Today’s inane image of the day:
Back in 2015, I had grand plans to write up entries discussing different specialties and my personal thoughts on why they were not quite a good fit for me but how I could see they could be a good fit for others. I only wrote up one entry on emergency medicine. But it’s never too late to keep adding to it, right?!
A lot of premeds and medical students have asked me about my journey and path to anesthesiology and I finally took the time to record a video outlining my journey AND threw in some fun throwback photos from over a decade ago, when I was in college! I hope you’ll take the time to watch the video above, if you haven’t already.
If you’re interested in reading more about what I like and do not like about the field of anesthesiology, keep reading!
Background
What is an anesthesiologist? Most people have a really broad concept/idea that there is someone from “anesthesia” that makes sure that a patient is asleep for surgery. Sometimes there’s confusion between an anesthesiologist [anaesthetist in the U.K. – linked is an interesting article from an anaesthetist in the U.K.] and a nurse anesthetist [certified registered nurse anesthetist, or CRNA – linked is an article on the basics of how to become a CRNA after RN] and more recently, an anesthesiologist assistant [certified anesthesiologist assistant, or CAA – linked is a short article from the American Academy of Anesthesiologists Assistants; this is a newer profession with limited practice states]. What I’ll be discussing in this blog post are my thoughts on becoming a physician anesthesiologist in the U.S.
I didn’t grow up dreaming of becoming an anesthesiologist. I doubt many people do; it’s a specialized field that patients rarely encounter other than in a surgical setting or in obstetrics. Maybe if someone has a family member or parent that’s an anesthesiologist, it would make sense. Either way, I am from a completely non-medical family. No one has ever worked in medicine in my entire family. But for some reason, I was drawn to practice medicine from a young age, so I followed the dream.
I struggled a bit with the application process to medical school, but eventually got my first acceptance 9 months after submitting my application. It was the summer prior to starting medical school that I stumbled across Dr. Michelle Au’s blog, The Underwear Drawer [it’s not what you think… really]. I devoured this blog every single day after work [I was a contract engineer for a few months before starting medical school] and learned about her journey through medical school, then to pediatrics residency then her transfer into anesthesiology. This was my first exposure to the field.
As a first year medical student, I joined the anesthesia interest group and shadowed during holiday breaks/vacations. It seemed like a magical experience, but I didn’t settle on pursuing the specialty until after my first rotation in it. Now that I’m actually an anesthesiologist, this list reflects experience from medical school, through residency, and now as an attending. So… it’s thorough, I guess?
One piece of advice I like to note for anyone exploring specialties within medicine is to really look at what the attendings are doing. Residency is a limited time. It sucks. Don’t let that cloud your judgment of what life is like in that specialty afterwards.
Okay, let’s dive in.
What I like about anesthesiology
The operating room environment
My first clinical rotation in medical school was surgery. I actually thought for a moment during the rotation that I might want to pursue surgery [mostly because I didn’t really get a good idea of what surgical life was like; it was the summer, volume was down, a couple surgeons were on vacation and I was on a subspecialty service so it predominantly elective cases/procedures, which is inherently different from realms of surgery like trauma]. I later realized that I was kidding myself; I didn’t love surgery enough to put up with the residency, the hours, and frankly, the abuse that pervades surgical culture. But I did like the operating room environment, so I focused my attention toward anesthesiology.
The operating room is like no other place in the hospital. It has its charm. Each OR has history. In some of our older operating rooms, something like thousands to ten of thousands of patients have been operated on. There are rituals in the operating room. There is some semblance of order. Sometimes there is chaos, but that’s a rare event. Overall, one can liken being part of a surgical team as being part of an orchestra. Every single person contributes in order to make something beautiful.
On the anesthesia side of the drape, there is a work area that beside induction [going to sleep] and emergence [waking up], should be relatively organized. We monitor vitals with numerous senses – we listen for the pulse ox rate, tone; we hear the suction in the surgical field; we watch the numeric vitals and EKG. When needed, we draw up medications and administer them. All in all, the operating room environment is a very special place within the hospital and can make the practice of anesthesiology rewarding.
Procedures
General anesthesiologists are experts at peripheral intravenous line placement, intubations, arterial line placement, and central line placement. In many practices, we are also facile in placing epidurals [e.g. laboring women] and spinals [e.g. c-sections OR certain orthopedic cases like knee arthroplasty and hip arthroplasty]. Anesthesiologists that specialize in pain management can do additional procedures targeted at addressing acute/chronic pain. In certain practices, specialized anesthesiologists may even cannulate for ECMO. Being comfortable with these life-saving procedures makes us very versatile physicians; there are few physicians in the hospital that are as good as us at getting venous access (e.g. an IV).
Physiology/pharmacology/instant gratification
Our day to day providing anesthesia to patients requires an in-depth knowledge of human physiology and pharmacology. Our practice allows us to be a “jack-of-all-trades” in a way – when I do my own anesthetic, I am the physician diagnosing an issue and establishing a treatment plan, I am my own pharmacist in deciding what medication and dose to administer, and I am my own nurse in being able to administer the medication.
What is truly special about our field is this instant gratification in the realms of vitals and pain management. If someone is hypoxic [e.g. their oxygen level is too low], then we can diagnose the underlying issue and either support their airway or intubate and manage the ventilator to fix this issue. If someone is hypotensive [e.g. their blood pressure is too low], then we can investigate the underlying cause and administer vasoactive agents [e.g. medications] to bring this vital sign to a normal level. We anticipate through our training and experience which kinds of surgeries cause more pain than others, and can provide a variety of pain medications [both narcotic/opioid and non-narcotic/opioid options] to address pain. Our interventions are typically through an intravenous line and work quickly, so there is an immediate effect and thus, gratification that we helped a patient.
One of the most gratifying procedures we do is epidural placement for laboring women. Nothing compares to peeking in on a patient who was just in excruciating labor pain from contractions just minutes prior and seeing their face relaxed and asleep. It’s an incredible feeling.
Shift work, sort of
Anesthesiology is practiced in a variety of models. It can be practiced in a shift model. There are practices where the expectation is that you will provide the anesthetic for the entire surgery, start to finish. There are practices where the call team will come and relieve you. I currently practice in a model that is more shift work structured, however, in complex cases, I typically stay for the entirety of the surgery. Handoffs can be dangerous if not done properly, and I have a professional obligation to provide safe care to my patients and minimize risks. The counter to this is that if you’re too tired to make good clinical decisions, then a handoff may actually be a safer option. It all depends on the case and situation.
The majority of straightforward cases can be handed off safely, and thus, a shift work model can be employed. This does allow for some semblance of predictability.
Collegiality
Anesthesiologists are a very collegial group. When I started as a new attending, I frequently reached out to my colleagues with questions I had about specific cases or surgical preferences. When we anticipate a difficult airway or that we will be caring for a particularly sick patient, our colleagues are always readily available to help as an extra set of hands. I love this about our field.
Team-based approach
In medicine, I’d argue that the best care is provided by a team. Sometimes there can be challenges in communication if there are multiple teams caring for a complex patient, but typically a team-based approach allows for patients to have multiple sets of eyes on them and thus, more smart people thinking about the best approach. I frequently reach out to my surgical colleagues with questions about their approach to surgery and any medical concerns I have in order to anticipate and prevent complications intra-operatively and post-operatively. In the operating room, we have numerous team members working in concert.
What I do not like about anesthesiology
Unpredictability
Most practices are setup so that anesthesiologists cover a specific operating room or multiple operating rooms when working in an anesthesia care team model. Sometimes there are add-on urgent or emergent surgeries that are placed into an anesthesiologists’ room. This is the unpredictable part of our job.
We are often forgotten
Often, patients do not remember us. Some may argue that we’ve done a good job with our care if this is the case. I usually do not mind this aspect of our job, but sometimes it can be a bit demoralizing. Patients do not see the work that goes in behind the scenes to coordinate their care and optimize their status for surgery. Nor do they see the times we are reaching under the drapes in awkward places in order to ensure that lines are working, or in the instance when they may not be, to place new lines.
No continuity
For most anesthesiologists, patient encounters are only in the operating room. This is just a small part of a patient’s overall life, or medical journey. While we play a vital role in a patient’s surgery, this does not foster a longitudinal relationship. There are subspecialties of anesthesiology that do provide more longitudinal care. For example, chronic pain providers will typically see patients in a clinic setting over years to decades, and critical care trained anesthesiologists will care for ICU patients for longer-term. There are certain patient situations in the hospital where we care for the same patient for repeated operating room trips [e.g. extensive burn patients], but other than that, the majority of general anesthesiologists do not have continuity of care with patients.
Reliance on surgeons
We rely on surgeons/proceduralists [e.g. endoscopists, cardiologists, or interventional radiologists often also rely on anesthesia services for specific procedures] to bring us work. That’s the reality of anesthesiology. In the peak of the pandemic when surgeries were shut down, there were some practices where anesthesiologists also took a big dip in income because there were no surgeries. Not every area of anesthesiology faces this – again, pain medicine and critical care trained anesthesiologists can practice even without surgeons.
Liability
While anesthesiologists are usually named as part of a group of individuals in lawsuits, many anesthesiologists can expected to be named in at least one lawsuit during their career. Medscape has an interesting malpractice report that goes over various factors on this matter. With how litigious our country is, this is somewhat expected and perhaps unavoidable in many specialties. This is why it is so important to have good malpractice insurance coverage as a physician in the U.S.
Doom and gloom about the future of the practice
I am frequently asked by medical students about whether I’m concerned about CRNAs taking over all physician anesthesiologists’ practices. I have many opinions about this topic, but when asked about whether I’m worried if I’ll have a job or not, I say no. One insurance policy on this is my fellowship training in critical care medicine – where there are ICU patients, there will be a need for physicians. Additionally, there are advance practice nurses and physician assistants in every field of medicine. There’s a lot of work to do and there are also a lot of underserved populations in our country. While the job of an anesthesiologist may not look the same in a decade, that’s okay with me. I anticipate that the practice of medicine will continue to change and evolve. Anyone who becomes a physician should anticipate these changes, too. Just because a certain specialty/job is structured in a specific way today does NOT mean it will look like that in the future.
Conclusion
I love working as an anesthesiologist. It’s both challenging and gratifying work. I also had the opportunity to pursue subspecialty training in critical care medicine, which addresses many of the negatives that I see about practicing general anesthesiology.
I hope this was a helpful blog entry! Please let me know if you have further questions by reaching out to me via any of my social media channels @amandasximd or by leaving a comment in my YouTube video above!