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1. Profile: 
   1. Positions: Associate Professor and Staff Cardiovascular Anesthesiologist and Intensivist (Toronto General Hospital); Postgraduate Program Director for Department of Anesthesia (University of Toronto); Former member of Examination Board for Royal College of Physicians and Surgeons of Canada; Surveyor for Royal College Accreditation Committee
   2. Training: MD (McMaster); Anesthesia Residency (Toronto); Fellowship in Cardiovascular Anesthesia and Transesophageal Echocardiography (Toronto General Hospital)
2. Pitch: An incredibly variable specialty where you get to make a difference in people’s lives when they’re most vulnerable in surgery. Lots of complex thinking involved, which can be hard to see from the outside. Specialty can differ significantly by practice setting.
3. Path: She initially wanted to go into surgery but didn’t like the unfriendly, aggressive environment. Then, she got interested in urgent and critical care and selected anesthesiology due its cerebral nature and ability to manage very sick and vulnerable patients. She loves working with extremely sick patients and teaching in cardiac anesthesia.
4. Philosophy: Anesthesia is really a specialty you have to experience hands-on but you can also get a lot of info by talking to residents and physicians. Keep an open mind as you will ultimately be happy in any specialty if your goal is taking care of patients!

• “Day to day application of knowledge, judgment, and critical thinking, often in life-threatening situations!”
• Very hard to appreciate specialty from distance- even if medical school offers anesthesiology rotation, you only get to see the physical aspect but not cerebral processes
• Amazing opportunity to care for patients when they’re most vulnerable and sickest, maybe beginning or ending of life 
• Surgery can be very scary for patients and they give up their autonomy and put their life in your hands so incredible privilege to take care of them!
• Many subspecialize in different aspects of anesthesiology and pain medicine, practice in intensive care on a daily basis (intubation, ventilation, vasoactive drugs, etc.) so a lot become intensivists
• Huge variety and potential for specialization but many enjoy community setting where there’s less subspecialized anesthetic care for critical ASA IV and V patients (but get to take care of more patients!)
• See many rare and uncommon diseases, literally a different day every day!
• She loves to take care of patients and develop a trusting connection with them minutes before they go to sleep (not a sleepy job!)

• She loves challenging patients and likes situations she knows how to manage
• She was driven to specialties like emergency medicine, anesthesia, and critical care where she would know how to take care of anything that comes her way.

• Negative perceptions included boredom and lack of continuity of care 
• Dr. Bahrey’s response: 
  • Boredom is a perception because you can’t see what anesthesiologist is thinking (cerebral process is 90% of the work and planning starts well before she meets patient)
  • Just as exciting when she does her job well and everything goes smoothly
  • If you like continuity of care and following patients throughout their life, this isn’t necessarily the specialty for you
    • However, you can follow-up with patients post-operatively or subspecialize in areas where you can follow patients for long time (like chronic pain)
    • She loved doing intensive care where she got to care for the same patient and their families for months!
    • It is mostly an acute care specialty like emerg or radiology with significant but brief interactions

• Other stereotypes: 
  • Anesthesiologists are just side people in the OR and surgeons are in charge
    • That’s absolutely not true- every patient care interaction is team partnership
    • Anesthesiologists create surgical environment that allows surgeons to operate, care for patient during traumatic surgery, consider and manage surgical positions and hemodynamics of patient
    • Not at all like Gray’s Anatomy- anesthesiologists are the leaders and experts in the OR!

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Referenced Material: Adudu et al. Medical student impressions of anesthesiology and anesthesiologists. Can J Anesth; 2010, 57: 792-793.

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• Dr. Bahrey knew she wanted to be a doctor from when she was a kid but always thought she wanted to do surgery
• She went to med school almost 30 years ago at a very different time
• She planned her first clerkship rotation in surgery and quickly realized that it was a very aggressive environment, wasn’t friendly, residents weren’t treated well
  • She didn’t want to go home and cry everyday or become a mean person as well!
  • Highlights how mentorships and experiences and med school can totally change your view of a specialty
• Her academic advisor (an anesthesiologist) told her to think about what she loved about surgery and what else would make her happy (she loved urgent care)
  • She was drawn to emergency medicine, did a lot of electives and loved it!
• She started realizing a lot of the stuff she experienced in emerg was strategically given to her (suturing, DKA, MI) but her life as an emerg doc would probably look very different
• She reconsidered late in clerkship, tried anesthesia and loved the OR environment!
• She took a convoluted path but ultimately landed on a specialty that combined all her interests
• After finishing residency, she loved working with very sick patients in cardiac anesthesia and did a fellowship at Toronto General
• She didn’t realize the cerebral nature of anesthesia until midway through residency because at the start of residency, you’re learning all the technical skills, physiology, and pharmacology and working with less sick patients
  • It’s not until you become a more senior physician and work with complex patients that you start to understand all the things you need to consider!
  • “Fun at the beginning and all goes smoothly until you get more complex, subspecialized patients”
  • Also the difference between family practice anesthesia and FRCPC anesthesiology (caring for harder, sicker patients)
• You do a lot of internal medicine in anesthesiology and she really liked internal med as a clerk (it was backup on CARMS for her)
  • The rounds and pace were very slow and sleepy though- much different perspective and approach to patient care
• Every single day is a different challenge even after 20 years!
• Your experience as a med student will be very different from a resident, which will be different from a staff physician (which is important to consider when making decisions)
• She loves medicine so much so she would have been happy in any specialty- med students should look at many different options and opportunities!
  • Don’t stress about finding the perfect discipline- it will all work out in the end

• Her interest in education came partly from going to academic center for cardiac anesthesia (she didn’t want to do research)
• Started out as undergraduate coordinator and became very involved in Royal College examination process and postgraduate training
• They didn’t have a lot of education on how to teach and she wanted some formal education in medical education
• The more you get involved, the more of a reputation you get and the more opportunities come your way
• Latter half of her career was much more directed- started planning what knowledge skills and attitudes she needed to accomplish her goals
• Encourage planning career and goal setting as early as possible- want networking and other things to escalate early

• Her love of more complex cases drew her to quaternary center at Toronto General Hospital but it’s not for everyone
• There’s a lot of anesthetic care not even in the OR (remote anesthesia- sedation for critical procedures, cath lab, care for endoscopy patient), also people who work in different environment like private clinics, pain clinics
• Community setting is also very different- rapid turnover, smaller cases, less sick but more patients, different procedures 
• Really understanding what part of anesthetic care do you want to practice on is important, sometimes lifestyle is major factor
• In rural setting, not enough anesthetic care unfortunately (lot of family practice anesthesiologists doing simple procedures and the complex cases brought downtown)

• Her weeks are different than a usual anesthesiologist since she’s a program director
• Anesthesiologists have to be morning people and even earlier for residents (set up rooms and morning teaching before operations even start)
• She gets up at 5 am and gets to work by 7, earlier if teaching (as early as 6:30 if complex cardiac case and no resident with her)
• Most of them review patients the night before and start planning for the next day
• After setting up rooms, most ORs want patients in by 7:45 (meeting them by 7:15 and know all about them from the night before or colleague’s preoperative assessment)
• Induction of patient is most important part of day (application of monitors, securing airways)- critical, emergencies could happen, then cerebral component starts (blood gases, monitoring patient)
  • If she’s doing cardiac case or transplant, it’s go, go go! (constant vigilance and movement of vital signs to specific targets)
  • If less intense, you could have an easier day (smooth course after induction but vigilance and thinking 3 steps ahead still crucial)
• Then prepare for emergence of this patient, induction of next one, thinking ahead to next few patients depending on how many you have that day (could have only one or multiple patients)
• For Dr. Bahrey, it’s mostly cardiac patients, transplants, or cancer surgeries
• If it’s an office day (Tuesday or Thursday), she’s doing program director work, caring for residents, and other responsibilities
• She maybe on call couple times a week (usually one weekend a month or every 6 weeks on average)
  • Anesthesiologists don’t have more than 24 hours call and get next day off (usually calls are 16 hours because very busy)
  • Many community sites do 24 hour calls because not as consistently busy but complex cases
  • If at a site where there aren’t many emergency surgeries at night, might get up to 6 hours sleep during call!
• Very complex cases so her days are long (might stay anywhere from 4 to even 9 pm depending on call), she stays late like once a week 
• Usually OR days are Monday, Wednesday, Friday unless she’s post call
• They do vascular surgery, general surgery, hepatobiliary, ENT, huge variety of cases (the more complex and urgent, the more fun it can be- making a difference in really sick patients’ lives can be super rewarding!)
• Remembering that you went into medicine to take care of patients can increase job satisfaction 
• The feeling of bringing the patients into the OR, the feeling of putting on the monitor and taking over, the excitement- you can’t experience these by just reading about it
  • It’s a part of the experience most people enjoy in anesthesiology rotations and electives

Personal Story:

“The patients who die and don’t wake up are the hardest patients. They stick with you. I still remember as a medical student the first unsuccessful resuscitation–it was the first time I saw a person die. Did I do everything I could and make those moments the best possible for the patient?… Even if you did, it’s so hard, especially if it’s a young patient. I still get emotional when I think about those patients… It shows that you care, and you’re a good physician, that you’re appreciating the importance of your role. Hopefully that’s why we all went into medicine.”

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Takeaway: As human beings, it is okay (and normal!) to be sad and emotionally impacted by your patients–empathy is key to being a good physician.

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Note: While we tried to keep these transcriptions as true to the speaker as possible, some dialogue is paraphrased and/or edited for easier reading.

• You really have to get some experience in anesthesia and there’s so many different aspects to explore!
• Talk to residents in the program and ask them how they made their decisions and how their day-to-day life is. Be open to learning about the specialty from talking to people as you can never experience everything from an elective.