Anesthesiology Resident Reflection and Perspectives

The internal medicine rotation was a fantastic way to build foundational medical knowledge. Though I admit, I was not initially excited for IM, I found this rotation to be an exciting journey into medical complexity and compassionate care. During the weekdays, we would have dedicated conference time to explore the depths of internal medicine. Our upper-levels were always ready to help at a moment's notice. This was supplemented by the fantastic, individualized lectures given to us by our attendings. We were also exposed to a lot of ultrasound guided diagnostic testing during our rounds, which really helped reinforce the skills we had learned. After completing our work for the day, we had plenty of time and autonomy to practice IVs and use of the ultrasound. I had a great time working with my internal medicine colleagues and filling in gaps in my database of knowledge. The broad spectrum of pathology that we were exposed to made me feel much more comfortable with managing a variety of conditions. Internal medicine can offer anesthesiologists a deeper understanding of complex pathologies, making for a better preoperative assessment and improved intraoperative patient safety.

As part of our intern year here at Wake, we have the opportunity to rotate through the PICU. It was one of my busier months, but definitely one of my favorite months as well! In the PICU, we are exposed to the full spectrum of pediatric patients, from recent NICU graduates all the way to teenagers. The census of patients is typically representative of this wide age range, so you quickly become accustomed to shifting gears and thinking about management of common pediatric conditions in various age groups.

The resident team is comprised of an anesthesia intern and two upper-level residents (either pediatrics or emergency medicine), and the patient census is split up between you and whichever resident(s) are on that day. You can usually expect to be primary for 4 to 6 patients. After pre-rounding on your patients, it is time for formal rounds. The rounding team includes the PICU attending, the residents, one or two PICU APPs, a member of the pediatric pharmacy team, as well as any medical or PA students who are on for the week. There was usually some case-specific teaching on rounds, as well as active discussion among team members with regard to management decisions. The attendings in the PICU are particularly great about eliciting your opinion and allowing you to take ownership of your patients and the plan for the day. Procedures are typically done later on in the day, although sometimes things come up that necessitate a rounding interruption. Again, the PICU attendings encourage you to take ownership of your patients and will help walk you through procedures as they come up. I personally got the opportunity to place central lines in a 2-week-old and a 2-year-old! At the end of the day, you hand over patient care to the night resident and night attending. The majority of your time will be spent on days, but you will get between 5 and 7 nights as well. Nights are varied, and some can be busy with admissions, but you will always have the PICU attending in-house and ready to help with whatever comes up.

Overall, the PICU was a great rotation. Though the PICU did offer exposure to a wide variety of pediatric pathology, the focus was definitely shifted toward respiratory pathology. This meant there was a lot of discussion about ventilator settings and weaning, as well as other modes of respiratory support, which felt particularly applicable and interesting for an anesthesia intern! I hope you enjoy your time in the PICU as much as I did!

Our month in vascular surgery as interns was one that seemed very intimidating to me. It was early in my intern year, our vascular patients tended to be extremely sick and there were many things to consider with their care. In addition, it's a surgery month, which brings back flashbacks from MS3 year of crazy long hours. Thankfully, this rotation was useful and engaging and much more enjoyable to me than surgery as a medical student!

The rotation is split in half between days and nights, both of which provided very different experiences and learning opportunities. On days, we typically partnered with an APP to take care of the vascular patients throughout the hospital. As a general rule, the APP would cover the floor patients while we covered the ones in the SICU. We do have a closed SICU, so it was a good opportunity to learn how to work with our ICU colleagues to co-manage our patients. Days were great to work alongside the APP and learn more about their contributions to the care team. We also had a lot of interaction with the fellows and attendings during days, allowing us to learn from experts about the complications that can be seen intra- and postoperatively with these patients. They were extremely nice and patient with all of my questions and all very willing to teach and explain things, which was wonderful!

Nights were super interesting. We are THE vascular person for the hospital overnight, which was terrifying to consider. However, I quickly realized that the fellows were only a phone call away and they honestly appreciated calls to keep them in the loop with changes or complications with their patients, no matter what time of night. In addition to vascular, we covered the transplant patients overnight also. It can be tricky to manage two different services, with two different fellows occasionally needing things at the same time. It definitely gave us a chance to practice communication skills! It can be very rewarding to help admit a transplant patient and see their gratitude to finally be receiving their organ.

Overall, vascular can be one of the more challenging rotations but it is definitely one of growth for our interns! It is beneficial to be able to learn how to manage some of our sickest patients, to consider what goes into their management, both before and after the OR, and to face a potentially intimidating rotation and see at the end that we are capable!

Intern year got off to a great start on my first rotation in the Emergency Department. I have to admit, I was a little nervous beginning intern year in the ED during a pandemic; however, I could not have found a more prepared, supportive and encouraging atmosphere! Each ED shift (which is a very doable 8 hours!) has you working closely with one attending, one to two upper levels and generally another intern (usually from EM). 

Overall, I found the sense of camaraderie in the ED very uplifting and even fun. Although you are an off-service intern, I was always treated with respect and value, just as an EM intern. Also, if I ever needed help, an upper level was never far. I was able to run questions, differentials and plans by the upper level prior to staffing with the attending. Also, I can't forget the fantastic ED nurses who certainly had my back when I needed help! As a quick side note, I had placed IVs before, but I definitely learned some new tips from the ED nurses who let me practice! Now, being a few more rotations into intern year, I am truly glad for the friends I made in the ED as we frequently cross paths.

Some memorable patients that I took care of included a submassive PE (my very first patient of intern year!), radiation-induced pericarditis, ARDS, and GI bleeds. I also got some great procedural practice with lac repairs, I&Ds, a foreign body removal, and a paracentesis in the ED. It was a fantastic way to start intern year, and after I completed my shifts and any outstanding charting, I had ample downtime which allowed me to enjoy exploring Winston by going running at Reynolda Gardens or hiking outside the city. 

I started my intern year on the hematology-oncology service. To be honest, when I got my final schedule I was not looking forward to that first month. This was mostly because as a medical student I had tried to avoid all of the cancer services and their intimidating treatment regimens. So when I was assigned this rotation, I felt very unprepared to care for the patients. Having been through the rotation now, however, I can say without hesitation that it was a great experience!

First off, all of the residents, fellows, nurses, and attendings that I worked with were extremely helpful. We all had a lot of fun getting to know one another, and the attendings provided a lot of opportunities for autonomy when it came to the day-to-day patient care. That being said, it was also very easy to ask questions and get help when it was needed. Secondly, when you are on this service you don't actually have to know all of the details of cancer treatments. Essentially, you are managing the patient's various medical problems - such as PEs/DVTs, diabetes, hypertension, chronic pain, etc. - while the fellows and attendings manage the cancer. Despite this, I also felt like I did gain a lot of important information relating to specific cancer presentations and chemotherapy drugs. I also learned a lot about some of the complications associated with various forms of cancers and their treatments. 

On this rotation you will become very comfortable with managing patient pain and related symptoms. I had only a tentative idea about pain regimens before starting this rotation but quickly learned when to escalate or de-escalate therapy, as well as how to manage some of the side effects of certain pain medications. In addition to pain control, you will also get a lot of exposure to palliative/hospice care and learn how to have difficult conversations with patients and their families. This can be tough at times, but overall it was a very beneficial and rewarding experience to help patients come to terms with their new cancer diagnoses or the progression of an existing cancer. Learning to deal with these types of difficult situations as an intern is going to be extremely valuable as I progress through my residency training. 

Each day kicked off at 6 am with a "sign out" from the night resident about what happened overnight. Then a full day of medical management, patient interaction, procedures, focused teaching and more began. 

The rounding team consists of two to three interns, one Internal Medicine or Emergency Medicine upper level, a Critical Care fellow, and an attending. The camaraderie between residents and staff is fantastic. It's always an added bonus when the attending brings in Krispy Kreme doughnuts, which I found out was founded in Winston-Salem! 

Ultrasound guided IVs and other procedures, like arterial lines, were one of my favorite parts about the month. Learning and becoming more comfortable with vent management was another highlight. The MICU rotation is certainly a pertinent rotation for us as anesthesia interns because we get to learn about procedures, vent management, and other aspects of critical care.

I feel that the Pain Medicine rotation is a perfect example of how Wake strives to continually improve upon its intern year curriculum. This rotation was originally available to only a portion of the class, but because of its popularity and educational value, every intern now has the opportunity to rotate through the pain clinic. I appreciated being exposed to this branch of anesthesiology early on in my career, and look forward to doing a second chronic pain rotation during residency as well.

The entire month is spent at a pain clinic in Winston-Salem, which is a nice escape from the typical hospital routine. I arrived at clinic around 8AM, and the final patient was typically scheduled for 4:30PM. I found excellent day-to-day variety within the clinic. The days consisted of seeing patients for follow-up visits and medication refills, meeting new clinic patients, performing bedside injections, and learning how to do nerve blocks under fluoroscopy. The pain fellows were excellent teachers and were enthusiastic about explaining the anatomy and techniques they utilized for every procedure. As the month progressed, I gained hands-on experience and was able to perform midline and transforaminal epidurals, medial branch blocks, SI joint injections, and hip joint injections under fluoroscopy with the guidance of the pain team. I was given a comprehensive pain medicine textbook, which helped explain different treatment modalities and will become a valuable resource when preparing for the anesthesiology boards. I also learned about the pharmacology of narcotics, membrane stabilizers, and other medications that I will commonly encounter in practice.

The fellows and attending physicians in the pain clinic were approachable and kind, and were willing to be mentors for individuals interested in pursuing a pain fellowship. The pain fellows were impressed that our residency program allowed for such early exposure to this specialized field, and were envious of our opportunities as first year residents. We were a welcomed presence at the pain clinic, since we helped to efficiently manage and treat patients in a high-volume, face-paced setting. We were treated with the same kindness and respect as the fellows, and were considered to be vital members of the care team.

This rotation was definitely a highlight of my intern year, and I look forward to learning more about the field during the remainder of my residency at Wake.

Welcome to Wake Forest Department of Anesthesiology. One of the things that attracted me most to this program was how invested the administration is in our education. One way this is demonstrated is in the organization of our intern year. Each rotation is deliberately chosen for its usefulness to our future careers as anesthesiologists. In this way it feels as though we begin our anesthesia training well before our CA1 year.

For example, recently I completed a rotation in electrophysiology (EP) consults. On this rotation I worked alongside a first year cardiology fellow to see the most interesting arrythmia patients in the hospital. Often this included managing persistent afib/flutter, high degree AV block, ventricular arrhythmias and many undifferentiated patients with mutliple cardiac issues. I had daily one-on-one teaching from EP attendings on advanced EKG and rhythm strip interpretation. I was able to assist in new patient workup and management as well as device interrogations. It was clear that I was respected as a valuable member of the team and by the end of the rotation was looked to for my opinion when deciding course of action. Whether it is working with patients with ICDs, chronic arrythmias, or a new arrhythmia, it is essential that we develop a comfort with diagnosing and managing these patients. Wake Forest has identified the areas of medicine which are crucial to our success and has integrated them into our training program. By doing this, we are not just "getting through intern year," but rather we begin our training as anesthesiologists as soon as we arrive on day 1. I hope you consider Wake Forest for your future training in Anesthesiology.

Anesthesiologists are the only physicians who routinely administer the blood products they order. Our program created an up-close, in-person, hands-on learning opportunity for us to familiarize ourselves with the acquisition, handling, storage and administration of blood products. Prepare yourself for an informative yet relaxing two weeks in the blood bank where experts in the field of pathology share their passion, insight and knowledge from behind the scenes.

Early exposure to the processing, matching and administration of blood products is critical for becoming a well-rounded anesthesiologist. The blood bank rotation during an intern’s year is where you will begin building this skill set. This introduction to the tenets of typing and crossmatching blood, transfusion reactions and risks of blood product administration will boost your confidence as you prepare for upcoming in-training exams (ITE) and board exams. More importantly, your blood bank rotation will aid in strengthening your patient care on the floor, in the ICUs and ultimately in the OR.

The second two weeks of this block are spent doing pulmonary consults with critical care/pulmonology fellows and attendings. Obviously, exposure to severe pulmonary pathology is valuable to us as future anesthesiologists; however, you will also observe a fair amount of airway anatomy (some of it quite unique) in the bronchoscopy suite. I was even able to drive the bronchoscope a number of times, and believe me, if you can get a bronchoscope through the vocal cords in a breathing, coughing, sometimes talking patient, a fiber-optic intubation in the OR will be a piece of cake!

While there is a vast wealth of useful clinical information gleaned during this four-week block, another fantastic benefit is the relatively relaxed schedule and weekends off. It's a great time to study for and take USMLE Step 3, spend time doing things you enjoy or take a weekend getaway. Definitely take advantage of the free time on this rotation!

As an anesthesia intern at Wake, we have the opportunity to rotate with ENT which provides us a chance to learn about and become more comfortable with surgical airways. There is an anesthesia intern and 1-2 ENT interns who work with the rest of the ENT residents – all of whom are great. The interns split the list – one on the head and neck team and the other(s) with the other teams – pediatrics, otology, facial plastics, laryngology and rhinology. Head and neck is where we get the most exposure to airway management. There is a PA on head and neck who is incredibly nice and helpful. The other teams allow an opportunity to learn about pre- and post-operative care of various ENT problems.

A typical day starts at approximately 5 a.m. with pre-charting before rounding with the other residents on your team around 5:30. All the residents then meet at 6 to run the list after the chiefs talk to the attendings about the plans. After this, it's time to put in orders, call consults, perform procedures and write notes.

The advantage of the ENT rotation is the flexibility the daily schedule provides. As the majority of work is done early in the day, this frees up the time to see a tremendous amount of airway anatomy, both normal and abnormal. Anesthesia interns are able to go to clinic to work with one of the laryngologists who scope the majority of their patients. They are incredible teachers and will have you assist with any scheduled procedures. You can also go to the ORs to watch interesting cases such as awake tracheostomies and fiberoptic intubations.

There is a big learning curve at the start of ENT, but it is a great rotation with a lot of chances to become more confident in airway anatomy and management.

What was your deciding factor for choosing Wake Forest School of Medicine?

The two aspects of the program that I held in high regard were the post-graduation plans of the residents and the overall culture of the program. Residents consistently match into strong programs within competitive subspecialties of anesthesia, and those who choose private practice secured excellent jobs in their location of choice all across the country. I felt that this spoke both to the quality of training and mentorship received at Wake Forest as well as the fact that Wake graduates are held in high regard both regionally and nationally. Further, it was abundantly clear that the residents got along well and enjoyed spending time with each other, and that attendings knew the residents well and had a vested interest in them not only as anesthesiology trainees but also as individuals. I felt that the culture within the program lent itself to an ideal training environment, and fortunately I have found this to be the case.

What’s unique/or what you like most about living in Winston-Salem?

Winston-Salem and Wake Forest offer a combination that I truly believe cannot be found anywhere else in the country. In Ardmore and West End, Winston offers local neighborhoods that are safe and affordable with good quality homes and apartments - all within minutes of a hospital that is a tertiary care, level 1 trauma center. As a frame of reference, it takes me longer to walk from my OR for the day to the outside of the hospital than it does to actually drive from the hospital back to my house.

For those who prefer more of a city feel, there are a number of very nice apartments and town homes in downtown Winston surrounded by restaurants, bars, breweries, and in close proximity to the UNC School of the Arts. If you prefer to have a little more distance from the hospital, Clemmons and Kernersville are suburbs roughly 15 minutes from Winston that are quite popular among residents and faculty. There are numerous options for outdoor activities such as hiking, rock climbing, fishing, and kayaking both locally and within a short drive. Charlotte, Asheville, and the beach are all within driving distance, making for ideal weekend road trip venues.

Reflections from CA-2 Year 

Why did you choose anesthesiology as a career path?

I chose anesthesiology as I enjoy the immediacy of making a diagnosis and fixing a problem by manipulating a patient's physiology. With my background in mechanical engineering, the practice anesthesia and study of human physiology were areas that were a natural fit.

What was your deciding factor for choosing Wake Forest School of Medicine for your residency?

I chose Wake Forest because I felt that in addition to unparalleled clinical training, the residents and faculty were great people that I would enjoy spending the next 4 years of my life with.

List two aspects that make Anesthesiology at Wake a unique educational experience.

One of the most unique aspects about training here at Wake is our experience with airway management. Not only do we get training in almost every ancillary airway device and technique, but we have faculty that train others nationally on the use of airway blocks and awake intubation. This allows us to routinely perform awake intubations extremely quickly and smoothly.

Another unique aspect of the training here is the approachability of attendings. I am an avid cyclist and race/train with many of my attendings on a regular basis.

What has been the biggest surprise about your residency?

The biggest surprise about residency is how much I love going to work every day. Some days are better than others, but overall I am truly excited to be able to learn and practice anesthesia here on daily basis.

What is unique about living in Winston-Salem?

Winston is a great place to live. It offers everything you need when it comes to outdoor activities. The mountains are only 1.5 hrs away and the beach not much further.

What are your career goals?

I hope to pursue fellowship training and possibly pursue a career in academics.

Do you feel your Wake training is preparing you to meet your career goals?

Yes! Not only are research interests supported but the clinical training is very strong. I think that after finishing here I will be equally prepared to either enter the world of academics or private practice.