So You Want to Be an Anesthesiologist

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Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as anesthesiology, and help you decide if it’s a good fit for you.  A lot of you asked for anesthesiology, so that’s what we’re covering here. If you want to vote in upcoming polls to decide what future specialties we cover, make sure you’re subscribed to our MSI YouTube channel.

If you’d like to see what being an anesthesiologist looks like, I have a personal YouTube channel, Kevin Jubbal, M.D., where I do a second series in parallel called a Day in the Life. Once the world is back to a more normal baseline, we’ll be doing a Day in the Life of an Anesthesiologist.

So you want to be an anesthesiologist. You like the idea of being in the operating room, being the patient’s guardian angel, and having a laidback lifestyle. Let’s debunk the public perception myths of what it means to be an anesthesiologist, and give it to you straight. This is the reality of anesthesiology.

 

What is Anesthesiology?

Anesthesiology is the specialty dealing with taking care of patients before, during, and after surgery, or pre-op, intra-op, and post-op. Think of them as the patient’s “guardian angel”, or the one responsible for making sure the patient gets through surgery safely. In addition to ensuring patients are properly sedated and comfortable throughout the operation, they also maintain stable vitals, hemodynamic status (meaning their blood circulation), and an open airway to ensure adequate breathing.

Surgery can be incredibly traumatic to a patient’s body, resulting in violent swings in their hemodynamic status. Without an anesthesiologist, patients would have dangerous shifts in their heart rate and blood pressure. Anesthesiologists administer drugs and make adjustments to maintain vitals in a stable and consistent manner – what they call “railroad tracks”. Patients are also unable to breathe on their own during surgery so an anesthesiologist places a breathing tube, called an endotracheal tube, connected to a ventilator.

Pre-op, the anesthesiologist will see the patient to make sure they are safe to proceed with the surgery, ensuring their medical conditions are stable and they haven’t recently smoked, eaten, or drank anything since the previous day. Otherwise, they could aspirate during surgery, meaning regurgitate and choke on their stomach contents. Intra-op, they’ll be taking care of the patient. And post-op, they’ll ensure safe recovery and pain management.

Contrary to stereotypes, anesthesiology isn’t just about putting people to sleep and then doing crossword puzzles. Sure, there are moments of downtime as an anesthesiologist, but even when things are calm and steady, it requires constant vigilance to anticipate any potential problems. And when things go sideways, they really hit the fan and it’s all hands on deck. This isn’t a specialty for those who aren’t able to handle high-intensity situations.

Anesthesiology is an active sport, and it’s important to anticipate how the patient’s body will respond to what’s happening in surgery. For example, right before the surgeon makes the first incision, they administer a bolus of pain medications to prevent an increase in the patient’s heart rate.

Alternatively, if a patient is losing a high volume of blood during a procedure, which often happens, they are responsible for maintaining stable hemodynamics, which may include fluids like normal saline, blood transfusions, and even vasopressors. This requires not only mastery of physiology and pharmacology, but also astute observation and quick clinical judgment.

You can think of anesthesiology in a few different categories.

Academic vs Community vs Private Practice

First, academic versus community versus private practice.

As an academic anesthesiologist, you’ll be working at a large hospital associated with a medical school. In addition to your regular clinical duties, you’ll also be responsible for teaching medical students and residents. You may also be involved with anesthesiology related research.

As a community anesthesiologist, you’ll be working at a smaller hospital mostly dealing with bread and butter cases, which often include general surgery and orthopedics.

As a private practice anesthesiologist, you’ll be working at privately owned hospitals or clinics where your day will also consist of more routine cases. Private practice and community practice are strictly clinical OR work only and do not include teaching and research. It’s usually higher compensation than academia, but some find it more monotonous.

Inpatient vs Outpatient

Anesthesia isn’t just inpatient as most expect. Inpatient anesthesiologists work in a hospital operating room, usually in larger surgeries that require general anesthesia. General anesthesia is when someone is put under, meaning they are unconscious and require assistance with breathing.

In comparison, sedation depresses one’s awareness such that their response to external stimuli is limited, and they usually have associated amnesia. Anesthesiologists working in outpatient are generally administering sedation rather than general anesthesia. These procedures are smaller in magnitude than surgeries in the OR and are performed either in clinic or in outpatient procedure centers.

Sedation is used for procedures like cataract surgeries performed by ophthalmologists, which we covered in a previous installment of So You Want to Be. Sedation is also used in procedures like colonoscopies, where a camera is used to look at your intestines and GI tract.

OR vs non-OR

Anesthesiologists are typically in the operating room, or OR, but depending on your type of practice, you may be working in other parts of the hospital. For example, critical care anesthesiologists manage patients in the intensive care unit, or ICU. Chronic pain anesthesiologists see patients in clinic, rather than the hospital, who suffer from chronic pain. This involves prescribing various pain medications or administering injections.

 

How to Become an Anesthesiologist

After completing medical school, anesthesiology residency is an additional 4 years.

The first year, or intern year, is a standard intern year where you rotate through a variety of specialties. Your actual anesthesia training begins during your second year of residency, or PGY-2, meaning postgraduate year 2. We call this second year of residency, which is the first year of anesthesiology training, as CA-1, standing for clinical anesthesia year. So as a PGY-2, you’ll be a CA-1.

There are two types of programs: categorical and advanced.

For categorical programs, you’ll do all 4 years at the same institution in an integrated program. The first year, or intern year, can be either a medicine year or surgical year, or even a mix of the two, depending on the program. Medicine intern years generally provide lighter hours than surgical intern years, and this experience provides valuable insight for managing a patient’s cardiopulmonary status, pain, and glucose levels, which will come in handy in the operating room. However, since anesthesiologists will mostly be working closely with surgeons during the rest of their training and their career, surgical intern years also offer valuable insight.

For advanced residency programs, the intern year and clinical anesthesia years are done at separate programs. In this instance, we call the intern year a transitional year, or TY. TY’s occur in other specialties too, such as dermatology, radiology, and ophthalmology. Transition years consist of a mix of medicine, surgery, electives, and research, and are overall considered an easier intern year with lighter hours.

In terms of competitiveness, anesthesiology used to be highly competitive two decades ago. These days, it’s one of the least competitive specialties, second only to family medicine, as we’ve outlined in our 6 least competitive specialties post. The average Step 1 score is 232, and the average Step 2CK score is 244, but the high number of programs and positions means there are several unfilled positions each year.

In terms of the rigor of anesthesiology residency, it’s generally more laid back with predictable hours and generally 55-65 hour work weeks, which is on the lower end compared to many other specialties. And as an attending, 40-50 hours a week is the norm.

It’s no surprise that the students applying to anesthesia are more easygoing and understand the importance of work-life balance. But don’t let the stereotypes confuse you. Anesthesiologists still work hard and have a great deal of pressure to perform and ensure patient safety.

 

Subspecialties within Anesthesia

After anesthesiology residency, you can subspecialize further with any number of fellowships. And good news, each fellowship is only 1 year in length.

Regional Anesthesiology and Acute Pain Medicine

Go into regional anesthesiology and acute pain medicine if you enjoy doing light procedures, like ultrasound-guided regional nerve blocks. You’ll see lots of patients pre-op, doing epidurals before labor, or managing pain in post-operative patients.

When we say regional anesthesia, we refer to blocking pain in a specific area of the body, such as doing a knee block for an ACL repair. This way, the patient doesn’t feel anything from the knee down. Alternatively, median nerve blocks are done in the wrist when operating in certain regions of the hand.

Cardiac Anesthesiology

Cardiac anesthesiology is for those who are hardcore, intense, and somewhat of adrenaline junkies. You’ll be assisting with big cardiothoracic cases, such as open-heart surgery, and may be involved in more sophisticated and nuanced techniques. For example, single lung ventilation is sometimes used to allow the surgeon to operate on the heart without interference from the lung.

This is the second-highest compensated anesthesiology subspecialty, second only to chronic pain.

Chronic Pain

Chronic pain anesthesiologists see patients in clinic and prescribe analgesics or administer injections. You can also become a chronic pain physician by pursuing 4 years of PM&R residency followed by a 1-year chronic pain fellowship.

Compensation for chronic pain specialists is quite high. After all, you’re prescribing medications and performing injections and procedures on patients who are highly dependent on your care, and they’ll be coming back for additional treatment.

Neuroanesthesiology

Neuroanesthesiology is for the brainiacs who are into the esoteric and weird stuff. You’ll assist neurosurgeons who need their patients to be awake during the middle of the case to test brain functions. This subspecialty requires a great deal of planning to execute successfully.

Obstetrics Anesthesiology

OB anesthesiology is strongly female-dominated. These are often anesthesiologists who enjoyed obstetrics but didn’t necessarily want to be the person delivering the baby. You’ll be leading mothers through C sections, and it’s ultimately very rewarding, because at the end of each case you’ll generally have a healthy baby and a happy mom.

Pediatric Anesthesiology

Pediatric anesthesiology is not surprisingly best for those anesthesiologists who love working with kids. Oftentimes, they had surgeries themselves when they were younger and were inspired to help kids because they remember how terrifying it was.

There certainly are big cases in pediatrics, but it’s also not uncommon to be assisting with minor procedures. Young children, after all, are generally less tolerant of certain procedures and may require anesthesia for their own comfort and safety.

Remember, kids are not just little adults, and not only do they have unique physiology, but also require special equipment, like smaller endotracheal tubes and Macintosh or Miller blades.

Critical Care

Critical care anesthesiologists care for patients who are admitted to the ICU. This includes patients who have had major surgery or who suffer from severe infections or trauma. As a critical care anesthesiologist, you will not be working in the OR. Instead, you will be managing the ICU.

Another way to become a critical care physician is 3 years of internal medicine residency followed by a 3-year critical care fellowship. This path will take 6 years, whereas going the anesthesia route will be 5 years. Four years for anesthesia residency, and only a 1-year critical care fellowship.

 

What You’ll Love About Anesthesiology

There’s a lot to love about the field of anesthesiology. It’s one of the ROAD lifestyle specialties, standing for radiology, ophthalmology, anesthesiology, and dermatology. These are specialties with great lifestyles, meaning high compensation and a good work-life balance.

Speaking of work-life balance, you can expect to work regular 9 to 5 hours. And when you’re off, you’re completely off. There’s no need to carry a pager home and be called in during the middle of the night.

If you don’t enjoy clinic, which is a common sentiment, particularly amongst surgeons, know that as an anesthesiologist you won’t have to do clinic at all, unless you want to pursue something like chronic pain.

If you love the OR but don’t want to necessarily be a surgeon, anesthesiology is your best bet. The operating room is a great place to be, where you’ll have an intimate sense of camaraderie with the rest of the surgical team.

 

What You Won’t Love About Anesthesiology

While anesthesiology is great, it isn’t perfect.

Anesthesiologists are unsung heroes, often not receiving the recognition they deserve. Patients will rarely thank you as the doctor. That gratitude gets directed to the surgeon. And oftentimes, others will consider you the sidekick to the surgeon, the Robin to their Batman.

If you’re not fond of high-stress situations requiring quick decision making, then steer clear of anesthesiology. While it’s often calm and relaxed, things can and will go wrong, and a patient’s life will be in your hands.

And lastly, mid-level encroachment into the field of anesthesiology is a growing concern. Mid-level providers, such as CRNA’s, are lobbying for independent practice rights, although this is controversial and is something I will explore in a future post. Many hospitals are now adopting an anesthesia care team model whereby an MD anesthesiologist simultaneously supervises several CRNA’s, each of whom is in an operating room.

This has raised concerns of decreasing employment opportunities for anesthesiologists. However, there are still many opportunities to work in the OR 1-on-1 with the patient, particularly in larger and more complicated cases that require a physician’s expertise.

 

Should You Become an Anesthesiologist?

If you were the student in medical school that loved physiology and pharmacology, enjoyed working with their hands, gravitated toward high-stress situations, and values the importance of work-life balance, then anesthesiology may be a good fit for you.

If you love the OR and want to make it the focus of your life, become a surgeon. But if you like the OR, become an anesthesiologist.

At the end of the day, the operating room is the surgeon’s domain, and you have to be ok with that. Those who crave the spotlight and want to be the person in charge would not be happy working in the background as an anesthesiologist. As my anesthesiologist friend says, “If you do your job right, the patient shouldn’t remember you.”

And finally, while anesthesiology is less competitive than some other specialties, it’s still extremely challenging to get into a strong and desirable residency program.

And who better to learn from and be mentored by than anesthesiologists themselves. Big shout out to the anesthesiologists at Med School Insiders that helped me in the creation of this post. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or anesthesiology residency, our anesthesiologists can share the ins and outs of what it takes and how to navigate the competitive process most effectively.

 

What specialty do you want me to cover next? Leave a comment!

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