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In anesthesiology residency training we learn to perform every kind of anesthetic—cardiac, trauma, brain surgery, transplant surgery, abdominal surgery, chest surgery—on every type of patient—newborns, one-hundred-year-olds, or pregnant women. We learn those skills, and then we pass the American Board of Anesthesia written and oral exams on these skills. Then for the rest of our careers we lose many anesthesia skills.
In the 1990’s the rock group R.E.M. sang,
That’s me in the corner
That’s me in the spotlight
Losing my religion
Trying to keep up with you
And I don’t know if I can do it . . .
Every year in June across the United States another class of anesthesia residents finishes training. The duration of this training is substantial. In total it takes a quarter of a century: thirteen years to graduate high school, four years of college, four years of medical school, and then four years of internship/residency, to add up to twenty-five years total.
During the last three years of this quarter century of training, anesthesia residents are exposed to every subspecialty of their field. Of their thirty-six months of residency, anesthesia residents must spend at least 16 months in various subspecialty rotations including obstetrics, pediatrics, neuroanesthesia, cardiothoracic anesthesia, critical care, preoperative medicine, and pain medicine. The pain medicine rotations will include ultrasound-guided regional blocks, acute perioperative pain management, as well as the pain clinic.
Following those years, some residents will choose to do an additional year or two of subspecialty training or research, a period of time known as a fellowship. Eventually the training programs are all completed, and each individual anesthesiologist will get a job. Will the anesthesiologist have the opportunity to utilize all the skills he or she learned in their residency during their post-training job?
No.
One anesthesiologist cannot remain skilled in every subspecialty. Some anesthesia groups are divided into subspecialty services. That is, a small percentage of the group will cover all the pediatrics, or cardiac, or acute pain medicine, or neuroanesthesia. If you take a job with such an anesthesia group, and you don’t make the roster for one or any of these subspecialties, you will likely do zero pediatrics, cardiac, acute pain, or neuroanesthesia. The advantage of such an anesthesia group is that each subspecialty service is specifically trained and highly competent in their subspecialty. The disadvantage is that general members of this group will not be competent in the subspecialties of anesthesia they no longer perform.
How common is this scenario? Very common. Many anesthesiologists avoid the subspecialties of cardiovascular anesthesia, neuroanesthesia, and trauma anesthesia after their residency is finished. Many anesthesiologists seek careers consisting of only stable daytime cases, with the goat that they will never have to do obstetrical anesthesia or transplant anesthesia at 2 a.m. for the rest of their lives.
Do the skills of these anesthesiologists erode if they shun subspecialty areas? Absolutely. If you cease taking care of a three-year-olds for tonsillectomies, eighty-year-olds for craniotomies, or seventy-year-olds for coronary artery bypass surgeries, you’ll lose those skills and most likely never reacquire them.
If you peruse advertisements for anesthesia jobs you’ll see offerings such as, “bread and butter anesthesia—no hearts, brain surgeries, or trauma.” This description is offered in the advertisement as a desirable situation, appealing to anesthesiologists who prefer to avoid more complex or stressful cases.
To be blunt, once you stop doing a subspecialty area of cases, you’ll likely lose those skills you gained in residency and never do those cases again. Why? Imagine this example: You haven’t anesthetized a three-year-old for a tonsillectomy for five years. Then you’re scheduled to do just that case in your sixth year, and the patient suffers a serious complication. The complication may have occurred because you erred, or it may have occurred because the surgeon erred, but the complication results in a malpractice suit. Can you imagine what your defense will look like when your case history list documents that you haven’t anesthetized a three-year-old in the past five years? You’d be unlikely to win that malpractice suit. If you take this scenario and expand it to all the cases you’ve dropped in the years since residency, what do you have? A narrow scope of talent, and an ever-growing chance of becoming an out-of touch anesthesiologist who has lost his or her skills.
Your anesthesia training was an investment in which you gained valuable knowledge and skills. If you accept a narrow job description, do so with your eyes open. You’ll become very comfortable with the cases you spend your time doing, and very uncomfortable with the cases in your rear view mirror.
My post-medical school education consisted of two residencies, one in internal medicine and one in anesthesia. By the time I finished my second residency I was weary of training. I was thirty-two years old and I wanted to go to work. Quality first jobs are often difficult to find, and my first job was a “bread and butter job” with few subspecialty cases. After four months I grew bored, and luckily I found a better job where I could do nearly every type of case, including cardiac, vascular, neuro, pediatrics, and obstetrics. (I did not do trauma or transplants.) Two years later I advanced to my current job, which included all the above specialties except obstetrics. Over the years I’ve maintained my skills in as many types of anesthetic challenges as possible, and I recommend the same to you.
Be forewarned—if you cease doing any area of anesthesia practice, you’re giving up a learned skill, and you are unlikely to be given the chance to regain it.
In the final months of my anesthesia residency, one of the younger faculty anesthesia attendings at the local county hospital asked me, “What kind of cases do you most enjoy? What kind of cases do you want to do when you’re out of training?” I answered, “I’d like to do a lot of aortic surgeries, carotid endarterectomies, and open heart cases.” He shrugged and said, “I’d like to do lists of ASA I healthy patients during the daytime. That’s what I want to do.”
And now thirty years later, that individual is employed doing anesthetics in dental offices. His practice is solely ASA I and ASA II patients in the daytime, and he’s quite content with just that.
The American Society of Anesthesiologists touts reasons why physician anesthesiologists differ from certified nurse anesthetists (CRNAs). One important distinction is that physician anesthesiologists are medical doctors who have completed a full four-year residency, and are competent to anesthetize sick patients for complex surgeries. What happens if that physician anesthesiologist then minimizes his or her practice to simple cases which require few subspecialty skills? It may be difficult to claim any advantage of that physician anesthesiologist over a busy nurse anesthetist.
In California, physicians are required to attend 50 hours of Continuing Medical Education (CME) every two years. One can accumulate CME hours by attending lectures or meetings, or by completing online or written tutorials. One goal of CME to insure that career physicians keep up with advances in their field. An additional goal is to insure that physicians retain and review basic knowledge from their training. I submit that the most important CME in your career will be your patients. If you have a broad base of patients and cases and you maintain the knowledge and talents to attend to them safely, you will remain a polished anesthesiologist.
An old adage read: medical students have all the book knowledge but can’t do anything, residents have all the book knowledge and can do everything, and doctors out of training have lost all the book knowledge but can do everything. There’s some truth to this. Ardent students memorize and learn facts. Resident doctors memorize and learn facts during their training, and also learn how to work their trade skills. And it’s true that after graduating from their training, doctors lose much of the rote memorized book knowledge. We can’t remember the Kreb’s cycle or the coagulation cascade—but we do know how to do our jobs.
My pitch to you is this: for your own good, keep your job skills broad. Losing your religion means losing your subspecialty skills. Don’t be the doctor who is looking at his colleagues and thinking, I’m trying to keep up with you, and I don’t know if I can do it . . .
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