The Heart of Cardiothoracic Anesthesiology

Session 228

In this episode, Dr. Maung Hlaing talks about being a Critical Care Cardiothoracic Anesthesiologist. Let’s chat about his path to this anesthesia subspecialty and why he chose to get into the critical care world as well.

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[00:31] Interest in Critical Care and Cardiac Anesthesiology

Growing up in Burma to physician parents, Maung witnessed the intensity of stress around his parents when they were practicing in Burma. This was what drew him towards critical care.

Then when his dad had a Type A dissection and had to have surgery, he became interested in cardiac. That interest was piqued, even more, when he started doing cardiac clinically in residency.

He then had mentors and people along the way that both critical care and cardiothoracic anesthesiology can both be practiced in your career.

There are people who do critical care through neurology, nephrology, and emergency medicine. In fact, their ICU fellowship takes residents from both anesthesia and emergency medicine backgrounds, as well as surgery, pulmonary, and anesthesia.

And so he had to consider what he had to do aside from critical care because nobody does critical care from 9 to 5 every single day.

[05:17] The Evolution of Specialties and Subspecialties

As to why we need all these different subspecialties in anesthesiology, Maung explains the evolution of the specialty.

Some 20-30 years ago, most of the anesthesiologists doing cardiac anesthesia would not be fellowship-trained. Once you do an anesthesiology residency, you could do everything – OB, pediatrics, cardiac, etc. And there are still people, probably more in private practice, who do all these specialties without fellowship training.

“As you get more and more complex, and your patients and your procedure are getting more and more involved, that's where the special subspecialization comes in.”Click To Tweet

For instance, cardiac anesthesiology is still evolving. Right now, they have board certification in transesophageal echo, but not in the subspecialty of cardiac anesthesiology. And there was just an announcement by the American Board of Anesthesiology that in the next couple of years, there’s going to be a board exam.

[06:56] The Biggest Misconceptions Around Cardiac Anesthesia

There’s a misconception that anesthesia is the easy path to having a stable, seven to three job. They don’t take many calls and they’re compensated well. And they think it’s a lifestyle specialty. But within ICU and cardiac, Maung feels it’s definitely not the case.

He adds that you can make yourself be in a situation or be in a practice where you’re working more, you’re dealing with really sick patients, and you’re very involved. It’s rewarding on an intellectual level as well.

Within anesthesia residents, there’s also this misconception that cardiac and ICU are too hard. And so, a lot of them shy away from them.

There’s not one mold for cardiac anesthesia. If you want to work in an academic center and have a busy practice, that’s possible. If you want to do cardiac and then go into private practice and have a reasonable lifestyle, that’s also possible. Maung clarifies this is more so true in the cardiac world than in the critical care world.

'Critical care is undergoing an evolution as far as how it looks within the private practice world.'Click To Tweet

[10:20] Traits to Becoming a Good Critical Care Cardiac Anesthesiologist

A lot of the procedures they do are urgent, emergent things. For example, someone could just come in with a Type A dissection or a cardiogenic shock, and you’re taking care of these patients. So you have to think on your feet and digest a lot of information.

Oftentimes, there’s information overload since you get a ton of numbers from all these invasive machines and monitors. And so, you really have to digest all of it relatively quickly to figure out what’s going on.

'Being able to think on your feet and respond quickly to changing environments is one of the big things about being in this specialty.'Click To Tweet

Being a Fellowship Director, Maung says that the thing they look for the most among applicants is a genuine interest in the field. He adds that it’s also important for someone to be able to roll with the punches. There are people who try to get into the field thinking they want to follow their mentors treating sick patients. But they don’t realize all the groundwork that goes into it.

He recalls his days back in medical school when he would go everywhere as far as trying to figure out what specialty he wanted to do. At one point, he wanted to do neurosurgery and ENT. He was all over and he realized he enjoyed being on the other side of the drapes. He loved thinking about physiology and pharmacology rather than the surgical side. He enjoyed the surgical side, but it was something where he realized he had other interests as well.

[14:49] Typical Day

Maung’s days in the operating room as a cardiac anesthesiologist or general anesthesiologist are totally different from his days in ICU. They do about a week, a month, or so, in the ICU and the rest of the time in the operating room.

Time in the Operating Room

In the operating room, cases start at 7:30 am. He is supervising residents so he doesn’t have to show up an hour early to drop IVs and things like that. But if you’re in practice by yourself, you’re going to spend a little bit of time preparing the room.

Then they interview the patient and get all the lines ready. And then the procedure starts with an echo. By the time they’re done with that and close to going on bypass. The bypass phase is a little bit of a lull for them.

Coming off bypass, they have to evaluate what’s going on and whether they need to change the pharmacology medications they’re giving. Once stable, they resuscitate them and then take them over to the ICU afterward.

This can last for the majority of the day, depending on the surgeons you’re working with and the type of patients you’re taking care of.

A lot of times, they might have a second-round case. And if you’re on call, you’ll be stuck doing the same thing for another time. This is what it looks like for most of your cardiac days.

Time in the ICU

In the ICU, there’s usually a lull in the late morning until the cases start rolling in. You’re managing those patients to make sure they’re doing okay. The next six hours, immediately after surgery, is where they’re most unstable. They have to deal with other things throughout the night. Usually, they are on call at night and on home call so they’re answering questions and things like that as well.

In their fellowship in Colorado, they have three fellows a year. This is on the small to medium size end of things. There are also smaller programs where they have one to two fellows.

The advantage of a smaller program like theirs, Maung says, is that you get to know the faculty really well. So you get to work with the same people day in and day out. It allows a closer relationship with the fellows and the faculty and that helps in learning a lot as well.

[18:19] The Training Path

After years of medical school, you do four years of anesthesia residency. Most of the anesthesia fellowships are one year. This is the one advantage of trying to do two specialties. You do one year of ICU and one year of cardiac. You end up with six years, which is on par for most medical subspecialties that do, for instance, three years of residency and three years of specialized training.

[21:38] The Work-Life Balance

Maung says this is something that’s hard to appreciate when you’re in medical school where a lot of students don’t have spouses and kids. You don’t think about all the other things that come with what it means if you’re up in the middle of the night, or if you’re gone on weekends. And those things can add up.

'Part of the appeal of anesthesiology is that you can keep that level of volume if you want and you can choose to taper down or switch or do whatever you want to make it work.'Click To Tweet

In the first seven years of his career, Maung focused on learning all the skills he wanted to learn. And as he felt more comfortable being in the attending role, he started thinking about the things that can make his life and his family’s life work. But generally, most anesthesia jobs are able to tailor that as you need.

[23:20] Negative Bias Against DOs

Whether you’re an MD or DO, Maung says he would still be looking at the same things when looking at applicants. They should be able to exhibit genuine interest. This may show up as academic projects or extracurricular activities focused on cardiac anesthesia.

For any sort of candidate, especially when your CV may not be as appealing, Maung suggests getting into academic projects with cardiac faculty to show your interest.

[24:19] What the Future Holds

Especially in the era of COVID, there is this massive critical care need. There’s certainly a need for critical care physicians. At the same time, fellowships are not as competitive as cardiac fellowships. But the adverse is true for cardiac fellowships.

Cardiac anesthesia is a very popular specialty and it’s very competitive right now. But when those fellows go into practice, the cardiac-specific jobs are not as prevalent.

Part of it may be the mismatch in the training of fellows versus jobs available. The other part is this continued trend in cardiac surgery as it’s leaning more toward non-invasive and interventional cardiology procedures.

'Within critical care, there is a massive need for critical care physicians.'Click To Tweet

Some of the roles of cardiac anesthesiologists have changed. A good part of their job also entails not just, open cardiac procedures in the operating room, but also things in the EP lab, Cath Lab, etc. They’re taking care of similar patients, but having less invasive interventional procedures.

[26:09] The Most and Least Liked Things

Especially as a program director, Maung likes learning about cardiac anesthesia and cardiac physiology. He loves the education aspect of it and being able to teach everyone at different levels is very rewarding for him.

What he likes the least, on the other hand, is the hours. It’s nice that the specialty calls for you to be extra alert at all times. But at the same time, when you go a decade of doing that, it can be taxing. And so, you have to focus on your mental health. Be able to tune out and have resources available for you to make sure you’re not overstressed and over-anxious because of the environment you’re in. Knowing that a little bit more before going into the specialty helps you prepare and gives you a little perspective.

[28:06] Final Words of Wisdom

If he had to do everything ever again, Maung says he would still have chosen the same career. That being said, he wishes to tell students who might be considering this path to find a mentor at their local hospital or a medical school.

Find someone willing to have you come along and see what these cases are like because, in a way, it sells for itself.

As for Maung, once he stepped foot in the cardiac room and saw what was going on and what they did, it was clear that it was what he wanted to do. So go out there and you will know if it’s right for you or not.