Non-cardiac fellowship pathway

[pasgasser2]

I'm 5 years out of training and have worked in a physician only group doing my own cases. I've become relatively comfortable with my practice doing alot of sick patients and a wide breadth of cases including thoracic, vascular, neuro, OB, regional, peds, etc. The one area I haven't been able to touch since training is cardiac. The hearts here goto my cardiac colleagues which I understand is the norm at most practices. However, pretty much everyone on our cardiac team has never done a cardiac fellowship. They are old-timers who have been doing hearts for a while (10-15+ years), though we do have some cardiac trained locums that provide coverage.

Recently, I was offered the opportunity to join the cardiac team. They would set up a structure in which I would actively observe a number of cases, be mentored throughout the process, and then proceed to do cases myself under close supervision. The expectation is that I would also be actively studying TEE on my own time via study materials, conferences, online education modules, etc.

I am curious as to what you guys think about this "pathway". I understand that it would never be as good as actually doing a cardiac fellowship, however going back to do a fellowship is not an option for me so this post is solely to gather thoughts on being trained to do cardiac cases by colleagues. If I were to join the cardiac team, it would be my full intention to go all out in studying both in and outside of the OR with the ultimate goal of passing the NBE echo board and becoming a testamur. The last thing I want is to join the cardiac team, only to be half-assing it and providing sub-optimal care to patients who would have had a better outcome if taken care of by a fellowship trained cardiac anesthesiologist.

I've asked several colleagues about this and the general mantra seems to be that much of doing cardiac cases involves what a generalist should be able to anyways- putting in invasive lines and resuscitation. But the crux of managing cardiac patients and what makes the difference in outcomes are the TEE skills of the anesthesiologist. So I figure if I can study hard enough to pass echo boards, I should essentially have the skills required of a competent cardiac anesthesiologist. Is this flawed thinking?

My true dilemma is that I also now have the opportunity to switch to full-time locum work at many institutions near me and with how great this market is, I would undoubtedly make alot more money for much lower hours than at my current job. However, I don't want to lose out on an opportunity to gain a skill set that would increase my capabilities and make me an overall better anesthesiologist. My thinking is that if I can legitimately be trained to do cardiac cases at my current job, I should stay as this is the better play for the long-game.

Appreciate your thoughts and feedback!

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[ToKingdomCome]

Would any group pay you to do a cardiac fellowship or give you some type of additional stipend with the expectation that you return to the group after ? Kind of like how companies pay for an MBA

 

[pasgasser2]

Would any group pay you to do a cardiac fellowship or give you some type of additional stipend with the expectation that you return to the group after ? Kind of like how companies pay for an MBA

I'm sure there are groups that would do this. But again for the purpose of this post, going back to do cardiac fellowship is off the table for me.

 

[IMGASMD]

My current and ex group’s cardiac teams are both consisted with mostly non-cardiac fellowship physicians. Even though we have a “cardiac team” less than 15% of them actually had fellowship training.

We are going through a transition right now, just heard one of the cardiac guy told CRNAs with such a shortage of “providers” maybe CRNAs will be start to staff cardiac again.(we are currently MD only for cardiac, crnas only does general cases.) The head cRNa was chuckling and said something like it’ll be like riding a bike. I almost fell out of my chair. (The last time this chief crna did cardiac or any complex case was at least 5 years ago, and he “really” thought it’s that simple really bothered me.)


Be that as it may, just like all other advices that had been given to residents on the board “should I do X fellowship….” It’s really up to you, if you really want to do it, no one will stop you.

Time, energy and payout. If all those things align with what you want in life.

Some other cardiac trained physicians here may have a different view on this.

 

[nimbus]

I went through a similar transition earlier in my career. If you want to do cardiac, your group is giving you a gift served on a plate. But you need to consider why they are not recruiting someone with a fellowship and echo boards. How’s the pay and call burden for the heart team relative to the rest of the group? There should be a premium for the extra call and early mornings.

 

[nimbus]

Would any group pay you to do a cardiac fellowship or give you some type of additional stipend with the expectation that you return to the group after ? Kind of like how companies pay for an MBA

There is a group in south Orange County that used to do this. I don’t know if they still do.

 

[vector2]

I'm 5 years out of training and have worked in a physician only group doing my own cases. I've become relatively comfortable with my practice doing alot of sick patients and a wide breadth of cases including thoracic, vascular, neuro, OB, regional, peds, etc. The one area I haven't been able to touch since training is cardiac. The hearts here goto my cardiac colleagues which I understand is the norm at most practices. However, pretty much everyone on our cardiac team has never done a cardiac fellowship. They are old-timers who have been doing hearts for a while (10-15+ years), though we do have some cardiac trained locums that provide coverage.

Recently, I was offered the opportunity to join the cardiac team. They would set up a structure in which I would actively observe a number of cases, be mentored throughout the process, and then proceed to do cases myself under close supervision. The expectation is that I would also be actively studying TEE on my own time via study materials, conferences, online education modules, etc.

I am curious as to what you guys think about this "pathway". I understand that it would never be as good as actually doing a cardiac fellowship, however going back to do a fellowship is not an option for me so this post is solely to gather thoughts on being trained to do cardiac cases by colleagues. If I were to join the cardiac team, it would be my full intention to go all out in studying both in and outside of the OR with the ultimate goal of passing the NBE echo board and becoming a testamur. The last thing I want is to join the cardiac team, only to be half-assing it and providing sub-optimal care to patients who would have had a better outcome if taken care of by a fellowship trained cardiac anesthesiologist.

I've asked several colleagues about this and the general mantra seems to be that much of doing cardiac cases involves what a generalist should be able to anyways- putting in invasive lines and resuscitation. But the crux of managing cardiac patients and what makes the difference in outcomes are the TEE skills of the anesthesiologist. So I figure if I can study hard enough to pass echo boards, I should essentially have the skills required of a competent cardiac anesthesiologist. Is this flawed thinking?

My true dilemma is that I also now have the opportunity to switch to full-time locum work at many institutions near me and with how great this market is, I would undoubtedly make alot more money for much lower hours than at my current job. However, I don't want to lose out on an opportunity to gain a skill set that would increase my capabilities and make me an overall better anesthesiologist. My thinking is that if I can legitimately be trained to do cardiac cases at my current job, I should stay as this is the better play for the long-game.

Appreciate your thoughts and feedback!

I will tell you as someone who performed ~100+ intraop TEEs and read another ~100 during CCM fellowship, crushed the aPTE, and who has been doing cardiac for the last 5 years, the learning curve is definitely much, much, much steeper going down this path than compared to CT fellowship trained folks. It took a couple years of practice to build a solid skills and knowledge base, both in TEE and cardiac anesthesia. This goes double if you have pretty sick / complex hearts and not just "B&B" CABGs and single valves.

So, unless you're willing to make that kind of commitment, AND you're OK with the fact that it doesn't really increase your marketability in most markets because there's so many CT fellowship trained grads nowadays, you should think twice. Especially if you've got some juicy locums in your area that you could pounce on.

 

[psychbender]

I say go for it. If you're motivated, study echo and current trends in cardiac anesthesia, and pass the APTE (and maybe the new ABA Cardiac board), you'll be a positive resource for your group, and do well by your patients. I know there are naysayers on here that will claim that the year of fellowship cannot be matched with any amount of training and testing, that you'll be harming your patients as you accumulate knowledge and experience, that CT fellowship makes one as far above a general anesthesiologist as a general anesthesiologist is above a CRNA, but that's all a bunch of bull****. You already have about 15,000 hours of intense clinical training, and can be mentored in obtaining the relevant skills over time.

 

[dabears505]

You are going to hear a lot of different opinions about this, especially from cardiac trained people. Obviously your skills will never come close to a fellowship trained person. However, at a lot of places, you can get by without a fellowship, just as your colleagues have been doing.

Do not think though that you are picking up a skill set that you can use anywhere. The non fellowship dinosaurs are dying and if you change job, it's not guaranteed you will be able to do hearts there just because you did at your current job.

I think of there's money for you to make as a generalist locum, I would make that money and not worry about doing cardiac. It's not going to help you as much as you think in the future.

 

[PpfSuxTube]

You will for sure be able to 'get by' and maybe even be good at it eventually. But your work won't ve very portable if you want to do cardiac elsewhere. You can't be grandfathered in if you're not a grandfather!

Cardiac is easy most of the time, but the stakes are high, and even my colleagues who are grandfathered in, really can get themselves into deep do-do quick especially if they cover the csicu and don't understand the dominant cardiac lesions and how to prioritize them...

Cardiac surgeons can be none too forgiving when it's their mortality numbers on the line...

All that said, you are being offered a very rare opportunity. To do Cardiac and make staff money all the while without the cruelty of fellowship...

And a guaranteed job...

Question is, why are they offering you this? It's rare for groups to give away the crown jewels, unless it's not as valuable as it seems

 

[Bertelman]

What is the breadth of cases at your facility? I think this is what matters most. Doing complex aortic repairs? Minimally invasive mitral surgery? Structural interventions like MitraClips? Or just straight-forward CABG, valve cases? I'm assuming no heart failure, VADs, etc.

 

[dchz]

So I figure if I can study hard enough to pass echo boards, I should essentially have the skills required of a competent cardiac anesthesiologist. Is this flawed thinking?

This is the personification of the dunning-kruger. Thinking is flawed.

In residency, I had an attending who was ICU trained who did similar path as you described. He missed a very OBVIOUS PVL after aortic valve replacement and the pt pretty much died as direct sequelae from it. To this day, I check for PVL 3 times before coming off pump because of how much the bring-back case scarred me. How would your institution reconcile that if it happened to you?

I passed the advanced PTE as a CA-2. Then did a ton more of cardiac under supervision CA3 and Fellowship year. I'm 3 years into a private practice that does >60% cardiac surgery. I still feel uncomfortable in a complex mitral repair.

The caveat everyone is pointing out is that doing cardiac anesthesia at your institution MIGHT NOT require a "competent cardiac anesthesiologist". This is suboptimal, but completely understandable in the current market conditions.

To provide a counter perspective: I also knew another anesthesiologist that took the same path, I'd let him do my anesthesia any day.

 

[PpfSuxTube]

So I figure if I can study hard enough to pass echo boards, I should essentially have the skills required of a competent cardiac anesthesiologist. Is this flawed thinking?

Yes. Very flawed.
No matter how much nbe wish to control cardiac anesthesia, echo practice itself is the absolute minimum required to practice cardiac anesthesia nowadays.

We are cardiac anesthesiologists that are also experts in tee, not the other way around. There is so much more about cardiac anesthesia than echo. It just so happens that echo is the most teachable aspect and examinable that NBE have cornered that 10% of cardiac anesthesia learning and made it their own.

 

[pgg]

I think that's a reasonable plan, assuming your case mix isn't of the complex sort you'd see at a referral center. But there's a reason most hospitals won't credential new people to do cardiac cases without fellowship training. In the long run it's not yourself you need to convince, or us, or your partners, but the credentialing committee where you work.

Achieving testamur status will put you well ahead of most of the "grandfathered" elders doing cardiac. And if you have partners willing to help you through some of the learning curve, so much the better. As noted above there isn't likely to be any direct financial return on the effort.

And if nothing else, any effort you make toward learning something relevant to your practice, especially with an advanced and objective end state like passing the adv periop TEE exam, is going to make you a better doctor. Worth doing for that reason alone.

But be wary of thinking some self-study and OJT will get you to a totally comfortable place. I'm 6 years out of fellowship and still sometimes get a bit of imposter syndrome. There's a lot that I wish I knew better, and part of the reason I'm aware of those edges is because I spent a year as a fellow.

 

[nimbus]

I think that's a reasonable plan, assuming your case mix isn't of the complex sort you'd see at a referral center. But there's a reason most hospitals won't credential new people to do cardiac cases without fellowship training. In the long run it's not yourself you need to convince, or us, or your partners, but the credentialing committee where you work.

Achieving testamur status will put you well ahead of most of the "grandfathered" elders doing cardiac. And if you have partners willing to help you through some of the learning curve, so much the better. As noted above there isn't likely to be any direct financial return on the effort.

And if nothing else, any effort you make toward learning something relevant to your practice, especially with an advanced and objective end state like passing the adv periop TEE exam, is going to make you a better doctor. Worth doing for that reason alone.

But be wary of thinking some self-study and OJT will get you to a totally comfortable place. I'm 6 years out of fellowship and still sometimes get a bit of imposter syndrome. There's a lot that I wish I knew better, and part of the reason I'm aware of those edges is because I spent a year as a fellow.

If his own group/department is supportive, he will have no problem getting credentialed. Usually the credentialing committee (most of whom are not anesthesiologists) will defer to the chief of anesthesia in these matters. If the chief (who is most likely one of his partners) is willing to sign off, he has a green light.

 

[pgg]

If his own group/department is supportive, he will have no problem getting credentialed. Usually the credentialing committee (most of whom are not anesthesiologists) will defer to the chief of anesthesia in these matters. If the chief (who is most likely one of his partners) is willing to sign off, he has a green light.

Agreed, I was thinking more of future jobs. Testamur status probably makes his heart-doing-status more portable, at least for a while. I see a lot of jobs advertised as "cardiac fellowship or TEE certification".

 

[vector2]

We are cardiac anesthesiologists that are also experts in tee, not the other way around. There is so much more about cardiac anesthesia than echo.

This is also an argument for why aPTE certification should stop being the de facto cardiac anesthesia certification. IMO the NBE practice pathway should open back up so that people who aren't fellowship trained (but who still know a lot about echo / do a lot of echo) can get certified.

Then, if your employer or credentialing committee explicitly wants cardiac fellowship training, they can make that apparent in their requirements.

 

[Bertelman]

This is also an argument for why aPTE certification should stop being the de facto cardiac anesthesia certification. IMO the NBE practice pathway should open back up so that people who aren't fellowship trained (but who still know a lot about echo / do a lot of echo) can get certified.

Then, if your employer or credentialing committee explicitly wants cardiac fellowship training, they can make that apparent in their requirements.

Sounds like someone is on board with the new ABA Adult Cardiac Anesthesiology Certification.

 

[vector2]

Sounds like someone is on board with the new ABA Adult Cardiac Anesthesiology Certification.

Only reason I'm in favor of it is because I'm CCM trained and I've practice pathwayed myself into being a somewhat competent cardiac anesthesiologist. I've testamur'ed the PTE and the ascexam. I digest a lot of material about CT surgery and cardiac anesthesia in my spare time. I'm an ASE and SCA member and I do a bunch of echo CME's + occasional echo week. I've completed an ELSO approved in-person ECMO course. And I've probably done 400-500 cases with TEE since I've been out.

But yet if I'm in a pump case and someone asks me if I'm a CT anesthesiologist, I get a bit imposter-y and I have to go through the spiel and blah blah blah. So I think taking that exam, at least for me, can make my standing a bit more clear, and maybe help me a bit if my health system or credentialing committee starts getting more curious in the future about who's doing hearts.

That being said, the number of exams required to be a fellowship trained anesthesiologist has gotten out of control, and I think people who are CT fellowship trained / NBE cert / regularly practicing shouldn't have to take it.

 

[abolt18]

I just signed up for the test this evening. The whole $1800. Thankfully my employer will reimburse it.

 

[SinghDoc]

OP in better financial shape than any broke CA-3 resident about to start fellowship. You’ll be a much better cardiac anesthesiologist having gone through real fellowship training. I’m pretty sure with studying I’d be able to clear exams for peds, pain, and CCM but wouldn’t want to shortchange myself or my patients. Winging it in the modern era is just CRNA mindset.

 

[vector2]

. Winging it in the modern era is just CRNA mindset.

And thinking one needs fellowship and an exam to pick up any new skillset is just as foolish.

Most people on this subforum are very clear in that if someone desires to do pain, peds, CCM, CT, he or she should just do the fellowship nowadays. OP is in a unique situation, and I think everyone here has given him a nuanced answer where doing the fellowship is probably the way to go, but if he can't then he should know that it's going to be an incredible amount of work to get a degree of competency, and these skills might not even be transferrable to another job if he leaves his current one.

More broadly, physicians are sabotaging themselves by thinking they can't incorporate broad advances into their practices without going back to training. Meanwhile, nurses take a weekend course and all of a sudden they're qualified. My dad used to do intensity modulated radiation therapy in his practice. It's a technology that was developed after his rad onc residency. Two of the CT surgeons I work with both do robot lungs. They did not learn how to do robot lungs during their fellowship. Most of the older interventional and structural cardiologists I work with use devices and do procedures that hadn't even been imagined yet when they were trainees. So why do we feel the need to handicap ourselves every time, even when there's a strong chance we could be proctored to a decent degree of proficiency?

 

[SinghDoc]

And thinking one needs fellowship and an exam to pick up any new skillset is just as foolish.

Most people on this subforum are very clear in that if someone desires to do pain, peds, CCM, CT, he or she should just do the fellowship nowadays. OP is in a unique situation, and I think everyone here has given him a nuanced answer where doing the fellowship is probably the way to go, but if he can't then he should know that it's going to be an incredible amount of work to get a degree of competency, and these skills might not even be transferrable to another job if he leaves his current one.

More broadly, physicians are sabotaging themselves by thinking they can't incorporate broad advances into their practices without going back to training. Meanwhile, nurses take a weekend course and all of a sudden they're qualified. My dad used to do intensity modulated radiation therapy in his practice. It's a technology that was developed after his rad onc residency. Two of the CT surgeons I work with both do robot lungs. They did not learn how to do robot lungs during their fellowship. Most of the older interventional and structural cardiologists I work with use devices and do procedures that hadn't even been imagined yet when they were trainees. So why do we feel the need to handicap ourselves every time, even when there's a strong chance we could be proctored to a decent degree of proficiency?

I actually agree with you, difference is just to what extent. I never trained in fellowship to do TEE for mitraclip or Watchman procedures, it took a lot of proctoring and self study. I just think that learning initial TEE and learning cardiac anesthesia are ideally done in a structured fellowship environment. I’d advocate for option to integrate fellowship into 4 year residency. If there was a huge shortage of fellowship grads entering market I’d see your point, but I don’t think that is the case.

 

[vector2]

I actually agree with you, difference is just to what extent. I never trained in fellowship to do TEE for mitraclip or Watchman procedures, it took a lot of proctoring and self study. I just think that learning initial TEE and learning cardiac anesthesia are ideally done in a structured fellowship environment. I’d advocate for option to integrate fellowship into 4 year residency. If there was a huge shortage of fellowship grads entering market I’d see your point, but I don’t think that is the case.

There is a concentrated shortage of fellowship grads joining certain centers (like mine). Either due to geography or due to the volume being too low. When I'm off work, it's straight generalists taking care of these pts, many of whom are pretty sick and/or undergoing complex surgery.

 

[pgg]

I I’d advocate for option to integrate fellowship into 4 year residency.

That used to be the case, sort of. Pre-2000-2005ish, it wasn't uncommon for anesthesia residents to do what they called a "mini fellowship" in which they spent 6+ months of their CA3 years doing only cardiac or only peds. A couple of my attendings in residency had taken that route.

The field has gone in a different direction though. Residencies don't have so much elective time any more. The trend is certainly toward more stringent requirements to do cardiac anesthesia, with most places demanding a fellowship year or at least TEE testamur status of new hires. With the ABA offering a cardiac subspecialty exam now (which has eligibility criteria beyond what a resident can accomplish), the trend continues.

We're not going to see a reversal such that residents can get either the subspecialty case load or exam eligibility necessary to get credentialed. That ship has sailed.

 

[PpfSuxTube]

And thinking one needs fellowship and an exam to pick up any new skillset is just as foolish.

Cardiac anesthesia is not a skillset. It is a career entirely unto itself.

And yes there is a difference between grandfather's and fellowship ppl. There is even a difference between good fellowships and mediocre fellowships.

I have some colleagues that did fellowships at places where 2 days a week they did gynae etc as service providers. So they did effectively half the numbers of cases we did... there is a difference. Sorry, not sorry.

Ppl who bundle icu with cardiac anesthesia, same story... one dilutes the other

 

[PpfSuxTube]

Cardiac fellowship is about 3k hours doing every type of crazy case. How is that interchangeable with a grandfather

 

[vector2]

Cardiac anesthesia is not a skillset. It is a career entirely unto itself.

And yes there is a difference between grandfather's and fellowship ppl. There is even a difference between good fellowships and mediocre fellowships.

I have some colleagues that did fellowships at places where 2 days a week they did gynae etc as service providers. So they did effectively half the numbers of cases we did... there is a difference. Sorry, not sorry.

Ppl who bundle icu with cardiac anesthesia, same story... one dilutes the other

Read the rest of my post again. No one has actually disputed what you're saying, which is why everyone including myself is telling him to just go do fellowship if he can.

Fact remains, there's a whole bunch of hospitals (probably the majority, in fact) which do cardiac surgery without CT fellowship trained anesthesiologists.

 

[pgg]

Cardiac fellowship is about 5k hours doing every type of crazy case. How is that interchangeable with a grandfather

What, did you take two years to do your fellowship?

Even my fellowship, which had a deserved reputation as a workhorse program, was probably about 60 hrs per week with most weekends off. Peds weeks maybe pushed 80 because I had to get there so much earlier to set up.

No cardiac anesthesia fellow is doing 100 hour weeks.

 

[nimbus]

Fact remains, there's a whole bunch of hospitals (probably the majority, in fact) which do cardiac surgery without CT fellowship trained anesthesiologists.

This includes OPs hospital which makes it a very viable pathway there.

 

[PpfSuxTube]

What, did you take two years to do your fellowship?

Even my fwllowship, which had a deserved reputation as a workhorse program, was probably about 60 hrs per week with most weekends off. Peds weeks maybe pushed 80 because I had to get there so much earlier to set up.

No cardiac anesthesia fellow is doing 100 hour weeks.

OK, 2500. I didn't count

 

[Ronin786]

Really don't get the angst towards OP's plan. He's not doing a week of cardiac cases and pretending he's done a fellowship. This is a longitudinal practice pathway that is being supplemented by book knowledge and exams. Way better than some of the ****ty cardiac fellowships out there.

As someone mentioned above, physicians really need to stop waiting for admins to tell them what they can and can't do. If the group is supportive and willing to credential him and he has zero desire to go elsewhere, this is an awesome opportunity.

 

[Ronin786]

Ironically, many of the "big wigs" in cardiac anesthesia never did a dedicated fellowship. Yet we've forgotten that it's still possible to master a field the good ole way;.