The Cost Of Academic Myth

Discussion in 'Anesthesiology' started by jetproppilot, May 16, 2008.

  1. jetproppilot

    jetproppilot Turboprop Driver
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    Man, how much I've learned having an S.O. who is a general surgeon.

    Its provided me with a personal, trustworthy perspective I was never aware of outside my chosen specialty.

    If you read some of the allopathic threads, residents posting in the general surgery forum, med student forums, etc,

    you'd think general surgeons are work gluttons with hundred hour work weeks and no life.

    :lol:

    My S.O. :

    is deft, busy, well respected, with a major referral pipeline from the OB dudes for breast issues......(READ: alotta breast biopsies and stereotactics on young girls with commercial insurance).....and FP docs, IM docs for other surgical needs...

    typically is done on a non call day by 3pm, whether shes seeing 35 pts in the office or doing 6-7 cases in the OR.....granted, she's there early, like me, around 0630...

    shares call with other groups so her weekend call is about one in twelve...

    has every Wednesday off...

    has the ability to take off whenever she wants, as long as its known in advance....(we're going to Vegas in June....to The Cove at Atlantis, Bahamas in November...)

    So what have I gathered from my S.O. concerning propegated mantras amongst people in training is:

    WHATS MORE IMPORTANT, WHEN IT COMES TO LIFESTYLE ISSUES, IS NOT THE SPECIALTY.....ITS THE INDIVIDUAL.

    Some people are not capable of efficiency....or are too proud to learn it....or arent taught it.

    For whatever reason, most docs in academia, regardless of specialty, fit this description. This is who we learn from.

    You have to learn on your own how to be efficient.....or wait until the private practice transition, then learn from your partners...

    this is WRONG!!! We should be taught this..I certainly wasnt..and I'd venture to say that hasnt changed...in anesthesia or any other specialty..

    ...this should be an integral part of our training, regardless of specialty, dontcha think? Doctors in training should be taught the value of time management. Learning how to be faster and at the same time efficient. At procedures. Rounding. Consults. Office visits. Managing problems. Waking people up. Putting them to sleep.

    Rounding CDAZY FAST........10 minute breast biopsies......15-20 minute lap-GBs....30 minute lap hernias.....1 hour colon resections....fast in the office seeing patients....fast with consults....1 hour open splenectomy on a trauma patient.....

    is what S.O. is made of in her professional life.

    She has shown me that many myths are propegated, even outside of our anesthesia specialty.

    You can be a busy general surgeon and have a great lifestyle too.

    I read an analagous thought from a post in the FM section....touting orthopedists as, yes, highly paid, but tied to the hospital with endless workweeks...and yet the successful orthopedists I work with have a lifestyle lifestyle similar to S.O. .....

    I learned something that would be valuable info for our colleagues in training......which is.....

    many, many myths are propegated in academia!

    About everything! How to do a case, how specialists are handsomely paid but dont have a life.....

    I hate these myths.

    Am still thinking about how we can bridge the information-gap between academia and private practice to the people still in training....
     
  2. anesonia

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    Excellent post! So many docs are horribly inefficient and poor business people/money managers. My previous career as a banker/broker taught me much of this outside of the medical realm, and medical school has exposed the inefficiency within medicine...I really think you hit the nail on the head with this one, Jet. I am still an MSIII, but would LOVE to have a residency that would expose me to exactly what you are talking about. Probably not gonna happen I know, but I nice thought none the less.
     
  3. dr doze

    dr doze To be able to forget means to sanity
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    #3 dr doze, May 17, 2008
    Last edited: Mar 10, 2009
  4. coprolalia

    coprolalia Bored Certified
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    Efficiency is definitely not taught in academia. It is also not rewarded. I've learned this the hard way.

    I figured out early how to wake a patient comfortably, you know, pull the tube as the drape is coming down and have them awake and breathing without screaming in pain going to the PACU. I can also get the next patient in the OR right as the scrub tech is walking out of the scrub room and getting gowned. All that this has done is won me over with the PACU nurses, and gotten respect from the surgical team I happen to be working with that day.

    It's punished.

    When you do more cases efficiently, you get more cases to do in residency. I hit the dreaded "2:00 PM and finished the booked cases" time and will inevitably get another add-on in my room or get sent on errands around the hospital that make it so I don't get out before 5:00 PM (and often 6:00 PM... or later).

    So, I've stashed these pearls away for PP land. Right now, I purposefully drag out cases so that I can be done by 4:00-4:15 PM time. This lessens my chances of getting add-ons or being sent on a fool's errand.

    It's sad, really. Academia is so woefully inefficient (with a few exceptions), and some of us first figure out how to get a patient safely and comfortably to the PACU as quickly as possible early on. Others never do (e.g. turn off the vapors as the drape is coming down and sit there another 25 minutes, etc.). They almost invariably get to go home before I otherwise would.

    I can't wait for PP. I don't mind working hard and safely, as well as getting the job done efficiently. But, it's just not rewarded in academia. The people "on the clock" don't care, the people evaluating me don't seem to notice, and there certainly is no incentive to be more efficient.

    So, I'm waiting. I'll use what I know to get 'er done when I'm done... with residency, that is.

    -copro
     
  5. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

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    Don't be too hard on those who turn off the vapor as the drapes come down. In academia you really never know how long the closure will take (ie. quick staple gun finish, or long-*** med student sew-job with teaching and joking around even though it's 2 am. Sometimes just when you think the resident is done, they go Old Master style on the dressings and take 15 minutes to perfectly place steri-strips, custom-shaped tegaderms, and gauze. I actually don't mind having the patient start to wake up and cough in those instances to put some pressure on Leonardo Da Vinci across the drapes.
     
  6. cchoukal

    cchoukal Senior Member
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    this is SO true. I started noticing this about half-way through my CA2 year. Coming into work with that 1400 finish time has come to mean burn or thoracotomy add-ons. Thanks for nothing! I will say, however, that good, smooth, efficient work does get favorable attention from our attendings and we have a couple (formerly PP) attendings that give us a hard time if we make too many unnecessary moves or are inefficient doing procedures. Some of THESE even offer suggestions for improvement :rolleyes:.

    There is, however, very little in the way of education regarding good business practices. We have a couple guys who did really well on the outside before coming back, and we can needle them for knowledge, but there's no real organized curriculum. This would be a cool thing to have, and our chiefs are supposedly working on it.
     
  7. GasEmDee

    GasEmDee Member
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    I have no desire to get into another argument about academics vs private practice, but do the anesthesiologists at your hospital honestly suck that bad? Yes, there definitely are inefficiencies in the academic hospital, but I don't know anyone who leaves vapors on full bore till the drapes come down.

    I learned on my FIRST day as CA-1 not to do this. Got put in a room, and the procedure ended while my attending was out of the room. I had no idea what I could and could not turn off. Never let myself be in that situation again.
     
  8. GasEmDee

    GasEmDee Member
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    Yes, i totally agree with this.
     
  9. GasEmDee

    GasEmDee Member
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    You don't need the gas on full bore for this. Narcotics, nitrous, and the occasionally small propofol bolus are your friends.
     
  10. coprolalia

    coprolalia Bored Certified
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    This isn't a matter of the attendings. It's the residents. Usually, by the time the case is nearing the end, they are not always in the room. And, if they walk into the room, it's usually when they're called because the tube is going to get pulled. So, there's not much oversight on "landing the plane" safely during that time.

    I've noticed this in my resident colleagues when I'm on "late/breaks" week. You come in late, and stay late. You're often there to get people out for lunch (etc.), and when you go into a room and the case is about 20 minutes from being done, you notice that your resident colleague is still running a full anesthetic. The first thing I do is shut the vaporizer off and turn up the flows. I had one "colleague" get all wide-eyed and deer in the headlights looking when I did this in front of her one time. She said, "Don't do that! They're not done with the case!" before she left the room. Unbelievable.

    You have an attending who's got two rooms and is also probably trying to juggle getting some academic/bureaucratic stuff done. This means they're often in their office (or at the coffee bar) during this time. No resident asks, "How can I be more efficient?" So, the onus is partially on them. But, you don't know what you don't know.

    It's about time spent doing cases and developing confidence. I see a lot of residents who don't have confidence in their own abilities or their anesthetic. I also see some attendings who operate the same way. I'm at the point in my game where I definitely feel I have a better inherent sense of the anesthetic than some of my attendings, and I've certainly been in the room doing the case the whole time and know what's going on. They don't.

    Not all of them suck, therefore. But, some clearly do. And, we definitely have some attendings who, quite frankly, just wouldn't/can't hack it in PP land. So, I agree with Jet. You can't teach this to some people. Their nerves can't stand running low MAC for the last twenty minutes of the case. They've never been taught/learned to do this. I figured this out without being taught. And, if these attendings didn't have a resident there doing the bulk of the case, they'd be completely lost. Scary indeed.

    -copro
     
  11. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

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    It's the last 0.3% of iso, and 0.2% of sevo that take 10-20 minutes to come off. I change over to des for the last hour of long cases, or nitrous/remi for a super fast and smooth wakeup. For shorter cases, nitrous/prop/narcotics work fine as the case is ending. You have to be careful with prop at the end of a case. A 50 mg bolus of prop with residual gas is a recipe for 10 minutes clock watching.

    I'd like to polish a technique of running iso only, and finishing with prop/narcotic with a fast, smooth wakeup for a more cost-effective anesthetic. I have little motivation to do that now with all the expensive short-acting drugs so readily available at no cost to me.
     
  12. BISof60

    BISof60 A polite young man
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    Amen. In 6 weeks med student/intern closures will no longer be a part of my life praise da lawd!
     
  13. BISof60

    BISof60 A polite young man
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    so when did she become fast? first year or two of private practice?

    i think efficiency is something we can all strive for. sure, you have 20 minutes to put in that thoracic epidural as a CA-3, but why not just do it in 5? i've definitely spent some time this year trying to be quicker with procedures....though i know i'm still probably slow by pp standards.
     
  14. coprolalia

    coprolalia Bored Certified
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    By the way, dude... When are you going to make her an honest woman?

    ;)

    -copro
     
  15. militarymd

    militarymd SDN Angel
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    Let me ask you this....do any of your attendings do any cases on their own.....ever?
     
  16. powermd

    Physician Lifetime Donor Classifieds Approved 15+ Year Member

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    Occasionally one of our attendings will get an "attending request" and may do the case entirely on their own. Other times they do it with a resident. The last VIP I did was not an attending request, but the attending stayed in the room for the whole case.
     
  17. GasEmDee

    GasEmDee Member
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    Yes. There are simply not enough residents to staff the volume of cases that we do.
     
  18. GasEmDee

    GasEmDee Member
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    Yes, I agree, but you were talking about turning off the gas as the drapes come down. I turn off the gas well before...a good level of background narcotics and some propofol suffices for closure of skin...

    I dont give big boluses or propofol. Sometimes, I'll run a low-dose propofol infusion. There is evidence showing that if you run a propofol infusion of 120 mcg/kg/min or less, the context sensitive half life doesnt increase exponentially....then u can turn this off 10 minutes before the drapes come down...

    I remember reading something suggesting that switching from ISO/SEVO to Des doesnt reliably decrease emergence time, so not sure about that one, but I dont remember the details of the study.
     
  19. GasEmDee

    GasEmDee Member
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    I dunno man. *Never* taught or *never* learned? Thats like saying there are anesthesiologists that were never taught or that never learned how to place IVs. It is a skill that we begin acquire on DAY ONE. Sure, some people are better at it than others... but you are telling me you have people who dont know how to titrate down an anesthetic? By extension, there are surgeons out there that would tolerate that kind of turnover? Even academic surgeons want to go home.

    I can see people around me with different strengths and weaknesses. Some are better at turn over than others. I am certain that private practitioners are far more efficient. But I have seen no one with the degree of sheer incompetence that you are describing -- except for the CA1 on their first week.
     
  20. Strength&Speed

    Strength&Speed Need more speed......
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    i can't speak to anes..but in general the docs in academic medicine chose academic medicine b/c they don't really feel like working that hard. so efficiency and speed aren't exactly their prime motivators. probably a lot have tried that and decided they didnt like that lifestyle.
     
  21. coprolalia

    coprolalia Bored Certified
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    I have even had one - unequivocally and openly - say as much to my face.

    -copro
     
  22. kmurp

    kmurp Junior Member
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    It is not just the individual, it is also the location. We had 19 general surgeons when I started years ago. All in private practice. As of this month, we are down to 6, with only 5 of them taking call, and 3 are hospital employees. Their lifestyle sucks. I recently read that not a single graduating general surgery resident from the many New York training programs are staying in the state this year.
     
  23. urge

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    I always thought the saying that "academic guys just want to take it easy" was junk. Until, one of my coworkers told me she took the job so that she wouldn't work that hard. Yeah. Brutal honesty. It didn't work out for her. Now she is complaining that pts are too sick and she is constantly stressed.
     
  24. fakin' the funk

    fakin' the funk ASA Member
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    :laugh:
     
  25. fakin' the funk

    fakin' the funk ASA Member
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    How about titrated 10 mg boluses? Too little to make a difference?
     
  26. Strength&Speed

    Strength&Speed Need more speed......
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    i am going to take the next few minutes to vent. If anyone needed any more advice than they already do that academic attg's are invariably lazy pos, I am sure we can all remember a time when you couldn't show up to work, or see a patient, or in the gas forum, do a case. I am sure your attg's got all atwitter and agitated because someone wasn't actually going to do their work for them. Holy cow I've never seen the attg's get so worked up about things then when they actually needed to work.

    Ok, ill go have a beer now.
     
  27. militarymd

    militarymd SDN Angel
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    I guess times have changed...I was partners with someone who trained at UCSF....no attendings did cases he was there.
     
  28. jennyboo

    jennyboo Senior Member
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    Then the dressings are on, drapes are down, you're ready to get the tube out but the legs are in stirrups and the intern takes f***ing 10 minutes to degown, de-glove, remove mask, brush hair, etc BEFORE putting the bottom of the table back on and putting the legs down.
     
  29. cchoukal

    cchoukal Senior Member
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    you can't extubate with the legs in the stirrups?
     
  30. rsgillmd

    rsgillmd ASA Member
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    I don't think "can't" is the write word. I'm sure all of us can do virtually anything. I don't like to, unless I'm doing a deep extubation, because I don't want the patient to have an uncoordinated movement with the legs in stirrups. I'm just afraid of some of these old people dislocating a hip or something.
     
  31. coprolalia

    coprolalia Bored Certified
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    Oh, man. I have. We have an attending now we just can't get rid of. He hasn't really done anything to get himself fired. But, they are trying everything they can (had someone in admin tell me this) to get him to leave. It's only a matter of time until he kills someone. It won't be because of something he forgot to do or missed, but because he simply will get into a situation that he won't know how to get out of. He's a one-string banjo. Everything is cookie-cutter. Every patient gets the same anesthetic. One yellow stick, one red stick, one blue stick and some purple stuff. Where to start with his level of incompetence, I just don't know.

    For example, I was working with him one day and he'd given me a lunch break. We had an LMA in and, per usual, the case was near-done when I came back to the room. We'd been running about 1.0 MAC of isoflurane for about two hours. When I got back to the room, the patient was breathing slowly but deeply and regularly, and we were still at about 0.3 MAC of iso. They were putting the steri-strips on. I said, "Let's just take the patient to the PACU with the LMA in." He says, "Okay, sure." I turn to grab the papers and shut the O2 off on the anesthesia machine, and he's unplugged the circuit and is putting a nasal cannula on the patient... to their nose... as I turn back around. I watch him for a second shaking my head, and as he walks to the foot of the bed to turn the O2 tank on, I start to move the nasal prongs up to the open end of the LMA tube. He turns back, glares at me with a deer in the headlights and bewilderingly confused look and asks accusingly, "What are you doing?!??!" with eyes as wide as saucers. He basically rushes back to the head of the patient, shoves me aside, and starts to put the prongs back into the nose. Then, as I'm getting a little pissed, I say, "Dr. XXXXX, think about that for a second."

    He stops.

    You can almost literally see the wheels turning in his head.

    It's a good ten-second pause as he's staring at the patient's face.

    I start to move the nasal prongs back to the end of the LMA tube, and he squeaks out a "but...," then he stops, stares at the patient for another few seconds, makes a little grunting noise, and then disgustedly turns away from me and leaves. And I push the patient out of the room. All of this occurred within a minute. But, the real irony is that if he'd been paying attention during the end of the case, we would've not had "awake MAC" vapors still in the patient and the damn LMA would've been pulled already. Hell, I would've pulled it right then and there but I knew the guy was going to be too chickensh*t to do it until the patient was sitting upright and ready to play Scrabble with us.

    Scary, scary ****, man. And, this is a guy that's supposed to be teaching me? I hate to say it, but he is an FMG who did his training during the "down" years of anesthesia in the mid-90's, and then somehow landed a job at our program during the recent desperate years where pretty much any warm body with anesthesia training could get a bonus-size PP job... except the very weak, who somehow landed in the lower-paying academia jobs. He practiced for almost 8 years before he finally passed the ABA board exam. Yes, he's now board-certified, which also scares me. No one has the balls to fire him, which - watching all of this over the past two years - has helped convince me that academia is not the place for me. That, and having the chance to work in a PP environment over a few weekends and to actually see how it's really done with people who are not marginally competent.

    -copro
     
  32. militarymd

    militarymd SDN Angel
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    cop,

    are you sure he's not one of mine here in PP land? the guy I can't deep six because of politics?

    You're describing him to a teee....right down the the BC timing!!!!
     
  33. toughlife

    toughlife Resident
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    Sorry, I couldn't help it. :laugh: Maybe an anatomical diagram taped to the LMA would have helped.
     
  34. Strength&Speed

    Strength&Speed Need more speed......
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    im not even a gas man and this scares me. wow. if you can't figure out how to get oxygen down the larynx, god forbid what happens when something actually complicated happens.
     
  35. dhb

    dhb Member
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    I've seen my share of crazy mofo's. The other day we had a dude with a bleeding ulcerated av fistula, the attending decided to do an infra-clavicular bloc under the drapes with the patient asleep and the surgeons working on the fistula :eek:

    Thursday we had a sick ESRD patient for a hip replacement, got her breathing spontaneously at the end of the case (she used up 70mcg of sufentanil) 500ml tidal RR 14 everything going fine until the attending decides to reverse her with 2.5mg neo .5 glyco and 0.15mg of naloxone 'cause he does that for these kind of . I was like what the f... if you do that i'm not seeing this patient in the PACU your gonna take care of her.

    In the PACU she was agitated (who would of thought) was discharged to the floor were they couldn't deal with her so she was sent to the ICU and died the next day during dialysis... f... up management... sad.
     
  36. coprolalia

    coprolalia Bored Certified
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    Yes, there are scary practitioners out there. It's only a matter of time until they do something really, really bad to someone.

    Another occassion with this same attending...

    I was finishing a thoractotomy on a hella-sick mid-twenty-something cachectic female patient with eng-stage cystic fibrosis. I had a double-lumen tube in. I had one of our excellent cardiac guys doing the case with me (i.e., started at around 2:00 PM with lines, etc.) and we were nearing the end of the case.

    Well, it was around 5:30 PM, and it was time for this attending to take-over for night call. So, the case got sold to him. I had a 35 left double-lumen tube in the patient. We were back on two-lung ventilation at this point. About this time, Dr. XXXXXX came into the room, wide-eyed dinner plate eyes and white-as-ghost look on his face. I just said to myself under my breath, "Oh, ****."

    Just a little after 6:00 PM, I page him back to the room letting him know that we're nearing the end of the case and that I'm going to extubate her here. He comes in and immediately walks over to the anesthesia machine to look at the numbers. The end-tidal CO2 was probably 45-ish, but she was spontaneously breathing. He starts to fumble with the ventilator trying to put her back on a rate. I literally said, "Don't do that. I'll take care of this patient. I was here for the whole case."

    He asks me, "Why is her CO2 so high? You need to get that down."

    I started to want to try to explain to him... then I stopped. I could immediately think of about 5 reasons why that was a perfectly acceptable end-tidal CO2 in this patient. I just took a deep breath and smiled under my mask. I said, "I pre-op'd this patient, I started this case, and I've been discussing the developing concerns with the surgeons the whole time." Vapors had been off for about 20 minutes, and about 2 minutes later while he was standing there I extubated her without any problems. If he didn't know the multitude of reasons why it was perfectly acceptable fo such a patient to have an end-tidal of around 45 (which isn't a problem for most patients, let alone her), that was his problem - not mine. I'm sure he hadn't done a single-lung ventilation case since residency (which ended in 1999 for him). I literally was doing everything I could to not let him touch the patient or somehow screw-up what was going to be a smooth extubation in an ASA 4 patient.

    The only good thing I can say about our program with this guy is that he only gets to work with residents about 30% of the time. Every time I am with him, I try my damndest not to let him touch anything during the case. Fortunately, he only gets most of the easy cases on patients who aren't that sick. But, on the rare occassion (such as this) where there is overlap in someone who's desperately ill, I run intereference.

    They just can't seem to get rid of this guy. I mean, they've given him every subtle sign they can that he should move on. But, it's a Catch-22. If they try to give him more call than his colleagues to make him get the point (etc.), then it's just exposing the residents and the patients to more risk. He hasn't done anything really terribly wrong yet, so there's no actionable item to put on the table to fire him. He's got teenage kids in the local school system, so I doubt he's going to be motivated to move along until they are out of school. But, seriously, there's nothing beyond a simple lap chole or hernia repair that he's competent at doing without heavy supervision. Fortunately, the majority of my resident colleagues are vigilant and know how to effectively run intereference.

    I could go on and on. Unnecessarily massive fluid administration for a case (e.g. hearing a story about a two-hour hysterectomy getting 4.5 L of crystalloid). Patients over-narcotized in the PACU. Taking a half-hour (or longer) to put an epidural in. It's painful to watch him work. Absolutely no "peripheral vision" to his anesthetics. The only positive thing I can say is that by watching him I've learned a lot about what not to do.

    Sad. Scary. But, de rigeur in academia, I fear. At least at our institution.

    -copro
     

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