Adjusting to higher acuity?

[GassedOut12]

Was talking with an old resident colleague. She has mostly been dealing with ASA2 and 3s. Now she is worried to take a job that is mostly ASA3 sometimes more with surgeons who want to start doing more complex stuff.

Who out there has dealt with the transfer and adapted? Who felt that the switch was too much and then left in a short time? How much of this comes down to the new coworkers assisting you a lot?

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[Arch Guillotti]

Was talking with an old resident colleague. She has mostly been dealing with ASA2 and 3s. Now she is worried to take a job that is mostly ASA3 sometimes more with surgeons who want to start doing more complex stuff.

Who out there has dealt with the transfer and adapted? Who felt that the switch was too much and then left in a short time? How much of this comes down to the new coworkers assisting you a lot?

what kind of stuff?

 

[GassedOut12]

She mentioned Whipples, open AAA, and awake crani. That’s not the usual for pseudo private practice. So I can see the hesitation if there isn’t a supporting cast.

I think the big cases are done 1:2 with the other room being something easy. But still would need a senior doc with the plan and what to anticipate with X surgeon

 

[Beeftenderloin]

She mentioned Whipples, open AAA, and awake crani. That’s not the usual for pseudo private practice. So I can see the hesitation if there isn’t a supporting cast.

I think the big cases are done 1:2 with the other room being something easy. But still would need a senior doc with the plan and what to anticipate with X surgeon

I did my first awake crani as an attending in PP. Just talked it over with a couple reliable colleague’s the night before. Everything went fine. Having supportive co-workers that want to see you succeed is key. I don’t supervise though.

Another doc in my group did mostly ASC work for the better part of a decade before joining our group. I’ve heard him talk before about how much he had to (re)learn when he joined our group but he echoed the same sentiment. Having a supportive group to bump heads with is essential.

Not uncommon to be sitting in the lounge and someone just comes in and polls the room on how they would deal with X, Y, or Z that they have coming up. Would you AFOI this person? Would you put an introducer for this case? Haven’t worked with such and such in forever (or ever before), anything special? Etc.

 

[GassedOut12]

Sounds like a good group.

People out there felt like they were out on their own?

 

[pgg]

This is a really common transition with people who get out of the military. Frequently they're leaving their first post-residency practice, which was 3-4 years of generally low acuity practice. Many but not all did some civilian moonlighting while on active duty for skill maintenance and growth. Some are overseas for a while, with very limited practice.

The short answer is they all do fine. They're all doctors who finished a residency. The memory is there. They're safe.

It helps to go to a practice where the other partners care about you and are invested in your success - as opposed to locums work. But even there you'll find other anesthesiologists willing to talk about cases, though they may not be able to physically help out as often.

You can expect them to not be super efficient right out of the gate, but no one is at a new practice.

People who have enough insight and humility to be asking this question of themselves are going to be cautious and conservative, and therefore safe.


If they're re-entering subspecialty work like peds or cardiac, after a long hiatus, maybe that's an issue. Or the old timer who's been doing 4:1 GI chart-signing work for a decade. But B&B anesthesia for "sicker" people - not generally an issue for people coming from less busy practices.


I'll also add that we all have done a number of things for the very first time as attendings out in practice. New blocks, or procedures we've only read about. It can be a little anxiety provoking but we're doctors and the foundation of our training and education is figuring this stuff out based on the knowledge, experience, and judgment we have.

It'll be fine.

 

[GassedOut12]

Well if it’s been like 7-8 years, then does the memory fade.

Signing GI charts is the worse way to practice unless you have a few years left

 

[Maz777]

The biggest thing is knowing your surgeons and somehow avoiding the Kevorkians. It's fine doing big, specialized cases if you have competent surgeons. It's an entirely different thing if you have incompetent surgeons that frequently get into trouble. You need to know what you are getting into before you make that transition.

 

[pgg]

The biggest thing is knowing your surgeons and somehow avoiding the Kevorkians. It's fine doing big, specialized cases if you have competent surgeons. It's an entirely different thing if you have incompetent surgeons that frequently get into trouble. You need to know what you are getting into before you make that transition.

I hear what you're saying but I don't know that this is useful/actionable advice.

How can one possibly know (and choose a job) based on the quality of one or more surgeons amongst the stable full of them at a potential job?

I would argue it's much easier and far more important to know the anesthesia dept culture at a potential job, lest you end up someplace where nobody will help you and the norms are unsafe. Are partners there for each other in a respectable department, or are they doormats constantly doing dodgy **** in the name of "efficiency" or pleasing surgeons?

Surgeons come and go, but ****ed-up anesthesia departments are what they are.

 

[PpfSuxTube]

Was talking with an old resident colleague. She has mostly been dealing with ASA2 and 3s. Now she is worried to take a job that is mostly ASA3 sometimes more with surgeons who want to start doing more complex stuff.

Who out there has dealt with the transfer and adapted? Who felt that the switch was too much and then left in a short time? How much of this comes down to the new coworkers assisting you a lot?

How were you/ her as a resident/ fellow? If you were fine then, you're grand now too.

If you flapped back then, then stick with the soccer mom stuff

 

[2019medstudent]

This makes me glad that I am starting out of residency at a mostly solo practice at a trauma 1 hospital. Probably will do this for a few years and then reassess.

 

[GassedOut12]

How were you/ her as a resident/ fellow? If you were fine then, you're grand now too.

If you flapped back then, then stick with the soccer mom stuff

Our resident world was fine outside of early CA1. That’s normal I take it. But further you get from academics, work changes.

What’s exactly soccer mom stuff these days?

 

[PlayToWin]

I went from a private practice gig doing mostly ASA 1-3 to a tertiary care center where plenty of ASA 4s and higher. One, it was a lil tough at first but I had help if needed on disaster cases. Also Ive done enough high acuity cases in my career so wasnt concerned.

The most important thing is having the mindset that these are sick pts but as long as you Identify what your anesthesia and hemodynamic goals are you’ll be fine.

 

[Burned_Out]

The limitations in taking care of high acuity patients do not lie with your comfort or skill level You have to ask whether or not your hospital has the equipment, appropriate ICU and specialists who can take care of these folks post-op. There are a lot of surgeons in these small comunity hospitals who like to play in the sandbox and challenge their abilities beyond their mundane cases. They get the idea that they can make a name for themself by taking on bigger, complex cases. They give no thought to the peri-operative requirements for them to do these cases.

Often times, I see things go wrong when the surgeon is perplexed by the problems he/she/they are encountering in the OR with these cases and they have no one to consult. It's the anesthesiologist's problem when the patient is unstable and they are left to care for them in the PACU.

 

[coffeebythelake]

I went from a private practice gig doing mostly ASA 1-3 to a tertiary care center where plenty of ASA 4s and higher. One, it was a lil tough at first but I had help if needed on disaster cases. Also Ive done enough high acuity cases in my career so wasnt concerned.

The most important thing is having the mindset that these are sick pts but as long as you Identify what your anesthesia and hemodynamic goals are you’ll be fine.

It's not just intraop management. Often times postop is the biggest concern for high acuity care.

 

[PlayToWin]

It's not just intraop management. Often times postop is the biggest concern for high acuity care.

Agreed, but i am at a tertiary care center so we have these services.

 

[Beeftenderloin]

The limitations in taking care of high acuity patients do not lie with your comfort or skill level You have to ask whether or not your hospital has the equipment, appropriate ICU and specialists who can take care of these folks post-op. There are a lot of surgeons in these small comunity hospitals who like to play in the sandbox and challenge their abilities beyond their mundane cases. They get the idea that they can make a name for themself by taking on bigger, complex cases. They give no thought to the peri-operative requirements for them to do these cases.

Often times, I see things go wrong when the surgeon is perplexed by the problems he/she/they are encountering in the OR with these cases and they have no one to consult. It's the anesthesiologist's problem when the patient is unstable and they are left to care for them in the PACU.

Very great points here. You need strong institutional support to provide good care in this setting. That means reliable robust anesthesia tech support that can get you anything and everything you need at every hour of the day. As well as robust back up protocols for true disasters. MTP that gets you blood, a Belmont and an ICU nurse to help run it. Code blue support from ICU when you don’t have another anesthesiologist immediately available to help in OR. OB hemorrhage protocols. Ours is basically an MTP plus it mobilizes an intensivist, IR and acute care surgeon depending on which direction things are going. Then there’s the after care. You need ICUs that are capable and comfortable caring for these sick, complicated patients post-op. We have them for hours. They have them for days to weeks/months.