VOLUME 29, Issue 1

Throughout our training we learn about the ways anesthesiology and cardiothoracic anesthesiology specifically have changed over time. As capitated payment becomes more widespread, my class of fellows already will have pay equivalency with non-fellowship trained graduates in many markets. As my colleagues and I start families, increased job competition in desirable areas can make paying off loans and securing a mortgage more difficult. Increasing administrative oversight over physician practice presents an ever-changing list of metrics and documentation standards that we must abide by, even while some doubt the merits of those metrics. Meanwhile, the distribution and nature of cases requiring a cardiothoracic anesthetist are both changing. Cases are being centralized to centers of excellence, while the overall volume of some cardiac surgery procedures declines. While the number of cardiac anesthesia jobs may or may not change, certainly many of these jobs have a declining percentage of time spent performing pump cases. It is not uncommon for a fellow to come across a cardiac anesthesia position that involves less than ten percent of time in the cardiac operating room. In some groups, partners earn an increasing percentage of billable hours rendering services in the catheterization and electrophysiology labs, a significant change for many providers accustomed to coronary artery bypass and valve replacement cases.

Many graduating fellows see these changes as opportunities for a more diverse and fulfilling career with meaningful leadership roles. A broader case mix is a draw for trainees such as myself who want the intellectual diversity of cases seen in outpatient pediatric, obstetric, and regional anesthesia. Practice improvement poses exciting opportunities to be woven into the fabric of the hospitals in which we work and actually shape the metrics on which we are judged. For example, at UCSF the anesthesia residents choose their own quality metric each year, design a project to study and measure the effect of its implementation, and receive a bonus if the incentive is met.

Equally important, there are unique qualities to cardiac anesthesiology training that, independent of case mix and compensation, make it a tremendous career for the right person. Our fellowship year endows us with knowledge to employ advanced monitoring to regulate cardiovascular physiology, including using real-time imaging technologies for diagnosis and management. We possess expertise in mitigating end-organ effects of critical illness and are used to solving problems in multidisciplinary teams under high stress. Every day, we counsel patients and comfort families facing life-altering surgery. We have the opportunity to leverage our knowledge and experience to prepare the next generation of anesthesiologists. I chose a cardiothoracic anesthesia fellowship because these were the areas of anesthesiology in which I wanted to be an expert, inspired by the excellence of my mentors in residency. No matter the type of case or quantity of pay, the satisfaction in using these skills to help my patients has been immense and worth the long hours, stress, and sacrifice.

In cardiac anesthesiology, there will always be change and uncertainty along with the appropriate anxiety about what that means for the future of our specialty and our own careers. Continually developing competence will enable us to become better consultants for our patients and the organizations that serve them and will position us to lead no matter what may come. It will remain a privilege to work in the operating room with such profound responsibility over the life of another and more than worthy of a life’s work.