Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

July 2012

I don't think there has ever been a better time to be an anesthesiologist

The role of the physician as the center of health care is under pressure. Everyday I notice that the system of care around the doctor is becoming more crucial. Now more than ever the individual doctor is part of a bigger team caring for patients. This will be even more true in the future as there wont be enough physicians to care for the growing and aging and sicker population.

Yet, I don't think there has ever been a better time to be an anesthesiologist. The role of the specialist is evolving, in part through the introduction of new technologies such as video laryngoscopes for airway management and new surgical treatments such as Placement of Aortic Transcatheter Valves. Correspondingly, the breadth of subspecialties, from critical care to pain medicine, has similarly mushroomed. As a result, research questions abound. Amazing advances, such as the imaging of nerve blocks and transthoracic ultrasounds, have come about in the past few years and new developments are on the horizon. And, of course, guiding patients who are fearful about a surgical procedure and taking them safely from induction to recovery remains a core honor and privilege of the anesthesiologist.

For the medical student looking at careers finding the right specialty will in many ways determine the quality of your life, both at home and in the workplace. Many preclinical medical students may not appreciate that anesthesiologists have continuous patient contact and are the go-to physician for invasive lines and acute care.

Fortunately, within the same specialty -- anesthesiology in particular -- there are myriad roles for the clinician, including teachers, researchers, quality managers, administrators, and mentors. There are also many different practice settings. That gives you limitless choices and opportunities within anesthesiology.

Keep in mind that your choice of specialty will be affected by chance events: the resident or attending who mentors you during your rotations, the location of your clerkship, whether it is an inpatient or outpatient experience, the patient population; even the condition of the physical plant of the rotation you have been assigned to. For better or worse, these different experiences affect your choice to enter a particular specialty. I am amazed that every yr medical students make career decisions based on limited and imperfect information, not possibly experiencing all the specialties available in a meaningful way. Alas, that is even more so now that the Dean's letter goes out one month earlier on October 1.

The Pros of Anesthesiology

For anesthesiology, the most commonly listed positives are:

The wide variety of patient types. In a few days time, for example, you could care for a 3-year-old for tonsillectomy, a woman in labor, and an 87-year-old who needs vascular surgery.

Working with your hands. Cognitive clinical decision making is the most critical element to being a good anesthesiologist, but it is also necessary to master procedures such as intubation and placement of catheters. Laryngoscopes and syringes filled with medications become an extension of your hand and body.

The physiology and pharmacology. Those were my 2 favorite classes in medical school. Anesthesiologists get to use drugs to control human physiology. What could be better?

Instant gratification and feedback in the operating room. For instance, you find out right away if the pharmaceutical administered is having an effect on blood pressure. In contrast, as a junior medical student in the medicine clinic, I remember being a bit frustrated with having to wait weeks to see whether the oral antihypertensive pill worked, or even whether the patient went to the pharmacy to get the prescription filled.

Short-term rewards also exist with putting the patient to sleep and having them wake up smoothly. It happens within an hour or two depending on the surgery. (And, amazingly, we still don't know the exact mechanisms that achieve the reversible coma that is general anesthesia.)

The potential for a flexible schedule. Because patients are brought to the operating room after assessment by the surgeon, the anesthesiologist assigned to the case is essentially interchangeable such that you can take time away from the practice without patients suffering. I admire my partners who take advantage of this and use that time for medical missions in remote and underserved parts of the world.

Putting patients at ease. Most patients are asleep with an airway in place while they are under an anesthesiologist's care. However, because patients are often quite nervous before surgery, the anesthesiologist can use his or her bedside manner to quickly and intensely bond with patients and reassure them.

Fewer complications. Most patients do well with anesthesia, without anesthesia-related complications. In contrast, surgeons have to accept more frequent and more severe surgery-related complications (eg, wound infection).

Best of all, I enjoy being responsible for one single patient at a time. Back in medical school I remember feeling stretched and overcommitted in the office environment with multiple patients. I couldn't give each patient the time I wanted to. In addition, I enjoy the close working relationship I have with other anesthesiologists, residents, surgeons, and nurses.

The Cons of Anesthesiology

What are the cons to a career in anesthesiology? I posed this very question to some of my partners. Their answers:

Lack of follow-up and continuity in patient care. If the anesthesiologist does a good job the patient generally won't remember who you are. The specialty is doing a better job of educating patients as to what we do and who we are. Progressive groups have an established system to follow up with patients.

Unpredictable days. On any workday it is difficult to know when your work will be done. This unpredictability in end time is caused by cases running longer than expected, or add-ons, or emergencies. The expectation that you will work late hours, even into later stages of your career, is particularly true at large busy hospitals. Taking overnight call to take on challenging cases is fun in the early years, but getting up at 3 am for an urgent case becomes progressively more difficult as one gets older. This is not a lifestyle specialty.

Less financial clout. Because anesthesiologists do not bring patients to the hospital, we may not have as much financial clout as do physicians who admit patients in a fee-for-service environment. Not being able to drive patient care revenue between hospitals can put anesthesiologists in a poor negotiating position. Surgeons can take their patients to another facility, but anesthesiologists don't enjoy that luxury. (This of course does not apply if the anesthesiologist is a pain medicine practitioner with an office practice and admits patients with complex pain syndromes, such as terminal cancer pain. This is also not a factor in a prepaid environment such as Kaiser Permanente.)

I hope I provided useful advice on why you should choose anesthesiology. Ultimately, medicine is satisfying because you get to help others in need, and there are a lot of different ways to accomplish this.

Thank you,

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