Scared about independent practice

[burnermdaccount]

I'm in a non-US program that trains GPs to do low risk anaesthesia. We are called GP anaesthetists. We only do 1 year of anaesthesia training after our GP residency and handle low risk ASA 1-2 in rural places. I'm halfway through my year but terrified at the thought of being independent. I've only ever gotten good feedback but everyday I'm terrified. I want to transfer into the 5-year anaesthesia stream but that requires 3 more years of additional training. People tell me that I will be fine but I don't trust myself. Any advice for me?

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[coffeebythelake]

I'm in a non-US program that trains GPs to do low risk anaesthesia. We are called GP anaesthetists. We only do 1 year of anaesthesia training after our GP residency and handle low risk ASA 1-2 in rural places. I'm halfway through my year but terrified at the thought of being independent. I've only ever gotten good feedback but everyday I'm terrified. I want to transfer into the 5-year anaesthesia stream but that requires 3 more years of additional training. People tell me that I will be fine but I don't trust myself. Any advice for me?

This is a model I've seen in Commonwealth countries. I think it really depends on how rigorous your training program is, and how your practice is structured. How does case stratification occur -- that is who decides what is a low-risk case? There are pertinent risks associated with the specific surgical procedure and there are risks associated with the patient comorbidities. Are you there truly working independently and without back-up in a rural location without access to a consultant anesthetist?

Most of our CA-1 anesthesiology residents develop a reasonably competent technical skills and clinical acumen to deal with low-risk cases, and have some proficiency with higher-risk ones as well.

When it comes to fundamentals, airway management (e.g., mask ventilation, intubation, different advanced airway tools), clinical knowledge of critical events (e.g., management of laryngospasm, recognition of cardiac events, common anesthetic complications such as PONV, corneal abrasions; and rare anesthetic complications such as MH) and medication interactions, and good-ol' vigilance are the key things.

 

[kidthor]

How does case stratification occur -- that is who decides what is a low-risk case?

This is key. IR and other off site sedation locations can sedate proceduralist designated "low risk" patients... and then I'll take a look back at their documentation (when the patient comes to the OR down the line) and they're all marked as ASA2. And of course these are ASA2s of the ESRD, ESLD, severe pulmonary HTN, had an MI yesterday sort. To be fair I never want to go to IR or cath lab or GI ever, so I'm not exactly jumping to rock their boat.

 

[Coffee PRN]

This is key. IR and other off site sedation locations can sedate proceduralist designated "low risk" patients... and then I'll take a look back at their documentation (when the patient comes to the OR down the line) and they're all marked as ASA2. And of course these are ASA2s of the ESRD, ESLD, severe pulmonary HTN, had an MI yesterday sort. To be fair I never want to go to IR or cath lab or GI ever, so I'm not exactly jumping to rock their boat.

Severe pHTN ASA 2?! 😐

 

[burnermdaccount]

As an independent practitioner you would decide who to take on (according to standard ASA classification) and take all liability. You have colleagues who can help you like any OR but at the end of the day you are the responsible physician on the chart (unlike the US for CRNAs I’ve heard). There is no consultant anaesthesiologist (unless you decide the case is too high level and refer to a tertiary site, in which you would not start the case at all ofc).
Edit to add:
Yes I’m in a Commonwealth country. I should add my GP training was rigorous and I did extra blocks in ICU. We are strong in our general medicine/ peds knowledge and expected to progress faster. For example, I can independently diagnose/manage STEMI, PE, unstable arrhythmias, COPD/CHF exacerbation, unstable GIB, brain bleeds, peds croup/asthma/bronchiolitis in the inpatient unit/ ER. So I know there is badness out there, but I feel like I haven’t seen enough/ experienced enough badness to know how to manage it in the OR.

 

[deleted1147063]

As an independent practitioner you would decide who to take on (according to standard ASA classification) and take all liability. You have colleagues who can help you like any OR but at the end of the day you are the responsible physician on the chart (unlike the US for CRNAs I’ve heard). There is no consultant anaesthesiologist (unless you decide the case is too high level and refer to a tertiary site, in which you would not start the case at all ofc).
Edit to add:
Yes I’m in a Commonwealth country. I should add my GP training was rigorous and I did extra blocks in ICU. We are strong in our general medicine/ peds knowledge and expected to progress faster. For example, I can independently diagnose/manage STEMI, PE, unstable arrhythmias, COPD/CHF exacerbation, unstable GIB, brain bleeds, peds croup/asthma/bronchiolitis in the inpatient unit/ ER. So I know there is badness out there, but I feel like I haven’t seen enough/ experienced enough badness to know how to manage it in the OR.

I don't think you should. One year is just scratching the surface. As we like to tell our residents when they make mistakes: there is a reason anesthesiology is a 3-year residency (with 60-70 hours/week in the US).

 

[chocomorsel]

As an independent practitioner you would decide who to take on (according to standard ASA classification) and take all liability. You have colleagues who can help you like any OR but at the end of the day you are the responsible physician on the chart (unlike the US for CRNAs I’ve heard). There is no consultant anaesthesiologist (unless you decide the case is too high level and refer to a tertiary site, in which you would not start the case at all ofc).
Edit to add:
Yes I’m in a Commonwealth country. I should add my GP training was rigorous and I did extra blocks in ICU. We are strong in our general medicine/ peds knowledge and expected to progress faster. For example, I can independently diagnose/manage STEMI, PE, unstable arrhythmias, COPD/CHF exacerbation, unstable GIB, brain bleeds, peds croup/asthma/bronchiolitis in the inpatient unit/ ER. So I know there is badness out there, but I feel like I haven’t seen enough/ experienced enough badness to know how to manage it in the OR.

I would give it the entirety of the training to see how comfortable you get. And if you are still uncomfortable you could ask to do some more work (free probably) at a residency program for more experience or scrap it all together and just do GP work.
Whatever the case, you are a physician who is ultimately responsible for these patients. With your strong GP background do not compare yourself to a CRNA.

 

[coffeebythelake]

I'm actually most surprised that ASA classification is used around thr world. Don't your national organizations have their own classification systems?

 

[Zekchar]

Bad idea. You should be terrified. Every nurse that calls me for a rapid response was "confident" in their ability to provide moderate sedation and they "watched that patient like a hawk." Yet there I am 10 minutes later, salvaging a blue patient and whisking them away to CT scan to diagnose the innevitable hypoxic encephalopathy. That nurse feels like shat, the doctor feels like shat, the techs feels like shat, and the second victim effect perpetuates itself. Then you get sued (rightfully so). Too much can happen too quickly in too familiar of circumstances.

 

[chocomorsel]

Bad idea. You should be terrified. Every nurse that calls me for a rapid response was "confident" in their ability to provide moderate sedation and they "watched that patient like a hawk." Yet there I am 10 minutes later, salvaging a blue patient and whisking them away to CT scan to diagnose the innevitable hypoxic encephalopathy. That nurse feels like shat, the doctor feels like shat, the techs feels like shat, and the second victim effect perpetuates itself. Then you get sued (rightfully so). Too much can happen too quickly in too familiar of circumstances.

So why would the doctor “rightfully so” get sued in a case they rescued?
And this person does not live in the good old USA, land of sue for everything. So their legal issues are not like they are in the US.
And getting a CT scan immediately at the hypoxic event to diagnose hypoxic encephalopathy? Really?
And if you are salvaging blue patients like you make it sound, you need to work somewhere else. How many of these have you been involved in?

 

[woopedazz]

JCCA/ACRRM (which OP almost certainly is) are rarely in the legal firing line. The community would murder whatever family sued them and took their doc away... and it would almost always be unsuccessful anyway... Australia is much less litigious. You need to truly **** up to get sued.

Honestly, if you're worried I think you probably get it. The majority of GP Anaesthetists are good, realistic, safe doctors who lament the lack of training they received in the ridiculously short program and are **** scared of killing someone. They continue to study after completing their time and upskill aggressively. I'd trust most of these to anaesthetise me after a year in the wild. Many come back for additional time prior to solo practice.

Then there's the handful who are natural born killers. The few I've met were high achievers in med school/GP training, but they just suck at anaesthesia. They are blind to their deficits. They read the chapter on DLTs/severe AS/morbid obesity and therefore know what to do... Until they don't. It works in the ED with a random snake bite/whatever, but not when the airway is lost.

If you feel unsure, it's good. Means you're in group one. Your training will be fine for most things and you'll continue to push and learn as you go forward.

I actually learnt a lot as a junior from GP Anaesthetists out bush, and you are a respected member of the anaesthesia team.

Don't fret. Apply for additional rotations at the end if you still want. Do your advanced courses and upskill. You'll be fine.

 

[Arch Guillotti]

Bad idea. You should be terrified. Every nurse that calls me for a rapid response was "confident" in their ability to provide moderate sedation and they "watched that patient like a hawk." Yet there I am 10 minutes later, salvaging a blue patient and whisking them away to CT scan to diagnose the innevitable hypoxic encephalopathy. That nurse feels like shat, the doctor feels like shat, the techs feels like shat, and the second victim effect perpetuates itself. Then you get sued (rightfully so). Too much can happen too quickly in too familiar of circumstances.

Your job sounds horrible. I have never had a case like that dealt to me.

 

[chocomorsel]

JCCA/ACRRM (which OP almost certainly is) are rarely in the legal firing line. The community would murder whatever family sued them and took their doc away... and it would almost always be unsuccessful anyway... Australia is much less litigious. You need to truly **** up to get sued.

Honestly, if you're worried I think you probably get it. The majority of GP Anaesthetists are good, realistic, safe doctors who lament the lack of training they received in the ridiculously short program and are **** scared of killing someone. They continue to study after completing their time and upskill aggressively. I'd trust most of these to anaesthetise me after a year in the wild. Many come back for additional time prior to solo practice.

Then there's the handful who are natural born killers. The few I've met were high achievers in med school/GP training, but they just suck at anaesthesia. They are blind to their deficits. They read the chapter on DLTs/severe AS/morbid obesity and therefore know what to do... Until they don't. It works in the ED with a random snake bite/whatever, but not when the airway is lost.

If you feel unsure, it's good. Means you're in group one. Your training will be fine for most things and you'll continue to push and learn as you go forward.

I actually learnt a lot as a junior from GP Anaesthetists out bush, and you are a respected member of the anaesthesia team.

Don't fret. Apply for additional rotations at the end if you still want. Do your advanced courses and upskill. You'll be fine.

That’s what I am talking about. Seems like some of these people think the world works like the crapola that’s the American way of self center-ness.

 

[chocomorsel]

Your job sounds horrible. I have never had a case like that dealt to me.

And apparently it happens to her not infrequently. Weird.

 

[Zekchar]

So why would the doctor “rightfully so” get sued in a case they rescued?
And this person does not live in the good old USA, land of sue for everything. So their legal issues are not like they are in the US.
And getting a CT scan immediately at the hypoxic event to diagnose hypoxic encephalopathy? Really?
And if you are salvaging blue patients like you make it sound, you need to work somewhere else. How many of these have you been involved in?

Your anger and frustration is palpable. You disliked my disagreement with you on a different thread and are lugging around that toxicity throughout the various threads. This is my last reply involving you, then you'll be ignored. Take your metastatic attitude to whichever country you are wishing to go to and keep it there. I love the United States and will support it with everything I can. I've got nothing more to say to you.

Not quite sure where you all are working, but its very common to get paged for a rapid or code to a sedation case being performed without anesthesia or an off-site (chemo or blood draw) area at large academic medical centers and walking into some real shat shows.

 

[coffeebythelake]

Not quite sure where you all are working, but its very common to get paged for a rapid or code to a sedation case being performed without anesthesia or an off-site (chemo or blood draw) area at large academic medical centers and walking into some real shat shows.

I also work at a large academic medical center and this scenario that you describe happens rarely here. Maybe there is something the sedation nurses aren't doing right at your place if these bad events happen "very common". Maybe they are snowing patients with massive doses when they ought to be getting a touch of versed and fentanyl. Or maybe you are exaggerating a bit. But I don't think you can speak to such generalizations about conscious sedation cases administered by non anesthesiologists.

 

[Arch Guillotti]

Not quite sure where you all are working, but its very common to get paged for a rapid or code to a sedation case being performed without anesthesia or an off-site (chemo or blood draw) area at large academic medical centers and walking into some real shat shows.

I have worked at a large academic medical center and rarely experienced this.

 

[chocomorsel]

Your anger and frustration is palpable. You disliked my disagreement with you on a different thread and are lugging around that toxicity throughout the various threads. This is my last reply involving you, then you'll be ignored. Take your metastatic attitude to whichever country you are wishing to go to and keep it there. I love the United States and will support it with everything I can. I've got nothing more to say to you.

Not quite sure where you all are working, but its very common to get paged for a rapid or code to a sedation case being performed without anesthesia or an off-site (chemo or blood draw) area at large academic medical centers and walking into some real shat shows.

Jesus Christ? WTF is wrong with you? I can disagree and move on to other topics. Clearly you can’t. You are not my psychologist. Stop holding on to crap and entitlement.

How about what @Arch Guillotti said? How about @woopedazz? How about @coffeebythelake? They both echoed parts of what I said: Can you palpate their anger too?

The entitlement from you is palpable. You aren’t my mom. You aren’t my boss. You aren’t here to teach me any lessons lady. So what ignore me! OMG I am gonna never wake up happy again because some entitled lady who’s clearly holding on to last weeks call out is annoyed with me. You think you are the only one here honey? Pick a number and stand in line.

Move on woman.

 

[burnermdaccount]

JCCA/ACRRM (which OP almost certainly is) are rarely in the legal firing line. The community would murder whatever family sued them and took their doc away... and it would almost always be unsuccessful anyway... Australia is much less litigious. You need to truly **** up to get sued.

Honestly, if you're worried I think you probably get it. The majority of GP Anaesthetists are good, realistic, safe doctors who lament the lack of training they received in the ridiculously short program and are **** scared of killing someone. They continue to study after completing their time and upskill aggressively. I'd trust most of these to anaesthetise me after a year in the wild. Many come back for additional time prior to solo practice.

Then there's the handful who are natural born killers. The few I've met were high achievers in med school/GP training, but they just suck at anaesthesia. They are blind to their deficits. They read the chapter on DLTs/severe AS/morbid obesity and therefore know what to do... Until they don't. It works in the ED with a random snake bite/whatever, but not when the airway is lost.

If you feel unsure, it's good. Means you're in group one. Your training will be fine for most things and you'll continue to push and learn as you go forward.

I actually learnt a lot as a junior from GP Anaesthetists out bush, and you are a respected member of the anaesthesia team.

Don't fret. Apply for additional rotations at the end if you still want. Do your advanced courses and upskill. You'll be fine.

Thanks this helps alot. Yes, 1 year feels way too short, I wish it were at least 2.


Regarding the other comments...nurses don't independently give meds where I'm from so I have no idea what a "sedation nurse" does.

 

[coffeebythelake]

This is key. IR and other off site sedation locations can sedate proceduralist designated "low risk" patients... and then I'll take a look back at their documentation (when the patient comes to the OR down the line) and they're all marked as ASA2. And of course these are ASA2s of the ESRD, ESLD, severe pulmonary HTN, had an MI yesterday sort. To be fair I never want to go to IR or cath lab or GI ever, so I'm not exactly jumping to rock their boat.

For a lot of proceduralists, the ASA score means nothing because the patient is going to get 5 mg Versed and 100 mcg fentanyl no matter what.

 

[WholeLottaGame7]

Severe pHTN ASA 2?! 😐

According to my radiologist wife, in residency they were instructed to call everyone an ASA1 or 2 so they could just proceed with moderate sedation, because if they called someone a 3 or 4, they had to consult anesthesia before sedating them.

She didn't have a great response as to how much training they had on using the ASA classification, or why they even used it in the first place vs making up their own radiology scoring system (that goes from 1 to 1?).

It came up because there was a pHTN/ESRD ASA4 patient (not hers) that coded in radiology twice in the span of a few weeks after getting moderate sedation. Go figure...

 

[coffeebythelake]

According to my radiologist wife, in residency they were instructed to call everyone an ASA1 or 2 so they could just proceed with moderate sedation, because if they called someone a 3 or 4, they had to consult anesthesia before sedating them.

She didn't have a great response as to how much training they had on using the ASA classification, or why they even used it in the first place vs making up their own radiology scoring system (that goes from 1 to 1?).

It came up because there was a pHTN/ESRD ASA4 patient (not hers) that coded in radiology twice in the span of a few weeks after getting moderate sedation. Go figure...

Everyone thinks they know more about anesthesia than the anesthesiologist

 

[chocomorsel]

According to my radiologist wife, in residency they were instructed to call everyone an ASA1 or 2 so they could just proceed with moderate sedation, because if they called someone a 3 or 4, they had to consult anesthesia before sedating them.

She didn't have a great response as to how much training they had on using the ASA classification, or why they even used it in the first place vs making up their own radiology scoring system (that goes from 1 to 1?).

It came up because there was a pHTN/ESRD ASA4 patient (not hers) that coded in radiology twice in the span of a few weeks after getting moderate sedation. Go figure...

So they didn’t learn the first time? They went at it again the second time? Poor patient. I think I would have said no thanks.
This arrogance and ignorance is what kills patients. Very sad.

 

[epidural man]

I'm in a non-US program that trains GPs to do low risk anaesthesia. We are called GP anaesthetists. We only do 1 year of anaesthesia training after our GP residency and handle low risk ASA 1-2 in rural places. I'm halfway through my year but terrified at the thought of being independent. I've only ever gotten good feedback but everyday I'm terrified. I want to transfer into the 5-year anaesthesia stream but that requires 3 more years of additional training. People tell me that I will be fine but I don't trust myself. Any advice for me?

Do the extra training. Become the expert.

You will never gain the skill for the real scary situations taking care of the hypoxic healthy person that just needs a jaw thrust, or an occasional Blood pressure bump, or an occasional beta blocker for racing heart. You will occasional ally see a junctional rhythm and give some robinol and think you are great.

But I really think to feel comfortable and confident, you need to be stretched with some training.

It’s just time. It will go quickly.

 

[woopedazz]

Do the extra training. Become the expert.

You will never gain the skill for the real scary situations taking care of the hypoxic healthy person that just needs a jaw thrust, or an occasional Blood pressure bump, or an occasional beta blocker for racing heart. You will occasional ally see a junctional rhythm and give some robinol and think you are great.

But I really think to feel comfortable and confident, you need to be stretched with some training.

It’s just time. It will go quickly.

It would be an additional 5+ years of training +2 reasonably difficult exams for OP once they get on an anaesthesia training program. Getting on isn't super easy... last year my program had 120+ shortlisted applicants for 6 jobs... So it's not super easy to make the decision to go all out.

Edit ... Sorry thought you were saying just do anaesthesia training. An extra year on their current program is a great investment. Not sure about pursuing specialist training

 

[jwk]

Not quite sure where you all are working, but its very common to get paged for a rapid or code to a sedation case being performed without anesthesia or an off-site (chemo or blood draw) area at large academic medical centers and walking into some real shat shows.

Not quite sure where you're working but its very UNcommon in all the hospitals I've worked over 40+ years. Except for the first month or two when Versed was first released and we had to tell the crappy GI docs that slamming in 10mg of midazolam was not smart.

 

[GassYous]

Not quite sure where you're working but its very UNcommon in all the hospitals I've worked over 40+ years. Except for the first month or two when Versed was first released and we had to tell the crappy GI docs that slamming in 10mg of midazolam was not smart.

Yeah I can only think of two cases and I've only heard about them, wasn't involved at all

 

[chocomorsel]

Not quite sure where you're working but its very UNcommon in all the hospitals I've worked over 40+ years. Except for the first month or two when Versed was first released and we had to tell the crappy GI docs that slamming in 10mg of midazolam was not smart.

That’s cuz she is lying trying to gain some clout. Hahah.

 

[barn80]

I'm in a non-US program that trains GPs to do low risk anaesthesia. We are called GP anaesthetists. We only do 1 year of anaesthesia training after our GP residency and handle low risk ASA 1-2 in rural places. I'm halfway through my year but terrified at the thought of being independent. I've only ever gotten good feedback but everyday I'm terrified. I want to transfer into the 5-year anaesthesia stream but that requires 3 more years of additional training. People tell me that I will be fine but I don't trust myself. Any advice for me?

Are you originally from the US? What program is this and where/what country is it located?

 

[PpfSuxTube]

I'm in a non-US program that trains GPs to do low risk anaesthesia. We are called GP anaesthetists. We only do 1 year of anaesthesia training after our GP residency and handle low risk ASA 1-2 in rural places. I'm halfway through my year but terrified at the thought of being independent. I've only ever gotten good feedback but everyday I'm terrified. I want to transfer into the 5-year anaesthesia stream but that requires 3 more years of additional training. People tell me that I will be fine but I don't trust myself. Any advice for me?

Sounds canadian?

If im right then unlikely you will get 2 full years credit if you do manage to switch to the full program. You'll be lucky to get any credit... sorry but thats just the truth...

Now on to good news... try take some more electives especially in icu or big centre's with lots of complexity... prepare yourself as best you can.

We had a lot of gp anesthesia coming thru our centre. Some very good that took nothing but anesthesia and icu electives their whole training. Some hopeless, lazy and full of themselves... totally unaware of the danger they were in...

You dont sound like the latter, just work hard at it and you'll be fine... its still just a,b,c... get a good iv, give sensible anesthetics, keep the bp up... its not rocket science... our propofol and phenyl and roc, glidescope is the same as yours!

 

[coffeebythelake]

Sounds canadian?

If im right then unlikely you will get 2 full years credit if you do manage to switch to the full program. You'll be lucky to get any credit... sorry but thats just the truth...

Now on to good news... try take some more electives especially in icu or big centre's with lots of complexity... prepare yourself as best you can.

We had a lot of gp anesthesia coming thru our centre. Some very good that took nothing but anesthesia and icu electives their whole training. Some hopeless, lazy and full of themselves... totally unaware of the danger they were in...

You dont sound like the latter, just work hard at it and you'll be fine... its still just a,b,c... get a good iv, give sensible anesthetics, keep the bp up... its not rocket science... our propofol and phenyl and roc, glidescope is the same as yours!

I doubt Canadian. They don't spell it anaesthetist and to refer to family medicine trained as GP is not technically correct