Disclaimer: These are my opinions/thoughts. There may be typos, as my writing style involves a train of thought.
In medical school, when I envisioned my career as an anesthesiologist, I was working in a community hospital. This was what I was exposed to in medical school. But when I applied to residency, I vowed to go to the institution where I thought I’d get the best training possible. Turns out that was at an academic institution.
At some point, I got an itch to be an ICU physician. It felt easier to stay where I trained (I was also waiting for my ex to finish his training). I do not regret staying in academic medicine. But I am at a stage in my career where I am wondering if I need a change of scenery.
When I posted a reel about whether I should leave clinical medicine, I got an outpouring of responses suggesting a change in my practice environment. Many of my colleagues noted that their own experience of changing environments reinvigorated their love of clinical practice.
My mind was blown at this prospect (perhaps I’ve been naive? or brainwashed by academia?) Now I’m trying to tease out: is the clinical work that is draining my essence, or is it the practice environment (academia)?
Let’s talk about the exhausting parts of academic anesthesia practice
Promotion pressure
Luckily my job does not require university promotion metrics to be met. It’s a big part of why I stayed on. I don’t have to do research just for the sake of publishing a paper. I find it fulfilling to mentor trainees, so I take on projects where I can design small clinically relevant projects to help them present at conferences and publish papers. Any project I start or join must be clinically relevant, otherwise, it doesn’t feel worth my time or energy.
Although I don’t have a “publish or perish” mindset, I am surrounded by extraordinarily smart and prolific researchers. My goal has always been to be the best anesthesiologist and ICU doctor I could be for my patients. But sometimes being surrounded by researchers makes me feel inadequate? Like maybe I should be applying for grants. Like maybe I should be conducting research?
It’s kind of funny though… I say I don’t do research, but I’m in the midst of applying for a grant and am part of a couple. I also have research meetings with a small group. Apparently I have imposter syndrome when it comes to research.
This all being said, while there isn’t a job requirement for me to publish, there is still some peer pressure that exists.
Extraordinarily complex and sick patients
When I’m on the pre-op service or the operating room or the ICU, I am often asking myself, where are all the healthy patients?
They’re out getting surgery/care in the community!
Many days in the operating room, I am spending a lot of time the night before learning about my complex patients to try to provide the optimal anesthetic. There was one time I was on the pre-op service, and I remember thinking, “Wow, this will be a tough patient for the anesthesia team.” Joke’s on me. I was the anesthesiologist assigned a couple weeks later. That case still haunts me to this day. Even after the trauma of the case, I was still coordinating this patient’s care the subsequent day when they went for another surgery.
The only time I consistently have relatively straightforward cases is when I am on our new anesthesia resident orientation period and I get to pick my cases. It’s a magical time and a reminder that there are straightforward patients/cases out in the world.
Now let’s consider the ICU. I often like to pick up shifts at the community ICU so I have a reference for comparison. When I’m out in the community, I get to look at a complex patient and say, “This patient needs higher-level care at an academic medical center.” While I’ve also experienced cases in the community where limited resources may have altered the course of a patient’s trajectory, they are far and few between. We’re really good at sending patients to the right place if they could benefit from it.
When I’m working in the academic medical center ICUs, the patients I am caring for are the ones that were “too sick” or “too complex” for care out in the community. We get patients transferred in from all around New England. We have all the resources in the world in care for patients. And it is a privilege to be able to work in a place with these resources.
But it is also a burden to carry the weight of patient care. When I work an overnight shift or I work a week of days, I do my homework the day before to learn about all of my patients. I literally spend hours reviewing and pre-writing my notes for my patients. In contrast, I never feel the need to learn the patients when I go to the community ICU, because most of the patients are “straightforward.”
And when I go home from an academic ICU shift, I take my patients’ clinical scenarios home with me to stew upon. Often I open the electronic medical record at home for the patients I’m most concerned about. I have a 70+ hour workweek ahead of me, but when you count the mental energy I am spending on my patients outside of work, it’s many more hours than just 70.
Efficiency is rewarded with more work
This applies to the operating room. In many anesthesia practices, when you hustle to get patients in the room efficiently (and most importantly, safely), you get to go home early. In an academic setting, you get rewarded with another case! Many community practices wrap up operating rooms by 3-4pm. I consider myself lucky if I am leaving the hospital by 5pm. While it doesn’t seem like much. to leave 1-2 hours earlier every day… let’s do the math across a week": 1-2 hours x 4 days = 4-8 hours of time weekly. Or 16-32 hours of time monthly. That’s like a lot of extra days’ worth of time.
Compensation gap
Historically, academic practices have offered lower pay than community or private practices. This being said, there are often reasons why this is the way it is. My full-time week is 4 clinical days, while most community/private practices are 5 days a week. But if you compare the type of work being done at each practice, it isn’t the same. As I alluded to, the patient population is different. And in academic practices, there are a lot of trainees, which adds another layer of complexity to patient care.
When I initially signed my first attending contract, the salary was literally one of the lowest ones in the area and across academic anesthesia practices. But I valued flexibility (4 clinical days) and the ability to practice in the ICU. My current salary is reasonable for the market, but there is still a discrepancy between academic practices and most community/private practices.
Another complicating factor on the compensation front is the fact that the anesthesia job market is hot right now. More and more anesthesiologists are doing locum tenens work (flexible, short-term contracts) that pays wild amounts of money. If I became a physician for the money, locum tenens work would be where it’s at.
Committee/administrative/education load (unpaid work)
There is a culture in academic practices that it is an opportunity to be invited into committees to do work. It gives you “face time” with influential administrative leaders. It gives you another line on your curriculum vitae. The unpaid work will pay off, they say.
But at what cost?
When I advise mentees and trainees, I find it fulfilling to be part of molding and shaping the next generation of anesthesiologists. I am proud when they go on to do great things. I find it gratifying to be able to be a trusted source of advice and a safe harbor during tumultuous times. Close human relationships are what nourish my soul. I certainly grow close to the residents I’ve worked with, mentored, and advised over the years. This unpaid work feels worth the investment.
Academic practices include nonclinical time to account for the extra committee/administrative/education work. But everyone’s contributions to those areas vary. I always told myself I wanted to work in medical administration. So I kept hustling and applying for positions until I finally got one. Then I spent a lot of the additional nonclinical time doing clinical operations work. And answering clinical questions during inopportune times (e.g., 8pm the night before a patient’s surgery… my bedtime is 8pm; or weekends!).
When I speak to my colleagues about the administrative work, it is clear that many of us go over and above in these commitments. Most of this work has an impact on our practice and patient care. Naturally, we are passionate about it. But ultimately, it’s additional work on top of what often are busy/exhausting/heavy clinical days.
What’s next for me?
I need to do some soul-searching. I wonder if I need to cut back my clinical time and reassess if that feels better. I wonder if I need to explore options in the community and see if it might be a better fit. I wonder if I need to explore industry options for an exit strategy from clinical medicine.
While this post was meant to focus on the specific challenges of academic anesthesiology practice, the overarching inspiration was from the question of whether I should leave clinical medicine altogether. I still need to explore whether the clinical part is what weighs on me. Hopefully I can explore that further in a future post!