Saturday, September 17, 2011

I Am An Anesthesia Grunt

I am an anesthesia grunt. A second banana. I'm at the bottom of the totem pole of anesthesia. An untouchable in the caste system of my profession. One may think that doctors, including anesthesiologists, are quite egalitarian. Don't we all have medical degrees hanging on our walls? Didn't we all go through an ABA certified residency training program and successfully completed our board examinations? Aren't we administering similar anesthetics to our patients with similarly excellent results? Though all our backgrounds may be comparable, eventually a hierarchy develops within the field. There are distinct levels of importance within an anesthesiology career and where you fit in determines the quality of your professional and social life.

Let me start by using myself as an example. As I said at the beginning, I am an anesthesia peon. I will probably forever be stuck in what my colleagues charitably call a Level C career step. My lot in life is to come to work day in and day out doing much of the work a CA-3 anesthesia resident could probably perform. The only difference is that with more experience I know how to sidestep the pitfalls that invariably trap a resident or newly graduated anesthesiologist and drags him into M&M conference hell. My job description is not glamorous. You'll never see my work illuminated in the movies or TV. How many people want to see a patient being anesthetized for a colonoscopy or an appendectomy? No, the truly seductive anesthesia cases go to the Level B anesthesiologists.

Level B anesthesiologists in general are the ones who went through subspecialty fellowship training. They're the anesthesiologists who perform the "difficult" anesthesia that a runt like me was not specially trained to do even though we all had some experience with them in residency. Level B anesthesiologists all seem to belong to different anesthesia societies with names like SOAP, SCA, or SPA. They are held in higher esteem within the group and the hospital. Their job security is more assured than a Level C doc like myself. Level B anesthesiologists could probably write their own meal ticket anywhere they want to live and work. This mid tier of anesthesiologist still has to take call, but at least it's a focused type of call. Whereas I have to take virtually anything that rolls in through the emergency room doors, the Level B anesthesiologist only needs to anesthetize a specific type of patient for which they were fellowship trained, whether it be an emergency C-section on an eclamptic, severely stenotic mitral valve parturient, a three year old with life-threatening epiglottitis, or an emergency CABG on a patient who just had his coronary artery dissected by the cardiologists in cath lab. They do much more complicated cases that I wouldn't touch with a ten foot pole. For that reason I don't begrudge them their higher professional standing.

So now you may be wondering who is at the top of the anesthesiology pyramid. Who are the Level A anesthesiologists in a group and how did they get there? They are not necessarily the most skilled of anesthesiologists. However the Level A's are the ones who can do no wrong. It is not possible to fire a Level A anesthesiologist no matter how bitterly the surgeons or OR staff complain about their work. Level A's also don't have to deal with career inconveniences like taking calls. That is far beneath them. How does somebody attain this status? One is through sheer longevity. Work in one place long enough and you gain a certain gravitas despite the fact that your best work was performed about twenty years ago. People just feel bad about getting you fired after so many years. Another way to become a Level A is to be friends with the chairman of the department or hospital board of directors. Friends can overlook multiple professional deficiencies as long as you all are out playing tennis together every Sunday morning. Finally, an anesthesiologist can reach this peak by achieving some level of academic success. A department is loath to fire someone who has published seventy-five papers in their career and gives lectures from Manhattan, NY to Manhattan Beach, CA. An anesthesiologist like this makes their department, and hospital, look good.

So that is my career advise to you anesthesiologists and anesthesiologists to be. We may all seem equally capable, as our surgical colleagues believe, but in fact there are different tiers of professional success within the field. Don't get me wrong. I'm not complaining about my status. I enjoy my Level C work. It's much less stressful than the cases that the Level B guys do. And I hate to get up early Sunday mornings to schmooze my way up to a Level A. I will happily sedate a hernia patient for the rest of my professional life.


  1. Which fellowship has the greatest income potential besides pain?

    Have you found it easy to find jobs paying $300,000 doing grunt work?

  2. Pain is the obvious choice for the highest pay. I'm not sure how the other anesthesia fellowships stack up paywise. But if I had to guess, it would be OB. In OB anesthesia, you get to bill for each epidural you put in and monitor. Therefore you could potentially have ten to twenty patients at the same time, and billing for each one. Of course, with high rewards come high risks. OB anesthesia can be extremely stressful and that's why they usually don't work five days a week.