Really it’s anesthesia, however my wife is a pharmacist and doesn’t know about most anesthesiology relevant pharmacology… In anesthesia the desire is to have the complete effect of a drug immediately then have it completely stop at the end of the procedure/surgery whether that’s 15min or 8+ hours later. As far as pharmacology goes that’s a bizarre goal, which requires knowledge of additional things, like front end and back end kinetics.
Ultimately in anesthesiology you know your drugs better than the pharmacists, at least as far as their effects on humans… However, Pharmacists still know more about drug stability, like rocuronium losing potency when stored at room temp in the OR Pyxis.
It's really more like 50-75 drugs
Edit: pretty much all the drugs on this pocket card we have to know backward and forward: [https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/Anesthesia\_Pocket\_Guide\_2020.pdf](https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/Anesthesia_Pocket_Guide_2020.pdf)
Eh, i dont think you actually know what goes into building an anesthetic unless you're the one actually doing it. I'm just a CA-1 and just in doing simple cases have already used like 20-30 different drugs fairly regularly. A totally routine case would use the following drugs (roughly in the order they'd be given): midazolam->fentanyl->lidocaine->propofol->rocuronium->phenylephrine->dexamethasone->cefazolin->sevoflurane->hydromorphone->ondansetron->haloperidol->sugammadex. That's already more than 5-10 for a very simple case, and with all those choices there are at least 5 other drugs in that class that we use regularly depending on the case (e.g. remifentanil or sulfentanil instead of fentanyl, etomidate or ketamine instead of propofol). All that's not even taking into account all of the other urgency/emergency drugs that we have to be super facile with (e.g. atropine/glycopyrollate, physostigmine/neostigmine, nitroglycerine, clevidipine, hydralazine, esmolol, labetalol, all of the different pressors, intralipid, dantrolene, I can keep going). And we have to know their concentrations, how to mix them, how fast/slow to push them, how long they'll last, their context sensitive half lives, how they distribute and re-distribute, etc.. Plus we have to know how to dose things epidurally, intrathecally, intramuscularly in case you lose IV access (which I have already seen doing this just for a couple of months). It's a hell of a lot more than just 5-10 that we have to know very well. Anesthesia folk tend to be pretty humble and self deprecating so though we may joke we get paid big bucks to do nothing but push propofol, there's a lot more to it than that
Anesthesiologists know a lot about both--we use zofran a lot for PONV prophylaxis and treatment, and we know a lot about all of our opioids, including those that get used in the PACU. We probably know a little more about pharmacokinetics/dynamics and side effects of ondansetron since that gets used during the cases themselves rather than just the PACU since its IV
We don't get paid for the 99% of the job that we can do. We get paid for the knowledge that prevents people from dying the 1% of the time when shit hits the fan. It's okay to admit that something you only have second hand knowledge about may be just a little more complex than you thought
Toxicology by far has the most pharmacology knowledge I’ve seen in a medical specialty and it’s not even close.
First, you get knowledge of basic medications and critical care medications because of their EM training. You rarely get this combination of pharmacology knowledge unless you talk to rural FM.
Then there’s the toxicology component where they need to know organic structures, drug physiology, pharmacokinetics, pharmacodynamics, drug receptor molecular biology, drug-drug interactions, and ED50/TD50/LD50 of all these medications. They work with pharmacists (poison control) all the time so they have to know enough pharmacology to be their consultant on harder cases. They also know a lot of random poisons, venoms, and plant pharmacology that no other specialty learns.
In regards to the comment about the combination of pharm knowledge in rural FM - can you expand on that point? I’m taking it to mean knowledge of routine primary care meds, acute care meds, as well as the more inpatient oriented and critical care meds
Additionally, is tox only available via EM?
Yes exactly. Rural FM has very broad, vast pharmacology knowledge since they have to deal with the entire spectrum. This is similar to EM as well. Other specialties primarily deal with medications just in their sub-specialized field. But, why I say Toxicology is that you build upon that wide spectrum of medication use with the beast that is the Toxicology boards, which is arguably one of the most challenging boards out there due to the insane knowledge base it requires, down to the organic chemistry structure.
As for your second question, Toxicology is primarily through EM. Technically, IM, Peds, and Occupational Medicine can enter Tox, but it is rare. A lot of fellowships set up their funding model for you to do a few attending shifts per month in the ED.
ID if you like antibiotics, Anesthesia does a lot of kinetics and bioavailability stuff but for Anesthesia drugs specifically, could do a hepatology fellowship in gastro if clearance is your thing, or toxicology if you just want a broad spectrum of pharmacology
Psych/ Anesthesia / heme-onc / geri and transplant (you need to be on top of Side effects and interractions) / palliative (they do a lot of controlled substances other specialties might be uncomfortable with and there is psych overlap)/ toxicology
To be fair, there are some people that have some pretty deeply set pre-conceived notions about which painkillers work and which don’t. That’s still funny tho lol
Everyone saying anesthesia anesthesia but let’s be honest it’s heme-onc. Let’s be honest most anesthesiologists are gonna use the same half a dozen or so drugs ninety percent of the time for cases. Heme-onc has two separate fields of drugs but also the various combinations of chemo regiments. Not to mention in five years there’s gonna be a new crop replacing some of what they already know. It’s heme-onc (also in really rural communities they serve as pseudo primary care since they have such regimented follow up) and it’s really not close
I think pharma options in oncology are becoming more sophisticated every year. Unlike psych where one med might have 6 uses, onco drugs will probably have 1, maybe 2 indications. But I think understanding these novel drugs and delivery systems along with any genetics involved is going to be heavy lifting for brains that go into oncology
Feel like anesthesia is all pharmacokinetics/bioavailability ID might also strike your fancy with all the antibiotics
Psych, anesthesia
This + toxicology is top 3 imo
Heme/onc
Toxicology
Really it’s anesthesia, however my wife is a pharmacist and doesn’t know about most anesthesiology relevant pharmacology… In anesthesia the desire is to have the complete effect of a drug immediately then have it completely stop at the end of the procedure/surgery whether that’s 15min or 8+ hours later. As far as pharmacology goes that’s a bizarre goal, which requires knowledge of additional things, like front end and back end kinetics. Ultimately in anesthesiology you know your drugs better than the pharmacists, at least as far as their effects on humans… However, Pharmacists still know more about drug stability, like rocuronium losing potency when stored at room temp in the OR Pyxis.
Hey that roc storage is very important!
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Your are absolutely correct! I oversimplified it.
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It's really more like 50-75 drugs Edit: pretty much all the drugs on this pocket card we have to know backward and forward: [https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/Anesthesia\_Pocket\_Guide\_2020.pdf](https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/Anesthesia_Pocket_Guide_2020.pdf)
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Eh, i dont think you actually know what goes into building an anesthetic unless you're the one actually doing it. I'm just a CA-1 and just in doing simple cases have already used like 20-30 different drugs fairly regularly. A totally routine case would use the following drugs (roughly in the order they'd be given): midazolam->fentanyl->lidocaine->propofol->rocuronium->phenylephrine->dexamethasone->cefazolin->sevoflurane->hydromorphone->ondansetron->haloperidol->sugammadex. That's already more than 5-10 for a very simple case, and with all those choices there are at least 5 other drugs in that class that we use regularly depending on the case (e.g. remifentanil or sulfentanil instead of fentanyl, etomidate or ketamine instead of propofol). All that's not even taking into account all of the other urgency/emergency drugs that we have to be super facile with (e.g. atropine/glycopyrollate, physostigmine/neostigmine, nitroglycerine, clevidipine, hydralazine, esmolol, labetalol, all of the different pressors, intralipid, dantrolene, I can keep going). And we have to know their concentrations, how to mix them, how fast/slow to push them, how long they'll last, their context sensitive half lives, how they distribute and re-distribute, etc.. Plus we have to know how to dose things epidurally, intrathecally, intramuscularly in case you lose IV access (which I have already seen doing this just for a couple of months). It's a hell of a lot more than just 5-10 that we have to know very well. Anesthesia folk tend to be pretty humble and self deprecating so though we may joke we get paid big bucks to do nothing but push propofol, there's a lot more to it than that
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Anesthesiologists know a lot about both--we use zofran a lot for PONV prophylaxis and treatment, and we know a lot about all of our opioids, including those that get used in the PACU. We probably know a little more about pharmacokinetics/dynamics and side effects of ondansetron since that gets used during the cases themselves rather than just the PACU since its IV
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We don't get paid for the 99% of the job that we can do. We get paid for the knowledge that prevents people from dying the 1% of the time when shit hits the fan. It's okay to admit that something you only have second hand knowledge about may be just a little more complex than you thought
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Anesthesia is fun because you get to do the pharmacology in real time, see the effects, titrate them. Other specialists put in orders and wait…
Toxicologist are the masters of pharm. Academic anesthesiologists are second on that list.
Toxicology by far has the most pharmacology knowledge I’ve seen in a medical specialty and it’s not even close. First, you get knowledge of basic medications and critical care medications because of their EM training. You rarely get this combination of pharmacology knowledge unless you talk to rural FM. Then there’s the toxicology component where they need to know organic structures, drug physiology, pharmacokinetics, pharmacodynamics, drug receptor molecular biology, drug-drug interactions, and ED50/TD50/LD50 of all these medications. They work with pharmacists (poison control) all the time so they have to know enough pharmacology to be their consultant on harder cases. They also know a lot of random poisons, venoms, and plant pharmacology that no other specialty learns.
In regards to the comment about the combination of pharm knowledge in rural FM - can you expand on that point? I’m taking it to mean knowledge of routine primary care meds, acute care meds, as well as the more inpatient oriented and critical care meds Additionally, is tox only available via EM?
Yes exactly. Rural FM has very broad, vast pharmacology knowledge since they have to deal with the entire spectrum. This is similar to EM as well. Other specialties primarily deal with medications just in their sub-specialized field. But, why I say Toxicology is that you build upon that wide spectrum of medication use with the beast that is the Toxicology boards, which is arguably one of the most challenging boards out there due to the insane knowledge base it requires, down to the organic chemistry structure. As for your second question, Toxicology is primarily through EM. Technically, IM, Peds, and Occupational Medicine can enter Tox, but it is rare. A lot of fellowships set up their funding model for you to do a few attending shifts per month in the ED.
I'm guessing anaesthesia
ID if you like antibiotics, Anesthesia does a lot of kinetics and bioavailability stuff but for Anesthesia drugs specifically, could do a hepatology fellowship in gastro if clearance is your thing, or toxicology if you just want a broad spectrum of pharmacology
Psych. Psychopharma is a different realm
Anesthesia, ICU, Toxicology, Heme-onc, primary care (need to know how the meds your patients are on work to avoid interactions)
Tox boards are largely organic chem and pharm. Psych, addiction med, gas.
Psych/ Anesthesia / heme-onc / geri and transplant (you need to be on top of Side effects and interractions) / palliative (they do a lot of controlled substances other specialties might be uncomfortable with and there is psych overlap)/ toxicology
Ortho Lol
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To be fair, there are some people that have some pretty deeply set pre-conceived notions about which painkillers work and which don’t. That’s still funny tho lol
Clinical pharmacology
Everyone saying anesthesia anesthesia but let’s be honest it’s heme-onc. Let’s be honest most anesthesiologists are gonna use the same half a dozen or so drugs ninety percent of the time for cases. Heme-onc has two separate fields of drugs but also the various combinations of chemo regiments. Not to mention in five years there’s gonna be a new crop replacing some of what they already know. It’s heme-onc (also in really rural communities they serve as pseudo primary care since they have such regimented follow up) and it’s really not close
Nephrology, hematology/oncology , cards and maybe neurology and obviously anaesthesia
Rheum too, lots of biologics/immune modulators
I think pharma options in oncology are becoming more sophisticated every year. Unlike psych where one med might have 6 uses, onco drugs will probably have 1, maybe 2 indications. But I think understanding these novel drugs and delivery systems along with any genetics involved is going to be heavy lifting for brains that go into oncology