Anesthesiology vs FM (vs Surgery)

[thebluecortex]

Hi all,

3rd year med student here. I'm nearing the end of 3rd year and have been able to rule out quite a few specialties, but I'm still undecided and it's driving me crazy. I love the clinic / outpatient setting, couldn't stand the internal medicine wards in the hospital, but enjoyed the OR setting. I've narrowed it down to FM vs Anesthesiology.

Surgery is a distant 3rd. I enjoyed the clinical work, but my personality just didn't mesh with the surgery residents and attendings. I'm also a family-oriented guy with many outside interests, and want a decent life with time available away from medicine. I've almost completely ruled surgery out, unless any of you say based on experience that in residency and beyond, personalities of fellow residents/colleagues don't really matter, and that a decent lifestyle is attainable in surgery.

Also, is it possible to loathe the internal medicine wards but love medicine in the clinic or perioperative medicine? In one possible career path, I envision myself eventually working as part of a pain management clinic. In another path, I see myself working as a Kaiser FP doc.

Anyways, I would really appreciate any opinions on gas vs FP, the future of Anesthesiologists with CRNA's and AA's, the future of FP's with NP's and PA's, and the factors that were most important to you when finally deciding on a specialty.

Thanks in advance.

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[DrBowtie]

Sounds like you want to do FM. If you don't like the surgeon personality, you certainly won't like them when they are barking orders over the curtain doing Anesthesia.

Also, have you done any pain management rotations? The patient population is certainly tough and not for everyone. How much do you actually like doing procedures and lines?

 

[sevoflurane]

Anesthesia as a specialty is certainly paying for mistakes of the past. Consequently, the CRNA model is here to stay. There is a big group in Idaho that is CRNA run. Those CRNA’s HIRE anesthesiologists... so THEY own their MD’s and therefore have the upper hand- Incredible!.

I believe that from now on there will always be a power struggle. I don't think solo practice is going to disappear into thin air, but these opportunities will eventually become less available and perhaps even be considered lucrative. Your income may some day be the same as a FP practitioner. That is what happened in the early 90's. I know of anesthesiologist that were making 100k back then. So don’t do it for $$$.

Additionally, it can be stressful... Had a patient arrive to the OR with a HGB of 3 a couple of weeks ago.... He was 19 y/o and his comorbidities were such that he was trying to check out.... spider sense was saying: “you have to take charge and make this right.. he’s only 19 y/o.” Most of the time it’s chill... but sometimes you need to down that coffee in one swift gulp and show your true colors. Personally, I enjoy that challenge and I’m sure others do too. It’s not for everyone.

All that being said, a day in anesthesia is extremely rewarding... Love the kids, love the moms, and even the pissed off 95 y/o with a story to tell. I like the nurses, the beeping, the procedures... you know... the vibe of anesthesia and the OR. The definition of anesthesia itself conjures some feeling of magic. It is.... Sometimes your patients need to have a gazillion drips doing their special thing... sometimes you step back and think to yourself... dang that’s a lot of stuff keeping this guy alive and I’m driving this train.
You make a difference acutely and in your career you will certainly use your residency acquired skills to save many lives. Sure... it’s not seeing patient after patient in the office...or being the FP on call making his rounds on the floors or ED.... Fact is, every specialty has their issues.

The 19 y/o kid with a hgb of 3 got a 14G angio cath placed and hooked up in nano seconds. Sterility was the betadine pour style technique. His first fibrinogen was 56. Long story short.... I asked my surgeon buddy how he was doing this past tuesday. His answer: “Discharged yesterday”. I would like think I had something to do with that.

Some people on this forum will tell you to find something else.... I will say, maybe so, but in the same breath I would say I hope our specialty can recruit quality med students that will someday represent us in our communities, hospital committees and most importantly our government. We need to show the world what we really do... cuz unless you are in it... you really don’t know.

In the end, I love what I do.... even if I had to supervise.

 

[peppy]

Someone who likes outpatient clinic, apparently enjoys procedures, and likes the idea of seeing patients with chronic pain? I vote for FM. It'll give you some flexibility but still let you have reasonable hours. If you got a "cowboy" program you can get more surgical experience and do things like c-sections. I definitely think it would be a mistake to go for general surgery with your concerns about lifestyle.

 

[BigRedBeta]

1) Is it possible to hate medicine rounds but still be a good general internist? Absolutely, there are a great many internal medicine residents who feel the way you do and are planning to do nothing but outpatient medicine (same thing with pediatrics residents going into gen peds).

I'm of the opinion that students should ONLY go into FP if they have an absolute desire to do every last bit of Family Medicine - paying particular attention to the OB portion (I could also make an argument that you need to plan on living someplace where you'll be allowed to do it all too - if living in a big city is a must, then it's hard to find pregnant women who won't be going to an actual OB). If you don't want to take care of pregnant ladies, don't care about taking care of kids, then you'll be better trained focusing only on Internal Medicine. If you absolutely cannot give up taking care of adults and kids (not just that one population is a nice "bonus") but you shudder at the thought of delivering babies, the possibility of doing C-Sections, etc, then you should go into a combined IM/Peds residency - again, you'll be better trained. This is not a sleight against FM, but simply looking at the length of the residency and all the expectations that have to be fulfilled. It seems to be a poor use of time to learn things that you're never going to use again at the expense of things you will. If you look at it and say, I don't absolutely need to take care of kids to be fulfilled in my career, but I'd be unsatisfied if I never got to see another adult patient, then IM is the best choice (or peds if it's the other way around).

2) Agree with bowtie about the procedure question. You're going to be doing a lot of intubations and lines before you get to that pain medicine fellowship. If those things aren't particularly exciting...you may have a rough go of it. Also, keep in mind that you'll be doing a number of ICU months, and if you go to a IM prelim year, you'll be a third of the way through an IM residency anyways. If clinic is what you really, really love, you're going to get way more time there as an IM resident than as an Anesthesia resident.

 

[PistolPete]

Sounds more like FP to me. You can still do procedures, even focus on derm if you like that, all while having a better lifestyle than surgery, and probably anesthesia.

Have you done an anesthesiology rotation? Do one if you're not sure. Maybe that'll convince you one way or another.

 

[GoodmanBrown]

This is a tough one because they're so entirely different.

I've spent some time shadowing anesthesiology residents in med school and I ended up becoming less interested the more I shadowed. In a weird way, I found that it had a lot of teamwork and simultaneously left me feeling like I'd be very isolated. It seemed like almost all the interactions were "business." It was always stuff like, "Mr. Jones says he's got 7/10 pain. Can we give him more meds?" or "Table up, please." And the rest of the time was mostly sitting at the head of the bed prepping meds, charting, etc.

FM was a different beast. Sure, there's a time crunch and you're not spending hours shooting the breeze with patients, but you at least ask how they're doing and how their day's going. Maybe ask about their daughter or wife or whatever. To me it seemed like there was more of a connection there with other people.

The other thing I like about FM is the autonomy. If you're willing to relocate to a smaller town, solo practice is still entirely doable. In almost any location, you can join a small practice and basically have 1/3 to 1/5 of the entire say in how the business is run.

Anesthesiology will never have something like that. You're too intertwined with the surgeons, the hospital, your partners, perhaps CRNAs. The autonomy just seems a lot lower. The pay is considerably better right now, though.

Sev's said some stuff about CRNAs, so I won't touch that. But every FM attending I've talked to isn't even remotely worried about NPs. One told me that only if every RN in America became an NP would FM docs notice a change. He said every FM doctor in his entire town is refusing new patients because they're booked. So, he said he's not losing sleep over it.