Anesthesiology Ask Me Anything

[AnonymousPD]

How do you feel about sub specialization affecting your program and non university positions? Specifically, with respect to call, compensation, daily scheduling? At trauma centers it takes a minimum of 3 radiologist to review trauma studies in a patient. A neuro, chest and body imager. All have to be on call each night. If a post open heart patient is bleeding and returns to the OR later that night, does a subspecialist come in for the case or does the generalist on call get a field promituon to handle a cardiac patient? I personally feel sub specialization diminishes quality of life. Your comments might be useful to residents ruminating over whether to do a fellowship. Thank you for posting on this forum. Not many program directors here.

Angus,

First of all, how with respect to how sub-specialties affect non-university practices in the areas you mentioned, I must defer to the others here who are living that experience every day. They are much more qualified to speak about it than I am.

Discussion of sub-specialization and academic medicine, the call burdens, comp and scheduling models needs to start with which sub-specialty you are talking about. You can imagine the call a chronic pain specialist takes bears no resemblance to the call a cardiac specialist takes. I would say that most sub-specialties outside of pain will obligate you to a regular amount of after-hours work. How much will mostly depend on your surgeons (the amount of work there is) and the size of your group (how the work can be spread around).

At my institution, our compensation model is partially tied to call, with the ability to trade calls to other faculty if you are willing to give up the pay that goes with that night. As a general observation, what you will see is older faculty who are at a different stage in life both financially and physically (being up all night gets tougher unfortunately), are more than happy to give up calls to their younger and hungrier colleagues. But even this has its outliers, I can think of one of our cardiac faculty who is well into practice who takes so many extra shifts that some of us wonder if he might not be the highest paid member of the entire department. In the example you listed, at my institution if a cardiac case comes in, the cardiac on call faculty and resident come in to handle it. However there is some overlap with the generalists with respect to certain thoracic and vascular issues.

To the residents who are considering fellowships and want to weigh quality of life issues, I would tell you to look closely at your own experiences during training. How disruptive did you find being on home call vs. being in-house? Which clinical environments did you enjoy the most? What constitutes a “high quality of life” varies from individual to individual. By that I mean we would all love to be compensated fabulously, work when we want, and do only what we want. But from a practical standpoint, the balance between hours/compensation/autonomy/availability are different for everyone.

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[AnonymousPD]

What do you believe is the appropriate role for CRNAs in the setting of a residency program? Resdients providing breaks for CRNAs? CRNAs providing space for resident lectures? Residents taking all call and staying late? Residents doing advanced cases and procedures or sharing everything? Teaching residents how to manage and medically direct CRNAs? Creating a future resident that's in fact a doc disguised as a CRNA?

When an applicant asks what is a typical PDs view on resident protection?

Modanq,

Okay lots to unpack one question at a time. Forgive me for not being able to quickly figure out how to format the reply so that each question is associated with each response.

As a matter of general principle, I feel that CRNAs at an academic institution exist to support the clinical footprint so that resident training is sufficiently broad and the trainees are able to make properly informed choices with respect their post-residency plans. In other words, if you are grinding out all of the cases, when are you going to have time to do research, participate in QI, go to meetings, study for boards, go to the sim lab, interview for jobs/fellowships, or any of the dozens of other things you do during residency?

No…the CRNAs should be giving breaks. Or preferably faculty should be doing this, as the more time faculty spend with residents the better. I don’t have a problem with residents breaking other residents if its occurring in the context of teamwork and solidarity. So outside of individual situations where you need to break someone out because its the right thing to do, I would work to change a situation where faculty board runners were using residents to break CRNAs as a matter of routine policy.

No, CRNAs should not be providing space for resident lectures. This is the responsibility of the “Sponsoring Institution.” I would refer you to the ACGME common program requirements, section I.D.1.a:
“There must be adequate space and equipment for the educational program, including meeting rooms, classrooms with visual and other educational aids, study areas for residents, office space for faculty members and residents, diagnostic and therapeutic facilities, laboratory facilities, computer support, and appropriate on-call facilities for male and female residents and faculty members.”
I have first-hand knowledge of programs that have successfully used this requirement in negotiations with their hospital administrators in order to secure or update resident facilities. It makes sense…there are a number of benefits to a hospital from having residents there. Beyond just financial for the cynics out there. If hospital administrators can be made to understand that these benefits will go away if they don’t support the educational mission, they can also be made to understand that it will be wise to make the proper investments. A new projector, re-purposing a rarely used conference room, a little furniture…those are rounding errors in a hospital budget.

Taking all the call and staying late? I might ruffle some feathers here, but I feel taking call and staying late to finish cases helps prepare you for life in practice as well as helping you understand what sort of job you should be looking for. Certainly there is a limit to this and I would never say that residents staying till 7pm each and every night or taking all the call is a good thing. You guys need time to study and do all the other things residents have to do in addition to living your lives. I would ask some of the private practice partners here to chime in on this one…how would you feel about a junior associate or potential candidate if they are always wondering about when they are going to get relief and aren't particularly interested in taking a personal interest in making sure the work your group has contracted to provide is done completely and at a high level?

As far as I’m concerned residents should always get priority for advanced cases and procedures. Nothing gets our team here on the phone to site directors and board runners faster than when we hear about a resident who got stuck draining abscesses while a CRNA was doing an open vascular case. The presence of a SRNA program can make this more difficult to accomplish in practice, but their educational experience is not my responsibility.

Managing CRNAs. Yes…this is something I feel all residents need exposure to during training. If you hate it during training…presto, you now know you might be happier finding a job doing solo cases in an MD only practice. Furthermore, I think limiting resident exposure to difficult CRNAs does the trainees a disservice. It has not been my experience that dealing with difficult people stops after graduation. Development of social and emotional intelligence is an aspect of residency that is rarely talked about. We need to make sure you are always supported, treated professionally with respect, and have faculty available to mediate issues. But we don’t think it’s appropriate to alter your schedule because someone might not like you or you might not like them.

Creating residents who act like CRNAs. Sadly, I think this one is mainly up to the residents. Are you going to going to cause a stink about relief every time you’re still in a case at 3pm? Are you going to study and learn why we do things or settle for just knowing the how? Are you going to find a way to add value to an organization other than just engaging in scheduled clinical activity? As programs we can only do so much. Some of us have more resources and better facilities than others, that’s for sure. And programs can do things like shifting resident supervision to the group of faculty that are the best role models. But ultimately it is up to the trainee himself to decide what kind of doctor he wants to be.

I would ask you to elaborate on what you mean by protection. That can refer to a lot of different things, and different problems require different solutions.

 

[Modanq]

Modanq,

Okay lots to unpack one question at a time. Forgive me for not being able to quickly figure out how to format the reply so that each question is associated with each response.

As a matter of general principle, I feel that CRNAs at an academic institution exist to support the clinical footprint so that resident training is sufficiently broad and the trainees are able to make properly informed choices with respect their post-residency plans. In other words, if you are grinding out all of the cases, when are you going to have time to do research, participate in QI, go to meetings, study for boards, go to the sim lab, interview for jobs/fellowships, or any of the dozens of other things you do during residency?

No…the CRNAs should be giving breaks. Or preferably faculty should be doing this, as the more time faculty spend with residents the better. I don’t have a problem with residents breaking other residents if its occurring in the context of teamwork and solidarity. So outside of individual situations where you need to break someone out because its the right thing to do, I would work to change a situation where faculty board runners were using residents to break CRNAs as a matter of routine policy.

No, CRNAs should not be providing space for resident lectures. This is the responsibility of the “Sponsoring Institution.” I would refer you to the ACGME common program requirements, section I.D.1.a:
“There must be adequate space and equipment for the educational program, including meeting rooms, classrooms with visual and other educational aids, study areas for residents, office space for faculty members and residents, diagnostic and therapeutic facilities, laboratory facilities, computer support, and appropriate on-call facilities for male and female residents and faculty members.”
I have first-hand knowledge of programs that have successful used this requirement in negotiations with their hospital administrators in order to secure or update resident facilities. It makes sense…there are a number of benefits to a hospital from having residents there. Beyond just financial for the cynics out there. If hospital administrators can be made to understand that these benefits will go away if they don’t support the educational mission, they can also be made to understand that it will be wise to make the proper investments. A new projector, re-purposing a rarely used conference room, a little furniture…those are rounding errors in a hospital budget.

Taking all the call and staying late? I’m might ruffle some feathers out there, but I feel taking call and staying late to finish cases helps prepare you for life in practice as well as helping you understand what sort of job you should be looking for. Certainly there is a limit to this and I would never say that residents staying till 7pm each and every night is a good thing. You guys need time to study and do all the other things residents have to do in addition to living your lives. But I would ask some of the private practice partners here to chime in on this one…how would you feel about a junior associate or potential candidate if they are always wondering about when they are going to get relief and aren't particularly interested in investing themselves into the work your group has contracted to provide.

As far as I’m concerned residents should always get priority for advanced cases and procedures. Nothing gets our team here on the phone to site directors and board runners faster than when we hear about a resident who got stuck draining abscesses while a CRNA was doing an open vascular case. The presence of a SRNA program can make this more difficult to accomplish in practice, but their educational experience is not my responsibility.

Managing CRNAs. Yes…this is something I feel all residents need exposure to during training. If you hate it during training…presto, you now know you might be happier finding a job doing solo cases in an MD only practice. Furthermore, I think limiting resident exposure to difficult CRNAs does the trainees a disservice. It has not been my experience that dealing with difficult people stops after graduation. Development of social and emotional intelligence is an aspect of residency that is rarely talked about. We need to make sure you are always supported, treated with respect and professionalism, and have faculty available to mediate any issues. But we don’t think it’s appropriate to alter your schedule because someone might not like you or you might not like them.

Creating residents who act like CRNAs. Sadly, I think this one is mainly up to the residents. Are you going to going to cause a stink about relief every time you’re still in a case at 3pm? Are you going to study and learn why we do things or settle for just knowing the how? Are you going to find a way to add value to an organization other than just engaging in scheduled clinical activity? As programs we can only do so much. Some of us have more resources and better facilities than others, that’s for sure. And programs can do things like shifting resident supervision to the group of faculty that are the best role models. But ultimately it is up to the trainee himself to decide what kind of doctor he wants to be.

I would ask you to elaborate on what you mean by protection. That can refer to a lot of different things, and different problems require different solutions.

Excellent response.

 

[Leinie]

One example of this are the “We are going to rank you to match” letters that are going around now. I would advise anyone who is cancelling an interview at a program of interest because you have a few of these in hand to strongly reconsider doing so.

I received one of these letters nearly two decades ago. I did not match at the program that sent it to me. I would heed this advice.

Leinie

 

[Clockdoc89]

Thank you for doing this!

How bad is it if I did well on step 1 (high 240s) but didn't honor a rotation? Assuming step 2 is on par or a bit higher would I still be competitive for top programs? Not really involved in extra curriculars or research either.

 

[Angus Avagadro]

I received one of these letters nearly two decades ago. I did not match at the program that sent it to me. I would heed this advice.

Leinie

I have tried to make this point several times to a few "deniers" on SDN. I have heard the identical story many times from students.

 

[AnonymousPD]

Thank you for doing this!

How bad is it if I did well on step 1 (high 240s) but didn't honor a rotation? Assuming step 2 is on par or a bit higher would I still be competitive for top programs? Not really involved in extra curriculars or research either.

Clockdoc,

How is your application affected given that you didn’t honor any classes? It depends on your school and how they have decided to distribute their grades. While some medical schools are still somewhat traditional and award Honors to the top 10% of a class, many are far less exacting. There’s an application on my desk right now where the school gave Honors to somewhere between 60% and 75% of the entire class for every rotation. Being outside the top 10% on all rotations is one thing, being inside the bottom 33% on all rotations is something different. Good MSPE’s (Dean’s letters) can help flesh out your medical school experience and give us some context outside of raw numbers.

As for your USMLE scores, the 2019 update we received told us that the mean and (SD) last year was 230 (19) for Step 1 and 242 (17) for Step 2. Assuming you go 245/245 you would be at the 76th percentile on Step 1 and 54th percentile on Step 2. This is very different from 15 years ago when the mean scores were about 220. Back then, 245s meant you were in the 90th percentile. I doubt there are any programs today that would feel scores in the high 240s are concerning in any way, but at top programs you can expect to be competing with hundreds of applicants with higher scores. So even though you might not have a ton of activities or research, the rest of your application is going to be important.

There was an earlier question about program side logistics of this process. Here’s a peek behind our curtain now that we’re finished with interviews. We received about 1500 applications this year. Because it is not possible to review all 1500, even with PD/APDs and several experienced faculty members helping, we must apply various filters. Steps 1 and 2 are two of these. We set things up in a way that results in us hand reviewing about 500 applications, which includes high potential applicants that we are made aware of that would have otherwise been screened out. This takes time and is the reason interview offers can be delayed. It takes me between 20-30 minutes to thoughtfully review a file the first time. Applicant files are reviewed by at least 2 members of the team and I think we invited a little more than 300 candidates to visit with close to 250 making the trip this season.

I can’t speak for anyone else out there, but for us this is pretty much all the scores are good for. To help sort a mass of applications into a pile of 500 that our finite human resources can give their full attention to. After interviews there are multiple stages of review and the rough rank list is refined into the finished one. During this process, large differences in Step scores might cause an application to move up or down a little, but the effect here is much smaller than what I think most would predict. An application with 255/265 will often only be 5 spots above a similar application with 220/235. I can state unequivocally that I’ve never seen us rank anyone at 120 that would have moved into the top 25 with better scores.

Think about it this way. Your extra curriculars, research, personal statement, hobbies, all of that...those are the tools you have to tell us who you are. If your scores and grades are the totality of your application, then okay that's all we'll use. In a sense, your test scores are only as important as you choose to make them. The back half of our rank list is littered with shiny 250s because those applicants couldn’t demonstrate being good at anything other than taking a test. Last week we interviewed someone who went 250s/250s and we are not going to rank them at all. I won't deny USMLE scores are a necessary part of everyone's application process. But they are less important than taking outstanding care of patients, your grades, being teachable, routinely prioritizing the needs of others, the ability to give maximal effort at all times, and being someone that makes positive contributions to their workplace/coworkers/specialty. It’s likely you’ve made a habit of doing many of those things. But unlike standardized test results, those are things we won't know unless you tell us.

 

[AnonymousPD]

My school has told us to interview at 10 programs to be safe. They also say 50% of students match their number 1 program, while 75% match at their top 3 programs.

I am curious as to how those numbers look for the programs' side of the rank list. How many residents do you take each year? How many applicants do you interview each year? And how far down your rank list do you go to fill your program on an average year?

Feel free to use round numbers for anonymity purposes. I'm just curious what the general trend looks like for programs.

Dantrolene,

These are questions I get a lot this time of year, so this might be a good place to answer broadly. I hope this brings you some peace of mind. The NRMP annually publishes a results and data report. Table 17 shows anesthesiology programs fill their categorical spots at a ratio of about 7.5 per spot. A program with 10 categorical spots will on average go about 75 deep. What NRMP doesn’t tell you, but tells us (and medical school deans), is that about 25% of programs will fill at 4.5/spot or lower and 25% of programs will fill at 10.0/spot or higher. It would be easy to assume that the higher quality a program is, the shallower they will fill. But that’s not exactly true. This average does not consider program size and isn’t intended to be a metric for program quality.

Program size. If you are a PD and want to fill quickly, it is easier to do this if you have a small program. Let’s say you have 4 categorical spots (25% of programs have 4 or fewer C positions). It wouldn’t be that hard in an interview season to put all the candidates with strong family ties to the area at the top of your list, fill at 12, and have an average of 3.0. You simply can’t do this if you have 25 spots to fill. Not only because you might not have that many candidates geographically tied to you, but programs that size are generally located in areas with other nearby programs and face more competition.

We all compete. All programs must compete similarly for their candidates. A great med student will likely be ranked to match at every program they interviewed at, but they are only going to one place for training. The best programs will all be interviewing out of the same pool of 300-400 applicants. And while there’s overlap, less selective programs have their own pool as well. When lists are submitted, programs of similar quality are all going to be fighting each other for the same students. Why do you think some programs call you or send emails saying how much they love you? It’s the same reason you send us notes saying “I’m ranking you #1." Anyone in this year's cycle, please listen to me. Programs go deeper than you think they do, even top ones.

Think about it like high school football players. If a Division 1, 5-star recruit has a choice between going to Clemson or Wagner College, of course they’re going to the powerhouse every time. But the reality is that recruit is choosing between Clemson, Alabama, Ohio State, LSU, Georgia, and every other top 25 football juggernaut. It’s the same for residency applicants. Alabama doesn’t fill their 25-member recruiting class out of their 50 favorite targets, and neither will your favorite anesthesia program. The Match prioritizes the choices of the applicants over the choices of the programs.

One final thing. There are roughly 1700 anesthesia residents per year. While the Doximity list is worthy of discussion another time, the top 50 on that list have half of all the residency positions. So, even if you think you’re just a middle of the pack applicant, you are likely going to match at a place everyone’s heard of. I know it’s a long 6 weeks till match day, but if you don’t do anything silly with your rank list (please ignore those rank to match emails and calls), you are in much better shape than you think.

 

[anbuitachi]

Hello everyone,
And on that note...let me know if there is anything I can help with.

Some questions. As PD, how much power do you have to change things, and what are some things thats beyond your ability to change that many residents often think you could? Do you feel like you are pressured by department chair, hospital admin to do xyz even though it may not be beneficial to residents at all?

Also, knowing that working at tail end of 24 hour shifts is equivalent to being working while intoxicated, do you let your residents do this? And since frequent night shifts (3 or more per MONTH) is shown to increase risk of stroke, cancer, CV disease, psychiatric disorders, and others, do you assign residents night shifts, and if so where do you draw the line on how many per month and how do you make this decision? As far as i know, working night shifts on anesth is not an ACGME requirement to graduate, and many jobs after graduation offer no calls. (this also relates to above question, is it one of the things you have control over? just deciding that residents will no longer take night calls? or is this decision above you?)

 

[nimbus]

And since frequent night shifts (3 or more per MONTH) is shown to increase risk of stroke, cancer, CV disease, psychiatric disorders, and others, do you assign residents night shifts

This is overblown. The average 27yo ASA 1 resident is not at increased risk for any of those things. I’d love to see a longitudinal study of their health. It is more relevant to a population of 50 year olds working the night shift in an Amazon warehouse or a Chinese factory.

 

[Dantrolene FC]

Dantrolene,

These are questions I get a lot this time of year, so this might be a good place to answer broadly. I hope this brings you some peace of mind. The NRMP annually publishes a results and data report. Table 17 shows anesthesiology programs fill their categorical spots at a ratio of about 7.5 per spot. A program with 10 categorical spots will on average go about 75 deep. What NRMP doesn’t tell you, but tells us (and medical school deans), is that about 25% of programs will fill at 4.5/spot or lower and 25% of programs will fill at 10.0/spot or higher. It would be easy to assume that the higher quality a program is, the shallower they will fill. But that’s not exactly true. This average does not consider program size and isn’t intended to be a metric for program quality.

Program size. If you are a PD and want to fill quickly, it is easier to do this if you have a small program. Let’s say you have 4 categorical spots (25% of programs have 4 or fewer C positions). It wouldn’t be that hard in an interview season to put all the candidates with strong family ties to the area at the top of your list, fill at 12, and have an average of 3.0. You simply can’t do this if you have 25 spots to fill. Not only because you might not have that many candidates geographically tied to you, but programs that size are generally located in areas with other nearby programs and face more competition.

We all compete. All programs must compete similarly for their candidates. A great med student will likely be ranked to match at every program they interviewed at, but they are only going to one place for training. The best programs will all be interviewing out of the same pool of 300-400 applicants. And while there’s overlap, less selective programs have their own pool as well. When lists are submitted, programs of similar quality are all going to be fighting each other for the same students. Why do you think some programs call you or send emails saying how much they love you? It’s the same reason you send us notes saying “I’m ranking you #1." Anyone in this year's cycle, please listen to me. Programs go deeper than you think they do, even top ones.

Think about it like high school football players. If a Division 1, 5-star recruit has a choice between going to Clemson or Wagner College, of course they’re going to the powerhouse every time. But the reality is that recruit is choosing between Clemson, Alabama, Ohio State, LSU, Georgia, and every other top 25 football juggernaut. It’s the same for residency applicants. Alabama doesn’t fill their 25-member recruiting class out of their 50 favorite targets, and neither will your favorite anesthesia program.

One final thing. There are roughly 1700 anesthesia residents per year. While the Doximity list is worthy of discussion another time, the top 50 on that list have half of all the residency positions. So, even if you think you’re just a middle of the pack applicant, you are likely going to match at a place everyone’s heard of. I know it’s a long 6 weeks till match day, but if you don’t do anything silly with your rank list (please ignore those rank to match emails and calls), you are in much better shape than you think.

Thanks for the awesome response, as usual. Although I don’t know which program you’re from, I’d be so happy to match into your program since you seem like such an awesome PD on this forum, plus you like college football

 

[anbuitachi]

This is overblown. The average 27yo ASA 1 resident is not at increased risk for any of those things. I’d love to see a longitudinal study of their health. It is more relevant to a population of 50 year olds working the night shift in an Amazon warehouse or a Chinese factory.

why is it overblown? studies have shown that cigaraette smoking is bad for health , even as short as 1 year, and even if you stop, it never goes back to baseline. i dont see why you can say its overblown without data to back it up. while i would agree if you said the data may not be the most robust, id still think its does more harm than good on your health.

Also in 2015, one of the best studies to date on night time shift work was published consisting of 75000 (after exclusions) nurses in a prospective cohort study with a follow up time of 22 years. Many of the nurses started working nights in their 20s. Their definition for night shift nurses were greater than or equal to 3 night shifts per month. Their conclusion was "All-cause and CVD mortality were significantly increased among women with ≥5 years of rotating night shift work, compared to women who never worked night shifts. Specifically, for women with 6–14 and ≥15 years of rotating night shift work, the HRs were 1.11 (95% CI=1.06, 1.17) and 1.11 (95% CI=1.05, 1.18) for all-cause mortality and 1.19 (95% CI=1.07, 1.33) and 1.23 (95% CI=1.09, 1.38) for CVD mortality "

I highly doubt the numbers would look better in DOCTORS...

And a large # of residents may not be ASA1s like you think

but even that isn't the point. i was just wondering how PDs think and make their decisions

 

[Angus Avagadro]

This is overblown. The average 27yo ASA 1 resident is not at increased risk for any of those things. I’d love to see a longitudinal study of their health. It is more relevant to a population of 50 year olds working the night shift in an Amazon warehouse or a Chinese factory.

I agree. Night call brings experience and confidence you dont learn during the day. Learning to work when tired or not feeling well is important. When tired or stressed, you fall back on your training. If your training is spotty, .....well.. the hospital wont close 3 ORs just because you have a cold. If you are in CCU with an MI, someone gets pulled off vacation or locums is hired. So you get to work fatigued and when you are not 100% with some regularity . Its not"ideal", but we dont live in an ideal world.
The data is interesting, but not surprising. Working nights is stressful to your system. An occupational hazard IMO.

BTW, I have had most of the CV issues listed as risk, all before the age of 50. With total cholesteral of less than 170, never smoked family history of longevity into their 90s., athletic, etc. So I'm quite aware of the stresses of long shifts and would support limits on hours. The only problem is that patients get sick and need us 24-7.

 

[D P356]

BTW, I have had most of the CV issues listed as risk, all before the age of 50. With total cholesteral of less than 170, never smoked family history of longevity into their 90s., ATHLETIC, etc.

are we talking subjectively? athleticism and cardiovascular fitness are not automatically synonymous. That term gets used rather loosely.
Overnight call can be tiring. Having post-call off can help you get rested up...until your little kids get into your room and pounce on you while you’re sleeping in your bed.
Trace Adkins’ song “you’re going to miss this” occasionally plays in my head, so I try not to get too irritated when my kids do that.

 

[anbuitachi]

I agree. Night call brings experience and confidence you dont learn during the day. Learning to work when tired or not feeling well is important. When tired or stressed, you fall back on your training. If your training is spotty, .....well.. the hospital wont close 3 ORs just because you have a cold. If you are in CCU with an MI, someone gets pulled off vacation or locums is hired. So you get to work fatigued and when you are not 100% with some regularity . Its not"ideal", but we dont live in an ideal world.
The data is interesting, but not surprising. Working nights is stressful to your system. An occupational hazard IMO.

BTW, I have had most of the CV issues listed as risk, all before the age of 50. With total cholesteral of less than 170, never smoked family history of longevity into their 90s., athletic, etc. So I'm quite aware of the stresses of long shifts and would support limits on hours. The only problem is that patients get sick and need us 24-7.

I dont want to derail the thread. I wanted to know what his opinion is in face of these evidence. I am not saying he should remove all night calls. I wanted to know how they determine whether to keep it or not, and also how they determine # of calls overnight with these evidence in mind etc

Also actually you really shouldnt be working if you are sick... (i know this is obviously not the case in real life in most places), but i believe studies have shown (correct me if im wrong), that you do more harm than good by coming to work sick, and most of the perceived need to be at work b/c your patients need you is overblown and mostly very subjective

Also the study excluded anyone with CV issues, so you wouldnt even have qualified for the study if it were to be done on doctors.


Also that's another question that can be asked, what is your opinion on residents who take sick time off when sick vs those who come in while sick? do you view the latter more positively?

 

[nimbus]

why is it overblown? studies have shown that cigaraette smoking is bad for health , even as short as 1 year, and even if you stop, it never goes back to baseline. i dont see why you can say its overblown without data to back it up. while i would agree if you said the data may not be the most robust, id still think its does more harm than good on your health.

Also in 2015, one of the best studies to date on night time shift work was published consisting of 75000 (after exclusions) nurses in a prospective cohort study with a follow up time of 22 years. Many of the nurses started working nights in their 20s. Their definition for night shift nurses were greater than or equal to 3 night shifts per month. Their conclusion was "All-cause and CVD mortality were significantly increased among women with ≥5 years of rotating night shift work, compared to women who never worked night shifts. Specifically, for women with 6–14 and ≥15 years of rotating night shift work, the HRs were 1.11 (95% CI=1.06, 1.17) and 1.11 (95% CI=1.05, 1.18) for all-cause mortality and 1.19 (95% CI=1.07, 1.33) and 1.23 (95% CI=1.09, 1.38) for CVD mortality "

I highly doubt the numbers would look better in DOCTORS...

And a large # of residents may not be ASA1s like you think

but even that isn't the point. i was just wondering how PDs think and make their decisions

I understand your point and agree night time work should be minimized when possible. However we don’t live in an ideal world and all kinds of things happen at night. It’s no secret that doctors sometimes have to work at night. So do policemen, pilots, factory workers and truckers. There are also plenty of jobs that don’t require working in the middle of the night including many in medicine. Anesthesia is not one of those jobs.

 

[deleted697127]

This is overblown. The average 27yo ASA 1 resident is not at increased risk for any of those things. I’d love to see a longitudinal study of their health. It is more relevant to a population of 50 year olds working the night shift in an Amazon warehouse or a Chinese factory.

Call let’s me surf and ski while everyone else is working. I guess not all calls are created equal but people used to fight for calls for the extra money, lighter schedule, interesting cases at night, post call days, and shorter week in residency. Even better now as an attending cause I get to sleep even more, have disposable income, and have the option of working post call if i want extra income.

I bet there’s also a correlation of people unhappy with their job and all those things you mentioned. If you’re not happy, find a new set up where you can thrive.

 

[nimbus]

Call let’s me surf and ski while everyone else is working. I guess not all calls are created equal but people used to fight for calls for the extra money, lighter schedule, interesting cases at night, post call days, and shorter week in residency. Even better now as an attending cause I get to sleep even more, have disposable income, and have the option of working post call if i want extra income.

I bet there’s also a correlation of people unhappy with their job and all those things you mentioned. If you’re not happy, find a new set up where you can thrive.

Agree. Night call is picked off within minutes when it is offered up in my practice too.

 

[anbuitachi]

I understand your point and agree night time work should be minimized when possible. However we don’t live in an ideal world and all kinds of things happen at night. It’s no secret that doctors sometimes have to work at night. So do policemen, pilots, factory workers and truckers. There are also plenty of jobs that don’t require working in the middle of the night including many in medicine. Anesthesia is not one of those jobs.

Yea and im wondering how as PD he is making these decisions. We all know some programs have way more night call than others.

 

[Angus Avagadro]

are we talking subjectively? athleticism and cardiovascular fitness are not automatically synonymous. That term gets used rather loosely.
Overnight call can be tiring. Having post-call off can help you get rested up...until your little kids get into your room and pounce on you while you’re sleeping in your bed.
Trace Adkins’ song “you’re going to miss this” occasionally plays in my head, so I try not to get too irritated when my kids do that.

Lol. My kids did the same! My wife has video of my toddlers straddling my chest and abdomen after a difficult call. They would bounce up and down, wake me, then sit still till I fell back to sleep, rinse and repeat. They thought it was hilarious and in retrospect it was! As far as fit, have belonged and frequented gyms for 30 yrs, played football with the residents, played basketball in a fat Dr league into my mid 40s, so fit is a relative term for sure. I wasnt sedentary and bmi well below 30. But that's life and I wouldn't change anything.

I dont want to derail the thread. I wanted to know what his opinion is in face of these evidence. I am not saying he should remove all night calls. I wanted to know how they determine whether to keep it or not, and also how they determine # of calls overnight with these evidence in mind etc

Also actually you really shouldnt be working if you are sick... (i know this is obviously not the case in real life in most places), but i believe studies have shown (correct me if im wrong), that you do more harm than good by coming to work sick, and most of the perceived need to be at work b/c your patients need you is overblown and mostly very subjective

Also the study excluded anyone with CV issues, so you wouldnt even have qualified for the study if it were to be done on doctors.


Also that's another question that can be asked, what is your opinion on residents who take sick time off when sick vs those who come in while sick? do you view the latter more positively?

2 points. In private practice, there is often not enough flexibility to cover rooms if someone calls in sick. That means the call guy stays over to cover if someone cant come it. Often till noon or later. The hospital wont reschedule rooms or.cases due to anesthesia staffing problems. One of.the problems with exclusive contracts.
With respect to resident using sick days? Cold, come in. Obviously avoid immunocomprimised patients. Fever, vomiting, diarrhea,( cant sit in a room with the runs), stay home. My Chief would insist we come in and he examined you if you called in sick. Most just came in.

 

[anbuitachi]

Lol. My kids did the same! My wife has video of my toddlers straddling my chest and abdomen after a difficult call. They would bounce up and down, wake me, then sit still till I fell back to sleep, rinse and repeat. They thought it was hilarious and in retrospect it was! As far as fit, have belonged and frequented gyms for 30 yrs, played football with the residents, played basketball in a fat Dr league into my mid 40s, so fit is a relative term for sure. I wasnt sedentary and bmi well below 30. But that's life and I wouldn't change anything.

2 points. In private practice, there is often not enough flexibility to cover rooms if someone calls in sick. That means the call guy stays over to cover if someone cant come it. Often till noon or later. The hospital wont reschedule rooms or.cases due to anesthesia staffing problems. One of.the problems with exclusive contracts.
With respect to resident using sick days? Cold, come in. Obviously avoid immunocomprimised patients. Fever, vomiting, diarrhea,( cant sit in a room with the runs), stay home. My Chief would insist we come in and he examined you if you called in sick. Most just came in.

wow what a chief! first time hearing that one

 

[Angus Avagadro]

wow what a chief! first time hearing that one

Oh, he was a gem

 

[watermelon master]

We all compete. All programs must compete similarly for their candidates. A great med student will likely be ranked to match at every program they interviewed at, but they are only going to one place for training. The best programs will all be interviewing out of the same pool of 300-400 applicants. And while there’s overlap, less selective programs have their own pool as well. When lists are submitted, programs of similar quality are all going to be fighting each other for the same students. Why do you think some programs call you or send emails saying how much they love you? It’s the same reason you send us notes saying “I’m ranking you #1." Anyone in this year's cycle, please listen to me. Programs go deeper than you think they do, even top ones.

1. Do you call or email your applicants to say how much you love them, if so or if not, why?
2. Do applicants who send you #1 letters change the way you rank them?
3. Do applicants who send you "I will rank you highly (you're clearly not my #1)" letters change the way you rank them?

Thanks!

 

[Drangue]

This is overblown. The average 27yo ASA 1 resident is not at increased risk for any of those things. I’d love to see a longitudinal study of their health. It is more relevant to a population of 50 year olds working the night shift in an Amazon warehouse or a Chinese factory.

I love working on call. I think i'm happier on call. It's actually a lot of fun if you know the other department residents and have an awesome senior.

 

[AnonymousPD]

Some questions. As PD, how much power do you have to change things, and what are some things thats beyond your ability to change that many residents often think you could? Do you feel like you are pressured by department chair, hospital admin to do xyz even though it may not be beneficial to residents at all?

Also, knowing that working at tail end of 24 hour shifts is equivalent to being working while intoxicated, do you let your residents do this? And since frequent night shifts (3 or more per MONTH) is shown to increase risk of stroke, cancer, CV disease, psychiatric disorders, and others, do you assign residents night shifts, and if so where do you draw the line on how many per month and how do you make this decision? As far as i know, working night shifts on anesth is not an ACGME requirement to graduate, and many jobs after graduation offer no calls. (this also relates to above question, is it one of the things you have control over? just deciding that residents will no longer take night calls? or is this decision above you?)

Anbuitachi,

Thanks for the simple questions with straightforward answers! So much for contributing to the substance abuse thread going on.

Within the rules of the ACGME and institutional policies, theoretically a PD and their administrative team has wide latitude to determine how they want to run their program. But I don’t think it comes as a surprise to anyone when I say on a practical basis, the number of things a team can unilaterally change is essentially zero…aside from picking out the pens they want the office to order. Our most miserable administrative failures have come from trying to implement changes without early involvement from the parties impacted.

The reality is that every program operates within boundaries set by several factors. The priorities of the Dean and Chair, financial resources, surgical productivity, physical layout of the campus itself, and so on. What one program can do easily might be impossible for another. For example, we have zero worries about case numbers, so we can move our residents around in ways that programs that must outsource their residents for cases can only dream about. Or this year, I heard candidates talking about a program that sends their residents on a ski trip every year, while we settle for buying books and providing a healthy education and meeting fund. When residents wonder why we can’t do things other programs can, its usually because they don’t understand this concept of programs having unique operating constraints.

Do we get asked to do things that don’t make a lot of sense or help the residents? Sure, but thankfully for us I wouldn’t say it happens commonly. Normally it’s part of a longer-term strategic goal from the higher ups. But that’s part of why a PD and their team exists, to advocate on behalf of the educational mission within the larger swirl of running a giant business. Especially during times when the needs of the residency oppose the needs of the operational mission. These non-educational mandates aren’t always terrible though. There have been times when accommodating an institutional ask has gotten us the final pieces of support needed to accomplish larger projects.

Amount of overnight work. This is one thing our team has changed over the last decade. Our residents continue to do a small amount of Q4-24H and have what we feel is an appropriate amount of Q4 overnight duty. I agree with the posters who feel that there are clinical experiences that occur and skills that develop overnight that you cannot duplicate during daytime hours. While you are correct that there are jobs without overnight commitments, there are many that do. We owe it to our residents to give them a realistic idea of what this means. It’s not dissimilar from our duty to insure they also have a realistic idea of what chronic pain management or pediatric anesthesia are like, even though most jobs do not require those skill-sets either.

With respect to the long-term health issues associated with overnight work, that was not part of our calculus in determining our number of overnight hours. Instead our process is more about looking at everything that we have available to us, and deciding what we think is the best mixture of experiences we can offer to the trainees that will best prepare them for the future. We're lucky to have a very rich environment that we wouldn't be able to take full advantage of by rotating through overnight locations again and again. How we would have handled this issue in a clinically simpler environment where residents would rotate more frequently through sites with overnight needs would be different.

If I understand correctly, your study showed the risks increase after being exposed to 3 or more night shifts every month after more than 5 years. Does doing 6 in one month, going back to a normal schedule, and doing another 6 seven months later count the same? I'm not sure the resident experience is the same as those nurses. Who knows, maybe doing 6 a month a few times a year is even worse. But the good news with wellness now being a top of the ticket item, there is a lot of research being done and I am confident that most programs will take the findings into account when they are published. Just look at trend in reducing 24 hour duty after we learned its equivalent to being intoxicated.

Unfortunately, there are already burnout and stress related health risks just by being a physician. There are health risks in many jobs. What we can do is make sure our trainees make use of their sick time, PTO, and all the other department/institutional wellness resources available to make their training is equally effective and more humane than mine was. But until patients stop getting sick in the middle of the night, the right thing to do is make sure there are residents there to take care of them.

 

[AnonymousPD]

Also that's another question that can be asked, what is your opinion on residents who take sick time off when sick vs those who come in while sick? do you view the latter more positively?

In this context, viewing a resident positively or negatively is more a matter of expecting residents to demonstrate a commitment to their patients, their fellow residents, and the organization. Residents who sign out when they are closing skin, leave work that their fellow residents have to finish for them, or are always asking their classmates to change their schedules to accommodate their life events without reciprocating themselves are the same ones who call in sick the day before a 3 day weekend and use PTO days to go to fishing.

Propagating an environment where calling in sick = weakness will unfairly stigmatize good residents with legitimate illnesses and puts patients at unnecessary risk. You can spot residents who work the system without hurting the ones that don't. Residents who are going to take advantage of the sick time policy are going to try and take advantage in other ways as well. If you are using your sick policy as a measurement for professionalism, I would tell you there are better places to look.

Rarely will this rise the the level requiring actions by the clinical competence committee. But it definitely affects what I'm going to say when a practice calls me up and asks which of the graduates they need to actively recruit.

Addendum:

A conversation this morning reminded me of an example perfect for this discussion. 6 or 7 years ago we had two residents who tragically lost first degree family members to accidents. Both guys ended up taking the same amount of time away. One of them called us after a few days to tell us he was planning to come back after the weekend because he didn't want his classmates to have to cover his shifts and for us to have to rearrange coverage. Our reply was, "Uh no. And one more word about the inconvenience to us will result in a call to security to shut off your badge access for another week."

The other, they day before he was scheduled to come back called us. Following is a dramatic re-creation of the conversation:

"Things are tough here, I'm going to need to take more time off"

"Okay...take all the time you need, do you know how long you're going to need?"

"No...its complicated, but I'll let you know when I know more."

"That's fine...take care of everything, family comes first. But it's my job to tell you that since you've taken all your vacation, PTO time, and been out sick a few times, you've reached the max limit the ABA allows away from training. Any additional time you take will require us to extend your training into July. This won't be a problem since you've picked a start date in the middle of August for your job and we can just give you short days in the main OR helping the fresh CA1s."

He showed up to work on Monday.

 

[AnonymousPD]

1. Do you call or email your applicants to say how much you love them, if so or if not, why?
2. Do applicants who send you #1 letters change the way you rank them?
3. Do applicants who send you "I will rank you highly (you're clearly not my #1)" letters change the way you rank them?

Thanks!

Master of Melons,

1. Without saying what my Chair may do on his own or request that I do, I will say that I feel these letters are unnecessary and affects the entire process negatively. I can remember getting a letter that said I was an excellent candidate while my friend got one that said they were outstanding, we sat around wondering who they liked more and what that meant. I know without a doubt this happens today. And I highly suspect that students who feel they aren't in the "favorite" group will often feel worse about a program and may unwisely move a program lower on their list for a poor reason. And we all know these letters will cause other candidates to make decisions that lead to them not matching at all. I don't think they work and all they do to students is cause a lot stress and confusion.

2. No. But this is mostly because of how I feel about the whole love letter process. Knowing that other members of our recruitment team enjoy getting them and from casual conversation with other PDs, I would tell you that a sincerely written note to your favorite program can't hurt you. But at best, the difference it will make is really small. If there was a bad interview experience, a Shakespearean sonnet isn't going to fix that. And if you had a great interview, we don't need a note from you to confirm our warm fuzzies.

3. No. Being bothered by not being a student's absolute favorite program is silly. But that's just me. People are people and maybe there are thin skinned PD's out there that this matters to. But I don't know anyone who cares that much about it, we all know you have lots of amazing programs to pick from. This is why there are NRMP rules, we can't ask you and you don't need to tell us. This is a process where the students have the majority of control, and you are worried about us thinking worse of you because you only like us, but not super-duper like us?

Now to be serious.

I suppose a person's stance on items 2 and 3 could potentially change if pressures that exist make a program want to fill as high as possible. That can lead to moving fantastic candidates lower because they're from the other side of the country without local ties or are unlikely to match because they are couples matching with a spouse who might not be competitive for their specialty. We have found that sort of thinking to be wrong because there are all sorts of things candidates value that are very personal to them that they will never tell you during recruitment which makes it impossible to predict what someone will do. I wish I could tell you the stories some of my favorite residents have told me about why they really came here.

So my advice to med students who now have to endure the agonizing wait till match day is this:

1. Disregard all communication from programs when making your rank list. None of the reasons programs do this are intended to help you the candidate. Go to the place where you will be happy and will give you the training you need to have the career you want. You are going to be treated the same and get the same training at your program no matter if you were #2, #79, or #201 on the list.

2. Talk to your family, be honest with what's important to you, think about your future goals and after carefully considering all the places you visited, rank your favorite #1. Do the same thing with your remaining places and rank that #2. Repeat until you no longer have places you prefer to scrambling in the SOAP.

3. Once you certify your rank list, find the person you trust the most in the world and have them change your password. Tell them they can only give you access back if you can convince them there has been some change that has truly altered your priorities. Go outside, take a trip, read a book for pleasure and above all else, enjoy the rest of your senior year.

 

[Drwine]

It only took about 5 minutes of research on this forum to notice that the most common questions asked all involve assessing a medical student's potential for residency based on just a few objective measures like USMLE/COMLEX scores or class rank. It looks like there are many posts already dedicated to answering some version of this question, so it may be helpful if you provide a little more detail or context to your situation if you haven't gotten an answer to your question. My own feelings about this are accurately reflected in aggregate by a number of posts so while I'm happy to clarify my own feelings about this, I wish I had a more satisfactory answer for you. But the honest answer to your question is "it depends."

The job of a resident physician is extraordinarily complex, and the ability to discharge those duties at a high level involves skills like raw retention of raw knowledge, cognitive agility, physical dexterity, and social/emotional intelligence. And within the specialty itself, the skills you need to excel in different domains differ. Being great in the OR requires different skills from being great in the pain clinic, or great in the ICU. I can assure you all that of the hundreds of PDs and APDs out there, I have met exactly zero who feel that the quality of a resident's experience during training is predictable by exams.

About about USMLE Step 1. Past threads show that many posters have correctly cited NRMP data which breaks down the percentages of candidates who have successfully matched based on their Step 1 scores. As all of you already know, candidates with sub 200 scores successfully find positions. If you pass Step 1 and successfully graduate medical school, you will more than likely be competitive...somewhere. You have the potential to get into college with virtually any SAT score, just like you have the potential to get into residency with any passing Step 1 score. But I don't think I'm going surprise anyone by qualifying this by saying programs with the ability to be more selective with their candidates will likely set higher testing thresholds than programs without the same ability to be as selective. But even if you change your question to "What is a competitive Step 1 score at Program X", you might be able to compile a range of recent match statistics, but the answer is always going to be "It depends" because scores are only a minor part of how candidates are evaluated. Every single program I am familiar with has story after story of how some of their best residents came in with lower than average board scores.

It's been said before and bears repeating again, because those exams are the only benchmark common to all student across all institutions, the scores exist as a something programs can use to differentiate between candidates with similar applications. But by no means should they be seen as a measure of your potential to provide outstanding patient care or contribute to the specialty. Wondering what Step 1 score you need to be an anesthesia resident same as asking a college football coach "How fast do you need to run to be a quarterback?" Its just one metric that contributes in a small way to a person's ability to perform an very complex task.

Just curious what your thoughts are of adding a nonacademic test on real world skills such as the CASPer test would aid in selecting residents that ultimately are successful?

Taking the Casper assessment

Casper and Duet give applicants opportunities to showcase their unique personal and professional strengths, providing programs with insights into your key personal and professional characteristics.

takecasper.com

 

[AnonymousPD]

Just curious what your thoughts are of adding a nonacademic test on real world skills such as the CASPer test would aid in selecting residents that ultimately are successful?

Taking the Casper assessment

Casper and Duet give applicants opportunities to showcase their unique personal and professional strengths, providing programs with insights into your key personal and professional characteristics.

takecasper.com

Drwine,

The idea of using testing like this been something our team has talked about multiple times over the years. I know HR people in tech and financial service industries who tell me it’s a common practice, and it makes a lot of sense for us to do something to better assess the “soft skills” essential for residency success. After all, we are happy to use tests that assess ability to accumulate and recall medical knowledge. I know of one program that used to put their candidates through an actual simulation scenario with standardized patients to assess train-ability and empathy. But we haven't been successful in finding a way to properly operationalize things.

First of all, these tests take a lot of time. The CASPer you referenced takes up to 90 minutes to finish, which is similar to other assessments that are out there. Our recruitment day is planned to give candidates a comprehensive exposure to who we are. We want them to talk to as many residents as possible, meet individually with departmental leadership, interview, see the physical layout, etc. Adding a lengthy exam both distracts from this candidate-centered focus and stretches the day longer than we feel is necessary.

But primarily, we have not done this due to the impression we think this would leave on candidates. I’ve taken the idea seriously enough to focus test this every few years with some of our best residents, the ones we hope these tools would help us identify. Universally they have told me the results would be poor. Instead of being seen as proactively acting to find residents who support each other, we would be seen as being too assessment driven. We might be thought of as a place that adds external pressure to do well on the ITE, with evaluations possibly being punitive, and so on. Students would think they would always be under the microscope and wouldn’t be able to relax. Despite being totally transparent about telling candidates we are trying to find them professional and collaborative co-residents, the feedback I always get is that it wouldn’t matter.

Until solutions present that solve these problems in a way my residents agree with, this idea stays on the shelf. But I’d love to ask current residents and students who just interviewed that are here on the forum for your thoughts. Either openly in the forum or privately to me, what you think of this? Is this something you’d want us to do? Or do you also agree that it would be a huge turn-off?

 

[abolt18]

Drwine,

The idea of using testing like this been something our team has talked about multiple times over the years. I know HR people in tech and financial service industries who tell me it’s a common practice, and it makes a lot of sense for us to do something to better assess the “soft skills” essential for residency success. After all, we are happy to use tests that assess ability to accumulate and recall medical knowledge. I know of one program that used to put their candidates through an actual simulation scenario with standardized patients to assess train-ability and empathy. But we haven't been successful in finding a way to properly operationalize things.

First of all, these tests take a lot of time. The CASPer you referenced takes up to 90 minutes to finish, which is similar to other assessments that are out there. Our recruitment day is planned to give candidates a comprehensive exposure to who we are. We want them to talk to as many residents as possible, meet individually with departmental leadership, interview, see the physical layout, etc. Adding a lengthy exam both distracts from this candidate-centered focus and stretches the day longer than we feel is necessary.

But primarily, we have not done this due to the impression we think this would leave on candidates. I’ve taken the idea seriously enough to focus test this every few years with some of our best residents, the ones we hope these tools would help us identify. Universally they have told me the results would be poor. Candidates would have an incorrect and negative impression of who we are. That we are too assessment driven, we’re a place that adds external pressure to do well on the ITE, evaluations might possibly feel punitive, and so on. Students would think they would always be under the microscope and wouldn’t be able to relax. Despite being totally transparent about telling candidates we are trying to find them professional and collaborative co-residents, the feedback I get is that it wouldn’t matter.

Until we can solve these problems, this idea stays on the shelf. But this is something I’d love to ask current residents and students who just interviewed that are here on the forum for your thoughts. Either openly in the forum or privately to me, what you think of this? Is this something you’d want us to do? Or do you also agree that it would be a huge turn-off?

I think this would only add unnecessary stress to an already overly stressful process that is the match. Personally I would have been hugely deterred by that when no other programs are putting you through similar things.

 

[watermelon master]

How will the new changes in Step 1 scoring affect how you decide whether or not to grant an interview and subsequently rank applicants?

 

[Drwine]

How will the new changes in Step 1 scoring affect how you decide whether or not to grant an interview and subsequently rank applicants?

I would bet that this will be a huge disadvantage for US and Canadian applicants from Caribbean medical schools to get interviews. It has been my observation that students who miss out on medical school in the US have been much more driven and put a more focused effort into Step 1.

 

[AnonymousPD]

How will the new changes in Step 1 scoring affect how you decide whether or not to grant an interview and subsequently rank applicants?

watermelon master,

This is a good question. It’s hard to predict how things are going to be 3 years from now when the first batch of pass/fail applications come through. But after thinking about it for a while, the short answer to your question is not very much. The qualities that make us want to extend interviews and the qualities that push an applicant to the top of the rank will be the same then as they are now.

The biggest difference is on the applicant side. What is changing is the fidelity in which applications now reflect a student’s medical school career. Whatever information we and other programs got from standardized testing used to come from two exams. Starting in 2022, 100% of that information will come from Step 2 CK. This benefits those successful at cramming once at the expense of those who are willing to do the work again and again. @Dantrolene mentioned how he struggled his first year due to lack of effort. But made up for it by working his tail off his second year. Because his school is pass/fail, that increased effort doesn’t show up anywhere in his application. There’s no way to tell him apart from someone in his class who coasted through both first and second years. This is a perfect example of what @FFP pointed out. A process that fails to measure anything contradicts one of the central tenants of quality improvement, the use of a measurable variable to track performance.

This is what I meant when I said these changes have made things worse for the students. Now you need to take Step 2 earlier and cross your fingers if you happen to be sick that day. Now it is harder to to show us that you were a fantastic team member and did superior work on your rotations. Subjective things like how you interview, your personal statement, your letters of recommendation are growing in importance. None of these things are good for the students who show the most commitment to mastering their craft. And it is frustrating to us on the program side of things because we can only use the information given to us. We may consider adding more evaluative elements to our elective rotation, but for most applicants our tools will be the same. They just don’t work as well as they used to.

It might be more helpful if I try and articulate how I conceptualize what programs are looking for in general.

During interview season, it’s common to hear about how a candidate picked anesthesia because of all the rotations they were on, that was the one they felt the most passionate about. They have a passion for the specialty. That’s great, but its importance is exaggerated because passion comes and goes. If that’s all you have, that means sometimes you’ll be good and sometimes you won’t. The great residents, they combine passion for the specialty with commitment. They come in every day committed to do the best job they possibly can. It’s easy to be passionate about the first pheochromocytoma you get to take care of. But its commitment that makes you treat the homeless guy off the street at 2am with the same attention to detail you’d give your best friend’s father.

Applicants at the front of the line for competitive residency positions have earned their spots. Earned by taking preclinical classes seriously. Earned by being great team members and dedicating yourself to your patients on every rotation. Earned by doing well on your exams. But it’s not the 265 on Step 1 that I’m looking for. I’m looking for the person willing to spend all the time and effort doing what it took to get that score. It’s not the honors you got in OB/Gyn that’s important, it’s your drive to achieve that when you really want to be an anesthesiologist. This is exactly what @pgg said in the other thread that is so critically important. It's easy to be good at the things we like. Rare is the ability to excel at things that are hard, things that seem trivial, things that you don’t enjoy. That’s what I feel all program directors are really looking for. Don’t worry about trying to demonstrate professionalism, or emotional/social/naturalistic intelligence, or practice-based learning…though it helps to articulate these issues during an interview. All you need to do is be dedicated to doing a great job, especially if it takes you multiple tries, and you will show us pretty much everything we need to know. Convincingly demonstrate you have the talent and commitment needed to do that and you’ll be genuinely ranked to match at every program that gets your application.

 

[Agent Michael Scarn]

MS3 planning on applying to a surgical sub, but have a sneaking suspicion I would enjoy anesthesiology. I'm doing an intro (non-sub-I) anesthesia elective in a couple months followed by a couple aways for the surgical sub. My question is that if I were to have an epiphany and realize I want to switch fields, what is the latest you've seen someone change their mind and successfully get into anesthesia? Probably wouldn't be able to get a home anesthesia sub-I until August/September, but could potentially get an away to replace a surgical away if I decided to go for it.

Step 1 was >260, a bunch of research in surgical field, honoring everything so far.

 

[dchz]

MS3 planning on applying to a surgical sub, but have a sneaking suspicion I would enjoy anesthesiology. I'm doing an intro (non-sub-I) anesthesia elective in a couple months followed by a couple aways for the surgical sub. My question is that if I were to have an epiphany and realize I want to switch fields, what is the latest you've seen someone change their mind and successfully get into anesthesia? Probably wouldn't be able to get a home anesthesia sub-I until August/September, but could potentially get an away to replace a surgical away if I decided to go for it.

Step 1 was >260, a bunch of research in surgical field, honoring everything so far.

There is no too late if the threat level is midnight.

If they ask why you are so late, tell them you were fighting Goldenface along with Katherine Theta-Scarn.

 

[Dantrolene FC]

MS3 planning on applying to a surgical sub, but have a sneaking suspicion I would enjoy anesthesiology. I'm doing an intro (non-sub-I) anesthesia elective in a couple months followed by a couple aways for the surgical sub. My question is that if I were to have an epiphany and realize I want to switch fields, what is the latest you've seen someone change their mind and successfully get into anesthesia? Probably wouldn't be able to get a home anesthesia sub-I until August/September, but could potentially get an away to replace a surgical away if I decided to go for it.

Step 1 was >260, a bunch of research in surgical field, honoring everything so far.

You have until the end of intern year. I’ve been on interviews with surgery interns who changed their mind and want to do anesthesia now. They have physician (R) spots you can apply for in the match, which allows you to not have to repeat intern year.

Although most programs don’t have R spots, and if they do, they usually only have 1. But top programs such as Mayo and UCSF have them.

 

[AnonymousPD]

MS3 planning on applying to a surgical sub, but have a sneaking suspicion I would enjoy anesthesiology. I'm doing an intro (non-sub-I) anesthesia elective in a couple months followed by a couple aways for the surgical sub. My question is that if I were to have an epiphany and realize I want to switch fields, what is the latest you've seen someone change their mind and successfully get into anesthesia? Probably wouldn't be able to get a home anesthesia sub-I until August/September, but could potentially get an away to replace a surgical away if I decided to go for it.

Step 1 was >260, a bunch of research in surgical field, honoring everything so far.

Agent Scarn,

It’s never too late to make the switch over. It is common to have residents who decide to change over in the middle of their residencies or even after years of board-certified practice. From what you said, you should be perfectly fine for the upcoming 2021 Match cycle. Just one minor thing you should think about.

If you were planning on getting a letter of rec during your August/Sept sub-I, given the amount of time it sometimes takes, you might not have it until well after your initial application review is done. Interview season will also be well under way. Applications without letters from someone in the specialty make people wonder. It wouldn’t necessarily be damaging to your application, but why raise questions if you can prevent them. Get a letter from your upcoming elective and all will be in order. You can always add a “better” letter from your sub-I if you wish.

Good luck on the rest of your clinicals and I’m sure you’ll make the right choice. Word of advice if you decide to dual apply, just make sure you associate the right personal statement to the right program. One of my favorite applications of all time was someone with an noncompetitive application who sent us his ortho personal statement. It went on and on about how the drunker he gets the better he works. Toss in a few anecdotes about how it improved his work both with patients “and the women who take care of them” and you have something I printed out and had on my wall for a long time.