Recent new attendings - anything you wished you worked more on during your last year of residency?

[propofabulous]

I am currently in my last year of residency, planning to go into private practice (if anyone is hiring in the time of Covid...).

I am looking for wisdom from those who have already gone through the resident -> attending transition, especially for private practice attendings doing bread and butter cases. Does anything stick out as something you wish you had experienced more, or tried or practiced or worked on during your CA-3 year of residency? Do you ever find yourself thinking "I wish I had done or seen more of ____"?

Examples I can think of (are these too exotic for private practice?):
-Procedures: awake LMA/glide, intubating through LMA, glossopharyngeal/superior laryngeal/transtracheal blocks, brachial/axillary/dorsalis pedis/femoral A-lines, subclavian/femoral central lines, perc cric, jet ventilation
-Regional: Cervical plexus, Infraclav, PECS1/2, QL, Serratus anterior, Anterior/Transgluteal/Subgluteal sciatic, Thoracic epidurals, Paravertebral, Catheters
-OB: epidural blood patches, CSE's, paramedian approach to neuraxial, lateral positioning during neuraxial
-Peds: peds caudals, peds A-line/C-lines
-Hearts: TTE, TEE

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[GassYous]

Nope. I did all of those things in training except QL, sciatic and crics.

With good partners you will pick up techniques very quickly. You don't need to waste a year in fellowship to learn how to do a QL block when you can look it up on nysora/youtube.

If I were you, I'd work on doing things quickly. Learn how to do blocks efficiently and time your wakeups for drapes going down.

Are You Ready For Private Practice?

(ADDENDUM: I wrote this a cuppla years ago. Its got alotta useful information in it for you. I'm bumping it for the benefit of my CA-3 colleagues who may have missed it and are gonna be on their own in a few months.) I'm starting a thread that I hope will be useful for the current and future...

forums.studentdoctor.net

 

[CUBR]

Regardless of how wide your breadth of experience you had during residency, there will be learning on the job at your practice. Hopefully, you'll have good partners that will get you up to speed as to what the group does.

Try to figure out what's your own strength and weakness, and how to deal with them. If you're going to PP, I would also start learning about finances.

 

[Justice4all]

I just started, supervision is a different beast. Dealing with CRNAs, residents, fellows is something you can't prep for until you are in it.
Try to get some supervision under your belt if allowed during CA-3.

 

[Simba1711]

For me I just started private practice

ultrasounded guided Ivs and alines
Awake fiberoptic intubations (haven’t done one as an attending but wish I did more in residency )
Femoral lines both central and arterial
Anesthesia in off site locations ( mri, stroke , ir, gi rooms)
Jet ventilation

 

[Lecithin5]

TEE

 

[surgndoc]

Use the US as much as you can - the faster and more skilled you are with it, and with different techniques for placing alines, IVs, blocks, central lines, etc. the better off you'll be. I use US all the time, sometimes multiple times per day.

Learn how to do paramedian approach for neuraxial, other than that CSE is just an epidural, and theres not much other routine things to know about OB besides placing the epidurals.

Caudals are pretty easy when you've done 10-15 so you could pick that up pretty quickly. The best way to do peds aline is to fill a small 22g or 24g angiocath with saline and go through-and-through, then wire on your way out. US not exactly necessary but can be useful if the kid is under 1yo.

 

[coffeebythelake]

Learn more about medical billing.
Make the tough decisions involving case cancellations

 

[Shimmy8]

Wish I worked on my short game a little more.

 

[buccsmf1]

Anesthesia in off site locations ( mri, stroke , ir, gi rooms)

this one for me. i graduated without ever doing GI, EP lab, TTEs etc. GI doesnt take too long to learn the tricks to a smooth day. But it took me a bit to learn the ins and outs of EP lab. lots of sick patients and its tough to understand exactly what the proceduralist is doing if youve never done the cases before.

 

[GassYous]

Reading these posts make me really appreciate my training program much more than I did

 

[Radar26]

Make the tough decisions involving case cancellations

this one for sure. Although most residencies will give you a range of attendings who are good and bad examples for making tough decisions

 

[Hork Bajir]

Agree with working off site (Endo, EP, IR).

Practice being independent. Your attendings do all sorts of stuff for you that you probably don’t even realize- pushing drugs while you hold the mask, handing you the ETT when you have a view, slowing down your IV fluids when you accidentally leave them wide open, calling for an ICU bed when your patient unexpectedly needs one, assisting with positioning, etc. whenever you are working with a staff who is willing to give you a longer leash, ask them to try not to do that stuff. You won’t realize which things you need to intentionally incorporate into your workflow until someone else stops taking care of them for you.

Also, as above, learn how to position patients safely. Esp for tricky cases like VATS, sloppy lateral, etc. No one taught me the intricacies of doing this as a resident, and I found it very stressful as a new attending... Positioning injuries are easy to have happen, and will always be blamed on you.

 

[Arch Guillotti]

Make the tough decisions involving case cancellations

Consult partner(s) before cancelling a case.

 

[Radar26]

Consult partner(s) before cancelling a case.

I totally agree but to be devil’s advocate what do you do when your partner says “whatever you feel comfortable with”

 

[GassYous]

Agree with working off site (Endo, EP, IR).

Practice being independent. Your attendings do all sorts of stuff for you that you probably don’t even realize- pushing drugs while you hold the mask, handing you the ETT when you have a view, slowing down your IV fluids when you accidentally leave them wide open, calling for an ICU bed when your patient unexpectedly needs one, assisting with positioning, etc. whenever you are working with a staff who is willing to give you a longer leash, ask them to try not to do that stuff. You won’t realize which things you need to intentionally incorporate into your workflow until someone else stops taking care of them for you.

Also, as above, learn how to position patients safely. Esp for tricky cases like VATS, sloppy lateral, etc. No one taught me the intricacies of doing this as a resident, and I found it very stressful as a new attending... Positioning injuries are easy to have happen, and will always be blamed on you.

My nurses do all that stuff. Put on monitors, hold the mask, hand me tube, hold the tube before I tape, etc.

It's especially nice in the outpatient setting where people go home when they're done and have an incentive to get things done.

 

[Arch Guillotti]

I totally agree but to be devil’s advocate what do you do when your partner says “whatever you feel comfortable with”

Put ‘em to sleep and see what happens.

 

[pjl]

Consult partner(s) before cancelling a case.

This is super important at the beginning (and later). A group should present a united front regarding cancellation of cases. Otherwise you have surgeons shopping cases and it can become a mess and divisive.
It helps to have some guidelines from the group, or at least talk about them. There will be some local culture variations between practices.

One of our unwritten rules is if a partner cancels a case, you accept it and back them up. Even if you disagree.
By running a cancellation by a partner, if you disagree, have a conversation away from all ears. These are times you both can learn a lot. If you are comfortable and they are not, you can swap cases before the surgeon ever hears one of you was planning to cancel.

 

[Arch Guillotti]

This is super important at the beginning (and later). A group should present a united front regarding cancellation of cases. Otherwise you have surgeons shopping cases and it can become a mess and divisive.
It helps to have some guidelines from the group, or at least talk about them. There will be some local culture variations between practices.

One of our unwritten rules is if a partner cancels a case, you accept it and back them up. Even if you disagree.
By running a cancellation by a partner, if you disagree, have a conversation away from all ears. These are times you both can learn a lot. If you are comfortable and they are not, you can swap cases before the surgeon ever hears one of you was planning to cancel.

Agree. Everyone has to be on the same page.

 

[Hork Bajir]

My nurses do all that stuff. Put on monitors, hold the mask, hand me tube, hold the tube before I tape, etc.

It's especially nice in the outpatient setting where people go home when they're done and have an incentive to get things done.

All well and good until you find yourself with a nurse who doesn’t know what you need. Or even better, when the nurse tries to get ready to hand you the tube, tell them “I’ve got this thanks- do you want to start working on the Foley?”

Step one is learning how to be independent. Step two is learning how to use resources effectively and direct others to maximize their helpfulness. Important for residents to be intentional about learning step one before skipping directly to step 2... At least in my opinion : )

 

[epidural man]

Do more TIVA's.

Do more MAC cases. MAC is an art I never learned as a resident. They never put residents in the cataract room. It seems silly, but those scared me more than anything at first.

Maybe the reason I hate MAC cases is because I never learned them as a resident. Or maybe they just suck.

 

[Iso4ane]

Do more TIVA's.

Do more MAC cases. MAC is an art I never learned as a resident. They never put residents in the cataract room. It seems silly, but those scared me more than anything at first.

Maybe the reason I hate MAC cases is because I never learned them as a resident. Or maybe they just suck.

I think one thing that is underutilized during MAC cases are narcotics. People move and jolt when they are in pain, if you can keep them comfortable, you don't need GA levels of propofol.

 

[nimbus]

I think one thing that is underutilized during MAC cases are narcotics. People move and jolt when they are in pain, if you can keep them comfortable, you don't need GA levels of propofol.

But the itchy nose....

 

[GassYous]

Give the patient 10-30 of ketamine and the numbers of problems you have with mac will decrease greatly.

 

[GlowInTheDark]

Give the patient 10-30 of ketamine and the numbers of problems you have with mac will decrease greatly.

CA-3 here. Discovered “Keta-fol” a few months ago and most MAC cases are NBD anymore.

 

[Realgassy]

Practice with lmas. I have done more lmas in my first 2 weeks as an attending than I did in my last 6months of residency. Wish I had more experience as the more you do... the more issues that can arise with seating. My group also utilizes lmas in for cases that go lateral (probably not something most attending’s in residency will allow) which is new for me and a bit stressful.

 

[Radar26]

CA-3 here. Discovered “Keta-fol” a few months ago and most MAC cases are NBD anymore.

just watch out for those PACU hallucinations, another thing that escapes the resident mindset is your anesthetic has gotta get the patient smoothly through the PACU stay as well

 

[nimbus]

CA-3 here. Discovered “Keta-fol” a few months ago and most MAC cases are NBD anymore.

I consider that more of a TIVA.

 

[D P356]

Consult partner(s) before cancelling a case.

This is important.
Example from my first few months as attending...

Elective Total Knee. LBBB on 1 month old ekg, numerous Cardiac risk factors. No cardiac work up. No ekg for comparison

rcri score 3, but mets>4, no cp. AHA says proceed to surgery. I didn’t feel that was best for pt.

spoke to a vigilant partner and spoke to cardiologist(advice from partner). Cardiologist agreed and said send for a work up; documented discussion. So I delayed* case. Some didn’t agree with me, but they weren’t signing the chart.

At the time the risk of doing the case outweighed the benefit.

 

[OTCAwesome]

I think one thing that is underutilized during MAC cases are narcotics. People move and jolt when they are in pain, if you can keep them comfortable, you don't need GA levels of propofol.

To each their own, but for 85% of our mac cases, my partners and I only give lidocaine and propofol. Pts do well, also you don't have anything else muddying the waters, pts are able to go home sooner. Nurses constantly complain about the 15% that insist on giving versed and fent to everyone for this last reason.

 

[coffeebythelake]

This is important.
Example from my first few months as attending...

Elective Total Knee. LBBB on 1 month old ekg, numerous Cardiac risk factors. No cardiac work up. No ekg for comparison

rcri score 3, but mets>4, no cp. AHA says proceed to surgery. I didn’t feel that was best for pt.

spoke to a vigilant partner and spoke to cardiologist(advice from partner). Cardiologist agreed and said send for a work up; documented discussion. So I delayed* case. Some didn’t agree with me, but they weren’t signing the chart.

At the time the risk of doing the case outweighed the benefit.

I had a patient for sinus surgery who was "cleared" by our preop clinic
progressively worsening shortness of breath on exertion believed to be due to sinus issues, refractory to oral steroids
equivocal < or > 4 METS (I said <4 METs, preop clinic says >>4 METs)
obese, HTN, DLP, OSA, no known cardiac issues,
in OR when put on monitors found to have new-ish LBBB (i called up his PCP and found that EKG from less than 6 mo ago was normal)
something didn't smell right about him but nothing on AHA guidelines to make me say hold -- still i talked to colleagues and decided to cancel case
talked to pt after he was around 60 years old and had pretty significant FHx of cardiac dz, both his parents w early CAD/MIs
preop clinic scoffed at me, cleared him again, and wanted to reschedule him for sinus surgery, but his PCP insisted on getting cardiac studies
dude was found to have severe 3 vessel CAD, DOE symptoms now attributed to angina, got a CABG a week later, did a ton better symptom wise

 

[Urzuz]

68M for elective THA. Pmhx: Htn only. BP in preop 220/125. Rechecked in both arms, no change. Pt does not have any symptoms of hypertensive emergency. Not anxious at all. He did take all of his usual home medications. Per patient usual BP is 140-160’s. In Preop Clinic, BP was 130’s or so.

A: cancel case
B: give versed and recheck BP
C: proceed with case knowing that his Preop Clinic BP was normal.

Thoughts?

To each their own, but for 85% of our mac cases, my partners and I only give lidocaine and propofol. Pts do well, also you don't have anything else muddying the waters, pts are able to go home sooner. Nurses constantly complain about the 15% that insist on giving versed and fent to everyone for this last reason.

Oftentimes, to stop a patient from moving during a deep sedation case, you can give them a boatload of propofol, or you can accomplish the same goal with as little as 25-50 mcg of fentanyl. This is especially true with surgeons who don’t do a good job injecting local, which in my experience, is most.

 

[D P356]

I had a patient for sinus surgery who was "cleared" by our preop clinic
progressively worsening shortness of breath on exertion believed to be due to sinus issues, refractory to oral steroids
equivocal < or > 4 METS (I said <4 METs, preop clinic says >>4 METs)
obese, HTN, DLP, OSA, no known cardiac issues,
in OR when put on monitors found to have new-ish LBBB (i called up his PCP and found that EKG from less than 6 mo ago was normal)
something didn't smell right about him but nothing on AHA guidelines to make me say hold -- still i talked to colleagues and decided to cancel case
talked to pt after he was around 60 years old and had pretty significant FHx of cardiac dz, both his parents w early CAD/MIs
preop clinic scoffed at me, cleared him again, and wanted to reschedule him for sinus surgery, but his PCP insisted on getting cardiac studies
dude was found to have severe 3 vessel CAD, DOE symptoms now attributed to angina, got a CABG a week later, did a ton better symptom wise

Solid work. Sounds like you did what was best for the pt.