Residents In a Room
Episode Number: 54
Episode Title: Ask an Academic Practice Attending
Recorded: August 2023
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This is Residents in a Room, anofficial podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point-of-view of anesthesiology residents.
Life as an attending
may vary quite a bit, depending on the type of practice you join after residency.
As residents, I feel
like we really don't get exposure to anything but academic medicine.
I honestly don't know
what my next couple of years after fellowship would be like if it's a private
practice or academic.
I think I still have
a lot to learn about the differences between those two.
It's just nice to
hear that there's differences and we have all different kind of options.
DR. ELIZABETH HALL:
Welcome to Residents in
a Room, the podcast for residents by residents. I'm your host, Dr. Beth Hall.
I'm CA3 at the University of Chicago, and I'm here today with some fellow
residents. And together we're going to ask an attending about transitioning
from being a resident to working as an attending. This month we're talking to
Dr. Jihye Ha, who is an assistant professor of
anesthesia and critical care medicine here at University of Chicago, where
we're recording this conversation. Unfortunately, Dr. Ha joining us via Zoom
because she has Covid. And next month, we'll share our conversation with the
private practice attending. But first, let's meet my fellow residents.
DR. NIKHIL NADLER:
Hi, my name is Nikhil
Nadler. I'm a CA3 at Loyola University Medical Center.
DR. SEAN POWERS:
Hi, I'm Sean Powers. I'm
also CA3 at Loyola University Medical Center.
DR. SHYAM DESAI:
Hi, I'm Shyam Desai. I'm CA3 PGY4 at Rush.
And Dr. Ha, can you also
introduce yourself and tell our listeners about your role?
DR. JIHYE HA:
Yes, of course. And
thank you for having me. First of all, I do apologize
for not being able to do this in person. I started having some symptoms a
couple of days ago and tested positive for Covid just yesterday. So I may sound a bit congested. As you already mentioned,
I'm an assistant professor of anesthesia and critical care at the University of
Chicago, and I work here as a general anesthesiologist. I did nearly all of my medical training at the University of Chicago from
medical school through residency, and obviously stayed on as faculty. I am also
the director of the Ambulatory Operating Rooms and also
the Associate Chair for Clinical Affairs in our department. You will often find
me in the ORs as the coordinator in the main hospital as well as the ambulatory
Great. Thank you. So Dr. Ha just starting off one of the questions that I'd
like to ask is how does the day in the life of an attending differ from that of
a resident? And what changes should we expect when we transition out of
As you might expect,
life as an attending may vary quite a bit depending on the type of practice you
join after residency. But since we're discussing academic medicine today, I'll
focus obviously on that. One of the biggest changes you might encounter is
taking care of multiple patients at the same time. As a resident in the
operating room setting, your main focus was often on
one patient at a time. However, as an attending, you may be responsible for the
care of up to four patients at the same time, especially in the care team model.
It becomes even more important to communicate well with other members of your
team, and you might need to gauge the level of training for residents and CRNAs
with whom you work and tailor your level of involvement based on these
individuals. At the same time, you might be expected to be preoping
patients in the pre-op area as well as discharging and evaluating them in the PACU.
So I often find that I'm busier as an attending
sometimes than I was as a trainee. In our institution as well as others, you
might still have opportunities to do cases solo. And of
course in these situations it might be a little bit more similar to what
you may have experienced as a resident.
So when you said you're taking care of four rooms
at once and you're going from a resident, where you're being supervised to
supervising others, what have you learned from that or and how that transition
occurs and what can you share about that with us?
I will say that
depending on your training institution and the role that senior residents often
play during calls, you may have already started to develop a sense of what it's
like supervising others. At our institution, we expect the senior residents to
act like junior attendings assisting with all starting cases in the afternoon,
developing plans with other trainees, pushing drugs for induction, being
present for emergence and being involved with floor intubation. As a brand new attending, it definitely takes time to develop
what your style of supervision might be like. Generally
speaking, it seems like more junior attendings are more likely to be
involved and hands on at first, and over time you become a little bit more
relaxed as you become more comfortable in terms of supervising others. And then
of course, after working with certain residents and CRNAs over time, you begin
to appreciate how much supervision is needed as well as how much supervision
they want. Og course you want to respect the wishes
of those you are supervising, but think the most
important thing is making sure that you're comfortable with implementing what
you think is best for patient care.
Do you feel like your
supervisory role has affected your your own skills in
any way, in any negative aspect?
Great question. I think
at first it definitely may seem that in a supervisory
role you may have less opportunities to perform procedures yourself. However,
what I've experienced is that supervising others might actually
improve my own skills because it enables me to see how others do certain
things, first of all. And if troubleshooting is necessary, I have the chance to
intervene. I know that some attendings try to keep up their skills by taking
opportunities every now and then to practice certain things like Intubations
and placing IVs, especially when working with non trainees.
Dr. Ha, why did you end
up choosing academic practice and how do you think that it differs from private
As I mentioned earlier,
I am a general anesthesiologist. I chose not to pursue a fellowship and during
the time that I was graduating, it actually seemed
like most of the providers in academic practices were fellowship trained. So
based on this, I initially was set out on looking for only private practice
jobs. However, I realized how little I knew about the private practice setting
and what to look for when choosing a job. Long story short, I did end up
staying in academic medicine because it ended up being the easier transition
for me, especially staying at the institution where I trained. I wanted to
continue practicing in a setting where I could be challenged and have all the
necessary resources to provide the best care. I wasn't sure what my long term goals would be and if I would stay here long term,
but here I am.
A few things that I did
want to point out is that there are obviously many things that differ in
academics compared to private practice -- working with trainees, the level of
resources, billing for anesthesia care and how you're compensated, patient
complexity, scholarly activity or advancement and the ability to have
non-clinical days for academic work are some of those differences. However, I
think it's also important to point out that there are
certain hybrid type of jobs out there where you still might be affiliated with
an academic institution, thus have the opportunity to work with trainees. And of course there are private practitioners who are motivated
and still do a lot of academic work. Some private practices might be MD only
type where you basically do solo cases, while others you may work with CRNAs in
a care team model or it could be a hybrid of both.
So given that you did your training at University
of Chicago, any surprises that came from the transition from resident to
Yes, there's definitely
a few things I didn't really anticipate coming out of residency. First of all, I would say the scope of academic work is very
broad and it's very important to find an area of focus earlier on to be able to
start having promotable work. Second, similar to
residency, you get out of it what you put into it. Although there are
mentorship opportunities and general guidelines for promotion, you are mostly
on your own. And then third, I would say that opportunities that you never
anticipated may come your way. For me, it was becoming the director of our
ambulatory surgery center and then later also becoming the associate chair for
clinical affairs. I never imagined I would be part of the administrative or
operational side of medicine.
So do you feel pressured by the academic ranks?
Like when you first start off, you start off usually as an instructor or a
clinical instructor, and then you get promoted to being an associate professor
or assistant professor, professor. So just kind of feeling pressured to kind of
work your way up that ladder.
I'll be completely
honest. Yes, I definitely do feel the pressure. And
this is an area that also might differ among different academic institutions.
For example, one institution may expect faculty to strive to continue
on the path of promotion, from assistant professor to associate
professor to full professor within a certain period of time. Whereas other
places you may remain an assistant professor indefinitely. So
this is obviously something that you may want to consider when looking for an
academic position as well.
If you could go back in
time and give resident Dr. Ha one piece of advice, what would that be?
have a lot of advice that I would have told myself, but one thing I
would say is always seek advice from as many people as possible during your
training regarding various aspects. Anything from deciding on a fellowship,
looking for a job, you obviously will get different opinions from different
faculty, but you will most often learn about things you might not have
previously considered. Furthermore, you can gain a better understanding of what
to look for in a specific job and the types of questions to ask when interviewing.
For me personally, I
kind of went into the interview process without as much information in the
background. And so along the way I started to learn what type of things to ask
for. But it would have been definitely helpful to know
in advance. One other advice I would say also is to involve yourself in as many
opportunities for presentations, research and attend a variety of anesthesia
meetings throughout your training, because it can definitely
be a little bit more challenging as you become more self
So when it comes to academic practice, how
important is a fellowship and do you think that that's kind of changing with
the current atmosphere? And are there any disadvantages to not having a
fellowship if you want to pursue academic medicine?
The importance of
fellowship is definitely really dependent on what you
want to practice. Academic institutions may actively try to recruit fellowship
trained providers in certain areas, depending on the staffing needs at the
time. Currently, however, there is a relative shortage of anesthesia providers
in general. So many places are obviously actively seeking general
anesthesiologists. I would say one disadvantage of not being fellowship trained
is that in academic medicine you may rarely have the
opportunity to take care of pediatric patients, practice OB anesthesia
or perform cardiac cases after training. If it is important for you to keep up
your skills in these specialty areas, you may be better off in private practice.
Or if there's one specific subspecialty, you never want to not be able to
practice again of course, that one might be something that you want to consider
for further fellowship training. At least in the past eight years or so, and
with the recent changes in the job market, I do feel that there are relatively
more residents not pursuing fellowships and going straight into practice or
considering going back later for further training after they've had a couple of
years as a generalist.
Dr. Ha, in private practice, I think we all kind of have this understanding that you quote, Eat what you kill. But in academic medicine, things are a little different. And what do you think we should know about billing in academic medicine?
Yeah, that's a very
interesting question that I feel a lot of us might not think about, especially
if you already know you're going to be going into academic medicine. But most
of the time in academic medicine, when we are practicing in the OR setting, we
don't really need to consider most aspects of billing except making sure that
certain things are documented in order for us to
actually submit the charges for reimbursement/ From this aspect, it is
definitely an advantage compared to what it might be in private practice. We
don't have to worry about the number of cases, the complexity of cases, patient
insurance or any downtime in between billable hours.
However, I do have a friend who does practice in a private setting
and he is also salary based and similarly don't have to take these aspects into
consideration as well. But it seems like in most private practices it seems
your compensation is based on your billable hours. Even in academics, paying
physicians I would say, are a little bit different in the sense that they probably a little bit more involved with billing
because procedures are reimbursed based on RVUs, but depending on the
institution, RVUs may or may not play a role in your total income.
So in differences between academics and private
practice, again, resources and personnel and equipment are very different. Can
you talk to us about the types of resources that you have in academic medicine
that you might not have in private practice? And along with that, balancing the
cost and being cost efficient with those resources.
In general, I think it's
safe to say that in academic settings we are likely to have a bigger buffer in
terms of resources in both personnel and equipment. So
for example, in our institution, we have an ultrasound in every operating room
and a large number of advanced airway equipment such as video laryngoscopes and
fiber optic scopes. If you need an extra pair of hands for a more difficult
case or procedure, you will likely have no problem finding additional help. Of
course, I didn't personally work in a private setting, but I know that during
my interview process it wasn't infrequent for me to find out that they might
only have one ultrasound machine that's shared among, you know, ten providers
or one fiberoptic scope. So that can be quite drastic. Of course, we want to be
good stewards of our resources and not be wasteful either as you mentioned. Although
I generally don't have the best grasp of the cost of various things that we
have, we generally have a, you know, a general idea. And so
it definitely is a balancing act. You know, we have to
balance the cost with the educational aspect of trying to provide training and
various techniques and using different types of drugs. But even simple things
that we can implement to reduce waste would be, for example, like not opening
certain types of equipment until we know it's absolutely
So you've talked a lot about your thoughts about
academic medicine and how your day typically runs. What do you see if you could
compile a list of the top pros and top cons of academic medicine, what would be
in that list?
As you mentioned, you
know, I did definitely already point out some things
already, but kind of a general summary of the pros of being an academic
medicine, of course, our opportunity to teach and work with trainees, the
academic opportunities that exist within the institution, and the abundance of
resources, and then also the ability to focus on care and less concern about
costs or billing. On the other hand, there are some cons to academic medicine
as well, and as I also previously mentioned, the inability to practice certain
subspecialties without fellowship training. And at times it also feels like it
might be more difficult sometimes to separate out your work and personal life.
For example, it might be harder to leave work at work and, you know, not do work
related things when you come home because of course you might have to pre-op
with residents, prepare a lecture, work on papers and other academically
What kind of leadership
opportunities do you see exist inside of academic medicine and how accessible
There are definitely a variety of leadership opportunities that I did
not previously realize myself as a resident. There are roles for section
leaders, not just in fellowships subspecialties, but also in other areas like NORA
or non based anesthesia and off site as well as
airway ENT. Within operations we have medical directors in each of the
different operating room locations. And then of course within education we have
residency and fellowship program directors, associate
and assistant program directors. And then also within faculty affairs, we have
various roles such as chairs and associate chairs, just to name a few. Since
becoming an attending myself, all of these
opportunities have actually become available at one time or another. And I
would say yes, they are quite easily, not easily accessible, but they are definitely accessible. I personally did not have any prior
training or experience in operations or administration, but currently have the
roles that I do and have received tremendous support along the way.
Yeah, I guess, Dr. Ha,
I'm wondering, do you even have a typical day given that, you know, the the wide variety of roles that you play in academic
medicine? And I'm sure we could say the same thing for private practice, but
I'm just wondering in general if it's possible, can you summarize what your day
as you, Beth, may have seen, oftentimes when I am clinical, I am usually
coordinating the main hours ORs the dcam. So, you
know, my role is probably a little bit different from some of my colleagues.
But as the role of being the coordinator, oftentimes I have one operating room
that I am paired with a nurse anesthetist and in addition to, of course, taking
care of the patients that are assigned to that operating room, working in
collaboration with the OR nursing to move cases around if necessary. You know,
putting cases on from the add on board to to certain
rooms as they come out, moving personnel around. And at the same time, I'm also
responsible for making the assignments for the next day. So that can take up
quite a bit of time.
The days rarely where I
am not coordinating, obviously, you know, I oftentimes most of the faculty
within our institution are supervising, you know, 1 to 2 rooms, whether it's,
you know, two residents or one resident and a CRNA or two CRNAs. But I think
that's a little bit more straightforward in terms of how that day goes. From
your experience, even as a resident.
With being at a large
academic institution, did case complexity play any role in your decision to
stay in academic medicine?
Yeah, definitely. And I
did briefly allude to that earlier. Coming straight out of residency. I definitely wanted to maintain my level of comfort in doing
more complicated cases. And so that definitely was one
of the major reasons I decided to stay in academic medicine just to continue
having that keeping up with those skill sets, I guess you can say.
And kind of piggybacking
off of that, as health care advances and we have more
and more treatment options, patients are becoming more complex. What are you
doing to kind of stay up to date on new technologies, new diagnoses, new
surgeries, new anesthetic techniques? And how do you kind of do that on a daily basis?
might say that being in an academic setting is an advantage from that
perspective. So, for example, you know, of course, as a practicing provider,
you're expected to keep up with your education, as you mentioned, and you, you
know, need a certain amount of CMEs and everything
like that to maintain your anesthesia accreditation, as you can say. But in
most academic settings and especially in ours, we have weekly educational grand
rounds that we can learn about some of these new things. And of course, there's
an abundance of colleagues who subspecialize in areas where they could more
focus on certain advances in a specific section, and then they can then share
that information with the rest of the department. But outside of that,
obviously, as in private practice, you need to also play a major role in
keeping up with literature and subscribing to, you know, anesthesia updates and
being involved in nationwide anesthesia groups and things like that.
Pretend you're a right
now a CA3 who's about to embark on finding their next job and they've decided
on academic medicine. What are things that you think they should know before
they accept a job or things that they might should ask during the interview
Personally, I didn't
really interview with other academic places, but from what I can think of, you
know, you obviously have to know how much
administrative or non-clinical time that you may be provided to be able to
pursue your academic objectives. So, you know, how much non-clinical time do
they provide? How does that affect your compensation? How much mentorship
opportunities is there? Is there a structured way of
achieving the path to promotion? Those are all things that you probably want to
know when looking at different academic institutions.
All right. So enough
about me. Obviously did a lot of talking here. So I
would like to flip the table a little bit and take this opportunity to ask you
guys questions as well. So first of all, I don't
personally know a few of you, so I'm just curious to know, since you guys are
all CA3s, you probably might have an idea of whether or not you're pursuing
fellowship. And also on top of that, whether you're thinking
of private practice or academics. If you guys could take a chance to talk about
Oh, sure, I'll start. So I am pursuing a fellowship. I'm doing cardiac
anesthesiology. And I think for a lot of the reasons that you talked about, Dr.
Ha, I'm really interested in staying in academic medicine. But it's also
interesting as residents, I feel like we really don't get exposure to anything
but academic medicine. I want to stay open minded but that I think I will end in
For me, I'm pursuing a
pain medicine fellowship and after that I honestly don't know what my next
couple of years after fellowship would be like, if it's a private practice or
academic. But I know ultimately at the end of a couple of years of whatever I
decide, I eventually want to have a solo private practice.
I am also pursuing a
fellowship in pain medicine. As of right now, I am not totally clear on if I
want to do academic or private practice pain management. I think I still have a
lot to learn about the differences between those two.
I'm also pursuing a pain
medicine fellowship. I think the first couple years out of fellowship, I definitely want to be able to kind of do a mixture of pain
and also some anesthesia. And just based on what I know so far, I think that
it's a little bit easier to kind of finagle a position like that at an academic
institution. But I'm also pretty open minded, I think
as years go on, I do want to just transition to solely pain medicine. So
potentially down the road, just private practice, but I'm not 100% sure on that
I didn't realize that the majority of you guys would be going into pain medicine,
so obviously this podcast didn't really talk at all at all about pain medicine,
but I did have a little, little blurb about it. But sorry I wasn't
able to talk more about that. I guess overall, based on the topics that
we did discuss, was there anything that surprised you guys?
I think it's always
interesting to hear about the promotion pathway for attendings in academia
because I think it's something that is not very resident facing. So I don't I don't know what it's like to go from assistant
professor to professor and the requirements and to fulfill that in a certain
period of time, potentially. And like you alluded to, Dr. Ha, how much
non-clinical time you get to achieve those goals. So that's all
new information for me that I'm going to need moving forward and
thinking about different opportunities and what's best for me. So thank you for bringing that up.
I was actually
going to say the same thing. I honestly, at our institution, I don't
really know what the big difference between an associate or assistant professor
is. I know a full professor is obviously the highest, but the promotion aspect
is just something I was unclear about kind of walking in here.
Yeah, I think one of the
things that, you know, is not surprising, but is always. you know something I
think about when especially when it's brought up, that your job as an academic
attending can look a lot, your day can look a lot different than what it was
maybe just a month ago when you were a resident, let's say, and how much know
your day can change just in that one month. You know, going from a resident to,
say, an academic attending.
Yeah, I kind of echo
everything that they've said. It's just nice to hear that there's differences
and we have all different kind of options to to kind
of pursue what our interests are and not kind of be pigeonholed even after
residency or fellowship.
Thank you, Dr. Ha. And
thank you all for joining us for Residents in a Room, the podcast for residents
by residents. We've enjoyed the conversation and hope you have
to. Join us next month for more.
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