One of my readers, Josh, asked me to comment on how I chose anesthesia as a specialty, and as I looked at things in retrospect, I thought it would be an interesting post. I have never been someone who makes decisions easily, and I struggled away deciding between internal medicine and anesthesia. On the other hand, I have also been someone who's been quite satisfied with my choices, and I rarely regret the decisions I make. Consistent with this, I have absolutely no regrets going into anesthesia.
I love medicine, and for me, anesthesia is medicine in the operating room. The things I like most about medicine are the acute inpatient concerns: the cardiovascular effect of an arrhythmia, the treatment of an overwhelming infection, fluid management in a patient with congestive heart failure undergoing surgery. These are the daily issues of an anesthesiologist and intensivist. I've never been incredibly interested in outpatient medicine, and perhaps it is because medical students and interns don't spend a lot of time in clinic. But adjusting a levothyroxine dose, struggling with an overzealous hemoglobin A1c, and long-term management of psychiatric illnesses were never my thing. These aspects of medical content guided me towards anesthesia, though I am certain that some medical subspecialties would have appealed to me as well.
But interesting medical content can be found everywhere, and differences between medicine and anesthesia extend beyond that. The anesthesiologist is a proceduralist, as much as an emergency physician, and becomes more comfortable with hands-on interventions than a general adult medicine practitioner. The time course of anesthesia (and even critical care) is an order of magnitude quicker than medicine; I get an instant response in blood pressure from pushing labetalol compared to a clinic doctor who increases metoprolol and books an appointment for the patient months later. Yet anesthesia lacks a lot of things, most notably continuity of care. There are no patients who identify me as their primary doctor, and perhaps there is less recognition and prestige compared to the master diagnostician or amazing family practitioner.
I think, though, when I chose a residency, the most important influence was the culture of the specialty. Though it gives rise to stereotypes, each field has its own personality. Because of that (moreso than medical content), I was dissuaded from joining the surgeons, obstetricians, pediatricians, and psychiatrists. I liked the medical doctors who exhibited an orderly, methodical, and critical approach to diagnosis. They appreciated evidence based medicine, addressed patients as a whole, and had an appreciation for the theoretical and book-learning in medicine. But occasionally, I found rounds to have a little too much repetition. Anesthesiologists tend to be fairly easy-going and laid-back with most things yet demanding with attention to detail to that which matters. We tend to multitask well and enjoy the smooth sailing when things go well, yet remain vigilant and respond immediately when something unexpected happens. The role-models I found in anesthesia and critical care have been the type of doctors I wanted to become, and I think that's what persuaded me to go into the field.
Looking back, I have no doubt it was the right choice for me. Work is immensely satisfying, allows a balance with the other priorities in my life, caters to my personality, and gives me the opportunity to take care of patients directly in real time. I would definitely choose anesthesiology again.
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Thanks so very much, Craig! I truly appreciate your thoughts. It helps me a lot, especially since I'm considering the same fields you considered, i.e., internal med with a hope toward pulm/ccm and anesthesia (and actually emergency too). I like the acute medicine in the OR, I like the procedures, and maybe best of all I like the personality of the field like you said! So maybe anesthesia is for me too. But although other classmates have to decide, thankfully I still got some time. :)
Great! I am a strong believer that there is no one perfect specialty, and that everyone will find things they like about each of the fields they try. It's really hard as a student (and as a resident) to see what life would be like as an attending, so keep that in mind. It's not an easy decision, and some people change their minds half-way through residency, but get as much exposure as you can, talk to residents and attendings alike, and see if you can learn about where fields are going. Good luck with the decision. If you have specific questions, feel free to leave a reply. If you leave an email address, we can continue the conversation over email. -Craig
Hey Craig,
I know you posted this a while ago but I came across your reflection while searching for some assistance - any assistance - to help me decide whether to choose anesthesia or paediatrics. I"m a Canadian fourth year medical student.
For as long as I can remember, I've wanted to be a paediatrician. My father is a paediatric intensivist, and even before I understood what that meant, it was what I wanted to be too. All of my past work experiences have been with kids because I love being with children, and I felt I was doing something really important and meaningful. However, during pre-clerkship, the parts of our curriculum I was most excited for were lectures about the types of shock, or respiratory mechanics... anything with a physiology focus. I wasn't very interested in the paediatrics lectures, but ignored this and continued. In third year, I loved internal medicine - specifically the really sick patients, who usually ended up on the ICU floor. I found my general paediatrics rotation excruciatingly boring. The kids weren't sick - they were admitted for simple things like a UTI or gastro - and I was bored to tears. I also didn't jive with the team around me. They were so intense about the tiniest of details, and while I appreciated this and would want my child's paediatrician to have these qualities, it just wasn't an environment that appealed to me. I found I didn't even get to spend much time with the kids themselves, I was too busy doing so-called "scut".
To be honest, I didn't love my anesthesia rotation. I LOVED the lectures and readings, and really clicked with the people, but I found sitting in an OR with the anesthetist for hours on end excruciating. I'm a people person, and I love working in teams. I hated the scrubs and hated wearing a mask. I didn't like trying to intubate a person who was twice my body weight. But when things went wrong, I loved every second. I loved chatting to my staff about the physiology behind the patient's clinical status. I liked the finicky procedures.
Longterm I want to do pediatric intensive care. I like the kids, but more importantly I love the medicine and the environment - it's the perfect combination of clinical and procedural, it's team based, there's no outpatient clinic, it's intraprofessional, tons of physiology, and the stakes are always high. I love the ethics of end of life care and the difficult conversations with parents. The only downside is the lifestyle. I've watched how hard my father works and although he loves his job, he's also continuously exhausted. I don't know if I can sustain this, and if that happens... then what will I enjoy more? Being a general paediatrician or a general anesthetist? I don't know. Further, anesthesia is constantly challenging - it takes a lot of intelligence to do that job, and I don't know that I'll be able to handle it. I'm not good at doing things I don't enjoy, and if I hate anesthesia, I don't know how I would be able to study as hard as I'd need to.
I have to finalize my rank order in seven days and I am at a complete loss. Anesthesia seems to be the logical choice, especially since I want to do ICU, but my heart is still attached to the idea of paediatrics - it seems safer, I know more about it.
Hi Jenna,
Sorry about the late response! I hope either you've figured out your decision already or you see this in time that it helps.
Several things first: you aren't alone in this situation; I know lots of people who've been in your boat, and it's not easy. Second, you've already done the most important thing which is to verbalize the various pros and cons going into the decision. Third, it's not a decision set in stone, and although it's not ideal, you can always change or do a second residency. In fact, there are two recent residents in my program at Stanford who did pediatrics first then went into anesthesia.
If your ultimate goal is without doubt to be a pediatric intensivist, then pediatrics may be the easiest path to take. At least last I checked, the only way to become PICU board certified in the U.S. is a 3 year pediatrics residency followed by a 3 year PICU fellowship. Unless things have changed, you cannot do pediatric ICU through anesthesia (though you can do adult critical care through anesthesia). Thus, if you are set on that career, the shortest path to get there is peds. I would say it's likely true that peds ICU is very intense and you wouldn't do it 100% of the time. If you don't like general pediatrics, clinic, or urgent care, you may decide to fill that time with administration, research, or other types of work. I haven't had any direct PICU experience, but I can tell you the adult ICU is a place of amazing physiology, satifaction and fulfillment, great procedures, and tough but engaging end of life conversations.
Even if you feel like you won't enjoy all of pediatrics residency, I wouldn't worry about that. There are few residents who love every part of their program. Many internal medicine colleagues I've talked to only want to be hospitalists, cardiologists, oncologists, GI, etc., and they hate outpatient primary care clinic. (Likewise, I know a few going into primary care and they don't like their ICU rotation). Don't let that offput you. It's simply a necessary step to reach where you want to go. Culture varies within specialty - you may not jive with the team in general pediatrics, but you may find the ICU group more consistent with your own personality. I do feel that culture and fit are important though.
I would put a little thought into whether pediatric anesthesia would be a good career for you. It is 4 years of anesthesia and 1 year of pediatric anesthesia subspecialty training. You will find that the subculture of peds anesthesia is very different from adult anesthesia and probably closer to what you want - a team model, patient-centered care, a little more detail oriented. Most anesthesia residencies don't have a lot of peds built in but you may be able to get some flexibility in that.
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Peds anesthesia may be more suited because it has a lot less downtime, a lot less boredom (because surgeries are shorter), fascinating physiology (esp in pediatric cardiac surgery - which you usually don't have to do additional formal training for), great procedures (intubating an adult becomes routine - intubating a premie never so), more surgeon respect, when things go wrong you are the expert (same in adult anesthesia). There are many "bread-and-butter" cases (tonsils and adenoids, tympanostomy tubes), but I don't think they will bore you as much as seeing kids with sniffles or a UTI. On our faculty, we have some who did pedatrics and a few who even did peds ICU before doing fulltime peds anesthesia. Career-wise, if you want to do 100% peds anesthesia, you will likely work in a major academic medical center or a children's hospital (esp if you want to do premies, neonates, or peds cardiac). Community jobs will have a mix of peds and adults.
I know some people who are doing peds residency, anesthesia residency, peds ICU fellowship, and likely peds anesthesia fellowship. That's a ton of training and will make you a better all-around pediatric physician. It's about 9-10 years. There are some programs (including Stanford) that combine peds and anesthesia residencies to 5 years and I'd recommend that to save time.
If you do anesthesia only, consider also adult critical care (1 additional year to the 4 for anesthesia). It's not PICU, but it might be close enough to satisfy you professionally.
I hope those thoughts help. You can always contact me at craigchen AT gmail, and I can put you in touch with people who've done both or changed careers. You will find something you love; I don't doubt that. However, pay attention that the perfect career may require a lot of time investment to reach and may be something that's not sustainable full-time for years on end. I remember how tough that decision was. Best of luck with the match - and if you want, keep me in the loop with what happens.
Craig
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