resident level of autonomy

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lgher

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I'm a 1st year resident, half way through my second month of anesthesia. My attending left me alone in a room for several hours during my day today, which included 2 complete cases (from induction to emergence). He was in a meeting at the time. One of my patients had some residual paralysis at the end of one case, and held up the next case for about 20 minutes while I dealt with it in the PACU. Although no one (Nurses or Surgeon) made any comments to speed things up, I felt some internal pressure to keep the room running on schedule, and felt like I was cutting a few corners with pre-op interviews for the upcoming case, getting the room set up exactly how i'd like it (iv was positional when tucked, cords tangled running from the maching to the bp cuff, iv, circuit etc...

Is this level of autonomy on par for my level of training? how much support do some of others have at this level of training (Most attendings are much more present or available during most days btw)....Just felt a little overwhelmed at some points today....wanted to hear a few others' thoughts
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CA-1? Either the attending has a lot of trust in you or.....

In my view this is unacceptable. Just purely in terms of billing they need to be present for induction, emergence, and all critical events. Plus see the patient. When I was in academics the only time I let a resident induce alone was in the last month of their Ca-3 year- and truth be told I was right outside peeking in the window. This is unacceptable in my mind.

drccw
 
wait so you are an intern?? we dont even let interns be alone without resident supervision, much less attending supervision. much more freedom as you hit CA-1 but at this point you are just learning your way around the cart/room/etc. you should not stand for this either. if something happened it would haunt you for your entire career
 
Oh boy...... that ain't right. So were you administering paralytics and intubating solo as an intern?
 
I'm graduating my anesthesia residency in a few months, and I still have attendings present at induction and around the time of emergence. Typically stop in a few times during cases, too, but that's more a function of the level of cases I am doing.

It's pretty much inexcusable for any resident, in any program, at any institution to run a case solo from beginning to end.
 
Wait, so you're a CA-1 with 6 weeks of anesthesia under your belt and you're running cases solo?

I don't think I've ever induced for a GETA in the OR by myself and I'm nearing the end of my CA-2 year. Maybe it's just our culture, but you don't induce until the attending is there.

As a CA-1, at 6 weeks in, we were still 1:1 with attendings; though they did leave during the case, you can bet they were e-stalking the electronic record and checking in frequently.

This is totally inappropriate and borders on fraud as far as supervision goes, as drccw pointed out.

Was there someone designated to cover you while your attending was at their meeting? This boggles my mind...
 
Bertelman said:
It's pretty much inexcusable for any resident, in any program, at any institution to run a case solo from beginning to end.
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I humbly disagree with this, although I'm pretty sure some on here will disagree with me. I did a lot of cases on my own. C/S, epidurals, days of appy's/gallbladders, hysterectomies, etc.

I would ask it from attendings (including my program director) whom I felt understood my level of proficiency. It was a great learning experience and gave me confidence going into PP. My last day of residency I managed a type A dissection essentially by myself. Attending looked through the glass window for the first 15 minutes and then went to sleep until I called him 4.5 hours later when we were getting ready to go to the ICU. He knew that I would call him if I needed help.

Heck, during my 1st year (different program than CA1-3), airways and traumas were done by anesthesia residents. Senior/CA-3 + Junior/Ca-2 went to all codes and AW's. Attending was on stand by.
 
sevoflurane said:
I humbly disagree with this, although I'm pretty sure some on here will disagree with me. I did a lot of cases on my own. C/S, epidurals, days of appy's/gallbladders, hysterectomies, etc.

I would ask it from attendings (including my program director) whom I felt understood my level of proficiency. It was a great learning experience and gave me confidence going into PP. My last day of residency I managed a type A dissection essentially by myself. Attending looked through the glass window for the first 15 minutes and then went to sleep until I called him 4.5 hours later when we were getting ready to go to the ICU. He knew that I would call him if I needed help.

Heck, during my 1st year (different program than CA1-3), airways and traumas were done by anesthesia residents. Senior/CA-3 + Junior/Ca-2 went to all codes and AW's. Attending was on stand by.
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I think it's fine for a CA3 at this time of the year (well, except for the Type A). It's never appropriate for a CA1. What I don't understand are the attendings who get upset about having to go to floor intubations with junior residents. None of them would ever allow a resident to proceed to the OR with an elective case.
 
sevoflurane said:
I humbly disagree with this, although I'm pretty sure some on here will disagree with me. I did a lot of cases on my own. C/S, epidurals, days of appy's/gallbladders, hysterectomies, etc.

I would ask it from attendings (including my program director) whom I felt understood my level of proficiency. It was a great learning experience and gave me confidence going into PP. My last day of residency I managed a type A dissection essentially by myself. Attending looked through the glass window for the first 15 minutes and then went to sleep until I called him 4.5 hours later when we were getting ready to go to the ICU. He knew that I would call him if I needed help.

Heck, during my 1st year (different program than CA1-3), airways and traumas were done by anesthesia residents. Senior/CA-3 + Junior/Ca-2 went to all codes and AW's. Attending was on stand by.
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I completely agree with Sevo. I sure hope by the time I am a CA-3 my program is giving me the autonomy to run a case on my own. I don't believe the time to try and fly on your own is during your 1st year as an attending. You have to have those periods where you can make decisions on your own when it is stressful and we as residents cannot on always rely our attendings for decision making. That being said, you need some supervision to ensure the safety of the patient is not endangered. My program has CA-2/3 respond to all codes, traumas and emergent airway. The attendings are available but do not respond unless needed. Additionally, epidurals are typically completed solo once the first epidurals are supervised.
RedAnesthesia
 
It's April, so wouldn't the OP be more likely to be an intern on an anesthesia rotation, rather than a CA-1?
 
When I was a resident 15 yrs ago, at our county hospital, the attendings went home and three anesthesia residents did the cases, codes, OB and everything at night alone. I know this doesn't happen anymore. There were plusses and minuses, for patients and residents.
 
RedAnesthesia said:
I completely agree with Sevo. I sure hope by the time I am a CA-3 my program is giving me the autonomy to run a case on my own. I don't believe the time to try and fly on your own is during your 1st year as an attending. You have to have those periods where you can make decisions on your own when it is stressful and we as residents cannot on always rely our attendings for decision making. That being said, you need some supervision to ensure the safety of the patient is not endangered. My program has CA-2/3 respond to all codes, traumas and emergent airway. The attendings are available but do not respond unless needed. Additionally, epidurals are typically completed solo once the first epidurals are supervised.
RedAnesthesia
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I'm not saying a CA-3 shouldn't have autonomy. I think throughout your residency, the leash should be slowly relaxed until you basically get to run around the yard free, collar on but leash dragging the ground waiting to be yanked. This poor guy was thrown off the back of the truck, attending speeding off at 65 mph down the PCH.

I'm usually mildly offended these days if someone tries to steer my anesthetic plan another way. But by god, they better show their face in the OR, if only for a couple minutes. I know we should all be able to run a day of cases solo as a CA-3, and I like to think I can, but that doesn't mean it should be practiced. This is coming from someone at a PP model program, with attending supervision on the low end of normal, and I still find it appalling. In fact, my attendings would find it odd, too, even though they survived residency when that was the norm. Each and every day, they go out of their way to make themselves available during critical parts of the case, even if they just stand in the corner and sign the chart. (And no, it's not because I am the dangerous resident that needs to be watched 😛)

There are certainly ways to be present for support while still cultivating resident autonomy. They aren't mutually exclusive.
 
My program, the official dept policy was that an attending anesthesiologist would be present for every induction and emergence, and start --> delivery of every c-section, no exceptions. A few attendings quietly disagreed with this and let residents (not CA1s) do cases start to finish with them watching from outside, or via remote monitoring, if they were especially ballsy.

We'd do our rotations at other institutions and I for one was initially kind of freaked out by the long leashes. I did more than one heart from lines & induction to well into the pump run without my attending in the room ... I don't think that was such a good idea but I didn't kill anyone.
 
Leaving a first year from start to finish is wrong.
On the other hand if as a CA3 you are not completely autonomous with the attending just dropping by to say hi then how do you transition to pp?
 
dhb said:
Leaving a first year from start to finish is wrong.
On the other hand if as a CA3 you are not completely autonomous with the attending just dropping by to say hi then how do you transition to pp?
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I completely agree. That's not the story posted by the OP, though, and it's not what I meant with my initial comment. That situation is completing 2 cases from induction through drop off without seeing, or hearing from, your attending. That's not "autonomy", its abandonment. Sounds like his attending didn't even meet the patient for a pre-op exam.

OP, at the very least you should have been able to page him/her for questions, eg residual paralysis. Did you do that when this happened? Is that even an option, or is thee some other way to get in touch with them if they aren't immediately available?
 
pgg said:
My program, the official dept policy was that an attending anesthesiologist would be present for every induction and emergence, and start --> delivery of every c-section, no exceptions. A few attendings quietly disagreed with this and let residents (not CA1s) do cases start to finish with them watching from outside, or via remote monitoring, if they were especially ballsy.

We'd do our rotations at other institutions and I for one was initially kind of freaked out by the long leashes. I did more than one heart from lines & induction to well into the pump run without my attending in the room ... I don't think that was such a good idea but I didn't kill anyone.
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History: So I've never done a cardiac case, and my first one is scheduled at the VA (where I'm gonna be taking call by myself all weekend) for Saturday morning. I phone the attending the night before--a very prominent cardiac anesthesiologist whose name everyone would recognize--and say we got this case in the morning... So he/she says, "...give me a call tomorrow when you are working in the narcotic."
 
imfrankie said:
History: So I've never done a cardiac case, and my first one is scheduled at the VA (where I'm gonna be taking call by myself all weekend) for Saturday morning. I phone the attending the night before--a very prominent cardiac anesthesiologist whose name everyone would recognize--and say we got this case in the morning... So he/she says, "...give me a call tomorrow when you are working in the narcotic."
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Awesome.

180 degrees the other direction at my program. We had someone put an emergent midnight c-section to sleep without staff in the room once. Staff apparently did not answer multiple pages. OB allegedly screaming to hurry up and induce or the baby was going to die. Mom-to-be begging him to not let her baby die. C-section went fine, mom & baby did great.

At the M&M (I wasn't there) supposedly one of the staff asked "Why are you still here?" implying that doing the case alone - and inducing a PREGNANT woman to boot, oh noes - was an immediate firing offense.

I may be screwing up some of the details (maybe it was a 1st month SRNA and not a resident) but that was the short-leash culture at my program.
 
pgg said:
My program, the official dept policy was that an attending anesthesiologist would be present for every induction and emergence, and start --> delivery of every c-section, no exceptions. A few attendings quietly disagreed with this and let residents (not CA1s) do cases start to finish with them watching from outside, or via remote monitoring, if they were especially ballsy.

We'd do our rotations at other institutions and I for one was initially kind of freaked out by the long leashes. I did more than one heart from lines & induction to well into the pump run without my attending in the room ... I don't think that was such a good idea but I didn't kill anyone.
Click to expand...

I honestly believe I am still traumatized by some of those "no one else around" experiences as a resident. Fortunately, I never killed anybody. I would NEVER want to put a trainee through that. I'm a believer in helping them develop autonomy, but when they want a hand it needs to be there.
 
imfrankie said:
I honestly believe I am still traumatized by some of those "no one else around" experiences as a resident. Fortunately, I never killed anybody. I would NEVER want to put a trainee through that. I'm a believer in helping them develop autonomy, but when they want a hand it needs to be there.
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I was abandoned once as a CA1 doing a neurosurgical case (not at my home program). Unexpected bad outcome, patient went to a rehab facility and recovered some function ... eventually. Surgeon blamed anesthesia. To this day I think my management was absolutely fine, and that it was strictly a surgical complication. But my attending was nowhere. The surgeon was a notoriously abusive guy and mid-incident was really going off on me. After the surgery he actually took the time to write a letter to the department complaining about me. He believed anesthesia was at fault, and the absence of an attending anesthesiologist was all the proof he needed. His viewpoint has some validity, but I still think he's the one who boned things up. The anesthesia department there seemed kind of spineless, and while they couldn't fault my work, they did actually counsel me on my attitude.


After 2 months there, my eval for that rotation was excellent overall, but said I was "reluctant to call for help" ...

Reluctant to call, my ass. I wanted to call the plantiff's lawyer.


The full story has some entertainment value to those who know the surgeon personally, and I'll even laugh about it all sometimes, but it's kind of a sad sick laughter in the context of the patient's injury.

I guess I've got some trauma issues too ... :lame:



And that's not even getting into any of the "all alone in a mud hut in Afghanistan" moments the Navy blessed me with during my 3 year GMO hiatus between PGY1 and PGY2 ...
 
Residency training has changed in the name of "quality". Gone are the days when attendings took call from home and told the residents that calling them was a sign of weakness. Now residents get their hands held from induction to emergence. Don't get me wrong, if I was a patient in an academic hospital, I would want close attending involvement. The unintended consequences of this are that residents aren't given a real opportunity to be on their own. June 30th of CA-3: hand still being held. July 1st of being an attending: scared ****less.

Its a difficult problem to solve. Many residents realize they are not ready for "prime time" and wisely stay on as staff at the home institution for a year or two to get their boards and some confidence. Some residents are Jesus-like and can make the transition without any problem. I think most residents who go straight to private practice have a large learning curve; some groups are understanding of this, others not so much.

A good academic attending will let the resident do as much as possible. I think even CA-1's should be pushing induction drugs unless it truly is a two-person induction. Medico-legally, the attending physician needs to be present for induction/emergence/critical events, but the attending certainly can let the residents be an actual anesthesiologist, not just an airway technician. The reality is that we can't ethically provide true autonomy in residency, but we can come really close to simulating it if we try.
 
pgg said:
Awesome.

180 degrees the other direction at my program. We had someone put an emergent midnight c-section to sleep without staff in the room once. Staff apparently did not answer multiple pages. OB allegedly screaming to hurry up and induce or the baby was going to die. Mom-to-be begging him to not let her baby die. C-section went fine, mom & baby did great.

At the M&M (I wasn't there) supposedly one of the staff asked "Why are you still here?" implying that doing the case alone - and inducing a PREGNANT woman to boot, oh noes - was an immediate firing offense.

I may be screwing up some of the details (maybe it was a 1st month SRNA and not a resident) but that was the short-leash culture at my program.
Click to expand...

wait, this is a "short leash culture"? we assume that every anesthetic will be induced/emerged and managed by an attending, unless that attending has explicitly decided otherwise (i.e. you induce and let me know if there are problems, etc.). i would expect to be severely reprimanded in such a case. theres no way to win here, especially if you are new and maybe a little cavalier about things.
 
Idiopathic said:
wait, this is a "short leash culture"? we assume that every anesthetic will be induced/emerged and managed by an attending, unless that attending has explicitly decided otherwise (i.e. you induce and let me know if there are problems, etc.). i would expect to be severely reprimanded in such a case. theres no way to win here, especially if you are new and maybe a little cavalier about things.
Click to expand...

Sorry, wasn't real clear. My program was religious about having an attending in the room for induction and emergence (or neuraxial --> delivery for sections). We were always 1:1 with attendings so often they'd be there the entire case, teaching or pimping or glaring at us as their personalities dictated.

Other institutions on out rotations, I'd sometimes get the "call me if you need me" line. Mostly I welcomed it, because they were (usually) immediately available.

That c-section story was an outlier. One unresponsive attending, one trainee who felt stuck. My memory is jogged. It was a guy in his final month of training, and there was talk of firing him for doing something without the attending in the room. That's a short leash to me.
 
lgher said:
I'm a 1st year resident, half way through my second month of anesthesia. My attending left me alone in a room for several hours during my day today, which included 2 complete cases (from induction to emergence). He was in a meeting at the time. One of my patients had some residual paralysis at the end of one case, and held up the next case for about 20 minutes while I dealt with it in the PACU. Although no one (Nurses or Surgeon) made any comments to speed things up, I felt some internal pressure to keep the room running on schedule, and felt like I was cutting a few corners with pre-op interviews for the upcoming case, getting the room set up exactly how i'd like it (iv was positional when tucked, cords tangled running from the maching to the bp cuff, iv, circuit etc...

Is this level of autonomy on par for my level of training? how much support do some of others have at this level of training (Most attendings are much more present or available during most days btw)....Just felt a little overwhelmed at some points today....wanted to hear a few others' thoughts
​
Click to expand...

In my training it was customary for an attending to be present for induction, until the airway was secured. This does not mean they did anything other than watch you -- thus at 6 weeks into my anesthesia training I could be doing all the things you mention. So I do believe the level of autonomy you got could be appropriate for your level. That being said, it is not customary in the USA for you to be doing your own induction with no attending in the room, this early in residency.

If you were unhappy with the lack of supervision, then you should speak up and page your attending for any assistance you want. It is his/her job to come.

If you were happy with the autonomy you had, then continue as you're doing.
 
jennyboo said:
In my training it was customary for an attending to be present for induction, until the airway was secured. This does not mean they did anything other than watch you -- thus at 6 weeks into my anesthesia training I could be doing all the things you mention. So I do believe the level of autonomy you got could be appropriate for your level. That being said, it is not customary in the USA for you to be doing your own induction with no attending in the room, this early in residency.

If you were unhappy with the lack of supervision, then you should speak up and page your attending for any assistance you want. It is his/her job to come.

If you were happy with the autonomy you had, then continue as you're doing.
Click to expand...

bad idea. any bad outcome you have now because you dont know any better will haunt you your entire career and will cloud others opinions of you. you need supervision for your sake as well as your patients sake.
 
gaspasser2004 said:
A good academic attending will let the resident do as much as possible. I think even CA-1's should be pushing induction drugs unless it truly is a two-person induction. Medico-legally, the attending physician needs to be present for induction/emergence/critical events, but the attending certainly can let the residents be an actual anesthesiologist, not just an airway technician. The reality is that we can't ethically provide true autonomy in residency, but we can come really close to simulating it if we try.
Click to expand...

I would absolutely agree with that.
 
imfrankie said:
When I was a resident 15 yrs ago, at our county hospital, the attendings went home and three anesthesia residents did the cases, codes, OB and everything at night alone. I know this doesn't happen anymore. There were plusses and minuses, for patients and residents.
Click to expand...
Did you train in nyc?
 
You need to be left alone starting Ca-3 year. Its a huge learning curve being by yourself. Especially in kids. Our institution much autonomy is given as it is earned. now finishing off Ca-3 year most of the time my attending is NOT in the room. I have no issues whatsoever going into PP.

I thank my program for that.
 
somedumbDO said:
You need to be left alone starting Ca-3 year. Its a huge learning curve being by yourself. Especially in kids. Our institution much autonomy is given as it is earned. now finishing off Ca-3 year most of the time my attending is NOT in the room. I have no issues whatsoever going into PP.

I thank my program for that.
Click to expand...

I was more independent as a ca1 than as a fellow. Different institutions.
 
I had to respond so I even registered!!!!........

I can't believe that it has not been stressed that this is billing fraud. If a bill was submitted for the attending services, they had to attest that they were "present for key portions and immediately available throughout". While leeway is given for what is a key portion, it would be indefensible to not be present at all.

Induction, emergence and key portions is the standard. Induction and emergence are not the same as intubation/extubation.

The VA story could be OK from a billing point of view since there is no bill there, but is still poor form for an anesthesiologist and has no place in a residency program of any worth.

A resident who proceeds without supervision is putting themselves at significant risk. If an attending is not showing up, do you trust them to back you in a problem instead of saying "I had no idea"?- I sure wouldn't.
 
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