By Juliet Farmer
Since 2010, Christopher G. Choukalas has been assistant clinical professor in the Department of Anesthesia and Perioperative Care at the University of California San Francisco, as well as staff physician at San Francisco Veterans Affairs Medical Center. Choukalas graduated magna cum laude with a bachelor’s degree from Gustavus Adolphus College in St. Peter, Minn., (1997), then earned a master’s degree in psychology from Iowa State University (1999). He attended the University of Minnesota Medical School, where he received his MD (2005). Dr. Choukalas then completed a residency in anesthesiology at University of Chicago Medical Center (2005-2009), and a fellowship in critical care medicine at University of California, San Francisco (2009-2010).
Dr. Choukalas is a diplomate with the American Board of Anesthesiology (2010), and
holds an American Board of Anesthesiology special certification in critical care medicine (2010). He is the volunteer anesthesia workroom director at the San Francisco VA Medical Center. Currently he sits on industry-specific committees including the University of California, San Francisco, Departmental Resident Well-being Committee, the San Francisco VA Medical Center ICU Quality Committee, and the University of California, San Francisco, Critical Care Ultrasound Curriculum Committee. He is member of the American Society of Anesthesiologists, International Anesthesia Research Society, American Society of Critical Care Anesthesiologists and Society of Critical Care Medicine. Dr. Choukalas has been published in ICU Director, Journal of Clinical Anesthesia, Current Reviews in Clinical Anesthesia, and The 5-Minute Anesthesia Consult.
When and why did you first decide to become a doctor?
It had never really occurred to me until I was already in graduate school to become a psychologist. It was so far off the radar that the only science course I took in college was geology. But there I was, in my first year of a PhD program in psychology, with a vague sense that I wasn’t in the right place. I came to really enjoy and excel at the statistics and psychopharmacology, and started thinking about maybe a transition to a neuroscience program, or a more “biologically oriented” clinical psychology program. I was lamenting the uncertainty one morning to a girl I had a bit of a crush on, and she blurted out, “It kinda sounds like you want to go to medical school.” And that was it. It was truly more of a struggle, though. I had the sense that I was “too old,” and that it was too late to change my course (all at the ripe old age of 23). The lesson, I guess, is that it obviously wasn’t.
How did you choose the medical school you attended?
I labored over the choice between my state school (a top-40 kind of place) and a more prestigious, private, East Coast school that was considerably more expensive. I spent a lot of time making lists of pros/cons (based on factors I couldn’t really comprehend first-hand anyway) and talking to admissions people at both schools, trying to figure out whether it would really make a difference where I went; would the extra money and moving away from home get me someplace “better” in the long run? In the end, I chose my state school, ostensibly for the money, but in part out of a fear of the unknown. Of course, during my time in medical school, tuition increased 40%.
Still, it was a great experience, but I often wondered if I would’ve achieved something different or greater if surrounded by a more prestigious environment. Given where I ended up today, I guess it probably wouldn’t have made much difference, but being at a relatively elite university now, and seeing the opportunities, or leg-up that the students and residents have as they apply for the next step, and the small number of places people that end up here come from, I don’t think it’s crazy to assume that going to a “better” place will give you “better” opportunities.
What surprised you the most about your medical studies?
How hard it was. I excelled at everything I did prior to medical school, and then promptly failed my first exam (an embryology quiz). I had to learn and study differently; passive reading was no longer sufficient for the massive amount of material to be learned. I was also surprised at how much people drank and partied. I hit it pretty hard in college, but in graduate school and my year in industry I was surrounded by more “mature” people. Medical school was like going back to college in that regard.
How and why did you decide on your specialty?
Like most people who match in anesthesiology, I liked the immediacy and intimacy of the work. I didn’t have physicians in my family, so when I pictured what a doctor did, I always pictured myself actually touching the patient and doing things to and for them. On my medical school rotations, though, I found that the bulk of the work involved writing things down on paper for other people to do to the patient, and then coming around the next day to see if it got done, and then spending a lot of time trying to figure out why half of what I wanted didn’t happen. I also interviewed in ENT, but ultimately knew I wanted to work in a critical care environment, and also didn’t want the stress of hiring and controlling staff (I envisioned surgeons having to be more entrepreneurial).
If you had it to do all over again, would you still become an anesthesiologist? (Why or why not? What would you have done instead?)
I think I would. It took a long time to come to terms with the fact that, at the end of the day, most other physicians and many lay-persons don’t understand what we do or why it takes a physician to do it (witness the many states that are opting-out of a legal requirement of physician supervision for nurse anesthetists to bill Medicare), an attitude that often leads to a lack of respect from others. But all that aside, I really like the actual work that I do. My academic position offers a tremendous degree of variety in my work and work setting from day to day and week to week, which appeals to me greatly, and my critical care practice offers the opportunity to fulfill the (small) part of me that wants a more tradition doctor-patient relationship than is afforded most anesthesiologists.
Has being an anesthesiologist met your expectations? Why?
I guess in some ways, it has exceeded my expectations. Residency is hard, and one doesn’t always see the light at the end of the tunnel, but I look forward to work nearly every day (jokes on me, I guess, because I actually do some work every day). The work is often fun, I like my colleagues, and when I’m in the operating room at least, when I’m gone for the day, I’m gone and I can move on to thinking about the next set of patients. I know myself well enough to know that if I had patients for whom I was primarily responsible, I wouldn’t be able to turn it off, to detach from it, and it would consume me (I see this when I’m attending in the ICU). I think for some people, anesthesiologists are perceived not to be interested in relationships with patients, or to have chosen their field because they were unable or unwilling to have relationships with patients. For me it was the opposite; I knew I would become too invested in my patients and practice, and I’d never be able to step away from it. Being an anesthesiologist lets me off the hook in that regard.
What do you like most about being an anesthesiologist?
The variety, the immediacy, the art of it. It appeals to the logistician in me, planning several steps ahead, thinking of numerous contingencies, weighing several “what-ifs” continuously, and knowing that because it’s a human being on the sharp end of the stick, the unexpected can occur. I’m not pretending that every minute is exciting, that I’m managing all sorts of acuity and emergencies all day (if my practice were like that, I’d be doing something terribly wrong), but even the mundane cases can take a turn, and even when they don’t, a perfectly timed wake-up is still a joy.
What do you like least about being an anesthesiologist?
The production aspect of it, the view that it is a commodity, often perceived to be performed by nameless, faceless cogs in a cost-center, ever under the microscope of cost-cutting. I don’t like how often I’m lied to (usually by surgeons who want me to believe their add-on is more urgent than it is, or who think I’m naïve to the gamesmanship in their schedule manipulation).
What was it like finding a job in your field –what were your options and why did you decide what you did?
I pretty much knew I was going to work for UCSF by the time I started my fellowship, so I never really had to look for a job. I did have to think a little bit about where in the UCSF empire I would work. That decision ultimately came down to where I could do the kind of research I wanted to do, and sharing time between the VA and the main university hospital really stood out as the best opportunity. There were lots of private practice opportunities when I left residency, and even fellowship, although it is not typical to do critical care as an anesthesiologist in private practice. To me, though, an academic anesthesiologist and a private practice anesthesiologist are like cops vs. firemen; they share some aspects, but in many ways are entirely different jobs, and private practice just wasn’t the job that I wanted.
Describe a typical day at work.
My days are highly variable, depending on whether I’m in the OR, ICU, or lab/office. I have a roughly 70% clinical commitment, and I split that about 2/3 OR and 1/3 ICU (roughly one week per month). Regardless, though, my days often start with some kind of lecture to residents and students, usually some ICU-related topic, although I teach residents on their OR rotations as well. In the OR, I work with both residents and nurse anesthetists. We arrive early (before 7 a.m.), see the patients together (I often supervise two rooms), do procedures (peripheral IVs, arterial lines, peripheral nerve blocks, central lines, epidurals) and head to the OR. I spend a lot of time in the room with the resident, pushing their knowledge and trying to teach them how to think critically and be vigilant. I’m often done any time between 3 p.m. and midnight, depending on the workload and where I am in the call schedule. My ICU days are a little more structured. Morning conference at 8 a.m., rounds from 9 a.m. to 12 noon-ish, then supervising, teaching, meeting with patients and families, and writing notes. My office days are spent catching up on paperwork (mostly online evaluations of students and residents, and online training/compliance modules on everything from HIPPA to radiation safety; these sorts of tasks are becoming an increasingly common and burdensome part of hospital credentialing) and managing a variety of research and administrative tasks. I’m PI or Co-PI on a handful of protocols right now, mostly related to the use of mathematical models to predict critical illness and noninvasive cardiac output measurement, and these things take up a lot of my spare time/mental energy.
On average: How many hours a week do you work? How many hours do you sleep per night? How many weeks of vacation do you take?
It varies, but it’s rarely less than 50, rarely more than 70. As an intensivist, I probably work more weekends than a strictly-OR anesthesiologist, as my ICU weeks are seven-days-on. Anesthesiology is one of the few specialties that often requires an in-house presence (usually at least to cover emergent airway issues and codes). This means that, although some of your days might be shorter than those of your surgical colleagues, you’ll spend a lot more nights sleeping in the hospital, including weekends and holidays, even into older age. I get five or so weeks of vacation per year.
Are you satisfied with your income? Explain.
I think it’s human nature to want to work less for more money, and I think it’s easy to look at the income of other people who required less education and have less stressful/important/demanding jobs with a jaundiced eye (lawyers, finance people, and the bevy of hospital executives who seem to make their money by getting you to do what they want via “quality initiatives” come to mind). There are a number of forces that seem to be conspiring to ensure physicians will earn less money in the future, but at the end of the day, I enjoy work and look forward to work almost every day. Of course, choosing to live in an expensive city probably changes the outlook a little, and I certainly wouldn’t want to earn any less.
If you took out educational loans, is/was paying them back a financial strain? Explain.
I had a pretty sizable debt from college, grad school, and med school. I made the decision to defer as long as possible, and then forbear through residency, reasoning that I had a very low interest rate, that life was hard enough during residency without the additional stress of making loan payments, and that whatever modest sum I could pay during residency wouldn’t make enough difference to justify the additional hardship. I don’t regret that for a second. My payments amount to a little under $1,200/month, and the money just disappears from my account; I don’t notice it or think about it. I wouldn’t have the job I have today without the loans, so I can’t get too bitter about paying them back.
In your position now, knowing what you do – what would you say to yourself when you started your anesthesiology career?
Career-wise, I’m not sure I’d do anything different. Like any job, though, it’s important to get whatever is promised to you in writing. That and I think in academics, we’re sort of discouraged from talking about money, as if you’re supposed to be grateful to be able to work for the University. You’ve worked hard for your skills and you deserve to know the numbers behind your employment. The world, including your warm and fuzzy academic department, would kick you in the nuts, given the chance, so you have to look out for yourself.
What information/advice do you wish you had known when you were beginning medical school?
I didn’t know what an anesthesiologist or ICU physician was when I started medical school, I’d never heard of UCSF, and it never occurred to me that I might want to live anywhere other than where I was at the time (Minneapolis), so my advice is mostly centered around remaining open to possibilities and trusting whatever your “gut” is telling you. Keep an open mind about your specialty. There is an intense perceived hierarchy in medicine that no one outside the hospital gives a **** about; don’t fall prey to other people’s biases about what drives you. Try not to let others’ opinions determine what you want and what you value. And try to see what the attending is doing on each rotation, rather than letting yourself get mired in what the med student version of each specialty is. That and make sure to devastate Step I. Everything else gets much easier if you score well.
From your perspective, what is the biggest problem in health care today?
The physicians are being turned into “labor” and business people are taking over at “management.” I recall as a resident being told that one of the drugs we used was expensive, and that there was a cost-cutting measure to use a cheaper substitute. Over a few months, we’d saved tens of thousands of dollars, but guess what? The people actually taking the (admittedly small) risk of using the cheaper drug did not reap any of the cost-savings. Instead, the money went to incentivize the mid-level executive who came up with the plan. That was an important lesson to learn, and the first of many examples of a person or organization without medical training basically driving practice decisions. Much of this is disguised under the mask of “quality” and “patient safety,” but mostly I suspect it’s about money. There are some great examples of CMS quality mandates that, if not met, result in less reimbursements (zero-tolerance for DVTs, perioperative beta-blockade, normothermia), even though the evidence of benefit is scant, or in the case of DVTs, the technology to succeed simply doesn’t exist.
Where do you see the anesthesiology specialty in 5-10 years?
That’s the million-dollar question. I don’t know anyone who thinks that physicians, in general, aren’t going to feel worse-off (be it financially or with regard to their station in life, or their sense of autonomy from corporate or government oversight) in the future, and I think anesthesiology may feel these insults a little more acutely than other specialties. Corporate management companies are buying out practices, these companies are consolidating, and once-entrepreneurial physicians are turning to “employment” models of work. When that happens, it’s possible that “quality” will improve through greater oversight of our practice, but it certainly gives us less autonomy. That said, I know plenty of private groups that are thriving and hiring, so there may be some regions and some arrangements that are somewhat (temporarily?) immune to these forces. The ACO model of care will present an additional challenge to anesthesiologists as they no longer merely have to negotiate with insurance companies for fee-for-service rates, but have to negotiate within their own hospital (where they often lack visibility) with administrators, ancillary service groups, and other specialists for their share of an ever-shrinking bundled payment.
What types of outreach/volunteer work do you do, if any?
Unless you count working at a VA, I don’t.
Do you have family? If so, do you have enough time to spend with them? How do you balance work and life outside of work?
I am on the verge of being engaged (if only she’d settle on a ring style.). She works many days out of town, so my work hasn’t been the limiting factor in my available family time. That said, many of my extracurricular projects (research and curriculum development) take place away from the hospital, and it gets harder as time goes by to carve out enough time for all the stuff I’m interested in doing.
Do you have any final piece of advice for students interested in pursuing anesthesiology as a career?
Don’t do it for the money or the “lifestyle.” Find something you love and you’ll never work a day in your life; it really is true.