Two days into my very first anesthesiology rotation, and I've got more questions than answers!

[Doctor_Strange]

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I did this rotation kind of on a whim -- I liked the pharmacology and physiology aspect that I was exposed to during my preclinical sciences and even when while studying for my Step 1 (ie blood-gas coefficient, PEEP, MAC, etc. these kinds of things). I don't think I have the personality for surgery, although, I have not yet done my surgery rotation (I've found myself paying attention to the surgeon during the operation more so, sometimes I need to remind myself to return my attention to the anesthesiologists/CRNA). Coupled with the fact that I often hear anesthesiologists are generally relaxed, chill, and easy-going physicians relative to other fields, I decided to check it out. Anyways...

I've enjoyed these last two days. The doc I am with manages four rooms concurrently usually, overseeing CRNAs, AAs, in a community hospital setting. As he put it, he does 20% with the patients one-on-one, but the remainder of his time is going between rooms, checking in on the patients, may relieve the CRNA/AA for bit, and then move onto the other rooms. He says the CRNAs are well-trained and he enjoys working with them. He loves the specialty, and after telling him of my interest, he is really passionate to teach me even more.

Despite this, I can't help but wonder something that I know is beaten to death on SDN and reddit: how the role of the anesthesiologist is changing. For instance, I spend probably half or two-thirds of the day in the OR with the CRNA, and they have been the ones teaching me the little details and concepts in anesthesiology. I'm okay with this entirely since I am such a novice. But, it got me thinking that what will the difference be in my residency if I were to pursue anesthesiology? Outside of a more intense and likely broader scope of training, I mean the CRNAs are kind of running the show albeit with careful oversight from the anesthesiologists? I don't know, but do most anesthesiologists practice like this, i.e. oversee multiple ORs, and not spend one-on-one time with a given pt throughout the case? Does the fact that there are only 5 anesthesiologists at a given time between the ORs with double or so CRNAs/AAs suggests the role of the anesthesiologists becomes less as we move forward (on the other hand, the attending said to me, "We need more anesthesiologists." so clearly the demand is there). I will eventually ask this of my attending, but I don't want to come as prude. I've been reading this forum and on reddit for quite some time -- I am aware that the CRNA professional societies are doing what they can to advance their field and even add anesthesiologist to their title. Despite this, I still have enjoyed the past few days.

I am also interested in emergency medicine, and I think one parallel that I was not expecting was the role of managing midlevels. Perhaps that is happening in every field though. Regardless, I welcome any thoughts, advice, or criticisms of my current thinking. I guess I am slightly anxious if I decide to actually go all-in on the field. While I haven't fallen head over heels yet, I will continue to keep an open mind over these next two weeks!

Sorry for the scrambled thoughts -- my mind is all over the place!

 

[p30doc]

Depends where you are in the country whether or not CRNAs are prevalent. 50% of my job offers when I finished a couple of years ago were for supervising crnas and the other 50% were for doing 100% of my own cases. I chose to do my own cases for a variety of reasons and am happy I made that choice.

 

[ethilo]

I project there's always going to be a need for anesthesiologists. The more you specialize the more you set yourself apart from someone who just goes through the motions. Since you are at the core a doctor, you're able to float between different areas, mainly the OR and ICU realm, also your a functional imaging person (ultrasound, TEE) which is a skillset unique to anesthesia. Your ability to float through so many facets in medicine sets you apart from a CRNA who can't really stay undifferentiated with a large skillset just because they don't have the hours of training to cover as much ground as you do.

Anesthesiology is such a central point for so many different directions that I don't think you'd be hurting yourself by pursuing this field.

 

[Doctor_Strange]

Depends where you are in the country whether or not CRNAs are prevalent. 50% of my job offers when I finished a couple of years ago were for supervising crnas and the other 50% were for doing 100% of my own cases. I chose to do my own cases for a variety of reasons and am happy I made that choice.

My suspicion is that that both types of jobs pay the same, or would that be incorrect? Because, I imagine managing four different ORs is four different billings to the anesthesiologist? Alternatively, the doc is 50+, so perhaps he has more of a thrill managing multiple rooms than doing one case at a time...

I live in the Southeast as well, so not sure what the landscape is like elsewhere in the country.

 

[dhb]

Despite this, I still have enjoyed the past few days.

Anything can be enjoyable when you are a premed with no responsability.
Try to think long term, it is very hard to grasp the intricacies and implications of a specialty as a med student.

 

[Doctor_Strange]

Anything can be enjoyable when you are a premed with no responsability.
Try to think long term, it is very hard to grasp the intricacies and implications of a specialty as a med student.

Well that is exactly my challenge! I am trying to understand and appreciate the intricacies and implications of anesthesiology and think long-term the direction of the field. Of course, I can only speculate but at least I've been trying to inform myself via SDN etc. The thought of picking a field and becoming dissatisfied after awhile is a troubling thought I often have coupled with the fact that as a medical student I only can spend so much time in a given field during third year before making such an important decision.

 

[Doctor_Strange]

I project there's always going to be a need for anesthesiologists. The more you specialize the more you set yourself apart from someone who just goes through the motions. Since you are at the core a doctor, you're able to float between different areas, mainly the OR and ICU realm, also your a functional imaging person (ultrasound, TEE) which is a skillset unique to anesthesia. Your ability to float through so many facets in medicine sets you apart from a CRNA who can't really stay undifferentiated with a large skillset just because they don't have the hours of training to cover as much ground as you do.

Anesthesiology is such a central point for so many different directions that I don't think you'd be hurting yourself by pursuing this field.

Thanks for the insight!

 

[Neopolymath]

Buddy, this forum has discussed all of these generalities for years. You probably need to be a little more specific and some posters will respond without sarcasm and angst.

 

[Doctor_Strange]

Buddy, this forum has discussed all of these generalities for years. You probably need to be a little more specific and some posters will respond without sarcasm and angst.

That's fair! I think I will talk to my attending first as a springboard later this week and then return to this forum with some more cohesive thoughts/questions.

 

[Consigliere]

Do ER. You'll thank me (profusely) later. Don't ask any follow up questions, kid cuz they won't be answered.

 

[UnoMas]

Do EM if you are ok with:
- Dealing with drug addicts, nutjobs, chronic abdominal pain that has been scanned thousands of times, homeless people, potheads that get paranoid and come to the ED everytime they get high and feel a little nauseous, people who come to the ED for med refills and work excuses, risk of physical and verbal abuse from all of the above
- Signing midlevel charts and be responsible for their action without seeing the patients
- Rapidly expanding residency programs, HCA ED residencies, random podunk ER level 3 trauma with 5k ER visits a year now has a residency
- Similar level of pressure from NP and PA lobbying for independence
- Facing the same level of pressure if not more from administration, you will literally be a cog in a machine
- Consultants from all specialties hate getting pages and calls from you cause the majority of the time it’s bs to cover your bases

 

[PieOHmy]

- Consultants from all specialties hate getting pages and calls from you cause the majority of the time it’s bs to cover your bases

Because the more you call them the less they make. If it were reversed they would LOVE you

 

[Clockdoc89]

Just to piggy back on this post I am an MS3 with the exact same mentality as OP and couldn't have worded my concerns any better.

I am between this and optho and just the super specialized nature of optho is a bit of a turn off for me so I'm leaning towards anesthesiology with a fellowship in something, haven't quite figured that out yet.

What fellowships would be useful in separating myself from CRNAs while making more of an asset to a hospital and give me more negotiating power?

Not necessarily concerned with maximizing profits (do want to make a good living though) as I am with finding a good choice for a career that is intellectually stimulating, a mix of procedural and cerebral, and is not a glorified triage service like ER.

 

[Mikkel]

What fellowships would be useful in separating myself from CRNAs while making more of an asset to a hospital and give me more negotiating power?

You don't need a fellowship to separate yourself from CRNAs, they do a good job at that.

All you have to be is a physician who actually knows how to practice medicine and you'll be automatically better than 99.999% of all CRNAs. (The other 0.001% ended up going through medical school training later.)

 

[Clockdoc89]

You don't need a fellowship to separate yourself from CRNAs, they do a good job at that.

All you have to be is a physician who actually knows how to practice medicine and you'll be automatically better than 99.999% of all CRNAs. (The other 0.001% ended up going through medical school training later.)

I definitely agree with the above but do administrators hold the same view?

It's sad that they have this much influence to begin with and I have to tailor my training to their perception of what is valuable but that seems to be the reality we're in unfortunately. My hope is what interests me aligns with what is deemed valuable and has a spot at the table but few are so lucky.

So the question is, what could I do as an anesthesiologist to counter this influence on an individual basis rather than legislative or political means? To me the answer seems to be subspecialize, and the follow up is in what?

 

[Mikkel]

I definitely agree with the above but do administrators hold the same view?

It's sad that they have this much influence to begin with and I have to tailor my training to their perception of what is valuable but that seems to be the reality we're in unfortunately. My hope is what interests me aligns with what is deemed valuable and has a spot at the table but few are so lucky.

So the question is, what could I do as an anesthesiologist to counter this influence on an individual basis rather than legislative or political means? To me the answer seems to be subspecialize, and the follow up is in what?

If they were bringing in business like surgeons, then that would be different, but they're just anesthesia nurses.

Administrators want efficient, well run operating rooms. Anesthesia nurses don't add anything to the management of that, so why would they be in charge?

What's their first order of business? Get longer lunches and breaks and fewer hours worked for same salary? Give me a break.

Anesthesia nurses will try to do "fellowships" in the future. What are you going to do at that point in your dystopian future?

 

[Doctor_Strange]

I worked today with two anesthesiologists, the first who was senior in the group, who sincerely said that for recent grads from residency a fellowship is essentially required to be hired by the group to be competitive. The second anesthesiologist, the one that was hired, did a cardiac fellowship, and said as much -- doing a one year fellowship guaranteed is necessary whereas 10 years ago it was not.

 

[Mikkel]

I worked today with two anesthesiologists, the first who was senior in the group, who sincerely said that for recent grads from residency a fellowship is essentially required to be hired by the group to be competitive. The second anesthesiologist, the one that was hired, did a cardiac fellowship, and said as much -- doing a one year fellowship guaranteed is necessary whereas 10 years ago it was not.

It's degree inflation. It's why people now say you need a graduate degree where a college degree would be sufficient, or a college degree where a high school degree would be sufficient.


If you "need" a bullsh*t fellowship to get a job, you're looking in the wrong geographic area.


That job is probably geared toward enriching the seniors at the expense of the younger guys, but it's just a hunch.

 

[PieOHmy]

It's degree inflation. It's why people now say you need a graduate degree where a college degree would be sufficient, or a college degree where a high school degree would be sufficient.


If you "need" a bullsh*t fellowship to get a job, you're looking in the wrong geographic area.


That job is probably geared toward enriching the seniors at the expense of the younger guys, but it's just a hunch.

I agree,
If you need a extra year fellowship just to get a job.. F*** that.
I can see ICU or pain. but NOTHING ELSE.

 

[nimbus]

I definitely agree with the above but do administrators hold the same view?

It's sad that they have this much influence to begin with and I have to tailor my training to their perception of what is valuable but that seems to be the reality we're in unfortunately. My hope is what interests me aligns with what is deemed valuable and has a spot at the table but few are so lucky.

So the question is, what could I do as an anesthesiologist to counter this influence on an individual basis rather than legislative or political means? To me the answer seems to be subspecialize, and the follow up is in what?

Subspecialize in a nice sales pitch and schmoozing administrators. 98+% of cases being done do not require a fellowship of any kind. We get more new hires with peds, cardiac, and icu fellowships than we know what to do with. There are not enough of those cases to go around. The need is primarily for generalists. That is the current state of affairs in my area.

 

[Mikkel]

Subspecialize in a nice sales pitch and schmoozing administrators. 98+% of cases being done do not require a fellowship of any kind. We get more new hires with peds, cardiac, and icu fellowships than we know what to do with. There are not enough of those cases to go around. The need is primarily for generalists. That is the current state of affairs in my area.

Who would have thought that a decade of a lot of academic anesthesiologists lying to residents about the necessity of a fellowship for getting a job would lead to an oversupply of subspecialized anesthesiologists.

 

[abolt18]

I worked today with two anesthesiologists, the first who was senior in the group, who sincerely said that for recent grads from residency a fellowship is essentially required to be hired by the group to be competitive. The second anesthesiologist, the one that was hired, did a cardiac fellowship, and said as much -- doing a one year fellowship guaranteed is necessary whereas 10 years ago it was not.

I can tell you that it is not "essential" because my program has plenty of people graduating the last few years who are not interested in fellowship and none ever seem to have any problem finding jobs at all.

 

[DirtDocMD]

There are going to be plenty of jobs for years to come, but the question is, will they be GOOD jobs??? Every hospital is literally ONE jerk-off administrator away from a complete shakeup of the anesthesia department.

There’s some good surgery center jobs out there. There are also plenty of bad ones, where your job is little more than herding patients through like cattle.

I can’t imagine, at this point, why ANYONE would pick anesthesia over opthalmology, if you’ve got the goods to go optho.

Pick your area of practice. No call schedule. No jack-off/jerk-off surgeons to wait on. No jack-off/jerk-off admins. You don’t even have to “kiss up” to PCP’s, like some surgeons do, in order to maintain a referral base. If folks have an eye problem, they just go to the eye doctor.

Endocrinology would be another interesting field. Little to no call. Everywhere I’ve been, they have so much business and so little competition, they can refuse basic diabetic and thyroid management, and stick with “interesting” stuff, and it’s the kind of work that actually allows you to sit down with a book and “study” a problem, rather than having to make a snap life decision in a matter of seconds. Maybe not “exciting”, but “exciting” gets old when you’re 55, up at 3 am, and are putting your license/earnings on the line for certain folks who can’t be bothered to care about their OWN health (drunken/drug fueled stupidity et al)....

 

[PieOHmy]

There are going to be plenty of jobs for years to come, but the question is, will they be GOOD jobs??? Every hospital is literally ONE jerk-off administrator away from a complete shakeup of the anesthesia department.

There’s some good surgery center jobs out there. There are also plenty of bad ones, where your job is little more than herding patients through like cattle.

I can’t imagine, at this point, why ANYONE would pick anesthesia over opthomology, if you’ve got the goods to go optho.

Pick your area of practice. No call schedule. No jack-off/jerk-off surgeons to wait on. No jack-off/jerk-off admins. You don’t even have to “kiss up” to PCP’s, like some surgeons do, in order to maintain a referral base. If folks have an eye problem, they just go to the eye doctor.

Endocrinology would be another interesting field. Little to no call. Everywhere I’ve been, they have so much business and so little competition, they can refuse basic diabetic and thyroid management, and stick with “interesting” stuff, and it’s the kind of work that actually allows you to sit down with a book and “study” a problem, rather than having to make a snap life decision in a matter of seconds. Maybe not “exciting”, but “exciting” gets old when you’re 55, up at 3 am, and are putting your license/earnings on the line for certain folks who can’t be bothered to care about their OWN health (drunken/drug fueled stupidity et al)....

Dont forget about Allergy/Immunology. That 's perfect as far as i can see.

 

[Doctor_Strange]

It's degree inflation. It's why people now say you need a graduate degree where a college degree would be sufficient, or a college degree where a high school degree would be sufficient.


If you "need" a bullsh*t fellowship to get a job, you're looking in the wrong geographic area.


That job is probably geared toward enriching the seniors at the expense of the younger guys, but it's just a hunch.

East coast, coastal city so that may indeed play a factor! Neither doc was bitter or pessimistic about it I should add; in fact, the fellowship-trained simply said he gets paid more as a result.

 

[Doctor_Strange]

Subspecialize in a nice sales pitch and schmoozing administrators. 98+% of cases being done do not require a fellowship of any kind. We get more new hires with peds, cardiac, and icu fellowships than we know what to do with. There are not enough of those cases to go around. The need is primarily for generalists. That is the current state of affairs in my area.

Interestingily enough, the fellowship-trained doc I was with does more general anesthesia than what he was fellowship was in; he doesn't mind since he gets paid by the minutes, not cases.

 

[Doctor_Strange]

There are going to be plenty of jobs for years to come, but the question is, will they be GOOD jobs??? Every hospital is literally ONE jerk-off administrator away from a complete shakeup of the anesthesia department.

There’s some good surgery center jobs out there. There are also plenty of bad ones, where your job is little more than herding patients through like cattle.

I can’t imagine, at this point, why ANYONE would pick anesthesia over opthalmology, if you’ve got the goods to go optho.

Pick your area of practice. No call schedule. No jack-off/jerk-off surgeons to wait on. No jack-off/jerk-off admins. You don’t even have to “kiss up” to PCP’s, like some surgeons do, in order to maintain a referral base. If folks have an eye problem, they just go to the eye doctor.

Endocrinology would be another interesting field. Little to no call. Everywhere I’ve been, they have so much business and so little competition, they can refuse basic diabetic and thyroid management, and stick with “interesting” stuff, and it’s the kind of work that actually allows you to sit down with a book and “study” a problem, rather than having to make a snap life decision in a matter of seconds. Maybe not “exciting”, but “exciting” gets old when you’re 55, up at 3 am, and are putting your license/earnings on the line for certain folks who can’t be bothered to care about their OWN health (drunken/drug fueled stupidity et al)....

As an aside, any regrets or "what-ifs" about not pursuing surgery? I wonder how many anesthesiologists came over from surgery or switched over during medical school.

 

[DirtDocMD]

As an aside, any regrets or "what-ifs" about not pursuing surgery? I wonder how many anesthesiologists came over from surgery or switched over during medical school.

I was in the middle of my med school class. Not a superstar, and not bad, either. Neurosurg or ortho would have been a stretch, and General Surgery didn’t interest me. I could have possibly “lucked out” and got a spot in ortho or neurosurg, but I never seriously saw myself in those specialties.

I had initially thought I’d do IM, with a pulmonary critical care fellowship. Realized I didn’t like the snail’s pace of ICU mgmt, and all day/all night phonecalls, either.

I started thinking I wanted to live in a SMALL town, and convinced myself Family Practice was the way to go. I got into a really great FP residency program, and within a month or two, knew I’d made a mistake. There was simply TOO MUCH info to ever really “master” it, and some of the pt’s simply made me miserable.

I had the good fortune of having a friend in a great anesthesia program, who put in a good word for me, that had a program director who was formerly an FP Doc. I was able to line up a spot, and finish up my first year of FP as my transitional year.

Anesthesia, to me, was kinda like the aspects of Pulmonary/CC that I liked, without the prolonged time frame to “see results”. I could make stuff happen in the OR in minutes, rather than waiting hours or days in the ICU.

I’ve enjoyed most of it. However, these days, there’s simply too many folks trying to boss “Anesthesia” around. It used to mainly just be the surgeons. Now, it’s administrators, AMC’s, OR directors, and the list goes on.

No matter what you do, there’s gonna be azzes to kiss, but the list is starting to get too long for Anesthesiologists....

 

[WholeLottaGame7]

Do EM if you are ok with:
- Dealing with drug addicts, nutjobs, chronic abdominal pain that has been scanned thousands of times, homeless people, potheads that get paranoid and come to the ED everytime they get high and feel a little nauseous, people who come to the ED for med refills and work excuses, risk of physical and verbal abuse from all of the above
- Signing midlevel charts and be responsible for their action without seeing the patients
- Rapidly expanding residency programs, HCA ED residencies, random podunk ER level 3 trauma with 5k ER visits a year now has a residency
- Similar level of pressure from NP and PA lobbying for independence
- Facing the same level of pressure if not more from administration, you will literally be a cog in a machine
- Consultants from all specialties hate getting pages and calls from you cause the majority of the time it’s bs to cover your bases

Are you still a resident? Because the bolded is only true in academic hospitals. In my limited experience in a community environment, consultants love getting consults, because it's more money. Even if it's bogus, because that just makes it that much faster/easier.

 

[WholeLottaGame7]

As an aside, any regrets or "what-ifs" about not pursuing surgery? I wonder how many anesthesiologists came over from surgery or switched over during medical school.

The ratio of anything transferring to anesthesiology vs anesthesiology transferring to anything else is at least 20:1, from what I can estimate.

 

[deleted171991]

The ratio of anything transferring to anesthesiology vs anesthesiology transferring to anything else is at least 20:1, from what I can estimate.

That's also because it's been way more difficult to get into categorical surgery than anesthesiology. Plus surgery is a harder residency.

Where I trained, the ratio was 1:1, maybe 2:1; we took a surgical resident and kicked out an anesthesiology one per year, on average. Every few years we would have an internal medicine refugee, too.