Choosing a Specialty - AAA (All About Anesthesia)

Today, ER doctor asked me to write an entry about anesthesiology. I am an anesthesiologist with a subspecialization in pain management. I work both in the operating room, take trauma call, and in my pain management clinic. I'm a few years out of fellowship...and today, will shed some insight into my professional world.
I decided to become a physician sometime in high-school. There was no magical 'calling', or parental influence. I just had to make a decision. I thought for awhile about my favorite subjects, those I learned with the most ease, and narrowed it down to a few applicable careers. Although nursing crossed my mind, as I learned more about the differences between what nurses did, and what doctors did...I decided I didn't really want to 'nurse' people. I considered PA, but thought to myself...I'll never regret going for the top rung, but I may one day (as a PA) regret not going full-speed to the top, and "settling" for PA. So, physician it was.

With regard to specialty choice, that came later. As a premed (and my first year or two of medical school) I thought family practice was for me. Back in those days there was a big "push" for medical students to pursue careers in primary care. Family practice is "the doctor" I visualized when I thought of "doctor." I liked the idea of treating the entire family, establishing a long-term relationship with my patients, etc.

As I progressed to my clinical years and gained exposure to the 'real practice of medicine.' After having candid discussions with primary care docs...I 'realized' that family practice isn't what many people/students expected it to be. It's very stressful, and doesn't pay well. The physicians didn't seem to enjoy what they were doing...and that bothered me. Haunted me, actually. So I had to consider (for the first time) that family practice wasn't for me.

Anesthesia isn't one of those specialties that students get much exposure to in medical school...unless they actively seek out the experience. So, it's no wonder appreciation for what we do isn't fully realized. For many students, the only exposure they have is via their surgery rotation....or OB with epidurals.

The process of - Passing the Gas
Anesthesiology requires a medical student to complete their degree, their USMLEs, and a preliminary internship (either surgery, medicine, or transitional). After that, you move on to your CA-1 year as a first year anesthesia resident. Training is 3 years after the internship. The first year of training (the CA-1 year), you mostly get acquainted to the anesthesia machine, and do relatively simple cases such as ortho (usually young healthy men), and ophthamologic cases (with sedation). Most cases are short (unless a new surgical resident is learning to do an appy). The CA-2 year consists of more advanced cases, longer cases, and children. OB/epidurals, c-sections, trauma calls. There were more outside rotations for more specialized experience...such as children's hospital, and transplant centers. You do ICU/critical care coverage. CA-2 year is the nitty-gritty of training. The CA-3 year you do advanced cases, such as long transplant cases, long cases in general, complicated cases (like patients undergoing major surgery that are likely to die). Heart transplants, burn cases, brain and spinal cord surgery, etc. The best part is you have more administrative tasks, like running the OR board (deciding if/when the various operative cases go to the OR). You get to choose your electives, and have exposure to those areas that interest you. Subspecialty areas include pain management, hospice/palliative, critical care - officially. There's also areas that aren't "officially" subspecialties but requires experience/training, some offer an exam and may become 'specialty' soon - such as pediatrics, OB, and neuro.

Why I chose anesthesiology.
During my 3rd year of medical school, I was quite convinced that I'd pursue internal medicine, and subsequently subspecialize in....say cardiology. I knew general internal medicine wasn't for me, but with the numerous subspecialty choices in the field, I figured I'd find something I enjoyed. Then, honestly, as a 'easy rotation' to break the monotony I decided to schedule an elective anesthesia rotation near the end of my 3rd year. That is when I learned what anesthesiologists do all day.

I went to medical school, and subsequently trained at a major trauma center. To me, trauma were the most exciting cases. It was during the traumas that 2-4 anesthesiologists were present. One intubating. One doing an a-line. One doing central line. One getting blood/saline and putting it thru the level 1. All working quickly, carrying out their various tasks of stabilization and resuscitation. I fell in love...
Typical OR day. Arrive between 5:30 and 6:00am to pre-op on the day's patients. Introductions. Acquisition of information. Reassurance. Then off to set up the OR. Pulling drugs into syringes. Getting various equipment set up. And above all, checking the anesthesia machine. There's an intimate relationship between the anesthesiologist and the anesthesia machine.

I have 3-4 scheduled cases that ideally end at 3pm or so. I get a couple of short breaks, either between cases, but usually during cases when a colleague comes in to relieve me. I also get bathroom breaks and lunch break if they are unable to be scheduled in between cases. There are times when I'll break the OR for lunch, depending on our staffing levels. There are intermittent emergency cases that supersede scheduled cases, but we usually have someone available specifically to cover those instances. One of us anesthesiologists runs the OR board, and it is up to us to decide who gets surgery that day, and when - despite what the surgeons believe or say. It is our prerogative to cancel cases, close OR rooms, and manage the operative suite.

When there's an airway emergency anywhere in the hospital (excluding the ED), we respond and assist with airway control. We respond to all code blue arrests. We backup the ED...if they have a problem airway, they call us. We also assist with intravenous access and spinal fluid access (for lumbar punctures, or anesthesia administration). We cover OB, do epidurals, and are available for crash c-sections. There is a pediatric 'fellowship' in which we work at Children's hospitals doing typical anesthesiology tasks.

In addition to airway, and emergencies, we do regional blocks to prevent or treat painful conditions. In pain management, we treat patients with chronic pain syndromes. We deal with end of life care, and palliative pain issues via hospice and ICU. And of course, speaking of ICU, we manage critical patients in the ICU - usually surgical, and usually post-op.

What I don't like. What I like.
The lifestyle isn't always great. 6am is a very early start to your day. And 3pm easily and frequently turns into 4 or 5 pm....which makes for a very long day. There isn't a lot of down time because an empty OR is costing everyone money. Eventhough you only have 1 patient at a time, there's a sense of hurry to get cases started, and to leave patients in the PAR (post anesthesia recovery) even if you're not quite convinced you should leave them just yet. Dealing with some surgeon types makes for a very stressful, or negative atmosphere in the OR. There is little exchange between you and your patients (practically speaking) since they're sleeping the entire time. The OR is the same everyday, and somewhat boring. They say it's 90% boring, and 10% "oh shit!!" I think that's true. The solitude behind the blue curtain is nice, mostly, but it can get lonely.

There are a few specialties in medicine known for their "problems". Stereotypes don't apply to individuals, but rumor has it that anesthesiologist tend to have drug addiction issues. I guess passing all that gas, and administering all those drugs, makes access easy. This is a problem that is made clear on day one of anesthesia training. This is a problem on the radar of every anesthesia department. Not unlike radiologists getting blood cell cancers, psychiatrists committing more suicide, or surgeons having more broken families/marriages.

Also, patients (and people in general) frequently are unappreciative of the work we do. It's difficult keeping a patient comatose, paralyzed, with adequate blood pressure; breathe for them, protect their eyes, monitor the blood loss, and then....wake them up *intact* after hours of a human digging around in their abdominal cavity (or brain, or back...). When things go wrong, they go wrong FAST. You need to be aware of many drug actions, interactions, indications for use, and how to deal with pretty much any foreseeable (and unforeseeable) catastrophe. You have to be exquisitely more familiar with the workings (on a mechanical level) of the anesthesia machine than you ever imagined possible. You have to have a grip of physics, and understand the differences in gas pressure and turbulent flow of air thru tubes depending on the atmospheric pressure, type of tubing material, diameter and length of the tubing, and the viscosity of the gas. You have to be familiar with all the different procedures the surgeons are doing...and read up on the procedure beforehand to be sure you can anticipate/prepare for complications of that procedure, and anticipate when significant changes in vitals signs are expected to occur. Some drugs are so potent, that mere drops of it makes a huge difference. There are reactions to blood products, failure of equipment...and surgical complications that affect the well-being of the patient. And when things go wrong, everyone is very quick to blame the anesthesiologist. These factors result in a very difficult board exam - amoung the most difficult of any specialty, and many of us do not pass them on the first 1 or 2 attempts.

The job's both exciting, and frightening. The compensation is great. By working with residents I'm not tied to an OR all day. I get to be present at the start of a case, and at the end of a case. I am not tied to one room, therefore I don't feel the boredom or loneliness. I work at a trauma center, so that's exciting. I also have a pain management practice...so I have more 'patient contact' and continuity than almost any other type of doctor. And, I get paid to see my patients in pain management -unlike primary care docs.

More and more students are choosing anesthesiology, and the specialty is becoming more competitive. For years students were told anesthesia was oversaturated...and that created a shortage that was subsequently filled with FMGs. As more American students choose the specialty, and competitiveness increases....our profile will elevate, and that's a good thing for gaining respect and prestige for the profession.


Anonymous said...

This is a really informative and great essay. Thank you for a glimpse into your world. I am a primary care doc and when I was an intern I was advised to go into "gas" because I would work 1/2 the time and get paid 5 X as much. I think that is true but I would hate starting at 5:30AM! I have regretted my choice over the years. Thanks for the good, the bad and the ugly.

Anonymous said...

Wow, your posts are all so enlightening...keep on tellin' it up!

travelRN said...

Thanks for the post. I have wanted to pas the gas, but I could not afford med school. My only hope was to be a CRNA, again the cost is a little out of my league.







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