New hospital day

Today I will go to another new hospital.  I'm meeting them at 6:30 in the lobby and I'm pretty sure it's a 7:30 start.  I've been up for 20 minutes and have a 45 minute drive... so here are my ten minute notes on today.   

I have an 8 hour day today so it's not so long and I know I'll make it through.   

When I drive into the parking lot I'll note the main entrance as that's where I'll meet another CRNA to give me the quick run-down.  Hospital systems are a little harder to just go in and 30 minutes later be in a room.  The "red-tape" isn't just paperwork and long credentialing.  These places require smart ID's to let you in and out, and sign-ins for multiple computers/programs/machines.  Even cases will typically be a couple starter cases to get used to equipment, paperwork, and get to know staff.  

Ok, well I hope your day is awesome... mine will start with a bit of a drive.  Thanks to podcasts at least I have the opportunity to learn a little as I go! :).  

Let's talk skill set.

A recent question was posed about skills and the fact that some of us get rusty or haven't done XYZ in a ... while.  What do you say? How do you talk about them?  Let's use pediatrics as the skill in question.

First, have you just not done any kiddos 0-18 in years and you want to start doing them again?? Maybe the case is you want nothing to do with kids but over 12 is ok?  Where does your comfort level sit?  

When you talk to agencies you should know they want to be realistic with where you are and where you are willing to go.  Are you willing to do pediatric cases but want a hand in the room until you are comfortable??? The first 5 - 10 cases or maybe you say I'm not comfortable and don't want to go a place I'll have to do pediatric hearts or solo pediatric ER intubations.  

This is all ok.  But, you have to realize each case type you can't do or won't do may limit your opportunities.  It totally may have zero effect.  My current hospital will put you where you are comfortable.  No blocks, heads, hearts, cvl's, art lines, peds... it's ok.   

Important! Don't tell them you do and you can't do!  You should get a credentialing packet that will ask your comfort with procedures, cases, and numbers (estimated) per year.   

Please, let your agency know where you are and be optimistic about what you do and what your willing to learn.   

Continue to show your education, CEU's, ask questions, and when you are at your assignment take initiative.  Ask questions, act interested, & be ready for opportunities. 

1st weeks

The first days in a new place are the hardest as one doesn't know the Doctors, CRNAs, Surgeons, Techs or admin.  

I had a lot of fun getting to do a variety of cases.  I'm hopeful that in the coming weeks I will have even more fun with the group here.  I have gotten back into hearts after at least a year or two off from them.  The surgeon is pretty nice and relaxed.  I've had a good group of people to work with and I truly look forward to the days to come. 

 I'm supposed to be going to multiple hospitals so next week will start a whole new day 1 process and a getting used to the system at a new hospital.  I'm excited to see this group and how they work together.  

It's interesting dynamics hearing what people do and don't like and how they express themselves.  It's not difficult to read people and see that they have reservations or dislike or like what they do.  

I have not seen it all and done it all.  I had a new experience of a doc on group text stating their displeasure with a call schedule and they will resign next week if it isn't changed.  It's just a whole new experience.  

I get a little perspective into other facets of anesthesia and management as I continue to work with people through this site, these facilities, and continually keep in contact with others.  The interesting thing is that it boils down to .. "just business".  What we do on a daily basis is truly the personal touch and a true people profession.  Please don't let me detract from that but the where we do, how we do, and when we do ... those things come down to business.  Some politics in how much hands are tied and what has to be done and how.  The thing is that business drives those decisions.  

When a new anesthesia management group takes over.  It's not because one was liked more or less or even that a group did a sub-par job.  It comes down to the buck.  Places get comfortable and complacent and happen to think they won't be taken over by another but they also have to realize that the board for the hospital, anesthesia group, surgical center, or whatever company ... may not be in the same profession.  They may have an MD/MBA and have never practiced medicine.  They may not have either a MD or MBA title.  The owner of a company may still outvote a board of directors that is supposed to be running the company.  All this is said to remind you that a contract is a contract and all have a term to them.  When things change it is business.  It is not because of the individual or that something happened.  

So, one week down and the business of anesthesia shows as a new group has merged with these hospitals and it seems to be eggshells for some.   I try to be mindful of the stress and go in happy and excited to be here.  There are things that help and happy patients are very important as the surgeons, anesthesia, and all parts of the group are more easy going and perceive a positive experience.  So ... the 1st week has to be a good week :)

Journey forward with me as we go :)

Pre-amble to the real day 1

I have to say that tomorrow is my real day 1.  I have some new Mindray anesthesia machines that I'll be using for the first time.  I'll get to the hospital without a problem.  Getting to the OR might be a little more challenging :)  They took us around the hospital... then another and now I remember very little.  The good news is that I get fireworks just for coming to Philly. That's pretty cool :)  

I'll let you know how goes tomorrow :)

Presence

Hi guys,

It’s another beautiful day.  We are going to talk about presence.  There are a lot of things that go into this.  We have to really think about this.  In this I would say that perception also plays a key role.

As a locum, key people have to know your presence during the day.  They have to see you working.  They have to see you available and hear that you are ready willing and able to work.  You can’t say yeah in 20 minutes after my break, at least not every time.  By that I mean, if they ask you to break in half every day and every second you get a 15 minute break or your lunch, I would not expect you to give it up.  But, in a special instance of the ICU called needing a stat intubation and you happen to be the only one free and the rest of the staff are saying we are at lunch.  It’s an opportunity to show you are the ultimate team player.  

So much of the time I hear about that locum that always seems to run and hide.  They rarely complain about the rest of the staff that don’t eat in the break room or immediately leave the OR area just after a case and then people are calling and looking for them.  It does seem however that if the rental is missing for 5 minutes they can never find them.   At which point, I say that I had to pee but I am back at their service.  

Presence is also a knowledge presence.  You have to exude the fact that you are knowledgeable regarding the cases.   For example, oh at the last place we only used Isoflurane and we seemed to always use Milrinone.  I hear your CV surgeon doesn’t like Milrinone. What does your surgeon prefer and do you know the rationale?  I hear your total joint guys don’t use Tranexamic Acid, do you find you have higher EBL’s?  What percentage of retro/peri bulbar block need supplemental topical or why does your surgeon require so many blocks on basic cataracts?  I’ve seen complications of the blocks and wonder if your surgeons are newer or older?  One of our cataract surgeons doesn’t do their own blocks and isn’t comfortable with them.  They only use topical and in event of it not working on a prior eye, they ask anesthesia to do them.  

I also venture to state understanding the billing structure and pay ratios is important.  That presence is important in the negotiation of your contract.  If you know the group, agency or people will keep you busy and you know the payer mix is strong, then you know that you will be earning the group 2-5 times what you bill.  If that is the case then you should be able to negotiate a higher rate.  That is typically true unless you are in a high demand area.  CRNA’s are like anyone else, they will take advantage, undercut  the higher person in order to get the life they envision as best.  

So keep a good presence about you and keep your eye, ears and body aware.  

So close to return

Good morning!  

Today, we head back to New England.  We'll fly into Boston and then back to our apartment for a couple days and then get ready for our trip to Philly!

Planes are great, airports are not my friend. 

OK, why write today?  Well I just hear a Locum was all set to go for my next assignement next week and they backed out last second.  Have I told you how bad that makes you look?  Have I said that it might blacklist you from going with that agency in the future?  Why burn a bridge?  If it was for more money, why didn't you negotiate for what you would work for in the first place?  

This disrupts my ability to get a schedule but thankfully means I'll get more hours.  I wonder if they'll give me 80?  That's do-able for a time but will get to burnout soon enough.  I'm typically around 60 so not a big jump :)  

Ok... gotta go catch a plane.  Someday, I'll have to describe all the business stuff that goes through my head and thought process :).  Continue the journey

Skills

Skill and Presence are left in the things that make a good locum.  First... Can you believe I started this little site one month ago?  If I can do all this in a month, imagine what the future holds.  Well, honestly that means we are so very close to going back to work. It seems like I was just at work.  Tomorrow, marks another travel day in the life.  We will be flying back to Massachusetts from Kansas.  If anyone is in Worcester or wants to say hi in worcester we might be able to do the evening on the 30th of June.  I'll open it up on the FB page.  

Skills.  

I usually say something like... say what you mean and mean what you say.  This would be in the same category.  Know your skills and do them well.  You have to be able to do the cases the facility needs you to do.  So for each assignement I ask what typical cases are and that I'll be set in the rotation to do all the cases.  I love my A-lines and Central lines.  I love Pediatrics and neonatal cases.  I enjoy a good heart and major vascular case.  Neurosurgery for a tumor or a neuromonitoring back.  C-section for breach twins or an eclamptic that needs a stat section are all in a days work.  It's not uncommon for me to go in and find my schedule changed to something else because they added XYZ case.  It goes back to being flexible and they know I am. I have the flexibility because they know that in my pocket of skills and case-load I have the ability to do what they need.  They can take me out of the Total joint and put me into the emergency add-on trach.  They also know that I'll ask questions or make sure things are ok in the event something isn't right.  I'm not a cowboy and I'm not going to try and do what I'm not comfortable with.  

You have to develop the skills and types of cases over your career.  If you are a new grad, you're untested and an unknown quantity thus most places ask you to get a minimum amount of experience in a facility and I would say get a year or two at a semi-independent site.  Completely independent sites will normally do more bread and butter and dominating supervised practice can be so crippling to a career that it'd be better to go locum as a new grad.  So, I can't say what you should definitely be doing.  You should be capable of blocks, and basic a-lines and IV's, general cases, spinals and epidurals.   If not, when you start locums ... state this upfront to your recruiter or if independently contracting, you need to let them know.  Then you might want to learn.  If it is a long term assignment they may take a couple days to help you learn.  

Develop your skills and continue to give yourself variety so you can stay marketable.  

Attitude

Let's take a minute to talk about attitude.  Sounds like a lecture from my mom but it's going to be key in your business as a locum.

im guessing that there are multiple reasons you decided a nice secure stable jobs wasn't going to fit with you.  Once again I'll bet there was a person or two that drove you right off the cliff leaving you finally ready to start locum tenens. So, was it this persons overall attitude, personality, attention, or some disagreement that just couldn't be overcome?  Now, in retrospect, was this truly a one sided thing or part (just the tiniest little fraction) a bit of your response to the attitude of the other person, group, or other?  I mention this because how you respond to others, and your overall character make up your attitude and perception.  Ones perception of you is their reality.  I had someone tell me that wasn't true and at that point I knew there was no hope that she would ever be able to overcome herself. 

Why are locums used?  Yes, on rare instance it's vacation or baby leave or some other fairly good reason.  What's typical??? Typical these days are that a group is losing $$ so they have downsized making the others in the group work harder then s couple people just leave or say no more of this.... then the hospital looks around for a cheaper anesthesia management group.  The current group starts to feel like they might be replaced and in come a few locums meant to make it appear that all is good, well staffed and that we are growing.   

You arrive and unfortunately you hear that people aren't as happy as they were a year ago.  So and so person has become so unhappy and hard to deal with but they just won't leave.  Finally, you hear the boss talking and financial stress of the group to make the new lower budget work with these expensive locums coming in is causing a problem and why can't we get some good CRNAs?   

You have to come in and overcome the hurdles and not get sucked into this.  You have to be the one that is happy and help others see that it can be good and it isn't just a horrible place.  That doctor that 4 other CRNAs refuse to work with is now the guy that is a little challenging but today is going to be awesome!  You have to hold the can do spirit.   

If you take on the OMG the world sucks mentality you will also start to feel that drive to leave, performance decreases, then all of a sudden notice comes that they don't need you despite not hiring any more people?! 

Politics, bad-mouthing staff, or saying you dislike... these are no no's.  You absolutely love this, & you can't wait for this opportunity in 3 weeks in the area because how awesome is it that you'll be here?! 

After your first week or two, ask the leadership how your doing for them? Where can I help you most?  Any challenges or issues?  This allows them to evaluate themselves and take a temperature on how you are assimilating into the group dynamic.  They might say well, what's your favorite type of cases?  Do you like a certain case type here? They might state all is well.  Then again you have to do an attitude check to... how are the bosses or surgeons or co-workers responding to you.  Do you feel more positive or negative?  How do you counter the negative?

For some this is endorphins from exercise, for some it's sharing the love and feeding some of all of the group, for some its taking weekends and site seeing, and for others it could be crafts.  You have to find your happy. That said, I don't think you should be the one that is nose to the grindstone, non-talkative, or super laser focused all the time... people will perceive you as quiet or snooty.  Quiet, it may just be who you are but I would explore you to make small talk and talk about all the happy things in the area... not the expensive wonders of the Cayman Islands... that's a whole other conversation that money talk is taboo!

I'm pretty sure I talked way too much!  Good luck and keep it positive!!

Flexibility

One aspect of being an amazing Locum CRNA is being flexible.  Yes, I mean being able to reach your toes and bend over backwards.  OK OK not so much.  Flexibility in this case refers to your time and ability.  Your ability to manage just about any case you need to do and be happy doing it.  Your ability to stay late ... again.  Can you come in early?  Are you able to take call?  Can you set-up the Heart?  Will you go do the epidural?  Will you take the student and teach them?  

These are definitely all questions I've had.  Flexibility is being able to answer the call.  The more you can say yes and be able to do so with a smile.  The more likely you will be seen as an asset the facility needs despite your being a rental.  I find that it leads to returning multiple times to facilities.  I think it leads to satisfaction of the overall group and interpersonal dynamics when everyone from the janitor, anesthesia tech, other CRNAs, and management can see that you are both knowledgable and have a can-do attitude.  Do I think you should do something that makes you uncomfortable?  No, but do you say "No, I won't do that"  ... I'd say that's a poor way to communicate.  I'd say, "Hmmm, I haven't done a retrobulbar block before would someone be able to do those with me or is there a room with Interscalene Blocks as I've dont hundreds of those?" This gives the group an opportunity to use you to the extent of your skills but also tells them that eyeballs just aren't blocks your comfortable doing.  So, flexibility with skills can be very important. 

Case flexibility is very important and is a play on skills.  The more comfortable you are in a variety of cases and practice types, the more marketable you become.  The better you market yourself or the agency is able to market you, the more likelihood you can ask for higher pay, more hours or keep yourself in demand.  

Hours flexibility.  Many times I hear someone say I just want to work 8 hour shifts.  Sometimes, locum providers are scheduled just 8 hour shifts.  Totally true.  I don't know what to do with myself only doing 8 hours.  Many places have gaps in their schedule because most employees want that cushy 8 hour schedule.  If you are flexible in your hours you might get to work overtime, get mid-week days off, or even have time to get some errands done before or after work on certain days.  Many times it's all in how you contract with a facility.  For example 8 hour per day guarantee versus a 40 hour per week guarantee.  

Flexibility leads to hospital and group satisfaction.  Consider this as you continue to grow as a locum provider.  

Topics to come will be skills, attitude, and presence. 

The things I do

You won't believe it's vacation time, the baby is with grandma and grandpa.  I'm awake :(

& it's 4AM. 

Yesterday, I set up internet/cable for Philadelphia while on the road to see Mount Rushmore!   

This morning I discussed with a fellow CRNA some contract terms that were not bad.  I mentioned that references are required for CRNAs but I think a new agency or one we haven't heard of ... should give a reference or two as well.  Very important that pay is correct and on- time.  Credentialing goes pretty smoothly with few hiccups on the agency or hospital side.  Then that the interpersonal dynamics are good and you feel comfortable working with the recruiter. 

Today we'll go see Mount Rushmore, the Dinosaur Museum, and Crazy Horse. We'll stay the night again then take off for Denver?!?