Q&A

I love getting comments on my posts, and I read all of them. Depending on how busy things are, though, I'm sometimes pretty late in replying. Here is a question posed by Ethan (thanks for the comment!). I'm posting it as a new post in case it helps any other readers.

Q: ...Looking ahead, I am very intrigued by the possibility of completing a critical care fellowship and practicing as a critical care anesthesiologist...If you ever have some time, I would be really curious to learn about your schedule on a monthly basis. Do you split time between the ICU and OR or do you work strictly in the ICU? Do your colleagues in critical care anesthesia have similar set-ups or is there some variation depending on the hospital system/institution? Any advice going forward would be appreciated.

Great question, but it's not really straightforward to answer. My advice is to talk to as many critical care intensivists as you can. In the U.S., most critical care units are staffed by pulmonologists (as opposed to Europe where last I checked, the ratio actually favored anesthesiologists). Particularly in private or community hospitals, a large proportion of departments are solely run by pulmonologists. I'm in a rare community hospital that actually has both anesthesiologists and pulmonologists in the ICU (and we are greatly outnumbered). Most places that have intensivists from different backgrounds (internal medicine, pulmonology, anesthesia, surgery, neurology) are large academic institutions or the VA. Keep this in mind if you choose the field; it's not easy to go into private practice and find a job that balances both specialties.

There are a number of reasons for this. Aside from historical or conventional reasons, money plays a big factor. Anesthesiologists can make more relative value units in the operating room than the intensive care unit. Private anesthesia groups don't have a large incentive for getting into the ICU. Most groups run lean in order to maximize revenue, and it's hard to organize scheduling between OR call and the ICU.

Nevertheless, I think it is important for anesthesiologists to be in the ICU (as well as those from all other backgrounds). The intensive care unit really requires a multispecialty approach, and we bring a lot of skills and knowledge to the table. Most community ICUs are mixed medical-surgical units, and we know the surgeons well. We understand the perioperative period best. We have special expertise in the airway, resuscitation, cardiopulmonary evaluation, and crisis management. But we also recognize our limitations; my medicine colleagues have more experience with other organ systems, interacting with other consultants, holding family meetings, etc. I strongly believe a multidisciplinary unit where all the attendings collaborate, especially in difficult cases, improves patient care, quality, and satisfaction.

In any case, the reality of it is that most anesthesia-trained intensivists who continue to practice critical care do so in academic or VA settings. However, I do know of some private practice anesthesia groups that are expanding their boundaries to cover the ICU. This is something strongly pushed by the American Society of Anesthesiologists, that we become physicians of the perioperative period, including covering critical care and pain management (the so called "surgical home" idea). It also integrates a private practice group with the hospital so that hospital administration recognizes what they bring to the table.

So regarding the specifics of your question - I spend the bulk of my time in the operating room. I spend about 20% in the intensive care unit, a 21 bed mixed medical-surgical-cardiothoracic unit. We cover a week of days at a time (Monday-Friday) during which I have no operating room responsibilities. We cover random night and weekend calls; if I'm on call for the ICU at night, I still have a day of cases in the OR (but it's usually light). We share this schedule with a group of pulmonologists who we have great relationships with. The schedule is made between the two departments so that my ICU and OR schedules don't conflict. I love my ICU time, and it reminds me of a lot of why I went into medicine, but it exhausts me. I enjoy my OR time as it tends to be a little less tiring.

Most critical care units have similar types of schedules. At my residency, for example, the ratio of anesthesia and non-anesthesia critical care faculty is about 50/50 so between two teams, there is almost always an anesthesiologist. They are on for a week at a time, and all the other weeks, they work in the OR, in teaching, or in administration. Nights and weekends are covered by random attendings who do work the daytime (but of course, nights and weekends are easier with residents).

Regardless of what you choose, when you finish, you'll get emails with locums tenens or per diem jobs, and the ICU ones are all quite similar: day or night shifts, usually a week at a time. Some look specifically for pulmonologists (to take pulm consults), others are open to any critical care trained physician.

I hope that helps! Please let me know what else I can answer. Thanks again for the comment.