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Which anesthesia fellowships are most popular? How many anesthesia residents choose further subspecialty fellowship education at the end of their residency, and which subspecialties are those graduates choosing?
The grid below, published in the California Society of Anesthesiologists Vital Times 2018, lists the fellowship choices from the last five years of Stanford anesthesia resident graduates:
The totals from most popular to least popular fellowship choices from this grid are as follows:
SUBSPECIALTY:
Cardiac anesthesia 17
Regional anesthesia 14
Pediatric anesthesia 12
ICU/critical care 10
Pain medicine 8
Research 8
Obstetric anesthesia 2
Neuro anesthesia 1
ENT/airway 1
Transfusion medicine 1
Palliative care 1
TOTAL 75
Approximately 28 residents graduate from Stanford each year, for a total of 140 graduates over five years. If 75 out of 140 graduates pursued fellowships, then approximately 53% of residents chose fellowships, while 47% entered the workforce without further fellowship training.
I’m a private practice/community anesthesiologist who also practices in a major university medical center at Stanford, and I have some reflections on this data. The fact that 47% of the graduates do not pursue subspecialty fellowship training doesn’t surprise me. If an anesthesiologist proceeds directly through college, medical school, internship, and then a three-year residency, he or she will be at a minimum 30 years old. Twelve years of post-high school education is enough for many graduates, and the desire to earn a paycheck can trump any desire to complete any more training. A board-eligible anesthesiologist without a fellowship can find a job in most geographical areas without difficulty. In a competitive marketplace such as the San Francisco Bay Area, I believe an anesthesiologist with fellowship training gains an advantage in the search for a plum job over someone who did not complete a fellowship.
Let’s look at the fellowships Stanford graduates chose, and discuss the merits of each subspecialty as of 2019:
Cardiac anesthesia continues to be popular. Stanford has outstanding cardiac surgery and cardiac anesthesia departments. The technology and challenges of cardiac anesthesia tend to draw ambitious residents into this subspecialty. I practiced cardiac anesthesia for 15 years. Those years were notable for very early morning arrival at the hospital (circa 6 a.m.), lots of invasive anesthesia preoperative procedures (arterial lines, central venous pressure catheters, pulmonary artery catheters, and transesophageal echocardiography), long complicated surgeries, sick patients, takebacks for bleeding in the middle of the night, and several surgeons with demanding difficult personalities. The field of cardiac surgery has changed dramatically since the 1980s and 1990s, when one of my surgical colleagues then lamented, “What’s the difference between a cardiac surgeon and a dinosaur?” His answer was, “Nothing.” In the 1980s invasive cardiologists began inventing techniques to apply balloons and stents in the coronary arteries to replace the open-chest coronary artery bypass grafting that cardiac surgeons used to do. Today even valve replacements can be done by cardiologists. Today cardiac surgeries are primarily difficult tertiary cases and revision procedures, i.e. cases that cardiologists cannot fix via intravascular access.
Regional anesthesia is a growing field. Both academic and community anesthesia groups need individuals with expertise in ultrasound-guided regional blocks. Regional anesthesia specialists should have no trouble finding jobs.
Pediatric anesthesia specialists are found in every large anesthesia department. Pediatric hospitals need fellowship-trained graduates on their staff, but for private/community groups, the role of fellowship-trained pediatric anesthesiologists depends on the volume of pediatric surgery. Community groups often expect multiple anesthesiologists to cover routine pediatric cases (e.g. age 1 and over) when they are on call. If only 10% of cases are pediatric and those cases sometimes occur on weekends or at night when an on call anesthesiologist will staff the cases, it’s unlikely the group will hire a specialist pediatric anesthesiologist to be on call every night. For a large group, this may be possible, but for a smaller group, it may not.
ICU/critical care medicine fellowships have always been popular at Stanford. For years the anesthesia department ran the intensive care units at Stanford, and these anesthesia/ICU attendings were outstanding role models. I decided to follow my internal medicine residency at Stanford with an anesthesia residency because I was so impressed with the ICU attendings and their training. The current Stanford anesthesiologist department chairman, Ron Pearl MD PhD, was initially a Stanford internal medicine resident who then completed the Stanford ICU fellowship, and after all that enrolled in and graduated from the Stanford anesthesia residency program. The unique value of an ICU fellowship is that you attend to sick patients of every type, and you become comfortable managing the most demanding medical situations day and night. ICU/critical care graduates are become outstanding clinical anesthesiologists who add value in either an academic or a community setting. Note that in a private/community practice setting, the clinical work in an ICU setting often becomes secondary to operating room anesthesia work, because there have always been superior financial reimbursements for the time anesthesiologists spend in the operating room versus the time they spend in the ICU.
Pain medicine is a vast frontier for anesthesiology. The anesthesia department at Stanford renamed itself the Department of Anesthesiology, Perioperative and Pain Medicine to emphasize the inclusion of pain medicine within our specialty. While the clinical features of operating room anesthesia care have changed very little in recent decades, the possibilities for research and growth in pain medicine are limitless. As an internal medicine doctor, I can tell you that almost everyone hurts in some part of their body, and the treatments for pain, especially for chronic pain, are still in their infancy. Opioid medications work for a while, but patients can become tolerant and addicted to the drugs. More specific pain treatments without the opioid side effects of respiratory depression, addiction, constipation, and nausea are desperately needed. The potential for basic science research in pain medicine is unequaled in any other field of anesthesia. In either community or academic practice, pain doctors staff pain clinics where other physicians can refer their most difficult and unhappy patients. Pain clinic waiting rooms are rarely empty.
Research fellowships are a launching pad to an academic career. Selecting an outstanding mentor is a key factor. If a mentor is known to publish extensively, he or she can teach their fellow how to select important projects, design experiments and studies, write grants, write research papers, and get those papers published. Basic science laboratory research is becoming the domain of investigators with PhDs. Significant clinical research is done primarily by MD anesthesia faculty members at universities. The reputation of a professors is judged by the extent of their publishing and research. Research fellowships are not an important step to a career in private/community clinical medicine.
Obstetric anesthesia is a valid subspecialty in academic centers. In private/community jobs, it’s expected that all anesthesiologists who are on call on weekends and nights can handle both routine and emergency obstetric cases. Completing an OB fellowship isn’t a direct link to landing a graduate an outstanding community job—almost every community anesthesiologist will be expected to have to have OB skills.
Neuro anesthesia training will prepare a graduate for a wide array of brain surgery cases. This specialty will be valued in an academic practice or in a private/community group that does a large amount of neurosurgery.
In Ear, nose and throat/airway subspecialty training, a graduate will gain expertise in managing difficult airway cases. This field will appeal to graduates seeking an academic job doing complex head and neck surgical cases.
I don’t have access to national data on the distribution of fellowships in graduates of anesthesia programs other than Stanford. While it’s possible that Stanford is an atypical peer group, I hope this analysis of the fellowships Stanford graduates choose gives you a better idea of the career choices available to anesthesia residents.
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