Real meaning of autonomy

[docno1]

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I am a FMG in a surgery program in new york(above average program).
Autonomy in the OR at my institution is pretty limited. Therw are very few attendings who would not scrub in but mostly the attendings scrub in and usually take the resident through the case. Now, the attending plans the surgery, marks the incision and guides you where to bovie and what to look for so do u consider this a good operative experience.

i just wanted to know if this is the norm or am i stuck at a bad place.
I have also heard at some places chiefs run their own service doing whipple without the attending scrubbing in. Is that true? could someone explain if there are some programs better than others or its same everywhere.
Thanks in anticipation

 

[Blade28]

Well it depends...is the program top-heavy? Do you get more experience and autonomy as you proceed up the ranks?

Are your chiefs capable of doing Whipples with minimal guidance?

Certainly some programs are better than others in terms of how much exposure their residents get to the OR.

 

[Amgen1]

i would venture to say that most gauge operative autonomy in varying matters for varying cases.

so a third yr should be able to do a hernia and lap chole where the staff never scrubs. we do it where the staff are called into the rm when the duct & artery are being clipped. usually they will not scrub

by end of 3rd yr or 4th yr you should be able to do LARs yourself with staff just scrubbing when the anastomosis is being complete
i think a chief would prob start a whipple by themselves, but the staff would still scrub early on. however, they would expect the chief to dictate the moves and they would try to first assist the chief



most true operative autonomy is gained at the county or va hospitals.

 

[dynx]

I am a FMG in a surgery program in new york(above average program).
Autonomy in the OR at my institution is pretty limited. Therw are very few attendings who would not scrub in but mostly the attendings scrub in and usually take the resident through the case. Now, the attending plans the surgery, marks the incision and guides you where to bovie and what to look for so do u consider this a good operative experience.

i just wanted to know if this is the norm or am i stuck at a bad place.
I have also heard at some places chiefs run their own service doing whipple without the attending scrubbing in. Is that true? could someone explain if there are some programs better than others or its same everywhere.
Thanks in anticipation

To give you something to contrast:
At my program, as an intern...at the end of the year i could start umbilical and inguinal hernias as well as breast cases (meaning make the incision and start getting to the meat of the case) while the attending was scrubing. I have gone through a lap choles, doing the whole case while a 3rd year was walking me through it (the attending is in the room for about 3 minutes total to make sure things are going fine...they ALWAYS stop by). I have done/can do a lap and open appy skin to skin but haven't had the opportunity to do one with a senior resident, just attendings...however if one ever came in during the day (they never do), I would probably do it with just a senior resident.

Whipples at my program are done with attendings. I have done the gastric anastomosis for a whipple but for the most part the attending is there guiding a senior through the case. I would be impressed if there was a program where chiefs where doing whipples w/o attendings.

 

[Winged Scapula]

As you can see, it varies widely. I also would be impressed if there Chiefs doing Whipples without an attending scrubbed.

My program did not have enough resident coverage for residents to be doing cases where an assistant was needed, because the juniors were busy on the floor or in the ICU, so the attending was always scrubbed. There was also no autonomy and faculty who were not in the room (at least) when cases were being done were crucified by the others. Some scrub nurses would not let the residents start cases without the attending in the room.

There does tend to be more autonomy at county hospitals but the days of residents doing big cases alone are waning in light of increasing oversight and liability.

 

[docno1]

Thanx for all replies

To dynx .. just curious about the geographic location of your program because i can never see that interns are starting cases without attendings in my program.

Also i have heard that northeast and southwest regions are poor in terms of autonomy...true?

 

[SLUser11]

i would venture to say that most gauge operative autonomy in varying matters for varying cases.

so a third yr should be able to do a hernia and lap chole where the staff never scrubs. we do it where the staff are called into the rm when the duct & artery are being clipped. usually they will not scrub

by end of 3rd yr or 4th yr you should be able to do LARs yourself with staff just scrubbing when the anastomosis is being complete
i think a chief would prob start a whipple by themselves, but the staff would still scrub early on. however, they would expect the chief to dictate the moves and they would try to first assist the chief



most true operative autonomy is gained at the county or va hospitals.

Well, I would say that your autonomy is better than mine. As a newly minted PGY-3 with almost 400 major cases and 1000 logged procedures, I don't have the level of confidence described in your post.

I feel comfortable doing simple cases (breast, choles, appys, etc) without staff, but would be hard pressed to do a colon case with the staff not scrubbed, and would have a record high level of anal tone in a liver/pancreas case without staff.

I would say that my operative experience is well above-average, but I'm not ready to run out into practice. We typically don't operate without staff until 4th and 5th years, and I guess I'll see at that point exactly how much (or little) I can really do on my own....

 

[CTS]

@ my program all attendings scrub for their cases. Nobody starts the case without an attending in the room.
They sometimes live before closure.
No autonomy......🙁

 

[Winged Scapula]

@ my program all attendings scrub for their cases. Nobody starts the case without an attending in the room.
They sometimes live before closure.
No autonomy......🙁

Sorry, I couldn't help but laugh at your (unintended) pun. Damn those attendings...if they scrub out, I'll let them live!!!!

 

[DrDre311]

@ my program all attendings scrub for their cases. Nobody starts the case without an attending in the room.
They sometimes live before closure.
No autonomy......🙁

I can't stand doing cases with attendings who live. I like to do my cases "Weekend at Bernie's" style, with the attending propped up at the foot of the table wearing cheap sunglasses. Of course, I have to think quick and make cheesy one-liners when staff flops over into the field, and hilarity ensues...

 

[SLUser11]

I can't stand doing cases with attendings who live. I like to do my cases "Weekend at Bernie's" style, with the attending propped up at the foot of the table wearing cheap sunglasses. Of course, I have to think quick and make cheesy one-liners when staff flops over into the field, and hilarity ensues...

A surgeon scenario would have made that movie a lot funnier.....

 

[Amgen1]

I can't stand doing cases with attendings who live. I like to do my cases "Weekend at Bernie's" style, with the attending propped up at the foot of the table wearing cheap sunglasses. Of course, I have to think quick and make cheesy one-liners when staff flops over into the field, and hilarity ensues..

the ortho residents at one of our hospitals do something eeriely similar to this. the residents used to operate w/ no supervision at all. however recently, to meet medicare guidelines that a staff must be present so that it is not fraud, they have hired the oldest orthopod staff you could ever imagine. he just wanders the halls smiling looking very confused. they have him around to sign the paper work for being "present"

a second best to proping up a corpse

 

[DrDre311]

the ortho residents at one of our hospitals do something eeriely similar to this. the residents used to operate w/ no supervision at all. however recently, to meet medicare guidelines that a staff must be present so that it is not fraud, they have hired the oldest orthopod staff you could ever imagine. he just wanders the halls smiling looking very confused. they have him around to sign the paper work for being "present"

a second best to proping up a corpse

F*** that sh**. I keep it f***ing real. Using anything other than actual dead attendings is bush league.

The ortho residents at your place are weak ass sellouts.

 

[ChiSoxMD]

For us it is really attending dependent. As a new PGY-3 (in 1 day), I start a lot of the simple cases on my own (hernia, lap chole), and the attending will scrub halfway. For our chiefs, the surg onc division heads gives them an hour to an hour and a half head start on the whipples, usually scrubbing in when they get to the portal dissection. With our private surgeons they are a little more hands on but also only get midlevels and juniors. At the VA we operate pretty much independently with the attending sticking their head in the room once or twice.

 

[kate0834tkjn]

On my surgery rotation, the resident/student/nurses get the patient positioned on the table, etc, then they page the attending to come check it out and make sure everything's OK. Then, everyone goes to scrub together, gown together, and then the surgery starts. The attending stays through the whole thing until the skin, which the resident closes alone most of the time. usually, the attending pops his head back in to make sure the resident is doing OK, although not always. (This was mainly in the case of neck/face procedures.)