SS4 : What is Anesthesiologist? A Community Doc Shares His Story

Session 4

In this episode, Ryan talks with Dr. Patrick Pickett, an anesthesiologist who practices in the community hospital in Oklahoma as he shares about his path to anesthesiology, his typical day at work, work-life balance, as well as the things that he like most and least about being an anesthesiologist. Finally, he gives his opinion on the future of anesthesiology specifically merging with CRNAs.

Here are the highlights of the conversation with Patrick:

Choosing the kind of setting to practice in:

  • Always thinking he wanted to do academics
  • Realizing he didn’t want to do academic setting after doing a fellowship in critical care medicine
  • Started looking for jobs and happened to find a community job and realized it was a better fit for him

When he knew he wanted to be an anesthesiologist:

  • Patrick majored in engineering and volunteered at a biomedical engineering department at a hospital and realized it wasn’t something he wanted to do.
  • Getting to watch surgeries and working with the anesthesia side of it
  • Went through shadowing and didn’t like it but after going through rotation and training, he had a turnaround

What caused him to like anesthesiology after rotation:

  • Coming from a family with medical background, he knew what specialties he didn’t like
  • Thinking he wanted radiology coming into medical school
  • Not liking clinic and liking hospital setting
  • Liked being in the operating room but not liking to be a surgeon
  • Choosing the specialty through the process of elimination

Traits that lead to being a good anesthesiologist:

  • Flexibility in time and treatment options
  • Thinking on your feet
  • Being well-versed and liking different things
  • Having broad knowledge
  • Being able to change gears quickly
  • Being able to get along with people and the team
  • Being able to assume leadership role at times

A typical day in the say of an anesthesiologist:

  • Starting before 7 am and ending the day 4-5 pm on average
  • There is no one typical day since you will be working at different locations for different cases
  • If in the operating room: 3-5 cases on average for 1-2 hours each
  • If in the GI lab: 10-15 cases for 30 minutes each
  • If in neurosurgery/spine surgery/cardiac: 1-2 cases for 4-8 hours each

If in general surgery:

  • Meets with patients; talks about the plan, risks, and alternatives and then to the operating room
  • Walks patients through the procedure to reduce anxiety; manages vital signs, making sure all things are in place
  • At the end of the surgery, takes them to the recovery room

Taking calls:

Less frequent calls but more likely to go to the hospital to be there

Work-life balance:

  • Yes.This is one of Patrick’s pre-requisites in choosing a specialty because he wanted something that would give him some flexibility.
  • 55-60 hours a week
  • Some days are predictable so he gets to see his kids more.
  • Being on call is part of the deal but it’s manageable.

What makes a competitive applicant for anesthesia:

  • It’s almost like Emergency Medicine in terms of the board scores and the grades
  • Intangible aspect: Being appropriately aggressive, knowing when to step back and when to step forward to help out
  • Doing well in your rotations
  • It’s not a small field as there are many programs in anesthesiology (around 1500 spots)

What residency looks like:

  • 4 years – Intern year (medicine, surgery, EM, ICU, etc.) + 3 years (general rotations)
  • Most programs won’t put you in the OR by yourself on day 1 of that 2nd year
  • More independence and advanced rotations as you go along
  • Pain management as a multidisciplinary field in anesthesiology similar to critical care
  • Less calls than surgeons but more than some others and almost always in-house and they couple a senior and a junior on-call

Orals boards:

  • 2 hours
  • 2 rooms (an hour each room and with 2 examiners in each room)
  • Each candidate has the same stem of the case but which direction each goes is up to the examiners.
  • It probes the limits of your knowledge and the format can be intimidating.
  • Written board exam first before taking the oral exams
  • Not a question of content but about being able to think on your feet

Bias among DOs vs. MDs:

Any bias perceived is not deserved.

Sub-specialties:

  1. Pain management:
  • Neurologist
  • Psychiatrist
  • PMnR
  • Internal Medicine
  1. Critical Care:
  • ICU medicine
  1. Other sub-specs:
  • Pediatric anesthesia
  • Cardiac anesthesia > echocardiography
  • Obstetric anesthesia
  • Liver transplant anesthesia

What he wished he knew going into anesthesiology that he knows now:

  • Job opportunities available
  • The business side of medicine

Other specialists he works the closest with:

  • All surgical fields expanding to procedural fields such as:
  • GI – endoscopy
  • Cardiology
  • Internal radiologist
  • MRI (they may provide sedation for really young patients)

Special opportunities outside of clinical medicine:

  • Expert witness testimony
  • Research
  • Quality improvement
  • Expansion of training
  • Quality management

What he wished other specialties knew about anesthesiologists:

  • Their focus on safety particularly a combination of three:
  • Patient and their medical problems
  • The surgery and how it affects the body
  • The anesthetic and how it affects the body
  • They have different ways of looking at patients.
  • Pre-anesthesia process to decide who’s a good candidate and who’s not and what they can do to make them a good candidate
  • They try to get everybody on the same page.

What he likes most as an anesthesiologist:

  • Variety of the things they do everyday
  • They also have their share of excitements but he also likes the routine stuff

What he likes the least being an anesthesiologist:

Night calls

Would he still choose anesthesiology if he were to do it again?

Yes, it’s the right fit for him. You have to go through it to find out what works for you.

The future of anesthesiology vs. CRNA’s merging:

The Anesthesia Care Team is a very safe approach. Patrick finds that although the topic is controversial, most people working get along just fine.

For premeds, you should be prepared to supervise nurses and you should be prepared to do your own cases because you can do both.

Some pieces of advice for those considering anesthesiology for a specialty:

If you like the fast-paced hospital-based specialty, give it a try. Give it a rotation and if you don’t like it, there are plenty other fields to choose from but if you do, it can be a great career.

Links and Other Resources:

www.mededmedia.com

Transcript

Introduction

Dr. Ryan Gray: Specialty Stories is part of the Med Ed Media network at www.MedEdMedia.com.
This is Specialty Stories, session number 4.
Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you will want to practice. This podcast will tell the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome back to Specialty Stories if this is not your first time joining us, but most likely it is since we are only four episodes into the Specialty Stories. This is part of- this podcast is part of the Med Ed Media network, I am your host Dr. Ryan Gray if I haven’t said that yet. I host several other podcasts, you can find them all at www.MedEdMedia.com.
Alright this podcast focuses on an anesthesiologist who practices in the community. Let’s go ahead and jump right in.

Anesthesiology as a Specialty

Dr. Patrick Pickett: I am Patrick Pickett, and I am an anesthesiologist, and I am currently in Oklahoma City.

Dr. Ryan Gray: Are you in an academic or a community environment?

Dr. Patrick Pickett: I am in a- I would say a medium to large general community hospital.

Dr. Ryan Gray: Okay let’s start off with what made you decide when you’re choosing between academic, or community, or what sort of environment you want to work in, how did you go down that path?

Dr. Patrick Pickett: Well it’s a little interesting. I actually always thought I would do academics and my dad is an academic physician, he’s retired, but I always kind of thought that’s what I’d do. And of course you know, as you’re going through this process you always start in academics because you’re in college, med school, residency, and those are all academic. I mean I guess there are some residencies that are community residencies but in general you start in academics, and so that’s sort of where I was comfortable with. But I did a fellowship in critical care medicine and that really ties you to academic settings, and then I kind of decided I didn’t really want to do that. So I started looking around for jobs, and the long story short is that the job I found that was available in the city I needed to be in because my wife was doing her training here, happened to be a community job and I kind of started thinking about it, and it made a lot of sense. And since I’ve been doing it I realized that it probably is a better fit for me than I ever would have thought had this not presented itself, this opportunity.

Dr. Ryan Gray: Okay. When did you know you wanted to be an anesthesiologist?

Dr. Patrick Pickett: That’s also interesting and I’m going to give you- because I assume you have some premeds on here. I shadowed- and ‘shadow’ is not the right word, but I was an engineering major and I got a summer sort of volunteer position with a biomedical engineering department at a hospital, and I quickly realized that it was pretty boring because they basically stayed in the basement and like repaired beds and stuff, and it wasn’t really what I wanted to do. I mean I liked engineering, I did that major because I liked it, but by that point I knew I wanted to do medicine. And so they were like, ‘Well we can plug you in with the anesthesia techs upstairs and they can get you in to watch surgeries.’ I’m like, ‘Cool.’ I mean I was a college kid getting to watch like heart surgery and that’s really cool to see for the first time. But I was working with the anesthesia side of it but I just didn’t have any concept of what they were doing. I mean I’ll say this as an anesthesiologist, it’s kind of boring to watch because it’s a lot of mental stuff. I mean it’s a lot of thinking, and we give medicine but it’s like a clear liquid in a syringe. I mean it doesn’t- you can watch a surgery and be kind of like, ‘Okay he’s cutting this, he’s sewing,’ I mean you can kind of get an idea of what’s going on. There’s obviously a lot more thought process to the surgery but anesthesia’s not really like that. So fast forward in medical school I thought I would- well let me say I didn’t really know what I would do, but I didn’t really think about anesthesia until I did the rotation as a third year medical student, so more than halfway through medical school. And it just really clicked now that I’d had more medical education, and kind of understood kind of the underlying concepts, and the things we worry about. You know, the medicine, the pharmacology, the physiology, all those things. And it makes a lot of sense but sometimes, you know for me at least, I just had to do it to get it and to understand the appeal. And I mean after I did the rotation that was all I wanted to do, and that’s what I ended up doing, and I’ve been very happy with it. I think it’s interesting, I mean I shadowed it and did not like it at all, so I had a complete turnaround with a little bit of more training.

Dr. Ryan Gray: What do you think led ultimately to that decision? Having that experience, shadowing and not liking it, but then going through rotation and liking it? What was it about it that you liked?

Dr. Patrick Pickett: Well you know going through the process of choosing a specialty, I have a little bit of a medical family, I’m fourth generation physician. My dad and both of his parents and his grandfather were physicians, and so I kind of knew what I didn’t want to do. I knew I didn’t want to be say a pediatrician, or an OBGYN. I didn’t want to be a surgeon. So I narrowed myself down to like those other kind of categories, and not necessarily non-clinical, but just sort of after you go through the kind of big five or six, like the big core rotations, you kind of get to other things that are kind of smaller fields. Emergency medicine I thought about, but that wasn’t right for me. Coming into med school after all my shadowing I thought I’d do radiology because I took a class on the physics of imaging. I thought that was really cool and then I realized well that’s not really what you do as a radiologist. But so going through the clinical rotations, and a lot of med schools now you start clinical experience even before your rotations. So like as a first and second year they’ll have you do some random days here and there. I kind of knew what I did and didn’t like. I didn’t really like clinic, I kind of like hospital based more kind of acute care, critical care stuff. So like emergency medicine, ICU, I put anesthesia sort of halfway in that category. I kind of like those things, and then I like to work in the operating room but I didn’t really want to be a surgeon, so that kind of narrows it down. So kind of going through process of elimination and just finding what I didn’t like and what I did like, and putting those things together. You know the operating room, and kind of the acute care medicine, that’s anesthesia right there. And so it wasn’t a straight path like, ‘Well I broke my bone when I was a kid, and the orthopedic surgeon was really nice,’ and I didn’t have that kind of moment. My dad was a neurologist and I found it very interesting but I knew that wasn’t right for me. So it wasn’t the typical you write your personal statement, ‘I’ve always wanted to be a-‘ whatever kind of doctor. It wasn’t exactly like that for me, I was more undecided until relatively late in the game. Although a lot of people are undecided until third year, a number at least that I knew were.

Dr. Ryan Gray: Yeah I think that’s pretty common which is why we do this podcast. Helps students find their way.

Dr. Patrick Pickett: It’s great. This is great.

Traits of a Good Anesthesiologist

Dr. Ryan Gray: What traits do you think lead to being a good anesthesiologist?

Dr. Patrick Pickett: Definitely being flexible in a number of ways. In one way would be I meet a patient, I know what surgery they’re scheduled for, I come up with a plan. In the first place I have to be flexible is for some things there’s different ways to do anesthesia that are totally acceptable. Say a spinal anesthetic versus a general anesthetic for a knee replacement. Those would be both considered acceptable. Each has its own risks and benefits. I might think one is better for a patient, they might say, ‘Absolutely not.’ Usually the spinal is what scares them although I don’t think that’s deserved. But they may refuse to do it a certain way and I can talk to them, but at a certain point the patient has to kind of decide, and as long as it’s not overly risky we do give them some leeway to choose different options. And so they may not want what my plan A was, or I may pick my plan A and let’s say the patient’s okay with that and we get going and then for whatever reason it doesn’t work. I mean nothing’s 100% in medicine so you start off doing something and you realize this isn’t working. So you might have to change gears, and it’s relatively quick so you have to be able to sort of think on your feet, and just realize plan A is not working, I’ve got to switch gears to plan B, and be able to execute that. It’s a fairly fast-paced, maybe not as much as emergency medicine, but we’re typically talking about seconds or minutes. Cases usually last maybe an hour or two is the average, so there’s a certain amount of turnover so you have be able to kind of- you do one thing and then I might- because of the variety in anesthesiology, I might- my first case might be a six month old, and then my next case might be a 99 year old. So I have to be able to sort of switch gears. I think it’s good to like a lot of different aspects of medicine. So part of that being undecided was not that I didn’t like so many things, I mean I mentioned some of the things I didn’t really want to do, but it wasn’t that I didn’t like anything about them, I just didn’t want to do only that one thing. So let’s see this past week I had- I was on labor and deliveries, so pregnant women, I had some pediatrics, I had some older people for knee replacements. And so there’s a lot of different variety of things we do. And so being well-versed, liking a lot of different things, and having a broad knowledge base, and being able to change gears quickly, those are all good traits. And also you know, you work with a lot of different people. There’s a team in the operating room so you have to be able to get along with people. And people always think, ‘Well the patient’s asleep,’ and most of the time they are. Under anesthesia is not exactly sleep but we use the word sleep as sort of a euphemism. But the patient may not be talking, but we have a half dozen or even more, maybe ten or fifteen depending on the case, people in the operating room and they all have a role and you have be sort of able to interact with all these people, and there’s times that particularly if something’s going wrong, patient has cardiac arrest or something, you’re leading that team and you have to be able to tell people, ‘You do this, you do that.’ So able to assume the leadership role but not necessarily- you’re not necessarily in that role all of the time. So it takes the sort of a right temperament. I mean it’s not the- I think for sports fans the best analogy, the anesthesiologist in the operating room is not the quarterback or the star running back, we’re more like the offensive line. We’re kind of the behind-the-scenes person. We don’t get all the attention and all the credit and that’s fine, but without us you couldn’t really do anything. We’re a necessary part, we have our expertise, we have our role, and it’s kind of we come in, and we do our job, and we do it well, and we kind of move on. And so it takes the right kind of person for that. So laid back is a phrase that’s used a lot. I don’t think anesthesiology is a laid back field, but I think a lot of anesthesiologists are laid back because that ties in that kind of flexibility, that kind of lack of ego, being able to kind of roll with different situations, and I think those are some traits I would say make a good anesthesiologist.

A Day in the Life of an Anesthesiologist

Dr. Ryan Gray: Describe a typical day.

Dr. Patrick Pickett: Well we do start early, and I’m honestly not a morning person. If I don’t have to work and if I didn’t have two small kids I would love to sleep in. But we do- I typically start before 7:00 AM so say 6:45, and the first case starts at 7:00 which is the most common time, and there’s a wide variety or a wide variability in when I’m done. The average might be say 4:00 to 5:00 in the afternoon, there are days when we may be shorter depending on the time of year and where I am in the call schedule, and there’s days that I’m on call and I could be there into the evening or even all night. Thankfully my practice, it’s not that common for me to be up 24 hours straight thankfully. It happens but it’s not all that common. And as far as what I do depends on what anesthetizing location I’m assigned to. So part of the growth of anesthesiology over the years is it’s not just the operating room. We have the GI or endoscopy suite, we have cardiac cath labs, and interventional radiology, ambulatory surgery, labor and delivery. So a wide variety of places and of course that determines- in the type of case I’m assigned to determines what my day looks like. And so like I was saying earlier this past week I’ve had all ages, all different kinds of surgery. So a typical day if it’s the operating room I might have three, four, five cases on average for one and a half to two hours each. If it’s the GI lab we might have ten, fifteen or more cases that are a half hour each. If it’s a neurosurgery, or spine surgery, or cardiac, it could be four, six, eight or more hours per case and you only have one or two. So it’s widely variable which I like. I like not doing the same thing every day. And so typical- let’s say I’m doing some general surgery, I’ll go in at 6:45 and meet the first patient, talk to them about my plan, talk to them about all of the risks and alternatives, and depending on the type of case there may not be a lot of alternatives. If you need your gall bladder out, that’s pretty much got to be general anesthesia with a breathing tube. That’s pretty much the only way to do that. But you talk to them about what you’re going to do, and what the expectations are, and part of our job is a little bit of psychologist. Anxiety is very, very common before a major surgery, or even a minor surgery, and some people have more anxiety about it than others whether they’re unexperienced or whether they’ve had a bad experience in the past. And so you kind of have to manage that. I found the best way to do that is to walk them through it, and I’ll kind of walk your listeners through it because you said what’s the typical day. So after I meet them, we’ll take them back to the operating room, and they move over to the operating room table, put the monitors on them, check their vital signs, and if it’s a general anesthetic give them medicine in their IV and they- to use the euphemism, go to sleep, but really it’s unconsciousness. It’s a reversible coma is probably the most accurate medical term. And depending on how the case goes I may have to do a little or a lot to manage their breathing and their vital signs, you know their heart rate and blood pressure. The anesthetic requirements, the different things we like to talk about. The components if it’s the general anesthesia, making them not aware, not remembering, not feeling pain, not moving around which is important that the surgeon can do their job. So making sure all those things are in place, and then at the end of the surgery one of the most important parts as far as the potential risks is the emergence from anesthesia. If they have a breathing tube in we have to get them breathing on their own and take that out before we can take them to the recovery room, and then when all those things have been done we take the patient to the recovery room and we kind of transfer our care, we give a handoff to the recovery room nurse, and then we move onto the next patient, and depending on what my day is scheduled like, repeat that as many times as necessary. So that’s a pretty typical day, and again the best way of saying with a typical day is there’s no one typical day. That’s what I like about it.

Anesthesiologists on Call

Dr. Ryan Gray: Do you have to take a lot of call?

Dr. Patrick Pickett: It varies by group, but I would say the difference- and my wife’s a urogynecologist as a comparison, she’s on call a lot more days than I am, and whenever she operates on somebody she’s on call for that patient or patients until they leave the hospital. But she really goes into the hospital. So she may get a lot of phone calls, me on the other hand there’s fewer days of the month that I’m on call, it could just be three or four, but I’m much more likely to go into the hospital. If it’s labor and delivery I’m more or less required to be in the hospital and we do about a twelve hour shift, 24 hours on the weekends, but I’m pretty much labor and delivery. I’m required to be in the hospital- the operating room. If there’s any surgeries going on then I have to be there. So a little less frequent call than some other people, but more likely to go into the hospital. There’s not a lot I can solve with a phone call unless somebody just had anesthesia and they’re in the recovery room, and I’ve gone home and they need some pain or nausea medicine or something like that. Not a lot I solve with a phone call. I usually have to be there.

Work Life Balance

Dr. Ryan Gray: Do you feel you have enough time for family?

Dr. Patrick Pickett: I do, yeah that’s one thing I really like about anesthesia. And that was one of my prerequisites to choosing a specialty. I knew when I was in college and med school that I wanted to have a family, and I wanted to pick something that would give me some flexibility to be with my family. And I probably work 55 to 60 hours a week, which is for medicine maybe average or certainly less than my surgical colleagues that I work with. But compared to a lot of other jobs it’s more than that, but the thing I like is that it’s somewhat predictable on a day-to-day basis. I can have a decent idea of when I’m going to be home, and of course if you’re on call you don’t know if you’re going to get called in, but you can choose days to not be on call if you have to do something with the kids, and I’m not on call that often that prevents me from seeing my kids on most of the weekends, so that’s nice. And of course having a two position household gets a little hectic but we both have some say over when we’re on call so we can try to not be on call at the same time, because that would be kind of hard to both be in the hospital because then nobody’s home watching the kids. So it’s a nice balance. It’s certainly- I knew going into medicine that being on call is part of the deal, but it’s manageable and I feel I get enough off time and things like that. The nice thing about having a long days and short days is you can kind of find when those short days are and enjoy your time off.

Competitive Applicants

Dr. Ryan Gray: What makes a competitive applicant for anesthesia?

Dr. Patrick Pickett: Well you know, it’s I think considered not the most competitive but it’s probably in the next kind of group down. It’s similar to like emergency medicine in terms of the things like board scores, and grades you need as a fourth year medical student to match. That part I can’t give you good numbers for because it’s been more years than I would probably like to admit since I’ve done that almost ten years- well more than ten years since I’ve applied. But you know as far as that’s kind of the numbers side, you know the intangible side. You know you need to- and this is a little- I don’t know how you evaluate this on paper but as far as your rotations and things, somebody that can- I always felt that it’s a little bit of a hard rotation because you know on the surgical side you can have half a dozen people scrub in and they can all find something to do, but in anesthesia we kind of work in a small space so you kind of have to know when to kind of step back, and when to step forward and help out, and kind of when to ask questions, and when to kind of let the anesthesiologist- if there’s kind of a critical moment, kind of stand back and let them do their thing. So I don’t know what the exact word is that describes that, but ability to kind of not be in the way, but be appropriately aggressive, and kind of helping out and offering to do things. And that’s more if you do a rotation. Certainly we like to see experience because it’s not a required rotation, so you need that experience to show that- I mean it’s certain fields are just different than everything else. Like radiology, there’s not really anything else that’s much like that. So anesthesia is one of those things, not really a whole lot else that’s like it. So you really have to have a rotation. And of course if you’re planning on doing anesthesia you want to do well on that rotation which means getting there early, staying late, getting to know everybody. So those are the kinds of things that I think would make you competitive. Fortunately there’s a lot of programs- I mean when I was applying I think it was about 1,500 spots. So it’s not a small field.

Dr. Ryan Gray: What does residency look like?

Residency and Boards for Anesthesiologists

Dr. Patrick Pickett: Well it’s a four year residency so it’s what’s considered- there’s an intern year and then there’s the three years starting at PGY2. So in other words the second, third and fourth year. And depending on where you go those can be separate or all combined, but your intern year is going to be not anesthesia for the most part. It’s going to be medicine, surgery, probably some emergency medicine rotations, ICU is the big part. Because not only can anesthesiologists be ICU doctors, but there’s a very strong overlap of the skillset. We have to take care of sick people, and a lot of times they’re sick because we’re giving them anesthesia, and that makes people temporarily ill in some ways. I mean so the ICU part is important. But that’s the intern year, and then the next three years you’re going to start off with some general rotations, and they kind of work you in gradually. So most programs, they don’t put you in the operating room by yourself on day one of that second year. They’ll have you paired with another resident, with an attending, something like that where there’s a little bit of a safety net. And of course you always have an attending supervising you, but I mean in the room for the first say month or two. Probably won’t have you take on for the first month or two but then you get progressively more independence, responsibility, and then you’ll go through more advanced rotations. So that’s going to be things like cardiac, anesthesia, neuro, neurosurgery, neuroanesthesia, labor and delivery, pediatrics. All those different things that are just different than the general case, and those are required as well. We do some pain management, that’s another- it’s not a subspecialty of anesthesia exactly, it’s a multidisciplinary field. Anesthesiology is one of the main fields of that, similar to critical care, it’s a multidisciplinary field that anesthesiologists are involved in. Those are all things you go through and at some point in time you kind of figure out what you want to do with your life. There’s fellowships, so that’s a separate thing after residency, but decide if you want to do that, which one? You know call is I guess depending on who you’re comparing to more or less frequent. Again compared to our surgeons that we work with, probably less call than them, but maybe more than some other folks. And it’s almost always in-house, and there’s almost always- I think most programs will have a couple residents like a senior and a junior on call. You know that’s a pretty standard sort of run-through of the residency experience. You know you have your board exams, oral and written that you’re going to have to take, and you’ll have didactics that help you prepare for those which probably are pretty common things for most fields.

Dr. Ryan Gray: There aren’t a lot of oral boards left since you brought that up. So anesthesia is still one that has oral boards?

Dr. Patrick Pickett: Oh we do, yes. And I can say this since I’m done with it, I enjoyed it in a weird way. I mean it’s- and I’ll talk a little bit about that since maybe your other specialty guests didn’t experience that. So the surgical fields typically do have oral boards. I know this because through my wife and through the other people I work with. But theirs are a little different than ours. A lot of times they prepare a case log and they ask you questions about specific cases you did. So ours is not like that. So the oral boards for us, basically two hours, we have two rooms each about an hour long, and you have two examiners in each room, and you walk in and every candidate has the same- we call it stem which is sort of the beginning of a case, but then which direction it goes is up to the examiner. So they’ll say, ‘Your patient is a 70-year-old male, he’s scheduled for heart surgery, he has these problems,’ and they always give you some hints as to what problems are going to arise. He has abnormal EKG, then he’s going to have a heart attack during the case. Or he has some weird breath sounds, he’s going to have some respiratory problems during the case. Things like that that make you kind of draw on that medical knowledge, the anesthesia knowledge, knowledge of all the surgeries we provide anesthesia for. And their goal is to really kind of- I think the phrase is to probe the limits of your knowledge, which basically means keep asking you questions until they get to something you don’t know, and then move onto the next thing. So it’s a little intimidating, but it’s an interesting format. I mean you know, in the US we don’t do a lot of oral exams in college or med school. I think in other countries, I know the one that comes to mind because I knew people that came up through the system is India. They do a lot of oral exams, so for them that may be second nature, but for us because we don’t do those it seems intimidating because we’re not used to the format. So you have to take the written board exam before you can take the oral board exam. So it’s not a question of the content, it’s a question of can you kind of think on your feet and it’s not like a multiple choice test which are most of what we take in medicine, where all five answers are already there, you just have to find the right one. So for the oral board you have to be able to come up with it from scratch and that can be a little hard. It takes a lot of practice, but like I said being done with it, I enjoyed it. Maybe I wouldn’t feel that way when I was preparing for it, but now I kind of look back but I think that was a pretty neat experience.

DOs versus MDs

Dr. Ryan Gray: Do you see any bias among DOs versus MDs?

Dr. Patrick Pickett: You know having done my training in the Midwest, and I feel like there are a lot more osteopathic physicians in the Midwest than the coasts, never practiced or trained on the coast so I can’t say that for sure, but I feel like I have more exposures to working with DOs and my impression of them was always really good. Now it could be a little bit of a selection bias because it could be that the DOs who chose to do allopathic residencies were whatever you want to say, more motivated or something, or whatever. But I think some of the smartest guys I know were DOs. I mean they’re some of the most amazing docs I know were DOs. So I always had a good impression. And I mean my understanding of it is they pretty much have to know all the things that MDs know and then a little bit extra, the osteopathic manipulation. So I don’t think it’s- I think that if there is- and there probably is some bias out there, you know I assume you asked me that because this has come up before. But I don’t think it’s deserved. I mean I work with a lot of DOs and they’re excellent doctors. So it’s just different, and it’s a little bit silly. I think at some point they should just combine them. But you know I don’t think any bias that’s perceived is deserved.

Sub Specializations in Anesthesiology

Dr. Ryan Gray: You mentioned a little bit ago about sub specializations. What opportunities are there for anesthesiologists to subspecialize?

Dr. Patrick Pickett: Yeah there’s a number, and as medicine grows and the knowledge base, this is common that I think all DOs are doing some sub specialization. So for us the two that are kind of different are pain management and critical care because those are multidisciplinary. So other physicians, so let’s say pain management, the neurologists, psychiatrists, PM&R which is physical medicine and rehabilitation, and maybe internal medicine can all do that. Most of the training programs that I know of are anesthesiology based and most of the people going into those are anesthesiologists because a lot of what they do is interventional meaning sticking needles in people and we kind of do that more than some other people as far as opioids. I mean we have a little more experience dosing opioids. Critical care, that’s ICU medicine. Most of- my understanding, I kind of went through this with my job search, is most of the programs are run through internal medicine. Pulmonology, which also deals with sleep medicine sometimes. So the anesthesiology is a smaller percentage of that field, typically affiliated with academic programs, but it’s very exciting. I’m biased because I kind of did my training in that as well. And in the other subspecialties are things that you’ll be in the operating room but it’s sort of more specialized. So pediatric anesthesia, cardiac anesthesia which is really growing because they do ecocardiography which is the ultrasound of the heart, so they’re trained to interpret those and tell the surgeon, ‘Hey this is what I’m seeing here, this mitral valve looks worse than we thought, or this is the size of the aortic valve so this is the size needed of the valve replacement you need to put in.’ So they’re really involved in the management of those cases. Neuroanesthesia, obstetric anesthesia, those are some of the other ones. There’s probably some really specific things that are some less on programs like liver transplant anesthesia that’s probably just a few of those. And the first ones I mentioned are much more common.

Dr. Ryan Gray: What do you wish you knew going into anesthesiology that you know now?

Dr. Patrick Pickett: Probably all the different job opportunities that are available because kind of as I alluded to earlier, when you go through training you’re always in academics and that’s kind of what you see, and you don’t really see community practices unless you have kind of a connection or something. Because there’s really most of the people in not just anesthesia, but in most fields, most of the people are out in the community, they’re not in an academic center. And it’s a different style of practice. But what I’ve realized is for me at least, I prefer that. Not to say that I could never go back to academics because I think you can certainly do both well, but I don’t know what the answers is as far as how do you get premeds, med students, and residents into the community in a formalized way. I think you kind of have to seek out those opportunities yourself. I wanted to add one other thing what I wish I would have known earlier, and this is not specific to anesthesia, but the business side of medicine. I’ve kind of done a lot of reading and I’m actually working on the MBA largely for my own entertainment, but I just get really interested in the business side of medicine. That’s something you really don’t get much in training at all, but it is important particularly if you go to community because you’re sort of responsible for the bottom line, and you’re much more aware of your own bottom line.

Dr. Ryan Gray: What other specialties do you work the closest with?

Dr. Patrick Pickett: For us in anesthesia it’s going to be all the surgical fields and really I’ll expand that to procedural fields. So every kind of surgery as well as things like GI, gastroneurology, they do endoscopy, and some of the cardiology like EP lab which is electrophysiology, some of the internal- or interventional radiologists. So basically anything that- any procedure that some physician is doing to a patient that would require anesthesia. Even for some folks an MRI if they don’t want to sit still, if they’re very young, or just have a lot of anxiety, we might provide some sedation for that.

Opportunities outside Clinical Medicine

Dr. Ryan Gray: Are there any special opportunities outside of clinical medicine for anesthesiologists?

Dr. Patrick Pickett: Well you know, certainly being in a field that I’ll say used to be a very litigious field, thankfully because anesthesia has gotten so much safer over the years where no longer- we used to be in the most litigious group which is obstetricians and neurosurgeons, and thankfully we’ve moved down to between ophthalmologists and internists, which is to say medium litigation risk. But there’s been opportunities for things like expert witness testimony because we are a field that uses a lot of technology. There’s some opportunities to play a role in that, and there’s always research opportunities, and that’s probably a lot of fields as well. You know a lot of the movement now- and thankfully our field has been early in their adoption of this, but quality improvement which is a buzz word now. But the field got a lot safer over time, and really that was sort of around the 1980’s when the monitoring technology got improved, and there’s standardization of the equipment we use in the operating room, and expansion of our training. And so if anybody that has exposure to the business world, they throw around this buzz word called Six Sigma which is a statistical term, but it’s been used to describe the quality of a process, and I think it’s something like one in half a million or I forget what the exact number is, or maybe it’s three out of a million defects. And when I’m talking about in anesthesia, that’s mortality. So that’s about the chance of dying from anesthesia today is one in 400,000 or something, and I’m sure that your listeners can Google and find out that I got the exact number wrong. But it’s something like that, and we’re the only field of medicine that’s achieved that level of safety which is kind of cool. So that was a little bit of a tangent. Quality management is another thing that you can get involved in and kind of it’s a heavy presence of anesthesia in there.

Dr. Ryan Gray: What do you wish other specialties knew about anesthesiologists?

Dr. Patrick Pickett: Well you know, I like to think- and predominantly this would be the surgical colleagues we work with. We have a little bit different approach to a patient. You know we’re really focused on safety. The surgeon’s maybe looking at through surgical reasons the patient needs to have the surgery. So they have something wrong with their gall bladder, or their knee, or whatever part of their body. But we kind of look at the whole patient, and particularly the heart and lungs because those are the most affected by anesthesia, but all of their comorbidities, and we try to understand it best. There’s a combination of kind of three things; the patient and their medical problems, the surgery and how that affects the body, and then the anesthetic and how that affects the body. And all things have to come together and affect the patient in certain ways, and so we have to kind of try to get an idea of how the patient’s going to handle that. And so they may have a very valid reason for needing surgery, but they also may be not a really good candidate for anesthesia. And so we have different ways of looking at patients, and it’s sometimes hard to get across to people that don’t do anesthesia so we have to be patient and kind of explain what our thinking is. You know fortunately most surgeries are scheduled ahead of time, and so we have- at least at our hospital, I think probably most hospitals as well, have a pre-anesthesia process of reviewing patients, trying to decide who’s a good candidate, who’s not, and what we can do if somebody’s not a good candidate to make them a good candidate. So that’s kind of where some of the struggles with other physicians comes from is that trying to get everybody on the same page, and oftentimes we work in other positions as well that are not surgeons such as cardiologists, or pulmonologists if the patient has those comorbidities, to get their expertise. There are a lot of times that I’ve had a patient, I’ve called both the surgeon and the cardiologist and tried to get everybody on the same page, and so we can get the best outcome for the patient.

Pros and Cons of Anesthesiology

Dr. Ryan Gray: What do you like the most about being an anesthesiologist?

Dr. Patrick Pickett: I think if I had to pick one thing it’s variety. Doing different things every day, and sometimes even within the same day. You know this is a little bit hard I think to explain to the premeds, but I remember I was really drawn as a premed to the really exciting stuff like the trauma surgery, and the gunshots, and being up until 5:00 in the morning. And what you realize over time is that it’s also nice to have more of a routine day. And so you know, that’s okay too, and actually that’s at the point I’m at in my life, that’s preferable. Sometimes excitement is not so good for the patient, you know? So we still have our share of excitement, so that’s also nice. But I like doing different things and I like that we have variety in how long I’ll be at the hospital that day, and the kind of patients I meet, and all those kind of things.

Dr. Ryan Gray: What do you like the least about being an anesthesiologist?

Dr. Patrick Pickett: Well you know, certainly night call can be not always fun. If you’re having to be up for 24 hours, that’s- at approaching 40 that’s not quite as easy when I was closer to 20. But again it’s not every day. But that’s probably the least enjoyable thing, having to be up all night which we do from time to time.

Dr. Ryan Gray: If you had to do it all over again, would you still choose anesthesiology?

Dr. Patrick Pickett: Oh I would, and I’ve thought about it, I’ve reflected on it, and for me it’s the right fit. It’s not the right fit for everybody, my wife thought it was the most boring specialty she ever rotated on, but we still get along, my wife and I, so that’s good. And she’s a gynecologist and I could never do what she does, it doesn’t interest me at all. So really there’s no right answer for everybody. There’s no one specialty that’s, ‘Oh this is the best thing for everybody.’ You’ve got to go through it and find what clicks for you.

Future of Anesthesiology

Dr. Ryan Gray: Now I like to ask what do you see as the future of anesthesiology? And I’m going to lead you a little bit with this one because it’s unique with you guys and CRNAs. Where do you see the future of anesthesiologists versus CRNAs merging?

Dr. Patrick Pickett: Well I actually- I don’t think the future is versus, I think the future is with. So it’s called the Care Team, the Anesthesia Care Team, which means a physician and a nurse, anesthesiologist and a nurse- or an anesthesiology assistant, she’s an AA which is another type of anesthetist that can work with the anesthesiologist. You know most of the evidence shows that the Care Team is a very safe approach, and I think there’s advantages of that. But I think that- in my practice I do my own cases meaning it’s just me. We’re all physicians, we don’t supervise other people, so there’s advantages and disadvantages to that, but there certainly is a large proportion of the country that has that supervision model. But I don’t know that necessarily that it’s quite as controversial or whatever the word is as people make it out to be. I mean I think most of the people out there working get along just fine as far as the nurses and the anesthesiologists. So I don’t think there’s- I think it is something that has been brought up and debated over the years, but it seems that most of the time people get along fine. I actually- I mean as far as the future of the specialty, I don’t know that that’s the number one issue even. I think it’s something that- and I would say for your applicants and for your premeds, there’s a chance- you should be prepared to do both. I mean you should be prepared to supervise nurse anesthetists, or AAs, and you should also be prepared to do your own cases. Because even in the same practice sometimes people do both.

Dr. Ryan Gray: Any last words of wisdom for those that are looking at anesthesiology as a specialty?

Words of Wisdom to Students

Dr. Patrick Pickett: Well you know I think for some people it’s a great fit, and for me it was, and keep it in mind. Kind of the things they say are that if you like pharmacology and physiology in the basic science years, you might consider anesthesiology. You know if you like those kind of fast-paced hospital-based kind of specialties, give it a try, give it a rotation, and if you don’t like it there’s plenty of other fields to choose from. But if you do, I think it could be a great career.

Final Thoughts

Dr. Ryan Gray: Alright there you have it. That was Dr. Pickett sharing his story about anesthesiology, and his thoughts about the field. If you’re interested in anesthesiology or any field, shoot me an email, Ryan@medicalschoolhq.net. If we haven’t covered the field you’re interested in, let me know and I’ll try to find somebody for that podcast. Or if you have somebody in mind, go ahead and introduce them to me, Ryan@medicalschoolhq.net.

I hope you have a happy and wonderful 2017, as we’re recording this, the first episode of the 2017 year. I hope everybody had a happy and healthy New Years, and here is to the rest of the year. Have a great year and don’t forget to check out everything that we do over at www.MedEdMedia.com.

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