Resident Colleagues, Please Post Here...

[jetproppilot]

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Resident colleagues,

I'm curious how you rate your attendings, who are teaching you our craft.

I believe that by the end of your CA-2 year, you are deft at assessing whether or not an attending wields, as Mil eloquently puts it, THE FORCE.

What percentage of your attendings wield THE FORCE?

Are they deft with their hands?

Not spooked easily, carrying a sixty-two heart rate when s h i t is hitting the fan?

Respected by their surgical-attending-colleagues?

How many of them take a sincere interest in your education, I mean, REALLY teaching you, in a non-threatening, fostering manner?

How many of them tell you there really will be a difference in the way you'll practice, in private practice, when you emerge from academia?

(OK....I am trying to relay that fact in an eloquent fashion....but f uk it.....here it is.....PRIVATE PRACTICE ANESTHESIA IN NO WAY RESEMBLES WHAT YOUVE SEEN AS A RESIDENT......which is really sad....since residency is supposed to prepare you for your future practice....but in alotta ways, it REALLY doesnt....)

How many of them want to help you in your transition to where ever you are headed after the last case you do as a CA-3?

How many of them have experience/knowledge of private practice: clinically, economically, and interpersonally?

One of the most important reasons I post frequently on SDN is to give my resident-colleagues a taste of the real-world....since I sense....at least from my training....that there is a HUGE void between an academic anesthesiologist and a private practice anesthesiologist.

And therein lies the dichotomy..... 90% of you are headed for private practice.. AND YET ALL OF YOU ARE EDUCATED BY ACADEMIC PHYSICIANS......but the HOLY GRAIL is held by private practice docs..both clinically and economically.....since MOST of the cases done in this country are done by private practice dudes...

So gimme some feedback on your education.

What you like. What you dont like.

And what you'd like to see.

And Mil, Noy, UT, please chime in on your opinion.

MIL, was your residency training commensurate to your current, lucrative practice?

UT, did your residency training compare with your current, lucrative reality anesthesia life?

If so, how?

If not so, how?

 

[VentdependenT]

Jet, you guys, and you know who you are, supply me with about 75% of alternative thought processes. Its friggen wonderful. I approach things with a more "real world" mentality vs. a contrived academic focus. Yes, I believe in academia, but SDN gives it up just how I want it.

You peeps would be proud of me. Extubating lateral position, under the drapes, just after last stitch thrown in a total hip in a difficult FOI airway in a 75 yr old female with megaloblastic anemia with end HB of 8 with pleural effusions and filthy HTN....yeah thats SDN baby. Hit the PACU asking for something to drink.

I rock it every day.

 

[jetproppilot]

Jet, you guys, and you know who you are, supply me with about 75% of alternative thought processes. Its friggen wonderful. I approach things with a more "real world" mentality vs. a contrived academic focus. Yes, I believe in academia, but SDN gives it up just how I want it.

You peeps would be proud of me. Extubating lateral position, under the drapes, just after last stitch thrown in a total hip in a difficult FOI airway in a 75 yr old female with megaloblastic anemia with end HB of 8 with pleural effusions and filthy HTN....yeah thats SDN baby. Hit the PACU asking for something to drink.

I rock it every day.

And as Will Smith said it in Bad Boys,

"NOW THATS HOW YOU DRIVE!!!!"

👍

 

[VolatileAgent]

What percentage of your attendings wield THE FORCE?

1 in 4.

i'd say the other 2 out of 4 are adequate to good anesthesiologists. but, they are certainly not stellar or anyone whose skills stand out as particularly special. iow, at this point for me, i don't feel like there's anything they can offer when i get "stuck" in a situation that i haven't already thought of or considered.

the bottom 1 in 4 my attitude with at this point is "don't get in my way, don't offer any suggestions, and just sign the record and let me do the case". even further, a couple of those in the "bottom 1 in 4" i can't figure out how they got through med school let alone an anesthesia residency. every program has a few of them. as the resident and on-paper subordinate, you spend a good amount of time in the OR making sure they don't f**k-up your case while they are supposedly "supervising" you.

a lot of this has to do with the fact that private practice gigs are paying too well right now to attract the serious talent into academia. we have a smattering of big name dudes who are full-time faculty (written texts, well-known nationally, etc.) who aren't in it for the money, love to teach, and honestly "get it". they are our superstars. we also have a couple of private practice guys who use their vacation time to locums at our institution because they love to teach, and they are equally awesome. i've learned a lot from them about what life will be like outside the ivory towers, and feel well-prepared. but, i "got it" early on about tayloring my anesthetic for the patient and being able to finish my part of the case when the last stitch goes in, etc.

i do agree (with what i think you're trying to get at here) that there is a different mentality in academia - and, to some degree, there should be - that is much more mentally masturbatory, though. in a sense, it's not just about getting cases done, but about considering the plethora of options in doing a case. this is good and what we need during residency - and also a good way for us to see a lot of different ways to do a case in a slick fashion... as well as see what absolutely NOT to do. so, in that sense, i like the fact that there is a mix from good to bad, with the majority being good. after all, not everyone is a superstar. and, as you know, this holds true for life in general. but, we can only be so prepared for private practice immediately upon getting out of residency... just like everyone else who has finished a residency program (as i am doing in the next couple weeks ). you gotta live it to know it. and, yes, we do have a share of academicians who've "been there, done that, got the t-shirt" and decided they'd rather be back in the safety of academia. i don't fault them for that.

 

[dhb]

Jet, you guys, and you know who you are, supply me with about 75% of alternative thought processes. Its friggen wonderful. I approach things with a more "real world" mentality vs. a contrived academic focus. Yes, I believe in academia, but SDN gives it up just how I want it.

I rock it every day.

Same here

as to: What percentage of your attendings wield THE FORCE?

i'd say 1% since there are about 25 attendings 2 of them keeping that pulse rate in the 60's under pression but 0/25 deft at teaching 👎

Almost eveything interesting i've learned so far has come from SDN thanks guys 👍

 

[Mman]

Out of about 60 attendings in our department, I'm guessing about 10-15 wield The Force. About 5-10 are frickin useless as far as I'm concerned and couldn't give a rat's ass about my education unless it involves helping them get their research done. The other 50-60% are pretty good (some more than others).

We've got a few folks that worked in private practice in the past that share some pearls. I'd say that the vast majority acknowledge that we will do things differently in private practice.

 

[Noyac]

I had only a few that I think could have been "rock stars" in PP if they left academics.

What gets me though, is how good the rest really thought they were.

I had this one chick who argued with me about everything. And I didn't argue with anyone in residency (well except for her but she started it) She was a new grad from a big "Ivory Tower" w/c I'll not mention and she thought she was the shizzle. Well I found out that after I left she failed her orals, I wonder why? Probably argued with the examiners as well. I'm not saying she was always wrong but there are many ways to skin a cat. Just b/c it wasn't her way didn't mean it was wrong.

I did a PP rotation in my last year and learned a little about the private world. When I returned from the rotation, all of my attendings were asking me what it was like. That should give you an idea.

 

[CremeSickle]

tough question.

lemme see if i can break it down by percentage:

Anestheia FORCE:

40% can probably do a good anesthetic
50% can probably do an excellent anesthetic (the Force)
10% are using the dark side of the force and not in the good way 🙂

Teaching prowess:

25% are excellent teachers (The force)
50% are horrible teachers. (darkside of the force)
25% are somewhere in the middle (can move a small marble with the force)

Skill Prowess:

60% have the force
30% can move small marbles with the force
10% are working with the darkside.

My overall feeling about my attendings.

1 is an absolute mentor who seems to have forgotten more than i can ever know. He is Yoda, i am a padewan.

75% overall have been helpful in some way

25% have NOT been helpful and actually made me dumber.

heheh

 

[VentdependenT]

lol

 

[fakin' the funk]

And therein lies the dichotomy..... 90% of you are headed for private practice.. AND YET ALL OF YOU ARE EDUCATED BY ACADEMIC PHYSICIANS......but the HOLY GRAIL is held by private practice docs..both clinically and economically.....since MOST of the cases done in this country are done by private practice dudes...

If PP docs hold the holy grail, why is it that the best and brightest go to the ivory tower programs where a lot of the grads stay in academia, perform cutting-edge research and become chairs of depts...and the lower-tier programs have a "community-practice" feel to them?

(or is what I've been told totally off base?)

 

[Calilove]

If PP docs hold the holy grail, why is it that the best and brightest go to the ivory tower programs where a lot of the grads stay in academia, perform cutting-edge research and become chairs of depts...and the lower-tier programs have a "community-practice" feel to them?

(or is what I've been told totally off base?)

Sometimes, GLORY outweighs da Benjamins baby!
Med school loans $200K
PP salary $360 K
Having your a ss kissed by the University after being named Chair of anesthesia = PRICELESS

 

[urgewrx]

If PP docs hold the holy grail....

Private practice guys start pushing the envelope little by little until they end up doing stuff they were specifically taught not to do, with ok results. After a few years of breaking the rules they feel they are better than any of the academic guys who trained them. This is not a result of having amazing clinical skills. This is all due to lack of job security or lack of balls to say no.

 

[The_Sensei]

This is all due to lack of job security or lack of balls to say no.

Spoken like someone FIRMLY entrenched in academia.🙄

 

[VentdependenT]

If PP docs hold the holy grail, why is it that the best and brightest go to the ivory tower programs where a lot of the grads stay in academia, perform cutting-edge research and become chairs of depts...and the lower-tier programs have a "community-practice" feel to them?

(or is what I've been told totally off base?)

Most grads go into private practice. Look at the average age of your attending. Folks do return to academics after a while for a change of pace. But I don't think that its too prevalent. Who the hell cares if youre a chair at some hot shot program when you could OWN YOUR OWN GROUP. Or be a big parterner at a wicked private practice group.

I'll do a fellowship because I'm interested, at least in the foreseeable future, in it. I'll join a private practice group right after. Done deal.

 

[Noyac]

Private practice guys start pushing the envelope little by little until they end up doing stuff they were specifically taught not to do, with ok results. After a few years of breaking the rules they feel they are better than any of the academic guys who trained them. This is not a result of having amazing clinical skills. This is all due to lack of job security or lack of balls to say no.

Are you sure about this?

Have you talked to your pts who have had surgery from a PP group and a academic group? They will not confirm your theory.

I am still in contact with my academic buddies and quite a few of my attendings. They are always attempting to lure me back to academics. I'm just not ready, yet. But if and when I do, I will not change a thing in my practice style.

You my friend, will change fairly dramatically if you choose PP. If not you will bounce around from job to job.

My partners and I are SAFE above all. We are fast. We can do many different types of anesthetics with one pt and all types will be end well. Its the pts choice. And we are respected by surgeons, nurses, hospitalists, and the administration. If we had "OK" results we would be gone. Actually, one of my partners is going to be released this August. He is good but not as good as the rest of us. He is an academic type that thought he could cut it in PP. He comes from Stanford and Dartmouth, his two academic spots. They both want him back. He is very smart and will be a good teacher but PP is not his style. Results have got to be great in PP and If they aren't they had better be at least good. If not you move on.

Urge, you speak of what you know very little about. It is obvious.

 

[VentdependenT]

Are you sure about this?

Have you talked to your pts who have had surgery from a PP group and a academic group? They will not confirm your theory.

I am still in contact with my academic buddies and quite a few of my attendings. They are always attempting to lure me back to academics. I'm just not ready, yet. But if and when I do, I will not change a thing in my practice style.

You my friend, will change fairly dramatically if you choose PP. If not you will bounce around from job to job.

My partners and I are SAFE above all. We are fast. We can do many different types of anesthetics with one pt and all types will be end well. Its the pts choice. And we are respected by surgeons, nurses, hospitalists, and the administration. If we had "OK" results we would be gone. Actually, one of my partners is going to be released this August. He is good but not as good as the rest of us. He is an academic type that thought he could cut it in PP. He comes from Stanford and Dartmouth, his two academic spots. They both want him back. He is very smart and will be a good teacher but PP is not his style. Results have got to be great in PP and If they aren't they had better be at least good. If not you move on.

Urge, you speak of what you know very little about. It is obvious.

Can you give us some examples of how he wasn't up to par. They don't have to be specific because I'm not into slighting people.

Stuff like: he's gotta tube everyone, gotta have full head lift and doing a tap dance before extubation, taking forever in PAR, holding up stuff for equivocal tests?

 

[Noyac]

Can you give us some examples of how he wasn't up to par. They don't have to be specific because I'm not into slighting people.

Stuff like: he's gotta tube everyone, gotta have full head lift and doing a tap dance before extubation, taking forever in PAR, holding up stuff for equivocal tests?

Lazy (this was also noticed by the surgeons)
Held up cases.
had some complications (not many) and didn't follow up on them.
Not very flexible
schedule ran poorly when he was in charge.
Blocks took longer to work and worked less often, still worked probably 90% of the time.

But mostly, he was inflexible/lazy which increased the workload for the others. He had that academic mentality if you know what I mean. Ordered more tests which delayed the cases and didn't change the outcome.

I could give more or elaborate but its not necessary, especially on a public forum.

 

[VentdependenT]

By not following up on complications do you mean he didn't see the patient the next day or didn't do stuff immediately in the PACU?

 

[Noyac]

By not following up on complications do you mean he didn't see the patient the next day or didn't do stuff immediately in the PACU?

Mostly the next day and further.

We are writing up a case of Sevo induced hepatits. It was his and he never followed up on it, so one of my other partners had to take over the followup. The pt was really upset and not to mention felt like crap for some time. Everyone (surgeon, family practice) kept telling her it was the flu but she new it was more than that and so did we once we heard about it. He dropped the ball after that.

I really hate to put all this out on a public forum but then I thought, well if he reads it, it may help him in the future as well as help others possibly.

 

[Noyac]

Another flaw, depending on how you look at it.

Thin Skin.

you have got to have thick skin in PP.

 

[urgewrx]

Are you sure about this?

Have you talked to your pts who have had surgery from a PP group and a academic group? They will not confirm your theory.

I am still in contact with my academic buddies and quite a few of my attendings. They are always attempting to lure me back to academics. I'm just not ready, yet. But if and when I do, I will not change a thing in my practice style.

You my friend, will change fairly dramatically if you choose PP. If not you will bounce around from job to job.

My partners and I are SAFE above all. We are fast. We can do many different types of anesthetics with one pt and all types will be end well. Its the pts choice. And we are respected by surgeons, nurses, hospitalists, and the administration. If we had "OK" results we would be gone. Actually, one of my partners is going to be released this August. He is good but not as good as the rest of us. He is an academic type that thought he could cut it in PP. He comes from Stanford and Dartmouth, his two academic spots. They both want him back. He is very smart and will be a good teacher but PP is not his style. Results have got to be great in PP and If they aren't they had better be at least good. If not you move on.

Urge, you speak of what you know very little about. It is obvious.

Noyac, I don't know how you got pt's opinion involved in this discussion.

It seems my previous post was not understood. In layman's terms I was talking about HUGE production pressure in private practice. That's how people start switching to the dark side and doing stuff they are not supposed to do(or omitting stuff they are supposed to do) because if not you'll be gone quickly/have a bad reputation (i.e., Jet not checking pt's airway, saves him 10 sec of preop time.) [Sorry Jet, I don't mean to belittle you, it was just a good example.] People do this, not because they are exceptional (maybe yes, maybe no, after a while the bad ones are weeded out), but because they are being pressured.

After few years of feeling successful on the dark side PP guys get a God like complex in which they feel like drink coffee from the Holy Grail.

BTW, you know very little about me. Stop making assumptions.

 

[jetproppilot]

(i.e., Jet not checking pt's airway, saves him 10 sec of preop time.) [Sorry Jet, I don't mean to belittle you, it was just a good example.] People do this, not because they are exceptional (maybe yes, maybe no, after a while the bad ones are weeded out), but because they are being pressured.

.

Sorry Urge.

Youre way off the mark about your assessment.

And you are misquoting me as well.

I never said I didnt look at airways...I DID say it is frequent that I see an airway for the first time right before induction.

I dont think it is necessary to know what the airway looks like until we're in the operating room.

Do I see some patients pre-op? Of course. But if called to a room to start a case on a patient I know nothing about because my partner is busy and now I'm starting his room, and they are in the OR ready to go, NO PROBLEM.

Happens all the time.

If alternative airway techniques are needed, I just call a tech and 20 seconds later everything I need is in the room.

If some modification needs to be done to the "routine" induction, no problem. Taken care of. Quickly.

I posted several weeks ago comparing how problems are handled academia vs private practice.

Difficult airway in academia is a big production.

It doesnt have to be a big production.

If I see a patient with a Mal 4 airway, minimal neck extension, and buck teeth, (even if the 1st time I see it is minutes before induction) know what I'm gonna do? I'm gonna put him to sleep, albeit with sux/minimal-no opiods...and take a look. Chances are I'll get it....may take an Eschmann, but like I said, most of the time....

and if unsuccessful, no problem. Call for the fiberoptic/fast-track or whatever.

Of course there are exceptions to this...like the very rare mediastinal mass, etc.

Whats amusing is your reaction...since I practice no different than all other physicians in busy private practices.

And since MOST anesthetics are performed by private practice docs (just by sheer numbers), it is amusing to hear academecians ridicule how we practice out here.

 

[epidural man]

Resident colleagues,
How many of them tell you there really will be a difference in the way you'll practice, in private practice, when you emerge from academia?

How many of them have experience/knowledge of private practice: clinically, economically, and interpersonally?

My residency is a little unique in that my institution is not hugely academic, and we have private physicians working at the hospital, so I don't think I can add much to the discussion. Also, as part of my residency, I have rotated at 6 hospitals, 3 private, 3 academic - so I do have some experience with the private world.

I did just want to put a plug in for academia - (and I know that isn't really the question and probably all would agree that there certainly is a PLACE for academic instistutions - and I think Jet's point is well taken that the academic institutions don't train for the real world.)

Anyway, what I have really appreciated about the academic places vs private is the access to equipment and drugs, and the willingness of the academicians to let me use CRAZY techniques. "Dr Big Shot, I want to intubate with a shikany optical stylet, run an infusion of ketamine, propofol, precedex, nitrous, sevo and remifentanyl with a BIS and Cerebral Oximetry for the first half, then switch to a lidocaine infusion, iv clonidine, and sufenta and des, then give some doxepram for the wakeup, oh, and lets monitor PVP and do some P6 accupuncture in the PACU. Let's run TEGS and ISTATS as needed" I've never really tried that - maybe tomorrow, but my point being that a lot is available at an academic setting. The last private hospital I was at didn't even have remifentanyl and they had horrible equipment and tech support. I don't think any of the private hospitals had point of care testing.

Another point is that even when the private places had something I wanted to try, most staff wouldn't want me to because it would slow things down or they didn't want some yahoo resident who they were unfamiliar with to try a wierd technique that they had never done before - all on their license. I totally understand this and it didn't really bother me because I knew what was at stake. However, my impression at the academic center is that most staff felt like they could bail me out no matter how I screwed up the anesthetic - since time wasn't necessarily a huge issue. I have appreciated this attitude greatly in my training.

Jet's point is about getting to a level of private practice anesthesia so of course me doing "unconventional" anesthesia doesn't bring me anywhere near that goal - but it is fun to do and probably does offer some benefit to my education. Although I will NEVER reach for the bullard scope (I hate that thing....), I have benefited from trying it a few times.

 

[Noyac]

Private practice guys start pushing the envelope little by little until they end up doing stuff they were specifically taught not to do, with ok results.

Ok mister, lets hear your examples. Whaat exactly are we doing that we were taught not to do? What are our "ok results?"



[/QUOTE]After a few years of breaking the rules they feel they are better than any of the academic guys who trained them. This is not a result of having amazing clinical skills. This is all due to lack of job security or lack of balls to say no.[/QUOTE]

Did you not read my recent post about the surgeon wanting to take someone to the OR that may have had an MI?

I still say, "Urge, you speak of what you know very little about. It is obvious."

 

[Mman]

I would agree with epidural man's post about how it is great to have attendings that will let me do damn near anything I want, even if it isn't the way they are used to doing something and even if it might slow things down a little. Sometimes it works nicely, sometimes it doesn't. If it doesn't I'll try to tweak it a little and make it better the next time.

 

[urgewrx]

Did you not read my recent post about the surgeon wanting to take someone to the OR that may have had an MI?

I read it. I also noticed how you felt compelled to do the case and were sorry that you had to cancel it.

"Can you do the case under local?" This is what you proposed. BS. That pt is not ready for elective surgery. How dare you ask me for private practice examples when you are posting stuff like this.

If I see a pt like that from a mile away, case is canceled. I don't even have to think it twice. Why? Because I can. I'm the Beast-Tamer. If the surgeon does not like it, he can complain to the big bureaucrats in my department who will tell him to waste someone else's time.

 

[Gern Blansten]

I'm the Beast-Tamer.

Siegfried or Roy?

🙂🙂

 

[Noyac]

Later Urge,

i have had enough of you.

But I will tell you why I considered doing the case.

the family wishes to have nothing done to their mother besides making her feel better. Kyphoplasty is one of the few cases that actually make someone feel better right away. I discussed the risks with the pts sons who said "I just want my mom to get some relief from her pain and if she dies from this or something relate, so be it." My problem was that I was not going to be the one to knock her off. they completely accepted the risks and I get the feeling that if she died during or after the procedure they would have been relieved. So why can't we do this for the pt? Because we are all affraid of the outcome and being sued. If you have followed my posts over the past few years you would know that I am not a fan prolonging life for the sake of the family.

But you seem to find joy in critisizing everyone here so say good bye, assh*le.

 

[cfdavid]

Later Urge,

i have had enough of you.

But I will tell you why I considered doing the case.

the family wishes to have nothing done to their mother besides making her feel better. Kyphoplasty is one of the few cases that actually make someone feel better right away. I discussed the risks with the pts sons who said "I just want my mom to get some relief from her pain and if she dies from this or something relate, so be it." My problem was that I was not going to be the one to knock her off. they completely accepted the risks and I get the feeling that if she died during or after the procedure they would have been relieved. So why can't we do this for the pt? Because we are all affraid of the outcome and being sued. If you have followed my posts over the past few years you would know that I am not a fan prolonging life for the sake of the family.

But you seem to find joy in critisizing everyone here so say good bye, assh*le.

Hang on a minute here Noy. I know I don't yet have the technical, or clinical skills, to know what's up, but are we banning people for disagreeing with you?

I love (well, not LOVE) you and JPP. But, just because someone disagrees with you (or JPP), does not mean they should be banned. I say this knowing that I'm at risk of being ostrasized myself. But, I'd rather have that then to bury my head in the sand about what's really, and truly, right.

My goal here is not to be the trouble maker that don't know jack. I'm just saying...

With absolute respect, please correct me if I am misunderstanding this situation. Maybe urge got it wrong. But, he hasn't been political in the CRNA sense. Nor has he really been a troll, that I can tell.

 

[fakin' the funk]

But you seem to find joy in critisizing everyone here so say good bye, assh*le.

Whoa dude. The guy has a different POV of private practice style and you ban him? Weak.

I don't think anything he did counted as trolling, or stirring up our favorite X vs. Y debate.

 

[Noyac]

Don't worry guys. Urge will be back.

I didn't ban him for disagreeing with me. If he wants to disagree thats fine but don't threaten me or other members.

He has a history of starting trouble but the ban will expire.

 

[VolatileAgent]

Don't worry guys. Urge will be back.

I didn't ban him for disagreeing with me. If he wants to disagree thats fine but don't threaten me or other members.

He has a history of starting trouble but the ban will expire.

maybe "account on hold" would be a better 'punishment'?

 

[GasEmDee]

But you seem to find joy in critisizing everyone here so say good bye, assh*le.

Lame.

What rule of this forum did he violate? Or did you just use your privileges as a moderator to advance a personal agenda?

There seem to be a few people here who want to turn this forum into a mutual masturbation society for a handful of self-aggrandizing individuals.

UrgeWrx had a different point of view; he violated no forum rules, and now he has been banned.

I wonder if I am going to be banned for posting this.

 

[epidural man]

Don't worry guys. Urge will be back.

I didn't ban him for disagreeing with me. If he wants to disagree thats fine but don't threaten me or other members.

He has a history of starting trouble but the ban will expire.

Can't you just make up a new username and rejoin? I am already posting as a medical student, intern, resident, 30 year anesthesia veteran, and a CRNA

 

[rmh149]

Can't you just make up a new username and rejoin? I am already posting as a medical student, intern, resident, 30 year anesthesia veteran, and a CRNA

Yeah, I saw you on the CRNA forums. 😉

 

[fakin' the funk]

There seem to be a few people here who want to turn this forum into a mutual masturbation society for a handful of self-aggrandizing individuals.

True dat.

Or, should I say, TRUE DAT.