Anesthesia

Theresa Hartsell, MD, PhD
Assistant Professor
The Johns Hopkins Medical Institutions
Baltimore, Maryland

Anesthesiologists make up the majority of critical care providers in Europe and many other countries abroad, and have a long history of critical care involvement within the US.  The foundations of knowledge and practice gained during training in anesthesiology lend themselves well to management of the critically ill patient -- from airway, respiratory, and hemodynamic support to titration of sedation and fluid management.  As a result, anesthesiology is a common training pathway chosen by those looking for a practical route to critical care medicine.  In addition, many anesthesiologists choose to enter critical care practice because of the expanded diagnostic, therapeutic, and psychosocial realms available there.

Primary training in this specialty consists of a clinical base year (medicine, surgery, or transitional internship) followed by three years of anesthesiology residency.   Often several months of ICU exposure are possible during the internship year; anesthesiology residency itself requires at least four months although some programs may require more.  The variety of experiences and resident roles within the ICU will vary from program to program, and some programs can provide experiences in surgical, medical, sub-specialty (often cardiac, neurological, or burn), and/or pediatric ICUs.  For the student interested in critical care, choosing a residency where anesthesiologists are active participants in critical care services, administration, and teaching is important.  In addition, for students who are already certain that they desire a critical care career, several programs are now offering integrated residency/fellowship experiences in critical care.

Because of the many parallels between anesthesiology and critical care, particularly procedural skills, an anesthesiologist need only one year of clinical fellowship to be eligible for board certification in critical care.  Anesthesia critical care fellowships exist at many, but not all, academic medical centers having a residency in anesthesiology; some are large programs offering a variety of experiences, while others are smaller programs designed primarily to train their own residency graduates.  The year must consist of nine months of direct ICU exposure, with the remaining time devoted to clinical or research electives related to critical care.  Many programs offer options for additional time in research, sub-specialty clinical training (neurological or cardiac critical care), or integrated time with other fellowships (cardiac anesthesiology).  

Following fellowship, career options for critical care anesthesiologists are many.  In the academic setting, individuals may divide their time between the operating room and the ICU, while some will focus exclusively on critical care practice.  It is not uncommon for critical care anesthesiologists, because of the focus on multidisciplinary team leadership and systems-based practice, to find themselves in high demand for administrative roles within the department or institution.  In the community, many anesthesia groups are being asked to provide critical care coverage and are actively seeking individuals with training in this area; other private practice critical care anesthesiologists work with multi-specialty critical care practices alongside medical and pulmonary intensivists.  Opportunities for research, including basic science, clinical research, and outcomes/safety areas, abound.  The military is actively fostering critical care training and has an active need stateside, at the front lines, and in critical care transport services.