The Four Pillars of Your Anesthesiology Rotation

Mike Thornton, MD Candidate Class of 2023, University of Texas Medical Branch at Galveston

The purpose of this article is to provide medical students with an outline of topics to focus on during an anesthesiology rotation. I felt overwhelmed before starting my anesthesia rotation because I did not know where to start. It seemed like stepping foot into a large gym filled with random equipment and having no training plan. Most of the time in life, it is better to learn the fundamentals or building blocks of an art before the more complex, specialized skills, comparable to how we acquired our native language. First, we learned sounds and syllables, then we formed words, and later, sentences. I think the same idea applies to anesthesia, and for this I asked anesthesiologists in the ASA Community Open Forum to provide information on the foundational building blocks of anesthesia; in other words, the components and concepts that aspiring anesthesiologists should learn first. I was pleasantly surprised by the great number of detailed responses that I received. The text in quotations comes directly from anesthesiologists who contributed to the open forum post. Using their wisdom, I developed the four pillars of anesthesiology that students should master early on to shine on their anesthesiology rotation.

General Flow of the OR
On your anesthesia rotation, you will likely be in the operating room for a significant amount of time. Thus, it is important to know the ins and the outs of the OR. For example, being aware of the sterile field, how to bring the patient into the room, and organization of the anesthetics preoperatively will help you understand the fast-paced environment. Situational awareness will pay dividends. In addition, many anesthesiologists harped on the importance of continuity, staying in the case from start to finish. They are more impressed by a student who sticks with the team throughout the case than a student who hops from OR to OR. This may come as a surprise to some students who believe that mastering procedural skills like intubations and IV placement is of utmost importance. Although eventual proficiency in these skills is essential, the consensus among the contributing anesthesiologists was that understanding the case in its entirety is more meaningful to the development of a fourth-year medical student. Being an anesthesiologist comprises so much more than completing procedures, hence why anesthesiologists are known as the "internists in the operating room." In summary, be the student who "shows up early and stays late."

Relevant Anatomy and Pharmacology
This pillar comes as no surprise to medical students. Consider how difficult it is to drive to a destination without a map. This is comparable to intubating a patient without knowing relevant airway anatomy. It is imperative to learn pertinent anatomy of the areas in which you will be working. Start by learning the anatomic structures of the upper and lower airway. If you are beginning an obstetric anesthesia rotation, review anatomy of the vertebrae and spinal cord to better understand epidural and spinal anesthesia. In addition to anatomy, learning the common medications used by anesthesiologists will prepare you for many questions you will be asked. Begin by focusing on the classes, mechanisms of action, and side effects of relevant medications. Because most medical schools do not have an extensive anesthesia curriculum, the onus is on you to become acquainted with this pillar before and during your rotation.

Know Your Patient
This next pillar is the most straightforward and arguably, the most important. When all is said and done, medicine is a service to the patient. It is important to maintain humility and remember that, as future physicians, we are people who chose to dedicate our lives to ensuring the wellbeing of our patients. The determining factor between a good and a great anesthesiologist is not a STEP score, intubation proficiency, or extensive knowledge of pharmacology. A great anesthesiologist is proficient in the aforementioned skills, but more importantly, he or she genuinely cares for the patient. During your rotation, go out of your way to meet your patients and reassure them before the operation. Observe how attendings talk to the patient. Do they launch into an esoteric oration, or do they use simple language that anyone can understand? Do they sit down, or hastily walk out of the room whilst they fire off the last details about the operation? Making connections with people is a skill that anyone can acquire through practice. Being personable and affable is like coal to a steam engine. If there is no coal, a steam engine cannot move forward. Always remember, you or your loved ones will likely require anesthesia one day. Treat your patients in the same manner that you would like to be treated.

Seek Mentors Seeking mentors is the final crucial pillar. Mentorship is not only important for learning the ins and outs of what an anesthesiologist does, but also to learn who an anesthesiologist is. The classic phrase, trust the wards; suggests that there is more to a specialty than what meets the eye. In other words, the wards will not tell you everything. Therefore, you must actively seek out information. If you are rotating at an academic center, seek out anesthesiologists in private practice to appreciate different perspectives. This advice may seem repetitive and simple; however, it is important to acquaint yourself with all aspects of the profession before making a commitment that will last a lifetime. In addition to imparting information about the field, a quality mentor will teach you how to think like an anesthesiologist - plans A, B, and C, rescue options, etc. You may be surprised by the willingness of anesthesiologists to mentor students, just like I was surprised by the overwhelming responses from anesthesiologists to my ASA Community Open Forum post. Do not be afraid to seek help. Just remember, "when the student is ready, the teacher will appear."

Posted June 2022