Today’s inane image of the day:
What is the value in a sub-I/away rotation in anesthesiology?
This is a question I’m frequently asked: What is the point of an away rotation? Every year, medical students match into anesthesiology residency programs without ever having done an away rotation. Many have read on SDN forums that doing away rotations could actually be detrimental to a student’s candidacy. Away rotations are expensive. Scheduling is a headache. Based on this information, it would appear that away rotations are not worth the hassle.
I beg to differ. Every individual will have to decide for her- or himself whether the investment in an away rotation is worth it. There will be some individuals where an away rotation would be detrimental to their candidacy. Either way, if you’re interested in learning more about the nitty-gritty considerations surrounding these rotations and some of my personal tips for excelling during either an anesthesiology sub-internship/audition/elective rotation at your home program or as a visiting medical student, keep reading.
Timeline (Away Rotations)
[If you’re not interested in away rotations, keep scrolling for my general tips for success.] I had the luxury of doing my first anesthesiology elective during my third year of medical school [this has now gone away for OUWB students, sorry]. I spent a month getting to know the department, attendings, residents, CRNAs, OR nursing, and get a glimpse of the practice of clinical anesthesiology. It was a glorious month. It seems obvious, but I recommend that you schedule your first anesthesiology rotation occurs prior to the start of the residency application cycle. If you cannot schedule one at your home institution, ensure that you have significant shadowing experience with the anesthesiologists at your institution and try to obtain an elective experience at a different institution.
Since I was part of the charter class of my medical school [and a pretty average test-taker], I knew that I needed to expand my network to match into a top-tier residency program. I planned early on in medical school to do away rotations and made sure to learn about my school’s requirements on repeating electives in the same specialty [OUWB only allowed one repeated elective, so I could only do my one month at OUWB and one away rotation in anesthesiology – I selected 2 other specialties to do my other aways in].
Here’s how I planned my aways/electives:
- December/January of MS3: At this point, I started looking into the institutions I was interested in doing away rotations at. Each institution had a unique application process [some were on the AAMC VSLO/VSAS, others had their own application] as well as differences in their block schedule. Sometimes I had to use the previous year’s information in order to plan for my year [generally, the types of rotations offered, block format, and application process are similar year-to-year]. I made a spreadsheet of the specific institutions and how I’d like to order my blocks in order to make them fit within my allotted elective time. I also looked into the rotation available at each institution [my medical school only allowed for ONE repeated specialty rotation, so I was creative about looking into other potential subspecialty opportunities or useful rotations for the practice of anesthesia].
- March-May of MS3: Start compiling the necessary forms [many institutions request immunization forms, a dean/registrar’s verification, a letter of good standing, transcripts, etc] in order to submit a complete application as early as possible. Some programs started accepting applications during this time and thus, I went ahead and submitted.
- May-August of MS3-MS4: Rotation acceptances started filtering in. As I confirmed these rotations, I also started arranging my housing options [I commuted for one, stayed with my partner at the time for another, and used RotatingRoom.com to secure one].
- August-October of MS4: Participated in 3 away rotations while arranging residency interviews. I was able to schedule a few of my West Coast interviews while I was doing my last rotation there.
An Investment in the Future
Hear me out on this one – you’ve spent [or borrowed] tens of thousands of dollars in order to get a medical education. Or, you decided to go with the more frugal approach and decided to go to the medical school that had the overall lowest cost. Either way, you’ve made a huge financial investment in your medical education… why wouldn’t you do that for your residency training?
There’s a lot to learn about the culture of a department, living in a new city, and exploring different types of anesthesia practices [e.g. academic versus community]. Spending a half day or day at an interview really does not elicit the big picture of an institution. I had a colleague who was sure of their first-choice residency program, but after an away rotation, quickly realized that it was a poor fit. I personally attribute my match at Massachusetts General Hospital to my away rotation at Stanford. Furthermore, many programs extend an automatic interview invitation to candidates that rotate at their institution; it’s important to recognize that by being offered an interview, you dramatically increase your likelihood and potential of matching at that institution.
This all being said, I believe that the application fees, housing and travel costs, and overall unforeseen costs with doing away rotations is an investment in your residency match and future career.
How to Succeed in an Anesthesia Rotation [e.g. sub-internships, audition, elective rotations]
- Be prepared.
This statement encompasses a lot of areas. You should figure out where you need to go ahead of your first day. You should arrive with some basic anesthesiology knowledge [good textbooks to start with: Miller’s Basics of Anesthesia, Morgan and Mikhail’s Clinical Anesthesiology]. If you know what type of surgery you will be part of, make sure to use a resource like Jaffe’s Anesthesiologist’s Manual of Surgical Procedures or if there is an OpenAnesthesia entry on the surgery, this is a good start to learn about the intricacies of the procedure and anesthetic considerations.
If you know the resident or attending you’ll be working with, see if there’s something you can find on their interests. In bigger cases, there is a lot of time to sit and talk – this is an opportunity to learn more about the people you’ll be calling your colleagues in the future. This could be an opportunity to learn more about the resident’s experience applying to and interviewing at various residency programs. This could be an opportunity to impress an attending you’re working with and learn about the program they trained at. - Be early.
You don’t have to be an early bird to pursue anesthesiology, but recognize that our days start earlier than most other specialties. As a medical student on a rotation, your goal is to make a good impression, so being early is one small part of that. Also, if you plan to pursue the specialty, consider that you never want to be the reason there is a delay in surgery [see Figure 1]. - Be inquisitive/interested.
You want to become an anesthesiologist, right? Show it. I know that some of you will be more introverted than others. That is ok. But this may mean you have to spend extra time beforehand coming up with questions to ask. You may have to force yourself out of your comfort zone to be inquisitive or “seem interested.” In life, you’ll find situations where have to force yourself out of your comfort zone to achieve specific goals – this may be one of those opportunities. - Learn to be helpful.
If it’s your first time on the anesthesiologist’s side of the drape, there will be a learning curve associated with how to be helpful. Often, it’s tough at the beginning. There are procedures to learn. There is a natural flow and order to the peri-operative period. There is equipment to get to know. There are protocols to follow. This all being said, learning to be helpful can be as easy as asking early on in the day, “how can I be helpful?” Just recognize that early on, you may not have the necessary knowledge/skills to be helpful… that’s ok. Over the course of your experience, pick up on where you can assist – sometimes it’s drawing up medications, priming IV bags, loading an infusion pump, helping with moving a patient, etc. - Introduce yourself.
Basically imagine you’re back on your surgery rotation and have to write your name on the whiteboard and introduce yourself to everyone in the room. The circulating nurse, the scrub tech, the surgical residents, the other medical students. Just make sure we all know who you are – if we don’t, someone will bring it up later and that could negatively impact your evaluation. - Ask for feedback.
As residents or attendings, we often forget to provide feedback. It has nothing to do with you or your performance if we forget. The same thing happens to residents working with attendings; without explicitly asking for feedback, you may not have an opportunity to identify specific weaknesses early on and address them. Sometimes this feedback later appears on an anonymous feedback survey where it is out of context. So, learn to ask for feedback regularly. OR, identify a weakness you’re working on, and ask the resident/attending you’re working with to point out specific instances where you could improve on that specific topic. For example, I have received feedback on my communication style – I told that to my program director when I worked with him and he made an effort to point out instances where what I said could have been misconstrued or better articulated. This type of feedback is immensely helpful, though admittedly, difficult to ask for. - Be human.
In bigger surgeries there can be a lot of down time. Once all of the lines and tubes are in, and the procedure is underway, there is an opportunity for education and casual conversation. This is where we can get to know you as a person and you decide if we are the type of people you want to work alongside [though, one thing they don’t tell you about anesthesia residency is that it can be really lonely; there’s a lot of time spent by yourself in an operating room and you really only get to work with your colleagues when on call, or rotations like obstetric anesthesia, or the ICU. In many programs, there is a lot of time spent working one-on-one with attendings]. This can be an opportunity to connect with the person you’re working with on something – whether that’s an alma mater, hobbies, or extracurricular activities. - Go home [when directed to].
When the resident or attending you’re working with tells you to go home… they really mean it. This is a luxury that medical students have and residents typically do not. So take advantage of it.
An aside: please be patient with your resident/attending
I am so grateful for the time and energy spent on me by residents and attendings during my anesthesia rotations. These individuals had a friendly, welcoming attitude while guiding me during procedures and provided reassurance while I learned to troubleshoot. I received valuable advice during these interactions that inevitably shaped my practice and career. These experiences were a testament to the commitment to education and mentorship that these individuals made.
Now that I’m on the other side, I recognize how mentally taxing it can be to have a medical student with you as a resident. Most days, it’s ok. Straightforward procedures on healthy patients are good rooms to have a medical student participate in care. Bigger cases with long periods of hemodynamic stability can be helpful in facilitating education. But sometimes having a medical student for most days of the week can be energy-sapping. There are a lot of external pressures to keep ORs running efficiently. There may be other stressors on a resident’s mind [e.g. studying for ITE or boards, fellowship applications, etc] that make it harder to focus on teaching. So, this all being said, please be patient with us if we seem distracted when working with you.
How my away rotation helped me match at my #1 choice
First and foremost, I am so lucky to have had an opportunity to work closely with the anesthesiologists associated with my medical school. The environment was structured more like a community hospital/private practice. Since this type of practice was what I was exposed to early in my medical training, I had assumed that would be my future practice.
One of my away rotations was at an academic medical center; it was this rotation that sparked my interest in training at an academic institution. And while I am not interested in the grind of applying for grants or publishing landmark papers, I have decided to stay in an academic setting because of the environment of inquiry and multitudes of opportunities to educate.
During a subspecialty rotation, I worked with one attending a couple of times. I’m not entirely sure what I did that impressed him, but at some point when we were sitting down discussing my upcoming application cycle, he noted that I would be a good “fit” where he did his residency – at Massachusetts General Hospital [MGH]. After we talked about my interests and geographical preferences, he offered to reach out to the selection committee on my behalf. One month later, I received my interview invitation and less than one year later, I matched at MGH.
I want to make it very clear that I do not have stellar scores. I was not selected to join the AOA. I did not have any publications at the time of my application. I had leadership roles within the American Medical Women’s Association [AMWA], but that didn’t feel remarkable. I was a middle-of-the-road applicant coming from a brand new medical school. So, I honestly do not think I would have been invited for an interview had it not been for that attending’s good word on my behalf.
A word on the COVID Pandemic
The world has changed. The medical community has changed. While I still advocate for away rotations, I only do so if it is done in a safe and educational manner. Many programs have suspended their visiting medical student electives [Harvard is one of them]. But a few programs are proceeding with opening away rotation opportunities. Ultimately, it is your decision how you think it’s safest to proceed. If I had been faced with this situation, I probably would not have pursued away rotations at institutions further away, but would still look for opportunities to explore how anesthesiology is practiced in different settings/institutions [e.g. I would have still done rotations at neighboring institutions in Michigan that I could commute to].
Residency programs recognize the challenges that this pandemic has placed on medical students and their experiences. This doesn’t mean that you’ve lost an opportunity to learn more about a program from afar… it just means that you’ll have to do more work virtually to connect with current residents and alumni. It means you’ll have to do the legwork to ask programs to open their doors to you in a unique manner.
Inspired by the medical students applying to anesthesiology residencies during the 2020-2021 application cycle that are looking for educational opportunities and engagement with residents/fellows/attendings in the field, I wanted to start a “Virtual Pre-op Call” program. To learn more about the idea and to sign up to be part of the pilot, check out this form: https://bit.ly/preoppilot
Conclusion
You’ll have to decide for yourself what makes the most sense for your career and future. If you have questions, please feel free to email or Tweet @ me. I’m always happy to chat/advise/help!