ANNOUNCER:
This is Residents in a Room, an official podcast of the American Society of Anesthesiologists. Where we go behind the scenes to explore the world from the point of view of anesthesiology residents. This episode of is sponsored by ASMG, a physician only, privately owned practice group serving the San Diego area. The ASA thanks ASMG for their support.
WEI:
The reason why I want to go to medical school…
JOE:
At least for me, appreciate what I’m doing.
RICKY:
THAT, scares me.
SHARRA:
Welcome to Residents in a Room, an ASA podcast featuring, you got it, Residents in a Room. I’m Dr. Azad a CA2 Resident at Tufts Medical Center and I’m here with some fellow residents.
JOE:
Hi, my name is Joe. I’m a CA2 from Beth Israel Deaconess.
RICKY:
My name is Ricky. I’m a CA3 Resident from Massachusetts’ General Hospital.
WEI:
My name is Wei Chen. I’m a CA1 Resident from Tufts Medical Center.
SHARA:
So, today we’re going to jump right into the subject of practice settings and career goals. So first let’s flesh out our options. What types of practice settings have you heard about.
JOE:
Um, so I think our best known area…where we spend most of our time is the hospital setting or in-patient setting but we also as anesthesiologists and trainees we go to out-patient settings like pain clinics and also different areas of the hospital, so…
RICKY:
You know, a big breaking point is academia versus private practice, right, and the challenges — not the challenges but the different types of practice settings or groups that come with each of those. You know, if you’re in the OR setting specifically.
SHARA:
Yeah, um, I think when you’re a trainee because you tend to be in academia since those are the settings that host trainees it’s pretty rare to know, like, very much about private practices but then most anesthesiologist are employed in private practices. Uh, so, what types of setting are you all considering?
RICKY:
I plan to stay in academia. I like the thought, at least, immediately post fellowship of working at a big academic center where they have, potentially, lots more resources. I don’t want to make a blanket statement and say you can’t have lots of resources at a large private practice but I think academia is attractive to lots of people for the reasons that you were just saying. You know, it’s what we’re used to so it kinda I think will help to ease the transition into, into practice a little easier.
JOE:
Yeah. I think that makes a lot of sense. Um, I’m kind of torn between what I’m going to do. I think I do want to do a fellowship, also possibly pediatrics too. Um, but after that I don’t know where I want to end up. Um, I think I do want to go to some sort of academic practice in the future at some point but I don’t know if I…right after fellowship want to do that so, maybe have a couple years of experience of private practice under my belt and then go back to academics.
WEI:
Yeah, I kind of have the same opinion as Joe. I want to go to a private practice, I want to do a fellowship but after that probably going to go to a private practice because I feel that I got so many years of training or even in medical school I studied in those big academic centers. I really want to have some experience in private practice to see um, like, how to work very efficiently like I heard from my attendings. How I can perform, like, with limited resources and, you know, take care of things myself.
RICKY:
And I think too it depends if you are pursuing a fellowship, it definitely depends on what fellowship you’re pursuing. If you’re pursuing ICU for example, you’re a little — I don’t want to say that you’re limited, it’s not that you’re limited but as an intensive care trained anesthesiologist you don’t have necessarily quite the same practice opportunities that an internal medicine trained intensivist would. I mean, I’m not saying it’s right, wrong, good, or bad but the academic centers tend to, tend to employ more intensive care unit anesthesiologists because that’s how it historically has been done.
WEI:
Uh, that’s true. I kind of like for fellowship-wise, um, I’m still thinking about what I’m going to do. I’m a CA1 so I still have time.
RICKY:
You’ve got time.
WEI:
For sure, yeah. Yeah, so I’m thinking about maybe one pathway’s going to be, like, pain because I can work in a clinic and it’s, like, designed for a private practice something like that. I’m pretty sure about that. Pain is definitely one of my target, uh, sub-specialties. And the other thing is, like, regional because I really like doing procedures. So if I’m working for regional maybe I can work in academic or private practice. I’m pretty sure about that.
RICKY:
I think that’s what attracts people to chronic pain specifically: if you’re interested in having kind of a dual practice. You know something that Joe mentioned earlier: out-patient versus in-patient setting. You can…it’s kind of the only opportunity that, as anesthesiologists I think we have to have a big presence in the out-patient world.
JOE: Yeah and I think people like the idea of pain too is because like you were saying, you get a little diversity. I hear some people that feel over time once they get through residency say “Oh well, I like the OR but I don’t want to do that all the time for the rest of my life”. I want some variability like you were just speaking about, you know. Um, so it gives you not only that to kind of change your location of where you practice and what you do but you also get to get a little continuity of care that we don’t necessarily get as often, as anesthesiologists.
SHARA:
RICKY:
One that immediately comes to mind is call burden specifically. If you’re in a small, private practice where you’re one of 7 or 8 anesthesiologists you’re sharing that call among 7 or 8 anesthesiologists which, obviously, means it’s going to be a little more frequent than if you’re in a large, academic center where you’re sharing that call among 30, 40, maybe even more, potentially, anesthesiologists. So one that specifically comes to mind for me is that. And I guess that’s a pro or a con depending on how you think of it if you’re taking more or less call. To me it would be a pro to take less call.
SHARA:
I think for most people it would be.
WEI:
Yeah, the minimal, the better.
RICKY:
I don’t know, everybody’s different. That’s one that immediately comes to mind and I think that academic places tend to employ more people and as a result the call pool’s a little more diluted.
JOE:
Yeah, um, I think also what is another important factor is kind of what you want in the future. You know, obviously, if you’re thinking of doing research or something of that vein, private practice you can do it but it’s not as beneficial for you I’d say, or as good of a choice I think because, um, academics is really where I feel like you would flourish if you if you wanted that because you have research labs, you have the clinical staff to help you, the research staff, um so you can kind of mix that in with it. Also if you’re into education and teaching the future generation of anesthesiologists I think academics is more beneficial for that too.
WEI:
What I really care about after, like, uh, so many years of training is about money as well. I really want a higher salaries. This is one of my thing. We have so many student loans to pay off, so, private practice you take more calls meaning you can probably earn more.
RICKY:
I think one interesting, sort of, at least in my mind, the way I think of it, a combination of both of those: I recently rotated at one of our local VA hospitals. I think that gets forgotten a lot but it’s, it was very much a private practice feel on a day to day basis but they were also very academic, publishing, researching. I think that gets forgotten a lot but it’s a way to mesh the two, like you guys were talking about, together.
JOE:
We have that flexibility to kind of switch the setting we practice in, um, depending on what we do too, in the field. So I think that’s really nice too so you can always go back and forth. You know, sometimes it’s easier said then done but it’s possible and I think that’s a nice part of anesthesia, as well.
RICKY:
Especially since we’re not carrying an office full of patients that we have to, I don’t want to say dismiss, but basically, dismiss.
JOE:
It makes it harder.
SHARA:
Well, let’s compare notes about common perceptions, good and bad. We have touched a lot upon the difference between private practices and academic centers. I think there are also kind of mmother subsets as well like a surgery center which would be a private practice but it’s like a very specific locale in which to provide anesthesia, or like an endoscopy center.
RICKY:
Yeah, at least, at my program, and I don’t, you know I don’t want to speak for you guys as well, but we don’t get a lot of exposure to that. I think it falls along the lines of something that was said earlier about the private practice world is, I don’t want to say totally foreign, but foreign-ish, at least to me personally just because we don’t get a whole lot of exposure to that and I think, you know, based on what you were saying, that tends to be where you see practice in endoscopy centers or surgery centers more but it would definitely fit more along a private practice model.
JOE:
I think those settings also are a lot about efficiency. It’s also about patient safety too, obviously, like any setting but it’s really about how efficient we can be, how profitable we can be, how much can we get done in a day and i think that as anesthesiologists, obviously— I don’t have much experience either with it— but what I’ve been told by attendants that I’ve worked with who used to do that you get good at learning how to master your craft but also do it safely and get everybody done in a day that you need to and I think that’s a, like you said, am skill that we don’t necessarily get in residency, to an effect, but not to be that efficient until you really get out there and if that’s what you want to do you gotta kind of learn that skill.
SHARA:
Um, okay, so building off of what Joe was saying: where do these perceptions that you all have about practices come from and where, exactly, are you getting your information from?
WEI:
I get most of these information from attending actually. These days I try to, because I’m thinking about fellowship which is a next year thing and I also, job is like, basically, 2 to 3 years later. I try to google some information but it’s not easy. You can find some information on LinkedIn or even on New England Journal of Medicine something career, uh, thier web pages but I don’t have a, like, a systemic view about things when I try to google it. So, most of these perceptions are coming from my friends, or my seniors, or attendings.
RICKY: Yeah, definitely word of mouth. I think that there’s a lot of potential for an individual sharing his or her opinions and that kind of shaping what your perception is about a certain practice or practice setting which may or may not be true. Especially since there’s such a wide variety of different types of private practice and different types of academic centers and differentmm types of even jobs within academic centers. It’s hard to kind of grasp the entirety of those options until you actually do it.
JOE:
I really can’t add much more to that honestly. I think it is definitely word of mouth. Um, like we were talking earlier, um, it’s definitely attendants that have been in these settings before that you work with that tell you about it. Also, um, prior residents like your colleagues that have either graduated and gotten jobs or done fellowships or worked at other hospital settings that are different from where you’ve worked or different types of settings that really you just talk to and get a description from or they tell you the good and bad, what they like about and how it changes kind of your perceptions of these settings in general for better or worse but…
SHARA:
JOE:
I think one of the things I always worry about is being in a practice that’s, one, not only questionable in what they do in terms of their practice and then also for patient safety, too. Um, so I worry about walking into a place and thinking everything is going to be great and it’s going to work out great and then you get into it and you realize, once you get in the real nitty-gritty of it’s not really what you expected and either there’s bad outcomes or you don’t have the equipment or the tools necessary to provide effective anesthetic to someone in a safe manner. That’s what I worry about and then having something happen to a patient. That would be really unfortunate so that’s what I’m always thinking about.
RICKY:
Particularly in the private practice setting if you were to get into a situation where as the new person…I think I would personally be afraid of my time not being as respected as the more senior individuals in the group. I’m not saying that I think that this is something that happens regularly but I could see that being a potential snag and causing lots of stress, so, that’s something that would worry me. And I think, I shouldn’t just say private practice because I think that can happen anywhere.
WEI: I’m like at the beginning of my residency training. For me, I, although I think I’m going to be a good anesthesiologist in the future but I’m still concerned if 3 years of residency is going to be good enough to train me to be, like, comfortable to independently take care of a patient in the OR. So my concern is am I going to be okay the first day and doing independent practice.
SHARA:
For me in particular, um, I don’t have much experience being in a supervisory role, uh, so when I end up being an attending it’s very likely that I’ll have to oversee residences or oversee CRNAs or AAs or something like that. And, um, we do have some electives in our final year to teach us more about that but I don’t think it’s exactly like the actual experience. Umm, so I think there are many ways in which that could go wrong for me. Either someone not listening to me or me not being able to troubleshoot any issues that they have. Uh, because it always seems like now if you can’t get an A-line or if you can’t get an IV or something somehow your attending is able to do it and there’s a possibility that I actually might not be able to do it.
RICKY:
That makes me very nervous. You’re that person that is being called and there have been very few times in my short career doing this where I have called an attending and he or she hasn’t been able to, to do what I wasn’t able to do and I’m thinking ‘Man, in, for me, 10 months…am I going to be able to do all these things?’ And I’d like to think that I am but THAT…scares me. Yeah.
JOE:
Yeah. And I think, speaking of that too, um, a lot of us you go through residency and you learn kinda how you like to do things, um, in practice. Like I like to set up things this way or I like to, I don’t know, do this or have this in the room, um, whereas someone else might see that and say ‘No, I don’t like this set up at all. I’m going to do it my way.’ And a lot of attendants have told me that it’s one of the hardest things they’ve had to actually accept over time is when they’re dealing with trainees, um, or CRNAs or what-have-you, um, you have to kinda take a step back and not be overbearing where you’re making people, or forcing people to, to do things your way. You want to let them flourish and learn their own intricacies that they like, um, but you also, like we were talking, you have to feel comfortable enough that if they don’t have something or if something goes wrong you’re ready and you can easily troubleshoot it or solve it. So, I definitely have thought about that too. I think that’s going to be a very hard skill for me definitely because I, uh, I’m very particular about how I like things too. So…
RICKY:
It’s tough exactly what you said. I’ve found it tough, you know now progressing to my CA3 year where, you know, we have the opportunity as well to, to participate in some supervisory, uh, supervisory like roles; obviously under the supervision of an attending anesthesiologist but of our, of our junior residents and there are certain circumstances where you see a junior resident doing XY or Z and you’re thinking exactly what you said ‘I would do it differently.’ But you want to let them learn to do it the way that they want to do it and you also want to teach but you have to foster independence and then, obviously, above all that comes patient safety so it’s a tricky, it can be a tricky, you know, thing to navigate.
JOE:
Yeah.
SHARA:
Okay, let’s get more positive. Any dream stories that you want to share? Stories of residents finding their perfect match situation that you’ve heard and perhaps covet? I can start with a story. Um, one of our graduating seniors last year, um, went into a pain management fellowship uh but I think he actually got a job within two months, like, into his pain management fellowship um, so he’s working at an eye and ear clinic and they don’t, um, do any overnight emergencies because they’re very close to a major hospital. Uh, so, all of the emergencies kinda go there so he doesn’t really take call because he’s not, like, employed by the major hospital, he’s employed by the eye and ear clinic. It’s very, like, 9 to 5 and he’s, like, very happy about this.
RICKY:
I think I might know the major hospital that you’re talking about. (laughter)
RICKY:
That is covering those emergencies. Um, little inside joke for the Boston folks, there. (laughter)
JOE:
I think we’re all thinking that. Um, yeah, I, I, you know, not to name names or locations but you know, I think a lot of people, at least in my program, have been very happy with what they’ve gotten for jobs or fellowships. Um, I think it’s just that they’ve put in a lot of hard work over the years and they really knew what they want to go for or what they liked and really set out to get that. And I think that it was, not that it was easy, but they were successful. And I think they’re all happy. Like I even haven’t met a single person from my program that’s like ‘Oh man, I didn’t get what I wanted’ or ‘ I didn’t get the job I wanted or the location I wanted to live.’ I think it all worked out. But, you know, it’s not to say that it came easy; they had to, to really, really work hard over the years to get where you want like we all did.
SHARA:
But it is fellowship season right now and, um, at least I know I personally am grappling with the decision of what fellowship to ultimately pursue and if I want to do, um, a combined fellowship which would be two more years, or just one year and, like, call it quits. Or, if I even want to do fellowship at all. Like maybe, like, pursue later down the line. Um, so, if you guys could all tell me a little bit more about, um, sort of, how you ultimately ended up choosing a fellowship or the field that you wanted to go into. Um, and what decisions kind of came into play with that.
RICKY:
I, personally, and I think this is what attracts a lot of people to pediatric anesthesia, I like the variety that comes with pediatrics, you know. You can take care of any human being from the time that they are born from the time that they die. And I think that that’s a really nice, unique skill set. I was fortunate enough to get exposure to pediatrics early on in my training uh, through Mass General. We do pediatrics at Mass General and I was also lucky enough to rotate through Boston Children’s. So to see two different, very different, types of pediatric settings. So, I just very much enjoyed it. I toyed with the idea of ICU for a little while but I found myself going back to the pediatric OR and the, the skill set it provides. I found that to be more enjoyable. And I just like working with kids, too. I think it’s very fun. Is that what you felt too?
JOE:
Yeah, I was completely on the fence. I went through all of, you know, my life making easy decisions. For me, at least, like you know, I wanted to go to undergrad; I wanted to do pre-med; I want to go to medical school; and then I found anesthesia pretty soon afterward in medical school. So it was always, like, an easy decision for me. But recently I was really torn about what I wanted to do. Um, I was on the fence, too, about a couple of things. There was, uh, sub-specialties in anesthesia that I knew I didn’t like. Um, but there wasn’t one that was really pulling one way or another but then I, fortunately, also went to Boston Children’s this past summer and I really liked it. And, even in med school, a couple of my mentors in the past were pediatric trained so I kinda always had that, that realm about me that I really enjoyed. But it really fostered it there. And, like you said, you can, I like the complexity of it. I like that you can take care of any patient. And, like you said, it’s just nice to see the kids um, and the families are so appreciative and it really makes you, at least for me, appreciate what I’m doing. Um, and it’s just humbles, it just makes you more humble, kinda, about the whole field in general, about what you’re doing, so…I really liked it. So, I’ve just decided on it about a couple weeks ago actually so pretty recent, so.
WEI:
Uh, I love procedures very well. I did my surgical internship and I, kind of like, even when I was in medical school, um, one of the reasons why I chose anesthesia because it’s very good combination kind of like both the medicine thing and some procedures. That’s kind of like foster me towards, um, sub-specialties like pain, or, uh, like, regional. But I’m not sure actually. Because I haven’t done any of these rotations yet, like cardiac and ICU are so fun because there are so many, uh, physiology and patients so sick in ICU which make you, which kind of like remind me of the reason why I want to go to medical school. Kind of, like, to save more people, to make medicine better or something like that. There are so many unknown things in medicine; I can still find something I wanna dig deeper and try to make it better. So, even I’m doing pain or regional, something like that, um, I can still make myself happy about what I’m doing. So, I will see.
RICKY:
And you’ll see, too, once you start doing more of these sub-specialties. It’ll make, at least for me, it, it either made sense or it didn’t. Or I, there were certain rotations that I enjoyed coming to work a lot more than others. I always like going, I really like what I do. I’m not saying there were days that I hated coming to work but, there were days where I was just happier. I was never unhappy taking care of kids. So I think that played a lot for me. And you’ll see that as you, as you start to progress and do more of the sub-specialty training.
SHARA:
So at least for me, with cardiac, um, I had a research mentor very early on who is also a cardiac anesthesiologist. Uh, so they, sort of exposed me to how interesting it was very early on. They’re very passionate about that field and that really rubs off on you I think, when you’re starting residency. Um, so I, like, learned ECCO very early on from this individual. And I thought that all of the devices in the cardiac OR were very cool. Um, and I think a job where I would be able to read ECCO’s part time is actually very interesting to me because that’s a skill unique to cardiac anesthesiologists. Um, that, like, not that very many other people have other than few cardiologists. And there’s so much demand for, um, knowing more about like structural heart disease and different types of heart disease in our population so you feel very useful. Um, and then it seems like cardiac and ICU really go together because there are so many patients on these devices like ECMO or LVAB and things like that. And, you don’t really learn about that unless you take care of those patients in the unit. So, it’s kind of why I thought about doing those.
RICKY:
That’s such a unique skill set, such a cool skill set to be able to have. To take care of all those different patients. It’s…I’m on cardiac right now and it’s not…I’m always so, I’m impressed by all of the people that I work with but I’m particularly impressed by the cardiac ICU folks. They’re just, they’re brilliant, for lack of a better way to put it. Their grasp and knowledge of physiology is like no other physician I have, personally, ever interacted with.
SHARA:
I certainly don’t feel comfortable taking care of children but I think I could probably take care of anything else.
RICKY:
Neo-natal physiology is pretty cool, too. (laughter)
SHARA:
This was like a, I think a very good discussion about fellowship. Um, I know that at our residency program in particular they really encourage people to pursue a fellowship although not everyone ends up doing that, um, just to, sort of, uh, give yourself an extra specialization when you go out into the job market. Uh, so this was really great. It was great to hear about, uh, all the different considerations you have: choosing a fellowship, um, from what you know about the different practice options that are out there. So I really want to thank you for coming here today and talking about these topics with us.
KENISHA MUSE:
Applications for the ASA Anesthesiology Policy Research Rotation in Public Affairs known as the Resident Scholar Program are now open through February 14. This is a unique opportunity for 2020 through 2021 CA3 Residents and Fellows to spend 4 weeks in Washington D.C. advocating for the specialty and experiencing firsthand the political, legislative, and regulatory factors that effect the delivery of patient care. For more information and to apply please visit asahq.org/residentscholar. Take it from me, I’m Dr. Kenisha Muse, a previous ASA Resident Scholar. During this experience, which was my favorite of residency, I worked on projects such as surprise medical bills, perioperative surgical home, and the opioid epidemic just to name a few. But most importantly, I met with numerous legislators conveying the importance of anesthesiologists. Apply today and become an ASA Resident Scholar.
ANNOUNCER:
Join us for Residents in a Room where we’ll share timely info, advice, and resources designed to help Residents succeed in residency and beyond. Find us wherever you get your podcasts or visit asahg.org/podcasts for more.