Tuesday, May 6, 2014

The Most Vulnerable Anesthesiologists

It's already May and another class of anesthesiology residents will soon descend upon the world as full fledged attendings. Many of you are already so brimming with confidence that you can barely stand doing cases with the attending standing in the same room. Little do you know that the first six months after finishing residency will probably be the most challenging period of your careers.

As the newest anesthesiologists, you will arouse the highest suspicions and given the shortest leashes. With your heads full of hair and wrinkle free skin, patients will inevitably ask how long you've been in practice. There will be an awkward pause as you ponder how best to answer that. Should you tell the truth about your recent graduation or tell a little white lie? You ultimately decide that your integrity and the patient's trust is paramount so you answer the truth--two weeks. You will then get the wide-eyed anxious stare of somebody about to enter the abyss. No amount of reassurance that you have spent years of training will comfort the patient the same way a few strands of gray hair can accomplish. There is no fix for this. You can only continue your usual affable way and laugh about it while proving to the patient, her family, and the entire hospital staff that you are worthy of wearing your hospital ID badge that identifies you as a staff member of the Department of Anesthesiology.

But patient acceptance may be the least of your worries. When surgeons find out there is fresh meat in the OR, it's like a seasoned lion about to pounce on a naive young gazelle. The surgeons know that the newest anesthesiologist will not want to be labeled a trouble maker right out of residency. They will take advantage of your willingness to please even if it is against your better judgement. They will make you do anesthesia that would get you thrown out of your oral board exams in a heartbeat. I once had a patient who simply couldn't help himself and ate a bagel on the way to the hospital the morning of his surgery. Naturally I cancelled the case when I heard about his transgression. But guess what. The surgeon went down the hall and asked one of our youngest anesthesiologist to do the case. And he took it. Whether all the big dollar signs that were flashing in his hungry eyes made him do it or he was intimidated by the surgeon, he just turned himself into a CA1 as far as anesthetic judgement was concerned. You think that this will never happen on your watch, but believe me, it happens all the time.

What's worse than the surgeons taking advantage of you will be your fellow anesthesia colleagues doing the same. Everybody knows that when you start in a new group, you want to be known as the team player. You don't want to rock the boat and make any sorts of demands that will stigmatize you for as long as you work there. Every new anesthesiologist is so insecure that he will do virtually anything if asked by one of his more senior partners. Within days of getting your call schedule, your phone will be ringing off the hook from your fellow anesthesiologists asking to trade calls, usually for a weekend or holiday call. Some may even ask you, ever so slyly, if you could simply just take his call that night because he suddenly "remembered" he had a family event planned and can't be at the hospital. Not wanting to appear to be difficult, and hoping this little favor will grant you more job security, you will bite your tongue and agree to take it. Of course this tiny act of kindness is quickly forgotten by the other person and your job security is no better off than it was before.

You will also quickly understand what it means to have patients get dumped on you. As an eager, indebted physician, the entire OR knows that you are hungry for work and money. Therefore don't be surprised when another anesthesiologist asks you to do his last case for him since he says he doesn't want to stay late. Thinking that you could use a few bucks, you quickly agree. Then you see the patient that rolls into the preop holding: 78 years old with CHF, ejection fraction of 20%, morbid obesity, diabetes, hypertension, renal insufficiency, hemoglobin of 8, for an exploratory laparotomy for small bowel obstruction. You curse under your breath that no amount of money is worth this medical risk. But since you have already agreed to do it you bite the bullet and do the best you can with what modern anesthesia has to offer you. You notch it up as one more scar on your way to becoming a seasoned, respected anesthesiologist.

So enjoy your last few weeks of residency while you still have the chance. You are currently at the pinnacle of your medical career for the next few years. You may strut around the OR's like you're the second coming of Ralph Waters, but in the next few months you will get beaten down until you barely know which direction of the epidural needle is up. You will question everything that has been taught to you in the last three years. Not until you have answered all these internal doubts will you at last truly be known as an equal partner in your department. Or until the next year's class shows up.


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  3. This is funny and hits close to home! Even though I'm not an anesthesia doc, when I first started working at a peds clinic, I would often make what I thought were innocent-enough suggestions to parents re their child's health. i'd often get met with a raised eyebrow and an "Oh, are you a parent?" Sometimes I lied.
    One time, I said, yes. The woman immediately responded, "what's your child's name?"
    Caught off guard, I replied "Umm, Wilma." She said, "Oh, you mean, like my name?" I was holding her chart in my hand (I changed the name for this story). I think it was abundantly clear I had lied but she had the tact not to call me on it.
    Every so often, other doctors at the practice would tell me, "Oh, one of your patients came in. They asked how your son is doing." Oh, sweet, sweet lies.