Department of Profundity
A wise person once observed that there are three types of learning. The most problematic type is to go out in the world and make a mistake, but not learn from this experience and make it again. This is not very smart.
The second type is to make a mistake but learn from it and move on. Much better.
The third and best type is to observe and learn from others wiser than you and never make that mistake in the first place.
Anesthesiology News assembled a group of anesthesiology educators and asked them what good advice they would pass on to newly minted physician anesthesiologists in hopes of avoiding learning type number 2 and instead enjoy the fruits of type number 3.
James E. Cottrell, MD
Chair, Department of Anesthesiology
State University of New York Downstate Medical Center
University Hospital of Brooklyn Clinics
Brooklyn, New York
Ehab Farag, MD, FRCA
Associate Professor of Anesthesiology
Lerner College of Medicine
Director of Clinical Research Department, General Anesthesia
Elizabeth A. M. Frost, MD
Advisory Board, Anesthesiology News
Professor of Anesthesiology
Mount Sinai Medical Center
New York, New York
Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP
Editor-in-Chief, Pain Physician
Professor, Program Director, and Chairman
Department of Anesthesiology
Director, Pain Services
Hospital Director of Anesthesia, LSUIH
Professor, Department of Pharmacology
LSU School of Medicine
Professor of Anesthesia and Pharmacology Tulane School of Medicine
New Orleans, Louisiana
Adam I. Levine, MD
Professor of Anesthesiology,
Otolaryngology, Structural and Chemical Biology
Vice-Chair of Education
Mount Sinai Health System
Program Director; Residency Training Program
Department of Anesthesiology
Icahn School of Medicine at Mount Sinai
New York, New York
Philip D. Lumb, MB, BS, MCCM
Editor-in-Chief, The Journal of Critical Care
Professor and Chairman
Department of Anesthesiology
Keck School of Medicine
University of Southern California
Los Angeles, California
Kathryn E. McGoldrick, MD, FCAI(Hon)
Editor-in Chief, Survey of Anesthesiology
Professor and Chair of Anesthesiology
Residency Program Director
Assistant Dean for Student Affairs
New York Medical College
Valhalla, New York
On Professional Relations
Philip D. Lumb, MD: Medical politics are an increasingly important aspect of practice, not necessarily to protect/preserve specialty or subspecialty careers but rather associated with the definition of medicine’s future practice prerogatives. The practice of medicine is changing, and it is important for physicians to be engaged in formulating the new and evolving paradigms of care. Lack of engagement will breed contempt for and increasing regulation of physician-based practices and patient access.
Adam I. Levine, MD: Be assertive and confident; don’t hesitate to speak up on behalf of your patients.
Dr. Lumb: When starting in a new practice following residency or fellowship, it is important to recognize that the skill set you have acquired reflects the style of practice at your training site(s). New surgical colleagues may have expectations that your training equips you to meet; however, it is important to introduce yourself prior to attempting the first anesthetic with a new surgical colleague in order to understand the particular flow of his/her surgical technique. You will be able to adapt preemptively after a conversation; this is more desirable for you and your surgeon than being surprised during the case.
Ehab Farag, MD: The progress of anesthesiology practice is mainly built on the basic sciences. Therefore, the anesthesiologist should be acquainted with recent advances related to anesthesia.
Dr. Lumb: Remember, surgeons stand for the duration of the procedure; whenever you are sitting and below the level of the ether screen, you cease to exist. It is appropriate to sit at selective times, if at all, and maintain contact and active engagement with the surgical procedure at all times. Our goal is to anticipate rather than to react to surgical actions.
Kathryn E. McGoldrick, MD:Excellent communication skills are vital to success in one’s personal and professional life. Studies repeatedly have shown that miscommunication is a major contributor to adverse outcomes—and wounded feelings. Effective communication skills are associated with enhanced patient outcomes and satisfaction, but these skills are not easily taught or learned. The best starting point is to become a thoughtful listener. Eventually, role modeling of talented communicators and cumulative experience will be instrumental in the development of these essential skills.
Alan David Kaye, MD: Befriend your leader and let him or her know what your long-term goals are as they can help assist to attain these personal and professional aspirations.
Dr. Levine: Don’t live by the adage, “Keep it simple, stupid,” otherwise down the road you will find that new knowledge, skills and technology have passed you by. Challenge yourself by trying new techniques, new devices, new medications and new technologies.
Dr. Lumb: Personal patient contact is an imperative for all anesthesiologists. Carry business cards and not only distribute them to patients, but make sure you are available to take their calls at all times during the perioperative sequence. Few will call, but all will have a lasting impression of your care and interest in their well-being.
Dr. Farag: The anesthesiologist and the surgeon work together as one team for the patient. Therefore, if you have any concern regarding the patient’s condition, discuss it with the surgeon first before talking to the patient.
Dr. McGoldrick: Be committed to life-long learning. Anesthesiology is a dynamic discipline; information and technology are expanding and evolving at a geometric, if not exponential, rate. That said, it is important to not be totally dependent on new technology. Specifically, video laryngoscopes have enhanced our ability to manage challenging intubations, but we should not let our skills with fiber-optic endoscopy or blind nasotracheal intubation atrophy. You never know when you’ll encounter a patient who is unable to open his or her mouth!
Dr. Farag: A good anesthesiologist is one who understands and recognizes what is happening on the other side of the ether screen. Do not hesitate to ask the surgeon if there is something going wrong with him or her during the surgery to be better prepared.
Dr. Lumb: Hospital medical staffs are independent organizations and as such have significant governance responsibilities. When you become a member of a medical staff, not only is it a privilege, but it is also a responsibility. Therefore, it is important to understand the rights, privileges and responsibilities associated with membership; these are detailed in the medical staff bylaws that will be supplied to you. Read them carefully prior to signing the statement that indicates you have done so.
Dr. Levine: While using new technologies, do not sacrifice your clinical skills with standard laryngoscopes and bronchoscopes. Mastering and perfecting the use of standard laryngoscopes and bronchoscopes takes longer and requires more nurturing than mastering and using video laryngoscopes. Never find yourself “rusty” with a bronchoscope.
Dr. Kaye: In our profession, best outcome wins. If you treat each patient as if it were your family member, your mother, your father, or your child, you will always make the best consultant decision and be on the right direction to the best result. This will earn you respect from your peers and surgical colleagues.
Dr. Lumb: When applying for medical staff privileges, read the application questions carefully; some are worded strangely—for example, in the negative—and may be answered incorrectly if read quickly. This is a critical document, and when completing any application for privileges, understanding the process requires your full attention, due care and diligence.
Dr. McGoldrick: Always remember that the most important person in the operating room is the patient—not you or the surgeon. Patient safety and well-being must always trump production pressures and other secondary considerations. A derivative concept related to the primacy of patient-centered care is recognizing when to ask for help. Never be too proud—or too intimidated—to acknowledge the need for assistance. Rather than a sign of weakness, this acknowledgment indicates strength, honesty and integrity.
Dr. Levine: Perfect and maintain the ability to do a superb awake intubation.
Dr. Lumb: Personal integrity is critical; interaction with professional colleagues must be the hallmark of your respect for our discipline and interaction with patients. Irrespective of political and/or production pressure, we are the patient’s final defense against inappropriate surgical risk. We may not get into the plane, but we certainly accept risk on behalf of the patient. Consider how this action becomes a part of your informed consent discussion.
Dr. Farag: Anesthesiologists are perioperative physicians dealing with acute situations, and our decisions could have major impacts on the patients’ outcomes. In difficult situations keep your composure and do not hesitate to ask for help if it is needed.
Dr. Levine: Always reflect on your care. Be your own worst critic and always strive to be a better physician with each passing day.
Dr. Kaye: When in a disagreement, first finish the case, as an angry surgeon will perform at a lesser level, which is not fair to your patient. Ask to speak to the surgeon at a later date and do it sitting down. Discussions standing up do not end well, in general.
Dr. Levine: Just remember that, during your entire practice, I bet you that you will never utter the following phrases: “Darn, my IV is too large and runs too well,” “I wish I didn’t put that A-line in,” or “I knew I shouldn’t have intubated that patient awake.” Think about it and manage your patients accordingly.
Dr. Farag: The first impression in any new job is very important; therefore, try your best to make a good impression on your colleagues—especially the surgeons.
Dr. Frost: When you are on call—especially on the weekends—plan to arrive a few minutes early. Your colleague may have had a rough night and will certainly remember your thoughtfulness. And do remember that in the springtime there is one day when Saturday to Sunday is only 23 hours long! Just a small point, but I do remember an attending who habitually “forgot” and arrived an hour late. We finally decided to always assign that person in October!
Dr. Frost: If you consider continuing in academic anesthesia, you will certainly be noticed if you complete any requested project on time or even a little early. Volunteering to write an article or comment is also certain to get a repeat invitation. If you are asked to write about a topic with which you may not be too familiar, accept anyway and research it. But do remember to use “spell check” before you submit your manuscript or paper.
Dr. Farag: If you are interested in research—especially clinical research—make sure to collaborate with surgeons and involve them in your research. Therefore, the surgeons will help you recruit the patients for the research and your professional relations with them will strengthen.
Dr. Levine: If you plan to stay in academics, don’t go it alone. Find a mentor or mentors. Don’t rely on your mentor to take you by the hand and do all of the work. Mentees have to “manage up” and take responsibility for the relationship, plan the meetings, set the agenda and determine projects to be completed. Above all, seek feedback.
Dr. Farag: The main pillars of anesthetic practice are mainly research, technical skills and knowledge. You might not be interested in research, but without improving your technical skills and your knowledge, you will lose your job security and become an easy target to be replaced. Always remember, the practice of anesthesia is an art and [a] science.
Dr. Frost: State societies are given a certain number of delegate and alternate delegate slots as part of the overall political process in the American Society of Anesthesiologists (ASA). Alternate slots are often not filled. Join or convert your resident membership in your state society and apply for a place. Chances are you will be elected and shortly thereafter, when a delegate position becomes available, you will be in an excellent situation to put yourself on the ballot. Thereafter, you can opt for several “jobs,” such as secretary, treasurer and even eventually representative to the ASA. It is a good way to network and to become more familiar with the political arms of the state and national societies.
Dr. McGoldrick: Remember who brought you to the dance. None of us would be members of our valued profession if it were not for the sacrifices and dedication of others. Pay proper respect and loyalty to those who helped you along the way, and lend a helping hand to those following you.
Dr. Kaye: Be earnest and happy to help. Those who are considered part of the solution are always well received in the long run in our field.
Dr. James E. Cottrell: Some old folks have more cognitive reserve than others, so they are less prone to developing Alzheimer’s. And if they do begin to show signs of dementia, they lose cognitive capacity more slowly than seniors who have less cognitive reserve. We are not sure where cognitive reserve comes from and we don’t know how to get more of it. Indeed, we’re still trying to figure out what it is.
A less mysterious concept is experience reserve. Let’s call it eReserve. We know what it is because we know where to get it. Some anesthesiologists in my generation got it in Vietnam … anesthetizing wounded soldiers with open-drop ether in an open field. Others of us had harrowing experiences in places like Reykjavik, Iceland, where I was stationed. eReserve is still available in an astonishing number of places today … places where the only available anesthetic is ketamine. More than half of the world’s population lives in such places.
eReserve comes in handy when you find yourself in an OR that doesn’t have the latest monitoring devices, has an elderly ventilator and lacks a seriously adjustable operating table. With eReserve, you can think back to the days when your only monitoring devices were the ones that sit above the right and left sides of the bridge of your nose. And with eReserve you can reflect back, and even smile, while remembering an OR that only had an Ambu bag, a face mask and no capacity for endotracheal intubation … and you can even remember being thankful that the operating table held up under the strain of a morbidly obese patient, never mind adjustment. With enough eReserve, you might even remember having had thoughts like “Ketamine really works … and these procedures really help these people … it’s all so much better than nothing.”
Whether you arrange some time with Médecins Sans Frontières [Doctors Without Borders] or sidle up to a mission sponsored by a religion that you may not believe in (!), my advice to young anesthesiologists is to establish and maintain a healthy eReserve account. eReserve accounts pay an astonishing rate of interest. They may even increase cognitive reserve!
On Financial Matters
Dr. McGoldrick: Don’t be greedy. If making money is one’s primary goal, then one should be an investment banker! Anesthesiology provides its practitioners with a comfortable, but not extravagant, lifestyle. Fundamentally, money should be viewed as a tool to accomplish worthwhile goals rather than as an end in itself. Do not succumb to acquisitiveness lest it control your behavior and consume your soul. It’s been said that happiness lies not in having what you want, but rather in wanting what you have. Be appreciative of the many gifts life has granted you. In this context, it is vital to select as your personal partner and your professional partners individuals who share your values, priorities and sense of purpose.
Dr. Kaye: Sadly, many young anesthesiologists believe only money makes you happy and enter into situations where they have little time to balance their personal lives, leading to divorce and other problems.
Dr. Lumb: Acquire disability insurance (specialty-specific, if offered) as early as possible (hopefully during residency) and never take the premium as a business expense tax deduction. In the event you need to take disability income, it should not be liable for income tax if premiums are paid with after-tax dollars.
Dr. Kaye: Learning to save is far more important than the income salary line from one place to another. Those who learn to save will all be multimillionaires over their careers in anesthesia. Those who do not will always have nothing.
On Personal Matters
Dr. McGoldrick: Substance abuse is an occupational hazard for anesthesiologists. Genetics, vulnerable brain chemistry and environmental triggers (including easy access, stress, lack of positive feedback) all play contributory roles. During the course of my long career, I have lost several cherished colleagues to this pernicious disease. Our anesthetic drugs have uniquely addictive properties, and it would be foolhardy to think that one can “experiment” once or twice and then escape their powerful grip. Do not eventhink about self-medicating with anesthetic agents. Ultimately, at the receiving end of the syringe is a person making a choice, at least initially. NEVER take that first dose!
Dr. Kaye: There is no perfect job. The people who are most satisfied in anesthesia believe that the glass is half full and have balanced their personal and professional lives.
Dr. McGoldrick: Develop interests and an identity outside your profession. Your sense of self-worth should not be linked exclusively with being an anesthesiologist. Given the extended longevity common in developed nations, many of us will be living for decades after we retire from clinical or administrative duties. Cultivate a variety of rewarding interests, hobbies and relationships with people of all ages and diverse backgrounds to bring joy, growth and fulfillment to those “golden years.”
Dr. Kaye: Appreciate your job and its importance, as anesthesia plays a critical role in many patients’ lives. Have a good attitude and realize that you are critically important.
Dr. McGoldrick: Stephen Hawking, the British theoretical physicist, cosmologist and author, has remarked that intelligence is the ability to adapt to change. In addition to death and taxes, another certainty of life is that circumstances will change. Maintain flexibility, a forward-focused vision, optimism and the ability to make lemonade when lemons are diverted in your direction. And always remember that we learn more from our mistakes than we do from our successes.
Dr. Kaye: Make friends with the surgeons, residents, nurses … everyone. This is just a logical and good idea.