tips on dealing with CRNAs

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lakersbaby

lakersbaby

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I haven't been supervising much at my gig, mostly doing solo but will start supervising CRNAs more and more. Any of you veterans have tips on dealing with CRNAs? From what I hear from this group there are quite a few "militant" CRNAs that like to give attitude to new attendings. How do you establish a good relationship with these clowns and at the same time making them respect you as the physician. If I could do solo forever I would but just not possible. I also don't want to have a cordial relationship with them because I want to work here for a long time.
 
lakersbaby said:
I haven't been supervising much at my gig, mostly doing solo but will start supervising CRNAs more and more. Any of you veterans have tips on dealing with CRNAs? From what I hear from this group there are quite a few "militant" CRNAs that like to give attitude to new attendings. How do you establish a good relationship with these clowns and at the same time making them respect you as the physician. If I could do solo forever I would but just not possible. I also don't want to have a cordial relationship with them because I want to work here for a long time.
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lay out the big plan you expect them to follow for a case and don't sweat the minor details if they have a particular preference. For example, if they like using sufentanil instead of fentanyl, don't sweat it. Or if they like cisatracurium instead of vecuronium, just go with it. That sort of stuff is irrelevant. Also try to not come up with some exotic way of doing a case that you personally think is awesome if they have never done it that way unless you can spend most of the case holding their hand. I find most CRNAs to be pleasant to work with and willing to do whatever I think is appropriate.
 
Mman said:
lay out the big plan you expect them to follow for a case and don't sweat the minor details if they have a particular preference. For example, if they like using sufentanil instead of fentanyl, don't sweat it. Or if they like cisatracurium instead of vecuronium, just go with it. That sort of stuff is irrelevant. Also try to not come up with some exotic way of doing a case that you personally think is awesome if they have never done it that way unless you can spend most of the case holding their hand. I find most CRNAs to be pleasant to work with and willing to do whatever I think is appropriate.
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I came out supervising in my first gig. What Mman said.

I can add that it can take time for them to get used to you as the new guy. At first they may be even nervous about what you may be like as a person and doc. This can manifest in all the ways that people behave when nervous. A lot of CRNA's you meet may have been there for 20 years or more. Respect that and things will go well. They are people and have pride in their job (but it does not mean they are good at it, but most are competent).

In time, they will learn how you communicate and do things. Most just want to punch a clock, but they also take pride in their work. If you do want to do something "different" than the norm, make sure you bring them into the decision making process. It's just so much smoother that way.

If you want to intubate the patient, just say "hey, you push meds and I tube?". They always say yes. In reality, you are not asking and they know that, but it's just better that way.
 
This "bring them into the decision-making process" is what sunk American medicine, but now it's too late to fix all that PC. Now midlevels expect to be taught what they haven't yet stolen from us. We are all a big happy family...

Never forget: they don't know what they don't know, and even the most experienced ones will give you some bad surprises, if you work enough with them. Watch them like a hawk, just don't micromanage them. Pick your battles, perfect patient care be damned. This is not solo anesthesia, and neither is the quality; learn to live with it. It's the difference between the Ritz and Hampton Inn (or Ramada, occasionally). Try to focus on the big picture and on the stuff you enjoy, to rationalize why you're doing this ****. ("I get to do many more cases, and gain more experience, and do more procedures, and blah-blah-blah, than the stool sitting mommy-track loser anesthesiologists.")

Just make sure they always feel comfortable calling for help. Don't give them a hard time even for the stupidest question. The more they call/text, the safer you'll be. You are there to be a "resource" for them (that's how the PC leadership will say), not to supervise/direct them (which is what you and the malpractice jury would say).

Don't forget to be nice, be nice, be nice to them... Treat them as if they were your boss's favorite children, because they are (even if he tells you otherwise). Spoil them, and they'll love you. You'll feel dirty and used, but you can't have everything. At least you have a job.

If you know your stuff, they'll figure it out, sooner or later. Just don't give them a hard time. First impressions, remember? Plus they are nurses, as in mob mentality: you piss off one, you piss off all.
 
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You have to find the balance between being collegial and being assertive. Try not to let the crna do the pre-op. Get to the patient first and explain the relationship with the patient. Talk to the crna about patient and the plan in front of the patient to re-emphasize who is running the show. I agree with not sweating the small stuff, but have a coherent plan and be able to explain why...it's almost like a daily oral boards session. The militant "good" crnas are the ones you have to be the most careful with. They are often overconfident and I've already caught them almost making really bad decisions a couple of times. If you demonstrate your knowledge and skills early on, you are more likely to be respected by them. The whole thing kind of sucks and I would much rather do my own cases, but welcome to the new world order.
 
lakersbaby said:
I haven't been supervising much at my gig, mostly doing solo but will start supervising CRNAs more and more. Any of you veterans have tips on dealing with CRNAs? From what I hear from this group there are quite a few "militant" CRNAs that like to give attitude to new attendings. How do you establish a good relationship with these clowns and at the same time making them respect you as the physician. If I could do solo forever I would but just not possible. I also don't want to have a cordial relationship with them because I want to work here for a long time.
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Jeez dude, I'm sorry to hear this. Your life is about to become infinitely harder/more miserable. I've supervised most of my career but I've also employed all of my CRNAs. That's the only way that I will supervise; if I can no longer be in this situation, I will do something else.
 
FFP said:
Just make sure they always feel comfortable calling for help. Don't give them a hard time even for the stupidest question. The more they call/text, the safer you'll be. You are there to be a "resource" for them (that's how the PC leadership will say), not to supervise/direct them (which is what you and the malpractice jury would say).
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Correct that you want to make them feel good about calling for something that doesn't seem right. You'd rather get called 100 times for nothing that not get called 1 time that turned out to be something. But no, you aren't a resource, you are their boss and are there to help keep the patient safe. And done well, the ACT practice is as safe as MD only care. Just gotta work at it and can't be lazy.
 
Though supervisory philosophies differ, this is my prefered method of supervision:

Punch.png
 
As noted above, you don't want to make them afraid to call you, that can lead to catastrophe.
If you are going to discuss concerns about how they managed something that's actually significant, do it in private. That's a change from residency where pimping, chest thumping, and belittling in public on rounds, etc. is the norm. They may not ever have your knowledge or skills, but they are professionals, take pride in their work, and usually want to "do the right thing" for "their" patients. Make sure that "the right thing" includes being able to call you for any concerns.


--
Il Destriero
 
The easiest way to make a crna happy is to be "on time" to give them their breaks and relieve them promptly at 3pm. Do that and they will likely follow your directions.
 
GravelRider said:
The easiest way to make a crna happy is to be "on time" to give them their breaks and relieve them promptly at 3pm. Do that and they will likely follow your directions.
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No, this is backwards. If they perceive you as useless except for breaks and end-of-day relief, they'll think you work for them.


CRNAs will listen and follow your directions if
1) you're competent
2) you're collegial and basically respectful of the ability they do have
3) they're not militant shoulder-chippy know-it-all loose cannons

2/3 of those are in your hands.

Everyone on SDN is a superstar, so (1) is a given.

Some people can't help but be dicks, so (2) may be a stretch for them.

The obnoxious (3)'s are out there, but pretty rare. Nothing to do about them, except fire them if you can, leave if you can't, and if you can't do either, watch them like a hawk.


Nurses are responsible for 93% of the headaches in hospitals (the rest come from LPs in the ER) but they're not bad people. They don't want bad outcomes. Give them a reason to call you, and most of them will, if they see trouble coming. Remember that they're nurses, and they might not see trouble coming. If they don't call you about something you think they should've, educate (privately) and don't berate them.
 
You should spend the first 2-4 weeks observing and avoiding conflict. During that time you try to get a feel of how CRNAs are treated by those who were there before you, how much autonomy they allow them, and which CRNA is militant and difficult and which is incompetent.
Your goal is to assimilate with the rest of the group and do what they do.
some CRNAs will try to test you initially and push your buttons, don't let them, and don't let any one see you sweat!
 
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CRNAs are either weak or strong and either timid or confident. Strong-confident can be left alone. Strong-timid needs a little push. Weak-timid needs teaching and direction. Weak-confident requires the closest monitoring and the most finesse in keeping them out of trouble without making them sad or angry.
 
CRNAs are like residents for life. Think about the attendings that you enjoyed working with and were considered strong clinicians. Mimic their style.
 
lakersbaby said:
I haven't been supervising much at my gig, mostly doing solo but will start supervising CRNAs more and more. Any of you veterans have tips on dealing with CRNAs? From what I hear from this group there are quite a few "militant" CRNAs that like to give attitude to new attendings. How do you establish a good relationship with these clowns and at the same time making them respect you as the physician. If I could do solo forever I would but just not possible. I also don't want to have a cordial relationship with them because I want to work here for a long time.
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You have much to learn about respect. Calling your anesthetists clowns won't earn you any.

GravelRider said:
The easiest way to make a crna happy is to be "on time" to give them their breaks and relieve them promptly at 3pm. Do that and they will likely follow your directions.
Click to expand...

I'm not sure where this fantasy of every CRNA in the country wanting to be out by 3pm comes from. Maybe academia? We have anesthetist and anesthesiologist coverage 24/7. I help manage a group with nearly 150 anesthetists - I start the day with 100 anesthetists, and we have 60 operating locations running past 3pm on any given day, all of which are staffed by anesthetists.


critical element said:
This is my preferred method of supervising

People_Not_To_Hire.jpg
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I know it was probably tongue-in-cheek but THIS ^^^^^ is a primary reason that many CRNA's have zero respect for anesthesiologists.
 
ryanjmy said:
CRNAs are like residents for life. Think about the attendings that you enjoyed working with and were considered strong clinicians. Mimic their style.
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Some of them are like residents with attitude and senioritis. Hence it's not that easy to keep them both safe and happy.
 
Have you guys ever had issues as a new supervising staff with CRNAs who extubated without calling you or converted a MAC to a general without calling? How did you deal with these kind of shenanigans, especially if the CRNAs weren't employed by you?
 
jwk said:
I'm not sure where this fantasy of every CRNA in the country wanting to be out by 3pm comes from. Maybe academia? We have anesthetist and anesthesiologist coverage 24/7. I help manage a group with nearly 150 anesthetists - I start the day with 100 anesthetists, and we have 60 operating locations running past 3pm on any given day, all of which are staffed by anesthetists.
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7-3 is the 8 hour shift that the CRNA works. True, some work different shift times, but calling it fantasy that crnas don't want to be relieved when their shift ends is itself a fantasy. I don't blame them. I am an employee and I wish I could have that mentality because I don't make any extra money by staying late, but a crna gets paid overtime.
 
GravelRider said:
7-3 is the 8 hour shift that the CRNA works. True, some work different shift times, but calling it fantasy that crnas don't want to be relieved when their shift ends is itself a fantasy. I don't blame them. I am an employee and I wish I could have that mentality because I don't make any extra money by staying late, but a crna gets paid overtime.
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Guess who gets to leave first? 🙂
 
Are you medically directing CRNAs or supervising them?
 
GravelRider said:
7-3 is the 8 hour shift that the CRNA works. True, some work different shift times, but calling it fantasy that crnas don't want to be relieved when their shift ends is itself a fantasy. I don't blame them. I am an employee and I wish I could have that mentality because I don't make any extra money by staying late, but a crna gets paid overtime.
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why would an MD be relieving a CRNA? We have other CRNAs (and AAs) working off shifts to relieve them. If you are using docs to relieve the CRNAs you are probably running a bit too lean on staffing.
 
Mman said:
why would an MD be relieving a CRNA? We have other CRNAs (and AAs) working off shifts to relieve them. If you are using docs to relieve the CRNAs you are probably running a bit too lean on staffing.
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If CRNAs are paid on an hourly basis and docs are not, it's cheaper to keep a solo doc in his last room of the day (once his other rooms are done), and let the CRNA go home. One can even direct free docs to relieve other people's CRNAs. Obviously, this wouldn't work in a partnership, but with employed suckers...

Let's just say I have seen it done before. 😉
 
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FFP said:
If CRNAs are paid on an hourly basis and docs are not, it's cheaper to keep a solo doc in his last room of the day (once his other rooms are done), and let the CRNA go home. One can even direct free docs to relieve other people's CRNAs. Obviously, this wouldn't work in a partnership, but with employed suckers...

Let's just say I have seen it done before. 😉
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I've seen all sorts of things done before, but that sort of thing is a system that is run too lean. What happens when emergencies come up and you are that tight? Call more docs back that are already gone home to do their own cases?
 
Mman said:
why would an MD be relieving a CRNA? We have other CRNAs (and AAs) working off shifts to relieve them. If you are using docs to relieve the CRNAs you are probably running a bit too lean on staffing.
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Oh it happens, trust me. I am employed and am a cheaper option than the hourly waged CRNAs. I don't get paid any extra for staying til 9pm.
 
vector2 said:
Have you guys ever had issues as a new supervising staff with CRNAs who extubated without calling you or converted a MAC to a general without calling? How did you deal with these kind of shenanigans, especially if the CRNAs weren't employed by you?
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Also want to know how people deal with this issue as a new attending (employee), especially if you find out it is longstanding culture of place to not be called?
 
MrSnowSun said:
Also want to know how people deal with this issue as a new attending (employee), especially if you find out it is longstanding culture of place to not be called?
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Ultimately you can refuse to work with a problem CRNAs. It's not something you want to do but it is the leverage you always have. The first time they are out of line just let them know. You can do this by text if you'd like a paper trail. 2nd time get some someone else to talk to them like the CRNA chief. I've never had to go beyond that.
 
Mman said:
I've seen all sorts of things done before, but that sort of thing is a system that is run too lean. What happens when emergencies come up and you are that tight? Call more docs back that are already gone home to do their own cases?
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In my last job, this is what we had to do sometimes in the evenings. It was a small hospital and we had plenty of staff. But sometimes GI would run late and there would be two rooms upstairs in the main OR or even three. We'd delegate the late CRNAs to those rooms and the docs to the other rooms. Then of course the rooms would wind down and the emergencies fell to the call person.
First come first served. The surgeons picked a number and stood in line. The most emergent case took priority if there was more than one. If a surgeon thought that their case was more emergent I gave them boxing gloves (so to speak) and let them sort it out.

The one thing I didn't like was there was no dedicated 2nd call person and a few of us ended up always staying later than others.
Other than that, worked fine.

Where I work now, yeah people get called back. Mainly because it's FFS and we don't like surgeons waiting. Another reason I am leaving.
 
Planktonmd said:
Well... then quit using a cutting needle for LPs! 🙂
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I've just about quit doing LPs....the utility is almost nil to detect SAH with the newest gen scanners. I rarely see a patient who I think has bacterial meningitis, and I don't really care about viral meningitis. Diagnosing pseudotumor isn't really an emergency....

Honestly, the most often time I find myself doing an LP is just to make a know pseudotumor patient feel better.
 
Mman said:
why would an MD be relieving a CRNA? We have other CRNAs (and AAs) working off shifts to relieve them. If you are using docs to relieve the CRNAs you are probably running a bit too lean on staffing.
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I know a hospital in the area that does just that. Not surprisingly, they are having a very difficult time recruiting anesthesiologists.
 
Consigliere said:
I know a hospital in the area that does just that. Not surprisingly, they are having a very difficult time recruiting anesthesiologists.
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As an employee, it's a big mistake not to have working hours defined in the contract. It's a big difference to get paid X for 8 hours versus 12 hours daily. Anything beyond 8-10 hours should be paid significantly better.

If the employer truly wants and respects you, they will amend the contract. If they don't, you've just dodged a bullet. This concept of being paid per "day" of work is for senior partners, not employees.
 
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I don't see the problem in my practice. It's not like we are arguing about the plan and I'm like, "Let's go with Prop, Roc, tube" and the crna is like, " F you mda, I know everything and I'm doing Prop, Vec, tube; always have and always will!"
It's a non issue. As long as they let me know about major issues I don't care about the small stuff and major issues are rare.
 
Mman said:
why would an MD be relieving a CRNA? We have other CRNAs (and AAs) working off shifts to relieve them. If you are using docs to relieve the CRNAs you are probably running a bit too lean on staffing.
Click to expand...

I know places where the anesthesiologists relieve the nurse when things wind down to the last case (smaller hospitals). If you employ the nurses and are paying them to stay, why wouldn't you send them out?
 
lakersbaby said:
I haven't been supervising much at my gig, mostly doing solo but will start supervising CRNAs more and more. Any of you veterans have tips on dealing with CRNAs? From what I hear from this group there are quite a few "militant" CRNAs that like to give attitude to new attendings. How do you establish a good relationship with these clowns and at the same time making them respect you as the physician. If I could do solo forever I would but just not possible. I also don't want to have a cordial relationship with them because I want to work here for a long time.
Click to expand...
it can be a challenge working with CRNAs, but I'd encourage you to try to solidify the docs goals/boundaries for what the CRNAs do! if everyone is consistent for what they allow, or don't allow (blocks, central lines , epidural) then half the battle is done. when you have variability in among the docs then that's when things can get tricky. I've seen it both ways and having clear boundaries for procedures makes life so much better. there is still other crap to deal with, but just be frank, clear and pick your battles.
 
ghastly75 said:
! if everyone is consistent for what they allow, or don't allow (blocks, central lines , epidural) then half the battle is done. when you have variability in among the docs then that's when things can get tricky. I've seen it both ways and having clear boundaries for procedures makes life so much better. there is still other crap to deal with, but just be frank, clear and pick your battles.
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Me allowing or disallowing crnas to do a procedure spinal and the like is above my pay grade. The clear boundaries have to come from leadership. And when I say leadership I mean Chief/Chairman of Anesthesia and/or medical staff at your local hospital. For example, (just an example) at Memorial Regional in Anywhere, nebraska the crnas are not priveleged to do spinals/epidurals or regional. Period. If they do, they are violating hospital policy set forth by medical by laws. This is not gray. It is Clear. So there is no discussion as to who will be doing what..

BUt most of the time, the chief of anesthesia is impotent, and the medical staff is as well so this is the kind of stuff you get when there is no leadership
 
criticalelement said:
Me allowing or disallowing crnas to do a procedure spinal and the like is above my pay grade. The clear boundaries have to come from leadership. And when I say leadership I mean Chief/Chairman of Anesthesia and/or medical staff at your local hospital. For example, (just an example) at Memorial Regional in Anywhere, nebraska the crnas are not priveleged to do spinals/epidurals or regional. Period. If they do, they are violating hospital policy set forth by medical by laws. This is not gray. It is Clear. So there is no discussion as to who will be doing what..

BUt most of the time, the chief of anesthesia is impotent, and the medical staff is as well so this is the kind of stuff you get when there is no leadership
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So what you are saying is that, even though it is against hospital policy, the CRNAs are placing epidurals? That sounds like a liability should something go awry in a spinal case where CRNA placed it. Will the hospital stand by you? We all know they will be quick to throw you under the bus.

At my last gig, the CRNAs weren't allowed down in OB. But upstairs, the Chief played favorites with some and hated some, so would let some do more regional than others, etc. Such bull****. I would let the CRNA have a crack and step in after a few minutes if they couldn't do it. Some were good, others, not so much.
 
criticalelement said:
Me allowing or disallowing crnas to do a procedure spinal and the like is above my pay grade. The clear boundaries have to come from leadership. And when I say leadership I mean Chief/Chairman of Anesthesia and/or medical staff at your local hospital. For example, (just an example) at Memorial Regional in Anywhere, nebraska the crnas are not priveleged to do spinals/epidurals or regional. Period. If they do, they are violating hospital policy set forth by medical by laws. This is not gray. It is Clear. So there is no discussion as to who will be doing what..
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Of course if they aren't credentialed they can't do the procedure. If they are credentialed to do various procedures (which they probably are if they are properly medically directed) the decision of whether or not to let them perform the procedure certainly is at your discretion.
 
Arch Guillotti said:
Of course if they aren't credentialed they can't do the procedure. If they are credentialed to do various procedures (which they probably are if they are properly medically directed) the decision of whether or not to let them perform the procedure certainly is at your discretion.
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Let's not fool anyone.. Medically directed, or not, it's within the practice scope of practice (nationally) for CRNAs to perform pretty much any procedure, anesthetically (perioperatively) related. That being said, it is up to the facility as to what they will 'allow'.


Sent from my iPhone using SDN mobile
 
deansrv72 said:
Let's not fool anyone.. Medically directed, or not, it's within the practice scope of practice (nationally) for CRNAs to perform pretty much any procedure, anesthetically (perioperatively) related. That being said, it is up to the facility as to what they will 'allow'.


Sent from my iPhone using SDN mobile
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Hmm... NO. As long as they are working under my license (i.e. direction or supervision), their privileges end where I say.
 
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psychMDhopefully said:
what?
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was it unclear what I said? Or do you have a lot of experience directing CRNAs that suggests otherwise? Because we employ our own CRNAs and if they didn't get along well with us they'd have to go find another job. It's pretty much that simple.
 
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