ASA May 2003 Newsletter

Opportunities for today’s graduating anesthesiology residents appear endless, including lucrative private practice jobs, academic careers, fellowships, medical management and even locum tenens positions for the undecided and curious. Hidden among these options is the often-forgotten subspecialty of critical care medicine (CCM). Originally founded by anesthesiologists, and integral to anesthesiology departments worldwide, anesthesiologist-intensivists in the United States now border on extinction. Only 12 percent of the members of the Society of Critical Care Medicine are anesthesiologists. Despite an intensive effort by ASA and the American Society of Critical Care Anesthesiologists (ASCCA) to increase the profile of CCM, residents remain hesitant to enter the field. In 2001, the American Medical Association (AMA) reported fewer than 50 active fellows at 52 institutions in the United States [Table 1].¹

The failure to translate the increased numbers of residents in anesthesiology programs into increased numbers of fellows in CCM can be attributed to both residents and programs. The perspectives of CCM that residents-in-training receive are often tainted by misrepresentation, misinformation and miscommunication. Clearly, a better dialogue between programs and residents is needed.

Many residents’ concerns are unrelated to a specific fellowship, per se. An important issue is the financial situation of the graduating anesthesiologist. With an average compensation of $43,040 during a CCM fellowship,¹ many simply cannot afford another year of training — there are families to support and student loans to pay. In a lucrative job market, the decision for a job and against a fellowship is often an easy one. In addition, the aggressive pursuit of residents by private practices in order to satisfy staffing needs does not help the academic cause. Residents who promise that they will come back for a fellowship after a year of work to ease the financial burden have little incentive to do so.

Measures to improve a potential fellow’s financial situation may increase the possibility of residents entering additional training. Intradepartmental moonlighting opportunities coordinated with the individual’s schedule might be difficult to achieve given the busy work hours of a critical care fellow but should definitely be considered. Fellows in critical care are typically eager to maintain their intraoperative skills and competitive compensation, as staffing intraoperative adult cases may help to narrow the compensation gap. Alternatively, subsidized housing and assistance with child care might be considered to offer a more substantial package and ease financial concerns of applicants.

Even if a resident chooses to pursue another year of training, CCM is an “outsider” among anesthesiology subspecialty fellowships. Why is that? More often than not, a resident chooses a subspecialty based on the experience gathered as a resident in the field. However, in no other field is the discrepancy between the work of a resident and that of a fellow or attending as big as in the intensive care unit. Arguably, CCM residents work more hours than any other subspecialty rotation. They often feel psychologically and physically overwhelmed by having to provide care for a number of critically sick patients in the intensive care unit (ICU) rather than a single one in the operating room. The high intensity of clinical and nonclinical duties often interferes with time that could otherwise be spent learning. Calls tend to be more frequent, and the work is often a grim reminder of internship. In some institutions with open units, surgeons retain control of critical care and relegate the anesthesiology residents to act as assistants. An extrapolation of this experience to a future career in critical care throws this field out of the competitive race for fellowship applicants.

Residency programs can make a big impact by more effectively marketing critical care. With 39.2 percent of residents being undecided concerning their career plans by the end of residency,¹ interventions could have a profound impact on their choices. Changes should be aimed at making the ICU rotation more enjoyable and educationally valuable. Physical and emotional exhaustion could be addressed by shortening rotations or increasing staffing to ease the call frequency. A vascular or cardiac anesthesia rotation focusing on the care of one patient at a time completed prior to an ICU rotation could add to the level of comfort in dealing with vasoactive drugs and invasive monitoring in multiple sick patients. Allied health professionals could be assigned to assist in those activities that are less educationally valuable and therefore increase the time available for teaching. A structured elective in CCM for third-year residents with graded “fellow-like” responsibilities would demonstrate that a fellowship is not simply a continuation of residency. The possibilities for improvement seem endless. The implementation of some of the mentioned ideas led to a dramatic increase in interest in CCM fellowships among residents at our institution.

Information about critical care as a career option among residents is limited, and the degree of misinformation is often astonishing. The fact that a CCM fellow’s on-duty hours average 55 per week, for example, comes as a surprise to most residents.¹

One misperception is that critical care anesthesiologists are forced to commit themselves to an academic career. According to data presented by AMA, only 55 percent of anesthesiologists with special qualifications in critical care continue to practice in an academic setting upon completion of their training.¹ This number might even decrease in the future. Recent studies have shown that staffing ICUs with physicians who have credentials in CCM can reduce the risk-adjusted, in-hospital mortality of patients by one-third² and is, in fact, cost-effective.³ Such evidence confirming the value of intensivists is likely to increase reimbursement in the future. Should this happen, ICU anesthesiologists are likely to be sought by private practice groups to provide services in smaller hospitals.

Academic career opportunities offered by critical care research are endless. The number of jobs available for a graduating fellow in critical care is steadily increasing, and only 16.7 percent of fellows report having difficulty finding their preferred employment.¹

Because the job market is dynamic, it is often argued that a fellowship offers additional job security during less favorable times. This argument may be true for all fellowships. In the light of recent political changes that threaten our position in our nation’s operating rooms, critical care may provide additional security. CCM remains a field in which competition with nonphysician providers is highly unlikely. At the same time, having more anesthesiologists in this subspecialty strengthens our position by demonstrating in a highly visible way to patients and their families that anesthesiologists can provide value-added services.

Another common misperception among residents is that once certified in critical care, most anesthesiologists give up work in the operating room. In fact, the majority of critical care anesthesiologists work only part-time in ICUs as part of a group. Many feel it is a welcomed environmental change from their duties in the operating room. The experiences gained in one setting help to better our care for patients in the other.

Choosing to train in critical care medicine places the anesthesiologist in the unique position to complete a circle of intrahospital care for a patient. Imagine a perioperative physician who is qualified to assess a patient’s fitness for surgery, order pertinent studies and treatments, perform an individualized anesthetic, recover the patient and take care of him or her in the intensive care unit. Instead of an alternative to anesthesiology in the operating room, critical care should rather be described as an integral part of our field. The anesthesiologist’s training and clinical repertoire empower him or her to be the optimal physician to provide care for patients with respiratory and cardiovascular compromise. Is that not exactly what we are being trained to do every day during residency?

With students interested in entering anesthesiology once again and a potentially very rewarding outlook for a career as a critical care anesthesiologist, we should do everything possible to translate this renaissance of our specialty into a renaissance of critical care. Our job as residents and program directors is to more accurately package information about this field. A closer dialogue between residents and program directors is clearly required.

References:

1. Fellowship and Residency Electronic Interactive Database, American Medical Association. <www.ama-assn.org/ama/pub/category>. Data reflect most recent publication on January 18, 2003.

2. Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999; 281:1310-1317.

3. Pronovost PJ, Waters H, Dorman T. The economic impact of the Leapfrog Group intensive care unit physician staffing standard. In: Economic Implications of the Leapfrog Safety Standards. Birkmeyer JD, Birkmeyer CM, Skinner JS, eds. The Leapfrog Group, Washington, DC; 2001.

Stavros G. Memtsoudis, M.D., Ph.D., is a CA-3 resident at Weill-Cornell Medical Center, New York, New York.

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