Thursday, May 12, 2016

How To Be A Star On Your Anesthesia Rotation

Another academic year is almost done and the number of medical students rotating through their anesthesia rotations has slowed to a trickle. As we wind down towards graduation, this is a good time to reflect on the qualities of what I thought made certain students really shine during their brief visits to this side of the ether screen.

Many of our students weren't even going into anesthesiology. It was usually part of their surgery rotation and they wanted a little taste of what anesthesiology is all about. This year it seemed like most were either going into emergency medicine or internal medicine. One thing they all had in common though was that they thought an anesthesia rotation was an exercise in learning how to intubate. When asked what they hoped to get out of this rotation, that was probably the most frequently mentioned objective.

Let me just say right off the bat that intubation skills is probably one of the least important reasons to rotate through anesthesia. One doesn't go through four years of medical school and four more years of anesthesia residency to learn how to intubate. It is a simple mechanical motion that anesthesia residents pick up in their first month. It is like taking driver's ed and only wanting to learn how to start the car. Intubating a patient is just a simple process in the middle of all the analytical thinking that is required for a successful surgery.

Instead, students who are going to do an anesthesia rotation will do themselves a huge favor and study a critical care book. Anesthesiology is essentially critical care outside the ICU. While I am in general pretty lenient about students who don't know the answers to my pimp questions, I have colleagues who will absolutely shut down the student if they can't answer seemingly simple questions about patient care. They will leave the student just standing there alone as an observer and not bother doing any more teaching. I don't expect fourth year students to know anything about anesthesia. That is something I may teach them if we have time but I will absolutely hammer them if they don't know simple patient physiology and pharmacology.

For instance, I had one student, just weeks away from graduating from a top ranked medical school, who couldn't tell me the normal values for an arterial blood gas on room air. After I gave myself the biggest eye roll, I almost questioned my own teaching skills. Am I asking too much of fourth year medical students? Was this something I would have known when I was a student? Then after discussing with other attendings, I decided that the questions was not unreasonable. Students who are about to get their M.D. should know what normal blood gas values are since that stuff was taught in physiology class back in the second year. There is no reason to not remember it just because they have already taken their physiology tests and passed the class.

Likewise many students don't know what a normal A-a gradient is or, even harder for them, how to calculate it. The ability to draw for me the oxygen-hemoglobin dissociation curve also eludes quite a few of them. These are not anesthesia questions that I use to stump students. This is basic knowledge that I feel every doctor should have a firm grasp of when they start their residencies regardless of their field.

And please know critical care pharmacology. When I ask students what drugs they would give to treat intraoperative hypotension, it always amazes me that so many of them say either dopamine or dobutamine. However not many know the mechanism of action of those drugs or indications for using them. If I gently remind them about other drugs like phenylephrine or norepinephrine, again I get a blank stare when they're quizzed about how they work.

This is essential information that all doctors should possess, not just anesthesiologists. If they know the answers to these questions, then I might move on to more anesthesia specific questions like the mechanism of action of volatile agents or the molecular structure of succinylcholine and why it's a depolarizing instead of nondepolarizing muscle relaxant. But if they're list of IV antihypertensives starts and ends at metoprolol, then I know they did not come prepared to learn on their anesthesia rotation.

So for anybody who is going to do an anesthesia rotation, forget about how many patients you're going to intubate. That is one of the least important things you will learn. You will gain an understanding of how to take care of critically ill patients who are on the verge of dying every minute they are under the knife and how anesthesiologists are there to keep that outcome from happening. Get yourself a condensed pocketbook on critical care and get a headstart on your colleagues who didn't bother to do a little homework before starting the rotation. We may actually move past the simple student questions and actually start learning anesthesia at a more advanced level.

One last thing. Please, PLEASE, don't whip out your smartphone and start searching Up-To-Date or Wikipedia if I ask a question you don't know. That just annoys the heck out of me and again shows me the student is unprepared to become a doctor, much less an anesthesiologist.


  1. Thanks for posting this. Going to be doing an elective after IM and surgery in a few months. Appreciate all of the tips.

  2. I'm so grateful I never had an attending like you, or I would not be applying anesthesia right now. I appreciate all of the down-to-earth docs who have served as mentors the last few years who asked questions to understand how a student thinks instead of trying to humiliate or judge them, showed students why the seemingly mundane things are really important foundations upon which to build an understanding of physiology and pharmacology, and were just all-around amazing people who were passionate about teaching and showing me how cool anesthesia is. Students shut down when you "roll you eyes in disbelief" or "just leave them standing there to observe", and you've just turned a potentially great candidate away from the field. It's understandable that you'd expect a student who is rotating through your department to come prepared, but they're also there to learn and not to have 100% of the knowledge up front. And no, it is not reasonable to expect students to remember everything they've learned in school, even if "it was just on their 2nd year exams". If you can say that as a student, you didn't feel like you were constantly drowning from all of the new information while trying to retain the previously learned stuff, I'd call bull on your huge ego.