Ask Me Anything: Dr. Christopher Choukalas, Academic Anesthesiologist and Intensive Care Physician

Dr. Choukalas is an academic anesthesiologist and intensive care physician. He is Co-PI on a study investigating the role of sleep, activity, and physical therapy in postoperative delirium and cognitive dysfunction; consults for medical device marketers; leads process improvement/systems redesign efforts using lean methodologies; and thinks and writes about the larger world of healthcare structure and policy. His work includes a book chapter on occupational exposures in anesthesia practice for Miller’s Anesthesia, the pre-eminent text in the field.

Note, this interview has been lightly edited for clarity.

Kyle Magatelli:

Dr. Choukalas, if you could tell us a little bit about yourself, that would be awesome.

Dr. Christopher Choukalas:

Sure. You bet. Thanks Kyle. Well, my name’s Chris Choukalas and I am an anesthesiologist and intensive care physician. And I am at the University of California, San Francisco, and spend most of my time at the San Francisco VA medical center. I do a whole range of anesthesia cases. I take care of intensive care patients in a medical ICU and a surgical ICU and in a neurosurgical ICU. So my practice is very broad. I have no two days that are the same which I’m looking forward to telling you guys all about. And I am recently, well, almost two years now a new parent at the rip age of now 47. So I’ve got two toddler girls at home which makes work in some ways, a lot easier actually. And I think parents of young children know exactly what I’m talking about. So that’s what I do. My hobbies, as with most people in medicine, are few and have only gotten fewer during the pandemic and, and fatherhood, but still try to get out on the road, bike and some of these beautiful roads and Hills and mountains in the Bay area. And mostly just spending time outside as much as possible. So that’s me in a nutshell.

Kyle Magatelli:

So first question, how and why did you choose the medical school you attended?

Dr. Christopher Choukalas:

Sure. So I attended the University of Minnesota medical school, which was my home state institution. And I applied broadly and I interviewed broadly and I was accepted and wait-listed somewhat less broadly, but still broadly. And ultimately it was kind of a checkbox decision for me in the sense that, you know, you asked these places like, well, what am I gonna get if I spend more money coming to you, as opposed to my state school, like, are your residency match statistics any better? Is there something about the curriculum that’s gonna be better? Are my prospects gonna be better? Am I gonna make more money or, match in a better specialty? And it was really difficult for anybody to answer that question with any kind of clarity. And so when faced with the huge difference in tuition it was an easy decision for me.

Now it just so happens that the University of Minnesota is an excellent medical school, so it was not a hard decision to make, but, but really it came down to tuition and just the sense that my prospects there would be just as good as any other more expensive place that I could have chosen. I think too, you know, all the other places were out of state and I’d never really lived out of state before, at least not that far away. And I think being close to family and friends was going to be important for me. And it was because I was broke through school and I had friends to buy me beer and pizza. So it worked out to my advantage.

Kyle Magatelli:

That’s always a good thing to have at any stage in life.

Dr. Christopher Choukalas:

Absolutely.

Kyle Magatelli:

Okay, awesome. So next question. Why did you decide to pursue your specialty?

Dr. Christopher Choukalas:

This was a very difficult and very personal decision process for me. I didn’t have any physicians in my family. I’m the first and other than seeing my primary care doctor as a teenager, I didn’t really have any memories of what a doctor did, but when I started my clinical rotations, I was impressed by a couple of things first that so many of the rotations had as my job to write a bunch of stuff down on paper for people to do to the patient and then to come around the next day and figure out why half of the things didn’t get done. And the actual work was so far removed from the patient itself. And by the way, something that’s only gotten worse with the advent of the computerized medical record. It just felt so removed from actually touching the patient that it felt kind of boring and also it didn’t really feel like doing medicine. The other thing that impressed me is that I did neurosurgery as an early rotation. And I think what I encountered was that people doing surgery were pretty miserable and unhappy and not very nice to be around. So what did that leave me with? I wanted to be in a specialty where you are actually touching people and doing stuff to them in a direct way, but that cutting into people, made you a jerk, at least that’s how it looked at the time. So once I started doing my anesthesia rotations, it just felt ironically more like what I thought being a doctor was, where you’re actually kind of there with your patient, you’re doing stuff and something happens and you do something different. And that just felt like what doctoring would I imagine doctoring to be but in a more immediate way.

I still did pursue surgery in the form of ENT residency actually, and my grandfather who served in World War II, it turned out, had been a, a medic for an ENT surgeon in the war. And around the time that I was having to make decisions about matching, he died. And I learned all these things about him, basically at his wake the day before the ENT early match forms were due. So suffice to say, I spent a lot of time and stress thinking about, well, is this a sign? Should I be trying to match an ENT after all? And in the end I didn’t. And I withdrew and I went straight for the regular match for anesthesia and have been very happy that I did.

Kyle Magatelli:

That’s awesome. So how did you become involved in intensive care? And can you please tell us a little bit about the training and role of an intensive care physician for anyone who may not be familiar and by anyone I mean me, because I don’t know anything about it

Dr. Christopher Choukalas:

Yeah, yeah, absolutely. So intensive care is really the care of patients that are too sick to be anywhere in the hospital other than the intensive care unit. So traditionally you might think of that as like patients on life support. So who’s on the ventilator, who’s on life support drugs, who has maybe had cardiac arrest, who might be on mechanical device support, who might have injuries so severe that they have equipment in them that can only safely be used in an intensive care unit. And I got interested in that part directly through work in anesthesia on the mechanical side. So sort of like running and managing the life support, organ support, kinds of things. That’s a very natural extension of what an anesthesiologist does in the operating room. The techniques are similar, the medications are similar, the goals are similar.

And but then from sort of a medical diagnostic standpoint is really different from what we typically do. So while there are a lot of pathways to train to become board certified in intensive care medicine, each of those fellowship paths might look a little different. So for example, if you’re an internal medicine person wanting to be an intensive care doctor, you would do a fellowship in pulmonary medicine critical care. You’ll focus a lot of time on perhaps, the more mechanical and management aspects of the care. As an anesthesiologist, your fellowship might focus a little bit more on the medical diagnostic side. And so those are the things that you wouldn’t have necessarily had in your residency, but now, you know, neurologists can become intensive care physicians, emergency medicine physicians can become intensive care physicians. So for me, for an anesthesiologist, it was a one year fellowship for an internal medicine person because it’s combined with pulmonary medicine, it’s usually three years of fellowship, emergency medicine is usually two. And so it really varies in terms of which specialty you come from. And I would add to that too, that surgeons train to be intensive, that’s usually combined with trauma surgery and that’s a two year fellowship.

Kyle Magatelli:

Wow. So with the time involved, it sounds like you’d have to have a real passion for that kind of work.

Dr. Christopher Choukalas:

Definitely as anesthesiologist, you know, you’re doing it’s, I suppose you could say it’s one of the shorter pathways in the sense that your residency’s four years and it’s a one-year fellowship. When I have trainees come to me and say, I’m thinking about doing fellowship X, I always run down the numbers for them because, you know, a year of lost income invested, you know, over the course of your career comes to a very large number. And so you really wanna be sure that you wanna take that extra year to get that extra training, because it’s costing you a lot of money over the course of your career to spend one more year out of the workforce. Intensive care is one of those things that you really can’t do without the fellowship. So in a way it’s, it’s kind of a moot point, but yes, you do have to want it because it’s more time. And then when you’re working, it’s often, you know, more weekends, more nights than what your non ICU anesthesiologist colleagues are likely doing.

Kyle Magatelli:

Okay. Thank you for expanding upon that. Sure. So how’d, you become involved in academia with anesthesiology rather than just being solely focused on practice?

Dr. Christopher Choukalas:

You know, it never, I mean, to me being an academic physician is as different from being a private practice physician as being, as being a cop versus a fireman. You know, they’re vaguely both in the public safety sphere, but the jobs are totally different. And to be honest, it never really occurred to me to go out into practice. I was always interested in being part of a large group, academic inquiry focused group, being at a big place that did lots of complicated things on sick people. Like that’s just what I, that’s just what I liked. I learned early on even before medical school, that a big part of my identity was, I don’t wanna say academic prestige, but I just, there’s something about being part of a large thriving university setting that’s very satisfying and very fun and very interesting. And so it was, to me that was plan A from the very beginning. And I never really saw myself in any other light. Now having said that, you know, I’ve been out 12 years, I got loans to pay. I’ve now got two toddlers, which I keep referring to. And the cliche is true. Once you have kids, everything changes. And I have had to start reexamining that decision, because I work a lot of hours, you know, I’m paid well, but not as well as out in some private practices. And so I’ve had to at least consider whether I could be happy in a setting other than the one that I’m in.

Dr. Christopher Choukalas:

As we age our priorities change.

Kyle Magatelli:

Yeah. I’m finding that one out myself, not enjoying it, but finding it out

Dr. Christopher Choukalas:

<laugh> fair enough.

Kyle Magatelli:

Okay, you know, I didn’t include this, but just to dovetail a little bit, can you tell us about what piece of published work are you most proud of or has been the most interesting for you to have been involved in?

Dr. Christopher Choukalas:

Well, so that, <laugh>, that’s a really funny question because if you, so a few years ago, well, I, I mean, people probably haven’t read my CV, but I, before going to medical school, I was in a doctoral program in counseling psychology. And I, I left after the master’s degree to do my pre-med. So I didn’t finish the PhD, but I published a few things along the way. And one of them was a statistical manual for how to make SPSS, which is a statistical programming language, how to make it do a particular thing that facilitated the analysis of these large data sets for this research institute on like family dynamics that I was, so I was part of this research Institute as a graduate student. And they did work on family communication episodes, and people would videotape families having discussions about things and then experts would rate them for certain behaviors and then I would analyze the data and so I wrote the statistical manual to do, to make a program, do a thing. So pretty dry, really technical, really boring. And if you ask me how to do it today, I, I would probably have a stroke, but when I Googled myself partway through my academic career, I’d published a bunch of other stuff. I mean, I’m a co-author of this, of Miller’s anesthesia. I have published a handful of things on COVID and on resource utilization and delirium, but I’ll tell you the thing that gets more hits and more citations by far is this quirky, wonky, statistical manual that I published in Ames, Iowa, like 25 years ago. <laugh> that I haven’t thought about since. So is it the thing I’m most proud of? I don’t know, but it’s certainly the thing that has generated the most interest since being published.

Kyle Magatelli:

Okay. Interesting.

Dr. Christopher Choukalas:

You simply, you simply can’t know what’s what people are gonna respond to. It’s really true.

Kyle Magatelli:

I mean, I’ve had to do data analysis and it’s terrible. Any tool that you can get to help make it a little easier, especially if someone else suffered, so you don’t have to

Dr. Christopher Choukalas:

I suffered

Kyle Magatelli:

Oh yeah.

Dr. Christopher Choukalas:

I suffered. I suffered greatly.

Kyle Magatelli:

All right. Awesome. Okay next question. What does a typical day look like for you?

Dr. Christopher Choukalas:

People are fond of saying there’s no typical day. And that kind of is true, each week for me, is a little different in the sense that some weeks I’m in the intensive care unit and some weeks I’m in the OR. The weeks that I’m in the intensive care unit, some of those weeks are at the VA and some of those weeks are at the university. So the VA weeks I drive to work, the university weeks I walk to work. So just the very, even the beginning of the day is just totally different. Obviously in ICU week, you know, I go to my office, I will look up the patients, try to do frankly, a little pre-rounding on myself, because you always wonder like why your attending seems to know more than you do, even though you’ve spent all this time, you know, pre-rounding on the patients is because we get there first. There’s no work hour limitations for your boss. But I try to look up the difficult patients, the complicated people review, whether anything’s happened overnight, there’s an ever growing list of huddles to attend and then we round, we talk about patients as a group. We go around, look at everybody, touch everybody, look at the labs, look at the x-rays talk about what we think the diagnosis is, what we wanna do. And then I write a bunch of notes because notes are how the hospital gets paid.

And then I teach, I go around with the medical students. I go around with the interns and residents and we do some kind of teaching rounds and sometimes that’ll be having them touch every bit of plastic in the room and see where it touches the patient, where it touches the machines and what it actually does. Sometimes we’ll do ultrasound rounds where we’ll go and look at people’s hearts and lungs and other body parts on ultrasound. See if there’s inferences, we can make about their physiology. And sometimes it’ll just be a question and answer session about like what we did today, why we made the decisions that we made and that’s that day, the operating room totally different I come to work, I get to my office, I look up the patient <laugh> so that sounds the same.

But then I go and see people and, and sometimes I’m working by myself. Sometimes I’m supervising residents and sometimes I’m supervising nurse anesthetists. So which of those I’m doing will determine kind of what, you know, what my day looks like, obviously with the residents, I’m doing a lot of teaching and I’m sort of patiently watching them try things, generally with a high degree of success, but we at the VA get residents in their very first year. And so they tend to be less experienced. So that means I get to do more with the nurse anesthetist, we have a really capable experience group here. So I’m usually doing less, but they’re often curious about decision making as well. So those are usually thoughtful and interesting discussions with them about sort of how we’re gonna tackle a problem, community relations with surgeons about why this is happening or that’s happening. And I basically spend the whole day either talking to patients, working on patients or communicating with other people about those patients.

Kyle Magatelli:

So it sounds like you’re just really busy all the time.

Dr. Christopher Choukalas:

It’s pretty busy. And they’re you know, once they’re out of the operating room, it’s not really over. So we’re managing them in the recovery room. We’re often helping to manage that transition to the intensive care unit for those patients going there. And, you know, because we are interested and because we care and because the patient deserves it, we often stay involved, you know, for hours. And sometimes days afterwards, when there are issues either with maybe they’ve got an epidural in that needs to be managed, or maybe they remained on the ventilator due to some complication, and we’re working with the intensive care team on what happened and why and what, where to go next. So there’s a, there is a, there is some continuity even in this field.

Kyle Magatelli:

Okay, excellent.

Dr. Christopher Choukalas:

I actually had, I wanna, I wanted to say one other thing because we don’t usually think of anesthesiologist as having continuity of care, but the other night on call, I actually had a patient come in for an emergency upper endoscopy for a GI bleed. And everybody was saying, oh, this patient has a history of difficult airway. They had some failed intubation attempt years and years ago. And somebody had to come into the room and do a slash cricothyrotomy on the patient, basically a neck incision and then a breathing tube inserted through the neck. And gosh, isn’t that terrible? What are we gonna do? And I’m thinking to myself, I’m pretty sure that was me <laugh> and I looked at this guy’s record and sure enough, I had trached this guy back in 2011 and here he is coming in now with this history of difficult intubation for an emergency procedure. And I happen to be on call. So even in anesthesia, you can get very interesting continuity of care.

Kyle Magatelli:

Pretty low odds on that one. That’s interesting.

Dr. Christopher Choukalas:

Pretty <laugh>, that’s you’ll do your whole career and not have that happen, but I, I was in the right place at the right time or maybe the wrong place at the wrong time, depending upon how you look at it.

Kyle Magatelli:

Yeah. Okay. Awesome. So, next question. This is a good one. What are your thoughts regarding state’s opting out of federal regulations, requiring physician supervision of certified registered nurse anesthetists?

Dr. Christopher Choukalas:

This is a highly charged topic and one that gets a lot of attention, all up and down the spectrum of policy, politics and training, residents and students wanna know like, am I gonna have a job? What about all these opt out states, are our quote unquote mid levels sort of taking over the specialty? And I guess what I would say to that is, in part of answer and part of dodge, I think the first thing we all need to acknowledge is there simply aren’t enough anesthesiologists to do every case that needs to be done. The requirement for anesthesia services is simply too high and is growing every year. There’s always some new things somebody wants to do that requires a patient, have a capable human, not just to keep them asleep, but to keep them safe. And there just aren’t enough doctors to do it. So if you’re gonna have somebody other than a doctor doing it, what do you want that system to look like? And I think that the anesthesia care team where a doctor is medically directing a small number of highly trained advanced practice nurses is a very good and safe model.

What you see in these opt out provisions is simply a way that states are responding to political pressure to expand and make less expensive the provision of services. This is largely a political ploy because these opt out provisions simply remove the requirement of physician medical direction for the purposes of billing Medicare. They don’t mean that nurse anesthetists can automatically practice independently in those states. Scope of practice is a state level, yes, but even more micro at hospital level. So if you’re, so firstly, most patients that you’re taking care of are, are not, um, are not Medicare patients. So this provision applies only to Medicare patients. Secondly, hospital bylaws almost exclusively continue to require physician oversight in one form or another. And that oversight can take different forms, but medical direction of a small number of nurse anesthetists is by far the most prevalent model.

And that’s baked into hospital bylaws. So I guess I would say that whether or not you agree that nurse anesthetists should be able to bill Medicare on their own or not is a very different question than, you know, are these, are these advanced practice nurses allowed to practice independently? And for the most part they’re not practicing independently for the most part. They don’t wanna practice independently has been my observation. And I actually think that either person, either physician or CRNA practicing alone is probably less safe than the two of them practicing together in some sort of ratio of direction.

Kyle Magatelli:

It’s interesting. I recently read an article on this and, I didn’t, I don’t recall having seen anything about Medicare in there.

Dr. Christopher Choukalas:

These are, these are CMS laws by and large. And the thing that, the thing that also needs to be acknowledged here, and I don’t want this to come across as a little bit of a dig, but people make it out that, and this isn’t CRNA versus anesthesiologist, but, you know, advanced practice nurses in general, they bill the same code to your Blue Cross or Medicare that I bill. So the idea that they’re somehow costing the system less, isn’t correct. They are paid less salary in part because they work fewer hours. There are unions and shifts and rules and laws about how many hours they are willing to work. And so it’s convenient to say that, that they are a less expensive alternative in a system that is getting more and more expensive and, therefore we should allow them to do more doctorly things, but at a granular level of what their services actually cost your health insurance provider, it is not different than what I’m charging.

Kyle Magatelli:

That’s interesting. Wow. So, so everything just comes back to money at the end of the day, it sounds like.

Dr. Christopher Choukalas:

Everything comes back to money and power.

Kyle Magatelli:

Okay. Well, that’s a, that’s a whole different thread that we’re not gonna pull any further on.

Dr. Christopher Choukalas:

That’s a different AMA <laugh>

Kyle Magatelli:

<laugh> okay. So this one, I’m a military veteran, so I’m pretty interested in this, part of your work is at San Francisco VA. How did that come about and what do you like and dislike about it?

Dr. Christopher Choukalas:

Well, I wanna talk about that. I wanna, I wanna step back very quickly to the last question and point out that what I hope came across in that discussion is that I actually think working together is safer than the other models that exist. And I feel that way, honestly, and earnestly because the nurse anesthetists and the ICU nurse practitioners with whom I’ve worked, have been almost a hundred percent, very motivated, very capable, and very competent. And I wish that there was a way to look past some of the rhetoric on both sides so that we all could, it would all be a pretty good gig if we all just kind of kept doing what we did and took care of the patient. And I think the efforts to expand this or limit that are mostly just a waste of time, that we could be continuing to do research on policy and technologies to just make our work safer and easier.

But with regard to the VA work, you know, I never set foot in a VA before working in one other than to interview here. So this came totally by surprise for me, when it was time to finish my fellowship and, joined the faculty, the universities’ ICU’s were pretty full. They didn’t have a lot of weeks available for me. And the VA was hiring somebody here and they needed someone that could do a lot of ICU weeks. So I kind of looked at it at the time other hospitals weren’t really using electronic medical records and my data analysis interest was in large data sets, trying to analyze them to predict bad outcomes. And the VA was really the only game in town that had that. So it was this nice energy of wanting more ICU time and also being a great place to do research.

I got here and I, you know, the pay was a little lower than other jobs I could have had, but the workload was also a little bit lower. I found it to be a very functional, friendly, collegial place to work in part, you know, all the faculty here are UC faculty most were UC trainees. So we had, you know, pretty high quality colleagues here, and, you know, a reasonable workload and work life balance. And you’ll hear a lot about the VA in terms of, oh, is the quality of care good? Are people dying? You know, because there’s not enough care. And I think those are mostly overblown stories with political motivations. I think it’s really difficult to look at a VA wait list out of context and say, well, this is too long for somebody to wait, but because the VA is the only shop in town that contractually has to publish their wait times.

You don’t actually know if those are any better than in the community. An example that I’ll give as a part of an improvement project that I was involved in to try to reduce wait times for veterans seeking dermatology care. And the goal was to make it easier for veterans to seek care outside of the VA. And so we’re in a room full of high level physicians and executives, all whom, all of whom have private insurance, that’s well paid kind of looking at each other, scratching our heads and saying, well, how are we gonna get dermatology wait times below 31 days when it takes me six months with private insurance to see a dermatologist? So that was just one example that clued me into the fact that a lot of the things you hear about the VA aren’t necessarily reflective of what’s actually happening on the ground, but that are based on political motivations to make a soundbite for somebody trying to get elected. I have found this to be a very functional, compassionate system where my ability to take good care of patients has never been hindered.

Kyle Magatelli:

Yeah, that’s been my experience a couple of times I’ve needed care. It’s, you know, I get, I got an MRI within like three weeks and I didn’t have to pay for it. I mean, that’s not endorsement for running out and joining the military, but as military members, before we get out, we hear horror stories about, oh, the VA like poor care, blah, blah, blah. A lot of that is, people, there’s a motivation to keep you in the service. So-hmm <affirmative> so you hear all kinds of horror stories about how, yeah. You’re going to the VA, you’re gonna be unemployed, et cetera, et cetera. So that hasn’t been my experience at all. The VA’s been I’m in the Los Angeles system. Uh mm-hmm <affirmative> yeah. It’s like you said, it’s, you know, functional streamlined, the physicians have been very focused on providing quality care. There’s been follow up and continuity. It’s been a pretty positive experience. So I’m glad to hear that that’s what you’re, you know, you guys are delivering up there as well.

Dr. Christopher Choukalas:

Well, and I have to say too, for your audience here, they’re mostly people that are gonna become physicians. And so they might think, well, is the VA good place to work? And I gotta tell you there have been exceptions to this month, over month, year over year, but for the most part, the work life balance is pretty fair. Like in other words, as I’ve said a couple times, you know, there are jobs I could take tomorrow that would pay me quite a bit more money, but what I’ve learned through the process of looking at some of those jobs is that I will work more for that money. That when I, when I really look at what I’m being paid and what I’m being asked to do most of the time, it is a very fair package. The benefits are terrific, I get plenty of vacation, the retirement has changed over time. And so while, while I still get a pretty good 401K match and I don’t have to contribute much to the pension, I think that as people have joined later, I think that those things are slightly less generous, but still very good. And I just, when I look at like what I’m gonna have in retirement, if I stay for 25 years or however many years, it’s very very good. Am I getting, am I getting rich? I’m not. But it’s, you know, it’s enough and I have enough, my job is not so intense most of the time that I’m stressed out or, you know, can’t go home to see my family or take the trips that I wanna take. Honestly, it’s a pretty fair gig. And I think that, I think that people should really look at the VA and this isn’t a plug, I don’t care if you can work for me or not, my course is set here, but I’m, having looked around I’m surprised at how fair and how good the package actually is.

Kyle Magatelli:

Yeah. That’s a lot of people don’t, think about how much vacation time you get with the federal government. It’s more than you expect. It’s very fair.

Dr. Christopher Choukalas:

Well, I’ll tell you, I get six weeks, plus there’s three weeks of sick time. Plus you get 12 weeks paid full leave when you have a kid, now, my kids were born one month before that went into effect so I did not get that, but I had saved up about five months of sick time. So I had five months of of paternity leave. When my twins were born, drove my wife up the wall, having me home that much, but I had it.

Kyle Magatelli:

That’s more vacation time than you get in the military. Also in the military fun fact kids, you don’t get sick time, they just pump you full of <laugh>They give you a cold pack and tell you to get back to it. You gotta be pretty messed up to, to get time off for being sick.

Dr. Christopher Choukalas:

No, you don’t get sick time in private practice either. You’re not working. You’re not paid. If you’re not submitting a bill, you’re not getting paid.

Kyle Magatelli:

That’s interesting. I’m glad you expanded upon that because the VA’s something I’ve thought about. Yeah, working with veterans is something that’s close to me. And I didn’t know all that about the compensation package. I mean that vacation and sick time alone is massive.

Dr. Christopher Choukalas:

Well, and I never have to think about a bill. I never have to think about whether the patient is insured. I never have to think about, well, this guy has blue cross and that guy has medical. What am I gonna do for it’s for somebody that’s not a business person, that’s not primarily motivated by, by eeking out every possible dollar. I have to tell you, I sleep really well at night knowing that the care that I provide and the way that I think about my patients is never impacted by how much we’re gonna get paid for doing the things that we’re doing to him.

Kyle Magatelli:

Yeah. Wow. That’s awesome. Thank you for giving us a detailed answer about that. Absolutely. So, next question here, getting close to the end of our list. If you had to do it all over again, would you still choose your specialty? Why or why not? Do you ever stay up at night wondering, should I have gone ENT or, you know, tell us a little bit about that.

Dr. Christopher Choukalas:

I did for a while, think about whether I had made the right choice. I think when you go through internship you are working in a team you’re, you’re kind of treated like a doctor, you have a little bit of control over your own time. You know, if you need to stop doing your pre-rounds to go to the bathroom and to get a coffee, like you can do that. And when you’re, when you finish intern year, you’re the best intern you’re ever gonna be. And then you start all over as an anesthesia resident. And instead of, thinking and writing, you’re kind of thinking and doing, so you’re really bad at everything. <laugh>, you’re all the people that you met and worked with as interns are all gone. So you’re working with a whole new crop of people doing really badly at things that you don’t know how to do.

And for me, that loneliness was very difficult and very stressful. And it, it really made me second guess my decision. And until I was in about a year, when you start to feel a lot more confident in what you’re doing, I really, there were times where I thought I might have made the wrong choice. I think like everybody says, you know, eventually residency ends and it gets a lot better and it did. And I think that, I think the way that I feel about being a physician now as an attending is really different than how I felt about being a physician as a resident. And I think I had as a resident, you know, you’re looked down on anyway. And I think as an anesthesia resident, you’re surrounded by surgery residents most of the time who, you know, look down at everybody.

And so it was really hard to have confidence in what you’ve chosen. And there’s such a, an artificial hierarchy in medicine about if you chose this or chose that, you know, what does that say about who you are, how smart you are, you know, what kind of person you are. And I think outside of academia and outside of the training paradigm, a lot of that disappears. And so it’s been a lot easier as a faculty member and as an attending to be more confident and more proud of what I chose and what I do. And then I would add to those lifestyle factors were really important. I know that if I were running a surgical practice and paying a staff and running an office and drumming up business, trying to keep, you know, keep the lights on, I think that I would be really stressed out by that. I think knowing that, you know, patients were dependent upon me, you know, even when I’m not there, that’s hard and that’s stressful for me. And so I, I think for me, the balance came out in the right place and that knowing where I am now, I would go back and choose the same specialty, but it took a little while to get there.

Kyle Magatelli:

Okay. Awesome. Thank you. So last question we’ve got, and we know this is no longer a rumor. You’ve got twin toddlers at home. How do you balance your family life against the demanding profession? We know that you already drove your wife up the wall with all that time off. Yes. We got that part out of the way. What now?

Dr. Christopher Choukalas:

Yeah. Well, I gotta tell you, it has been very hard, not to get too deep into the weeds, but those first several months really into the first year, I almost certainly had, I had postpartum depression, postpartum anxiety, panic attacks. And ironically, I think being out of work made that worse because I had no escape from what was happening at home and let me be clear, there was nothing happening home. They’re fine. They’re healthy. They’re, you know, they’re they’re, but you know, the sleep deprivation and just the sheer stress and agony of trying to bring two life forms from, you know, newbornness to something that, I mean, it was tough.

You know, now it’s easier. And I think the answer, you know, the real answer to the question is like, you have to prioritize. And that means that doesn’t mean like on any given day, you have to decide, oh, I’m gonna go home and be with my kids today. But it goes farther back to like, what specialty am I gonna choose? What type of practice am I going to join? Am I going to become a neurosurgeon and work 120 hours a week for nine years during residency? Well, that if you make that choice, you don’t really get to make the other choices about seeing your family. Like, it just doesn’t, there’s just only so many hours in the day. So everybody has different priorities and different passions and different ambitions that drive them. And of course you won’t be happy if you don’t follow those. And, but you know, making choices to balance your work and family life go back, you know, to the very beginning of the choices that you make about your specialty and your practice. And then within that context, particularly as an academic, you have to start saying no to things, because there will be no shortage of things that people want you to do. And the reason that you’re taking the pay cut to be in academics is because you also wanna do those things. You wanna join this work group on diversity, equality and inclusiveness. You want to write that book chapter with your buddies. You want to, you know, help enroll subjects so that you can publish a paper, you know, but those things are gonna, those things aren’t free. Nobody’s giving you more time to do those things. So you’re doing them cuz you’re passionate about ’em, but there’s no free lunch. You know, those things are gonna take you away from home. So eventually you have to decide what’s the most important to you and start saying no to other stuff.

Kyle Magatelli:

I feel like there’s a good lesson in there much like earlier about having friends that buy you pizza and beer, you also that’s right. You need that. And you also need the ability to say no to be successful in life.

Dr. Christopher Choukalas:

Yeah, exactly. Well, and people will say things like, well, once you have kids Yike, yes, it’s harder and it’s more work, but paradoxically it’s easier because now you become so focused on what’s important that you can blah, blah, blah. I have. I’m not, haven’t gotten there yet. Like there, I I’ve definitely gotten to the point where saying yes to everything is not as important for my ego, for like how I feel about myself as a, as a doctor and as a professor in this profession. I’m not all the way there yet, but I’m, I’m getting there. And my kids now are to the point where they’re, where they’re sort of fun. And so I wanna go home and I, I don’t wanna sit here and fill out more paperwork or whatever. So I think it is definitely evolving and moving towards saying no to just about everything.

Kyle Magatelli:

Okay, awesome. So what age do children start being fun specifically?

Dr. Christopher Choukalas:

For me and a lot of people disagree with this. For me, it was the toddler stage when they started walking around getting into stuff, because I just found that that was so much more engaging and so much less stressful than, you know, the infant phase where they, you know, cry all night or scream for no reason. Or you can’t like even put ’em down for five minutes to go to the bathroom. I mean, it it’s that. So for me, like when they, when everybody else is like, oh, toddlers are terrible. I’m like, oh no, no, no, no, this is, this is where I shine. I’ll come right in there. I’m on it. I’m on it.

Kyle Magatelli:

Awesome. Thank you. Well, Dr. Choukalas, did I say it right that time? Perfect. Okay. That’s again, I apologize for messing that up after having like five walkthroughs. It’s fine. It’s just been, it’s been one of those last two and a half years, I guess you could say, Hey, thank you for taking the time outta your day to, engage with us. Sincerely appreciate it. One last question that I didn’t include on the docket, but what advice do you have for anybody looking to go into medicine or anesthesiology?

Dr. Christopher Choukalas:

Good question. I would say, be sure you wanna do it, because it’s hard and expensive and the financial and professional rewards for doing so that have been traditionally kind of automatic are not as automatic as they used to be. I love what I do and I’m paid well and yada yada, yada, but, it’s true what they say that it’s not like it was in the old days and if you’re gonna borrow 400 grand to do it, like you’re gonna be paying that off your whole life and it will definitely impact your life to have that kind of, that kind of loan burden. But if you get past that hurdle and decide you still wanna do it, my advice is to be open about the things that you might actually like in terms of specialty. And I say that because everybody in medical school from your classmates who don’t know anything about the specialties to the professors that you work under, everybody’s got an opinion about what specialty you should choose. And you wanna know the secret to life? I’ll tell it right now.

Figure out what makes you happy? Be honest with yourself about it, and do it. Sounds easy. It ain’t easy. But if you can find that specialty that you actually like, no matter what that they’re telling you, oh, this is too, this isn’t, you know, badass enough for that. That’s, that’s not a real clinician. You’re not a real clinician. If it’s what you like, you, and you can be honest with yourself about it, do it. If, if everybody in your residency program is like, oh, I’m gonna do a fellowship and I’m gonna go and work at Duke or this big academic center, these hard cases, blah blah. And you wanna go work, you know, seven to three at a surgery center because it means you’re off in the afternoon, you know, and you’re doing simple cases on healthy people and that’s what makes you happy, man, tell that classmate to shove it, figure out what makes you happy. Be honest with yourself about it and do it.

Kyle Magatelli:

Okay, perfect. Thank you again, Dr. Choukalas. Appreciate your time. Thank you for joining us.

Dr. Christopher Choukalas:

Thanks Kyle. It was a lot of fun.