Friday, October 29, 2010

How This Anesthesiologist Lowers His Carbon Footprint

Recently an anesthesiologist at the University of California, Davis made headlines when she described how anesthesiologists can help the environment by using a lower carbon footprint inhalational agent (think sevoflurane). I'm a responsible citizen of this planet. I too would like to help the environment and decrease my carbon footprint. (Is it just me but every time I hear carbon footprint I have a mental picture of Han Solo frozen in carbonite in "The Empire Strikes Back".)

I have previously mentioned the Z-Stick. What better way to conserve energy than to spend as little of it as possible? By remaining in my chair but still able to reach all my anesthesia monitors, I can burn off fewer calories and exhale less carbon dioxide. Voila, less greenhouse gases escaping into the atmosphere to destroy mankind.

Now here is another possibility for anesthesiologists to help our progeny stay cool on this planet.  Anesthesiologists face a wall of equipment every single day.  Each one of these run on electricity and generate heat, sometimes lots of it. Some of the monitors can run quite hot to the touch. Therefore I place bags of IV fluid on top to heat them up and keep them warm. Sure there are faster and more expensive fluid warmers you can buy but they cost money and use electricity which most likely will lead to further generation of greenhouse gases. My method uses heat that is already available and wasted every day. This excess heat has to be cooled off by turning up the air conditioning in the operating room. Why not harness it for another purpose?

If you look at the picture, the control box for our monitors has heat dissipating grills on the exterior surface. I can put one or two bags on top of these extensions and they warm up the fluids quite nicely. Most of our screens now are LCD but in the past when we had CRT monitors, the top would get very warm. I could also put a few bags of fluids up there and keep them nice and toasty.

Granted this is a very slow process for warming IV fluids. A Hotline machine will get your fluids hot almost instantaneously. My method requires about one hour for a room temperature (a cold OR temperature) bag to not feel cold to the touch. It takes about another hour for the bag to actually feel warm. But you'd be amazed how even lukewarm IVF can keep the patient's body temperature from scraping 35 degrees Celsius. Plus you're recycling otherwise lost energy in the operating room. What could be greener than that?

Sunrise In L.A.

Thought I'd share with my readers this gorgeous sunrise in Los Angeles today. The picture doesn't do reality justice as my evil iPhone only has a two megapixel resolution but it is still pretty. Hope you all have a nice day and weekend. And remember what your mother always told you on Halloween; don't eat too much candy.

Wednesday, October 27, 2010

Fastest Way To Wake Up A Patient

One thing that anesthesiology residency doesn't teach you is how to quickly and efficiently wake up a patient from general anesthesia. Sure, we all get grilled on the SAFEST method for emergence and extubation. However, in the real world, safe emergence is a given. Therefore to a surgeon what differentiates one anesthesiologist from another is how quickly the patient is transferred to recovery after a case is over. If the patient is still asleep after the surgeon has written the postop orders and finished talking to the patient's family, then you, my friend, are a slow anesthesiologist.

I've noticed this lack of exactitude results in two different philosophies (and possibly three which I will get to later) on how best to quickly wake up a patient. When I come in to the OR in the morning, I do my anesthesia machine check and I can easily see what the anesthesiologist who last used it was thinking about how to awaken the patient.  The machine usually has the last ventilatory setting of the previous patient still in place. From this, I can deduce two methods that are generally followed by anesthesiologists at the end of a case.

One is the slow and go idea for emergence. The vent settings on the machine will show a respiratory rate of about five with tidal volumes below five hundred. I presume the anesthesiologist is attempting to revive the patient's spontaneous respiration by allowing the patient's pCO2 levels to rise quickly. Once the patient is breathing on his own then the endotracheal tube can be removed.

The other method is the fast and furious approach. The vent setting will have the respiratory rate set in the high teens with large tidal volumes. The anesthesiologist was apparently trying to wake up the patient by swiftly blowing off the inhalational agents accumulated in the blood stream and lungs.  Once the patient is conscious, then the ETT can be safely taken out.

I don't think there has been a study on which process for emergence is better. There are just too many variables and either one works satisfactorily.  During residency I had attendings who advocated one or the other technique and the patients did just fine either way. Again the goal of residency training is safety first. But now in the real job market there is no real consensus on the best and fastest plan for emergence. So some unfortunate anesthesiologists get labeled as "slow."

So finally let me tell you about one colleague's practice for achieving fast emergence. I don't advocate his methods but it sure gets the job done. During surgery he gives absolutely no narcotics. He doesn't believe in preemptive analgesia. He thinks any narcotics given during the case will slow down emergence, which is true. His patients wake up in blinding pain from surgery whereupon he gives liberal doses of pain meds. Unfortunately the narcs rarely work rapidly enough before the patient is transferred to recovery. You can imagine the anesthesiologist is not one of the recovery room nurses' favorites when they are confronted with a miserable postop patient. But he gets the room turned over quickly and is thus well liked by the surgeons. Try it if you dare.

Wednesday, October 20, 2010

The ASA Fiddles While Anesthesiologists Are Getting Burned

The American Society of Anesthesiologists held their annual meeting last weekend in beautiful San Diego, CA. From all reports, it was a great success. They held an opening day reception on the field at PETCO Park. There were the usual lectures on dealing with difficult airways, difficult patients, and difficult colleagues. Good times were had by all.

But while the party was happening in sunny San Diego, storm clouds are brewing over the nation's anesthesiologists.  Colorado recently became the sixteenth state to opt out of Medicare's requirement for physician supervision of CRNA's. In a public statement, the ASA, "expressed its grave disappointment with the election-year decision of Colorado Governor Bill Ritter to exempt his state from Medicare's longstanding patient safety standard providing for physician oversight of anesthesia services." The statement goes on to assail the governor as a "lame-duck" who went against the strong wishes of doctors and patients in the state.

None of this drama appeared to trouble the celebration at the annual meeting. The president of ASA, Dr. Alexander Hannenberg, gave a written interview on the accomplishments of the ASA over the past year. The Medicare opt out problem was not even mentioned. While perusing through the meeting's thick course catalog, I didn't notice a single talk about the dangers of CRNA's practicing independently of anesthesiologists. Not one breakfast meeting, panel discussion, or symposium was held on how anesthesiologists are slowly and inexorably losing their profession to nurse anesthetists.

By contrast, the nurses really have their acts together. They trumpet their self-sponsored "studies" that tout the safety of their practices that are readily picked up by the mass media. They have strong state and national organizations that are able to persuade government officials to see these issues their way over the objections of the states' doctors. The CRNA's even have meetings that teach the proper method for developing relationships with elected officials.

Where is the urgency to hold back this onslaught? While the ASA elite mingle and laugh it up, anesthesiologists are inexorably being corralled into isolated urban hospital settings. In the meantime the suburban and rural jobs, where two-thirds of surgical cases are done, are being usurped by CRNA's. The ASA calls these opt out decisions by the likes of Gov. Ritter and Gov. Schwarzenegger politically motivated. That raises the troubling question of why the ASA and physicians in general are so politically disconnected and impotent when compared to the AANA, the trial lawyers, or the government employee service unions. The ASA trumpets their accomplishment in reversing the Medicare teaching rule bias against anesthesiology residencies, but if these residents don't have anywhere to practice when they graduate, the whole battle would have been Pyrrhic indeed. We can try to convince the CMS about the unfairness of Medicare reimbursements to anesthesiologists, but at the end of the day, if we don't have jobs to go to, the viability of anesthesiologists will be in doubt.

Tuesday, October 19, 2010

Why Do Anesthesiologists Use Cheap Drugs?

Got another email from our hospital pharmacy. Succinylcholine is currently in critically short supply. Therefore they are going to stock only one 10 ml bottle of sux in each anesthesia cart. Any leftovers at the end of the day will be collected by pharmacy, even if there is only one ml of drug in the bottle. Sigh. This is just the latest in a series of drug shortages that has afflicted anesthesiologists.

So far this year we've faced an ongoing scarcity of propofol, especially after Teva pulled out of the market following the bone-headed $500 million jury verdict against the company in Las Vegas. We've been discouraged from using TIVA if gas will do. We are also facing a shortage of morphine. If we order morphine for our patients, the pharmacy will kindly substitute a dilaudid equivalent dose. Last year there was a deficit of protamine. They were only stocked in the vascular and heart rooms unless requested from pharmacy.

Why do these problems keep recurring in anesthesia? I suspect it is because we anesthesiologists seem determined to undermine our own self interests by using the cheapest drug available. The aforementioned drugs are all generics, costing just pennies per dose. There really is little incentive for drug companies to stay in that sort of market. As Teva demonstrated, one adverse event can devastate the cost structure of generic drugs and cause these companies to withdraw their products.

You certainly don't see other specialists racing to be the most cost efficient provider. Pharmaceutical companies spend billions every year trying to persuade internists to prescribe their latest treatments for hypertension and hyperlipidemia with great success. Orthopedic surgeons are feted by the hardware manufacturers to use their newest implants. General surgeons frequently demand to use the latest and most expensive laparoscopic equipment. They never seem to run short of those in the OR.

Newer drugs like Precedex and Lusedra are just subjects I read about in anesthesia journals. Our pharmacy refuses to stock them because of the price. We don't have patients coming into preop to demand that we give them fospropofol for their anesthesia. Anesthesiologists, in their attempts to appease the hospital administration, try to keep costs low by using generic drugs whenever possible. But this discourages drug companies from conducting research on the latest anesthetics. There aren't twenty pharmas in competition to develop an alternative to succinylcholine the way there are for the next ACE inhibitors.

So maybe we can do ourselves a favor and start administering the newest drugs on the market instead of one that have been generic for a decade or two, or four. This will show the drug companies our commitment to make sure their drug research pays off and we can finally stop having these regular drug shortages.  And maybe we'll get a few free dinners and golf games along the way.

Monday, October 18, 2010

Bizarre Piercing Ritual

At the Phuket Vegetarian Festival in Thailand, it is a custom to pierce one's face to ward off evil spirits. Now I've seen strange piercings in the U.S., but these guys really take the cake. Besides looking awfully painful, the piercings present the practical dilemma of how these people eat or drink. I hope none of them need surgery because it will be impossible to mask ventilate with the giant holes in their cheeks. Ouch

Thursday, October 14, 2010

Willie Sutton Lives..At The American Board of Anesthesiology

I recently received an email from the ABA. In the letter they clarified the requirements for board recertification through their Maintenance of Certification in Anesthesiology (MOCA) program.  They included a convenient chart listing the CME hours necessary for recertification based on year of completion of residency. What struck me is that the requirements are different depending on year of graduation.

Here is the chart showing what an anesthesiologist who finished residency in 2004 has to accomplish before he can recertify. You'll have to click on the image to magnify it and make it legible.

And here is the chart for somebody who finished in 2010:

You'll notice that the total CME necessary to satisfy MOCA recertification are the same, 350 hours over a ten year period.  But for the class of 2010, ninety of those hours have to come from the American Society of Anesthesiology's ACE or SEE at-home study program at a cost of $250 per year for ASA members.  In addition, twenty hours of the required CME have to be on Patient Safety offered by the ASA for even more money.

Now I ask, why would the ABA require that anesthesiologists achieve part of their CME obligations by purchasing ASA programs? Were the CME credits from non-ASA sources not good enough to guarantee knowledgeable anesthesiologists? I think it is because they are following Willie Sutton's famous philosophy, "Go where the money is..and go there often." I suspect this is another method for the ABA and ASA to raise more funds from their captive audience.  There is no other avenue for recertifying your board certificate.  All the rules are made by them.  Therefore it is very easy for them to say, "You now need to buy 90 hours of CME from us in order for us to renew your certificate. If you don't like it, too bad."

Granted I use the ACE as my CME not just for MOCA but also for my state medical license fulfillment. It is very good for reviewing information that I haven't read since residency. However the idea that the ASA and ABA will require thousands of anesthesiologists to purchase them in order to meet a requirement that was forced on all anesthesiologists who started after the year 2000 to me smacks of unscrupulousness and greed. This policy is also a financial penalty on all recent anesthesiology graduates. Older anesthesiologists with lifetime certificates won't have to shell out thousands of dollars to fulfill MOCA obligations and recertification examinations ($1500 last year and $2000 next year). Is this fair? Are the majority of anesthesiologists, who happen to graduate in the last century, discriminating against the graduates of this century?

What would be more fair, and give credence to the idea that recertification is good for everybody, is to make all anesthesiologists recertify their board certificates. What is the ABA afraid of, that some anesthesiologists might be forced to retire because they couldn't pass their exams? Perhaps we might find out that other than pushing big syringe, little syringe, and intubate, some anesthesiologists know more about yesterday's issue of The Wall Street Journal than how desflurane works? Maybe those people shouldn't be practicing anesthesiology and possibly endangering patients' lives. If maintaining knowledge of anesthesia is good for younger anesthesiologists, shouldn't it apply to all anesthesiologists, especially older generations who probably haven't picked up a journal in 15 years? Or is this only about the money?

Wednesday, October 13, 2010

Want A Ride In My Suppository?

2011 Honda Fit

A homely little lozange of an automobile beloved only by the frugal and the practical.  On the other hand, my tastes run more towards:

2011 Bugatti Veyron 16.4 Super Sport

Even though it is ugly as, well, a rectal suppository, I wouldn't mind if somebody offered me a ride in this $2.4 million, 1200 horsepower insanely awesome supercar. Here's a video on how Bugatti assembles these cars/rockets-on-wheels.

You Expect Me To Examine My Patients? I'm An Anesthesiologist.

Do anesthesiologists perform physical exams? And is it necessary? These questions came up when I read a really interesting article about Dr. Abraham Verghese in The New York Times. This Indian born doctor's mission is to reintroduce the art of the physical to Stanford's medical students. In an era when no patients make it out of the emergency room without a CT scan, the idea of actually examining a patient seems quaint and antiquated.

We anesthesiologists are probably the worst physicians at doing an H+P (except maybe pathologists). In fact, I rarely see anesthesiologists with a stethoscope around their necks. The difference for anesthesiologists is that by the time the patient makes it to preop, the patient has had at least one, and frequently multiple H+P's in the chart. Besides the primary care doctor's, there's a physical by the surgeon and probably physicals by the cardiologist, nephrologist, ID, pulmonologist, etc.. What could anesthesiologists possibly add to the patient's workup that was missed by all these subspecialists' probing exams? Sure if the patient shows up orthopneic, wheezing, with an O2 sat of 91% on 6L face mask I might dust off my stethoscope and listen to the chest. But if the patient is a young healthy adult for outpatient surgery, do you expect me to do an independent H+P that will be substantially different from what's already in the chart? I'm more likely to browse through the history, glance at the labs, and wheel the patient to the OR than to slow down the turnover time by percussing the chest and palpating the belly for virtually zero gain in patient safety.

Anesthesiologists are probably one of the guiltiest physicians for demanding multiple lab tests be performed in place of the physical exam. Does it make sense to order an ECG on an otherwise healthy 56 year old even if the guidelines are anybody over 50 gets an ECG before receiving an anesthetic? Do surgeons reflexively order CBC, Chem 7, PT/PTT on young healthy patients because they fear their case will be cancelled by the anesthesiologist if everything is not in the chart? Is it logical that chest x-rays are frequently ordered and not seen by anybody just so the surgeon can tell the anesthesiologist that a CXR was completed?

Yes there is the rare occasion where I discovered a poorly controlled atrial fibrillation taching away at 135 beats per minute in preop.  But more often than not this will be found by the nurse during her preop documentation. The combination of a surgeon's history and the nurse's examinations appear to be sufficient for most anesthesiologists to proceed with a case without physically examining a patient. Sloppy? Yes. Dangerous? Probably not. However, as Dr. Verghese points out in the article, the laying of hands on the patient forms a sacred bond between physician and patient. When anesthesiologists skip this crucial step, it reinforces in the public's mind that we aren't really doctors.  Thus we are reduced to little more than stereotypes like "gasmen" or "gas passers". Or, horrors, nurse anesthetists.

Congratulations Chile!

As I am sitting here writing my blog, the Chileans have just pulled the fourth trapped miner from underground. It is an incredible demonstration of a nation's will and persistence that they are able to perform this feat. It boggles my mind that they were able to drill a rescue tunnel seemingly blindly on the surface and somehow reach the miners' survival shaft thousands of feet below ground a couple of weeks later. How could the miners down there even have the will to survive that long when there seemed to be no hope of escape for them at the time? And then having to wait for two whole months before this rescue could begin. Simply incredible.

This mining accident in Chile also sadly reminds me of how antagonistic life and government has become in our own country. The era of pulling together for the common good seems to be as passe as doctors making house calls. Every facet of life in the United States now involves conflict and accusations. From the Gulf oil spill to repairing the economy to health care reform, every issue in this country seems mired in finger pointing and mudslinging. Americans are defined by hostile factionalism: Republicans vs. Democrats, men vs. women, gay vs straight, anesthesiologists vs. CRNA. There seems to be nothing that can ever bring the citizens of this country together anymore. Presidents are just another figurehead waiting for us to tear down. Captains of industry are vilified for their greed. Physicians are rich, money grubbing, drug pushing whiners who only care about their Medicare reimbursements. Even when our nation was attacked by terrorists on 9/11, the sense of unity lasted only a few precious months. This harmonious period only appeared to temporarily suppress the desire for us to rend each other apart, which quickly reappeared and became the political theme for this decade.

Perhaps the Chileans will also display the same level of antagonism against their government and industries after all the miners are rescued. I hope not. I hope they relish their proud achievement in the face of impossible odds. Their national unity is a pleasure to behold and something we can learn from here in the Disunited States of America.

Wednesday, October 6, 2010

Dirtiest Joke I've Heard In The Operating Room

This is one of the dirtiest jokes I've ever heard in the OR. Tell it in mixed company only if you all are good friends. Otherwise risk being accused of sexual harassment.

What bird represents Thanksgiving?    Turkey
What bird represents wisdom?      Owl
What bird represents peace?      Dove
What bird represents birth control?


Monday, October 4, 2010

Peter Orszag, You Ignorant Slut

Peter Orszag's editorial in The New York Times today perfectly illustrates the ignorance of the government when it comes to America's health care industry and how dangerous it is these people are deciding how, when, and to what capacity we doctors are to treat our patients. Mr. Orszag's self incrimination of his inexperience with how medicine operates in this country starts in the very first paragraph.  He likens doctors not wanting to work weekends with drug stores that are open only five days a week. He goes on to say,

And then there are the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time. If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully.

So the director of the White House OMB thinks hospitals are essentially closed for the entire weekend, with no work getting done. He obviously has never stepped foot into a hospital, and particularly the emergency room or the ICU on a weekend.  If he did he would know what a fallacious lie that is. Hospitals are fully staffed on weekends to handle patient care. Just because there are fewer people physically in the building doesn't mean staff is not available. That's why people take call. 

Anybody who has worked with or been married to doctors know how hard they work, to the point of self exhaustion and personal detriment. I would compare the hours worked by doctors to your average government employee, who shut down their work stations promptly at 4:58 PM.  And don't forget all the time Congress and the POTUS take off for their multiple vacations each year. So Mr. Orszag, before you spout off on how much more efficient healthcare can be if we all just work seven days a week, why not improve the efficiency of your own employees and have them work 24/7? Wouldn't it be so convenient for us taxpayers if we can make it to the DMV or other government offices on weekends rather having them sit dark and empty for at least quarter or more of the time?

Saturday, October 2, 2010

Seeking Personal Redemption And A Good Night's Sleep

If you're going through hell
Keep on moving, face that fire
Walk right through it.
You might get out
Before the devil even knows you're there.
Rodney Atkins, "If You're Going Through Hell"

Now I conclude my series on why I chose anesthesiology as a career.  It took years of self immolation to wake me up to the fact that I hated the surgical lifestyle. But if not surgery, what else should I do? I knew that I still didn't want to treat chronic diseases. That eliminated Medicine and other primary care fields as my next career move.  I also knew I wanted to stay in the OR. But what kind of doctor works in the operating room but is not a surgeon?  There really is only one answer--anesthesiologists.

Luckily for me during the late 90's it was relatively easy to find an open position in an anesthesiology residency. It was not the highly competitive field it is today. I was afraid I would have to hang out for a year to wait for a spot in a training program. But I was able to locate an anesthesiology residency nearby that had vacancies to fill and I could start immediately.

Anesthesiology was everything I expected residency to be and everything my old surgery program was not. The work was intellectually stimulating. The attendings actually seemed to care about the well being of the residents.  The idea of getting breakfast and lunch breaks was a revelation. The other residents felt more like my kindred spirits, not competition ready to pounce at the slightest stumble.  And of course anesthesiology residency allowed a much saner lifestyle. While the other anesthesia residents complained about taking five calls a month, I reveled in the luxury of having three of every four weekends off.  Slowly I regained the self confidence I had lost after years of humiliation and abuse. I could see that I was not a worthless piece of human excrement. Nobody is perfect and anesthesia attendings didn't make me feel like s*** if I had a difficult day. I was finally able to enjoy living in Southern California, something I didn't have a chance to do in the years holed up in the hospital before. I went to the beach without concerns about how my patients were doing in the ICU or dreading another call the next day. I lost 30 pounds by the time I finished anesthesiology training. Life was good at last.

All those years of surgical training were not in vain. I had already placed hundreds of central lines and arterial lines as a surgeon so those presented no problems for me at all in anesthesia. I once impressed an attending when I was able to use a long alyce clamp to retrieve a broken tooth during an intubation (not my intubation). The one procedure I needed the most practice on was starting an IV. Never had to start one in surgery; either the nurse did it or we put in a central line.

I found that about 70% of my experiences in surgery were applicable to anesthesiology. The main things I had to brush up on ironically were all the different chronic disease processes an anesthesiologist is likely to encounter in preop. But that's okay because we only need to take care of these maladies for the duration of the case.  Anesthesiologists don't have to follow the course of the illness for the patient's entire life, or even the duration of the hospital stay. Once the patient makes it safely out of the PACU the problems were no longer mine to deal with.

This is of course the main attraction of anesthesiology. At the end of the day, when the patients are safely out of surgery, I can turn off my pager and go home to enjoy time with my family. There is no need to worry about how my fifteen patients are doing in the hospital. I don't get awakened at 3:00 AM because somebody on the floor needs a sleeping pill, or my patient in the ICU is suddenly desaturating. I am not tethered to the hospital or the answering service. I can enjoy life without fear of getting called back to the hospital for an emergency. Freedom of mind far exceeds the so called prestige of being a surgeon.

So that is my story of why I chose anesthesiology as a career.  I entered a dark tunnel in search of surgical glory and emerged into the light as an anesthesiology professional.  Yes surgery was fun, but there is more to life than the hospital. I give kudos to doctors who can tolerate such a work environment but I belatedly realized that was not for me. I have now been in practice for nearly a decade and love my job more than ever. I make a decent salary and have a devoted family I can go home to every night.  Hopefully the medical career you choose will be more straightforward than my circuitous path but ultimately you have to be satisfied both professionally and personally with your choice. It's alright to start over if you decide you went down the wrong road; there is no shame in realizing you made the wrong career decision. In the end it doesn't matter if you trained at a "prestigious" training program or authored fifty papers or make half a million dollars a year. If you can find job satisfaction, that is all that matters.

Friday, October 1, 2010

Surgery, A Siren That Will Break Your Heart And Crush Your Soul

Continuing my autobiography of why I became an anesthesiologist, I will now recount My Lost Years as a surgery resident. This is a long sad story of lost opportunity and spirit crushing rejection. So let's get started, shall we?

Let me just say right off the bat that surgery residency was probably the hardest thing I have ever experienced. Internship is just a blur of calls, rounds, scutwork, more rounds, more scutwork, and getting pimped and yelled at a lot.  Few things in life compare to the dejection of getting up at 5:00 AM to pre-round on your 10-20 patients then round on them again with the team in time for the senior residents to make it to the OR. After rounds, I was usually left with about 50-75 items I needed to get done on my scut list before afternoon rounds around 5:00.  After that there was usually another list of things that had to get finished before going home. If something didn't get done, the usual question was "Why not?", not "How can we help you?" It was not excusable to say the Radiology File Room couldn't find that one CT scan that was vitally crucial for this patient's surgery the next day. Or why the lab results haven't come back. Or why lines haven't yet been put into a patient, despite the fact that I've been running around like a rabied dog trying to get as much of the scut completed before tackling a time consuming line placement.

This certainly wasn't as much fun as I remembered as a student. Of course as a student I was shielded from all this tediousness. We got to go to the OR after rounds to watch the cases. When we were done in the afternoon all the work had been magically completed by the interns. I never paid enough attention to the dark side of surgery training. The few times I actually got to do cases were not that much fun either. Every surgery intern remembers their first case. Mine was a butt pus. I remember being on call and getting summoned to the OR at 2:00 AM to perform an I+D of a perianal abscess. The case took all of five minutes, but the stench will last me a lifetime. When the senior resident asked how I liked my first surgery, I had to force an eager smile and enthusiastically announce, "Great case!" then trudge back to the call room to try and get a few more minutes of sleep before getting up again to preround on my patients. Not a great start.

Okay, so internship isn't the surgical career I had envisioned. If I make it through internship, things will get better, right? I'll go to the OR and actually perform real surgeries my second year, correct? While I did start doing lots of cases the next year, sadly the overall residency experience was not an improvement. This was in the days before all the rules against residency abuse. There were rotations where I was on call every other day for months at a time. And it wasn't just 24 hours on/24 hours off. No, this was more like 36 on/12 off. You see, I couldn't just leave the hospital at 7:00 AM post call. I still had to round to explain to the team what happened overnight, which took hours. Then there was usually an emergency that required I stick around to help out before I could leave. I recall one time I didn't get home until 2:00 PM. I just collapsed into bed after an all night session of traumas and other emergency cases. I suddenly woke up and looked at my clock, which read 7:00. I panicked and jumped out of bed, ready to throw my scrubs on and try to explain to the team why I was late for morning rounds. It was not until I was halfway out the door that I realized it was 7:00 PM. Then I crawled back to bed and slept until the following morning.

All this stress took a physical toll on my body. I gained about 20 pounds. You would think so much running around will cause one to lose weight. But just the opposite happened. I didn't get any proper exercise. Every chance to eat was quickly wolfed down in about five minutes.  I developed anal fissures because I was so uptight all the time. I had a bad case of irritable bowel syndrome, particularly right before M+M Conference. That's where residents were publicly grilled and humiliated in front of the whole surgery department, particularly if you weren't a Chosen Resident, someone who could perforate the left ventricle while putting in a chest tube and still not get shredded by the faculty wolf pack. One time I was so exhausted post call that while riding in an elevator my pager went off. In my sleep deprived haze I looked around asking people "Do you hear that noise? Where is that coming from?" They looked at me like I was an escapee from the Psych ward.

Okay, so surgery residency was exactly what everybody warned me about. Well, it will be better once I'm an attending, right? While several of my fellow surgical residents bailed out into anesthesiology, plastic surgery, and medicine, I was going to tough this out. I've never quit anything I started in my life and it was not going to happen now. But the higher I got through residency, the more I could see what a horrible lifestyle surgeons suffer. Sure it was still fun to do cases in the OR; by then I'd done hundreds of lap choles, appendectomies, and assisted multiple CABG's, Whipples, and AAA's. But as I moved away from the scut, I could see how the attendings lives were miserable. Being in the OR only constituted about 30% of their time. The rest of the time they were in their offices seeing patients, or doing consults for clueless internists, or being called to the ER. I saw how irritated and tired they were when they were operating all day and being paged constantly by their office, a floor nurse, or the ER. There is nothing more miserable than finishing a long line up of cases at 8:00 PM then having to go see three consults in the ER and the ICU. Do I want to have that kind of lifestyle for the rest of my medical career?

Plus surgery isn't all just acute disease either. Sure it's exciting to rush a patient to the OR to fix an acute abdomen. But there is a lot of chronic diseases that are overseen by surgeons, which was why I didn't want to go into Medicine to begin with. We had the Diabetic Foot Clinic. You've never seen so many black toes or nonhealing foot ulcers in your life. Then there was the Breast Clinic. For hours we were palpating large sweaty stinky breasts to find breast cancers. Sometimes they came in with advanced Stage IV massive breast masses that were oozing pus and blood because the patient neglected this thing for the last nine months. Then who could forget Colorectal Clinic, otherwise known as Butt Clinic. If I never had to do another anoscopy and hemorrhoid banding in my life it would be too soon.

I think the final realization came when I started looking longingly at the happiness of the anesthesiology residents. I remember an incident where my patient coded in the ICU. The anesthesiology team came down and intubated the patient. Then they were off on their merry way while I had to stay up the rest of the night to stabilize the patient and explain to the team why he went into arrest. "I wish I could just walk away like that," I thought.

Finally I was at a crossroad. With constant delusion and denial I had completed FOUR years of clinical residency. But now I wasn't sure I wanted to be a surgeon. Just stick with it, I was told. I only had one more year to go then I can get boarded in Surgery. But what's the point of going through one more year of surgery residency then studying like a madman to pass the surgery boards when I didn't want to be a surgeon anymore? The surgeries were still fun. However the constant paging by the office and hospital, the long unpredictable hours, and the chronic anxiety made surgery much less glamorous than I had envisioned. Do I still want to live like this when I am fifty? That's when I made the hardest decision in my whole life. I told my chairman I wanted to quit. He asked me what I wanted to do. Urology? Plastics? "No," I said. "I want to go into Anesthesiology."

Continue here.