Question for those mostly supervising CRNAs

[CaliDreamin4Life]

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This is a follow up to the recent post directed at those attending a doing their own cases. It seems like the general consensus is that most enjoy and find it easier and safer to do their own cases.

I am a new grad joining a practice where I will be mostly supervising. This has me now thinking what I am embarking in.

Any tips on how to do this? We didn't have Crnas in my residency program so that entire dynamic is new to me. How does that work in terms of the interaction? How much autonomy do you give them? And what battles do you absolutely pick re: patient care vs. not even bother with.

Most importantly, how do you keep your skills up? Would appreciate any insight. Thanks!

 

[GasEmDee]

This is a follow up to the recent post directed at those attending a doing their own cases. It seems like the general consensus is that most enjoy and find it easier and safer to do their own cases.

I am a new grad joining a practice where I will be mostly supervising. This has me now thinking what I am embarking in.

Any tips on how to do this? We didn't have Crnas in my residency program so that entire dynamic is new to me. How does that work in terms of the interaction? How much autonomy do you give them? And what battles do you absolutely pick re: patient care vs. not even bother with.

Most importantly, how do you keep your skills up? Would appreciate any insight. Thanks!

What is the percentage of supervising vs doing cases solo? I think that the first 5 years out of residency are when you fine tune your skills most. You start to realize that some of the stuff you learned is wrong and was taught to you by people who don't know what they are doing. I hate to say this, but usually these are folk who never do their own cases.

Hopefully you can put yourself in a position to maximize your solo experience. How to supervise, be it CRNAs or residents, is a matter of persona style and personal comfort that you'll have to get a sense for on your own. Most important thing though: do not allow them to do anything that makes you uncomfortable or that your disagree with or that you wouldn't do yourself. If a complication happens, you will have to justify why you allowed it.

 

[IlDestriero]

The best thing a new graduate can do is go to a place that is as full service as possible where they work solo. I did this for several years and it was pure gold. Others argue that supervising 3 or 4:1 gives them 3-4 times the experience, let's just say that I disagree.
The second best thing you can do is to go somewhere that you can do your own cases regularly. Unfortunately many places are 99.9% supervision.
Call a few of your new partners and take the time to find out what the culture is at your shop with the CRNAs. Forewarned is forearmed. You do need to pick your battles, ignore trivial matters and figure out what the hard lines are for particular cases and patients. If you all have a nice relationship with the crnas this is an easy conversation. If you are populated with many militant dunce CRNAs, every deviation from their "plan A" will be a painful interaction. Finally, try to keep as close an eye on the rooms as you can, you may be shocked and/or horrified at what is done/tolerated without any thought of calling you. Of course you have to recognize that something is wrong first ...
Hopefully you have an electronic record, that will keep them honest. I could tell you many stories from the "trained to be independent" Navy CRNAs that would give you grey hairs.
We have a good group of CRNAs that understand that they will be closely monitored and be given plans, not allowed to do procedures, etc. They knew this coming into the job. They live in a nice place, make good money, and have great hours, competition will keep them in line forever. If they dreamed of independent practice they would never have taken the job. Hopefully your set up is similar.

 

[Consigliere]

We have a good group of CRNAs that understand that they will be closely monitored and be given plans, not allowed to do procedures, etc. They knew this coming into the job. They live in a nice place, make good money, and have great hours, competition will keep them in line forever. If they dreamed of independent practice they would never have taken the job. Hopefully your set up is similar.

This is easy to do in an academic institution when you're a pediatric anesthesiologist. Not so easy for the rest of us slobs.

 

[BuzzPhreed]

Any tips on how to do this? We didn't have Crnas in my residency program so that entire dynamic is new to me. How does that work in terms of the interaction? How much autonomy do you give them? And what battles do you absolutely pick re: patient care vs. not even bother with.

Whoa, boy. This is a friggin' minefield.

Let me just tell you this: it doesn't matter that you were a resident for the past 4 years (including internship). You are a newbie. Okay? Even to that 25-year-old CRNA who's graduated in December and got her first job after the community program qualified her and she passed her test. To her, you don't know anything. There is one way to do a case. Her way.

Now, what do you do in that situation? That's a tough one. You know why? Because she's friends with all the other CRNAs. They are going to go to lunch together. They probably hang out together after work. You get the drift. Maybe she's a good CRNA, too. Maybe not. You see, those other CRNAs won't really know because they don't actually work with her. All they're gonna talk about is how good or bad the attendings are (that is, how much autonomy they are given without being interfered with). You still with me?

You are walking into a bombshell situation. You are the new guy. And it doesn't matter if you were doing hearts in 95-year-olds with 3% EFs at UCSF and Ronald Miller himself was asking you how to do cases. Nosiree. You are the new guy and, while they appreciate your training (maybe), you automatically don't understand how it things work in private practice. Their job is going to be to teach you.

So... here's the tricky part. How do you stand your ground? Because that's what this is going to be about. How much of a spine you have. And how much of a spine you have is going to be predicated on how much of a spine your fellow anesthesiologists have. That and how much power those fellow anesthesiologists have.

This is why this is a tricky minefield. Because they are going to test you to see what they can get away with. It's going to come in all ways, shapes, and forms....

Not calling you for that wake-up in that critical airway? "Eh, I forgot. Sorry. I'll call you next time."

Gowning-up and starting that central line in your third room while you're busy in the other two? "Well, Dr. Spineless always lets me do the central line on his cases. I just assumed it'd be okay with you too."

Walking into the pre-op area and they've already drawn-up all the meds for the femoral nerve block, when she turns and looks at you with those doughy fawn eyes and sweet voice, "Mind if I do the femoral nerve block? I've done 25 of them already and I'm allowed to by the hospital's credentialing."

A lot of this is going to be precendent. That is, the precedent that's already been set before you walk in there and the precedent you set yourself. My advice? I'd find out exactly what's expected of the CRNAs you're going to be working with. I'd also get a list (I'm not joking, an actual list) of the ones who everyone considers weak and who everyone else considers strong.

Bottom line is you are not going to change what has occurred there when you walk in the door. If you're expected to just do consents and sign charts, well, buck-up buddy and get with it. You will not change this. Oh, you may be able to change it over time, but chances are you picked the wrong practice to start with.

If there is a difference of opinion about who does what, then try to side with the docs who are stronger (if that's what you want) in their stances with the CRNAs. I know you're the new guy and don't want to make waves, but if you start acting like a doormat from Day-1 you're going to get walked all over. Conversely, if you try to stand up for yourself, you are going to be fighting the dynamics and alliances that have already been well-established since before you were there.

This is a bad situation for any freshly minted doc to be in. My bottom line advice? Use humor to point out when they've done something stupid. Don't humiliate or belittle them. Don't try to instruct them or re-teach them how to be a nurse anesthetist. Don't lecture to them like you're a professor. They don't care. All they want is someone who is easy to work with and will let them do what they want to do. And that is fine unless they do something dangerous and stupid.

The rest is how much philosophically you want to let them do. That's up to you and the other peeps in the practice.

 

[urge]

I wonder if the majority of people enjoy doing their own cases. Somehow I doubt it.

 

[Surfer]

Yes, most of us doing our own cases prefer it this way. unquestionably. if i wanted to be a nurse supervisor i would have gone to nursing dnp school.

 

[deleted126335]

Everybody has to find and maintain their own place in the jungle.
Different jungles have different hierarchies.
Inability to adapt to local customs and practices will kill a newbie.
If the CRNAs work for the docs in a private practice group, you can expect a very different dynamic than if one or both are hospital employees.
You can count on the long term CRNAs to test a newbie.
Don't be afraid to bounce stuff off a doc that you like and get a good vibe off. If your judgement is sound they wish you well.

 

[BuzzPhreed]

If your judgement is sound they wish you well.

Unless you slow **** down with all your questions and "need to be there".

I'm not so optimistic as you, bro.

 

[deleted171991]

I am a new grad joining a practice where I will be mostly supervising. This has me now thinking what I am embarking in.

A lot of very good posts in this thread. Not much to add, except that you have probably chosen the wrong practice to join. Your questions should have been part of your due diligence before taking the job. Any seasoned attending worth his/her salt would have told you exactly what has been posted here so many times: work solo at least for the first 5 post-residency years.

The best thing a new graduate can do is go to a place that is as full service as possible where they work solo. I did this for several years and it was pure gold.

Couldn't agree more. Whenever I have to deal with CRNAs (1 day in 10), it makes a big difference that they know that I can do everything they can and better, because I have provided anesthesia for those procedures myself many times, solo.

 

[BuzzPhreed]

I will reiterate for those of you who do not know my story.

I was in a practice where I was able to do my own cases 60-70% of the time. I was paid well. We had a good structure with CRNAs who were well-seasoned and "knew their place" for lack of a better term.

For some reason mostly at my wife's behest, I left this practice for fairer climes. It was a disaster. And exactly as I had described above. I went from 60-70% solo down to about 5-10% solo. And my supervision went from 2:1 with occasionally 3:1, to mostly 4:1 sometimes 3:1 (which felt like a vacation when it happened).

Very quickly I realized that this new place was just a machine that didn't really care about anything but getting the work done and not pissing the surgeons off. Whatever corners needed to be cut were cut. The scenario I described above was exactly what it was like, except I finished residency in 2007. Even I, at 37 years old, was treated like I didn't even know how to start an IV. Okay, I'm exaggerating a little. But I had all manner of people trying to show me the "correct" way to do things. It got to the point that I jokingly asked the chief if it was okay if I went and took a **** and whether or not he wanted to come along to show me how to wipe my a$$ properly. 100% true story. I already knew I was leaving by that point.

Fortunately for me I recognized this quickly and got out of it. Yes, it was a pain in the ass but my old job wanted me back and I'm happy for it. Don't make the same mistake I did.

A wise man learns from the mistakes of others, a fool from his own.

 

[sleepallday]

I'll add my 2 cents.

I do my own cases about 85% of the time, on the occasion that I am supervising, I've let it be known from day one that I have to be well informed of whats happening in the room. For example, if surgeon suddenly loses 500cc blood in the last minute, you page me. If you want to transfuse blood, you page me first. If you just used a whole syringe of phenylephrine in the last 20 mins, you page me. I even have them page me for all wake ups (I won't necessarily be in the room every time, but I at least like to know its happening). Of course, I try to get my message across in the nicest way possible and my experience has been that most don't mind my rules at all.

 

[chmd]

I like my 3-1 job to start the day, then slows to 2-1 by noon and stays that way. It's all supervision except hearts (25/ year per doc probably).

To answer your question, don't demand things, just be there for induction and emergence. And check in every 30-45 minutes to ask if your nurse "needs anything."

Be upfront about your plan, but after a few months don't treat the nurses like you don't trust them, ie stop saying "the usual" and instead expect them to know it.

Also, dont let them do pnbs or thoracic epidurals. Get to work early.

 

[IanMcGalt]

A lot of discussion of supervising on sdn is misleading I think so I'll add my opinion. You aren't sitting around arguing about the plan all day. The plan is almost always the obvious choice- prop, roc, tube anyway.

In my group, the decision is already made that docs do all the blocks and central lines, nurses can do ivs and alines. I'm not too quick to take over the aline so by the time I do, they're usually happy enough to give it up, if they get it quickly then great! We are also always there for induction too.

I also don't sit around being afraid of what harm the crna is doing all day. I'm confident that they are doing a good job and that if things aren't going well I'll get a call. The only thing that really matters is knowing I'll get called if there's a problem.

If some people let nurses do blocks orlines and induce without you then that sucks, but it isn't inherent or necessary in supervision jobs.

 

[BLADEMDA]

Nurses can be "steered" into doing the right thing over time. That is, you start out day 1 explaining how and WHY you like things done. You are nice about it and non confrontational but assertive. The key is to be reasonable, logical and flexible (does it really matter how they tape the tube in a supine case) in your dealings with the CRNA.

For an average knee scope your approach should be different than for an ASA 4E SBO or Open AAA. I also agree that doing your own cases for the first 4-5 years makes one a better Anesthesiologist. I did 50% of my own cases for the first 5-6 years of my career so I could actually become slick in giving anesthesia. I would not be nearly as good today if I was supervising CRNAs doing all their own blocks, lines, fiberoptics, etc. from day 1 post residency.

 

[CaliDreamin4Life]

Thanks for replies folks.

Wondering if I made the right decision now re: quantity of supervision vs. own cases. Not many options where I am at.

 

[loveumms]

I supervise residents and CRNAs. I ask the CRNAs if I can do the intubations. I don't want to steal procedures from my residents but I also don't want my airway skills to get rusty. Every single one of them comments on how awesome it is that I ask. They don't care and I'm not too proud to ask.

I will let them try a-lines. I do central lines and advanced blocks when working with the CRNAs.

The job market is tough right now. You made the right decision for yourself and your situation. Just try and make the best of it. Go in with a positive attitude and don't flex your muscles. Some of the CRNAs you are working with have been practicing for longer then you've been alive. Some will be really good, others not so good. Same thing with your partners.