With an acceleration in retirement across the medical field due to the COVID-19 pandemic, the demand for anesthesiologists has boomed across the country. Simultaneously, academic medicine has had to adapt to a virtual world, taking on both the challenges and opportunities this new reality presents.

Pedro Tanaka, MD, PhD (Medicine), MACM, PhD (Education), worked as a private physician at an academic center in Brazil before coming to Stanford University in 2007. He is a clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine and the associate program director of the anesthesia residency program. He shares his insight on students’ experiences in becoming anesthesiologists in the U.S. today.

Because of his background, Dr. Tanaka is uniquely positioned to discuss the differences in global medical programs, and he writes frequently on the topic. The experience of studying anesthesiology in the U.S. is unique compared to the academic requirements of other countries. U.S. students are required to complete an undergraduate program before matriculating on to medical school, unlike students in the U.K. and Brazil, who begin their medical training after high school (Brazilian J of Anesthesiology 2021;71:162-70). This results in varying durations of each anesthesiology residency: In the U.K, a full medical and specialization residency is nine years, compared to Brazil’s three-year anesthesia residency and the U.S.’s four-year anesthesia residency (Brazilian J of Anesthesiology 2021;71:162-70).

The evaluation systems differ slightly in foreign countries, as well. In the U.S., the Accreditation Council for Graduate Medical Education (ACGME) has a minimum number of rotations that physician trainees must complete, as well as a minimum number of cases trainees must fulfill in each of their subspecialties. Brazil and Canada do not have the same quantitative requirements for a resident’s case load. Brazil, for example, requires physician trainees to complete a total of 440 cases and 900 hours during their training, but without specifications as to how their cases and hours break down in each subspecialty (Brazilian J of Anesthesiology 2021;71:162-70). In addition, expectations in training are broken down into different areas of competency in different countries. In the U.S., the competencies set by the ACGME – “patient care,” “interpersonal skills,” or “medical knowledge,” to name a few – don’t exactly equate to the terms used by the Canadian Medical Education Directives for Specialists, such as “communicator and collaborator,” “medical expert,” or “health advocate” (Cureus. 2017;9:e1060).

Because there is no global standard of training requirements for anesthesiology trainees, foreign medical graduates (FMG) looking to practice in the U.S. are often required to repeat aspects of their medical training to meet the U.S.’s unique requirements. Most FMGs have multiple requirements to meet before they can begin practicing in the U.S., even if they’ve been practicing in another country for many years already. These requirements include taking various exams and obtaining certification from the Educational Commission for Foreign Medical Graduates (ECFMG). To earn an ECFMG certification, the FMG must have proof of graduation at a foreign medical school and must complete any additional educational requirements set in the U.S. The FMG must pass all steps of the U.S. Medical Licensing Examination (USMLE) and complete a U.S.-based residency (asamonitor.pub/3YB9tzF). FMGs also need a visa that allows them to participate in clinical training. The Bureau of Educational and Cultural Affairs offers the J-1, a temporary nonimmigrant visa (asamonitor.pub/3JOEwnc). For many foreign physicians who have already completed their education and have established careers overseas, repeating their medical training can be a frustrating obstacle.

However, Dr. Tanaka presents some good news for soon-to-be-graduating anesthesia residents: “Many anesthesiologists retired during the COVID-19 pandemic, so there is a high demand for anesthesiologists. Our residents often receive more than one offer.”

As a result of the COVID-19 pandemic, much of the residency application and interviewing process has moved to virtual platforms in the U.S. With the use of online applications, residency candidates apply to 30-50 national programs on average. When choosing potential programs, medical students must consider their personal and professional desires: Is the specialty you’re interested in an area of study available at the institution? How important are factors such as salary, geography, or call schedules? Do you want to manage your own cases, and what case types are common at this facility? These questions and answers provide clarity as a potential resident grows to understand practice requirements and personal needs.

Building relations in your academic career as early as possible will help when it comes time for residency applications. Medical students should try to connect with as many professors and fellow students in their program as possible, but they should also network outside of their facility. Dr. Tanaka champions an “away rotation,” which some schools allow, as a valuable chance to become familiar with other institutions in person.

Some programs offer virtual open houses to familiarize candidates with their faculty and curriculum. Online networking allows interested students to connect with current residents. “Residents are very honest in terms of sharing information about the culture of a program, whether it’s a hardworking program, a toxic one, a research-oriented one, or one in which they received very good clinical experience,” Dr. Tanaka observed.

Residency candidates should also educate themselves on the residency Match process. Familiarity with how common Electronic Residency Application Service (ERAS) and Match programs work will prepare you for the application process. Social media platforms like Twitter’s “FutureAnesRes” have insider tips on how to navigate the Match process. The Twitter page “#LifeofaMedStudent” and Facebook’s “Medical Student Diaries” connect online communities of medical students and residents by providing a space for aspiring anesthesiologists to speak candidly about their experiences, ask questions of their peers, and explore options outside of their local community.

Interviewing for an anesthesia residency is similar to interviewing for a job: it requires a good deal of preparation and professionalism and is ultimately a self-reflection exercise. “You must have some procedural skills, which include the combination of your decision-making process and your thought process behind the scenes. You must excel in your medical school. Do your best during your clerkships and show that you have very strong clinical skills. Show who you are, show empathy. It’s not only about grades anymore, because grades are pass or fail,” shared Dr. Tanaka.

Utilize an institution’s anesthesiology department website to prepare specific questions for your interviewer and do not asking for information that is already available online. Practical information on salary and call schedules is important, but your time with an interviewer is an opportunity to learn about the culture and mission of a facility from an insider.

Prepare to present more than just grades: residency directors want to know the candidate and witness passions about anesthesiology and their institution. Keep a record of what you do throughout medical school – research, areas of study, any accomplishments and recognitions – to refer to when organizing a CV for residency applications. Dr. Tanaka added, “Be thoughtful in terms of making a connection. Present research papers in a way that shows how it will be helpful to you in becoming an anesthesiologist. Self-reflect and know what skills you can bring to a residency program and translate into becoming a physician.” When it comes time for the interview, make sure you’re familiar with the virtual platform; check your Internet connection beforehand and make sure you’re in a quiet room with good lighting where you won’t be disrupted.

After gathering as much information about a program as possible, it comes down to listening to your gut. “You have to follow your heart, and we try to highlight that in the interview process. You need to follow the feeling you get from the conversation,” said Dr. Tanaka.

The world of medicine can be intensely clinical, but it also requires a great deal of empathy and emotional intelligence. Finding the right facility requires self-awareness of personal goals and the ideal environment. “We always try to consider if there is a stereotype of the resident who would do well in our program, but really the answer is, you have to be you. The mission of a program is to develop exceptional physicians. You have to be an outstanding clinician by the end of the program, and the program will nurture someone who is passionate about that. So, if you ask me, is there a stereotype? I’d say no, and to look at the potpourri of people we have in our program,” Dr. Tanaka remarked. He continued by citing an example of a student who wanted to train to be a flight surgeon, and now works for SpaceX. Essentially, understand your aspirations and find the program that will develop the skills you need to reach them – whether those aspirations are to be a private practitioner in your community hospital or to work in space. “If you have that passion, we know you’re going to make changes meaningful to your community when you’re back there after training,” Dr. Tanaka reasoned.

Most experience during the four years of residency occurs during rotations, in which residents have exposure to different anesthetic fields like obstetrics, pediatric, or regional anesthesia. During this time, residents must meet the academic requirements of the ACGME. Dr. Tanaka explained that, in Stanford’s anesthesia residency, formal evaluations that become part of a resident’s portfolio are done monthly. Evaluations also come informally, in the day-to-day interactions with mentors, professors, physicians, and other residents. “We’re going to do three or four cases together and we’re going to interact throughout the day, so I’m going to be providing feedback regarding what you’re doing on a daily basis,” noted Dr. Tanaka. Students are also evaluated every six months based on the standards set by the ACGME Clinical Competency Committee, which determines if their performance is satisfactory or unsatisfactory. The results are reported to the ACGME and to the American Board of Anesthesiology.

Ultimately, after graduating medical school and completing a residency program that fits who you are, what makes a good anesthesiologist in the U.S.? “You need to have exceptional interpersonal and communication skills, you need to have empathy and understanding, you need to be a thoughtful leader and try to be fair in terms of your decision-making. You have to consider working as a team and not focus your decision-making on one person. You have to understand that being an anesthesiologist can be a stressful specialty. You’re going to be exposed to high-acuity cases on a daily basis, sometimes. You need to do the right thing for the patient – above all else,” summed up Dr. Tanaka.