An Obstetric Anesthesiologist Delivers On Her Subspecialty

Session 205

Dr. Jennifer Dominguez is an obstetric anesthesiologist. She joins me this week to share her journey into this unique subspecialty and shares why you should consider it.

If you would like some more information about obstetric anesthesiology, check out theSociety for Obstetric Anesthesia and Perinatology (SOAP).

For more podcast resources to help you with your medical school journey and beyond, check outMeded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:28] Interest in Obstetric Anesthesiology

Jennifer has always liked women’s health and was passionate about women’s health so she thought she would become an obstetrician. She had done research in reproductive endocrinology prior to medical school and had been very interested in that as a potential specialty.

Then when she rotated through her third-year clerkship in medical school, she realized she didn’t like operating.She liked the environment of the operating room and the type of problem-solving but she didn’t enjoy operating. Obstetricians are surgeons. They do a lot of surgery. In most of their subspecialties, they work in the operating room.

Knowing she liked the O.R. environment, she started exploring anesthesiology, something she didn’t know a lot about. When she first got into it, she thought she would be giving up women’s health. And that was one of the major considerations for her in choosing anesthesiology.

She initially didn’t realize there was a way to go into women’s health through anesthesiology. And only through exploring the subspecialties of anesthesiology that she learned she could go on and do a fellowship in obstetric anesthesiology. So she went to Duke and ended up staying on the faculty and being there for almost 10 years as an obstetric anesthesiologist.

[03:45] Why We Need Specific Sub-Specialties in Anesthesiology

Their anesthesiology residency program is four years. Compared to some of the other specialists that go through internal medicine, for example, they do a three-year fellowship.Their training is still relatively shorter and when you add on fellowship, you’re looking at five years. So it’s still shorter than, say, pulmonologist, which would take six years doing internal medicine for three years and then another three years of pulmonary critical care fellowship.

In terms of kind of the overall number of years in anesthesiology, it’s really not that different than a lot of other specialties. The patients, however, are getting sicker. The population is getting thicker, at least in obstetrics. Jennifer says they’re seeing how patients are getting older and sicker.

One of the ways their specialty has responded to that is by training more obstetric anesthesiologists. These are people who have the knowledge and experience not only of critical care from their anesthesiology residency but also deep knowledge of obstetrics and taking care of critically ill, high-risk pregnant women.

[05:23] Biggest Myths or Misconceptions Around Obstetric Anesthesiology

Jennifer says they hear a lot of folks who come to do a fellowship in obstetric anesthesiology are told by general anesthesiologists they don’t need to do fellowship to do obstetric anesthesiology. And she explains that historically that has been true, but there’s a movement for more representation in the specialty by ACGME of fellowship-trained OB anesthesiologists.

The fellowship wasn’t always available. So the ACGME approved this fellowship in 2012. Historically, a lot of people have done obstetric anesthesiology without a fellowship. Many of those people are great OB anesthesiologists and provide great care to their patients. They just didn’t have a fellowship available to them when they trained.

'Our specialty is a lot more than putting in epidurals, we take care of some really, really sick moms, and I think we add a lot of value to their care.'Click To Tweet

[06:49] Traits that Lead to Being a Good Obstetric Anesthesiologist

Jennifer says the ability to multitask is important as well as flexibility. You might be doing one thing, and something more important might come up. So you have to flex and figure out how to take care of the other thing that’s more pressing.You also have to be a really good communicator.

'A labor floor can be really chaotic and we are managing a lot of different kinds of problems and issues at the same time. And so, you have to be able to multitask.'Click To Tweet

They work with a lot of different types of medical providers including labor nurses and other subspecialties like obstetricians and Maternal-Fetal Medicine specialists and neonatologists.

Outside of the O.R. setting, they provide labor analgesia at a birthing center. They meet patients when they come in laboring, or when they come in for induction of labor. And they talk to them about analgesic options for their labor, whether it’s an epidural or combined spinal-epidural.

They also help with operative delivery. Some patients have a need to requires forceps to deliver their babies. So they provide analgesia for those types of procedures and operative deliveries.

They do consultations meeting patients while they’re pregnant. They give them different options for their anesthetic care and help them understand better what to expect. Then they make some recommendations to the Maternal-Fetal Medicine specialists who refer the patients to them.

[10:26] Typical Day

Jennifer belongs to a team of obstetric anesthesiologists at their hospital. One of them is always covering during the day and then covering during the night.

They have a demanding day when they’re on labor and delivery, starting at around 6:30 in the morning. They start with reports then they get the handoff from the night anesthesiologist and learn about all the patients they cared for overnight. They find out about upcoming surgeries, talk to the team and strategize and plan for all the work they have to do that day. And then they start taking care of the patients.

They do a mixture of care and deliveries, labor analgesia to ligations. They take care of critically ill women who might be having a postpartum hemorrhage, or some other acute medical issue on the labor floor.

Jennifer is usually done at 6 pm where she hands off to the night anesthesiologists. They don’t have any scheduled cases overnight but they take care of emergencies and laboring patients.

[12:33] Does an obstetric anesthesiologist have to only do obstetric cases?

Jennifer does a variety of general anesthesia. Her division in her hospital is called Women’s Anesthesia. So she takes care of a lot of women with reproductive cancers as well as women with gynecological oncology surgeries like hysterectomy. In a lot of those cases, she does epidurals to help not with labor, but with post-op pain.

'We use our skills that we hone and get very, very good at on the labor floor to help patients who are undergoing surgery with their post-op pain.'Click To Tweet

Jennifer also cares for men who are undergoing urologic surgery like prostatectomies for cancer, and a lot of robotic surgery.

[13:57] Life Outside of the Hospital

Jennifer has a busy academic practice in addition to the clinical work she’s doing, as well as a couple of administrative roles.She is the director of the fellowship program in obstetric anesthesiology at their hospital. She trains fellows every year, which she finds rewarding. She gives lectures and teaches in a simulation lab in addition to working with them clinically. She is also the chair for diversity and inclusion in her department.

Jennifer does a number of initiatives to work on advancing diversity, equity, and inclusion in their department and in the School of Medicine as a whole.

She’s involved with the societies outside of her hospital nationally for obstetric anesthesiology and also for sleep medicine because she has an interest in sleep medicine in pregnancy. She works on a society level on a variety of initiatives.

Jennifer says she also has a personal life. She’s able to spend time with her children and her husband who’s also a physician. And she’s got time for hobbies and recreation as well.

[15:34] What Fellowship Looks Like

The one-year fellowship is done after the four-year residency. Residents typically apply on their third year. The PGY-3 year is called the Clinical Anesthesia year 2.

'Application is through a matching system and they come to them after the residency for a one-year fellowship.'Click To Tweet

In fellowship, they spend about seven months spread out over the entire year on the labor and delivery floor. They care for the sickest moms on the floor as well as the most complex cases and conditions.

One condition is called the placenta accreta spectrum where the placenta invades like cancer through the wall of the uterus. Sometimes, it also invades into adjacent structures like the bladder and it causes a lot of problems.

And so, an obstetric anesthesiologist might be the only person available with that skill set to help resuscitate that baby. They’re trained in neonatal resuscitation and they also rotate with their colleagues in maternal-fetal medicine to learn more about their specialty.

They also get point of care ultrasound training. Their fellows learn how to do diagnostic point of care ultrasound of the heart, lung, and stomach to help guide their clinical decision-making.

They do three months of research as well, and sometimes they do electives in transfusion medicine, which is a huge part of managing hemorrhage. And so it’s helpful to know more about blood banks and about what their colleagues do there so they can work better with them and more effectively with them. And then some of the fellows rotate through cardiology or even the pulmonary hypertension team.

[18:59] How to Be Competitive for Matching

Jennifer says they’re looking for someone who has demonstrated a commitment to obstetric anesthesia in their residency in some way.A lot of their fellows have done research projects and obstetric anesthesiology during their residency. Or they’ve done interesting quality improvement projects. Some of their fellows have worked abroad and done service projects in other countries working in a maternity hospital in another country.

Several of their fellows also have a specific interest in some aspect of obstetric anesthesia. It might be something like health disparities, helping bridge the gap in health disparities in maternal care. They should also have a career goal and they have some demonstrated evidence of accomplishment in that area.

“We're looking for people who have demonstrated excellence in residency and medical school, through their clinical rotations, and through other initiatives and projects as well.”Click To Tweet

As for Step 1 going pass/fail, Jennifer doesn’t think those numbers have been very indicative of who’s going to perform well in fellowship. From her perspective, as a program director and looking at a lot of applications over a number of years, she wouldn’t say that test scores necessarily predict who’s going to do well in fellowship. So she doesn’t really see any issue with it.At the end of the day, Jennifer says that test scores do not necessarily predict who’s going to do well in fellowship.

[21:08] Special Opportunities to Subspecialize

Once you’re a fellow, there are ways to get into other sub-specialties. In fact, they recently accepted one of their residents who is going to be staying with them to do a second fellowship.

She’s going to do obstetric anesthesiology and critical care medicine, which are two fellowships back-to-back as a two-year cycle at their institution.And she’s going to become an obstetric anesthesiology intensivist. She will have a special skill set in critical care and be able to provide care for pregnant women on the labor floor, but also in the ICU.

There is another subset of folks doing obstetric anesthesia and then, cardiothoracic anesthesiology, and so that’s a two-year cycle, two fellowships back-to-back. Those folks are uniquely positioned to care for mothers with cardiac disease in pregnancy, which is a really complex comorbidity to have during pregnancy.

In the face of COVID, they’ve also seen a number of women who need ICU care during pregnancy. And a lot of those women have been completely healthy prior to them acquiring COVID. And then, unfortunately, going on to have respiratory failure and needing respiratory support.

[24:36] Message to Osteopathic Students

Jennifer assures students that if they come to their program, they won’t encounter any bias. In fact, she has a lot of DO colleagues, including that person dual trained in obstetric anesthesiology and critical care medicine. She also has other DO colleagues she works with on a daily basis. That being said, they look at the DO applicants the same way they do MD applicants.

[25:23] What She Knows Now That She Wished She Knew Before

Jennifer reckons she could have just reassured herself that she chose this specialty because she really likes her work. She finds it extremely gratifying. She gets to take care of women and alleviate pain at a time where there’s a lot of fear, uncertainty, pain, discomfort, anxiety, and she gets to help with all of that.

She also gets to save lives sometimes and save babies in distress and get delivered quickly and safely. She gets to intervene in maternal hemorrhages and save lives that way.

'It's a really, really gratifying job. I think it makes a big impact on patients, and it makes a big impact on families.'Click To Tweet

[26:32] The Most and Least Liked Things

Jennifer likes how she gets to talk to her patients more than a lot of anesthesiologists. She’s able to connect personally with their patients. And then during C-sections, their patients are also awake. They don’t do general anesthesia for C-sections unless they have to in an emergency.

'It's a huge privilege to be able to be with families when their child comes into the world.'Click To Tweet

Even when there are bad outcomes and unfortunate things happen, or babies are sick when they’re born and they require advanced levels of care. Jennifer thinks it’s still a tremendous privilege to be with people during that time and to help them.

On the flip side, she doesn’t like working at night and staying up all night. But it’s just a necessary aspect of what she does. And so it’s just a necessary part of what she does but it’s not her favorite part.

[28:53] Major Changes Coming to Obstetric Anesthesiology

The CRNAs are already part of their care team in obstetric anesthesiology. And that varies depending on the institution, the care setting in terms of whether they actually place epidurals and spinal anesthesia or whether they work in conjunction with an anesthesiologist that does the procedures.

She adds that more and more obstetric anesthesiologists are going to be trained in point of care ultrasound. This is something they’re training all new fellows in right now.

Jennifer asserts it’s a really useful tool when you’re trying to make a clinical decision in an emergency. For instance, you may not have access to a cardiologist who can come down and do a formal scan. She clarifies that they’re not trying to replace cardiologists and their skill set by any stretch of the imagination.

“There's a big national push to expand the training in point of care ultrasound.”Click To Tweet

Point of care ultrasound can be extremely useful in managing conditions such as hemorrhage. There are also other ways in which they use point of care ultrasound. And as the technology develops, and these machines become more affordable, they can be utilized in a greater variety of settings. And as people develop the skills to use them, that’ll be one way in which our specialty changes.

[31:28] Final Words of Wisdom

If she had to do it all over again, Jennifer says she would still be an obstetric anesthesiologist.

Finally, Jennifer encourages students or residents thinking about obstetric anesthesiology to go for it since it’s a great, extremely rewarding career. They’re in high demand.