What advice would you give to new attendings?

[Mehd School]

Many recent graduates, myself included, will be entering the workforce very soon. It's an incredibly big transition as those who have done it are well aware. If you could go back in time and give yourself some advice when starting out what would it be?

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[DocVapor]

Many recent graduates, myself included, will be entering the workforce very soon. It's an incredibly big transition as those who have done it are well aware. If you could go back in time and give yourself some advice when starting out what would it be?

Introduce yourself to EVERYONE. Be confident in your skills and knowledge, but don't be afraid to ask for help. Sometimes things at the new place will be done very, very different from what you did in residency. Doesn't mean it's wrong or unsafe, so try and fit in at first and go with the flow. Then once everyone is comfortable, start introducing the changes you'd like to see - go slow. People don't do well when things deviate too far from the pattern they've become accustomed to. Be positive in your attitude but keep your eyes open and on the lookout for nefarious things that can be hidden during interviews. Likewise, if you like the area, plan to stay, but keep an idea of your worth and have at least a basic exit plan. This will generally require $$$, so be thrifty for a little while longer.

 

[Mman]

Be confident in your skills and knowledge, but don't be afraid to ask for help. Sometimes things at the new place will be done very, very different from what you did in residency. Doesn't mean it's wrong or unsafe, so try and fit in at first and go with the flow. Then once everyone is comfortable, start introducing the changes you'd like to see - go slow.

I usually say go with the flow for a year. Let people see that you are safe and competent. Then you can start worrying about things you'd like to do differently than what they are already doing.

 

[Gern Blansten]

-Avoid being the "At XXXX we did this..." person. In other words, don't be an "Ivy League" name dropper. Just eliminate it from your vocabulary for 6 months. Especially if it is a well known place. It will make you sound like you think your're smarter than everyone else. You may be, but they have got you on experience, so listen to them and fit in.

-Pick your battles. Recognize that there are multiple safe ways to do something. Unless you see someone doing something truly unsafe, go with the flow and learn something from the new group you are with.

-If you supervise, offer restroom breaks. You can limit it and say you have just five minutes because you have to start a room, but letting someone out to pee in a long room is a big deal. They will remember that. If you know they just had a break, you can get a freebie by asking them if they have had one yet. They will assume you were offering and will decline, saying, "Thanks, I just had a break." You still get the goodwill credit. If they accept, you have learned something else about them that you would normally take longer to figure out (they are likely lazy).

-first impressions are lasting impressions. Show up earlier than you think you might need to at first until you get a lay of the land.

-Save someone's life in the first month in a very dramatic way. You will get years worth of mileage out of this one.

-Be calm under pressure. As someone once said, anyone can make it look difficult. Your job is to make it look easy. The people that matter know that it is not.

-Live well within your means for at least 4 years and pay off debt asap. Do not buy expensive homes or cars until you know you will stay somewhere or until the majority of your debt is paid off. Give yourself a 50-75% pay raise from resident salary and apply the rest to debt.

-Pass oral boards on the first try. Life gets significantly better once this chain is lifted from around your neck. Take at least 20 practice exams administered by anyone from faculty to course directors, to residency classmates, to a non-medical friend. The key is to speak out loud often and say as much as possible in as few words as possible (concise). Your non-medical friend does not have to grade you because you will know how you did. Study content because, ultimately, knowledge deficit is what causes most people to fail. If you start babbling incoherently on a subject, it is likely not because you are not good at speaking publicly. It is more likely that you do not have a command of the material that you are discussing.

 

[banister]

Find people in the group you're comfortable with who will walk you through the nuances of the group/hospital/surgeons. Briefly review every case with them to see what the norm is for the group/case. It's assumed you know how to administer a safe anesthetic. Not standing out is good. Being a team player and assimilating within the group is the way to go.

 

[Mehd School]

Thanks for the awesome replies guys

 

[Gern Blansten]

Thanks for the awesome replies guys

Best of luck!! The best advice is to just be a nice person. That will go a long way.

 

[pgg]

-Save someone's life in the first month in a very dramatic way. You will get years worth of mileage out of this one.

Seems like a hard thing to plan ...

-Be calm under pressure. As someone once said, anyone can make it look difficult. Your job is to make it look easy. The people that matter know that it is not.

... especially since the #1 guiding principle of all anesthesiologists should be to stay out of trouble and make it look easy.

People who are constantly doing dramatic stuff to save the day are probably causing the problems they have to fix.

 

[pgg]

Many recent graduates, myself included, will be entering the workforce very soon. It's an incredibly big transition as those who have done it are well aware. If you could go back in time and give yourself some advice when starting out what would it be?

Pre-oxygenate everyone to an end-tidal O2 over 80%.

Everyone.

Make the people in the OR wait while you sit there with the mask.

If the circulating RNs are in the habit of holding the mask with a bad seal, correct them.

Don't get lazy and confident and induce people on room air. The points / "credit" the flunkies in the room give you for being a minute faster aren't worth it. And they probably won't notice anyway ... in time though the smarter ones will connect the dots and realize they don't hear the 65% sat boop boop boop very often when you're there.

 

[Gern Blansten]

Pre-oxygenate everyone to an end-tidal O2 over 80%.

Everyone.

Make the people in the OR wait while you sit there with the mask.

If the circulating RNs are in the habit of holding the mask with a bad seal, correct them.

Don't get lazy and confident and induce people on room air. The points / "credit" the flunkies in the room give you for being a minute faster aren't worth it. And they probably won't notice anyway ... in time though the smarter ones will connect the dots and realize they don't hear the 65% sat boop boop boop very often when you're there.

If you attach BP and O2 first as you’re getting other stuff ready, the time to preoxygenate adequately is imperceptible. In my experience, those are the two things that you end up sitting there waiting on, so I try my best to get both cooking early in the process.

 

[nimbus]

If you attach BP and O2 first as you’re getting other stuff ready, the time to preoxygenate adequately is imperceptible. In my experience, those are the two things that you end up sitting there waiting on, so I try my best to get both cooking early in the process.M

That’s @Drwine ’s brilliant American breakfast analogy. Start the potatoes first. Good for PACU too.

 

[Mman]

If you attach BP and O2 first as you’re getting other stuff ready, the time to preoxygenate adequately is imperceptible. In my experience, those are the two things that you end up sitting there waiting on, so I try my best to get both cooking early in the process.

a true mild irritation to me is when people get everything completely hooked up and working before they put the oxygen on the patient. It's called parallel processing. They can pre-oxygenate while you stick the EKGs and pulse ox on and the cuff cycles. No it isn't a big deal but yes it is 2 minutes of my life I will never get back.

 

[nimbus]

Seems like a hard thing to plan ...



... especially since the #1 guiding principle of all anesthesiologists should be to stay out of trouble and make it look easy.

People who are constantly doing dramatic stuff to save the day are probably causing the problems they have to fix.

Yep. Don’t be the arsonist/firefighter.

 

[Gern Blansten]

Yep. Don’t be the arsonist/firefighter.

I knew one of those types. Constant chaos.

 

[Gern Blansten]

Seems like a hard thing to plan ...

Mostly tongue-in-cheek, but I know someone who did that exact thing. Didn’t matter much what she did after that. She was already a legend.

 

[BlueRug]

Mostly tongue-in-cheek, but I know someone who did that exact thing. Didn’t matter much what she did after that. She was already a legend.

Similar anecdote (not me). You become a walking deity.

 

[pgg]

If you attach BP and O2 first as you’re getting other stuff ready, the time to preoxygenate adequately is imperceptible. In my experience, those are the two things that you end up sitting there waiting on, so I try my best to get both cooking early in the process.

The problem I continually run into are RNs who can't/won't get a good seal. Blow-by isn't preoxygenating.

I don't like or use the BDSM face strap on awake patients, which seems to be the only reliable way to preO2 in a hands-free way. Using that device seems rude to me. I don't want to presume that any given patient is into that scene.

 

[kidthor]

Don't get pressured into doing anything unsafe, unfair, or illegal. And just walk away if the place is a disaster. Hopefully you're in a good environment where you'll want to stay. But there are also no shortage of sketchy places out there.

When it comes down to it the buck stops with you individually, not your group, not the surgeons, not your hospital. So do whatever you truly believe is right for the sake of your patients and for the sake of your own integrity.

 

[Gern Blansten]

The problem I continually run into are RNs who can't/won't get a good seal. Blow-by isn't preoxygenating.

I don't like or use the BDSM face strap on awake patients, which seems to be the only reliable way to preO2 in a hands-free way. Using that device seems rude to me. I don't want to presume that any given patient is into that scene.

Besides you and Tupperware, you know who else appreciates a tight seal?




















A walrus
*Okay, you knew it was going to be bad.

 

[vector2]

Many recent graduates, myself included, will be entering the workforce very soon. It's an incredibly big transition as those who have done it are well aware. If you could go back in time and give yourself some advice when starting out what would it be?

Supervision or MD only?

 

[Angus Avagadro]

All reasonable advice above. Have the table in an elevated position after induction. If it is low, the surgeon says " Raise the table". If elevated, they say " Lower the table, please". Try it. It sets the tone.
Absolutely agree with not dropping names of institutions and how you did things there. Ask how they do things at your new institution. Otherwise, if you do things differently, you get " Why are you doing it THAT way?" Better to be ..when in Rome... My first PP job, an older CV surgeon, wanted the majority of his carotids done under cervical plexus block. Needed a fast refresher. I'm sure today few carotids are surgically repaired rather than stented. The OR staff and your colleagues will appreciate your flexibility.

 

[Drwine]

Lots of good advice above. Be humble and seek out mentorship. Even if you were the best resident in your graduating class and have a lot to learn from experienced colleagues. Be nice to everyone in the OR.

 

[drmwvr]

I don't like or use the BDSM face strap on awake patients, which seems to be the only reliable way to preO2 in a hands-free way. Using that device seems rude to me. I don't want to presume that any given patient is into that scene.

I use it most cases, but I'm sure the patients have a decent buzz going before I place the mask.

 

[jwk]

The problem I continually run into are RNs who can't/won't get a good seal. Blow-by isn't preoxygenating.

I don't like or use the BDSM face strap on awake patients, which seems to be the only reliable way to preO2 in a hands-free way. Using that device seems rude to me. I don't want to presume that any given patient is into that scene.

We used to use mask straps on everyone back when we actually did mask anesthetics. I probably haven't used a strap in 20 years.

I never want the circulator touching anything unless I ask (but of course we have a doc and anesthetist for all inductions). I'm very deliberate about where I place everything I use before, during, and after induction. I hate it when I have a difficult intubation and need to ventilate the patient before I take a second look and the helpful RN has put the mask on top of my monitors "to get it out of the way".

I realize in an MD-only practice their help is great - in a team practice, they're usually one pair of hands too many.

 

[Status Sciaticus]

We used to use mask straps on everyone back when we actually did mask anesthetics. I probably haven't used a strap in 20 years.

I never want the circulator touching anything unless I ask (but of course we have a doc and anesthetist for all inductions). I'm very deliberate about where I place everything I use before, during, and after induction. I hate it when I have a difficult intubation and need to ventilate the patient before I take a second look and the helpful RN has put the mask on top of my monitors "to get it out of the way".

I realize in an MD-only practice their help is great - in a team practice, they're usually one pair of hands too many.

You could just have the patient hold the mask and tell them to hold it tight.

 

[DocVapor]

You could just have the patient hold the mask and tell them to hold it tight.

Also, anyone that wears CPAP should have no problem getting the mask strapped to their face for a few minutes.

 

[Drwine]

The airlines figured out "Crew resource management" 50 years ago but for the most part we are not very good at it. In general we are so good at what we do everyone else in the OR takes us for granted during induction and emergence. Most commonly they are totally distracted on computers or smartphones and engaged in extraneous conversation. I am usually fairly lenient but if I anticipate a difficult airway on induction or a difficult emergence, I communicate my concerns and assign them potential tasks if my concerns come to fruition. I also ask them to focus on what I am doing until the airway is secure or the patient is successfully extubated. Not something I do frequently but when I pick this battle they comply. Maintain poise and be in control of crises. When other colleagues are available your threshold should be low to seek their input/assistance if you anticipate difficulty.

 

[DrOwnage]

Might sound obvious, but always be vigilant. You can get distracted pretty easily by multitasking during important parts of the anesthetic. Chit chatting with the room, joking around, or just plain old trying to act slick with people you are making friends with can be distracting. You do have something to prove in regards to your skill and consistency. But do the things that have worked for you and concentrate at crucial times. There will be instances when you get complacent and that's ultimately when something bad will happen that was avoidable (not preoxygenating, lazy RSI, medication error).

Be familiar with the anesthesia work room and where things are. I.e. know your options in regards to IV catheters, spinal needles and which ones you are familiar and best with.

Don't cancel cases for trivial things.

Be nice to all staff. Especially the person who stocks the physician lounge (if you have one).

If you get free food, take advantage of it. You can save hundreds of dollars a month.

 

[Mehd School]

Thanks everyone for your incredibly helpful and experienced answers.

One thing I'd like some more advice in is interactions with CRNAs. As a resident I had an attending month rotation where I supervised both residents and CRNAs. Seemed like 50% of the CRNAs followed the plan we agreed upon and 50% just did whatever the hell they wanted to and I had trouble tactfully navigating those waters.

 

[abolt18]

Thanks everyone for your incredibly helpful and experienced answers.

One thing I'd like some more advice in is interactions with CRNAs. As a resident I had an attending month rotation where I supervised both residents and CRNAs. Seemed like 50% of the CRNAs followed the plan we agreed upon and 50% just did whatever the hell they wanted to and I had trouble tactfully navigating those waters.

For me, I found I just had to choose my battles carefully. I didn't try to dictate little and unimportant things like which volatile to use (which would more likely lead to deviation from the plan). Pick one or two things that are really important for the case, like BP goals, induction agent or dose only if it's different from just giving a bunch of propofol, art line or not and IV access (size and quantity), tube vs LMA.

I just worked very hard to be helpful and and supportive of our combined goal of taking good care of our patient and I made that as clear as I possibly could. If that means grabbing something from pharmacy or helping draw up drugs or set up for the next case. Whatever.

For the few turds who aren't going to play nice in the sandbox, I'll just make the changes myself that I want made. I'd send them on a break and start the phenylephrine gtt that I suggested an hour ago that they've neglected to do because they would apparently rather bolus phenylephrine and ephedrine every 5 minutes for hours on end (with frequent intermittent hypotension). I'd make vent changes from the 700cc tidal volumes or turn down the volatile from the 1.3MAC of gas. I found these instances to be uncommon but not rare.

Definitely did not love supervising crnas. On the other hand, I loved working with residents and teaching/challenging them.

 

[Dr. Rude]

Thanks everyone for your incredibly helpful and experienced answers.

One thing I'd like some more advice in is interactions with CRNAs. As a resident I had an attending month rotation where I supervised both residents and CRNAs. Seemed like 50% of the CRNAs followed the plan we agreed upon and 50% just did whatever the hell they wanted to and I had trouble tactfully navigating those waters.

Local customs and politics are important.
Take your cues from the other docs who supervise. Learn the ropes while establishing your reputation. If you find that the local custom is to let the CRNAs do everything while the docs drink coffee- Stay away or start looking for another job if you have already committed.

 

[vector2]

Thanks everyone for your incredibly helpful and experienced answers.

One thing I'd like some more advice in is interactions with CRNAs. As a resident I had an attending month rotation where I supervised both residents and CRNAs. Seemed like 50% of the CRNAs followed the plan we agreed upon and 50% just did whatever the hell they wanted to and I had trouble tactfully navigating those waters.

You'll discover that many, many CRNAs have significant inferiority complexes and fragile egos, both which stem from the knowledge and training deficit that they themselves may or may not be aware of. What this means is that the more your anesthetic plan sounds like a "command" or an "order," the more excuse they're going to find to do whatever wrongheaded harebrained scheme they've got cooked up.

Like it or not, they're desperate to be seen as your colleague, so when you have an anesthetic plan for a slightly complicated patient, taking a minute to explain your reasoning (while slyly filling in some of their knowledge gap) and then politely requesting *WE* do x, y, and z goes a long way in managing the drama.

 

[pgg]

You'll discover that many, many CRNAs have significant inferiority complexes and fragile egos, both which stem from the knowledge and training deficit that they themselves may or may not be aware of. What this means is that the more your anesthetic plan sounds like a "command" or an "order," the more excuse they're going to find to do whatever wrongheaded harebrained scheme they've got cooked up.

Like it or not, they're desperate to be seen as your colleague, so when you have an anesthetic plan for a slightly complicated patient, taking a minute to explain your reasoning (while slyly filling in some of their knowledge gap) and then politely requesting *WE* do x, y, and z goes a long way in managing the drama.

Agreed. I tell them why I'm concerned, and what I'd like US to do about it. The great majority are receptive.

Saying "start a phenylephrine infusion" as the tube is taped and you leave the room isn't as effective as "I'm a little concerned that this guy's arteries aren't as clean as advertised, so I think we ought to keep his MAPs above 75 the whole case, do you have a bag of phenylephrine made up or would you like me to get it ready?"

Most of them want us to be there to help, and they want to be respected for the skilled advanced practice nurses they are. A little politeness goes a long way.


I did have some trouble recently, not sure how to best handle it in the future. The CRNA was just ... rough. Intubated with a sharply bent stylet in place and just rammed that thing in to the hilt. Head bobbling around like a rag doll when positioning. Later, suctioned with a yankauer like he was aiming for the spine. Plastic tape ripped off the eyelids of an old person like he was starting a lawn mower. Etc. I'm not sure there's a polite way to correct that kind of thing. I said "hey when you're intubating with a stylet, just get the tip past the cords and pull the stylet, otherwise the sharp angle on it will scrape the trachea and cause pain, coughing, possibly bronchospasm" and "old people have fragile skin, plastic tape can cause skin tears" and he just looked at me like I looked at the obnoxious attending in residency who fine-tuned my tube taping. I feel like this is an issue that goes beyond skill or knowledge and I have no idea how to correct it.

 

[GassYous]

Agreed. I tell them why I'm concerned, and what I'd like US to do about it. The great majority are receptive.

Saying "start a phenylephrine infusion" as the tube is taped and you leave the room isn't as effective as "I'm a little concerned that this guy's arteries aren't as clean as advertised, so I think we ought to keep his MAPs above 75 the whole case, do you have a bag of phenylephrine made up or would you like me to get it ready?"

Most of them want us to be there to help, and they want to be respected for the skilled advanced practice nurses they are. A little politeness goes a long way.


I did have some trouble recently, not sure how to best handle it in the future. The CRNA was just ... rough. Intubated with a sharply bent stylet in place and just rammed that thing in to the hilt. Head bobbling around like a rag doll when positioning. Later, suctioned with a yankauer like he was aiming for the spine. Plastic tape ripped off the eyelids of an old person like he was starting a lawn mower. Etc. I'm not sure there's a polite way to correct that kind of thing. I said "hey when you're intubating with a stylet, just get the tip past the cords and pull the stylet, otherwise the sharp angle on it will scrape the trachea and cause pain, coughing, possibly bronchospasm" and "old people have fragile skin, plastic tape can cause skin tears" and he just looked at me like I looked at the obnoxious attending in residency who fine-tuned my tube taping. I feel like this is an issue that goes beyond skill or knowledge and I have no idea how to correct it.

Tube him with his technique

 

[Angus Avagadro]

Agreed. I tell them why I'm concerned, and what I'd like US to do about it. The great majority are receptive.

Saying "start a phenylephrine infusion" as the tube is taped and you leave the room isn't as effective as "I'm a little concerned that this guy's arteries aren't as clean as advertised, so I think we ought to keep his MAPs above 75 the whole case, do you have a bag of phenylephrine made up or would you like me to get it ready?"

Most of them want us to be there to help, and they want to be respected for the skilled advanced practice nurses they are. A little politeness goes a long way.


I did have some trouble recently, not sure how to best handle it in the future. The CRNA was just ... rough. Intubated with a sharply bent stylet in place and just rammed that thing in to the hilt. Head bobbling around like a rag doll when positioning. Later, suctioned with a yankauer like he was aiming for the spine. Plastic tape ripped off the eyelids of an old person like he was starting a lawn mower. Etc. I'm not sure there's a polite way to correct that kind of thing. I said "hey when you're intubating with a stylet, just get the tip past the cords and pull the stylet, otherwise the sharp angle on it will scrape the trachea and cause pain, coughing, possibly bronchospasm" and "old people have fragile skin, plastic tape can cause skin tears" and he just looked at me like I looked at the obnoxious attending in residency who fine-tuned my tube taping. I feel like this is an issue that goes beyond skill or knowledge and I have no idea how to correct it.

My old Chief taught me.to be diplomatic. Diplomacy defined as allowing the other person to have my way. When polite explanation doesn't provide the desired result, well then there is gunboat diplomacy. I explain that it's not a Democracy, although they can lobby, and we will do it this way. I agree, there is no other way to deal with people like this when polite explaining fails.

 

[vector2]

I did have some trouble recently, not sure how to best handle it in the future. The CRNA was just ... rough.

After asking nicely with sugar on top...there's only a couple ways the future can go...

Does your group employ your CRNAs?

 

[kidthor]

Saying "start a phenylephrine infusion" as the tube is taped and you leave the room isn't as effective as "I'm a little concerned that this guy's arteries aren't as clean as advertised, so I think we ought to keep his MAPs above 75 the whole case, do you have a bag of phenylephrine made up or would you like me to get it ready?"

I don’t disagree with your technique given the state we’re in.

But damn, there’s a lot of ego diplomacy and tip-toeing around we now have to do. Can you imagine the cardiac surgeons speaking with their PAs like that?

This is the sad midlevel race to the bottom we’re in.

 

[vector2]

. Can you imagine the cardiac surgeons speaking with their PAs like that?

The cardiac surgeon doesn't sit in an office while the PA sews in a new valve.

 

[IMGASMD]

The cardiac surgeon doesn't sit in an office while the PA sews in a new valve.

They can be at multiple places at the same time with residents?

I gave anesthesia for a IR patient, something not too involved, biopsy (?) perhaps. I did not see the radiologist one time.

I am not saying give officer sitting senior partners a pass; however, I think nature of the work is different. Are we being paid for “doing” like proceduralists or “thinking” like internists?

 

[Dr. Anonymouss]

What is the level of authority that anesthesiologists ultimately have over CRNAs? I mean if anesthesiologists are supervising CRNAs and they are deviating away from plans that the anesthesiologists make then that doesn't sound like supervision it sounds like independent practice. So I am asking this as a serious question. What do you do or what can you do if your CRNAs continue to do their own thing and deviate from the plan? I hope it's not as passive as "You can take a break" and then continue to make the changes you asked them to do which they did not...

 

[Mman]

What is the level of authority that anesthesiologists ultimately have over CRNAs? I mean if anesthesiologists are supervising CRNAs and they are deviating away from plans that the anesthesiologists make then that doesn't sound like supervision it sounds like independent practice. So I am asking this as a serious question. What do you do or what can you do if your CRNAs continue to do their own thing and deviate from the plan? I hope it's not as passive as "You can take a break" and then continue to make the changes you asked them to do which they did not...

depends on the employment model. If they work for you, well the door is that way. If they work for the hospital you probably have to bring issues up their chain of command.

 

[Status Sciaticus]

What is the level of authority that anesthesiologists ultimately have over CRNAs? I mean if anesthesiologists are supervising CRNAs and they are deviating away from plans that the anesthesiologists make then that doesn't sound like supervision it sounds like independent practice. So I am asking this as a serious question. What do you do or what can you do if your CRNAs continue to do their own thing and deviate from the plan? I hope it's not as passive as "You can take a break" and then continue to make the changes you asked them to do which they did not...

document that the CRNA is deviating from the anesthetic plan, then promptly call risk management to let them know that youve documented it as such. I've seen that move get the ball rolling much faster than bringing it up with nursing/CRNA admin. My experience is limited though

 

[Dr. Rude]

document that the CRNA is deviating from the anesthetic plan, then promptly call risk management to let them know that youve documented it as such. I've seen that move get the ball rolling much faster than bringing it up with nursing/CRNA admin. My experience is limited though

It helps if the plan is written in the EMR. Otherwise it could be spun as a "misunderstanding" or communication problem.

 

[kidthor]

depends on the employment model. If they work for you, well the door is that way. If they work for the hospital you probably have to bring issues up their chain of command.

This is spot on. If your department doesn’t employ / control the crnas, then it’s a set up for rogue behavior.

And for OP - if you’re at a place where the crnas run wild with impunity then find a new job asap. It’s not a scenario you can fix and it’s not worth your time trying.

 

[Dr. Anonymouss]

This is spot on. If your department doesn’t employ / control the crnas, then it’s a set up for rogue behavior.

And for OP - if you’re at a place where the crnas run wild with impunity then find a new job asap. It’s not a scenario you can fix and it’s not worth your time trying.

Very solid advice!