45: What is a Cardiac Anesthesiologist?

Session 45

Dr. Maninder Singh is an academic Cardiac Anesthesiologist. He's been out of his fellowship now for four and a half years. And he's in a large academic medical center in Cleveland, Ohio. In our conversation, we talk about everything that you need to know about the field.

Check out The Premed Years Podcast Episode 256 where I interviewed the dean of the brand new medical school, Carle Illinois College of Medicine. Also check out all our other podcasts on MedEd Media.

[01:35] Why He Chose Cardiac Anesthesiology

Being the medical student that loves everything, he was interested in every rotation he was on. And he found that anesthesiology was the perfect mixture of everything. So it was more of a decision of exclusion where after he excluded everything else, the only one left was anesthesia.

What really drove him to the specialty was being close to the fire, and it gets ugly really quickly, then you get to control things and everything gets back to normal.

Cardiac was fun for him too. He always had that interest in cardiology because of the physiology. So it's the level of understanding and the impact you can have on the patient in an acute setting. Not to mention the outcomes you get to see right away were the things he was attracted to cardiology.

What really drew him to anesthesiology over emergency medicine is because the days are a little more regimen from a standpoint that he was able to have more control over his schedule. It made more sense to him back them.

[05:15] Traits that Lead to Becoming a Good Cardiac Anesthesiologist

"Being a team leader, regardless of the setting is the most important trait."

Maninder cites the traits that lead to becoming a good anesthesiologist such as being a good leader and a good communicator. Also, you have to be confident in your skills. He best describes it as being closest to the fire without being inside the fire. He also mentions that cardiography has become huge in the last five to ten years.

[07:10] Why Anesthesiology Subspecialty is Important

Maninder explains having a subspecialty gives you different options within the field. And from the patient population standpoint, it's different when you're putting a four-old-baby to sleep versus a 30-year-old athlete with an ACL tear to sleep. And versus a 90-year-old person with another severe condition to sleep. So it depends based on the type of surgery, the comorbidities of the patient, etc.

"You need a certain group of people that get advanced training in that particular field to provide the best care for the patient."

The field is changing dramatically with all the procedures they have available. So it's nice to be an expert for that exact procedure and that exact population.

[09:10] Types of Cases

Maninder cites cardiovascular as the number cause of death. From a cardiac standpoint, cases they deal with are bypass surgery, issues with valves. Moreover, congenital cardiac patients are living longer now so they see them in their adult lives.

From a heart failure standpoint, there is a huge shortage for heart transplant organs. As a result, lots of people are placed on assist devices until an organ is available.

50% of their cases are cardio-thoracic which includes lung surgery as well. And some cardiac surgery which is half bypass operation and half of which are valve replacements or valve repairs.

[11:06] Community versus Academic and Taking Calls

There are lots of community-based programs that are busy and have a huge demand for cardiac anesthesia. It used to be that after the surgeon does the surgery and comes for bypass, and now you call the cardiologist to the operating room to take a look at the valves. So you bring another physician provider into the room. Now, you've taken cardiology out of the operating room.

Maninder says this is one of the reasons to be in academic is that the acuity of patients you see are a lot sicker. The operations you're doing are much sicker.

"You get to teach residents which also would keep you on your toes and keep your skills up to speed."

In terms of taking calls, they take one weekend day call per month which is about 24 hour-in house on a weekend. They they'll do anywhere from one to two weekend days, which is usually a sixteen-hour call. You go at 3pm and stay until 7am. A cardiac call ends up being a home call. There are 25 of them so they end up having to do it one weekend a month for calls, which is a big academic practice.

[13:20] Work-Life Balance

Maninder says it's one of the main benefits of being in anesthesiology is that you get to live a more structured life. Cardiac is one of the busiest subspecialties out of all subspecialties in anesthesiology. But it's pretty well-balanced.

"One of the benefits of being in anesthesia, your life is a little it more structured."

It's also center-specific. So they would do one case a day and they're done by 2-3 pm. By that time, they finish their paperwork and then be home by 4-5pm. And probably go to the hospital by 7am. So he still gets to have dinner with his family and take care of his kid.

[14:25] The Path to Residency and Fellowship

Out of medical school, you will apply for an anesthesia residency. It used to be advanced which is some sort of general training. And a transition year from general surgery to medicine. And then you have three years of dedicated anesthesia training. Then the cardiac fellowship is one additional year where you deal with high intensity programs. You basically do multiple cases a day while getting good at providing anesthesia for patients in terms of anesthetic management. Then you try to become sufficient and be certified in doing cardiography. So it's five years in total.

Maninder describes matching to not as terribly competitive in general. Chronic pain and cardiac are the most competitive. Pediatric is getting more competitive as well. But certainly, it's much easier to get into cardiac anesthesiology that it is to get into anesthesiology.

For students interested in doing cardiac anesthesiology to stand out, Maninder recommends to learn the residency program you're in. Shadow a cardiac anesthesiologist to see what they're doing. Understand the intensity to see if this is the right field for you. If you have the intensity and the dedication and the desire, Maninder says you will succeed no matter what. You can do research or anything that's going to help you in your anesthesia residency. This shows that you're really interested in the field.

"There's understanding the intensity that goes with it and seeing if this the right field for you."

[17:10] Bias Against Osteopaths and Working with Primary Care and Other Specialties

Maninder sees no roadblocks for osteopaths who are looking into taking this path. He has met multiple cardiac anesthesiologists that are DOs and he finds them phenomenal and even better. He has trained with DOs and he has trained DOs. At least on the East Coast where he did his training, he didn't see any bias against DOs.

Sometimes, they do work with primary care providers depending on the situation. Other specialties he works the closest with include medicine, surgery, all kinds of surgical subspecialties, pathology, psychiatry, internal medicine, endoscopy, GI bleeds, and just about every subspecialty there is.

[19:33] Special Opportunities Outside of Clinical Medicine

Maninder doesn't see a lot of opportunities outside of clinical medicine but there's teaching on one hand.

But if you wanted to go into the industry, Maninder admits all the big stuff is coming out. The big thing right now is the percutaneous valves they're doing. it's probably the only research going on relating to valves. There's a lot of percutaneous devices coming out for patients with atrial fibrillation. And a lot of things coming out related to assit devices for patients with heart failure. That said, the industry is booming as more and more procedures are getting available and people are getting well.

"Cardiac anesthesia and cardiac surgery is booming because of all that's going on in the industry."

[21:02] What He Wished He Knew that He Knows Now

Just the intensity of it at times is what he should have known before. Because you don't appreciate it while you're in the moment. And you only appreciate it when you have a nice easy day or case. So at times, he thinks the intensity gets a little bit too much. But even if he had known that, he still would have gone through the same.

What he does now during intense situations to remind himself that there are things that you can't fix. You do the best you can. You have to have all your algorithms so you don't miss anything. Just be a good leader and be a good communicator. Make sure you don't leave any stone unturned. Be loud and clear

"It's okay to ask for help from the standpoint of just having a fresh set of eyes."

[22:52] What He Likes the Most and Least

Maninder's favorite part is echocardiography, which is essentially one of the main reasons he got to do his electrocardiography elective as an anesthesiology resident. This was the time when he was still considering between pediatric and cardiac anesthesiology. And so it was the last thing that made him switch over to cardiac anesthesiology.

On the flip side, what he likes the least is not having enough cases. Not enough crazy cases. But he's quite sure that will change when he's 50 years old. But at this point, he says it would be nice to do more craziness.

[24:05] Major Changes in the Future and Collaboration Between Specialties

A lot of devices are coming up in the cardio scene like microregurgitation when patient would have to go in for an open chest procedure. Now, they can do a percutaenous device so the patient can go home the same day or the next day. They do the procedure on valves. They started with aortic valves and now they're doing mitral valves. These are the patients that are high risk for all the long rehab that goes with an open heart surgery.

They're doing more and more assist devices for the heart transplant patients waiting for an organ to come in. When the organ comes, they'd come in and call them essentially a bridge therapy, which is a bridge to their transplant.

Moreover, there's a lot more management for atrial fibrillation, which are high risk patients for stroke, secondary to atrial fibrillation. And who has contraindication for being on anticoagulants. They have procedures to close up the atrial appendage so patient don't have to be on anticoagulation.

As cardiac anesthesiologists, they don't deploy the valves directly but they are an integral part of that. For example, they identify the appendage for the cardiologist or they are finding exactly where to put the valve in. Too deep or too shallow, the valves are not going to sit exactly where you need it to sit. This is all guided by electrocardiography. And this is what's going to help a cardiologist and a surgeon do the procedure.

"Even though we are not actually deploying the valve, we are actually telling them exactly where to deploy the valve."

As a result, it makes you feel like you're a big part of the team because they rely on the information you're telling them. This is a concrete example of collaboration. Maninder also likes to tell his residents that they are the eyes of the surgeon. Sure, there is pressure, but you need to back yourself up and train the best possible way you can. And there are times when you have to make those big decisions because they need you.

[28:50] Final Words of Wisdom

If Maninder had to do it all over again, he would still have chosen cardiac anesthesiologist. Lastly, his advice to students interested in the field is to just do it. Don't think twice about it. It's one of the best specialties. From a job security standpoint, you're doing something that not many anesthesiologists can do in terms of cardiography. You've gotten all this training so make sure you're always in demand. Be prepared to work hard and people will appreciate your hard work. You will essentially become the go-to person for every sick patient, for every big case, and for managing patients. And if you don't shy away from those things, then it's the best field you can possibly go into.

[30:06] Last Thoughts

If you're thinking about anesthesiology, take a look at cardiac anesthesiology. Find a cardiac anesthesiologist to shadow. It's the best next step you can take on this journey.

Links:

The Premed Years Podcast 256: A Look at Carle Illinois College of Medicine with Dean Li