, and totally not getting how it could ever seem that easy. Since my "epiphany case", I consciously think to myself "this dudes already dead and anything I can salvage is gravy" (whether it's true or not). Of course, my heart still gets pumping, but I've had multiple debriefs after complete sh*tstorms where people marveled at how calm I looked in the middle of it all. And even just looking the part (zen master) goes a long way. You're supposed to be the one with the plan. The anesthetists, circulators, techs, and even the surgeons are looking at you for guidance and if they think you just dropped a load in your pants and don't know what to do, it's gonna be chaos.

 

[periopdoc]

I am only a year in, but had great training and a background in EMS beforehand which gave me a higher baseline level of equanimity than most. I will let you know in another 5 years if I feel that Jet is on the mark, but at this point there is really only one area where I still feel uncomfortable and that is peds. For some reason those "hard to kill" buggers still keep me on edge.

A few cases from the last month -

Off pump CABG with a failing a-line and an unreliable pulse ox tracing - no problem.

One of my colleagues undergoing emergent laparotomy for life threatening hemorrhage - no problem although my heart rate was up a little bit since we didn't have time to transfer to the main OR and did the case in the obstetric OR.

One lung ventilation of a patient with severe interstitial lung disease and a PaO2 of 60 on a FiO2 of 1 before initiating 1 lung ventilation - no problem.

Tomorrow I have 2 healthy peds for dental work and I am a bit nervous.

Don't know why.

Maybe I should have done that peds fellowship.

- pod

 

[urge]

I would say 3 years if you're doing your own cases. I can't say how long in the care team model as that's not how I got started.

Around 5 to 6 years in ACT model. More for solo practice. You do way more cases in ACT model. You also learn how to deal with the anesthetists sabotaging you. It's harder to get in problems when you are practicing solo since you have control of everything.

 

[sevoflurane]

1) Go to a good residency. This is the first step. Do as much as you can and volunteer for all the difficult cases... even if it means that you have to leave at 11:00pm when everyone else has already gone home. I use to try and sell my soul to do a liver tx case during residency. I found them to be some of the best experiences to date.

2) Once you get out, go solo before you supervise. This WILL make you grow some hair on your chest... especially in the middle of the night when it's you and only you. I believe it makes you an efficient anesthesiologist without the need of another anesthesia provider to lend a hand when things get dicey. Amazing what you can learn of yourself at 3:00am during a trainwreck case. You often realize areas in which you can improve... tightening the screws little by little.

3) Your first job should be one that is not bread and butter. Get into something that has neuro, trauma, cardiac, peds, etc. If you go right into bread and butter... you may not have the opportunity to hone in certain skills. IMO, we should learn to land a burning plane with no fuel and no rudder and no copliot (solo practice).


I'm not a supa-star and certainly don't have the experience that many on this forum have. But honestly, there is not much that scares me in the OR and I'm midway through my 3rd year out (holy crap... time is flying 😱). You just focus and take care of business. No time to think flustered. You just take care of business.

I don't do <6mo. olds much... and since I don't do them frequently, I would feel anxious doing a 4 mo. old, ex-premie, BPD, VP shunted, FLK, goldenhar's kid for a crani. I wish I had the opportunity to hone in that skill set, but my current practice doesn't do these types of cases... so I am getting rusty with these patients. I think this in natural no matter how many years you've been out.

Learning how to effectively deal with surgeons, nurses and administration is something that def. requires good thought and experience.

My 2 cents. 🙂

 

[BLADEMDA]

I'd say 24-36 months if you finished a strong Residency program AND get to do some cases solo during that time frame.

 

[gtb]

. . . which gave me a higher baseline level of equanimity than most. . . .

Periopdoc's mention of equanimity reminded me of an attending in Seattle who frequently invoked the value of equanimity for anesthesiologists. Here's the Osler essay he quoted. http://www.medicalarchives.jhmi.edu/osler/aequessay.htm

 

[pgg]

Periopdoc's mention of equanimity reminded me of an attending in Seattle who frequently invoked the value of equanimity for anesthesiologists. Here's the Osler essay he quoted. http://www.medicalarchives.jhmi.edu/osler/aequessay.htm

Thanks, that was an good read.


This made me

"in matters medical the ordinary citizen of to-day has not one whit more sense than the old Romans, whom Lucian scourged for a credulity which made them fall easy victims to the quacks of the time"

Some things never change