A GUIDE TO ANESTHESIOLOGY

FOR MEDICAL STUDENTS

Courtesy of the ASA Committee on Residents and Medical Students

 EDITORS IN CHIEF

Emmett Whitaker, M.D.

Johns Hopkins Class of 2010
Former Resident Component President
Johns Hopkins University Medical Center

Ronald L. Harter, M.D.

Jay J. Jacoby Professor and Chair
Department of Anesthesiology
The Ohio State University Medical Center

Basem B. Abdelmalak, M.D.

Professor of Anesthesiology
Departments of General Anesthesiology and Outcomes Research
Director, Center for Sedation and Director, Anesthesia for Bronchoscopic Surgery
Cleveland Clinic Lerner College of Medicine

ASSOCIATE EDITORS

Rafi Avitsian, M.D. Jia Lin, M.D., Ph D.

Cleveland Clinic Cleveland Clinic
Cleveland, Ohio Cleveland, Ohio

Thomas B. Bralliar, M.D. Mohammed Minhaj, M.D.

Cleveland Clinic University of Chicago Medical Center
Cleveland, Ohio Chicago, lllinois

Sorin J. Brull, M.D. Kathy Schlecht, D.O.

Mayo Clinic Florida South Oakland Anesthesia Associates
Jacksonville, Florida Troy, Michigan
Beaumont Hospital
Stephanie Jones, M.D. Royal Oak, Michigan
Beth-Israel Deaconess Medical Center
Boston, Massachusetts Brian Vaughan, M.D.
The Christ Hospital
Stephen J. Kimatian, M.D. Anesthesia Associates of Cincinnati
Cleveland Clinic Cincinnati, Ohio
Cleveland, Ohio

Created 12/2014, Revised 12/2018

2
 INTRODUCTION

Welcome, and congratulations! By picking up this book, you are exposing yourself to one of the most exciting and rewarding specialties
in medicine. I invite you to peruse these pages and experience what anesthesiology is all about.

Anesthesiology is a specialty that traverses many other fields. For an anesthesiologist, day-to-day practice doesn’t just mean putting
patients to sleep for surgery. A good anesthesiologist needs solid foundations in medicine, surgery, physiology, and pharmacology to
deliver a safe and effective anesthetic. Further, our specialty is clearly thought-driven, but it also represents an opportunity for
practitioners to utilize procedural skills on a daily basis.

We have developed this book as a guide for any medical student with interest in anesthesiology. In the following chapters, you will
find information relating to the specialty as a whole, information relating to training as an anesthesiologist, introductions to the many
subspecialties of anesthesiology, and finally a medical student’s guide to the ASA. We hope that you will find this book helpful in
choosing a specialty that is right for you. Best wishes for success in your career!

– Emmett Whitaker, M.D.

Johns Hopkins Anesthesiology Class of 2010

Disclaimer
This document has been developed by the ASA Committee on Residents and Medical Students but has
not been reviewed or approved by the ASA House of Delegates. It shall not be construed to contain official
ASA policy (except where otherwise indicated herein), nor is it intended to provide medical or legal
advice. The content provided in this publication represents the opinions and interpretations of the
authors of such content and not that of ASA.

3
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

CHAPTER 1 pain and spurred the development of anesthesia as a specialty.

The inscription on Morton’s tombstone reads: “Inventor and
History of Anesthesiology Revealer of Inhalation Anesthesia: Before Whom, in All Time,
Surgery was Agony; By Whom, Pain in Surgery was Averted and
Viji Kurup, M.D.
Annulled; Since Whom, Science has Control of Pain.” Although
Associate Professor
this was the first public demonstration, even before this date,
Department of Anesthesiology
Dr. Crawford Long from Georgia had been administering ether
Yale University School of Medicine
for surgical anesthesia since 1842, but he did not make this
discovery public and remained silent until 1849. A long battle for
Paul Barash, M.D.
the credit of discovery of anesthesia ensued, and has been termed
Professor
“the ether controversy.” It remains unresolved even today. The
Department of Anesthesiology
other important early milestone in the history of anesthesia was
Yale University School of Medicine
the use of chloroform by James Simpson. As an obstetrician in
Scotland in 1847, Simpson published his experience in the Lancet.
The discovery and application of anesthesia has been the single Anesthesia during childbirth was a controversial issue in the
most important contribution of American medicine to mankind. 19th century due to religious ramifications of the subject. The
All the major advances in surgery would not have been possible religious debate quieted when Dr. John Snow was invited by
without the accompanying vision of the pioneers of anesthesiology. Queen Victoria to administer chloroform for the birth of her
Anesthesiologists today are like no other physicians: we are experts child, a technique soon-to-be-known as “chloroform a la reine.”
at controlling the airway and at emergency resuscitation; we are This was followed by the discovery of additional inhalational
real-time cardio-pulmonologists achieving hemodynamic and agents: ethyl chloride, ethylene and cyclopropane. Since the
respiratory stability for the anesthetized patient; we are real-time majority of anesthetics were “explosive,” the search for the
pharmacologists and physiologists administering and titrating drug ideal nonflammable anesthetic agent was on. In the 1960s the
dosages to patient responses; we are internists evaluating patients fluorinated anesthetic halothane was introduced into clinical
perioperatively; we are actively engaged in pain management of practice. This was followed by other nonflammable inhalation
patients on the labor floor and in pain clinics; we manage critically anesthetics: enflurane, isoflurane, desflurane and sevoflurane.
ill patients in the intensive care units; we are trained researchers However, we have not yet discovered the “ideal anesthetic.”
looking for answers and delving into the mystery of the human A number of agents are being studied, including xenon, a gas
body. Today, the boundaries of anesthesiology extend far beyond with many properties of the ideal anesthetic.
the operating room into the arena of critical care, pain, space The development of regional anesthesia does not lag behind
medicine and underwater expeditions. in sensationalism. The coca leaf had long been known for its
The story of the evolution of the specialty of anesthesia is a anesthetic properties when applied to the mucous membranes.
fascinating one, filled with visionary individuals who held on to However, the clinical application of this anesthetic property was
their dreams in the face of adversity, tales of serendipity, intrigue, not appreciated until 1884, when Carl Koller, a surgical intern,
secrecy and controversies. The antiquated methods to control recognized this. He was working in Vienna looking for a topical
surgical pain, such as nerve compression, cold application, ophthalmic anesthetic. His friend Sigmund Freud was studying
mesmerism and herbal remedies, paved the way for more scientific the cerebral-stimulating effects of cocaine and gave Koller a
methods of pain relief. A few dentists were looking for new ways small sample in an envelope. A few grains of cocaine leaked and
to relieve pain during dental procedures. Horace Wells, a dentist stuck to Koller’s finger and he absent-mindedly licked his finger.
from Hartford, Connecticut, experimented with nitrous oxide and To his surprise, he found that his tongue felt numb. As Pasteur
had some initial success; however, a public demonstration at the proclaimed, “Chance favors only the prepared mind.” The
Bullfinch Amphitheatre of Massachusetts General Hospital in significance of this finding was not lost on Koller. He reported the
January 1845 failed, and this proved to be a setback for all those finding in his article, which sparked a revolution in ophthalmic
pursuing the goal of pain-free surgery. The first public demon- and other surgical disciplines. This discovery was soon followed by
stration of ether anesthesia was by William Thomas Green Morton reports of sensory nerve blocks of the face and arm by two young
on October 16, 1846, again at the Bullfinch Amphitheatre. This American surgeons, Halsted and Hall. The self-experimentation
demonstration was a success, and the surgeon, Dr. John Warren, of these surgeons led to one of the early reported cocaine
turned to the audience after the procedure and said “Gentlemen, addictions in the medical profession. The possibility of blocking
this is no humbug.” This day is celebrated as “Ether Day” across individual nerves was attractive, and multiple nerve and plexus
the globe; it was a turning point in the attitudes of people towards blocks were described. Neuraxial anesthesia was not far behind.

4
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

In 1885, Corning described epidural anesthesia, while August CHAPTER 2

Bier introduced intrathecal (spinal) anesthesia. The introduction
of various types of local anesthetic drugs with different durations
Patient Safety and Outcomes
of action and better spinal and epidural needles led to the
Lee A. Fleisher, M.D.
development of regional anesthesia as a specialty.
Robert D. Dripps Professor and Chair of Anesthesiology and
Anesthesiology began evolving as a specialty among
Critical Care
physicians in the early part of the 20th century and led to the
Professor of Medicine
formation of professional societies. The first organization in
University of Pennsylvania School of Medicine
America was the Long Island Society of Anesthetists, formed
in 1905. This organization later became the New York Society
of Anesthetists and subsequently became the American Society The specialty of anesthesiology has been lauded as one in which
of Anesthesiologists (ASA). Francis Hoeffer McMechan founded safety has always been of paramount importance. In the landmark
the International Anesthesia Research Society (IARS), which Institute of Medicine report, To Err is Human, anesthesiology was
together with the ASA are the premier American organizations cited as the specialty to emulate with respect to improving safety.
in anesthesiology today. After World War II, specialties within The first study of anesthetic safety (and risk) occurred shortly
anesthesia began to thrive, and pediatric, obstetric, pain, after the first report of the delivery of anesthesia for an operative
critical care, vascular, cardiac, thoracic and other distinct fields procedure in 1846. Subsequently, Ruth et al. helped to establish
continue to evolve. the first anesthesia study commission to analyze perioperative
The story about the development of the field of deaths in 1935.1 They relied on voluntary submission of cases and
anesthesiology is incomplete without mentioning the immense determined the cause of death by majority vote. This was followed
work of former ASA President Ellison “Jeep” Pierce and the by a report by Beecher and Todd of anesthetic death in
ASA leadership (1984) in championing the cause of patient 10 institutions, published in 1954.2 The cause of mortality was
safety. The mortality attributed to anesthesia has seen a determined at the local institution by a consensus reached between
dramatic decrease from 1:2,680 in the 1950s to 1:200,000 in a surgeon and the chief anesthetist. Overall, the chance of mortality
the 1990s. Evidence is accumulating that anesthesiologists are was 1:75 cases. They reported that anesthesia was the primary
experiencing the greatest decline in the incidence of medical cause of mortality in 1:2,680 cases, and was either the primary or
liability claims of any specialty, according to the Anesthesia contributory cause of mortality in 1:1,560 cases. Surgical error in
Patient Safety Foundation. diagnosis, judgement or technique was the primary cause of death
The art and science of anesthesiology continues to grow in 1:420 cases, while patient disease was the primary cause in
and evolve. We are continually challenged with advances in 1:95 cases. Over the past five decades, most anesthesiologists
technology, by our own drive to make anesthesia safer than believe that anesthetic risk has decreased.
ever, and to make the perioperative experience better for our The importance of perioperative mortality in England led to
patients. Anesthesiologists today are involved in diverse areas the development of the Confidential Enquiry into Perioperative
such as molecular biology, tissue engineering, novel drug delivery Deaths (CEPOD), which assessed nearly a million cases of
techniques, nanotechnology and functional imaging research. anesthesia during a one-year period in 1982.3,4 Deaths within
We are pioneers in incorporating simulators as a tool for 30 days of surgery were included in the study. There were 4,034
education and fostering safe practices. We are also in the forefront deaths in an estimated 485,850 operations, resulting in a crude
in studying and integrating complementary and alternative mortality rate of 0.7 to 0.8 percent. Surgery had contributed
medical practices into the mainstream of medicine. totally or partially in 30 percent of all patients. Progression of the
We have come a long way, but we still have a long road ahead presenting disease had contributed to death in 67.5 percent of all
in our quest to make the perioperative experience a safe and patients, with progress of an intercurrent disease being relevant in
pleasant one for our patients. We have some answers, but there 44.3 percent of patients. Anesthesia was considered the sole cause
are still a lot of questions that need to be answered by painstaking of death in only three individuals, for a rate of 1:185,000 cases, and
research. This is an exciting and challenging phase in the growth anesthesia was contributory in 410 deaths, for a rate of 7:10,000.
of this specialty and all associated with it! The accumulating data clearly demonstrate that risk directly
attributable to anesthesia has declined over time. The etiology for
References:
1. Smith HM, Bacon DR. The History of Anesthesia, Clinical Anesthesia. this reduction in mortality is unclear. Numerous factors have been
Edited by Barash PG, Cullen BF, Stoelting RK. Philadelphia, LWW; implicated in the improved outcome, including new monitoring
2006:3-26.
2. Stoelting RK. A historical review of the origin and contributions of the modalities, new anesthetic drugs and the changes in the anesthesia
Anesthesia Patient Safety Foundation. ASA Newsletter. 2005:25-27. workforce. However, it is difficult to document reduced risk
3. Wetchler BV. Ellison C. Pierce, Jr., M.D., to receive ASA’s highest honor.
ASA Newsletter. 1997;61(10):21. related to any one factor. Interestingly, although newer monitoring

5
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

modalities, particularly pulse oximetry, would be expected to

lead to improved outcomes, no randomized trial has been able to
document such a conclusion.5
Studies similar to the CEPOD study have not been performed
in the United States, most likely because of the legal system.
Therefore, information related to perioperative mortality had
to be obtained from other sources. This basic concept led to the
formation of the American Society of Anesthesiologists Closed
Claim Study. The Committee on Professional Liability of the
American Society of Anesthesiologists conducted a nationwide
survey of closed insurance claims for major anesthetic mishaps.
Both fatal and nonfatal outcomes were reviewed and a series
of landmark papers discussing both the potential etiology and
treatment of morbidity and mortality were also studied. For
example, cases involving unexpected cardiac arrest during
spinal anesthesia were observed in 14 healthy patients from the
initial 900 claims.6 Two patterns were identified: oversedation
leading to respiratory insufficiency and inappropriate resuscitation
of high spinal sympathetic blockade which led to general Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.
recommendations for perioperative care.
be applied rigidly. The American Society of Anesthesiologists
Improving Anesthesia Safety has established Standards for Intraoperative Monitoring, which
Over the past several decades there have been numerous major was developed from safety guidelines adopted at the Harvard
initiatives to improve the safety of anesthesia. In 1984, Cooper, hospital system. Guidelines are intended to be more flexible than
Kitz and Ellison hosted the first International Symposium on standards, but should be followed in most cases. Depending on the
Preventable Anesthesia Mortality and Morbidity (ISPAMM) in patient, setting, and other factors, guidelines can and should be
Boston. Approximately 50 anesthesiologists attended the meeting tailored to fit individual needs. Like standards, guidelines should
from around the world and, after much debate, established a series be cost-effective. There have been a number of guidelines adopted
of definitions of outcome, morbidity, and mortality. Such meetings by the American Society of Anesthesiologists for diverse issues
have been held every two years since the first symposium. such as the difficult airway, use of pulmonary artery catheter, and
The Anesthesia Patient Safety Foundation (APSF) was use of blood components. The goal is to define the evidence upon
established as a result of the Boston meeting. The society has been which optimal practice can be based.
active in publishing widely-circulated newsletters and awarding Finally, there is a great deal of interest in the use of anesthesia
annual grants. Similar societies have now been established in simulators to train and test individuals and their ability to react
countries outside the United States, and a National Patient Safety to simulated crises. Standardized scenarios have been developed
Foundation has also been created based on the APSF model. upon which comparisons between individuals can be made.
Starting with the American Society of Anesthesiologists Current research is ongoing to determine how best to utilize this
Closed Claims Study, there has been a great deal of interest technology in anesthesia training and potentially in recertification.
in establishing guidelines for best and safest practice. Practice
policies or guidelines are the summation by clinicians of the References:
1. Ruth HS. Anesthesia study commissions. JAMA. 1945;127:514.
available evidence about the benefits and risks of a treatment 2. Beecher HK, Todd DP. A study of deaths associated with anesthesia and
plan. Guidelines are a method of codifying recommendations surgery. Ann Surg. 1954;140:2-34.
regarding the use of a given technology. There are several types of 3. Lunn JN, Devlin HB. Lessons from the confidential enquiry into
perioperative deaths in three NHS regions. Lancet. 1987;2:1384-6.
recommendations that fall into the general category of a practice 4. Buck N, Devlin HB, Lunn JL. Report of a confidential enquiry into
parameter. A standard implies that a therapy or practice should perioperative deaths. London: The King’s Fund Publishing House; 1987.
5. Moller JT, Svennild I, Johannessen NW, Jensen PF, Espersen K, Gravenstein
be performed on patients with a particular condition. Standards JS, Cooper JB, Djernes M, Johansen SH. Perioperative monitoring
are only approved if an assessment of the probabilities and utilities with pulse oximetry and late postoperative cognitive dysfunction. Br J
Anaesth. 1993;71:340-7.
of the group indicates that the decision to choose the treatment 6. Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest
or a strategy would be virtually unanimous. If a particular therapy during spinal anesthesia: a closed claims analysis of predisposing
factors. Anesthesiology. 1988;68:5-11.
or strategy is considered standard, it is cost-effective for those
to whom it is being recommended. Standards are intended to

6
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

CHAPTER 3 result, we have been the pioneers in perioperative medicine,

Choosing a Career in Anesthesiology intensive care, pain management, resuscitation and patient safety.
What traits do anesthesiologists share? Typically these
Saundra Curry, M.D. individuals enjoy crisis management as well as watching physiology
Clinical Professor of Anesthesiology and pharmacology in action. They also like instant gratification
Director, Medical Student Education and don’t mind short-term contact with patients. Since the
Department of Anesthesiology operating rooms are the centers of activity, liking surgery and
Columbia University Medical Center surgeons are critical. Anesthesiologists also handle stress well.
What skills are required to make a great anesthesiologist? There
You’re interested in becoming an anesthesiologist. If you are are no personality profiles in literature describing the “ideal”
seriously considering this field then you probably have a number anesthesiologist. However, based on the daily work required,
of questions. What is anesthesia? What traits do anesthesiologists the best anesthesiologists are smart, willing to work hard and
share? What do anesthesiologists do after training? What kinds have “good hands.” Outsiders often see anesthesia as a specialty
of skills should I have to become a good anesthesiologist? of procedures, and certainly there are plenty of those, but
What are the challenges of the specialty? How should I plan my anesthesia is far more than that. Multitasking is a critical part of
fourth year with an eye towards residency? the specialty. There are multiple alarms and monitors that need
Anesthesia was an early, important American contribution to to be supervised regularly and simultaneously. The needs of
medicine. In 1846, surgery and medicine were primitive at best. the surgical staff and the needs of the patient must be regularly
Patients preparing for surgery were expected to drink alcohol to assessed, balanced and addressed. People who can only focus on
reduce insensitivity to pain, bite a bullet to keep from screaming one thing at a time tend to have difficulty handling the multiple
or be tied down to keep from moving. When dentist William tasks of anesthesia. The operating room is often stressful due to
Thomas Green Morton performed a public demonstration multiple personalities and the life-or-death situation of the patient.
of the use of ether to render a patient insensible to pain for an Prior to surgery, patients are oftentimes frightened, sometimes in
operation at Massachusetts General Hospital, surgeons instantly pain and fearful of the unknown physician who is asking them to
realized that they had a new, important tool with which to care trust their lives to him or her. An anesthesiologist must be able to
for their patients. Within two years surgery was being regularly communicate well to establish trust quickly and effectively with
performed under anesthesia. Anesthesiology and surgery have these patients. They also must be able to communicate well with
been inextricably intertwined ever since. As surgeons have other physicians and health care professionals in the operating
brought increasingly unwell patients to the operating rooms, rooms and hospital to best care for patients.
anesthesiologists have met the challenge with drugs, monitoring What do anesthesiologists do after training? Most end up
and the firm conviction that patient safety is paramount. As a working in private practice, administering anesthesia to patients
in operating rooms. “Operating rooms” these days include the
traditional operating room but also include endoscopy suites,
invasive cardiology and radiology suites, doctors’ offices, virtually
wherever a procedure can be performed. Others who train in our
field work in intensive care units or pain clinics. Doctors who
choose an academic career perform bench or clinical research
and participate in the training of residents and medical students.
During training and in practice, anesthesiologists interact with
physicians from all specialties and deal with patient safety issues,
critical incidents and rapidly-changing situations on a regular
basis. This is perfect training for hospital administration, and
anesthesiologists often find themselves running clinics, preoperative
areas, hospitals and becoming deans of medical schools.
What are the challenges of anesthesia? Anesthesiologists
do not tend to be independent practitioners today. Call
responsibilities preclude that so we work in groups. If you want
to be independent, this is a problem. Call can be burdensome
and tiring, offset only by the fact that patients need our services.
Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.

7
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

CHAPTER 4
Practicing in the Anesthesia Care Team (ACT)

Ronald L. Harter, M.D.

Professor of Anesthesiology and Chair
Ohio State University Medical Center

Anesthesiologists can deliver anesthesia care primarily in

two modes of practice. The first mode is Personal Performance,
in which the anesthesiologist personally administers all facets of
a patient’s perioperative care. This chapter will address the other
primary mode – the Anesthesia Care Team (ACT).
When providing perioperative anesthetic management in the
ACT mode, the anesthesiologist may interact with three different
types of providers:
• Anesthesiology residents
• Nurse anesthetists
Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved. • Anesthesiologist assistants

We are a service specialty, so we don’t admit patients to hospitals. The interaction between the anesthesiologist and the other
The patients “belong” to other practitioners, although we maintain provider in the ACT is known as Medical Direction. Medical
an important responsibility to them while in our care. direction requires performance and corresponding documentation
Anesthesiology is an extremely rewarding career path. As of participation by the directing anesthesiologist at specific points
with all careers in medicine, there are stresses to deal with, some throughout the perioperative anesthetic management of the
of which are beyond our control. But the rewards of caring for patient. Those points include:
patients and making them pain- and stress-free as they undergo 1. Preanesthetic evaluation of the patient.
operative procedures far outweigh the stresses. Medicine as a
whole is changing, and anesthesiologists are at the forefront 2. Prescription of the anesthesia plan.
of these changes. We are leading the way in patient safety, 3. Personal participation in the most demanding procedures
operating room efficiency, surgical homes and cost management. in this plan, especially those of induction and emergence, if
We are also heavily involved in the science of medicine, applicable.
researching how drugs work, the pathophysiology of diseases 4. Following the course of anesthesia administration at frequent
and outcome studies. If you want to become involved in these intervals.
exciting areas, anesthesia is the field for you.
How should you prepare for training in anesthesia? Do your 5. Remaining physically available for the immediate diagnosis and
best to excel throughout your years of medical school. Though treatment of emergencies.
AOA is not a prerequisite to getting into a good residency 6. Providing indicated postanesthesia care
program, doing well keeps your options open. Students usually (www.asahq.org/publicationsAndServices/standards/16.html).
feel they need to learn how to intubate in order to go into
anesthesia. In truth, you’ll learn how to do that during Thus, the anesthesiologist in the ACT must remain closely
residency. It’s best to concentrate on taking elective courses involved in the preoperative, intraoperative and postoperative
that interest you, such as cardiology, pulmonary, renal and management of each patient for who medical direction is provided.
critical care. Fourth year is an opportunity to take all the An anesthesiologist may medically direct up to two residents
coursesyou’ll never get to take again, and you should take at one time, according to current guidelines for anesthesiology
advantage of it. If you are still unsure about anesthesia, resident supervision from the Residency Review Committee
the time to take an elective to confirm your choice is early for Anesthesiology (RRC) (www.acgme.org). When the
in fourth year. anesthesiologist medically directs nurse anesthetists or
anesthesiologist assistants, up to four cases may be medically
directed at one time. Obviously, the number of concurrent sites

8
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

that an anesthesiologist medically directs depends upon a number When nonanesthesiologists supervise nurse anesthetists,
of factors, including the available personnel and resources, perioperative mortality rates are higher than when an
the severity of illness of the patient, and the complexity of the anesthesiologist is performing the anesthetic or is providing the
surgical procedures to be performed. supervision. In a study of nearly 200,000 Pennsylvania Medicare
A nurse anesthetist, also referred to as a Certified Registered patients from 1991–1994, there were 2.5 more deaths within
Nurse Anesthetist (CRNA), is a registered nurse who has 30 days of hospital admission per 1,000 surgical patients when no
satisfactorily completed an approved nurse anesthesia training anesthesiologist was involved with the provision of the anesthetic
program. An anesthesiologist assistant (CAA) is a physician’s care. When patients experienced complications during the
assistant who has completed an approved anesthesiologist’s perioperative period, there were an additional 6.9 deaths within
assistant training program. CAA programs, which operate in the 30 days of admission per 1,000 patients when no anesthesiologist
medical school model, have been in existence since 1969 and are was involved, compared to when an anesthesiologist was either
presently fewer in number than nurse anesthetist (NA) training performing or directing the anesthesia care.1
programs. The curriculum and prerequisites for entry into an CAA In summary, anesthesiologists frequently practice in the
program are comparable to those for NA programs, but typically Anesthesia Care Team mode. The close interaction between
require pre-med course completion.. The pathway into each the directing anesthesiologist and the anesthesiology resident or
program requires completion of a bachelor’s degree prior nonphysician anesthesia extender (CAA or NA) results in the
to admission. At present, many states do not yet extremely safe delivery of anesthesia care for patients in a variety
provide licensure for CAAs, although the number of of surgical settings.
states that formally recognize CAAs has increased in
the past few years. Those anesthesiologists who practice in Reference:
states which allow practice by both CAAs and NAs generally 1. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction
and patient outcomes. Anesthesiology. July;93(1):152-163.
note that CAAs and NAs perform similar roles within the ACT
(http://www.anesthetist.org/content/view/14/38/). CAAs are
generally permitted statutorily to practice only under the medical
direction of an anesthesiologist, whereas NAs may be supervised
not only by anesthesiologists, but also by other physicians, as well
as by nonphysician health care providers such as dentists and
CHAPTER 5
podiatrists, depending on the laws within one’s state. A Career in Academic Anesthesiology

Berend Mets, M.B., Ph.D., FRCA

Eric A. Walker Professor and Chair of Anesthesiology
Penn State Milton S. Hershey Medical Center

A career as an academic anesthesiologist is a riot. This

career affords an opportunity for continuous personal growth
while developing the specialty through educating residents,
contributing to the literature by scholarship and research, and
in this way building upon and further developing the history of
anesthesiology.
While most of the academic anesthesiologists practice in
1 of the 125 academic anesthesiology departments in the United
States and have built their career after completing residency
training, there are colleagues who return to academia later in
life while others work outside these centers and so contribute
significantly to the development of our chosen specialty.
Reprinted with permission, The Cleveland Clinic Center for Medical Art & Nevertheless, most successful academic anesthesiologists have
Photography © 2015. All Rights Reserved. chosen this career early on. The skills needed are hard won and
the expertise developed takes many years to attain. As an
academic colleague of mine states, “Private practice anesthesia
is a job, while academic anesthesia is a career.”

9
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

More usually, a resident-in-training will develop an interest Once this fellowship or clinical instructorship has been
in pursuing an academic career and then progress from there. completed and board certification has been achieved, the individual
While many decry the high salaries that are now prevalent in will be appointed as an assistant professor of anesthesiology.
private practice, I believe that this is an opportunity. Academic
salaries – while not as high – are substantial. One can have a very Promotion and Tenure
fruitful academic career (under current conditions) without fear of The promotion and tenure process may be different in many
becoming impecunious (and pay off student loans fairly rapidly). institutions. Suffice to say that most clinical anesthesiologists
are not promoted on the tenure track and that most institutions
(and departments of anesthesiology) have well-defined promotion
guidelines upon which the promotion to associate professor
and subsequently (full) professor are based. The promotion to
associate and then full professor usually takes at least six years
for each step. With this promotion, in most departments there is
an incremental increase in base salary scales, although nationally
there is a trend for narrowing the gap between base salaries of
assistant and full professors.

Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.

Career Path
After residency, the usual route is to do a fellowship in one’s
area of interest. This can be a clinical fellowship or a research
fellowship. American College of Graduate Medical Education
(ACGME)-accredited fellowships are now available in pediatric
and cardiac anesthesia as well as pain medicine and critical care. Reprinted with permission, The Cleveland Clinic Center for Medical Art &
An ACGME-approved obstetric anesthesia fellowship is likely Photography © 2015. All Rights Reserved.
in the future. Some institutions provide fellowships in regional
anesthesia and neuroanesthesia. The importance of a fellowship is Tracks
that it builds an area of clinical subspecialty expertise upon which While there are no well-defined steps on building an
you can build your career. A research fellowship is an outstanding academic career one can review the careers of previous academic
opportunity, as this allows one to really develop the necessary anesthesiologists and characterize these loosely into tracks.
expertise for a research career in the future, which includes The key is the development of unique expertise, upon which
learning to write manuscripts and apply for grants. During the scholarship and possible research can be based.
time of your fellowship, you will also prepare for the oral board Although research is not essential to an academic career,
examinations. A further benefit of a fellowship in an academic believe scholarship, the collation of (new) knowledge and wide
department is that you will continue in an academic environment dissemination of this through peer-reviewed mechanisms, is
during the period of preparation for these examinations. Instead of absolutely essential.
the fellowship, some institutions will have a 2-year clinical rotating In the past, academic anesthesiologists were expected to
instructor position, allowing you to gain expertise as a consultant be “Triple Threats,” i.e., clinicians, researchers and educators.
while preparing for the boards.

10
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

This requirement is unrealistic today; however, the successful

academician is often a “Double Threat,” both experts in a
subspecialty clinical area and in education, administration or
research.

Clinical Subspecialty
This “track” could be developed as follows: the assistant
professor, having done a fellowship in cardiac anesthesiology,
decides to develop clinical expertise in echocardiography, with
a special interest, for example, in intraoperative evaluation of
mitral valve disease. The assistant professor will start by building
his or her knowledge of echocardiography, lecture to the
residents and Fellows, and design a research project around this
subject area of interest. He or she will give a Grand Rounds
lecture in his or her institution on the subject and progress to
lecture locally and then nationally on the subject of interest.
The research project will be written first as an abstract for
presentation at a national meeting and then as a full manuscript
Reprinted with permission, The Cleveland Clinic Center for Medical Art &
of the completed research project. Additionally, a case report Photography © 2015. All Rights Reserved.
and/or a review article on the subject could be written and
published. Hence, the assistant professor evolves into an expert
on the subject, and soon will be invited to speak nationally, Research
and possibly internationally, on the subject. This “track” is often preceded by a research fellowship,
but the latter is not a prerequisite.
Education/Teaching This can take the form of clinical, education or basic science
This “track” would develop as follows: the assistant professor research. Substantial additional training is often required and it is
has decided that education is the area of his or her interest. essential to have appropriate mentorship within the department
Education is clearly not just teaching but all that goes with and/or the institution to assure that the assistant professor does not
providing an environment in which medical students and become frustrated and give up on a promising career.
residents may develop and learn. This includes developing and
implementing the structure, curriculum and evaluation of the Operating Room Management and Administration
education process. The assistant professor would start by developing With the increasing complexity of perioperative care as
expertise in education. Joining the Society for Education in well as the administrative processes within the departments
Anesthesia, www.seahq.org, would be a good start in support of anesthesiology, there is an increasing trend for academic
of this endeavor. The assistant professor would serve on medical anesthesiologists to build a career around scholarship in
student and/or resident education committees with the goal of these areas.
eventually heading a clinical competency committee, medical
student rotation or residency program in the department. Along Skills and Expertise
the way, the individual would become particularly interested in a There is a great deal that needs to be developed in an
certain area, such as resident evaluation systems, and study and academic anesthesiology career beyond the obvious need to
develop these, and so become a regional and, possibly national, be a knowledgeable and consummate clinical anesthesiologist.
expert on this subject. From this would flow scholarship which Below is a brief summary by way of illustration.
could be presented and published.
Teaching
Simulation/Education Teaching can take many forms. All require special expertise
Another track would be developing expertise in education and knowledge. By way of example, one will need to develop
through simulation in its many forms. Well-known examples are different expertise whether one is teaching in the operating room,
the full-body simulation systems, but any model used to allow a small group, conducting a problem-based learning discussion or
practice independent of patient care can be used in simulation to giving a lecture in an auditorium filled with 200 to 300 people.
achieve this.

11
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

Presentation CHAPTER 6
The development of presentation skills is crucial to an
academic career. Think only of how differently you would Anesthesia in the Armed Forces
approach preparing a poster at an academic meeting, illustrating
the presentation of an anatomy lesson for medical students, Jamison Elder, M.D., Major, USAF, MC
putting together an instructive talk on your area of expertise, or Board Certified Anesthesiologist, WHMC, LAFB, TX
presenting options for analgesia to expectant mothers planning to Wichita Falls, Texas
visit the obstetric unit. Oscar Wilde has said, when talking of a
presentation, “I would have made it shorter but I did not have Introduction
enough time.” A former chairman once said to me, “I wish I could hire
a department full of former military anesthesiologists. Their
Writing expertise, maturity, work ethic, sense of duty and ability to adapt
The skill of writing for publication will be one that requires are simply amazing, which are qualities that would solve many
support and practice to develop. A way that you can learn this of the problems that I face as a chairman in anesthesiology.”
is through a good mentor who supports you in writing, from your He asked me, “How is it that the military generates such
first case report to manuscripts and grant submissions. While this exceptional providers?” Although I acknowledged many influences
may seem trivial, the writing of a case report teaches one to be that shape these providers, our discussion highlighted several ideas
singularly focused on teasing out the key issues and writing this that uniquely describe anesthesiology in the military.
down in an instructive, readable, yet parsimonious fashion.
Military Unique Activities
Leadership and Management and Communication The fundamental distinction of military anesthesiologists
As you grow in your area of expertise, you will be asked to is in their military unique activities. A casual inspection of
become a director of a division, chair of a department of hospital military anesthesiology reveals a work environment similar to any
committee, chief of a clinical service, a residency or fellowship American civilian institution with its equipment, supplies and
program director, or perhaps even a departmental chairman. anesthetic approaches common to most anesthesiologists.
Clearly you will need to develop skills in administration and However, a closer inspection discovers the military
leadership to help create an environment that brings out the best anesthesiologist removed from comfort zones to face tasks
in your colleagues. and circumstances that demand his or her deepest reserves of
expertise, endurance and emotional resolve. Some find themselves
Conclusion in the tensions of war, the extremes of natural disasters or the
I hope that I have been able to encapsulate what a career in medical hunger of third-world countries.
academic anesthesiology may look like. As in life, there is no set Following a mass casualty experience, an anesthesiologist
path. Half the fun is the journey. If you want to make a difference stationed in the Middle East stated that “while six anesthesia
to your chosen specialty and help build its history, academic providers ran six operating rooms in three 15-feet-by-15-feet
anesthesia beckons. Will you take the challenge? tent rooms, we completed over 80 trauma cases in the first
24 hours, which included 40 percent craniotomies and some of
the most complex multi-trauma injuries I have ever seen. We
had no complaints or perioperative complications. We just had
80 excellent resuscitations and anesthetics.”
Another provider described the destruction of Hurricane
Katrina as absolute chaos. He found the city of New Orleans
submerged to its roof tops without food, power, communication or
transportation. Helicopters served as ambulances and a collection
of tents on an airport runway served as the only medical system for
the tens of thousands of patients and evacuees. While one military
anesthesiologist was performing an emergency cesarean section
by flashlight, another initiated on a chalkboard the plans for a
medical triage and evacuation system, which spanned across
multiple services, technologies and aircraft. Military
anesthesiologists can find themselves on humanitarian missions

12
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

providing relief for underserved countries across the world and Level-1 trauma emergency center for a city that once enjoyed
equipped with limited space, finances and supplies. These providers several giant and sophisticated medical centers. Their success
design, prepare, transport and deliver the entire anesthetic for followed careful planning, preparation, teamwork, expertise and
these remote areas. All providers report of their service with relentless efforts to adapt and overcome the many unimaginable
fondness and are eager to return to the deeply grateful patients obstacles.
and the adventure of rural medicine with its dramatic pathology
and the simplicity of their preparations. It is this combination of Emotional
extreme circumstances and tasks that forge new perspectives and Most providers agree that military anesthesia deployments
increase their abilities to adapt and overcome, despite a surplus of can test their character and emotions. While some find humor
crisis, chaos and critically ill patients. amid the boredom of maintaining a quiet installation of past
conflicts, some describe dodging the heat and sand of the desert.
Clinical Duties Others speak of wrestling with the noise, temperature and
The military anesthesiologist’s scope of clinical practice spans turbulence of military aircraft. Several have told of filing into the
across multiple specialties, such as intensive care medicine, local bunker as a siren alerts to possible mortar attacks.
emergency medicine, trauma medicine, internal medicine and Remarkably, many agree that their initial fears melt into
others. In addition, they negotiate extremes in climate, contribute common place when engaged in the selfless act of patient care.
to the manual labor to sustain the military compound, and create Others recall their most cherished moment while emergently
diversity within the constraints of compound life. caring for a wounded American troop as they enter the operating
They function in portable surgical suites, such as metal room still dressed in dirt, camouflage and bullet proof vests. It
containers or tents. Their routine duties are interrupted with is learning their names and of their loved ones at home, while
marked mass casualties that exceed most modern American imparting hope through a smile and an encouraging word as
Level-1 trauma centers. Patients are stabilized and transported they drift to sleep. Despite their personal peril, it is common to
across escalating levels of care, which span across continents, all hear American troops ask, “Doc, how long until I can return to
forms of transportation and various providers from all uniformed fighting? My friends are still fighting and they need me!”
services. Several of my peers have confided that deployment life is a personal
For example, the Air Force employs some anesthesiologists hardship. But, caring for wounded American troops has been one
as the intensivists for its Critical Care Air Transport Team of the most meaningful things they have ever done in their life.
(CCATT), which moves critically ill patients from remote areas,
such as the theater of war, to tertiary care centers. These missions Training
require the anesthesiologist to plan, prepare, pack and employ Providers enter military training in anesthesiology for
all the needed equipment and supplies to resuscitate and sustain many reasons, which commonly include finances, intrigue and
critically ill patients for many hours and thousands of miles in the patriotism. Despite their motives, military training programs are
dark and deafening noise on a military cargo plane. postured toward these military requirements. The stated goal of
Some military anesthesiologists are sent as part of forward the SAUSHEC anesthesiology residency program is to turn out the
surgical teams with surgeons, emergency physicians and registered very best-trained anesthesiology consultants, who can excel in the
nurses to provide emergent triage and surgery out of backpacks military environment.
in forward combat positions, natural disasters, humanitarian relief As a result, military residencies in anesthesiology attempt to
and terrorist-related scenarios. These providers plan, prepare and equip trainees for deployment anesthesiology. Their training has
deploy their care from five backpacks. an added emphasis in trauma surgery, regional anesthesia and
Similarly, natural disasters frequently involve military burn medicine. Their training is mingled with annual workshops
anesthesiologists as the initial providers during the resuscitation in difficult airway management, transesophageal echocardiography
and transportation of critically ill patients to tertiary facilities. and advanced regional anesthesia. The Navy, Army and Air Force
Hurricanes, tornados, volcanoes, forest fires, tidal waves, have ACGME-accredited residency programs across the nation.
earthquakes, explosions and riots have all required these providers Wilford Hall Medical Center (WHMC) in San Antonio, Texas,
to adapt to unpredictable injuries and unimaginable conditions has served as the flagship of Air Force medicine for decades,
with limited resources and support. which offers nearly every aspect of tertiary medical care and
Following Hurricane Katrina, Air Force anesthesiologists the bulk of its medical training programs. Brook Army Medical
assisted in the transport of hundreds of critically ill patients from Center (BAMC) in San Antonio, Texas, is the Army’s newest and
the flooded city of New Orleans to neighboring states. The Army most technically advanced hospital, which functions as a Level-1
created a tent hospital center, which served as the only hospital trauma center and the home of the Institute of Surgical Research

13
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

and Extremity Trauma (ISR), a state of the art burn care center Compared to its civilian counterpart, military anesthesiology is a
and research depot. The anesthesiologists at BAMC maintain the selfless, industrious and relentlessly demanding profession without
Research Center of Excellence for Total Intravenous Anesthesia commensurate praise, comfort or financial gain. Nonetheless, a
(TIVA) as the home of the Triservice Anesthesia Research Group military anesthesiologist finds meaningful reward in raising the
Initiative on TIVA (TARGIT) to explore its military applications. fallen soldier, in the grateful tears of his or her family, and the
The National Naval Medical Center (NNMC) and Walter Reed consolation that their expertise may have aborted the misfortune
Medical Center (WRMC) are similar institutions on the east coast, of those serving who dare to give everything.
which are associated with the nation’s primary medical research
center, the National Institutes of Health (NIH). NOTE: The content of this publication is the exclusive opinion and
Historically, military graduates have been outstanding, with interpretation of the author and not that of the Department of Defense
near perfect passing rates of the written and oral board exams. or one of its uniformed services.
Military anesthesiology alumni have contributed to respiratory
care through the advent of intermittent mandatory ventilation
(IMV) and high positive end-expiratory pressure (PEEP)
ventilation. As alumni, they have gone on to be departmental CHAPTER 7
chairmen, leaders in academic residencies, authors of anesthesia
What Makes a Competitive Anesthesiology
textbooks and numerous medical and public publications. Some
have become editors of major journals and served as a president
Candidate?
of the American Society of Anesthesiologists (ASA). Indeed,
Stacey Watt, M.D.
military anesthesiologists become inclined to serve as leaders,
Clinical Instructor of Anesthesiology
educators and innovators that have dotted the map and history
Jacobs School of Medicine and Biomedical Sciences
with their contributions.
University at Buffalo, SUNY
Summary
Mark Lema, M.D., Ph.D.
My former chairman recognized a pattern of “expertise,
SUNY Distinguished Professor and Chair
maturity, work ethic, duty and ability to adapt,” which were forged
Department of Anesthesiology
by early responsibility and heroic challenges. These providers
Jacobs School of Medicine and Biomedical Sciences
learned firsthand the critical value of teamwork, determination
University at Buffalo, SUNY
and adaptability. They succeeded at doing more with less,
traveled many extra miles and improvised when many would yield.
I believe it was these ideas that caused my chairman to suggest that Anesthesiology is a very demanding field. It requires skill,
a department full of military-trained anesthesiologists “would solve speed, knowledge, judgement and vigilance. These traits have
many of the problems that I face as a chairman in anesthesiology.” not only brought you success in medical school but are your main
In many ways, the military houses one of the last frontiers of highlights in gaining acceptance into the anesthesiology residency
anesthesiology where technology and sophistication must give of your choice. Use the tools that have brought you to this
way to simple tools and basic medical principles. Their solutions point. Highlight your strengths and brush up on some tips about
are won through innovation, determination and adaptation. Like interview skills. Use this chapter as a guide to prepare yourself for
all pioneers, these providers emerge with war stories and battle the application process. Good luck.
wounds of the soul and body. But, they emerge stronger, undeterred
and more able than before. More importantly, most report that the What are Residency Programs Looking For?
care they rendered during their military missions was the most Residency programs are not only looking for the best and the
meaningful of their career. One provider commented that he brightest, they desire an applicant who will be a “good fit” into their
thought he enjoyed delivering anesthesia, but he added with tears program. As an interviewer, I remember my first interview session
in his eyes that “helping our soldiers in their dire need was the best when I was told to look at the applicants not only as the future of
experience of my career and possibly my life.” anesthesiology but as future partners.
Some would argue that greatness is not what we become Applicants must be able to function compatibly within the
but rather what we do. A military anesthesiologist is not a life program, having similar goals and educational styles. For example,
of wealth, privilege and prestige. However, the life of a military a student who learns only from lectures and tutorials will not do
anesthesiologist will involve thousands of military members that as well in a program noted for clinical excellence and independent
volunteer to stand in harm’s way for America and its allies’ sake. study. Both the applicant and programs are searching for a
successful partnership.

14
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

• Medical School Grades

Residency programs are not looking for only passing grades
but some high passes to honors. If you come from a program
that is mainly pass and fail, your class ranking may be a way
of evaluating you against your peers. Anesthesiology programs
look for candidates who are strong students, especially in the
fields of pharmacology and physiology.
If you have incompletes or failing grades you may be
excluded early in the process. If you have a good explanation for
a blemish on your record, explain it in your personal statement,
or find a way to get this information to the anesthesiology
department to which you are applying. They may overlook a
failed grade if it is inconsistent with an outstanding record and
a good explanation furnished.

• USMLE Scores
The USMLE Step I examination is taken in the summer
of the second year and is usually basic science oriented.
Step II of this examination process is taken at any time during
your fourth year of training.
Anesthesiology programs are looking for a decisive passing
grade on Step I. If you are debating whether you should take
Step II before applying you must look at your test taking skill
and confidence that you will score well. If you had a weak
Step I score, a strong Step II performance may make you
more competitive. Conversely, a poor Step II exam may put
a strong Step I score into question. If you take the exam and
pass it solidly it will definitely enhance your desirability to your
program. Many prograsm directors believe that high USMLE
scores correlate with good to high scores on anesthesiology in-
Reprinted with permission, The Cleveland Clinic Center for Medical Art & training exams and ultimately to success in passing the written
Photography © 2015. All Rights Reserved. certification exam. Thus, high USMLE scores generally result
in an invitation to interview.

What Sets You Apart?

• Letters of Recommendation
You want to be the best, and that is a natural desire, but so Having strong letters of recommendation often will tip the
does everyone else! Being competitive in an anesthesiology odds in your favor when it comes to being granted an interview.
application requires certain basic skills as well as those elements As a candidate you should seek out letters of recommendation
that set you apart from the rest. from people who can write powerful letters of support and
• Basic Requirements who know you well. You want someone who can emphasize
Many programs have basic requirements that they use as your strengths as an applicant. Remember that when you are
a filtering device for applicants. These requirements are very applying that you are marketing yourself. When deciding who
good medical school grades (mostly high pass to honors), should write these letters, it is a good idea to have at least one
solid USMLE I scores and strong letters of recommendation. of your letters be written by an anesthesiologist. The most
Top programs will have more stringent guidelines. Residency highly ranked letters are typically those written by academic
programs will sort through applicants based on the student’s heads of their departments.
ability to meet their pre-set requirements. When asking for a letter of recommendation it is a good
If you meet these basic requirements, you can be relatively idea to provide that person with a copy of your curriculum
assured of a second look and usually an interview. Now vitae and personal statement. It is also advisable that you spend
let’s break down the basic requirements and examine each some time with your recommender honestly discussing your
component of a winning combination. strengths and weaknesses so that emphasis can be placed in
the appropriate areas.

15
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

why you want to be an anesthesiologist and what attributes

would help you in achieving that goal, as well as how you tested
your interest in anesthesiology (rotations, shadowing, etc.).
Other ways to approach this component of your application
is to tell the story of your life and how it has steered you to
anesthesia as a specialty. Draw your audience in and give them
a glowing first impression. Having said this try to avoid the
cliché statements like “I want to be an anesthesiologist because
I like physiology and pharmacology.” Virtually everyone
applying for anesthesia likes these things as well. Also, when
discussing your personal attributes avoid definitive statement
such as “I have exceptional IV and intubating skills.” Short
of an applicant who was a nurse anesthetist before going to
medical school, an overly confident statement such as this
only tells the program director how little insight you have as to
how much there is to learn. Lastly, just before you submit your
personal statement have someone you trust proofread it! Minor
grammar, spelling and word use error might not seem all that
important, but anesthesiology mandates attention to detail,
and a sloppy personal statement says all the wrong things.

• Anesthesia Electives
Having added exposure to anesthesiology shows the
interview committee your dedication and knowledge of the
field. It relays to them you know what you’re getting into
and you really want a career behind the “ether screen.”
If possible, make sure at least one rotation is at a tertiary
care center. If all your rotations are at small community
hospitals or surgery centers it may raise the question of whether
you really understand the implications of caring for critically
Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.
ill patients in the operating room.

• Work Experience
Setting Yourself Apart Some applicants have further polished their applications
You have all of the basic requirements and now you are with extra exposure to the field of anesthesia. This usually
looking at how you can get ahead of the other candidates. Start takes the form of summer internships or work-internships
with your personal statement. Other components of a competitive over the summer or during breaks. It places an exclamation
application include anesthesia electives or work experiences and point after your stated dedication to the field of anesthesiology.
research. Remember that anesthesiology is more than a technical If you have the time and opportunity, we highly recommend
skill or applied pharmacology. The anesthesiologist is the leader gaining further exposure.
of the health care team and program directors are looking for
leaders. Avoid filling your application with “fluffy” one- or two-day • Research
volunteer positions and focus on projects that have required drive, As interviewers, we give a nod of approval to those
initiative and leadership. applicants who have research experience. Having done many
projects ourselves, we know the extra time and work required
• Personal Statement to participate. We offer this with a word of caution. If you have
Programs often use this part of your application after you participated in a research project make sure that you know
are granted an interview to find out more about you before what role you played in the project and the project’s goal.
your personal meeting. Interviewers often use this essay as a We see many applicants that spent a few days in the lab and
question generator during the interview session. Remember really made no strong contribution to the study. Moreover,
that your personal statement will be the first impression your they had no idea what the goal of the study was other than
interviewer is given. Make it a good one. You want to mention reciting the title. Please do not be one of these applicants!

16
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

It will take your application down a few notches and perhaps CHAPTER 8
cost you a residency position.
We encourage you to get into the lab and participate.
Choosing a Residency
Find a mentor and be relentless that you want to do some
Stephen J. Kimatian, M.D., FAAP
type of research project and follow through. You will be
Chair, Department of Pediatric Anesthesiology
rewarded for your efforts when you get accepted into an
Vice Chair for Education, Anesthesiology Institute
anesthesiology program.
The Cleveland Clinic
Some Helpful Hints
Congratulations on deciding to join the field of anesthesiology. Having made the decision to pursue a career in anesthesia,
You made an excellent decision. Remember to get the basic the next decision to be made is where to go for residency. The
requirements aligned and then work toward adding extra elements National Resident Matching Program (NRMP) match process
to your resume that will make you an extremely competitive can be intimidating; however, a systematic approach that assesses
candidate. your goals as well as your strengths and weaknesses as a learner will
To prepare for a successful interview have a trusted professor help guide you to the correct decision.
or mentor give you a mock interview. Gain feedback on your
appearance, speech and behavior. You don’t want to appear Self-Assessment
coached, but the last thing you need on interview day is to The first fact that needs to be established is that not every
represent yourself poorly. On the day of your interview dress person learns best in the same environment, and as such there is
professionally. You want the interview committee to look at you no single “best” program. While many people ask “What is the
as a future partner. Smile and act confident. You are an excellent best program,” the question should be “What is the best program
candidate. Listed below is a checklist of items/tasks to be for ME?” This is an important distinction because it implies that
completed prior to the interview in order to look, act and talk like before you can start to examine programs, you must first examine
a successful applicant. yourself. Looking back over your education to date, where have
you had the most success? Where have you encountered difficulty?
Considerations for Presenting a Positive Image Do you function best in a small, more intimate setting or in a
large group? Are you a very self-directed person or do you function
When Interviewing
better when you have mentorship and direction? Would you
Walk the Walk rather be in an urban or a rural environment? These are but a
1. Subdued mannerisms (no wild hand motions) few of the many questions you must ask yourself before you get
2. Manners (“Yes, doctor” and “No, thank you”) started. This type of personal introspection is difficult at times,
3. Firmness of handshake (no limp fish, no weight lifter’s grips) but it is important to be honest and critical if you want to find
4. Maintain eye contact (don’t stare!) the best fit. The reality is that you have already accomplished a
5. Posture (no slouching, small of back against chair) great deal and passed a number of competitive selections to get
6. Speaking (not too loud, not too loquacious) to this point. You have developed a set of strategies for learning
7. Tone of voice (vary pitch, use pauses to keep interest) that have served you well and set you among some of the most
educated people in the country. The only thing standing between
Talk the Talk you and your future career is post-graduate training, and selecting
1. Be honest, tactful, respectful a program that matches well with your personality and learning
2. Know your personal topics well (research, anesthesia interest) strategies will be the key to future success. It is often helpful to
3. Learn about the program via website, literature, and get an outside perspective from a trusted friend or mentor when
ask follow-up questions based on that reading considering these issues, but the end result should be a personal
list of criteria to use when assessing programs.
Look the Look
1. Appropriate appearance (remove facial piercings or
Identifying Programs
unnatural hair color)
Once your self-assessment is complete, the next step is
2. Appropriate dress (look professional)
determining your list of programs to send applications. The
3. Being overdressed may be as bad as sloppily dressed
simplest way to start this process is to sort programs based on your
(could look too “slick”)
list of personal criteria. If location is important, then an initial sort
4. Remember your appearance is a nonverbal form
by geographic location would be important. If the potential for
of communication
research or a future academic career is important, you may want

17
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

to sort by institutional reputation. Most residency programs have 2. Have a faculty member, advisor or mentor review your CV and
excellent websites that will help you identify important aspects of personal statement for content before you submit. I advise my
the program. Keep in mind, however, that these are their websites medical students to have a personal statement that gives me
and are meant to paint the program in a positive light. Statistics insight into who they are (and not why they like anesthesia).
from NRMP are helpful in determining the number of programs In addition, I advise people only to list research and activities
to visit and are available from their website (http://www.nrmp. where they have made a substantial contribution. Go for
org/) in the section on data and reports. NRMP data from 2007 quality, not quantity.
suggests that senior United States medical students interested in
anesthesiology who ranked eight programs or more had a very high 3. Have a trusted family member or friend review your CV and
rate of matching in anesthesiology compared to those who ranked personal statement for grammar and spelling. Anesthesia is
a lesser number of programs. If we assume that not every program all about attention to detail and your application is the first
we visit is one we would rank, then you probably need to interview impression we have of you.
at more programs than you intend to rank. Depending on your
academic statistics and USMLE scores you may have to anticipate The Interview
sending out even more applications to ensure an adequate Once you submit the paperwork the real fun begins.
number of interviews. Once you have a “wish list” of programs, Remember that the interview process is as much for you to
it is important to sit down with a faculty member or mentor from evaluate the program as it is for the program to see you.
your home institution who can help you sort them out. As of Preparation for your interview starts before you arrive. Start by
2007, there were 131 anesthesiology programs accredited by the going to the ACGME website (http://www.acgme org/acWebsite/
ACGME, so it is likely that the faculty at your institution have home/home.asp), click on “Review Committees > Anesthesiology,”
firsthand knowledge of a large portion of these programs. and download and review the Common Program Requirements.
These requirements are the minimum standard that a program
must meet to maintain accreditation. While there are a few
specific requirements, such as the requirement for
“Forty anesthetics for vaginal delivery” (Section IV Patient care
A 5 a (1) (a)), there are others that are vague, and it is in these
vague requirements that you can find a measure of a program’s
commitment to education. Take for example the requirement
2 D (1), “There must be adequate space and equipment for the
educational program …” How is space allocated for education?
Are there sufficient areas to study? Are there resources for
education readily available (i.e., library, journals, texts, computers)?

Accreditation
Periodically, programs are reviewed by the ACGME Resident
Review Committee (RRC) for Anesthesiology and reaccredited
Reprinted with permission, The Cleveland Clinic Center for Medical Art & based on the criteria set forth in the program requirements.
Photography © 2015. All Rights Reserved.
At the time this article was written, program accreditation can
be from 1 to 5 years, with most programs receiving 4- or 5-year
The Application cycles. In addition to an accreditation cycle, programs often
The application through the NRMP match process is fairly receive citations that describe areas where the RRC felt the
standard and straightforward, but based on my experience as a program was deficient. The citations are accompanied by a
program director, I will offer you the following advice about the recommendation that these issues receive special emphasis prior
application process: to the next accreditation cycle. One indication of how a program
has progressed and what they have done to improve education
1. Make sure your application is as complete as possible on the
is to ask what their accreditation cycle is and how they have
day the ERAS application process opens (typically on or
addressed any citations they have received.
around Sept. 1). As anesthesia has become more competitive,
programs have been offering interviews earlier and earlier
and the best application in the world will not get interviews if
it is not available relatively early.

18
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

Did you see these values in their residents, their faculty, their
leadership, their curriculum? Did you get the impression that
the residents you met would be colleagues you could rely on, or
new best friends? Was the program open to critique, willing to
make change and responsive to its residents? Was the executive
leadership accessible to the residents and open for discussion? Is
the department willing and able to make the same commitment to
you that you are prepared to make to them? If the answer to these
questions is “yes” then you may have just found your new home.

Good luck!

Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.

CHAPTER 9
Outside of the O.R.
Beyond the obvious areas of clinic teaching there are several Categorical Versus Advanced Programs
areas where a program can show its commitment to education. Can
faculty be promoted in an education or clinical educator track? John E. Tetzlaff, M.D.
Are there funds available (endowments, grants, scholarships) Professor of Anesthesiology
for resident research and presentation at meetings? Are the Cleveland Clinic Lerner College of Medicine of
residents engaged in political advocacy (state and ASA resident Case Western Reserve University
components)? Do residents sit on departmental or institutional Anesthesiology Institute
committees? Have they developed any novel or unique rotations Cleveland Clinic
for residents outside of the O.R.?
The educational pathway for anesthesiology residency is
Personal Fit 48 months and can be accomplished by two distinct approaches.
Perhaps most importantly is the question of personal fit. One option is to match into a program that offers 48 months
When all is said and done, any accredited residency program at one site (categorical). The other option is to match at the
should be able to help you become a competent anesthesiologist, PGY-2 level (advanced) and choose a PGY-1 year at another site.
but not every program will be a fit for your personality. In his Each of these choices has advantages and disadvantages that
book, “The Five Dysfunctions of a Team,” Patrick Lencioni should be considered by each student as an individual.
discusses the fundamental aspects of cohesive team function. Many students choose the categorical option for practical
The foundation is Trust; trust that the team shares the same reasons. Being at one institution for the entire residency means
goals and objectives. In this case, these goals and objectives only having to move once. It also means that at the start of
should focus around concepts of excellence in patient care and clinical anesthesia (PGY-2), the resident has the familiarity
excellence in education. Lack of trust results in Fear of Conflict with the hospital that originates from being an intern (PGY-1)
and the inability of the team to openly discuss issues of concern. in that hospital. Other students choose an advanced program
Without effective and open communication there is a Lack of for equally practical reasons. Some students want one more
Commitment. If your concerns have not been heard, why would year in the same city as the medical school for personal reasons
you be expected to commit to the plan? Without commitment (e.g., family, significant other). Other students have formed
there can be no Accountability, and as a result no one takes satisfying professional relationships with faculty who also
responsibility for the education process. Without accountability participate in PGY-1 programs, and they prefer to continue
there can be no Results. In this case the results are safe and these relationships during the legendary “intern” year. Some
effective patient care and your education. Trust, Communication, osteopathic students choose a traditional rotating osteopathic
Commitment, Accountability, and Results. As you consider internship to facilitate working in the small number of states
each program, ask yourself how the program lives up to these that require D.O. physicians to complete an internship approved
values as they relate to your future as an anesthesiologist. by the Osteopathic Society.

19
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

For the programs that aggressively market anesthesiology-

controlled CBY positions, the motives are related to recruitment
and faculty perceptions. Having a CBY is a plus to a candidate who
wants a 4-year experience. The faculty at these sites are pleased
with the familiarity with hospital function that the CBY brings
to the CA-1 year in the beginning when orientation to clinical
anesthesia starts.
For those programs that offer both options and offer an
anesthesiology-controlled CBY, there may be a shift toward the
4-year option. Those who have followed this path are often its
strongest advocates. The reasons cited included becoming a part
of the anesthesiology family from the start, rotations in pain,
critical care and perioperative medicine, as well as the academic/
social advantage of having the opportunity to participate
Reprinted with permission, The Cleveland Clinic Center for Medical Art & in anesthesiology teaching activities. Since current resident
Photography © 2015. All Rights Reserved.
satisfaction is a well-known feature for recruitment of future
residents,3 this is an important element.
Many students are completely undecided and want So what should you do if you are a senior in the match
information to help in the choice. In the 2006 NRMP match, process interested in anesthesiology? Since either option
1,040 traditional seniors matched with anesthesiology programs (advanced or categorical) will prepare you well for a career in
(of a total of 1,311 who matched into anesthesiology), and 451 anesthesiology, you should interview at sites that offer both
were categorical and 589 were advanced positions.1 Overall, options and consider this element of anesthesiology residency
there is no evidence that there is a difference in outcome along with the dozens of other issues presented by the match.
between the categorical and the advanced path (completion Solicit opinions on this issue from as many different residents,
rate, training scores, board pass rate). This may be a chance faculty and program directors as you can and decide what is
phenomenon or related to the high degree of variability between best for you.
categorical PGY-1 years, ranging from preliminary positions in
medicine, surgery or pediatrics, transitional years, or the growing References:
minority of programs that sponsor an anesthesiology-controlled 1. Grogono AW. National Residency Matching Program results for 2006:
recruitment shifts to the PG-1 Year. ASA Newsletter. 2006;70(5):23-7.
Clinical Base Year (CBY). 2. www.acgme.org
There is evidence for the movement toward the 48-month 3. Wass CT, Long TR, Randle DW, Rose SH, Faust RJ, Decher PA. Recruitment
of House Staff into Anesthesiology: a reevaluation of factors responsible
curriculum. In 1996, there were 234 PGY-1 positions which for house staff selection anesthesiology as a career and individual
expanded to 552 available in 2006. Although they backed training program. J Clin Anesth. 2003;15(4):289-94.
away from a mandatory, integrated 48-month curriculum, the
RRC for anesthesiology published new rules2 this year requiring
greatly increased control of the CBY curriculum, allowing
some of the curricular elements to occur during the CBY. The
wisdom of an anesthesiology-controlled CBY has been debated
extensively within the ASA reference committee system, at the
SAAC/AAPD meeting (several), and informally throughout the
specialty. The argument against anesthesiology control of the
CBY is resource- and logistically-based. At sites where there is
no current CBY, there are issues about funding new positions and
a reluctance to give up PGY-2-4 slots to create PGY-1 positions,
undoubtedly related to the ability of anesthesiology chairs/
program directors to demonstrate value-added benefits to the
hospital by creating these positions. With the 80-hour rule, there
has been a redistribution of work and some sites have been able to
fill teaching services with new CBY residents.

20
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

CHAPTER 10 or emergency medicine, pediatrics, surgery or any of the surgical

specialties, obstetrics and gynecology, neurology, family practice,
Transitional/Preliminary Year critical care medicine, or any combination of these as approved
for the individual resident by the director of his or her training
Gerard Costello, M.D.
program in anesthesiology. The CBY must include at least
Program Director, Transitional Year Residency
10 months of clinical rotations during which the resident has
Ball Memorial Hospital
responsibility for the diagnosis and treatment of patients with a
variety of medical and surgical problems, of which at most 1 month
The following is based on information provided in the Graduate may involve the administration of anesthesia. At most, 2 months
Medical Education Directory 2005–2006 published by the American of the CBY may involve training in specialties or subspecialties
Medical Association. that do not meet the aforementioned criteria.”
The Program Requirements for Graduate Medical Education
The ultimate goal of a graduating medical student entering in Anesthesiology as put forth by the ACGME describes the CBY
a program in graduate medical education in anesthesiology is as follows: one year of the total training must be the CBY, which
(or should ultimately be) board certification by the American should provide the resident with 12 months of broad education
Board of Anesthesiology. A review of documents by the American in medical disciplines relevant to the practice of anesthesiology.
Board of Anesthesiology includes the following statement from its It repeats the board requirement that the CBY must include at
Booklet of Information: “It is crucial that the resident know least 10 months of clinical rotations of which at most one month
the requirements described in this document, since the resident may involve training in anesthesiology.
ultimately bears responsibility for compliance with the require- From a practical standpoint, the graduate medical student
ments and bears the consequences if one or more aspects of is given two choices: 1) To enter into a CBY affiliated with an
training prove unacceptable.” Further in the document it anesthesiology residency program, or 2) To enter an independent
describes an entrance requirement into the certification process CBY program.
being “fulfilling all the requirements of the continuum of In the 2006 NRMP match, 77 anesthesiology programs
education in anesthesiology.” The continuum of education offered 552 CBY spots affiliated with their programs. Of these
in anesthesiology consists of a clinical base year (CBY). It is spots, 539, or 97.6 percent, were filled in the match. There
described as follows: “During the CBY, the physician must be were 759 spots available at the PGY-2 level in the match in
enrolled and training as a resident in a transitional year or anesthesiology residencies.
primary specialty training program in the United States or its The second option is to match in an independent first year
territories, that is accredited by the ACGME or approved by the program. If a student chooses this option they have two choices.
American Osteopathic Association, or outside the United States The first is to enter a transitional year residency program.
and its territories in institutions affiliated with medical schools The other is to complete one year of a residency in another
approved by the Liaison Committee on Medical Education. acceptable specialty. Most commonly these are referred to as
Acceptable clinical base experiences include training in internal preliminary medicine, preliminary surgery, or one year of a family
practice, obstetrics and gynecology, or pediatrics residency.
Of these two choices, the Transitional Year Residency is the
only independently accredited program by the ACGME. The
purpose of the Transitional Year is to provide a well-balanced
program of graduate medical education to a number of medical
students. Most commonly these students have chosen a
career specialty that requires one year of fundamental clinical
skill education and which may also contain certain specific
experiences or the development of desired skills. Students
entering Transitional Year programs have most commonly
chosen a career specialty in anesthesiology, radiology,
ophthalmology, physical medicine and rehabilitation, or are
planning to serve in active duty in the military as a general medical
officer or flight surgeon.

Reprinted with permission, The Cleveland Clinic Center for Medical Art &
Photography © 2015. All Rights Reserved.

21
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

The content of the Transitional Year program is specifically 90 percent filling. As you can clearly see there are a variety of
stipulated by the ACGME in the program requirements for available choices.
the Transitional Year. During the 12 months of the program, at Numerous sources are available on the web to assist the student
least 24 weeks of the curriculum must be in disciplines that offer in making his/her choice. An incomplete but useful list follows:
fundamental clinical skills, that is, emergency medicine, family 1. http://www.ahme.org/councils/ctypd.html
practice, internal medicine, obstetrics and gynecology, pediatrics
or surgery. Fundamental clinical skills are further defined as 2. Search Google for “preliminary medicine” and
developing competencies in obtaining a complete medical history, “preliminary surgery”
performing a complete physical examination, the ability to define 3. http://www.ama-assn.org/ama/pub/category/2997.html
a patient’s problems, the ability to develop a rational plan for 4. www.scutwork.com
diagnosis, and the implementation of therapy based on the etiology,
pathogenesis and clinical manifestations of various diseases.
In addition, Transitional Year programs are required to
provide no fewer than eight weeks of electives. Transitional Year
programs must also have at least a 4-week rotation in emergency
medicine and a 4-week experience in ambulatory care.
As stated previously, Transitional Year residency programs
CHAPTER 11
are independently accredited by the ACGME. This is of some ERAS: The Application Process
importance to the resident in that any program so accredited
will have to meet minimum standards in order to maintain Rita M. Patel, M.D.
accreditation. Professor and Vice Chair for Education
The other option, completion of one year of a residency in University of Pittsburgh Medical Center
another acceptable specialty residency, is not independently
accredited by an external organization, and consequently provides The Electronic Residency Application Service (ERAS),
a more variable experience. The quality of these experiences provided by the American Association of American Medical
can be and in many cases is exceptional. The quality, however, Colleges (AAMC), allows applicants, Deans’ offices, and other
is more dependent on the underlying quality of the parent program credentialing organizations to submit materials electronically to
and the integrity of the institution where the parent program is residency programs and program directors. It allows for electronic
located. For example, there is no defined curriculum for one transmission of medical school records, letters of reference
year of an internal medicine program. While this could include a and other credentials, such as USMLE/COMLEX scores, for
variety of experiences, even including electives in such rotations application to fellowship, osteopathic internship and residency
as surgery and pediatrics, it is equally possible that it could include programs. Anesthesiology residency programs began using ERAS
only ward medicine and intensive care unit opportunities. in 2001. Use of ERAS is not mandatory and is independent of
The decision to enter a particular CBY program is frequently the National Residency Matching Program (“match”) process.
predicated on a number of issues. Geography is frequently However, it is the preferred method of application by most programs.
important, as residents wish to minimize their potential number Few programs in the country still accept “paper” applications.
of moving experiences, or wish to remain close to a significant Prior to using the ERAS system, students can research
other, spouse, or family. Frequently, residents will also choose programs and contact them for information regarding
to match a first-year program close to their ultimate categorical requirements and processes. It is important to note that ERAS
program choice. For those residents who are not confined by these does not set program application deadlines. These are set by the
constraints, there a number of good choices available. In the 2006 individual residency programs.
NRMP match the following positions were available. The 2006 Fees for applications are based on the number of programs
NRMP match offered designated positions in transitional year, selected per specialty. The fee schedule can be found on the
preliminary surgery, and preliminary medicine. It is unknown ERAS website. The system can automatically calculate fees.
how many students opted for a single year in other programs. Payments may be made online.
Ninety-four Transitional Year programs offered 759 positions,
with 748 or 98.6 percent filling. Two hundred seventy-nine
preliminary surgery programs offered 1,234 positions with 748
or 60.6 percent filling. Two hundred eighty-five preliminary
medicine programs offered 1,943 positions with 1,749 or

22
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

There are four components of ERAS: The ERAS Post Office closes on May 31 every year to
• The MyERAS Website – This is where the candidate completes prepare for the next application season. Records are NOT
the application and personal statement, selects programs and maintained from year to year, i.e., all servers are purged of all
assigns documents to be received by those programs. applications and supporting documents.
Applicants work mainly with the MyERAS website, which
• The Dean’s Office Workstation (DWS) – This is where the has the following areas:
Designated Dean’s office uses software to create ERAS tokens
that candidates use to access MyERAS; also to add supporting 1. Account – Gateway to the entire application service;
documents to the application, e.g., transcripts, photos, candidates can review checklist for progress on application;
Dean’s letters and letters of recommendation. update profile with new contact information; check
messages from programs.
• Program Director’s Workstation (PDWS) – This software is used
by program staff to receive, evaluate and rank applications. 2. Application – Contains the majority of information about
the candidate; includes educational and work experience,
• The ERAS PostOffice – This is a central bank of computers honors, published papers, etc.; can be completed in multiple
that transfer applications. The candidate can track his or sessions, but once certified and submitted, cannot be altered.
her file on the ERAS PostOffice through the Applicant Data Twelve pages.
Tracking System (ADTS).
3. Documents – Candidates create their personal statement;
The first action is to contact the Dean’s office. Each office identify individuals for letters of recommendation; release
follows its own procedure for applications, including the COMLEX or USMLE transcripts.
schedule for distributing materials, downloading applicant files, 4. Programs – Search for and select programs to receive
scanning transcripts, attaching documents, processing letters application materials; assign USLME/COMLEX transcript,
of recommendation and sending files to programs. RESPECT personal statement and letters of recommendation to
DEADLINES. Do not assume they can transmit files at individual programs.
the last minute.
The usual process for applications through ERAS is listed The ERAS website (http://www.aamc.org/students/eras/
below (approximate dates/exact information can be found on the start. htm) contains detailed information as does the Dean’s office.
ERAS website): Good luck!

Date ERAS Candidate/Applicant

Late June Applicant manuals available for download on ERAS website Obtain MyERAS tokens from Dean’s office

July 1 MyERAS website opens Begin working on applications

Osteopathic internship programs contact

July 15 Apply to osteopathic internship programs
ERAS PostOffice to download applications

ACGME programs contact ERAS PostOffice to download

September 1 Apply to ACGME-accredited programs
applications

November 1 Dean’s letters are released

December Military match Military match

January Urology match Urology match

Late January Osteopathic match Osteopathic match

March NRMP match results NRMP match

May 31 ERAS closes until next year

23
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

CHAPTER 12 Preparation
Preparation for your interview starts as early as preparing
Interviewing for Anesthesiology Program your personal statement, as it is a key feature of the application
and serves as an introduction to you. It should be an interesting
Peter S.A. Glass, M.B., Ch.B., FFA (SA)
piece of reading with personal stories and should address why
Emeritus Chair
you are a good match for that particular residency. Don’t focus
Department of Anesthesiology
the entire essay on why you want to become an anesthesiologist,
State University of New York at Stony Brook
but rather what qualities and qualifications you possess that will
make you a good one. You may want to look back at evaluations
Jaya Bahl
from previous rotations and try to pick out three to four consistent
Medical Student
qualities that you can put in the essay as positive character traits.
Stony Brook Medical School
Also, make sure to include any research experience in the essay.
Be prepared to answer questions about your personal statement
General Info and the information within it. Be prepared to discuss hobbies and
The goal of the interview is for you to find the program that fits extracurricular interests as well. You may want to review your
you best and for the programs to find the best candidates for them. personal statement and CV the night before an interview to have
It is thus a two-way street. It is important for you to show who what you wrote fresh in your thoughts.
you truly are during the interview process. You must be your own Another important preparatory step is to do extensive
advocate, as no one will do that for you. research on each program before you interview. The program’s
website is a good starting point. Look to see if the faculty are of
Scheduling national or international recognition, and look at the educational
Most programs begin to send out invitations in October programs offered.
while others wait until your school sends out its Dean’s letters on Prepare a set of questions before the interview. This will
November 1. Your contact information should be easily available allow you to make comparisons between and within programs.
and accurate. Be sure to check your email after sending out the Do not put off asking these questions even if you feel they were
ERAS application as programs may invite you for an interview answered in the initial introductory talk at the department.
right away. Also, do not be afraid to ask the same questions of several people
You should submit your application by early October and in the program to get a true reflection of what the program
reference letters by the middle of October, but no later than after offers. Be prepared to answer questions about yourself as well as
the Dean’s letter is received. The interview season generally questions about the field.
begins in November and ends in early February. Departments Arrive on time. Dress professionally and, more importantly,
may interview four to 20 candidates at a time, any day of the behave professionally. Remember to be courteous. If the program
week (except around the holidays), and perhaps one Saturday has provided accommodations or dinner, thank the program
per month. Sometimes arrangements outside of these guidelines director and chairperson as soon as you walk in and greet them.
can also be made under certain circumstances.
Don’t visit your most desirable program first or even second, The Interview Day
as there is a learning curve to the interview process. Try, however, A sample day may resemble the following: Interview session
to make it somewhere between the second and fifth interview. begins at 9 a.m. A faculty member interviews candidates for
This way you will be able to compare it against other programs approximately 30 minutes. There are usually three to four
you visit later. It is hard to maintain enthusiasm through a long interviews. Group interviews are also common. A catered
interview season. Avoid scheduling more than one interview per lunch for the candidates, faculty and current residents is often
day or on a day when you will be post-call. provided, followed by a tour of the institution conducted by the
How many interviews are enough? Clearly, this depends on current chief resident or an available senior resident. Pay attention
many factors. For anesthesiology, we suggest most applicants will during the tour so that you can ask pertinent questions later.
not need to go to more than 10 interviews. The specialty has On the interview trail, talk to other students and ask them what
gone through several cycles. However, the current popularity of they think about the programs where you are interviewing.
anesthesiology seems to be on the rise, so increasing numbers of Allow the interviewer to make an opening statement.
interviews may be prudent in coming years. During the interview, take notes. This creates a good impression
and allows you to recall facts later when you fill out your final

24
 ASA GUIDE TO ANESTHESIOLOGY FOR MEDICAL STUDENTS

match list. It is critical that you make eye contact. Smile, be department’s policies, or save them for a more informal setting,
cheerful, and don’t let the conversation drag. That’s also why it such as during lunch with residents. Questions you do not want to
is good to have prepared questions. Expect the first few minutes ask include: How many hours can I moonlight, questions regarding
to be “chitter-chatter,” but if this continues for too long, feel free rank order (it is also forbidden for the program to ask you about
to break that. Know what the chair and the program director rank order), or questions that may appear to be condescending.
do clinically. For example, if the program director is the head of If you want to ask about information stated in the program
OB-GYN anesthesia, make note of this so that you can make brochure/catalogue or detailed during the interview day
a better connection with him or her. Being familiar with the information session you can state it as such, “I know it is in here
chairperson’s, programs director’s, and interviewer’s major or that it was mentioned earlier, but what is your opinion on x, y
publications and research interests also scores points for you. and z?” As mentioned above, such questions are encouraged, as
This information is usually accessible on the department website they will demonstrate consistency of the response.
or by doing a simple search on the Internet. Asking a question If you have the chance to speak candidly to residents only,
specific to your interviewer shows that you are willing to put in ask questions you really want to know. How is the learning
a little extra work and generally gives the message that you are environment? Do you see enough cases of this or that? How do
really interested in the program. This also helps you to stand out the residents do on the in-training exam and on the American
in the interviewer’s mind when the candidates are discussed. They Board of Anesthesiologists’ certification exam? Do you feel the
will likely become your advocate to have you ranked as highly as chairperson really cares about you as a resident? Is there mentorship
possible on the departmental match list. When the conversation is and support for your ideas? Could I stay on as faculty? Do the
appropriate, feel free to slip in some of your major accomplishments. residents really get along this well all the time? Questions about
Make sure you do not dominate the interview with questions; call schedule, vacation time and financial compensation should
they also want to ask you questions. The balance should be 50/50. be asked casually. Probe to see how happy the residents are.
The interview is the most heavily weighted portion of the Is the department aware of how the residents feel? If the
application. The interviewer will judge whether or not you are department is aware of an issue that the residents are having and is
compatible with the program. They will be assessing whether up front about it, this would be optimal as it shows the faculty are
you are a hard worker, committed to the field, professional, in-touch with their residents.
compassionate and whether you get along well with other people. When you meet the residents, ask yourself if these are people
You may be asked strange questions! This is to assess whether you you would feel comfortable with as friends.
can think on your feet and deal with awkward situations. This is
very important in anesthesiology as the operating room is a very Finishing the Interview
fluid and challenging environment and things may rapidly become At the end of the interview day, it may be helpful to ask
“life or death.” A good anesthesiologist will remain calm and know yourself what you thought about the overall organization of the
how to think on his or her feet. Thus do not be put off by such day. This may be a good indication of how well organized and
questions. Often the answer is not critical, but showing you are receptive the department and program are to their residents,
able to think and formulate an answer is essential. medical students, etc.
Before you leave, make sure you have the names of people
Questions to Ask you have spoken to, particularly those who interviewed you, the
Important questions to ask include those that gain program director, coordinator, and one or two of the residents.
information regarding the department’s educational philosophy Get addresses and telephone numbers when possible, in case you
and objectives, didactic programs, clinical exposure, and research want to follow up with a letter or a telephone call. The easiest way
opportunities for residents. of doing this is by asking people for their business cards. It is always
Where have previous graduates gone? Are they enjoying the polite to send a thank you letter within a week. In late January,
kinds of careers (or continuing their education) in a way that send an email to the program director asking them a question or
you hope to enjoy yours? How do residents perform on the board two. This demonstrates interest and reminds them of who you are.
examinations? What are the weaknesses of the program? What Written notes will be of immense help three months from
are the strengths? What changes are you expecting to see in the now when you compile your rank order list. When you get home,
field? What changes are you expecting to see in your department in review your notes. Make more notes. Keep a running rank order
general, as well as in response to these changes? If you want answers list as you interview in various places. If additional questions come
to questions such as how many hours a day/week/month will I have up, call back a faculty member or resident. This will give you
to work, how many sick days can I take, etc., ask for a copy of the additional information and serve to communicate your interest.

25