Or: How I decided that putting people to sleep was a perfectly reasonable career choice
Choosing a medical specialty is a slightly bizarre concept.
At the age of 18, I barely knew how to wash my pants. Yet, somehow, I was deemed sufficiently mature to start a degree that would eventually require me to decide which branch of medicine I wanted to dedicate a fairly sizeable portion of my life to.
Thankfully, you don't actually have to make that decision at 18.
Unfortunately, several years later, you do. And after spending medical school repeatedly changing my mind, followed by Foundation training repeatedly confirming and then unconfirming those decisions, I eventually landed on anaesthetics.
More specifically, ACCS Anaesthetics.
"I definitely always wanted to be an anaesthetist"*
*This is a lie
I don't think anaesthetics was really on my radar when I started medical school. Like many medical students, my early ideas about specialty choice were based largely on the approximately twelve minutes of actual experience I'd had of each specialty.
You spend an afternoon in theatre?"
Maybe I'll be a surgeon"
Said surgeon calls you an incompetent idiot whilst you hold the retractors
“Maybe I definitely won’t be a surgeon”
Nice paediatrician teaches you something?
"Perhaps paediatrics is my calling"
Manage to correctly identify atrial fibrillation on an ECG?
"CARDIOLOGY"
Medical students are nothing if not easily influenced.
For quite a long time, I was particularly interested in paediatrics. I enjoyed the variety, the physiology and the fact that children have the tremendous advantage of generally having fewer medications than adults. Anyone who has attempted to reconcile and write the medication chart of an 87-year-old with eight comorbidities will understand why this is appealing.
But somewhere along the way, another interest started developing.
I realised I really, really liked looking after very sick people.
Okay, that sentence probably requires clarification. I obviously don't like people being sick. What I mean is that I found myself drawn towards the parts of medicine where physiology mattered immediately. Where you had to assess somebody, work out what was going wrong and actually do something about it. Particularly when the something you do gives an almost instant result!
Airways. Ventilation. Circulation. Tubes.
Especially tubes. All tubes great and small.
Say hello Anaesthetics and Intensive Care!
During my Foundation training, I was lucky enough to spend four months working in anaesthetics and intensive care. This was probably the point at which things started to click.
For the first time, I was able to give my whole undivided attention to one patient at a time, all whilst nerding out about physiology. Graphs, diagrams and Poiseuille’s law in real life action.Being a physiology nerd became useful.
Blood pressure wasn't just a number that had to be somewhere vaguely around 120/80.
Ventilation suddenly involved far more than remembering that oxygen goes in and carbon dioxide goes out.
For once, multiple brain cells could be equipped to answer the question every parent of a 3 year old learns to fear ‘why?’
Why is the blood pressure low? Why is the CO2 rising? Why has the oxygen saturation fallen? And crucially, what can we actually do about it?
It could involve turning some knobs, giving some very snazzy drugs or my personal favourite, inserting some tubes.
Big cannulas, central lines, arterial lines and of course the anaesthetist’s pièce de résistance; the endotracheal tube.
There is something incredibly satisfying about airway management. You assess. You plan. You prepare. You have backups for your backups. Then you carry out a practical procedure with an immediate physiological result.
When it goes well, it is enormously satisfying.
When it doesn't go well, it is an extremely effective cure for overconfidence.
During that placement I started learning airway management, the basics of ventilating critically unwell patients, attending cardiac arrests and finding out what furosemide actually does. All under the caring watchful wing of the calmest doctors in the hospital: anaesthetists and intensivists.
And I loved it.
Again: not the cardiac arrests themselves.
I feel this clarification may be important for any future GMC hearing.
I loved the teamwork, the physiology, the practical skills and the fact that when somebody became critically unwell, everyone suddenly had a very clear common purpose.
Anaesthetists also seemed suspiciously happy...
There was another factor. I liked the people.
This sounds like a very poor basis on which to choose an entire career, but I actually think it matters enormously.
During placements, you slowly notice that specialties seem to attract certain personalities. I am not going to elaborate on that sentence because I would quite like to remain employable. But I found that I got on well with anaesthetists.
They were generally calm. They enjoyed teaching. They liked physiology. They liked gadgets. They could have extraordinarily detailed conversations about cannulas. These were my people.
There is also a particular kind of calm that I noticed in anaesthetics and intensive care.
When the proverbial fan has been bombarded by sh*t, the best anaesthetists I worked with didn't suddenly become louder or more frantic. They became quieter. More structured. More deliberate. That really appealed to me.
It's also something I've tried to emulate in my own practice: when the situation becomes chaotic, becoming more chaotic yourself rarely improves it.
But I still wasn't completely sure
Because that would have made the story far too straightforward.
I still really liked paediatrics. So during Foundation training, I deliberately tried to explore both interests. I completed a paediatric anaesthetics taster, worked in paediatrics as an FY2 and spent time in Emergency Medicine. And rather than making the decision harder, those experiences gradually made it clearer.
I loved paediatrics. I still do. But I increasingly realised that the bits of every specialty that excited me most were the bits that looked suspiciously like anaesthetics and critical care.
The deteriorating patient. The resuscitation. The difficult airway. The physiology. The practical procedures. The moments where somebody says: "Can someone get anaesthetics?"
I wanted to be the person they were calling.
Admittedly, future me may one day read that sentence at 3am while carrying the emergency bleep and strongly disagree.
So why ACCS?
For anyone outside UK medical training (or indeed anyone inside UK medical training who has reasonably chosen not to memorise the various combinations of letters we use to describe ourselves) ACCS stands for Acute Care Common Stem. And it was the route that made the most sense for me.
One of the things I enjoy most about anaesthetics is that it sits at the intersection of several different areas of medicine. You need to understand physiology. You need practical skills. You need to recognise deterioration. You need to be able to resuscitate. You need to make decisions with incomplete information. And you need to remain useful when things have gone spectacularly pear-shaped.
ACCS gives you broader training across acute specialties before progressing further through anaesthetics. In practice, that means spending the early part of training developing experience across anaesthetics, intensive care, emergency medicine and acute medicine before progressing further through anaesthetic training. That appealed to me enormously because I didn't want to become somebody who was comfortable in theatre but terrified the moment somebody wheeled the patient through a different set of doors.
I wanted broad acute experience. I also have a strong interest in intensive care, so training that develops skills in the management of critically unwell patients felt like a natural fit.
In other words, ACCS seemed to combine most of the things I enjoy in medicine into one training programme. Which is either excellent career planning or evidence that I have an unhealthy attraction to chaos. Time will tell.
What do I actually like about anaesthetics?
Admittedly I'm a bit biased as I think anaesthetics is the best specialty in the world. But I have trawled through my interview prep notes for the key themes that, to me at least, make it the best specialty!
I like physiology.
Anaesthetics forces you to actually understand what the body is doing rather than merely admire the abnormal number and write "continue to monitor" in the notes.
I like practical skills.
I enjoy procedures. There is something satisfying about developing a physical skill, practising it repeatedly and gradually becoming better. Plus the added bonus of unlimited access to tubes.
I like immediate feedback.
You give a drug and something happens. You change the ventilation and something happens. You give fluid, start a vasopressor, adjust the anaesthetic or reposition an airway and you can often see the physiological response almost immediately.
Sometimes the response you see is not the one you wanted. This is generally considered suboptimal.
I like teamwork.
Anaesthesia is absolutely not a solo sport.
Operating department practitioners, theatre nurses, surgeons, recovery staff, anaesthetists and many others all have to work together. A good theatre team feels almost choreographed. A bad one feels like trying to assemble IKEA furniture with six people who each have a different idea of what an Allen key is.
And I like looking after one patient at a time.
After spending Foundation training carrying lists containing enough jobs to require a minor supercomputer to organise, there is something refreshing about concentrating intensely on the person directly in front of you.
Not that anaesthetics is relaxing. You're just stressed about fewer people simultaneously. Progress.
The slightly strange thing about choosing a specialty
I think when you're a medical student, you imagine that one day you'll discover The Specialty™.
There will be a moment. Perhaps you'll walk dramatically into an operating theatre. A beam of light will shine through the window. Hans Zimmer will start playing. And you'll suddenly know exactly what you're supposed to do with the rest of your career.
That wasn't my experience at all.
My decision came gradually. It came from noticing which placements I looked forward to. Which doctors I wanted to be like. Which cases I went home thinking about. Which parts of medicine made me want to read more after work rather than throw my ID badge into the nearest river.
And eventually the pattern became fairly obvious.
Anaesthetics combined the things I enjoyed most: physiology, procedures, acute medicine, teamwork and critical care. ACCS gave me a route into that while preserving the breadth of acute medicine that I wanted.
So here I am. An ACCS Anaesthetics trainee.
I now spend a considerable portion of my working life thinking about airways, blood pressure, intravenous access and whether the cannula somebody has described as a "good green" is actually a good green. And so far? I think I chose well.
Ask me again after the Primary FRCA.
Four Eyed love,
Dr Steff
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