Published on the first day of every month. Produced in collaboration with editors of the New England Journal of Medicine.

Anesthesiology

A NextGen Pathways in Medicine Article
By Roger Batt

10…9…8…7…6…I cannot recall what came after that, as I reclined into the soft cushions of the dentist’s chair and drifted into the solitude of unconsciousness. The sodium pentathol seeped through my veins, dulling the strident trill of the drill entering my jaw, and softening the cracks of breaking bone into a quiet murmur. The cutting and tearing of my flesh went unnoticed and the entire hour and twenty minutes of surgery was hardly enough to disturb the dream I slipped into. While a tiny sliver can irritate for days, the miracles of anesthesiology allowed the agonizing extraction of four wisdom teeth to pass in an effortless haze.

With an increasing number of operational procedures becoming possible thanks to today’s technology, anesthesiologists are assets to the medical field now more than ever. Dr. Angela M. Bader [1] is an anesthesiologist at Brigham and Women's Hospital in Boston, Massachusetts, who kindly agreed to supplement our 'pathway' through anesthesiology with her personal experience in the field.

Anesthesiologists [2] are essentially doctors that have been trained to relieve pain and maintain patients' stability before, during, and after operational procedures. These doctors deliver chemicals called anesthetics to the body, which block certain sensations and allow surgery to proceed with less discomfort to the patient. Before the development of anesthetics, surgery was a rare practice that doctors used as a last-resort in only the most extreme circumstances. In fact, between 1821 and 1846, doctors at Massachusetts General Hospital performed just 333 surgeries, or less than one operation per month [3]. When operations were performed, they were horribly painful and gruesome experiences for patients. Alcohol and opium were often given as numbing agents before the surgery, but worked to little avail as patients screamed in agony. It was not until 1842 that anesthesiology came into practice, after Dr. Crawford Long of Georgia gave one of his patients an ether-based anesthetic before removing a tumor from his neck. Dr. Long subsequently used ether during amputations and childbirth, a practice that was mimicked in 1846 by Dr. William T.G. Morton at Massachusetts General Hospital. Dr. Morton is often considered to be the first physician to give a public demonstration of the way anesthetics work, spurring an interest in the field that has caused it to grow rapidly ever since.

Today, the available anesthetics extend far beyond ether. Of the forty million anesthetics delivered annually in the United States, nearly ninety percent are administered by anesthesiologists [4]. The anesthetics most commonly used by anesthesiologists are categorized according to the extent to which they desensitize the patient's body. Anesthetics that lead to a completely loss of consciousness are referred to as general anesthetics. Anesthesiologists typically administer general anesthetics when patients are undergoing extensive procedures, such as heart bypass surgeries, which exert stress on the body that would be too painful to overcome without complete sedation. General anesthetics can suppress protecting reflexes, such as coughing and breathing, so anesthesiologists are often readily at hand during extensive surgeries and regulate these anesthetics intravenously or through inhalation.

Anesthesiologists can also put patients into a state of conscious sedation with intravenous anesthetics that relax the entire body and make patients feel fatigued. Though patients often do not remember what happened while they are consciously sedated, they remain awake during the surgery and can respond to doctors' questions and requests. Anesthesiologists use conscious sedation for relatively routine procedures, such as colonoscopies.

In combination with conscious sedation, regional anesthesia can be administered. This form of anesthesia numbs a particular region of the body and is often used in operations dealing with a specific area. During hip surgery, for example, regional anesthetics are injected into the network of nerves associated with the region of the hip being worked on. Regional anesthesia is particularly useful, because it desensitizes the patient to the area of their body in distress, without affecting the other vital regions of the body, such as the heart, lung, and brain. The effects of regional anesthesia often remain post-operationally, so patients do not have to take as much pain-relieving medication after their surgery.

An additional type of anesthesia available to doctors is local anesthesia, which desensitizes a particular part of the body (usually more localized than the regions affected by regional anesthesia). The area numbed is usually small and superficial, so local anesthetics are often administered by injection. Doctors tend to use this type of anesthesia during minor procedures, such as skin biopsies and dental work.  

Anesthesiologists do more than simply administer anesthetics. At the most fundamental level, these physicians have to regulate the patient's blood pressure, heart rate, breathing, and toxin levels among other vital signs. Blood pressure is closely monitored with a blood pressure cuff, heart rate and rhythm are tracked using an electrocardiogram, and blood oxygen saturation is kept in check by a special machine called a pulse oximeter. Anesthesiologists arguably carry some of the most stressful responsibilities in the medical field, as the lives of patients rest in the precise adjustments they make to the anesthetics.

They also perform in a wide variety of roles and disciplines. Dr. Bader explains that "in a typical day, we have anesthesiologists that work in places like the operating room giving anesthesia; in the pain clinic seeing patients or performing procedures; in the ICUs managing patients; in the pre-op clinic evaluating patients for procedures; or in the out of operating room managing patient flow and functioning in administrative roles."

Furthermore, due to the wide variety of anesthetics and situations requiring pain relief, there are many subfields in which anesthesiologists can choose to specialize. For instance, ambulatory anesthesiologists are specifically responsible for patients during procedures in outpatient settings [5]. One of their primary responsibilities is to determine whether or not the patients are even fit to proceed with outpatient surgery. Following this assessment, ambulatory anesthesiologists work primarily with anesthetics suitable for same-day recovery. These doctors are especially important in the recovery room, as they must ascertain whether or not the patient is ready to be released from the hospital. This specialty is on the rise in conjunction with the increased number of outpatient procedures being performed.

Other anesthesiologists sedate patients specifically during cardiac and thoracic procedures. These doctors are accordingly called cardiac and thoracic anesthesiologists. In this specialty, anesthesiologists are most often involved with thoracic epidural analgesia, fiberoptic intubation, and lung isolation techniques. In some cases, thoracic anesthesiologists administer anesthetics during pulmonary transplant surgeries, as well.

During neurological procedures, doctors known as neurosurgical anesthesiologists are on hand to administer anesthesia in the operating room, in the neuroradiology suite, and sometimes even in MRI and CT scan suites. These anesthesiologists are responsible for SSEP, MEP, and EEG [6] monitoring and often conduct neurological exams at the end of the operation. Neurosurgical anesthesiologists closely watch BIS [7] monitors to assess the level of consciousness resulting from the general anesthesia given during these procedures. Procedures during childbirth often require obstetric anesthesiologists, who are specialized to administer anesthetics and monitor women in the delivery room. These anesthesiologists are responsible for managing the pain of labor and delivery, administering anesthetics for cesarean sections, and managing emergencies that may arise. The use of "walking" epidurals [8] and PCEA [9] are among the recent advances in this specialty.

Dr. Bader works in yet another subfield of anesthesiology, known as perioperative medicine. As she describes, "this means preparing patients who may have multiple other medical issues to have surgery or other procedures safely with optimal outcomes." As evident from this extensive (yet not inclusive) list, the possible careers to explore in anesthesiology is seemingly endless. Pediatrics, critical care medicine, liver transplantation, acute and chronic pain management, and 'post anesthesia care' are just a few of the many specialties within anesthesiology.  

Pros and Cons

The variety of anesthetics and procedures that anesthesiologists work attests to the critical function of these physicians within medicine. Rather than spending the majority of their time treating and evaluating their own patients, anesthesiologist are usually on hand alongside doctors from nearly every other field during surgery. The anesthesiologist is in charge of administering the anesthetics, while it is the doctor's job to attend to the rest of the procedure. Because the majority of an anesthesiologist's responsibilities take place in the operating room, there is not as much routine clinical work as in most other specialties. Therefore, these doctors usually do not carry on long-term relationships with patients.

While this may deter some who wish to maintain a personal interaction with their patients, Dr. Bader saw these relatively short-lived interactions as a unique benefit of anesthesiology. In fact, she started in pediatrics, and later switched to anesthesiology for this very reason. "What I found interested me most," she writes, "was acute care of very ill patients rather than long-term chronic follow up. This is what attracted me to anesthesia." It can be easy as an anesthesiologist to see the direct impact on the patient's life. The lack of patient follow-up is also conducive to a less-scheduled lifestyle. If an anesthesiologist is not on call at the end of the day, he can leave the hospital with no responsibility for any patients until the start of the next operating list. Some anesthesiologists can even work part time or on a locum basis. This mobility additionally allows these doctors to more readily relocate to new hospitals and begin work as soon as they join the clinic, while most medical specialists must build up a roster of patients before moving forward in their profession.

Education and Training

While the benefits of being an anesthesiologist certainly seem appealing, anesthesiologists work very hard to earn this comfortable lifestyle. The basic pathway to becoming an anesthesiologist involves four years of college, four years of general medical education, and three to four years of training in an accredited Anesthesia Residency Program. Like other medical students, anesthesiologists can fulfill their general medical education requirements by enrolling in either an allopathic or an osteopathic medical school.

Once the four years of medical school have been completed, doctors must apply for a residency with an accredited Anesthesia Residency Program, often in a location where they eventually hope to secure a permanent position. The first year of residency (called the clinical base year) involves non-anesthesia clinical training, followed by a year of basic clinical anesthesia-training (called CA-1), a year of sub-specialty clinical training in anesthesia (called CA-2), and a year of advanced clinical training in their subspecialty of anesthesia (called CA-3). As the residents progress from CA-1 to CA-3, they are given increased responsibilities and additional exposure to the various subspecialties of anesthesiology. Residents must pass both the Annual American Board of Anesthesiology (ABA) In-Training Examination as well as the ABA Written Board Certification Exam to receive their degree. Residents often take the ABA In-Training Examination at the start of year CA-3 and site for the ABA Written Board Certification Exam sometime during year CA-4 (double check these facts). Upon the successful completion of these examinations, residents officially become certified anesthesiologists.

Trends in the Field

Statistics indicate that anesthesiology is an auspicious field to enter, perhaps now-so more than ever. According to an April 2001 article in the American Society of Anesthesiologists newsletter, "a curtailed supply of anesthesiologists and a growing demand for surgical health care have brought about a national anesthesiologist shortage that could continue well into the next decade." [10] This research was updated and the findings confirmed by Alan W. Grogono, M.D., in a November 2003 article for the American Society of Anesthesiologists newsletter [11]. Dr. Bader agrees that "right now and in the future...there will be great demand, because as the population ages the need for surgery is increasing." The benefits of entering anesthesiology are multiplying and the possibilities are endless. Whoever chooses to take the 'pathway' to anesthesiology assuredly has a bright and promising future in medicine.

1. Dr. Angela M. Bader graduated from Harvard Medical School in 1981 and earned an MPH from the Harvard School of Public Health in 2006 with a specialty in health care management. (Bader, Angela M. Interview with Roger C. Batt. 24 Apr. 2008.)
2. Anesthesiologists are also called 'anaesthetists' and 'anaesthesiologists' in the UK, Canada, and Australia.
3. "History of Anesthesiology." Harvard MGH. Harvard. 14 Mar. 2008.  http://neurosurgery.mgh.harvard.edu/history/beforeth.html
4. "ASA Fast Facts: Anesthesiologists Provide Or Participate In 90 Percent Of All Annual Anesthetics." ASA. http://www.asahq.org/PressRoom/homepage.html
5. Outpatient surgery refers to same-day procedures that do not require inpatient hospital admission. These procedures often deal with ears, nose, and throat; urology; and the extremities.
6. SSEP is a 'steady-state evoked potential' in which stimuli are presented in a rapid succession. The evoked potentials overlap in time and the presentation rate is high enough to evoke a steady wave. Electroencephalography (EEG) is the measurement of electrical activity produced by the brain, recorded by electrodes placed on the scalp.
7. BIS (Bispectral index) monitors take neurophysiological readings to assess the degree to which patients are sedated. These machines essentially take an EEG, analyze it, and process the result into a single number.
8. "Walking" epidurals make use of microprocessor-controlled infusion pumps, local anesthetics, narcotics, and alpha adrenergic agonists to provide maximum pain relief with minimal side effects. Developed in the mid-1990s, "walking epidurals" relieve pain without affecting muscle strength, which allows women to effectively push during labor.
9. PCEA (patient controlled epidural analgesia) allows patients to regulate the amount of pain medication they wish to receive. They are often used to regulate pain after both vaginal delivery and cesarean section.
10. Eckhout, Gifford M. and Armin Schubert. "Where Have All the Anesthesiologists Gone? Analysis of the National Anesthesia Worker Shortage." American Society of Anesthesiologists. ASA Newsletter, 2001. 18 Mar. 2008. http://www.asahq.org/Newsletters/2001/04_01/eckhout.htm
11. Grongo, Alan W. American Society of Anesthesiologists. ASA Newsletter, April 2003.

 
Roger Batt is a writer for the Next Generation and a member of the Harvard class of 2010.

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