Anesthesiology

A poorly understood specialty, especially among surgeons who tend to look at the anesthesiologist in the same way airline pilots look at flight attendants. It certainly doesn’t look like much of a specialty. The anesthesiologist starts the lines, sedates the patient, intubates, turns on the gas and then reads his magazine or does crossword puzzles. If you think about it though, it’s the anesthesiologist flying the plane while the surgeons tinker around in the cabin. The anesthesiologist is responsible for keeping the patient alive and neurologically intact during the procedure.

Almost everyone who undergoes a major procedure gets general anesthesia which involves not only rendering the patient unconscious but also paralyzing his muscles. This explains the need to intubate as a patient in this state needs both ventilatory support and airway protection. The patient is placed into a drug-induced coma, the depth and duration or which are controlled by the anesthesiologist. This also explains the need for residency training as well as the high degree of operating room terror if anything goes wrong.

Anesthesia also involves pain management. If you think about it, the presenting complaint for almost all outpatient visits and hospital admissions is pain of one kind of another. A lot of this is chronic pain and a growing part of most anesthesia practices is pain management.

A lot of the pain is bogus and you will deal with drug seekers like my little old 78-year-old Baptist Aunt who has been addicted to Percocet for the last twenty years. Her doctor prescribed it for something she can’t remember and she has been taking it ever since. She’s not hooked, of course. She’s too respectable for that. But that’s a topic for another day.

It is a lifestyle specialty. The residency hours are pretty good once you get through a standard intern year. You will come in pretty early, earlier than most, but the trade-off is that you’ll have your afternoons free. The anesthesiology residents carry a lot of weight when they are on call, especially when there is a code. We almost never attempt an intubation of what looks to be a difficult airway without having them standing by. I’ve seen an Emergency Medicine Chief resident and a Medicine chief resident both fail to get an airway which the anesthesia junior resident put in while still half-asleep.

They also know the ACLS protocols backwards and forwards as they use them on a regular basis.

Dermatology

Somewhere in this unhappy medical world of ours is a happy place. A place where the grapes hang down from the vines and beautiful maidens cavort in the green pastures and cool forests of Elysium. In this place cows with full udders waddle happily to be milked and the cheeses and hams abound, rich provender for the easy taking.

They call this place “Dermatology.”

Or at least that’s the idea you will get talking to your fellow medical students, the majority of whom will be sick of smelly patients, bodily fluids, the indigent, and the kind of frothy green vaginal discharge that can only be experienced, never described. Dermatology provides an escape from all this. A way out. Not only is the residency, by repute, pretty easy but once you get done you become one of the only physicians around (with the possible exception of the plastic surgeons) who laughs, yes laughs, incredulously at the preposterous notion that he should work for free. And not just any laugh but the full-throated jolly guffaw of a guy who has the world by the scrotum…and has a comfortable grip.

No pay, no play. So sorry. Next.

Now, in reality Dermatology involves quite a few things that people don’t think about. Like severe burn injuries, perhaps the most horrific sight, bar none, you will ever see. It is a legitimate specialty. The skin is the largest organ of the body and if a simple organ like the friggin’ kidneys can have specialists then the so should the skin.

Still, it is the good life, especially as a resident. No call to speak of (“Somebody page the Dermatology resident…his rash is out of control and I’m out of ideas”). Decent work hours, too. Sure, you may work a little in the burn unit but the rest is all outpatient clinic. Nine to five, baby.

This explains the extreme competitiveness of the specialty. The smartest and most capable medical students, all other things being equal and unless they have a zeal for some other specialty, will match into dermatology. Kind if ironic when you think about it because I don’t think anybody professes love for the skin in their AMCAS essay.

We must all weep, as we toil through months of Q4 call, that we are not Derm residents.