Anesthesiology Residency Questions

[TempleChairman]

Temple Anesthesiology:
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Thanks ZzzPlz. On this we are in agreement...

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[Doc Unknown]

Good morning, Mr. Chairman. Looking for a bit of guidance. I am a US MD who graduated in 2009. I always enjoyed being in the OR but couldn't commit to the general surgery lifestyle. I naively did a prelim surgery year thinking it would help guide my career path. Instead all it did was push me out of medicine for a while. After working in a non-clinical capacity for a few years, I decided it was time to get back into medicine. I was able to match into FM and am currently a PGY1. Although I am grateful for the position I have, I am slowly becoming dissatisfied with the field (constant rounding, social work headaches, clinic boredom, etc.). I have done 2 surgery rotations as well as an ICU rotation and have found that I miss being in the OR, doing procedures, and am drawn to the intellectual challenge of treating critical care patients. I am contemplating making a switch to anesthesiology but am unsure how an applicant like me would be perceived. Basic stats: step 1/2/3 - 209/220/210 all passed first attempt, state med school, did not remediate or fail any classes or rotations, bottom 1/2 of class, minimal research. I appreciate any insights you might have. Thank you.

 

[Psai]

Good morning, Mr. Chairman. Looking for a bit of guidance. I am a US MD who graduated in 2009. I always enjoyed being in the OR but couldn't commit to the general surgery lifestyle. I naively did a prelim surgery year thinking it would help guide my career path. Instead all it did was push me out of medicine for a while. After working in a non-clinical capacity for a few years, I decided it was time to get back into medicine. I was able to match into FM and am currently a PGY1. Although I am grateful for the position I have, I am slowly becoming dissatisfied with the field (constant rounding, social work headaches, clinic boredom, etc.). I have done 2 surgery rotations as well as an ICU rotation and have found that I miss being in the OR, doing procedures, and am drawn to the intellectual challenge of treating critical care patients. I am contemplating making a switch to anesthesiology but am unsure how an applicant like me would be perceived. Basic stats: step 1/2/3 - 209/220/210 all passed first attempt, state med school, did not remediate or fail any classes or rotations, bottom 1/2 of class, minimal research. I appreciate any insights you might have. Thank you.

He didn't spend six years in chairman medical school to be called mr. chairman thank you very much

 

[Doc Unknown]

I apologize. No offense was intended. I appreciate the hard work and sacrifice for Dr. Chairman to reach the position that he is in and am grateful for the opportunity that he has given all of us by making himself available on this forum.

 

[Psai]

Was just joking, it's an Austin powers reference. Something dr evil says

 

[TempleChairman]

Good morning, Mr. Chairman. Looking for a bit of guidance. I am a US MD who graduated in 2009. I always enjoyed being in the OR but couldn't commit to the general surgery lifestyle. I naively did a prelim surgery year thinking it would help guide my career path. Instead all it did was push me out of medicine for a while. After working in a non-clinical capacity for a few years, I decided it was time to get back into medicine. I was able to match into FM and am currently a PGY1. Although I am grateful for the position I have, I am slowly becoming dissatisfied with the field (constant rounding, social work headaches, clinic boredom, etc.). I have done 2 surgery rotations as well as an ICU rotation and have found that I miss being in the OR, doing procedures, and am drawn to the intellectual challenge of treating critical care patients. I am contemplating making a switch to anesthesiology but am unsure how an applicant like me would be perceived. Basic stats: step 1/2/3 - 209/220/210 all passed first attempt, state med school, did not remediate or fail any classes or rotations, bottom 1/2 of class, minimal research. I appreciate any insights you might have. Thank you.

Doc Unknown,

Please relax - don't lose any sleep. I am very hard, if not impossible, to offend. After 20 years of working in the OR, my self-worth is not critically dependent on superficial external reinforcements.

From the details you have related there do not seem to be any negatives or "red flags" that would eliminate you from consideration for most anesthesiology residency programs. The fact that you have undertaken a longer path to determining your career goals is not a detractor. In fact many programs would see this as a positive. Often the most focused and satisfied residents are those that bring a broader perspective and an appreciation for all of the things they don't want to do for their entire career. Your major hurdle will be signaling that you have now found the clinical discipline to which you want to dedicate yourself.

My suggestion would be to cultivate a few longer term relationships with anesthesiologists who can provide both direct introductions to program directors (either in the center where they are located, or at the center where they trained) as well as letters of reference. This would most obviously be achieved in the course of an elective month on the anesthesiology service, but could also occur simply by introducing yourself to one or two and asking if they would be willing to share some advice. Find some time, meet them over a cup of coffee and explain your thoughts. Ask them how they decided on their career. Ask them what they like most and least about what they do now. Then ask them if you could come and work with them on days you are finished early or have no major patient commitments. Showing initiative, reading, asking intelligent questions, and simply being present will impress. Once you have convinced one or two clinicians, they can often serve as your bridge into matching with a residency.

Hope this helps.

 

[Doc Unknown]

Thank you very much. Very insightful and encouraging.

 

[anesthesia1567]

I am currently an anesthesia resident in a malignant program. I have tried multiple times to get feedback from PD and staff but all have been very vague with nonspecific complaints. PD has told me to to really consider switching specialities. However, I am in still in good standing. I am very passionate and committed to anesthesia with plans of pursing a Pain fellowship. I am trying my best not to let this situation deter me. Ideally, I would like to switch anesthesia residency programs (and I know of an open spot), but I understand it is difficult to do so without my program's LOR (which I am afraid she will not be willing to write).

My other option is to do PM&R and hope I can get into a Pain fellowship. I know my last option is to tough it out and continue in this program, but I am afraid I will not get a letter from my current PD when the time comes to apply to Pain fellowship. I am not sure what to do in this situation and what the odds are that my PD would be willing to write a LOR for this open anesthesia spot given that I would also be happier being closer to family. Thanks for all your help in advance. I really appreciate it.

 

[Chloroform4Life]

I am currently an anesthesia resident in a malignant program. I have tried multiple times to get feedback from PD and staff but all have been very vague with nonspecific complaints. PD has told me to to really consider switching specialities. However, I am in still in good standing. I am very passionate and committed to anesthesia with plans of pursing a Pain fellowship. I am trying my best not to let this situation deter me. Ideally, I would like to switch anesthesia residency programs (and I know of an open spot), but I understand it is difficult to do so without my program's LOR (which I am afraid she will not be willing to write).

My other option is to do PM&R and hope I can get into a Pain fellowship. I know my last option is to tough it out and continue in this program, but I am afraid I will not get a letter from my current PD when the time comes to apply to Pain fellowship. I am not sure what to do in this situation and what the odds are that my PD would be willing to write a LOR for this open anesthesia spot given that I would also be happier being closer to family. Thanks for all your help in advance. I really appreciate it.

That sounds like a rough situation you are in, if the PD is telling you to switch specialty. With due respect, but have you sit down and objectively try to determine why your PD and attendings are concerned about you becoming an anesthesiologist? Do you need to make a dramatic changes in your attitude, habit, or behavior? These things can be hard to realize and change. The fact that you are in good standing is a positive. If you are determined and committed to become an anesthesiologist, assure your PD of this fact. Assuming youre a CA1, you only have 2 more years of this. Buckle in, work hard, don't complain, study, and you can make it out of your situation in one piece. Unless you're certain this "open spot" will take you (i.e. you have strong connection), you shouldn't really try for it. You may end up in the same position where you hate that program too if the problem is you (no offense). Stirring this pot can put your future at risk, especially if your good standing was to become bad.

This is probably not the encouragement you're looking for.

There were a few "bad apples" in my residency. They were often the lazy residents who complained all the time and couldn't get along (not saying this is you). They were sat down with our PD and were told of their weaknesses. Some learned, got with the system, graduated, and went on with their life. Others couldn't cope and quit. Noone switched anesthesia residency. Thats really almost unheard of.

 

[DetectiveAlonzo]

@TempleChairman

What is your take on applicants from DO programs? Are step 1/COMLEX scores held in much higher regard for osteopathic applicants and do you feel that Anesthesiology is impossible or doable for future DO students? What else do program directors such as yourself value from an applicant besides Step/COMLEX scores and away rotations? Do rotating students need to get LORs from Anesthesiology directors and attendings to shine?

Thanks!

 

[Doc145]

@TempleChairman

What is your take on applicants from DO programs? Are step 1/COMLEX scores held in much higher regard for osteopathic applicants and do you feel that Anesthesiology is impossible or doable for future DO students? What else do program directors such as yourself value from an applicant besides Step/COMLEX scores and away rotations? Do rotating students need to get LORs from Anesthesiology directors and attendings to shine?

@TempleChairman as incoming DO student interested in Anesthesiology, I'd love to hear your answer to this question as well
Thanks again for your thorough answers!

 

[deleted212936]

@TempleChairman
Thank you for your time.

 

[minutemen11]

Thank you chairman for shedding light on the doom and gloom of anesthesia on SDN, I am going into anesthesia regardless (currently a rising M4). I wanted to know how much you value away rotations at Temple, do you recommend students who are interested in Temple rotate there? I am currently torn between doing an away anesthesia rotation vs. doing a consult medicine rotation (eithers cards, pulm or renal) at my home institution from mid-august to mid-september. My other summer rotations include an OR anesthesia month, SICU month and Medicine Sub-I. A letter for an anesthesia rotation that ends in mid-September might not be in on time and I know that most programs like a letter from medicine so I'm not sure what to do with this block of time. I could theoretically move my medicine Sub-I to mid-aug-mid-sept, to make time for an away to get a letter but I like my current Sub-I placement... Confused, please help! By the way, I go to a good US MD school, however, my step I is very low (212) so I feel that I need to do an away to improve my chances..

PS: I havent used sdn since being a neurotic pre-med posting about the MCAT lol... hard to believe I made it and actually a M4 now!

 

[TempleChairman]

I am currently an anesthesia resident in a malignant program. I have tried multiple times to get feedback from PD and staff but all have been very vague with nonspecific complaints. PD has told me to to really consider switching specialities. However, I am in still in good standing. I am very passionate and committed to anesthesia with plans of pursing a Pain fellowship. I am trying my best not to let this situation deter me. Ideally, I would like to switch anesthesia residency programs (and I know of an open spot), but I understand it is difficult to do so without my program's LOR (which I am afraid she will not be willing to write).

My other option is to do PM&R and hope I can get into a Pain fellowship. I know my last option is to tough it out and continue in this program, but I am afraid I will not get a letter from my current PD when the time comes to apply to Pain fellowship. I am not sure what to do in this situation and what the odds are that my PD would be willing to write a LOR for this open anesthesia spot given that I would also be happier being closer to family. Thanks for all your help in advance. I really appreciate it.

Aneshesia1567, first, my apologies to you and the other posters above. It seems that, for reasons that I have not yet determined, SDN stopped sending email notifications of new posts to this thread roughly one month ago. I only stumbled across these posts because I received a notification of a personal communication and subsequently logged in to the site.

I would largely echo Chloroform4Life’s comments. Below is a repeat of some advice that I recently offered (not on this thread) in response to a very similar inquiry:

You are not the first to ask for my advice in this type of scenario. Unfortunately it is very difficult to adjudicate interpersonal conflicts from a distance. Once you’ve heard one side of the story, you’ve heard one side of the story.

I do understand the conditions you describe and have frequently seen similar stories unfold during training on multiple accessions.

On the one hand, anesthesiology is a team sport and there is an obligation for every member of the work group or training team to be fully invested in the group success. It is never appropriate to start a work day looking for someone else to fail - they will.

On the other hand, anesthesiology is also a “performance art”. An essential component of our job is to quickly and completely gain the confidence and cooperation of the patients, surgeons, nurses and other anesthesiologists that we work with in every scenario. Some individuals simply have a pattern of behavior and communication that make this exceedingly difficult. I have known brilliant individuals who could not find success in our field essentially because they could not conquer this aspect of the profession.

Look very carefully at the other residents in the training program, particularly the ones you consider “successful” and perhaps even admire. Being as honest as you can, do you truly embody the same personal characteristics, work patterns and performance at work? If you do, then be true to yourself, soldier on and you will be an anesthesiologist. If not, it is possible that your love of the specialty might not translate into a competency (it doesn’t always).

The critiques of even the most obnoxious and abrasive individuals often contain a core nugget of truth. It is important to recognize that truth and, difficult but essential, to determine the degree to which anything they throw at you is true. That is the only way to improve.

I recognize that this advise is vague and does not provide you with a concrete answer to your specific question, but is unfortunately the best I can offer under the circumstances.

 

[TempleChairman]

@TempleChairman

What is your take on applicants from DO programs? Are step 1/COMLEX scores held in much higher regard for osteopathic applicants and do you feel that Anesthesiology is impossible or doable for future DO students? What else do program directors such as yourself value from an applicant besides Step/COMLEX scores and away rotations? Do rotating students need to get LORs from Anesthesiology directors and attendings to shine?

Thanks!

DetectiveAlonzo, Doc145, and Minuteman11,

I can only accurately speak for our program, but do think that our approach reflects that being adopted by a reasonable number of other quality anesthesiology residencies. You can find additional detailed discussion of our selection criteria in the posts under this thread from November 2015 (first page into second page).

Our screening process is structured and fairly objective. It assigns weight to a number of factors that we feel have correlated over time with success in our program and specialty. The USMLE and COMLEX scores are weighted equally (on different scales), and not as heavily as I suspect most medical students assume. There is no distinction in our screening process between MD and DO applicants. The proportion of these two pathways amongst our residents has varied over time largely based on the qualities of the specific applicants. Finally, reference letters are used mainly to ensure that there are no “red flags” identified by the mentors who have seen the candidates in clinical settings - largely with regard to personal attributes (work ethic, organization, interest, interpersonal skills). There is no formal mechanism by which the identity of a reference letter’s author is weighed (i.e.: anesthesiologist vs. other specialist, faculty member versus PD versus Chair). The location of preclinical rotations actually plays no formal role in our evaluation and only occasionally influences our decision making process on the margin.

Although it is not the answer that most medical students are hoping to hear, our process is focused on identifying long term patterns of achievement, a wide breadth of experiences, and key durable personal characteristics. The “sum-total of one’s life to date" is the core metric. As such, there is probably little that can be done over the course of a few months (specific reference letters, specific rotations) that will peak our interest in a candidate who otherwise would not meet our criteria, or alternatively that would dampen our enthusiasm for someone that we would think of as an outstanding candidate.

I sincerely hope that this provides some reassurance or, at the very least, minimizes any wasted effort or anxiety on your part.

 

[nando1404]

@TempleChairman

Hi Dr. Chairman,

THANK YOU! I felt like this thread was something I really needed to read today. You're insight and committment to answering questions speaks a lot for yourself. I am an MS3 from a Philadelphia average medical school with a step score of 201. I was wondering if you had any advice on dual applying for Anesthesia and say internal medicine as a backup (not at any top tier programs). I'm fully committed to Anesthesia but don't know if it's an unattainable residency for me. I've gotten two faculty opinions thus far. One said I don't need a backup I'll match fine with that score. The other saying take a year off and dual apply or reconsider my speciality. Just wanted some honest feed back and again thank you so much for shedding light on an extremely daunting process.

 

[TempleChairman]

Hi Nansai,

Thank you for the question. You have stumbled on a subject near and dear to my heart - appropriate and logical interpretation of quantitative data. Although it is impossible to give you a well rounded opinion on your ability to match to a specific program given the limited information presented above, let's examine your likelihood of matching based solely on your USMLE step 1 score of 201.

If you look at the published data for the 2016 NRMP match results you will see that a total of 1917 applicants were vying for a total of 1696 anesthesiology residency positions. However, these numbers include new US graduates, practicing US physicians, and foreign medical graduates. If you limit the analysis to new graduates of allopathic or osteopathic medical schools, you find that of the 1076 who listed anesthesiology as their first or only choice of specialty, 1048 (97%) matched. If you limit the analysis even further to examine exclusively the 783 that only listed anesthesiology programs on their rank list, 777 (99%) matched. From this, we can surmise that a US graduate who is genuinely interested in anesthesiology can almost always find a position somewhere.

Nonetheless, 1% still didn't match and you are worried about your Step 1 score. Let's dig slightly deeper.

If you look at the distribution of Step 1 scores amongst US medical students applying to anesthesiology residencies in 2016 you find the following pattern:
Step 1 score: 181-190, five out of five (100%) matched to anesthesiology
Step 1 score: 191-200, twenty out of twenty-eight (71%) matched to anesthesiology
Step 1 score: 201-210, fifty-six and of sixty-two (90%) matched to anesthesiology
(Just for fun I will note that one candidate with a score in the range of 251-260 went unmatched...)

Also consider the likelihood of matching based on the total number of anesthesiology programs listed by each candidate:
1 program - 50%
5 programs - 85%
>11 programs - almost 100%

Finally, I will turn to our program's 2017 match list to illustrate my concluding point. Our match list is not yet finalized, but using its present configuration I can tell you that within the current top 20 candidates the Step 1 scores range from 193 to 264. Without giving away anyone's identify, I can tell you that each of the 20 individuals listed display personal characteristics through their life history and / or interview scores that lead us to believe that they would be exceptional trainees for our program.

Therefore, my best advice is to follow your true passion, work hard, demonstrate the qualities (adaptability, team work, discipline, perseverance) required to thrive as an anesthesiologist, apply widely, and don't lose sleep over your Step 1 score. There are many vastly more important determinants of what sort of physician you will turn out to be.

Hope this is of some use to you.

 

[BLADEMDA]

The analysis provided evidence on a national scale that results from the USMLE and the ABA Part 1 were correlated and that success on the latter examination was associated with level of USMLE performance. Both testing programs have been successful in conceptualizing many of the knowledge areas of interest and in developing test content to reflect those areas.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693694/


I think this correlation between Step scores and passing the ABA written exams is why many top tier residencies weigh Step score more heavily in the application process. If a program can pick among all the applicants then why not take those who are good team players in addition to good test takers? I certainly agree that scoring high on the USLME or ABA written exams is no guarantee that one will become a good Physician but it does remove one obstacle from the process: Board Certification

 

[Chip N Sawbones]

Finally, I will turn to our program's 2017 match list to illustrate my concluding point. Our match list is not yet finalized, but using its present configuration I can tell you that within the current top 20 candidates the Step 1 scores range from 193 to 264. Without giving away anyone's identify, I can tell you that each of the 20 individuals listed display personal characteristics through their life history and / or interview scores that lead us to believe that they would be exceptional trainees for our program.

Thank you for taking the time to post this. I've crunched the national match list numbers as well, but it's very nice to be able to take a glimpse inside one program's Step scores to see that people with low Step I scores really are able to match in this specialty, and not just to bottom-tier programs either.

 

[TempleChairman]

The analysis provided evidence on a national scale that results from the USMLE and the ABA Part 1 were correlated and that success on the latter examination was associated with level of USMLE performance. Both testing programs have been successful in conceptualizing many of the knowledge areas of interest and in developing test content to reflect those areas.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693694/


I think this correlation between Step scores and passing the ABA written exams is why many top tier residencies weigh Step score more heavily in the application process. If a program can pick among all the applicants then why not take those who are good team players in addition to good test takers? I certainly agree that scoring high on the USLME or ABA written exams is no guarantee that one will become a good Physician but it does remove one obstacle from the process: Board Certification

BLADEMDA,

You are correct, there is a wealth of data to indicate that the ability to do well on standardized testing is a durable characteristic. Those who do well on one test usually tend to do well on subsequent unrelated challenges, and vice versa for lower performers. Actually, I suspect most people bothering to read this post might have expected a stronger correlation between USMLE scores and scores on the old ABA Part 1 examination. Most authorities on practically applied statistics consider a correlation coefficient of 0.59 to be of marginal real-world significance - it indicates an influence of one variable on the other, but an influence not nearly strong enough to have functional predictive value.

Nonetheless, your point is well taken and I agree with your premise. We do track USMLE scores (I could obviously quickly reference them in our rank list) and factor them in to our overall assessment of a candidate's ability to complete the ABA certification process, because that is our final objective in every case. However, it is not uncommon to see candidates who have a single USMLE score that is discordant with their rest of their academic profile and ability to achieve their goals. When we accept a candidate with a lower USMLE score but other highly desirable characteristics we earmark them for close observation and coaching in preparation for their ABA In Training Examinations. More often than not the concerns turn out to be baseless.

My point to Nansai was simply that, as a single isolated data point, a USMLE Step 1 score is not a reasonable basis on which to make life altering decisions (either on the part of the candidate or the program).

 

[TempleChairman]

Thank you for taking the time to post this. I've crunched the national match list numbers as well, but it's very nice to be able to take a glimpse inside one program's Step scores to see that people with low Step I scores really are able to match in this specialty, and not just to bottom-tier programs either.

Chip N Sawbones,

You are very welcome. Glad you found it to be of some use.

 

[easternether]

Chip N Sawbones,

You are very welcome. Glad you found it to be of some use.

The other thing I would add is that there are a lot of review courses that can help you develop study techniques that will help you pass the exam. This is what they do. In the end, you will do well if you have the proverbial 'fire in your belly,' for this field.

 

[feathersaurus]

@TempleChairman ever grateful for info thus far which has been illuminating.

I am a third year med student who used to be interested in ER and neurology and sometimes gynecology but could never commit. I had an epiphany a few weeks ago, realizing that anesthesia had been my specialty all along.

I am currently trying to figure out how to build a good application package for 2017-2018 season. Conventions seem to vary between specialties--for instance ER programs like to see 2 or 3 ER letters of rec to "demonstrate commitment"; however I have read various sources that say anesthesia does NOT want you to do several fourth year anesthesia rotations and they instead prefer only 1 anesthesia supplemented with rotations in Pain, ICU, general surgery, radiology etc--these being areas where you would pick up good skills for eventual training in anesthesiology.

Do you agree with this assessment? With this approach how can I demonstrate my commitment to anesthesia and set myself apart from applicants that choose it as a back-up or were undecided? What primer book would you recommend at my level to prepare for 4th year clerkships? (I go to a small community medical school and we don't have an anesthesia department so I appreciate all resources)

Another question: I found out a that I am partially colorblind last year. I can pass a red/green test but have trouble with pink/red/purple and green/brown/grey/blue. Can you think of any instances where color vision is necessary in your job? Definitely no cytology in my future.... (I can see jaundice and cyanosis just fine)

Cheers and thanks again!

 

[notcool]

Hi @TempleChairman. Thank you for taking the time to do this! I have heard it is a good idea to do a fellowship and work in academia. Do you think academic anesthesiology is a good career path for the future?

 

[propofol454]

Hi Dr.
I have a question. I am still thinking about ranking IM higher or anesthesio. By the way, I am so worried about radiation exposure during anesthesiology process in the OR. Does it carry a risk? I appreciate your response

 

[Drangue]

Hi Nansai,

Thank you for the question. You have stumbled on a subject near and dear to my heart - appropriate and logical interpretation of quantitative data. Although it is impossible to give you a well rounded opinion on your ability to match to a specific program given the limited information presented above, let's examine your likelihood of matching based solely on your USMLE step 1 score of 201.

If you look at the published data for the 2016 NRMP match results you will see that a total of 1917 applicants were vying for a total of 1696 anesthesiology residency positions. However, these numbers include new US graduates, practicing US physicians, and foreign medical graduates. If you limit the analysis to new graduates of allopathic or osteopathic medical schools, you find that of the 1076 who listed anesthesiology as their first or only choice of specialty, 1048 (97%) matched. If you limit the analysis even further to examine exclusively the 783 that only listed anesthesiology programs on their rank list, 777 (99%) matched. From this, we can surmise that a US graduate who is genuinely interested in anesthesiology can almost always find a position somewhere.

Nonetheless, 1% still didn't match and you are worried about your Step 1 score. Let's dig slightly deeper.

If you look at the distribution of Step 1 scores amongst US medical students applying to anesthesiology residencies in 2016 you find the following pattern:
Step 1 score: 181-190, five out of five (100%) matched to anesthesiology
Step 1 score: 191-200, twenty out of twenty-eight (71%) matched to anesthesiology
Step 1 score: 201-210, fifty-six and of sixty-two (90%) matched to anesthesiology
(Just for fun I will note that one candidate with a score in the range of 251-260 went unmatched...)

Also consider the likelihood of matching based on the total number of anesthesiology programs listed by each candidate:
1 program - 50%
5 programs - 85%
>11 programs - almost 100%

Finally, I will turn to our program's 2017 match list to illustrate my concluding point. Our match list is not yet finalized, but using its present configuration I can tell you that within the current top 20 candidates the Step 1 scores range from 193 to 264. Without giving away anyone's identify, I can tell you that each of the 20 individuals listed display personal characteristics through their life history and / or interview scores that lead us to believe that they would be exceptional trainees for our program.

Therefore, my best advice is to follow your true passion, work hard, demonstrate the qualities (adaptability, team work, discipline, perseverance) required to thrive as an anesthesiologist, apply widely, and don't lose sleep over your Step 1 score. There are many vastly more important determinants of what sort of physician you will turn out to be.

Hope this is of some use to you.

Thank you for taking the time to answer that. Very helpful and explains that applying to A LOT of programs goes a long way.

 

[TempleChairman]

@TempleChairman ever grateful for info thus far which has been illuminating.

I am a third year med student who used to be interested in ER and neurology and sometimes gynecology but could never commit. I had an epiphany a few weeks ago, realizing that anesthesia had been my specialty all along.

I am currently trying to figure out how to build a good application package for 2017-2018 season. Conventions seem to vary between specialties--for instance ER programs like to see 2 or 3 ER letters of rec to "demonstrate commitment"; however I have read various sources that say anesthesia does NOT want you to do several fourth year anesthesia rotations and they instead prefer only 1 anesthesia supplemented with rotations in Pain, ICU, general surgery, radiology etc--these being areas where you would pick up good skills for eventual training in anesthesiology.

Do you agree with this assessment? With this approach how can I demonstrate my commitment to anesthesia and set myself apart from applicants that choose it as a back-up or were undecided? What primer book would you recommend at my level to prepare for 4th year clerkships? (I go to a small community medical school and we don't have an anesthesia department so I appreciate all resources)

Another question: I found out a that I am partially colorblind last year. I can pass a red/green test but have trouble with pink/red/purple and green/brown/grey/blue. Can you think of any instances where color vision is necessary in your job? Definitely no cytology in my future.... (I can see jaundice and cyanosis just fine)

Cheers and thanks again!

Hi feathersaurus (unrelated editorial comment: some of the user IDs here do completely crack me up),

I can only speak authoritatively regarding our program, but I believe many programs do find a varied background to be as valuable as we do. Because of the broad interactions of anesthesiologists across the healthcare system, experience with a wide variety of clinical specialties prior to your residency will ultimately enhance your ability to function as a specialist in our field. Several decades ago my path to anesthesiology lead through a "rotating internship" (med, surg, OB, ICU, peads - I think they are now called "transitional" internships?) and then several years of family practice and locum tenens work in small town ERs across Ontario. Those experiences significantly enhanced the range of "non-anesthesiology" medical knowledge I could call upon during my residency.

With regard to distinguishing yourself, my advice is simply to apply to multiple anesthesiology programs (which demonstrates your commitment), and to make certain that those who will be writing your letters of reference know what your choice of speciality is. It does raise eyebrows (and doubts) when we receive three LORs for a candidate, all of which name a different specialty that the candidate is pursuing, none of which are anesthesiology. Provided that at least one of your references is from an anesthesiologist (showing that you invested the time and effort to cultivate such a contact) the identity of the rest of your letter writers is less important than their attestation that you work hard, adapt to change well, and have a personality compatible with the (sometimes challenging) working environment we face daily.

Any introductory textbook in anesthesiology would suffice for your 4th year rotation. Examples would include Morgan and Mikhail's "Clinical Anesthesiology", or Miller and Pardo's "Basics of Anesthesia". You should be able to order a paperback copy of either for around $30-$40. I personally find the Miller text easier to read, but other's prefer M&M. Keep in mind that with either text you really should only focus on reading 10-15 core chapters during your 4th year elective. I would suggest taking your copy at the beginning of your rotation to the clerkship director or one of the faculty members that you find particularly approachable and asking them to identify a dozen chapters that they would recommend.

As for the color blindness - you have me stumped (first time for that question). There are some aspects of anesthesia machines and video displays that are color coded, but this tends to be simply one safety measure amongst many and I do not think this should be a significant problem. Certainly I have known many outstanding clinical anesthesiologists that have effortlessly dealt with greater physical limitations.

Hope all this helps.

 

[TempleChairman]

Hi @TempleChairman. Thank you for taking the time to do this! I have heard it is a good idea to do a fellowship and work in academia. Do you think academic anesthesiology is a good career path for the future?

Hi notcool,

I would refer you back to my answer to 'mostwanted', posted on September 12th, 2015. Having just re-read this response I don't think I can answer your question more completely - although I am happy to try if you still have questions after reviewing the post.

 

[TempleChairman]

Hi Dr.
I have a question. I am still thinking about ranking IM higher or anesthesio. By the way, I am so worried about radiation exposure during anesthesiology process in the OR. Does it carry a risk? I appreciate your response

Hi propofol454,

I am not sure I completely grasp your question - you are struggling with IM versus anesthesiology? It would be difficult to give you much guidance without a much better understanding of your background, your interests, and what you have identified as your strengths and weaknesses to date. Hopefully there is someone within your medical school who knows you well and can provide some guidance. If not, please feel free to message me through SDN and I would be happy to set up a time to speak with you.

As for radiation exposure in the OR, given usually low and intermittent exposure levels as well as the safety equipment currently mandated for use during fluoroscopy, I would not think it should be your top health concern unless you: have a BMI of 25; don't smoke or drink alcohol; consume >70% of your caloric intake as fresh fruits / vegetables / whole grains; exercise for at least 30 minutes a minimum of 5 times per week; have a family history free of cancer / cardiovascular disease / dementia; and all of your direct relatives live to at least 85 years of age. Unless all of these conditions apply, something else is far more likely to lead to your demise before the incidental radiation exposure typical for an anesthesiologist.

Hope this puts your mind at rest! (or at least prompts you to go for a jog and eat a carrot...)

 

[trainmap]

Hello Dr,

I have a question, what if someone failed a Step exam, like a US IMG who failed Step 2 CS. What are your thoughts on interviewing a prospect who has such a red flag? Also, what advice would you give as far as redeeming themselves in order to give them the best chance of still matching into Anesthesiology? Thank you so much for this. Reading this thread has given me a lot of useful information.

 

[TempleChairman]

Hi trainmap,

With regard to difficulty on a single standardized examination, I would not describe this as a disqualifier. The application process is meant to give programs a picture of each individual as a whole. If you have other acceptable standardized test scores and good grades on your medical school transcript, these will serve to provide balance and perspective on your academic capabilities.

With regard to the Step 2 CS exam specifically, I would suggest that you spend little time worrying. I think the widespread perception of individuals involved with GME is that performance on the Step 2 CS does not seem to correlate well with any other assessment of candidates or their future performance. There are many very bright and capable individuals who do not pass the CS on their first attempt, and many others with borderline academic performance overall who do perfectly fine on the exam. At Temple we are now at a point where the only relevance we lend to the Step 2 CS is that candidates must pass it prior to taking Step 3. If not for this fact we would have no interest in the results whatsoever.

 

[trainmap]

Hello again Dr.,

Thank you for your time and input, it's greatly appreciated. As you could imagine, the results left me both shocked and devastated. Glad to hear that it isn't a nail in the coffin as this forum could be intimidating at times.

If it's ok, another question that I have is how important does geographic location matter for applicants? I was told that my best chance at matching is to go back to my home state (which is Pennsylvania, grew up in the Pocono Mountains) but how much truth is there to this in your opinion?

 

[TempleChairman]

Hello again Dr.,

Thank you for your time and input, it's greatly appreciated. As you could imagine, the results left me both shocked and devastated. Glad to hear that it isn't a nail in the coffin as this forum could be intimidating at times.

If it's ok, another question that I have is how important does geographic location matter for applicants? I was told that my best chance at matching is to go back to my home state (which is Pennsylvania, grew up in the Pocono Mountains) but how much truth is there to this in your opinion?

Hi Trainmap - in my opinion, none. During our interview process we do attempt to determine an applicant's genuine interest in relocating to our program. Regardless of complicating factors (immediate family elsewhere, never seen snow before!) we place the greatest emphasis on a candidate's stated preferences. If they express a genuine and specific interest in training at Temple we place no weight on their recent geographic history. Reviewing the past several residency classes we have trained individuals from across the continent.

 

[trainmap]

When it comes to residents in your anesthesiology program, what would you say are the pitfalls that trouble residents fall into and how could they have been avoided or at least improved upon? I've read info regarding what makes a good anesthesiology resident, but not so much on what made the bad ones "malignant". Thanks again.

 

[cluelessmedstudent411]

Hi Dr. __,

Thank you for taking the time to let us pick your brain!

My question is regarding asking for a recommendation letter. I'm an osteopathic student and as such dont have an anesthesiology home program. Therefor, I am doing few away rotations at residency programs for the exposure as well as to get a recommendation letter from a PD. How do PD's feel about writing a recommendation letter for an away student? Lot of times, there is very little exposure to the PD at large programs. Is there a way to get around this hurdle?

Thank you again!

 

[TempleChairman]

When it comes to residents in your anesthesiology program, what would you say are the pitfalls that trouble residents fall into and how could they have been avoided or at least improved upon? I've read info regarding what makes a good anesthesiology resident, but not so much on what made the bad ones "malignant". Thanks again.

It goes without saying that there are a broad range of personalities that pursue medicine in general and anesthesiology in particular these days. I would not want to suggest that all, or even a majority, suffer from one common handicap. However, if I were to name one pitfall as being the most common amongst junior residents in the past few years it would be the failure of a significant proportion of them to recognize the transition they have made from "customer" to "service provider".

For many, their entire existence through to the beginning of internship has been that of the paying consumer. They have invested heavily in their education and have expected those collecting the fees to provide value in return vis-a-vis opportunities to learn. However, once joining the graduate medical education workforce the shoe is on the other foot for these individuals. They are now service providers, assuming critical responsibilities for the institutions in which they work and for the patients whom they serve. Although this work provides an expected side-effect of transferring further knowledge and experience to the residents, the primary purpose of any licensed physician is service to their patients. When there is a conflict between doing what is right for a patient and providing a unique educational experience, the patient's needs must always be seen as taking precedent. In addition, the residents' evolving dedication to their professional responsibilities is as essential to their success as anesthesiologists as is their academic performance. The requirement for self-sacrifice and putting the needs of patients first is sometimes shocking to those with a lifelong self-identity as "the customer". However, providing insight to this state of mind is one of the essential formative functions of a residency program. These are the standards against which these anesthesiologists will be judged by their group partners or institutions for the remainder of their careers and instilling the correct perspective for their work is no less critical than teaching them how to manage an airway or massive hemorrhage.

 

[TempleChairman]

Hi Dr. __,

Thank you for taking the time to let us pick your brain!

My question is regarding asking for a recommendation letter. I'm an osteopathic student and as such dont have an anesthesiology home program. Therefor, I am doing few away rotations at residency programs for the exposure as well as to get a recommendation letter from a PD. How do PD's feel about writing a recommendation letter for an away student? Lot of times, there is very little exposure to the PD at large programs. Is there a way to get around this hurdle?

Thank you again!

Cluelessmedstudent411,

Good question (and a variation on a common theme - "how do I get the best letter of reference?"). I will start by quoting my own post from roughly 18 months ago on this thread: "To be clear, in the reference letters the important information is usually not a candidate's aptitude for anesthesiology related functions. We can train (almost) anyone to intubate or mask ventilate. The purpose of the reference letters is to attest to an individual's work ethic, resilience, temperament and team-working skills. These are what most often distinguish exceptional trainees from those that simply complete their course. A surgeon or an internist that can relate such details in their letter of reference will carry more weight than an anesthesiologist who does not."

My best advice is to seek reference letters from individuals that know you well and who can speak to your individual strengths and characteristics. Despite the common wisdom often circulated amongst medical students, reference letters from Chairs or PDs don't necessarily carry more weight during the application process, especially if they are somewhat generic and don't sound as though they know you well. It is helpful to have one or two references from an anesthesiologist who can speak to your apparent "fit" for the OR workflow and culture. However, after satisfying that criteria you should find individuals that can provide personal insight and anecdotes to compliment their recommendation of you.

 

[trainmap]

Thanks again TempleChairman for your invaluable insight, i'll certainly keep everything you said in mind going forward so that I can be the best resident and ultimately doctor I can be. But getting back to the application process, what are your thoughts on extended breaks in between coursework? I know this is seen as a red flag, but i'm once again curious about your outlook on it. Thanks again in advance.

 

[TempleChairman]

Thanks again TempleChairman for your invaluable insight, i'll certainly keep everything you said in mind going forward so that I can be the best resident and ultimately doctor I can be. But getting back to the application process, what are your thoughts on extended breaks in between coursework? I know this is seen as a red flag, but i'm once again curious about your outlook on it. Thanks again in advance.

Hi trainmap,

Much like most issues, the devil is in the details. Breaks in academic progress occur for a variety of reasons. I have seen candidates who interrupted their undergraduate or medical training to pursue entrepreneurial or political opportunities for fixed periods of time. This is a different matter than withdrawing from a program because of an inability to cope with the academic workload. I do not think breaks in coursework are inherently a problem, but the underlying explanation does matter.

 

[ElmerFudd]

Hi sts84,

I think the two most common questions I am asked are about the requisites to obtain a residency spot (see answer to bashwell above) or about the future of the specialty (see mostwanted below).

I think the most insightful questions (i.e.: most helpful for the medical student) usually involve the themes of what I like most about the specialty (working in a team environment, very performance based, immediate feedback on decisions, very intense patient interactions - you really have their attention when you are preparing to anesthetize them) or what I like least about the specialty (you do not control your own schedule and the hours can be long and grueling).

That's it? What you like least about the specialty is thay you don't control your own schedule and the hours can be long and grueling?

I certainly hope you answer that question more honestly than this! Not controlling one's schedule and long hours are part and parcel of many fields in medicine (especially the higher paying ones), and are probably ranked quite low on the list of things most anesthesiolgists dislike about anesthesiology.

I'd level with your applicants and tell them that if they want to be respected as physician consultants, then anesthesiology isn't the field for them.

 

[TempleChairman]

That's it? What you like least about the specialty is thay you don't control your own schedule and the hours can be long and grueling?

I certainly hope you answer that question more honestly than this! Not controlling one's schedule and long hours are part and parcel of many fields in medicine (especially the higher paying ones), and are probably ranked quite low on the list of things most anesthesiolgists dislike about anesthesiology.

I'd level with your applicants and tell them that if they want to be respected as physician consultants, then anesthesiology isn't the field for them.

Hi ElmerFudd,


The post that you reference was completely candid on my part. I agree that currently the practice environment for physicians is evolving. Many specialists are now, for the first time, facing oversight and production pressures in employed situations that restrict their ability to control their schedules. However, over the majority of my career the lack of control (pace of work, end of day, ability to take vacation) was nearly unique to anesthesiologists and, anecdotally, the number one cause of burnout I experienced amongst colleagues.


The professional practice environment for anesthesiologists undoubtedly varies widely from setting to setting. I have genuine sympathy if you find yourself working in an institution where you do not find your input as a consultant valued. However, I think it is important for the medical students who read this thread and who are weighing important career decisions to know that your sentiments represent your specific experience and perhaps not a wider reality. In our institution the faculty from the department of anesthesiology have accountability for a broad range of processes extending from the preoperative selection and preparation of patients for surgery, managing a variety of components of the perioperative patient flow, direct care in several of our critical care units, and are routinely asked to participate or direct when groups are being assembled by the institutional leadership to tackle specific operational issues. Rather than lacking influence as physician consultants and logistics experts, I believe it is fair to say that most of our faculty feel overtaxed with requests to participate in organizational governance.


Perhaps you would be happier at Temple?

 

[ElmerFudd]

Hi ElmerFudd,


The post that you reference was completely candid on my part. I agree that currently the practice environment for physicians is evolving. Many specialists are now, for the first time, facing oversight and production pressures in employed situations that restrict their ability to control their schedules. However, over the majority of my career the lack of control (pace of work, end of day, ability to take vacation) was nearly unique to anesthesiologists and, anecdotally, the number one cause of burnout I experienced amongst colleagues.


The professional practice environment for anesthesiologists undoubtedly varies widely from setting to setting. I have genuine sympathy if you find yourself working in an institution where you do not find your input as a consultant valued. However, I think it is important for the medical students who read this thread and who are weighing important career decisions to know that your sentiments represent your specific experience and perhaps not a wider reality. In our institution the faculty from the department of anesthesiology have accountability for a broad range of processes extending from the preoperative selection and preparation of patients for surgery, managing a variety of components of the perioperative patient flow, direct care in several of our critical care units, and are routinely asked to participate or direct when groups are being assembled by the institutional leadership to tackle specific operational issues. Rather than lacking influence as physician consultants and logistics experts, I believe it is fair to say that most of our faculty feel overtaxed with requests to participate in organizational governance.


Perhaps you would be happier at Temple?

"Evolving" - what a great word!

Surgeons (grudgingly) acknowledge us as gatekeepers who allow or block procedures, but by no means do they routinely value our input. To them, we are a tool for them to get their surgeries done and they are often uninterested in our input unless it really matters (and even then, sometimes they're not interested). Don't tell me that you've never performed a procedure under general anesthesia rather than regional, or given a unit of blood you didn't think was necessary, simply because the surgeon requested it! This is the way of private practice, which is where most of us end up working. In the end, it's the surgeon's patient, they think they know more than we do on pretty much everything, and they have the final say. We simply comply (as long as it's not harmful) and document "at surgeon's request" on our records.

While it's true that we can be "logistic experts" who can tackle "operational issues", I'd hate to think that I went through all this training for non-clinical purposes.

 

[ElmerFudd]

As someone with awful Step I scores but lots of things that will qualify as good character indicators, I'm delighted that your program places so little emphasis on Step I. Are scoring systems like yours common among residency programs, or do most programs just look at grades and test scores?

Don't believe everything you read. Your step 1 scores are very important to every program. Saying "we look at the whole applicant" sounds nice for the papers, but they still have to find ways to rank applicants - all of whom have many good qualities - and thus you can guarantee that your USMLE scores weigh in heavily.

Do I know this for a fact? No. I've never been on any admissions committee or served as a residency coordinator. But common sense should tell you that I'm right!

 

[Drangue]

Don't believe everything you read. Your step 1 scores are very important to every program. Saying "we look at the whole applicant" sounds nice for the papers, but they still have to find ways to rank applicants - all of whom have many good qualities - and thus you can guarantee that your USMLE scores weigh in heavily.

Do I know this for a fact? No. I've never been on any admissions committee or served as a residency coordinator. But common sense should tell you that I'm right!

I absolutely agree, but at the same time you need to remember that these programs are having to deal with you closely for hours on end every single day for 4 years. I don't think they are just looking at your STEP scores and then making their decision on that.

Looking at your character and personality is pretty huge. There is common sense there as well.

 

[BLADEMDA]

I absolutely agree, but at the same time you need to remember that these programs are having to deal with you closely for hours on end every single day for 4 years. I don't think they are just looking at your STEP scores and then making their decision on that.

Looking at your character and personality is pretty huge. There is common sense there as well.

The degree to which programs utilize Step 1 and Step 2 scores depends on the quality of their applicant pool. Some programs have "cut-offs" and unofficial "cut-offs" for actually matching at their program. Others simply want an "average" Step 1 score and a decent applicant they can work with for 3-4 years. Temple is more in the latter group than the former so Step scores above a basic number like 215-220 (?) may simply not be that important to the Chair. After all, what matters is the ability to interact with others, do cases, learn the specialty and pass your Boards.

 

[BLADEMDA]

"Evolving" - what a great word!

Surgeons (grudgingly) acknowledge us as gatekeepers who allow or block procedures, but by no means do they routinely value our input. To them, we are a tool for them to get their surgeries done and they are often uninterested in our input unless it really matters (and even then, sometimes they're not interested). Don't tell me that you've never performed a procedure under general anesthesia rather than regional, or given a unit of blood you didn't think was necessary, simply because the surgeon requested it! This is the way of private practice, which is where most of us end up working. In the end, it's the surgeon's patient, they think they know more than we do on pretty much everything, and they have the final say. We simply comply (as long as it's not harmful) and document "at surgeon's request" on our records.

While it's true that we can be "logistic experts" who can tackle "operational issues", I'd hate to think that I went through all this training for non-clinical purposes.

The Chair is in academia. His world is NOT your world so relax a bit with the negative comments. The specialty has lots of issues with the Number 1 being CRNA/AANA encroachment and my bet is the Chair is well aware of this issue. The second big issue, maybe even the elephant in the room, are the AMCs/Management companies which have taken over a significant percentage of private practices in the large Cities on the East Coast. These two issues may mean the newly minted Temple Anesthesiologist is simply a "provider" of services for the man. This translates into less than full "physician" status at some institutions but I am not sure the Chair is fully aware of the decline of the specialty based on his vantage point from the Ivory tower.

 

[ElmerFudd]

I absolutely agree, but at the same time you need to remember that these programs are having to deal with you closely for hours on end every single day for 4 years. I don't think they are just looking at your STEP scores and then making their decision on that.

Looking at your character and personality is pretty huge. There is common sense there as well.

And you think they can accurately judge an applicant's character and personality from thirty minutes of interviews?

Interviews take place so that they can determine that you're not a weirdo. That's pretty much the limit of an interview, which is fairly important. A candidate ability to make it through a program is best determined by grades and test scores.

 

[BLADEMDA]

And you think they can accurately judge an applicant's character and personality from thirty minutes of interviews?

Interviews take place so that they can determine that you're not a weirdo. That's pretty much the limit of an interview, which is fairly important. A candidate ability to make it through a program is best determined by grades and test scores.

Each year programs admit Med Students who simply can't pass muster. These med students, who have now become Residents, flounder/struggle or simply can't cut the mustard at the Residency. The purpose of the interview is primarily to "weed those people out" regardless of their Step scores. Also, weed out the malignant personalities and anything else that's obvious at the interview. But, despite their best efforts almost every program accepts a "problem child" to their residency every 1-2 years.

Finally, the program needs to "sell" the applicants their bill of goods so they can fill. Remember, programs need to fill because Residents are a cheap source of labor. In addition, mid and lower tier programs may not get good med students from the SOAP (unlike top tier programs which always know that surgical residents or failed ORTHO match people will choose them). This means the program needs to sell itself well enough to get good applicants to rank them. Otherwise, they may end up with more "problem children" than they care to deal with.

 

[ElmerFudd]

Each year programs admit Med Students who simply can't pass muster. These med students, who have now become Residents, flounder/struggle or simply can't cut the mustard at the Residency. The purpose of the interview is primarily to "weed those people out" regardless of their Step scores. Also, weed out the malignant personalities and anything else that's obvious at the interview. But, despite their best efforts almost every program accepts a "problem child" to their residency every 1-2 years.

Finally, the program needs to "sell" the applicants their bill of goods so they can fill. Remember, programs need to fill because Residents are a cheap source of labor. In addition, mid and lower tier programs may not get good med students from the SOAP (unlike top tier programs which always know that surgical residents or failed ORTHO match people will choose them). This means the program needs to sell itself well enough to get good applicants to rank them. Otherwise, they may end up with more "problem children" than they care to deal with.

SOAP?

 

[BLADEMDA]