Anesthesiology

An anesthesiologist is trained to provide pain relief and maintenance, or restoration, of a stable condition during and immediately following an operation, obstetric, or diagnostic procedure. It is the anesthesiologist's foremost purpose and concern to protect the patient's well-being and safety just prior to, during, and after surgery. Anesthesiologists have many responsibilities: preoperative evaluation of patients to determine conditions that may complicate surgery; management of pain and emotional stress during surgical, obstetrical, and medical procedures; provision of life support under the stress of anesthesia and surgery; immediate postoperative care of the patient. (Adapted from the American Board of Medical Specialties' Guide to Physician Specialties and the Pathway Evaluation Program for Medical Professionals' Specialty Profiles 2003.

Intraoperative anesthesia is the cornerstone of practice, but there are some evolving office-based practice areas outside of pain medicine. Regional anesthesia is becoming more popular by patients and by surgeons. Some programs may still have a rather weak regional anesthesia experience, although this is changing, and regional fellowships are now available.

The practice of anesthesiology is extraordinarily broad. Patients range in age from premature infants to our geriatric population. Just as the ages vary, so do the numerous responsibilities. These include anesthetic care, intensive care medicine, pain management, and various leadership roles in the hospital. These varied opportunities attract physicians who enjoy the relatively brief encounters seen in a busy ambulatory surgical center as well as those who prefer the extended relationship of the chronic pain manager.

If you are interested in academic medicine/research, anesthesia is an excellent specialty. We still don’t know how general anesthetics work, and any area including the heart, brain and the lungs are within your domain. There is so much to be done. However, be careful about the program you choose to go to if this is your interest; some programs foster research more than others during training. Some programs include an option for six months of research elective time in your PGY-4 year, while others even have specific research scholarship positions for which you can apply. With the anesthesiology lull in the late 1990’s as well as competitive salaries in private practice, many academic centers are recruiting academicians (teachers and researchers), especially female academicians!

The Anesthesiology Residency Review Committee (RRC) defines a "continuum of education" which consists of "4 years of training: the Clinical Base Year (CBY) and 36 months of Clinical Anesthesia training (CA-1, CA-2, and CA-3 years)."

Anesthesia programs require 4 years of training and are organized as a categorical four year program (with the first year considered the internship) or an advanced three year program that requires a separate internship. When interviewing for advanced programs, you will also interview for preliminary or transitional year programs and will need to rank and match into each. The intern year can be organized as a preliminary year in medicine or surgery or as a traditional transitional year. A preliminary year in pediatrics is also possible, but not common. More than fifty percent of match spots are now categorical, with the first year often called the “clinical base year” or “CBY”. These programs often contain a mix of medicine, surgical, ICU, OB, and pediatrics months.

In your CA-1 to CA-3 years, ACGME requires exposure to general OR anesthesia as well as sub-specialty anesthesia, including at least two 1-month blocks of neuro, peds, OB, and cardiac anesthesia. 4 months of critical care and 1 month of preoperative evaluation are also required, as well as pain management.

As a resident, per regulations, you cannot be on duty for more than 24 hours; therefore you go home in the morning when you are post-call (usually around 7:00 am). Your regular days can be rather long, though. It is not the easiest of residencies, but it is far from being the worst. The work hours are variable by the program. Some programs make a point of relieving the residents at 4- 5 p.m., while in others you are expected to finish up with the case in your room even if it goes to 11 p.m. Some programs have a night float system so there is no weekday overnight call.

Fellowships for sub-specialty anesthesiology are typically 1 year of additional training. The board-certifiable fellowships include critical care, pain medicine, pediatrics, cardiothoracic, OB. Regional anesthesia is newly ACGME-approved and many programs will soon be offered as an accredited fellowship. Other non-accredited (non-boarded) fellowships commonly available include neuroanesthesia, trauma, and transplant anesthesiology, which provide additional training in these sub-specialties, but do not have their own board certification.

According to NRMP data from 2018, the match rate for U.S. seniors whose preferred specialty was anesthesiology was 96%. Of those who matched, the mean number of programs ranked was 14.6 (5.3 for those who did not match.) The average Step 1 score for 2018-2019 first year residents entering anesthesiology was 230.6, and the average Step 2 CK socre was 241.3. Many successful applicants also have some research experience; the average number of research experiences per matched applicant was 2.9.

According to the NRMP Program Director Survey Results from 2012, the most important application factors for anesthesia program directors when selecting applicants to interview were, in order, letters of recommendation in the specialty, Step 1 score, personal statement, and grades in required clerkships. The good news is that a U.S. grad with good grades, board scores and letters of recommendations are very likely to match in one of the many top programs in the country. Set your standards high when choosing places to apply and keep in mind that you are very likely to match in one of your top three choices.

When exploring programs on the interview trail, factors to consider include the regional and TEE experience, didactic structure, written board pass rate, the length of time it takes residents to reach their “numbers” (e.g. specific case types), how residents do/don’t interact with CRNAs (if a program has them), and call structure.

Anesthesiology offers a reasonable lifestyle. You are off when you are off, i.e. you do not carry a beeper when you are not on duty at the hospital. (This does not apply to pain medicine). The morning start is early, typically 6:30 a.m., but often, you are done early. Most anesthesiologists work for a hospital and they have to take some in-house call, but they do get paid rather well for it. The average anesthesiologist makes $392,000/year (per Medscape Physician Compensation Report 2019). Private practice jobs now may involve overseeing multiple operating rooms that are mainly staffed by CRNAs or AAs, as the direction of the field is constantly changing. It would be wise to gain some understanding of the future possibilities of the field during your clinical rotations.

Your exposure to anesthesiology will begin in either your third-year subspecialty surgery clerkship or as an elective. Previously a required one-week rotation, the surgical clerkship has been reorganized and not every student will rotate through the anesthesia department. However, if you do rotate, you will get to spend two weeks! If you think you may want to go into anesthesiology, it would be best to attempt to do the third year rotation. It will help you to decide whether or not to pursue a full month long elective, which can be done later in your third year (provided you have completed the medicine and surgery clerkships as prerequisites) or early in your fourth year if you think anesthesia is for you. Of note, the general anesthesiology elective is not offered during July so you may want to structure your schedule with that in mind. The month-long anesthesiology elective at Maryland is very well organized and highly recommended. During the elective, you will spend one week split between the regional service (MAPRAS) and OB, one week in Shock Trauma, and two weeks at University (one week on general cases and one week in subspeciality cases). During this time, you will perform mask ventilations, peripheral IVs, intubations, and assisting with central and arterial lines. Be proactive while in the operating room and make sure to help the resident set up the room and medications. There is also a pain medicine elective, where you will spend time in a pain clinic at UMROI (University of Maryland Rehabilitation & Orthopaedic Institute).

Critical care exposure is also highly recommended, as anesthesiologists may more heavily rely upon this aspect of training in years to come. A critical care anesthesia sub-I through the anesthesia department is available in the University SICU, and other critical care electives are available through Shock Trauma. In the SICU, you will work with both anesthesia and surgery attendings and residents, and it offers great exposure to a popular branch of anesthesiology. Another popular elective is the Emergency Medicine Bedside Ultrasound where you can learn many skills that are essential to the practice of anesthesiology.

Dr. Caron Hong (Residency Program Director) and Dr. Matthew Tulis (Assistant Residency Program Director) are both great mentors. If you decide to go into anesthesiology, Dr. Hong or Dr. Tulis will give you a departmental letter of recommendation. Be ready with your CV, board scores, and clinical evaluations from your third-year rotations.

Most programs require three or four letters of recommendation. These do not have to be all from anesthesia. In fact, it is probably better that they are from other departments, but at least one should be from a senior level attending if possible. It is best to get letters from people who know you well and can speak to you in depth. Note that if you are also applying to preliminary programs, the medicine department will provide you with a department letter, usually written by Dr. Dittmar, and you should also plan to ask for at least one more letter from a medicine attending.

Away rotations are not generally necessary but can be helpful if you are particularly interested in or “need” to be at a certain program for specific reasons (e.g. family).

Similarly, you are not required to do a research project in anesthesia to become a more competitive applicant, but some programs may be more interested in recruiting researchers for future academicians. If you are interested (or still need to complete FRCT!), there are many opportunities within the Department for students to become involved in research projects. Just ask any of the faculty or residents if they are working on anything current, and you may take an entire month and dedicate it towards a research project in your 4th year.

• Many anesthesia programs will offer you a complimentary hotel, especially the programs located in southern states.
• Most programs will have a pre-interview dinner the night before the interview. Go to these! Even more than the interview, the dinner gives you a good sense of the residents and how happy they are.
• The interview usually consists of a light breakfast, introductory remarks by a faculty member, 2-5 20 minute individual interviews, a tour, lunch, and then you’re finished.
• The interviews themselves are generally very low-key and relaxed. Very rarely, if at all, will they ask “tough” or behavioral questions. They’re just trying to get to know you. The vast majority of anesthesiologists are chill, easy-going people. So that’s what they want to see from you. You’ll usually interview with the Program Director, possibly the Chair, and then another faculty member or even a chief resident.

Some things to ask the residents during the interview day or dinner:

Are there CRNAs and how involved are they in the program?

• Having CRNAs in a residency can be a good thing. They can often relieve you for didactics or get you out earlier so you aren’t there late every day. They can also take the cases that are less educational (lap choles, eyeballs, etc).

How does your call schedule work?

• This varies widely among programs, so it’s good to ask the residents when and how much they really work. Some take 24 hr call, others do night float. Most work 55-65 hrs per week, while others get very close to the duty hour limits.

How is living in [city]? What do you do for fun/Do residents socialize outside of work?

• Consider the location of the program and lifestyle of the residents – after all, it’s where you’ll be spending the next several years.

Some things to ask the faculty:

What fellowships are available in this program? What percentage of graduates go to fellowship and where do they go?

• Fellowships are also becoming more popular, particularly for those interested in pursuing academic careers and for those wanting more sub-specialty exposure before going into private practice. Many programs offer fellowships and often give preference to their own applicants, but it can also be nice to know that residents get great fellowships elsewhere if they want them. Higher percentages going to fellowship isn’t necessarily “better,” but you want to make sure that residents get where they want when they graduate, be it fellowship or a private practice job!

What are research opportunities available?

• Some programs push this, others not so much. If you’re interested, ask about exciting opportunities or Clinical Scientist Track-type programs that may offer an extra stipend during your residency for an additional year of research.

How does the program prepare you for exams? What about didactics, simulation, mock boards, review courses/Qbank etc?

• Anesthesiology training requires lots of exams: the Basic exam, In-Training Exams, written boards, oral boards, and the soon-to-be OSCE. Find a program with educational opportunities that match your learning style.

When the interview is over, you can send thank-you emails to anyone you interviewed with, the program director, and the program coordinator. Program coordinators usually provide you with email contact information for your interviewers, but some students still prefer to send snail mail. If a program tells you not to send these thank you notes, do NOT send them (it is not a trick).

An excellent reference with more details on the residency application, match process, and anesthesia subspecialties is the American Society of Anesthesiologists.