How To Become An Anesthesiologist

You've heard about the great incomes that anesthesiologists make. You long for the legendary lifestyle of working with propofol and volatile anesthetics. So now you're wondering what it takes to become an anesthesiologist. 

You could search through the history of this blog to get all the scintillating details of anesthesiology as a career. Or you can read through this nice little article from Forbes on the process of becoming an anesthesiologist. 

It details the long education process necessary to earn the title, at least a decade of schooling and training after high school. First you have to earn a Bachelor's Degree, which takes at least four years. Then there is another four years of medical school to become a physician. That doesn't include the extra time some students take get another degree like an MPH, PhD, or JD. After that, with any luck you will match into an anesthesiology residency, which is getting harder all the time. There you will spend four more years of anesthesia training to just qualify for taking the anesthesia boards. But that's not the end of the line. Most anesthesia residents now take another year for a fellowship like cardiac, pediatric, or pain medicine. Add it all up and it's a minimum of twelve years to become become board eligible to sit for your certification exams.

Phew. It's not an easy road to earn the moniker of anesthesiologist. If that path is too daunting, Forbes has some alternative choices which involves some anesthesia work. You could become an anesthesia technician, which only takes two years. Or you could be an anesthesia assistant, which requires a bachelor's degree and needs about six years total. Or you could become a CRNA, which takes about seven to ten years. 

While the article in general is fairly accurate, I have a quibble with their assertion that board certification is optional to be an anesthesiologist. That may have been true fifty years ago, but nowadays, no hospital will hire you if you are not at least board eligible working towards certification. I know anesthesiologists a generation older than me who were grandfathered into their positions despite not ever having been board certified, but that generation is quickly retiring or dying off so now almost every anesthesiologist is BE/BC. That is not the same thing as having limited vs lifetime board certification, which is a whole other discussion.

If you're curious about how well trained anesthesiologist are, and why we're not just frustrated surgeon wannabes, take a careful read of Forbes. You'll realize that anesthesiologists are some of the best trained physicians in the country.

Anesthesiology Compensation In 2022

Medscape has released its annual Physician Compensation Report for 2022. The report polled over 13,000 doctors about their salaries and other details about their work. It looks like the pandemic induced reduction in physicians' incomes are over. For the first time in Medscape's survey history, all medical specialties saw increases in compensation during the past year. ENT topped the list with a 13% increase in average annual income.

Anesthesiologists fared well, as usual. This year, anesthesiologists reported an average income of $405,000. That is up significantly from last year when they disclosed an average of $378,000. That is a seven percent improvement over 2021 which was down five percent from 2020 due to Covid shutdowns.

Since 2015, physician salaries have increased an average of 29%. By comparison, inflation in the U.S. over the last five years has been 14.7%. Anesthesiologists didn't fare as well. In 2015, Medscape said anesthesiologists made an average of $358,000. So In the past seven years, anesthesiologists salaries have flatlined, not even keeping up with inflation. Perhaps that's why our specialty doesn't rank in the top ten anymore of the highest paid physicians. And the ASA wants to keep opening more anesthesia residency spots at the same time.

The top five states with the highest physician incomes are: Kentucky, Tennessee, Alabama, Missouri, and Oregon. If you think you would never live in a rural state even if they have very low cost of living and high salaries, then you're stuck in a bicoastal elitist mentality. Though these states may seem rural, they have very cosmopolitan urban centers too, such as Nashville, Louisville, and St. Louis. Alabama even has nice beaches also. So if you're looking for the biggest bang for your buck, don't overlook this list. 

There's a lot more information in Medscape's survey than what I have listed here, including one nice aspect of working in anesthesiology that tops all other specialties. Check it out.

Wordle For Doctors

Think Wordle, the word guessing game, is too easy? You think five letter words are boring? Peeved that middle school kids are better at this game than you? MedPage Today has a new distraction for you. They call it Wordosis. First of all, the words in this game require SIX letters. So there's that challenge. Next the words are medically related so not just anyone can play it since medical terminology is an actual class in medical school. That adds a bit of exclusivity to this puzzle. Just don't play while you're supposed to be vigilantly monitoring your patient in the operating room. Good luck.

Medical Schools With The Best Anesthesiology Programs

The recently completed Match Day once again demonstrated how hard it is to get into an anesthesiology residency. Of all the PGY1 spots for anesthesiology, 99.9% of them were filled on Match Day. Out of 1,509 open positions, 1,508 were taken. It's an incredible statistic and shows how extremely competitive it is to get accepted into anesthesiology.

To gain an edge in the residency match, one should attend a medical school that is highly ranked in anesthesiology training. Luckily for us, U.S. News & World Reports made a list for 2022 of the best programs in the country. Get into one of these med schools and graduates will have a leg up in receiving one of the coveted anesthesiology positions.

This list is based on a nebulous combination of factors including quality assessment, student selectivity, undergraduate GPA, MCAT scores, etc. If you're talented enough to ace all these different components, you're on the ROAD to one of the best jobs in America. 

So here are the top medical schools with the best anesthesiology programs as ranked by U.S. News:

1. Harvard University

2. Johns Hopkins University

3. Duke University

4. University of California, San Francisco

5. Columbia University

6. Stanford University

7. University of Michigan, Ann Arbor

7. University of Pennsylvania

9. University of California, Los Angeles

9. Washington University in St. Louis

11. Mayo Clinic School of Medicine

12. Vanderbilt University

Other schools that made the list but U.S. News demands money to see their rankings include:

Baylor College of Medicine

Cornell University

Emory University

New York University

Northwestern University

University of Washington

Yale University

While getting into one of these schools is nice, remember that a vast majority of anesthesiologists did not graduate from these elite programs. So if you are not a student in one of these schools, don't fret. Most medical students aren't either but that doesn't mean you can't score a treasured spot in an anesthesiology residency in the future.

"Ailee Was Massively Poisoned By The Anesthesiologists"

Ailee Jong, from SF Chronicle

In a 9,200 word article in the San Francisco Chronicle (behind a paywall or free if you have Apple News), the newspaper details the tragic death of two year old Ailee Jong at John Muir Medical Center in Walnut Creek, CA. 

In 2019, Ailee started complaining of abdominal pain. Her parents, Tom and Truc-Co Jong quickly took her to a hospital emergency room. The CT scan results were devastating. The little girl had a 12 cm hepatoblastoma in her liver and probable lung mets. 

When they heard the diagnosis, the parents quickly searched for the best possible care for their daughter. Since they live near San Francisco, they naturally gravitated toward Stanford University and University of California, San Francisco. As they looked through the list of doctors that could treat their daughter, they noticed one pediatric oncologist who was affiliated with Stanford Children's Health and also worked at John Muir Health in Walnut Creek, which is only 15 miles from their house in Danville. This would make commuting to the hospital easier than driving 40 miles to Stanford. 

But little did the Jongs know that John Muir had little experience taking care of complex pediatric liver disease. Their pediatric ICU had only been in operation for about a decade and they'd never had a liver resection like Ailee's before. According to Tom Jong, "They did say, in these words: 'We can treat her. She can be cured.'"

When Dr. Alicia Kalamas, medical director of perioperative medicine and an anesthesiologist, found out about this upcoming hepatectomy, she immediately questioned whether the hospital was capable of successfully doing the operation on such a small child. However, Dr. Jeffrey Poage, medical director of pediatric surgical services and a pediatric anesthesiologist, countered that the surgeons were up to the task. When Dr. Kalamas brought her concerns to Dr. Thomas Greely, the vice president of clinical affairs at JMH, she was told that Stanford physicians who had been consulted about the case had assured them the small hospital could handle the operation. She brought the case to Dr. Moussa Yazbeck, the chief of staff at JMH who did not question the procedure. Dr. Kalamas's contract was not renewed in 2021.

Dr. Poage was originally supposed to be Ailee's anesthesiologist for the procedure. Less than a week before the operation, he reported a scheduling conflict and two other anesthesiologists were brought in: Drs. Wayne Lee and Romerson Dimla. Dr. Lee finished his fellowship in pediatric anesthesiology at Johns Hopkins in 2017 while Dr. Dimla completed his fellowship at Children's Hospital of Los Angeles in 2019.

On November 12, 2019, Ailee entered the operating room at 7:30 am. By 9:30 am, the anesthesiologists documented that the estimated blood loss was 345 ml, significant for a 24 pound patient with a total blood volume of 800 ml. They noted that they had already transfused four units (1,261 mL) of PRBC and one unit (222 mL) of FFP. 

Ailee's body temperature started to drop, going below 95 F. With all the blood products her potassium level went from 4 in preop to 5.6. At 12:10 pm, she went into severe bradycardia then asystole. They were able to resuscitate Ailee by 12:30 pm. Echocardiogram showed no PE or air embolism. Instead of stopping the surgery, the surgeons continued with the resection.

The anesthesiologists noticed blood emanating from the endotracheal tube, mouth and nose of the patient. Labs at 12:32 pm showed Ailee's potassium had jumped to 8.2, a critically high level. Then 15 minutes later, she had another cardiac arrest. An operating room nurse desperately searched for help and found Dr. Poage, the medical director of pediatric surgical services and "begged him to come to the OR." He threw his anesthesia colleagues under the bus and refused to get involved. 

The surgeons continued with the operation despite the second arrest. She was now bleeding profusedly everywhere and the anesthesiologists kept pumping more PRBC and FFP. By now, the anesthesiologists stopped documenting the amount of blood products they were giving. Ailee's heart stopped again. Several times during the resuscitation, the ETT fell out, requiring the anesthesiologists to reintubate her while chest compressions were taking place.

When the surgical team finally realized the operation was futile, they went to the waiting room to inform the Jongs and asked for permission to stop the resuscitation. The parents refused and demanded to see the little girl in the operating room. They were informed that that was against policy but relented. 

When they walked into the OR, they noticed a stack of bloody towels on the floor three feet high and a nurse doing chest compressions. The room smelled of blood. They said Ailee was unrecognizable. Her head was massively swollen and blood was seeping out of her eyes, ears, nose, and mouth. After almost five hours of CPR, she was declared dead at 5:12 pm. 

The lawsuit the Jongs are bringing against the hospital complained that the anesthesiologists did not transfuse an adequate amount of FFP to allow her body to clot properly, leading to the massive hemorrhage. They also said that too much PRBC was given, leading to the critical hyperkalemia. The lawsuit claimed that "By 12:32 p.m., Alee was massively poisoned by the anesthesiologists."

This story illustrates that there is more to an operation than just the surgeon. It takes an entire ecosystem to successfully perform surgery. John Muir Health was not candid with the Jongs when they assured them that the hospital could do the hepatectomy despite internal warning flags raised by staff. The anesthesiologists, who only recently completed in their pediatric anesthesia fellowships, probably had not done such a complicated case since they finished training. The Jongs were wowed by the hospital's decor and amenities but were not given relevant information about the experience of the hospital and its staff in doing pediatric liver resections. Just a sad case for all involved.