What is the day-to-day life of an anesthesiologist on 2:1 or 4:1 supervision?

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ace_inhibitor111

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My anesthesiology rotation doesn’t start in a couple of months, but I’m interested in the specialty. The issue is that I work the best when my role is well-defined and I have certain goals in the day to accomplish. With supervisory roles I’m worried that the work would be less-defined and I would have a lot of downtime where I would have to search for productive things to do. Can anyone explain what their day-to-day is like if they are in a supervisory role? What responsibilities do you have and how do you work at the “top of your license” so to speak.
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I’m not in an supervisory role, nor do I plan on it. With that said, you dont have to work in a supervisory role if you dont want to. In private practice which is typically small community hospitals, there’s a good chance you’ll find a job where you do your own cases. Yeah you’ll work hard, but youll probably be financially rewarded for it and will have peace of mind, which has infinite intangible value.

I’m not so sure about the supervisory roles with 4:1 ratios, I personally think that anesthesiologists shouldn’t touch those jobs with a 10 foot pole. People still take those jobs though. You’re assuming an inherent risk no matter how good the certified and also registered nurse anesthesiologist is :laugh:
 
I don’t have all that much downtime. Even staffing 2:1 which is what we do majority of the time at the hospital and 2-3:1 at the surgery center. We have very slick orthos and bread and butter GS, urology, ENT, and very busy OB for community hospital. So turnovers are rapid and cases aren’t that long. Once the day is going it’s a circuit of preop, OR, PACU, repeat. Most days at our surgery center, I don’t sit down until noon or later just getting sips of coffee throughout the morning. Days go by very fast.

I enjoy supervision, which I know is sacrilege on this board. I imagine I see more cases, do more procedures, and encounter more difficult and challenging situations than if I were sitting my own. We have, for the most part, amicable CRNAs and also in an opt out state so they know they have that option and choose to work under this model.

I’m never in one spot for more than a few minutes. It’s great for that little bit of ADD that some of us have! I am everywhere and nowhere at the same time.


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Last I checked my license said "physician and surgeon" and in order to follow the example of my nurse colleagues, I always stride to practice at the top o my license. I will operate on straightforward lap appys and let the surgeon do anesthesia and for the complicated stuff I stick to the anesthesia and let the general surgeon operate. I also do the same with ECTs. It lets the psychiatrist and I lead unrestricted professional lives while using the full extent of our education and training.

In all seriousness, If you are worried about having to supervise, don't take a job with a supervisory role. You might have to sacrifice location and possibly income potential but you'll be happier. The idea of being the fire fighter and fall guy was never appealing especially when I'm also the liability magnet.

ace_inhibitor111 said:
My anesthesiology rotation doesn’t start in a couple of months, but I’m interested in the specialty. The issue is that I work the best when my role is well-defined and I have certain goals in the day to accomplish. With supervisory roles I’m worried that the work would be less-defined and I would have a lot of downtime where I would have to search for productive things to do. Can anyone explain what their day-to-day is like if they are in a supervisory role? What responsibilities do you have and how do you work at the “top of your license” so to speak.
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Last edited:
Money location lifestyle pick two.
I know someone who works up to 1:8 can make 600k + and more vacations they know what to do with. They’re okay with it.


Some of my older partners cannot stand the idea being in a room for more than a lunch break. They have other skill sets that I don’t have.

It’s a whole spectrum of skills and priorities..... they all change and evolve with time.
 
IMGASMD said:
Money location lifestyle pick two.
I know someone who works up to 1:8 can make 600k + and more vacations they know what to do with. They’re okay with it.


Some of my older partners cannot stand the idea being in a room for more than a lunch break. They have other skill sets that I don’t have.

It’s a whole spectrum of skills and priorities..... they all change and evolve with time.
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600k for 1:8 is garbage.
 
What responsibilities do you have and how do you work at the “top of your license” so to speak.
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I practice at the top of my license by going to Africa (underserved areas) and performing gynecologic, obstetric, orthopedic, neurologic, and spine surgeries, even though I'm trained primarily as an anesthesiologist. I feel like since I've seen so many of these as an anesthesiologist and I'm an MD like the surgeons, I'm qualified to do these surgeries on poor patients who don't know any better.

I do it all independently. I don't need or utilize any supervision from actual surgeons.

Hope this helps! 👍
 
I know it’s heresy on this board but I do a lot of 4:1. For the most part the CRNA’s are competent enough (or lucky enough) and the cases are pretty straightforward in my community hospital. I do alot of sitting on my a$$...
 
We supervise usually around 2:1 or 3:1 at the start of the day and occasionally up to 4:1 depending on the cases later in the day.

Roll in at 630 and preop 2 or 3 patients, potentially putting in a preop block or epidural if needed. As 1st cases get rolling be there for induction on all of them and help start art lines or extra IVs as AA/CRNA is masking the patient after induction (cases are almost never getting going at the same exact time).

As the day progresses check in with each room q 30-45 min to see how cases progressing and preop subsequent patients. As cases finish check on patients in PACU and do any postop blocks needed. Occasionally pick up a room from a colleague as things wind down so we can send people home.

Rinse, repeat. Occasionally have a difficult airway or patient who needs a central line that ties me up for a bit longer. Also occasionally help out a colleague that is tied up in a room do something for one of their other rooms.

I find it tremendously rewarding and much more enjoyable (although physically more demanding) than doing my own cases where I can just sit in a room and not worry about anything else.
 
Working at the top of your license is the stupidest saying that ive heard. Anyone who actually says that term is revealing how much independent thought they really have.. Having said that....


Doing your own cases is a cake walk compared to supervising 1:3 or 1:4/
 
I usually supervise 3-4:1. Like anything else, it depends. Days can be busy but smooth to hectic and even terrible. Factors that influence: Case mix of the four rooms, How sick the patients are. Case turnover rate. Is there a technically difficult regional or line placement that puts me behind? Am I working with good CRNAs that I trust? Luck of timing in the rooms, (multiple starting at once), etc.

The above is assuming that you use and follow a medical direction practice.
 
PieOHmy said:
Working at the top of your license is the stupidest saying that ive heard. Anyone who actually says that term is revealing how much independent thought they really have.. Having said that....
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working at the top of your license is a nursing phrase meant to say they should be able to do anything that anybody in their profession has ever done once or that they have ever witnessed somebody do on youtube
 
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The irony is we all have licenses to practice medicine and surgery. So an anesthesiologist operating at “the top of their license” would do the induction and then the Whipple
 
My point is, there are Physicians who ****ing use that term "working at the top of your license."

Stop saying that dumb ass term.. It means ZERO. It really does.
 
PieOHmy said:
Doing your own cases is a cake walk compared to supervising 1:3 or 1:4/
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Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t 👍
 
Its more challenging because there are more decisions to make. More spinals on patients that have been off plavix for 5 d vs 7 d, more difficult airways to deal with, more borderline competent nurses. More blocks that you have to rush through more problems in the pacu more everything sometimes all happening at once..
 
PieOHmy said:
Its more challenging because there are more decisions to make. More spinals on patients that have been off plavix for 5 d vs 7 d, more difficult airways to deal with, more borderline competent nurses. More blocks that you have to rush through more problems in the pacu more everything sometimes all happening at once..
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Looks like a system where patients are getting worse care.
 
Urzuz said:
Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.
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None of those things are a function of supervising cases, they are a function of a poor practice and it doesn't have to be that way. Most commonly I see that situation in places where the CRNAs do not work for the physicians but are hospital employed.
 
You guys have the wrong mentality when it comes to supervision/direction. It is not “your case”, you are only there because of state regulations/hospital bylaws. That’s it. So long as the patient is alive and intact at the end it goes in the win column. The outcomes will be largely dictated by dumb luck or the skill of the individual CRNA’s. Just sit back, have an coffee and cash the paycheck for however much longer the bubble known as the American healthcare system will continue.....
 
Urzuz said:
Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t 👍
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Best of all the insurance company/ employer/ patient pays exactly the same for the above as it would for physician only anesthetic care. Give me a full time anesthesiologist practicing medicine for my surgery any day vs playing Russian roulette with some patsy running around like a chicken with its head cut off.
 
dannyboy1 said:
You guys have the wrong mentality when it comes to supervision/direction. It is not “your case”, you are only there because of state regulations/hospital bylaws. That’s it.
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Check out the "BIG BRAIN ON DANNY". You are the winner. This is what it is. As soon as state regulations/hospital bylaws are lifted, the Anesthesiology profession go up in smoke. And there are many forces who want to make that happen.
 
And even if you get a job doing your own cases EVERYONE knows they can hire a CRNA to do the job for cheaper... So you have that to contend with..
 
PieOHmy said:
And even if you get a job doing your own cases EVERYONE knows they can hire a CRNA to do the job for cheaper... So you have that to contend with..
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CRNA OT and breaks are the killer of budgets. You have to overstaff to minimize both. Coupled with an inefficient OR and high local prevailing wages, the savings start to get really slim. Nurses are used to annual cost of living increases and getting paid their regular rates for things like going to ACLS and meetings.
 
nimbus said:
And AANA has evidence that independent CRNA anesthesia is equivalent.
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no they don't, they merely claim they do. But almost every major hospital in the country utilizes ACT model care including every program with a residency.
 
SaltyDog said:
Attending anesthesiologists supervising physicians residents in anesthesiology is not ACT practice.
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by definition it is ACT practice (according to CMS and insurers). You do not have a BC/BE anesthesiologist doing the entirety of the case themselves and they are delegating portions of the anesthetic to someone else. Arguing a CA1 resident being left alone in a room is the same thing as a BC anesthesiologist is quite untrue.
 
Mman said:
by definition it is ACT practice (according to CMS and insurers). You do not have a BC/BE anesthesiologist doing the entirety of the case themselves and they are delegating portions of the anesthetic to someone else. Arguing a CA1 resident being left alone in a room is the same thing as a BC anesthesiologist is quite untrue.
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That resident is still a physician, and they are being trained. They are not a mid level left to their own devices in the name of profit.

Would you say that surgical residencies practice in a “SCT” model?
 
SaltyDog said:
That resident is still a physician, and they are being trained. They are not a mid level left to their own devices in the name of profit.

Would you say that surgical residencies practice in a “SCT” model?
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You are trying to differentiate hypothetical intent when I'm pointing out records of safety and legal definitions. We don't have anybody left to their own devices in the name of profit, we have a wonderful team working together to provide the best possible care we can.
 
I’m saying that you can’t compare safety records of residency programs where physician trainees are supervised at 2:1 ratios to high ratio ACT practices. Apples and Oranges.

Sorry for the hyperbole in my previous post.
 
SaltyDog said:
I’m saying that you can’t compare safety records of residency programs where physician trainees are supervised at 2:1 ratios to high ratio ACT practices. Apples and Oranges.

Sorry for the hyperbole in my previous post.
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I guess you'd have to define what "high ratio" means. ACT is perfectly safe anesthesia if practiced appropriately. We go 1:1 for appropriate cases and up to 4:1 for appropriate cases, it all just depends. There is nothing inherently unsafe about the model.
 
Mman said:
I guess you'd have to define what "high ratio" means. ACT is perfectly safe anesthesia if practiced appropriately. We go 1:1 for appropriate cases and up to 4:1 for appropriate cases, it all just depends. There is nothing inherently unsafe about the model.
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I'd say 4:1 is always high ratio, and 3:1 is high ratio if cases are high acuity. I agree with what you say about ACT being safe when "practiced appropriately", and I commend you for altering supervision ratios based on case acuity - as it should be.
 
dchz said:
Does this actually happen in real life? I don't think this happens in real life... If so very rarely.
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I'm not the one to ask - I'm MD only, always have been and hope to always be. He says that's how they do it, and I'll take his word for it. I hope he's telling the truth.
 
PieOHmy said:
Its more challenging because there are more decisions to make. More spinals on patients that have been off plavix for 5 d vs 7 d, more difficult airways to deal with, more borderline competent nurses. More blocks that you have to rush through more problems in the pacu more everything sometimes all happening at once..
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You do spinals when the patient has been off plavix <7 days?
 
dannyboy1 said:
I know it’s heresy on this board but I do a lot of 4:1. For the most part the CRNA’s are competent enough (or lucky enough) and the cases are pretty straightforward in my community hospital. I do alot of sitting on my a$$...
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Your place of work is very different than mine. When I am 4:1 there is virtually no sitting around. Are your cases lengthy with a very low acuity?
 
The guys I know that work/worked 4:1 most of the time all ran/run themselves ragged. Preop, postop, block, induction, help, lines, repeat x10 hours. They do it for one reason. They chase the dollars. Anyone working 3 and 4:1 for a management company making 350-400 is a fool. Maybe for about 20 weeks of vacation.
 
Even jobs4:1 in major SE cities capped at 500k after partnership with less vacation than academics. As the AMCs expand, those opportunities to chase the moolahalthough available are not worth it in long term
 
PieOHmy said:
Its more challenging because there are more decisions to make. More spinals on patients that have been off plavix for 5 d vs 7 d, more difficult airways to deal with, more borderline competent nurses. More blocks that you have to rush through more problems in the pacu more everything sometimes all happening at once..
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Do you do spinals on patients off plavix for less than 7 days?

What kind of cases?
 
Arch Guillotti said:
Do you do spinals on patients off plavix for less than 7 days?

What kind of cases?
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ASRA Coags app says 5-7 days. Probably good to check p2y12 assay before proceeding.
 

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Urzuz said:
Supervising cases is more challenging for ALL THE WRONG REASONS. The anesthetic management isn’t more challenging, it’s that you have to worry about if your RN is appropriately fed and watered, if the patient isn’t coding next door and you haven’t gotten a phone call, biting your tongue when you know they chose a less-than-ideal anesthetic plan but you don’t want to hurt their feelings so you let them do it their way.

Yeah, if those elements are what make supervisory jobs more challenging, by means you all should pat yourselves on the backs for doing something that the average PP MD-only anesthesiologist can’t 👍
[/
F that noise.
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It takes an appropriate temperament and level of tact to be a good supervisor. Excellent time management skills and clinical judgment are a big plus.
 
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