@BeddingfieldMD would you care to share your views on the future of anesthesiology as a career and how you think medical students view it nowadays?
Thanks for asking. I actually remember the earlier variation of this thread several years ago when I was still considering specialties. I think anesthesiology is still in the "moderately competitive" pack as it was in 2010. By that I mean the mean Step 1 score of matching applicants is squarely in the middle of the second tier (230s). There are a cluster of specialties whose mean matching Step 1 scores are clearly above, which could be considered the first tier specialties--and most competitive. These include dermatology, ENT, neurosurgery, orthopedic surgery--as well as some not in the main match such as urology. Then there are a handful of specialties whose mean matching Step 1 scores are lower (200-220), which could be labeled the third tier. These are family practice, general pediatrics, and PM&R. Assigning adjectives to these tiers, I would say the first tier specialties are "highly competitive," the second are "moderately competitive," and the third tier are "less competitive." Because at the end of the day, there is obviously some competitiveness with any specialty in the match process. You're probably going to be limited geographically even in something like family practice if you have failed Step 1 multiple times, have lots of failing grades on your transcript, have some bad letters of recommendation, and were suspended for unprofessional conduct for some period of time. A truly "noncompetitive" specialty would literally take anyone with a pulse. But of course, we all know there's a difference between ENT, EM, and FP, to use one example from each tier of specialties.
So then the question is, "Why is anesthesiology not
more competitive?" In other words, why isn't it in the ranks of ENT, orthopedics, plastic surgery, etc.?
A specialty's competitiveness is a combination of several factors. First is the number of available residency positions. Most very competitive fields have small residency classes--and are small fields altogether. Think of ophthalmology, dermatology, ENT, and plastic surgery. This is a simple supply and demand equation. If a program only needs to find 2-3 warm bodies to fill its available positions, it can be
very picky compared to a program that needs to fill 15-20 positions in order to keep the operating rooms running each year. Per the NRMP in 2014, there were 1,564 anesthesiology residency positions offered (including both advanced and categorical). Compare that to 400 dermatology positions or 295 ENT spots. Even orthopedic surgery (one of the largest of the highly competitive specialties) only offered 695 positions.
Second, a specialty becomes more competitive if it offers a reasonable lifestyle--even more so if that is true during training
and post-training practice. Here again, many highly competitive fields like dermatology, ophthalmology, and radiology fit the bill. Orthopedic surgery, ENT, and plastic surgery don't typically fit this description during training, but there are certainly opportunities for many of these surgical subspecialists to lead fairly regular lives after training--much more so than with OBGYN, for example. I would say anesthesiology is in kind of a middle ground here. It often has a lot of overnight call, both in training and afterwards (unless one subspecializes in pain medicine). But it is certainly among the hospital-based fields (many of which populate the ROAD specialties, as already mentioned) that offer the benefit of being truly "off the clock" once one leaves the hospital. Unless an OR-based anesthesiologist is on home-call, the pager can be routinely turned off without repercussions. So for most anesthesiologists that have to do labor epidurals or respond to trauma cases during at least some portion of their careers, the field isn't quite as nice as office-based specialties like dermatology. But it's still on the nicer end of the spectrum compared to most medical specialties.
Third, a specialty obviously becomes more competitive if it pays well. Depending on which part of the country one works, reimbursement and/or salaries in anesthesiology are still lucrative. Without trying to get into too many specifics, I'll say that I don't know many anesthesiologists working full-time in an OR-based setting (i.e. not at a cushy, 8-3 surgery center) that make less than $250k. And I know many in "less desired" locations making in excess of $500k. There are even a few hard-working jobs out there that approach or exceed seven figures--though as hospital/insurance conglomerates continue to gobble up private groups, that is becoming less and less common. Sure, the average orthopedic surgeon, neurosurgeon, or interventional cardiologist may make a bit more than the average anesthesiologist. But in all reality, the diminishing returns at those salary levels due to the progressive tax system in this country makes any real differences fairly insignificant. And obviously, that leaves a whole lot of specialties that typically earn quite a bit less than most anesthesiologists. I would imagine this reality is why anesthesiology is as competitive as it is--and as we saw in the 1990s, its competitiveness as a field would decline drastically if salaries were to drop significantly. The same has happened to radiology in the past. Then there comes to be a big shortage of specialists in the field, salaries go up again, and the cycle repeats. Because anesthesiology just isn't a "typical doctor" specialty that most med students think of when choosing specialties, it will always be more susceptible to these waxing and waning periods of popularity--again, much like radiology.
Fourth, a specialty will be more competitive if it is enjoyable work. I think many medical students choose anesthesiology in part because they find it a refreshing respite from many of the things they
don't like about other specialties through which they rotate. I know this certainly influenced my decision. Many students enjoy the pace and atmosphere of the operating room. They like the hands-on nature of the work: putting in lines, managing the airway, etc. They enjoy the lack of endless rounding and paperwork. You get the idea. I'm sure for those who choose the specialty, this is a check in the positive category for anesthesiology. On the other hand, many don't like working with surgeons, dealing with OR nurses, not having patient continuity, etc.--so I guess it could go either way.
Finally, a specialty should be stable and have a predictable trajectory over one's career (20-30 years) for it to be in the highly competitive tier of specialties. I think this is one category in which anesthesiology doesn't do as well. One could argue that hardly any specialties fit this bill currently, and there's probably truth to that. But because of the much smaller size of the field and the fact that many more of its practitioners still own their own practices, I would argue that ENT, for example, is probably much more stable over the next 2-3 decades than anesthesiology. Of course, the overall national healthcare environment, reimbursement, insurance, and other such factors are out of everyone's direct control. But because most anesthesiologists are completely dependent upon hospitals and/or surgery centers for their employment, they are particularly susceptible to national and regional trends among hospitals and insurance companies in regards to employment models (1099 vs employee), group contract negotiations (always the threat of the outside staffing agency or the "competitive group down the street with lots of promises"), staffing models (MD-only, ACT, AA vs CRNA, CRNA-only, collaborative), and arbitrary hospital requirements (TEE certifications, in-house call, OB coverage, trauma, pediatric certification).
Unlike specialties that drive patient acquisition (surgeons, proceduralists, clinic-based docs), hospital-based specialists that depend on patients coming to them by way of others (anesthesiologists, radiologists, hospitalists, pathologists) inherently have less control and can dictate fewer demands upon the hospitals. To be sure, there are benefits to
not driving patient acquisition in the way of no long-term responsibility over patients, a "pager-off" mentality once one leaves the hospital, more geographic flexibility, not having to build up a practice, etc. But there are also downsides, and the biggest one is probably the complete dependence upon the hospital and/or surgery center for one's livelihood--and the resulting loss of control. The anesthesia groups with the most power are those in remote geographic locations, where there is seldom more than one anesthesia group in town and hospitals know they would have a hard time recruiting adequate replacements if necessary. Personally, I think this is why in large, urban areas, private anesthesia groups with stable hospital contracts continue to cede territory to hospital employment models and competitive from outside staffing firms.
Oh, and of course I would be remiss without mentioning CRNAs. I do think the drawn-out bickering and political infighting between the ASA and the AANA is probably a drag on anesthesiology's competitiveness. But in all reality, as a practicing anesthesiologist, I would argue that the above issues are more concerning to me personally than politically active CRNAs. Not to say there aren't real issues with that situation. Yes, there are CRNAs who would love to staff surgery centers independently. There are some who think they are equivalents and can do everything exactly the same. It is certainly annoying when these political battles enter one's workplace. And it's a shame that the ASA has devoted and continues to devote so much energy to these issues, considering that there are so many battles also being fought against politicians, insurance companies, hospitals, etc. But I think this is more of an abstract concern than one of actual employment security. I have seen some hospitals that were previously MD-only migrate to a care-team environment, and that can certainly be unsettling to the labor market over a short period. And indeed, some parts of the country may benefit from shrinking the sizes of their residency programs over time because of this continued trend. But I don't foresee a time in the next 20-30 years in which busy, high-acuity hospitals with lots of ASA III/IV patients completely replace anesthesiologists with CRNAs. But yes, of course it would be foolish to suggest that the time and energy wasted on this issue in the specialty isn't another drag on the specialty's competitiveness. To be sure, there are certainly other specialties with similar political battles, including EM, family practice, etc. But it's been going on much longer with anesthesiology. From my perspective, I just took this issue for granted when choosing specialties and considered it already "baked into" the specialty. It's been going on for 30 years and will likely continue in some form through the end of my career.
So to summarize... I think anesthesiology was what I would consider a "moderately competitive" field 7 years ago when I chose my specialty--and probably still is. One thing I did notice is that my residency class actually had a couple of FMGs (very good clinicians who had rocked Step 1 and I'm sure were among the best from their classes), but we didn't interview a single FMG by the time I was a senior resident helping with interviews. And overall, it seemed like average Step 1 scores of applicants had increased--though there was a bit of general score inflation during that period, I believe. So could one say the specialty is a bit
more competitive currently than it was 7-8 years ago? Maybe, but probably still within the same general tier of competitiveness. If anything, I think the overall interest in medicine and number of med school applicants has increased, so the overall pool is probably more competitive now than a decade ago.
Is it still a good specialty? I think so, as long as you have reasonable expectations and know what you're getting into. Much more than any issues with CRNAs (and more importantly their political lobbying groups), I think the biggest continued battle our specialty will have in the next 10-20 years will be a result of the continued consolidation of hospital networks and insurance providers. That ultimately reduces our power and increasingly turns us (along with other hospital-based specialists) more and more into interchangeable cogs in the medical machinery--at least from the perspectives of the hospital administrators.
One other thing I would mention to med students considering the field is that nearly all hospital-based jobs that most folks get out of training will involve a decent amount of overnight call, which is frequently in-house and includes a lot of OB practice. Residency programs sometimes separate out OB rotations, such that you spend the vast majority of your training in the operating room and then do a few months of OB, completely separate from the rest of your practice. Know that in private practice anesthesia, a big chunk of your time is spent with OBGYNs, epidural placement and management can be a large part of your practice, and women still want epidurals at all hours of the night!
🙂 So there are some "lifestyle" aspects to the field, to be sure. But dermatology it ain't.
Good luck!
