In anesthesia, the patient relationship typically ends once the operation is over. In internal medicine, it often begins well before or after a patient begins their surgical journey. Combined training in internal medicine and anesthesiology prepares one to tackle essentially any part of patient care, from outpatient preoperative optimization to individualized intraoperative care and transitioning to postoperative intensive care and beyond. Most residents in our program are interested in a career in critical care, cardiac, or transplant anesthesia. Intensive care is the natural intersection of medicine and anesthesia, and the combined program enables you to navigate both arenas proficiently. Combining the procedural and intraoperative skills of an anesthesiologist with the diagnostic reasoning and breadth of knowledge of an internal medicine physician makes for a comprehensive critical care physician. Combined training would also be beneficial for a career in pulmonary medicine, perioperative medicine, pain medicine, or working in a preoperative clinic.
The combined training teaches us to think about how both preoperative and intraoperative choices will affect recovery well after surgery has ended. There have been many instances where we have been able to help optimize one of our own primary care patients for an upcoming surgery, discuss the perioperative plans with them, connect with our fellow residents performing the anesthetic about recommendations, visit our patient in the hospital postoperatively, and then follow their recovery afterward in the clinic. The complete experience has been very rewarding.
Most of the combined training programs are similar in that many of the required rotations and procedural competencies are dictated by the ABA and ABIM. Residents are fully integrated members of each department and complete two and half years of total training in each specialty. As an intern, your full year is spent training in internal medicine, just like any other internal medicine resident. Your second year is spent training in anesthesiology, like any other CA-1 resident, albeit with primary care continuity clinic monthly. Years PGY-3 through 5 are divided equally between internal medicine and anesthesiology. At our program, the years are split into alternating three-month blocks in each specialty. As part of the ABIM requirement, residents spend time at a continuity primary care clinic with their own panel, which happens a few half-days per month when on internal medicine rotations and one half-day per month when on anesthesiology rotations.
One of the many unique parts of the program is the opportunity to rotate through essentially any ICU in the hospital, which sometimes is restricted to only residents from one specialty or the other. Additionally, we’ve been able to blend and tailor our schedules to focus on specific interests. For example, one can choose medicine electives in cardiology, pulmonary hypertension, or infectious diseases and additional anesthesia rotations in cardiothoracic or liver transplant anesthesiology. Moreover, rotating through so many unique services allows you to get to know faculty and staff throughout the health care system. This expands your network for academic or clinical endeavors, research projects, and career advice.
Graduates of combined internal medicine and anesthesiology programs are board-eligible in both specialties and are equipped to pursue fellowships within the full scope of internal medicine or anesthesiology. Recent graduates from our program have gone on to work with both private practice and academic groups. A popular career path is combining critical care medicine and OR anesthesia, often with a focus on complex cases, such as liver transplant anesthesia. Another common pathway is pursuing dual fellowship training in cardiothoracic anesthesia and critical care medicine, as it mirrors many of the unique aspects of the combined residency program. Even if one does not pursue fellowship, combined training in two complementary fields affords a comprehensive knowledge base and skill set that makes one that much better of an anesthesiologist and internist.
The application process to a combined residency works similarly to other programs in either anesthesia or internal medicine, with a few key differences. In addition to an ERAS application to the combined program, many applicants also apply individually to the anesthesia and/or medicine residency programs at that institution. Most programs tailor the interview days to allow applicants to interview back to back in one trip (often two days in a row). At some programs, including our own, you must match into each program individually to be accepted into the combined internal medicine and anesthesia program and can use the unique ERAS codes to submit your rank list with your order of preference. While we recommend applying to the combined program from the outset, there have been select circumstances of categorical internal medicine or anesthesiology residents who have “switched” into a combined program after intern year. We think this speaks to the desirability of dual training and seeing firsthand the skills of residents in the combined program.
Overall, training in a combined residency program offers a host of clinical skills and career opportunities not typically available to categorical residents. However, it should be noted that it does require more work than a single residency, including the need to study for both programs’ in-service training exams, written board exams, and the anesthesiology oral boards. Outside of inpatient medicine and the OR, residents must also learn to manage a primary care panel with inbox messages throughout the five years. Many residents describe the PGY-3 year to be the most challenging as you learn to flip back and forth between each specialty and adjust to the role of senior resident on medicine teams. However, this training in team leadership and adaptability for transitioning between clinical environments has been beneficial for grooming trainees for the next level of training as fellows or attendings. We encourage trainees with a true interest in both medicine and anesthesia to consider exploring a combined residency to provide a comprehensive training experience.