Couple questions about CT fellowship

[McPoyle]

Before its suggested, yes I am talking to people in my program too but am hoping to get some more perspective too.

So, I'm a CA3, going to do CCM at my current place next year. Now I am looking at applying for CT to follow that. We have a program here but don't want to feel 100% inbred and am looking to go elsewhere for that year. So my questions for those who have done CT are:
1.) what (besides volume) did you feel was important in evaluating programs
2.) doing own cases vs supervising... I can see benefit for both but my gut tells me I'd like to be somewhere with a mix tilted towards doing own cases. How did y'all address this dichotomy?
3.) I've done a few transplants (double and single lungs as well as hearts), I know I enjoy these. How important is having a higher volume of these specific cases? I would extrapolate this to how important is a large volume of any individual case?
4.) what extras did you feel to be important? (Electives, meetings, formal TEE courses, etc)

Thanks in advance, and feel free to PM or move to private forum if needed.

-Eric


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[deleted171991]

This is just my 2 cents coming from somebody who hasn't done a CT fellowship (yet?), and who's not the wide-eyed puppy most programs want. I apologize for the interruption.

I honestly think it's not a fellowship if one does more than 2 days solo a week, or at least if the rooms are not set up by somebody else. That's just cheap labor; I hope people will recoup the 300K and life force lost.

Most anesthesia subspecialty fellowships should be junior attending jobs (7 to 5), not super-residencies (6 to 9). One should function mostly as an extra layer between the resident/midlevel and the attending, so one can focus on advanced stuff one needs to get better at (e.g. TEE), and not on petty resident-level stuff (which can be a ton in a cardiac case, just think about setup). This year should be about learning and practicing advanced skills; anything else is scutwork, waste of "tuition". You should have time for self-study, too.

The main reason these completely solo fellowships are proliferating is because the demand is so high that programs can get away with anything, including putting fellows in solo rooms, so that they don't have to hire more anesthesia providers (for the rooms the respective residents are in). There is no reason to have to set up the room, intubate, do lines, chart, manage the general anesthesia part etc. in almost every single case; there is very little to learn there, beyond residency.

Some would argue that if one does twice the solo cases with maybe half the education one gets in an easier program (just imagine what a difference it makes to be able to move from room to room, at least during bypass, and discuss all those cases, instead of setting up for the next one), one will get a better training overall. To me, that's just a year of pain and exploitation (but I am not hellbent on a CT fellowship). In the end, most people do a cardiac fellowship to excel at TEE and hemodynamic resuscitation (unless their residency sucked).

 

[RK.md]

So, I'm a CA3, going to do CCM at my current place next year. Now I am looking at applying for CT to follow that.

Another two-fer! Good choice man.
I'll leave the people who have actually done CT fellowships to give their input.

 

[McPoyle]

This is just my 2 cents coming from somebody who hasn't done a CT fellowship (yet?), and who's not the wide-eyed puppy most programs want. I apologize for the interruption.

I honestly think it's not a fellowship if one does more than 2 days solo a week, or at least if the rooms are not set up by somebody else. That's just cheap labor; I hope people will recoup the 300K and life force lost.

Most anesthesia subspecialty fellowships should be junior attending jobs (7 to 5), not super-residencies (6 to 9). One should function mostly as an extra layer between the resident/midlevel and the attending, so one can focus on advanced stuff one needs to get better at (e.g. TEE), and not on petty resident-level stuff (which can be a ton in a cardiac case, just think about setup). This year should be about learning and practicing advanced skills; anything else is scutwork, waste of "tuition". You should have time for self-study, too.

The main reason these completely solo fellowships are proliferating is because the demand is so high that programs can get away with anything, including putting fellows in solo rooms, so that they don't have to hire more anesthesia providers (for the rooms the respective residents are in). There is no reason to have to set up the room, intubate, do lines, chart, manage the general anesthesia part etc. in almost every single case; there is very little to learn there, beyond residency.

Some would argue that if one does twice the solo cases with maybe half the education one gets in an easier program (just imagine what a difference it makes to be able to move from room to room, at least during bypass, and discuss all those cases, instead of setting up for the next one), one will get a better training overall. To me, that's just a year of pain and exploitation (but I am not hellbent on a CT fellowship). In the end, most people do a cardiac fellowship to excel at TEE and hemodynamic resuscitation (unless their residency sucked).

No, my residency definitely doesn't suck. I'm on pace for about 100 bypass cases in addition to major aortic (TAA repairs etc) and livers that all require guided resuscitation. I see your point about 100% doing my own cases and don't think that is what I am looking for, definitely looking for a mix I think but don't want 100% supervising either because I think there is still knowledge to be gained by being the in room person, especially for more complex cases.


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[deleted171991]

No, my residency definitely doesn't suck. I'm on pace for about 100 bypass cases in addition to major aortic (TAA repairs etc) and livers that all require guided resuscitation. I see your point about 100% doing my own cases and don't think that is what I am looking for, definitely looking for a mix I think but don't want 100% supervising either because I think there is still knowledge to be gained by being the in room person, especially for more complex cases.


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Oh, I absolutely agree with the staying in the room part. But there is a difference between being the scut monkey and telling the scut monkey what to do (while you are doing stuff that is meaningful to you).

 

[weirdomikey014]

Completely agree. I ended up choosing a supervising kind of program for all of the reasons you mentioned.

 

[AdmiralChz]

Sweet, the cardiac-CCM trained individual is a strong physician indeed. I just went through the application process myself, I really considered doing both as well but over the past 18 months my interest in CCM has faded away. Like most things in medicine, totally my personal preference. I have good friends who are doing both and I respect them for it! So take this advice from someone who hasn't yet completed CT so definitely with a grain of salt.

I interviewed fairly broadly, and I will give you my perspective (which actually totally changed on the interview trail):

1) You allude to it already, but case mix is very important in addition to volume. It is very important to see what sort of cases are being done at your institution, and trust me it is not the same everywhere. Will you get ample ascending/circ arrest exposure (something which +/- may be dying away), assist devices (primarily VAD, but also ECMO, Berlins, etc...) and transplants? Trust me, some of the places I interviewed I was so surprised that all they did was simple CABG/Valves, and it sounds like you are already getting that in residency (some do not, which is OK).

Second I really tried to look at how the fellows enjoyed the program along with how friendly and welcoming the attendings were. I didn't think this was very important until I interviewed at a place (and heard about others) where the fellows were quite miserable and didn't do a very good job at hiding it (putting their head down in exhaustion at lunch and dinner was a tip off!). I think FFP would agree (maybe this is only point though ) that you shouldn't waste a year of foregone income being miserable.

2) For solo vs supervising cases: I will hedge here and argue that this is totally up to YOUR preference. I am heading to a program where I will primarily be doing my own cases and definitely don't view it as being a super resident or a waste of my time - I will likely be heading to a physician-only practice afterwards where I will need to be facile at doing everything by myself in the room without help of a resident or CRNA/AA, so a solo fellowship became more attractive to me. That being said, with a double fellowship you are likely setting yourself up for an academic career, so the value of supervising residents and learning that skill of teaching/directing others is more important. There are some (actually, many) programs where you would be almost entirely supervising except for the ~ 30 cases you are required to do on your own. These are most of the 1-3 fellow/year programs. I love the idea of doing 50% supervision - 50% solo, but to be honest with you there are very few programs that TRULY are half and half and >90% are skewed in one direction or the other.

3) I think transplant experience is important, but it's only a piece of the puzzle. If all goes well, a heart transplant actually can be easy since um, they have a new good heart! Device (VAD, etc...) exposure I think is more important, but you want to be able to tell potential employers you have exposure to transplants.

4) Almost everywhere had the same electives (Thoracic, perfusion, TEE, etc...) so that didn't move the needle for me. Definitely talk with your home faculty to get their input, I am going elsewhere for CT and they totally understood and didn't take it as a slap to their own face. It is important to think about the regional nature of jobs, particularly in academics. By that I mean, if you want to be in the mid-Atlantic east coast I would head to a fellowship in that area. The exceptions are the large, well-known programs with large alumni networks (primarily Duke, Texas Heart, Cleveland Clinic and BWH but also some on the west coast).

I hope this helps, you can totally PM me if you'd like to discuss further!

 

[deleted50478]

This is just my 2 cents coming from somebody who hasn't done a CT fellowship (yet?), and who's not the wide-eyed puppy most programs want. I apologize for the interruption.

I honestly think it's not a fellowship if one does more than 2 days solo a week, or at least if the rooms are not set up by somebody else. That's just cheap labor; I hope people will recoup the 300K and life force lost.

Most anesthesia subspecialty fellowships should be junior attending jobs (7 to 5), not super-residencies (6 to 9). One should function mostly as an extra layer between the resident/midlevel and the attending, so one can focus on advanced stuff one needs to get better at (e.g. TEE), and not on petty resident-level stuff (which can be a ton in a cardiac case, just think about setup). This year should be about learning and practicing advanced skills; anything else is scutwork, waste of "tuition". You should have time for self-study, too.

The main reason these completely solo fellowships are proliferating is because the demand is so high that programs can get away with anything, including putting fellows in solo rooms, so that they don't have to hire more anesthesia providers (for the rooms the respective residents are in). There is no reason to have to set up the room, intubate, do lines, chart, manage the general anesthesia part etc. in almost every single case; there is very little to learn there, beyond residency.

Some would argue that if one does twice the solo cases with maybe half the education one gets in an easier program (just imagine what a difference it makes to be able to move from room to room, at least during bypass, and discuss all those cases, instead of setting up for the next one), one will get a better training overall. To me, that's just a year of pain and exploitation (but I am not hellbent on a CT fellowship). In the end, most people do a cardiac fellowship to excel at TEE and hemodynamic resuscitation (unless their residency sucked).

I wish you had been my fellowship program director or chairman!

 

[confusingleaf]

just finished my CT fellowship. I agree with what lots have said here

1) when evaluating the program, i think case mix is the most important, as said above. will you be able to do a peds rotation if you want it? will you do enough assist devices and transplants? do you do adult congenital?--i do believe adult congenital is going to become a much bigger market and if you have done it it will just be another marketing point.

2) I agree with FFP--there is NO REASON to do a cardiac fellowship to sit there and run all your own cases. If you do that, you're missing out on participating in all the other cardiac cases going on. At our instution, most days there are two heart rooms, if i was supervising that meant I got to look at all the echoes and participate in induction/weaning from bypass. that meant i saw a lot of different things. granted, i still did a good number of cases by myself (when the OR was short--basically free labor, as FFP said), but if there were a few days of that in a row I would respectfully speak up to the service director and ask to supervise. 9/10 times that is actually more stressful--it's easier just to do it all myself and know it is done right, but there is value in learning how to supervise, especially if that is what you will be doing in private practice. i actually ended up liking my "hybrid" of doing probably 30-40% my own cases and the rest supervising. this got me VERY facile with lines. and i started to view the days i was doing the cases myself as a break (other than being there at 0600 to set up).

3) i don't know that there is a specific number for transplants, vads, etc., but the more you do of all of these "unusual" cases the better. for me, i used the year HARD--i know many fellows will say that it is the best year of your life, but i worked a LOT because i knew i had one year to get all these cases. i came in for almost every weekend and came in quite a few nights for dissections, transplants, etc. i don't regret it. do what it takes to become comfortable with the cases, and maybe that is less for you, but every complication you see is one you then know how to treat and manage.

4) i didn't do a ton of extra rotations--i could have, i just wanted the OR time. i did go to echo week and i went to the echo review that UCSD puts on every year. both helpful.

feel free to PM with questions!

 

[Man o War]

just finished my CT fellowship. I agree with what lots have said here

1) when evaluating the program, i think case mix is the most important, as said above. will you be able to do a peds rotation if you want it? will you do enough assist devices and transplants? do you do adult congenital?--i do believe adult congenital is going to become a much bigger market and if you have done it it will just be another marketing point.

2) I agree with FFP--there is NO REASON to do a cardiac fellowship to sit there and run all your own cases. If you do that, you're missing out on participating in all the other cardiac cases going on. At our instution, most days there are two heart rooms, if i was supervising that meant I got to look at all the echoes and participate in induction/weaning from bypass. that meant i saw a lot of different things. granted, i still did a good number of cases by myself (when the OR was short--basically free labor, as FFP said), but if there were a few days of that in a row I would respectfully speak up to the service director and ask to supervise. 9/10 times that is actually more stressful--it's easier just to do it all myself and know it is done right, but there is value in learning how to supervise, especially if that is what you will be doing in private practice. i actually ended up liking my "hybrid" of doing probably 30-40% my own cases and the rest supervising. this got me VERY facile with lines. and i started to view the days i was doing the cases myself as a break (other than being there at 0600 to set up).

3) i don't know that there is a specific number for transplants, vads, etc., but the more you do of all of these "unusual" cases the better. for me, i used the year HARD--i know many fellows will say that it is the best year of your life, but i worked a LOT because i knew i had one year to get all these cases. i came in for almost every weekend and came in quite a few nights for dissections, transplants, etc. i don't regret it. do what it takes to become comfortable with the cases, and maybe that is less for you, but every complication you see is one you then know how to treat and manage.

4) i didn't do a ton of extra rotations--i could have, i just wanted the OR time. i did go to echo week and i went to the echo review that UCSD puts on every year. both helpful.

feel free to PM with questions!

Agree with all of this. I also came in a lot more than what was required for the same reasons listed above. The year is very much about what you put into it. Also, I can't stress enough how important faculty quality is. Echo ability and willingness/enthusiasm to teach those skills was a big factor for me. I looked at the programs each one graduated from. I personally wanted a good mix of younger and older faculty with quality programs represented.

 

[Robotic Wis-Hipple]

I agree with pretty much everything that's been said. The ability of the program to be fluid, and allow you to move around where the best experiences are was key for me. I felt it would also lead to more TEE exposure as well as teaching as you would be "extra". If you truly end up with ~100 heart cases in residency you will have the monkey skills down pat, fellowship should be about the ability to pick your cases/experience, focus on VADs, transplants, TEE, and supervising/triaging juniors management. One thing I personally liked was a dedicated didactic day, some, especially the old schoolers will call that lazy, but I felt that a nonclinical day would be great for echo review, primary literature/guidelines study, etc. With all that said, I didn't go for a 100% supervisory place, I felt like I wanted to continue to do cases so that I could continue to develop the slickness the PP places will desire.