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Is the gas always greener?

The New Physician March 2007

Anesthesiology at a glance

  • Average salary: $330,000
  • Residency slots: 1,283 in 160 programs
  • Residency requirement: intern year plus three clinical years
  • Number of U.S. practitioners: 37,000

Resource: The American Society of Anesthesiologists hosts a wealth of information for students considering the specialty.

One of the defining characteristics of modern medicine is its focus on pain. Though suffering certainly remains, the alleviation of pain and even consciousness during medical procedures is de facto. Anesthesia interfaces with nearly every specialty, and as the number of surgical procedures climbs, so does the need for someone to champion patients’ sensations.

For those choosing a specialty, anesthesiology is fast-paced and hands-on, but carries the lifestyle advantage of manageable and relatively predictable hours. It is the content of those hours that is unpredictable, and thus exciting, anesthesiologists say.

When Duane Ellsworth volunteered at Utah Valley Regional Medical Center as an undergrad, he noticed that patients were more complimentary of the anesthesiologists than anyone else. Ellsworth, who is now a second-year at the Arizona College of Osteopathic Medicine (AZCOM) and strongly considering the specialty, believes this has a lot to do with lifestyle. “I believe they were happy doctors and, in turn, uplifted the nurses and patients who they were involved with.”

According to physician salary surveys, anesthesiologists earn an average of just over $330,000 a year, though salaries range widely by experience. But beyond money, the practice setting is often the main appeal. “I absolutely love the OR, and I love physiology and pharmacology,” says Dr. Adam Cotton, an intern in a private hospital in Oklahoma City. “I don’t much care for clinics or rounding or long-term care. So the choice was really pretty easy for me.”

Dr. Josh Atkins, a PGY-4 anesthesiology resident at the University of Pennsylvania Medical Center, says this is a specialty for dynamic people who like to respond quickly and put their hands on patients—not for those who like to take time deliberating over cases. “Almost all of what we do, especially in the operating room…is very unpredictable,” he says. “You really need to thrive on the idea that what is happening now may be completely different than the situation you’re managing 10 minutes later.”

That flexibility also leads to a wide variation in the number of patients an anesthesiologist might see daily. In a cardiac rotation, residents might see only two cases a day, Atkins says. In an outpatient setting, they might be involved in five or six surgeries. The maximum number of patients would probably be eight or nine in a pain clinic.

“It also helps if you are the kind of person who really likes a constantly changing interpersonal dynamic,” Atkins adds. In a day, an anesthesiologist may work directly with a constant parade of surgeons, residents and nurses. “You need to enjoy and be able to operate in a complex social infrastructure.”

Once out of residency, anesthesiologists in private practice may oversee certified registered nurse anesthetists (CRNA), stepping in to monitor the critical junctures of an operation. In an academic setting, they’ll work with residents who monitor the patient’s condition minute by minute.

Most anesthesiologists enter private practice, but Atkins plans to join Penn’s faculty, spending about 75 percent of his time on clinical work doing most types of anesthesia, save cardiac or pediatric, which tend to be limited to those who’ve completed the appropriate fellowship. Atkins, who also holds a Ph.D. in organic chemistry, hopes to research genetic variation and response to anesthetics in patients.

Lifestyle is a common draw for students considering anesthesia. Though anesthesia is not shift work, Atkins says, its schedule is somewhat predictable. Practicing in a team-care model, the anesthesiologist is not the only person responsible for the patient, and is generally relieved by another physician when working hours are done. “You might work a little later, but in that sense… you can usually plan your schedule,” Atkins says.

There are about 160 anesthesiology residency programs in the United States, according to the American Society of Anesthesiologists (ASA). The average has about eight residents per postgraduate year.

There were 1,283 anesthesiology positions available in the 2005 Match, with 965 U.S. applicants seeking them, according to National Resident Matching Program data. Another 544 applicants included osteopathic students and international medical graduates.

Anesthesiology residency takes at least four years, but the first, the clinical base year, can—for now—be spent in a different specialty or institution. Many programs, according to the Accreditation Council for Graduate Medical Education (ACGME) and the ASA, are moving toward incorporating the clinical base year into a complete package with the other three years, the clinical anesthesiology years. In the meantime, interns can spend their year in a transitional internship or in another specialty, including surgery and pediatrics.

Residents do four- to eight-week rotations through subspecialties, generally starting off with “straightforward” general anesthesia in the OR with relatively healthy patients, according to Atkins. Eventually, residents rotate through pediatrics, obstetrics, neurosurgery and cardiac surgery.

“The day-to-day in the OR is very similar for all those different rotations. It is just that the patients and the complexity and the specific issues of the day change,” Atkins says.

Residents learn what types of anesthesia to use in outpatient settings, when their patients might be walking around later that day.

In the OR, anesthesiologists may work with strong personalities in a high-stakes environment, and that can factor into selection. The characteristic of getting along with fellow residents is much the same as inter-specialty diplomacy, says Heather Ebbs, anesthesiology residency coordinator at Oklahoma University (OU) Health Sciences Center. “I expect my guys to be able to get along and play well with others…. This is the big sandbox, right?”

OU’s program is four years. Residents train at the medical center during their three clinical anesthesiology years, but their first year is multidisciplinary, spent at a private hospital across town. Ebbs says this is a good experience for them. “We’ve been told that we have one of the best clinical base years in the country.”

Certifying fellowships are available in cardiology, pain management, critical care and pediatrics. Other fellowships in obstetrics, neuroanesthesia and regional anesthesia are also available.

Though the role of the anesthesiologist may seem constant and necessary, it may be entering a period of flux. Just as the ACGME training requirements are changing, so too are some of the theaters of practice.

With the explosion of outpatient procedures like colonoscopies and biopsies, anesthesiology has been stretched, and other specialties have been filling the gap.

“There is increasing encroachment on this area by gastroenterologists, emergency physicians and plastic surgeons,” Atkins says. “There is a lot of debate right now about whether anesthesiologists should be the only ones who are able to do deep sedation with certain types of anesthetic drugs.”

The role of the anesthesiologist outside of the complicated operating cases may be changing, and it’s not clear exactly what’s in the future, he says. Someone entering anesthesia to work outpatient cases at a surgery center, for example, may find those opportunities less available in five or 10 years.

There is a general shortage of anesthesiologists—about 37,000 are currently practicing outside of residency, according to workforce studies—so CRNAs provide a large number of anesthetics. In some programs, you work side by side with them, Atkins says. Eventually, you may oversee their work in a private practice setting.

Atkins adds that there is a movement to position anesthesiologists as a complete perioperative physician, not only taking care of an unconscious patient during operations, but perhaps consulting days or months in advance and following up with patients several hours after procedures for the lingering effects of anesthesia.

On the technological side, regional anesthesia—using highly targeted blocks to speed postoperative recovery time—are becoming increasingly sophisticated and more common, Atkins says. The military has been making significant strides in the technique, which is useful in combat conditions.

Chronic pain management and palliative care are also growing areas for anesthesiologists, ones they share with other specialists.

There are a lot of opportunities in the field, and picking a focus doesn’t lead to being pigeonholed. “With some certainty,” Atkins says, “you can be sure that one day is going to be completely different from the next.”
Pete Thomson is associate editor of The New Physician.