Critical Care Anesthesiology – A Fellow’s Perspective

There are several options to get into a critical care fellowship. Our hospital has programs for those who completed residencies in anesthesiology, surgery, internal medicine (IM), or emergency medicine (EM).

I’m often asked about the differences in the IM versus anesthesiology route. IM residents complete a three year residency and can subspecialize in critical care (two year fellowship) or pulmonary/critical care (three year fellowship). On the other hand, anesthesiology residents complete a four year residency and have the option to pursue a one year critical care fellowship.

Traditionally, IM critical care tends to be heavy in the medical ICU whereas anesthesiology critical care will primarily target the surgical ICU; however there is significant overlap and we both do rotations across all the ICUs. I’ll elaborate on why anesthesiology was the perfect primer for a career in critical care.

I wrote this segment for the American Society of Anesthesiology’s (ASA) Monitor editorial – January 2018:

Critical Care Anesthesiology – A Fellow’s Perspective

Rishi Kumar, MD
Fellow, Critical Care and Adult Cardiothoracic Anesthesiology
Brigham and Women’s Hospital – Harvard Medical School

Over the last decade, the role of the physician anesthesiologist continues to expand outside of the operating room (OR) into environments involving chronic pain management, various points in the perioperative surgical home, and the intensive care unit (ICU). Critical care is very much a natural extension of the skill set we acquire during anesthesiology residency: cardiopulmonary resuscitation, ventilator management, ECMO, hemodynamic monitoring, massive transfusion, risk stratification, airway management, renal replacement, line placement, and ultrasonography are just a few of the topics which overlap from perioperative care to the ICU.

Critical care anesthesiology (CCA) is a one year fellowship path through the San Francisco Match service. The application opens in November (early in comparison to other fellowships) and has grown by approximately 25% since 2014 to include 202 positions across 53 participating programs in 2017.1 Per the Accreditation Council for Graduate Medical Education (ACGME), at least nine months must be spent “in the care of critically-ill patients in ICUs or transitional care units” with the remainder of the fellowship “spent in elective clinical activities, research, or scholarly activity relevant to critical care.”2As I near the halfway mark of my CCA fellowship, I have realized some of the pitfalls but extraordinary benefits of pursuing such a dynamic career.

I started my fellowship in a combined surgical, burn, and trauma unit to quickly learn that transitioning from the OR to the ICU would require a new level of patience. Waiting for a clinical pharmacist to verify medications that I was accustomed to pushing myself and managing 10-20 patients for many days rather than a single patient for one operation were foreign concepts. I now had to justify my reasoning to consultants, nurse managers, and of course the patient and his or her family. While communication is undoubtedly a crucial component in providing quality healthcare, it was nevertheless a drastic change from residency where I had autonomy to execute my treatment plan with very little resistance in the OR.

After an adjustment period, I began to realize the benefits of my anesthesiology training in an environment with hour-to-hour flux, multi-organ pathophysiology, and where quick thinking is essential. Physician anesthesiologists are traditionally the calm, collected decision makers who know when and how to provide acute interventions. This same mentality is utilized to methodically approach problems by organ system, create a differential diagnosis, and act in concordance with input from consultants, nurses, dietitians, respiratory therapists, social workers, and a myriad of other healthcare providers in the ICU.

From a skills and knowledge standpoint, critical care is increasingly utilizing point-of-care ultrasound (POCUS) to perform bedside cardiopulmonary, abdominal, and vascular exams. We are trained in diagnosing and treating ailments ranging from altered mental status and malnutrition to renal failure and sepsis. Many of our patients also have an added component of frailty or terminal illness which creates other challenges and often times difficult discussions regarding goals of care. By serving as consultants, we can offer assistance with procedures like endotracheal intubation, thoracentesis, chest tube placement, bronchoscopy, paracentesis, line placement, and as mentioned, POCUS. Many of these skills can translate back to perioperative care to better optimize patients for surgery and post-operative management.

Many CCA programs also blend fellows from surgery, emergency medicine, and internal medicine backgrounds. We share didactics, rotate through ICU/elective rotations together, and most importantly learn a great deal from each other’s experiences. For example, my colleagues who completed surgical residencies are often the best teachers regarding the rationale behind surgical approaches and potential complications. Internal medicine critical care fellows offer tremendous insight about the management of chronic disease states and unusual presentations of systemic illness. Emergency medicine trained fellows offer a synergism of many specialties in a highly acute setting. I am able to utilize my anesthesiology background to offer diverse analgesic options, acute resuscitation techniques, and procedural skills. Together, we learn a great deal from each other and are able to offer our complex patients the safest and most appropriate care.

In summary, CCA has instilled a passionate enthusiasm for patient care beyond what residency cultivated. Managing the critically ill population has given me so much perspective regarding the frailty of life and understanding my role as a physician in the team-based approach to care. Although several workflow aspects are a stark contrast to operative anesthesiology, CCA provides an unparalleled opportunity to further my knowledge base and skills to become a more complete perioperative physician and consultant.

References:

  1. Residency and Fellowship Match – San Francisco Match website. Accessed November 5, 2017. https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=25&typ=1&name=Critical%20Care%20Anesthesiology#
  2. Program Requirements for GME in Critical Care Anesthesiology. ACGME website. Accessed November 3, 2017. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/045_critical_care_anes_2017-07-01.pdf?ver=2017-05-17-155711-140

Drop me a comment below with questions! 🙂

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6 Comments
  1. Veronica says

    You, anesthesiologist are amazing. From what I understood,you guys are trained to be self efficient, can work on your own and because of it you guys value the importance of teamwork and respect each specialty within healthcare. Anesthesiology is a very scrutinous and humbling specialty. Thanks for sharing and all that you do to educate others.

    1. Rishi says

      Thank you Veronica! At the end of the day, it’s about knowing how to use a team to best serve a patient. 🙂

  2. Tanya Rene says

    AMAZING!!! Congratulations on your publication Rish! Wonderful insight and perspective on your dual fellowship program and how it is attributing to your growth and knowledge as a complete physician.

    1. Rishi says

      Thanks as always for your support, Tanya! Hope you’ve been doing well! 🙂

  3. Ting says

    Can you talk about the combined CC/Cardiac fellowship and your decision to pursue both rather than one or the other? Thanks!

    1. Rishi says

      Definitely a topic I’ll talk about in the coming weeks! Stay tuned!