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Q&A: Professional Paths in Anesthesiology Critical Careby Kyle Bruns, DO
Recent investigations into the critical care physician workforce show that anesthesiology intensivists make up only 5% of intensivists nationally.1,2,5 A majority of these have found employment in cardiothoracic ICUs.3,5 Over the last few years there has been an apparent waning interest in the field as we have observed fewer applications for the critical care fellowship programs and positions going unfilled.4,5 In the following question and answer presentations we will explore niches within the field that trainees may find exciting and compel them to apply to fellowship training programs. While these experts share their own critical care career paths, the list is by no means exhaustive. Other career paths beyond those interviewed include, but are not limited to: administration, rapid response programs, tele-critical care, surgical ICU, burn ICU, critical care transport, private practice, research, international critical care, and transfusion medicine.
Dr. Megan Hicks completed her training in critical care and cardiac anesthesia at Vanderbilt University and she now practices at Wake Forest University, where she staffs both the cardiac ICU and ORs while continuing to advance the education of trainees.
KB: What interests you about cardiac critical care and how did you find your way into this field?
MH: Entering residency, I was pretty sure that I wanted to do cardiac anesthesiology, as I had initially been drawn to anesthesiology because of the fascinating real-time physiology and the coordinated, collaborative dance that is cardiac surgery. However, as I spent more time in the OR, I realized that I was consistently wondering what happened to my patients after I handed them off and ultimately realized that I just truly missed the comprehensive care, the softer sides of patient and family interaction and goals of care, and ultimately, truly “feeling like a doctor” in the intensive care unit. When I imagined my career, I couldn’t imagine fully enjoying it without either component, so I decided to pursue dual fellowship training. As I’ve honed my interests, I have enjoyed the interplay between my fields which uniquely prepared me to care for complex cardiac surgical patients, manage mechanical circulatory support, and contribute to perioperative optimization through my research in glucose control.
KB: Can you describe how your training is utilized in practice? What does a typical day entail?
MH: The best part of my job is that there isn’t a “typical day!” On a given day, I could be caring for patients in any number of settings, from the cardiac OR to a general OR to the cardiovascular ICU or a community medical-surgical ICU. Both sides of my training make me stronger in the other aspects of my job, as I truly feel that I am a better anesthesiologist by being an intensivist and visa versa. I am well-equipped to care for most any patient in the operating room (just no infants, please!) and function as a true anesthesiology consultant, allowing me to thoughtfully discuss and plan complex cases or assist with emergency diagnostics and resuscitation, including via echocardiography.
KB: What advances have you seen in your field during your career and what do you anticipate in the future?
MH: The expanding mechanical cardiac support capabilities (a walking, talking patient in ventricular fibrillation?!) including percutaneous options and other developments in transplantation continue to blow me away. This is particularly true about organ care systems and regenerative medicine technologies for cardiac and lung transplant, which would allow us to expand the pool of available organs.
KB: Why did you choose the academic pathway and what suggestions would you have for someone considering this?
MH: As the daughter of two educators, teaching is in my blood and I have always enjoyed the role of educator. I get great joy in working with residents throughout training, discussing complex topics in an approachable way, and mentoring trainees through their next steps and career choices. Further, I love the close peer to peer interactions with co-faculty, which allows me to continue learning with excellent mentorship and collaboration. While I have only recently developed a true research career, I have also always enjoyed the inquisitive nature of academic medicine and a focus on improving care and quality.
Personally, as a wife and mother, I also appreciate the staffing redundancy that academics provides, allowing flexibility in scheduling for important events and relief when there are emergencies or illness. Further, the post-call time that is built in to many academic critical care positions, including mine, is excellent for work-life balance. I think key things to look for in those seeking academic positions are the strength of faculty development and mentorship infrastructure as well as the overall priority of academic endeavors as compared to clinical responsibilities as well as the degree of protection and incentive tied to them. An established pattern of academic productivity, even through education and quality improvement, if not clinical research and publication, is key to effective recruitment; one must keep in mind that academics does not solely hinge on an enjoyment of teaching, however.
Dr. Kiersten Norby completed her training in neuro-critical care at the University of Pennsylvania and her surgical critical care at the University of Hawaii. She currently practices at the University of Missouri, where she staffs the neuro-critical care unit.
KB: What brought you to the field of neuro critical care?
KN: I had somewhat of a winding road into neuro-critical care probably beginning in medical school after I had several impactful experiences with patients and became involved more and more in research in neurosurgery and neurology. Witnessing the evacuation of a subdural hematoma for the first time, the urgency and efficiency of the operating room team when setting up and beginning an emergent decompressive craniectomy and the anatomy on display in a retrosigmoid craniotomy for trigeminal neuralgia as a medical student were experiences that stayed with me as reminders of how quickly things can change in life and in medicine, how impressive the healthcare system can be when we work as an effective team and the elegance of the human body. Life ultimately led me into general surgery residency and onto surgical critical care fellowship during which time I again had impactful experiences with patients and also with mentors in the neuro-critical care field. Having subsequently left general surgery residency and starting anesthesia residency I gravitated towards those neurosurgical and neuroendovascular cases reminding me of my interest in those patients and pathologies I had as a medical student. Having such a varied background across different specialties has impressed upon me how isolated we often can be in our specialty and coming out of anesthesia residency and into neuro-critical care I find myself continually trying to improve perioperative care for these patients as well as communication not only among ourselves as physicians but also to patients and families as well. While the effects of neurological disease can be devastating we are also an adaptive species and part of what captivates my attention in the field is the pathology of the central nervous system and its capacity for recovery and how we apply that to an individual and their disease process.
KB: Can you describe the new process of obtaining certification in neuro critical care?
KN: Because of my varied path into anesthesia and neuro-critical care I would say I have less of an understanding of the traditional pathway into the specialty. All of my co-fellows were from neurology residencies and in practice our fellowship has had both neurosurgery and internal medicine candidates. It is my understanding that first one must complete a residency in neurology, neurosurgery, anesthesiology or internal medicine followed by a neuro-critical care fellowship. Following the fellowship, one must then pass a certification exam either from the American Board of Psychiatry and Neurology or the United Council for Neurologic Subspecialties. I would recommend anyone interested in the field, especially if they are from a less common residency (such as internal medicine or otherwise) to reach out to a program director or mentor in the field to talk through whether it would be a worthwhile option.
KB: What advances have you seen in your field during your career and what do you anticipate in the future?
KN: It is an exciting field with advancements in the area of neuroprognostication following cardiac arrest, in expanding treatments for those patients who have had either ischemic or hemorrhagic strokes as well as improving perioperative care for those patients undergoing neurosurgical or neuroendovascular procedures. Often times we are consulted on patients who are in coma following cardiac arrest and while there are guidelines to follow in terms of what an evaluation should consist of and the timeline for which it should be conducted research into different modalities of evaluation, more subtle exam findings and longer follow up are going to be critical in terms of better assisting patients and their families during this critical time. Emergent thrombectomy for ischemic stroke and less so minimally invasive hematoma evacuation for hemorrhagic stroke has become a treatment option for more and more patients with improvement in outcomes often which we can witness during their ICU stay. Enhanced recovery after surgery protocols are seeing more applications in both neurosurgery spine and craniotomy patients which leads to better postoperative outcomes and perioperative care of these patients. Lastly there seems to be an application for noninvasive monitoring techniques whether hemodynamic monitoring, ICP monitoring, cEEG monitoring which I hope to see continue to advance our understanding of pathophysiology as well as early detection and warning signs so we can intervene early for these patients.
KB: Why did you choose the academic pathway and what suggestions would you have for someone considering this?
KN: While it is not a choice I made intentionally when embarking on training and practice it seems to have evolved naturally out of my wanting to practice both anesthesia and neuro-critical care, participate in resident/fellow education and conduct a small amount of research. I would say I felt like there was a point somewhere along my varied training experiences (and probably once my children were born) that I really took to heart that my time is limited and finite. I had to evaluate whether I was doing things simply to check a box or because I truly enjoyed them. After approaching any projects, or my career in general, with that in mind it became much easier to determine what practice context would be best for me. I would encourage anyone thinking of going into the field to also reach out to any mentors or people that you have worked with in the field as they can often provide some insight or perspective into the benefits/drawbacks of a particular practice setting.
Dr. Joseph Deng completed his critical care training at Loma Linda University. In addition to his anesthesiology background he is also board certified in family medicine and neuro-critical care. Practicing in Portland, OR he is the leader of a team of ECMO experts who deploy to surrounding communities to initiate mechanical circulatory support (MCS) and then transport back to the hub from the spoke for further management.
Q: How did your fellowship training prepare you for this aspect of critical care?
JD: I attended a relatively new fellowship and many things were not “set in stone.” This allowed for and also required a fair amount of custom tailoring and personal diligence to get the training experience I wanted. That is the single most important lesson I learned in fellowship: Don’t get put in a box of someone else’s making. Do what you need to, to get the experience you need, to have the career you want.
My current job is great. It requires a doctor who can practice internal medicine, surgery, administration, and yes echocardiography too. Without my fellowship experience, I think this opportunity would have come and gone.
Q: What does being a part of the ECMO response team entail?
JD: It’s a lot of things but in the end, it means a gut check. My mentor who founded our program in 1985 told me that in order to “do ECMO” you need to “have it in your DNA”. That means...rolling out of bed in the middle of night and kissing your wife and kids goodbye, to maybe get on a small bumpy airplane, to god knows where, for lord knows who, that did heaven knows what to themselves...(that last part was my addition to the saying). And when you get back, get right back to work with a smile on your face and maybe doing the same thing the next night...
And yes, it means being able to lead a team — be the surgeon if they need one. An anesthesiologist when they need one. And even letting your team RN place the IV when you know you can do it better so that they can build confidence...and then you must be their biggest cheerleader.
You must be whatever and whomever your team needs.
KB: If you were hiring a new colleague, what would you desire in their training?
JD: Some medicine training, some surgical training. There must be evidence that they have grit and are able to persevere and “get in the trenches.” Over focus on compensation and “work-life-balance” would be red flags.
It is difficult to figure out who will fit or not fit so we never hire “from the street.” ECMO team members are currently promoted from within after working with them for some time.
Dr. Yanni Angelidis has completed training in cardiac anesthesia, obstetric anesthesia, and critical care medicine in addition to other advanced training. He currently practices at the University of Pittsburgh.
KB: Considering obstetric critical care is a relatively new field, what has changed in the practice landscape to create this need?
YA: Over the past decade, we’ve seen a significant rise in maternal morbidity and mortality in the United States, driven by increasing rates of chronic health conditions in pregnant patients, such as cardiovascular disease, obesity, hypertension, and diabetes. In parallel, maternal age is rising, and more patients are entering pregnancy with preexisting complex medical conditions. At the same time, there has been greater recognition that pregnant and postpartum patients with critical illness benefit from care that integrates both obstetric and critical care expertise. These changes have created a clear need for specialized care models, dedicated obstetric ICUs, and clinicians trained at the intersection of maternal-fetal medicine, anesthesia, cardiology, and intensive care. Our evolving understanding of conditions like peripartum cardiomyopathy, amniotic fluid embolism, and severe preeclampsia also demands a multidisciplinary, systems-level approach—precisely what obstetric critical care provides.
KB: What is the training path and what is a typical day like for you?
YA: There is no single pathway into obstetric critical care, making the field flexible and richly multidisciplinary. Most physicians come from backgrounds in anesthesiology, internal medicine, or maternal-fetal medicine, often combining their foundational training with additional fellowships. In my journey, I’ve completed three fellowships—in obstetric anesthesia, cardiac anesthesia, and critical care medicine—which have uniquely positioned me to care for pregnant patients with complex cardiac and critical illness.
A typical day varies depending on my clinical assignment. I might be managing cardiothoracic ICU patients, leading care for high-acuity obstetric patients in a specialized OB critical care unit, or coordinating perioperative planning for complex deliveries. I also spent 45 % of my clinical time managing complex adult cardiac cases in the cardiothoracic OR. Beyond clinical work, my time is also dedicated to research, developing institutional protocols, mentoring trainees, and advancing maternal safety initiatives through national society work. The diversity of each day is one of the most fulfilling aspects of this career.
KB: For someone contemplating this career path, what should they look for in a training program?
YA: Please look for programs that embrace interdisciplinary care and actively support maternal critical care initiatives. Key features include:
Intense exposure to both medical and surgical ICU environments
Opportunities to care for critically ill obstetric patients, whether through high-risk obstetrics services, OB anesthesia, or specialized ICUs
Mentorship from faculty with an interest in cardio-obstetrics or maternal-fetal medicine
Institutional commitment to maternal health equity, quality improvement, and team-based care
Seeking out programs with formal collaborations between anesthesiology, OB/GYN, and medicine departments. Participation in national societies such as SOCCA and SOAP provides essential networking, education, and leadership opportunities.
References
AuthorKyle Bruns, DO
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