Seeking career advice: Critical Care Fellowship or Job?

[seelee]

I apologize if this has been discussed before but I am looking for career advice.

A bit about me:
I am a CA-2, medical school in Texas, and residency in the midwest. I am married with children and I am debating whether I should do a fellowship or go straight into the job market. I have a significant amount of debt, nothing saved for retirement, and college tuitions to save for.

My ideal job would be private group working in a moderate sized hospital in a smaller to moderate sized city (population of 100-200K) where I can do some legit cases (hearts, vascular, neuro, etc.). Doing my own cases would be a big plus. A job where I worked 1-2 weeks/month in the unit would be great, but not essential. I am interested in going back to Texas, but I could also see myself in other states (Idaho, Nevada, Arizona, Oklahoma, Kentucky, Tennessee). Bottom line, I am willing to move to a smaller, more remote town if it means making a significantly higher salary with a lower cost of living.

I have been interested in critical care and I have been told that the fellowship spot in my program's critical care fellowship is mine if I want it. This program would give me the opportunity to get my basic TEE cert. as well.

My main question is whether a CC fellowship would have significant benefit, either in terms of salary, job security, or in facilitating getting the kind of job I want.

I know that finding a PP job where I could work in the ICU would be rare, but I have been told that doing a fellowship can make you better and more comfortable with dealing with very sick patients and those "big cases". Can anyone attest to this?

I have also been told that a CC fellowship would be overkill given the places that I am wanting to live.

If you did a CC fellowship and are working in private practice, do you regret it? Has it opened more opportunities for you? Would you do it again?

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[teeva]

Based on my friends' experiences and current jobs, you don't need a fellowship if you want to work in KY, TN, OK or BFE and make good money with 10 weeks vacation and benefits, unless you really want to do ICU.

 

[Twiggidy]

I never discourage anyone from additional education and critical care positions can be very good jobs vs straight OR work (plus, rare to no L&D). Plus if the doom and gloom everyone speaks of on these forums happens, it'll be nice to have a little extra something to distinguish yourself.

 

[amyl]

Even the people I know who do OR anesthesia w a cc fellowship don't regret the fellowship. It's a year.... To keep lots of options open. I thought like you as a ca-3 n took a $ bfe job. Life changes. I can't leave fast enough for the pay cut of academics and a cc fellowship.... Money isn't everything ok? I know it seems like it bc you have debt and have lived "frugally" as a ms n resident. You think $ will make you happy.... And it might... but you will never regret having more options for just a year.

 

[Random Anesthesiologist]

I could have written the OPs post too, except I'm not from TX, and while no spot has been unofficially "guaranteed", there is interest in me. I wish the ASA would push CCM Anesthesia more within the overall CCM realm. Fortunately my program is really developing their fellowship and adding great attendings. I'd love to be able to stay on, but we will see.

 

[secants]

My only issue with CCM anesthesia is that since it's heavy sicu/cticu, I don't know if you can walk in a community micu right off the bat as an attending

 

[seelee]

Even the people I know who do OR anesthesia w a cc fellowship don't regret the fellowship. It's a year.... To keep lots of options open. I thought like you as a ca-3 n took a $ bfe job. Life changes. I can't leave fast enough for the pay cut of academics and a cc fellowship.... Money isn't everything ok? I know it seems like it bc you have debt and have lived "frugally" as a ms n resident. You think $ will make you happy.... And it might... but you will never regret having more options for just a year.

I agree that a small town in BFE isn't for everyone. I am from a small town like that and I have lived in larger metropolitan cities as well. I have always been a country boy. The money offered at hospitals like that is an added benefit.

 

[G-Man82]

My only issue with CCM anesthesia is that since it's heavy sicu/cticu, I don't know if you can walk in a community micu right off the bat as an attending

Those jobs exist. I applied to both PP and Academic Anesthesiogy/CCM mixed jobs and found places where anesthesia groups (really AMCs) had a grip on the ICU. This was in community practice and involved mostly MICU because most surgical patients there tended to not need he unit post-op. Yeah some of the medical minutia is not a part of our training but I think after a year in a MICU that I'd be just as comfortable as the medical/pulmonary intensivists.

 

[Ezekiel2517]

My only issue with CCM anesthesia is that since it's heavy sicu/cticu, I don't know if you can walk in a community micu right off the bat as an attending

I don't believe being in a community micu would be tough. Remember that most sicu pts are critically ill due to medical reasons and have many comorbidities like micu pts. The vast majority of pts in these community micu's are there with bread and butter stuff that any intensivist could manage. For the stuff you may not be familiar with you just need to have the right consultants on board. More than anything else, the most important role of the intensivist in these non-academic icu's is that of a coordinator and facilitator. Being able to communicate and coordinate care amongst different specialists and manage all the various ICU personnel and resources. The training background is less significant. The one setting I would not feel comfortable is a neuro-icu in a major academic type center. But I'm pretty sure most pulm-CCM docs would not feel comfortable either. Those pts need neurointensivists.

 

[deleted50478]

If you do a cc fellowship and take a 100% OR job, it'll just be a few years before the fellowship become a waste of a year and 300k.

 

[GA8314]

If you do a cc fellowship and take a 100% OR job, it'll just be a few years before the fellowship become a waste of a year and 300k.

For sure. This decision should be based upon what you want to do after fellowship. Contact groups in the area you are seeking when you finish and see what their needs are. Demand seems way stronger in academics so if you plan on PP, then see if those groups currently staff (or have plans to staff in the future) the ICU's in the hospitals they cover.

If NOT, then you'll "be a better doctor" by practicing the specialty you'll actually be doing (i.e. anesthesia). Also, if you really feel ICU will make you a more well rounded anesthesiologist, then do some extra months CA3 year if possible.

There is a significant opportunity cost to fellowship and it should be determined based upon career not some ideological perspective on magically helping you an a general anesthesiology practice.

I did not do a fellowship. I'm one year further along in my partnership track and our partners have a very good gig. Guess who will be sitting at the round table determining our needs (future pain or ICU expansion) going forward? So, if you have a good PP track job with CURRENT needs in an area you are interested, you need to think long and hard before going and doing a fellowship.

Doing PP anesthesia this past year as an attending has been a very good year, both learning, as well as earning. Please consider this strongly.

 

[G-Man82]

At the same time, some groups are seeing a value added to their position within the hospital to have some involvement with the ICU. If said Anesthesia group also provides critical care services, they are more visible to the hospital administrators and other physicians and possibly harder to replace.

Also, the PP "groups" that I interviewed with were AMCs. I think I saw some normal PP groups on gaswork asking for CCM, too, but they were fewer.

Besides, by fulfilling a week per month in the ICU, my regular call responsibilities for the group would have been covered. Most offered me no OR call or weekends as an ICU guy.

 

[Twiggidy]

Besides, by fulfilling a week per month in the ICU, my regular call responsibilities for the group would have been covered. Most offered me no OR call or weekends as an ICU guy.

crucial.....home call covering the ICU vs stuck in hospital babysitting epidurals and doing C/S .

 

[kazuma]

If you do a cc fellowship and take a 100% OR job, it'll just be a few years before the fellowship become a waste of a year and 300k.

For sure. This decision should be based upon what you want to do after fellowship. Contact groups in the area you are seeking when you finish and see what their needs are. Demand seems way stronger in academics so if you plan on PP, then see if those groups currently staff (or have plans to staff in the future) the ICU's in the hospitals they cover.

If NOT, then you'll "be a better doctor" by practicing the specialty you'll actually be doing (i.e. anesthesia). Also, if you really feel ICU will make you a more well rounded anesthesiologist, then do some extra months CA3 year if possible.

There is a significant opportunity cost to fellowship and it should be determined based upon career not some ideological perspective on magically helping you an a general anesthesiology practice.

I did not do a fellowship. I'm one year further along in my partnership track and our partners have a very good gig. Guess who will be sitting at the round table determining our needs (future pain or ICU expansion) going forward? So, if you have a good PP track job with CURRENT needs in an area you are interested, you need to think long and hard before going and doing a fellowship.

Doing PP anesthesia this past year as an attending has been a very good year, both learning, as well as earning. Please consider this strongly.

The above reasons are exactly why I decided to not do a CCM fellowship. At this point in my career, I have no interest in supervising nurses or residents so academics was out the door. I do like to teach and with my PP job I have the ability to do that with med students which I think I'll find rewarding. Most of my pre-residency anesthesia exposure was with private practice and that's what got me excited about the field.

I did almost 6 months of ICU throughout residency and we ran the show since we didn't have fellows to lean on at night. Between that and my CT months, I felt comfortable taking care of virtually any sick adult and I didn't feel like I needed a CCM fellowship to make me any more comfortable in PP.

I wouldn't by the whole echo/CCM BS helping out in PP either. For one, ANYONE including a resident in training can take the basic echo exam, you don't need a CCM fellowship for that. While it is technically possible to obtain advanced certification through CCM (not just testamur status because anyone can do that as well), it's extremely difficult at almost all the programs and is usually discouraged (Duke is one of the exceptions). I felt comfortable doing basic CABG's and valves on my own by the end of my CT months, so had my PP group been looking for more people to join the CT team I could have considered studying for and taking the advanced exam to obtain testamur status without a CCM fellowship. I know many CCM fellowships are struggling to fill each year and guaranteed advanced echo certification would be a sure fire way to add value to fellowship but unfortunately there was significant resistance at all the programs I was interested in. Although some of the programs had a decent TTE curriculum.

The market isn't the greatest, but I still had a few great PP prospects and offers when I wasn't actively looking for a job. Every PP group I talked to told me I didn't need the fellowship and that it would be a waste of my time and that I should go straight into PP. Even the PP group that had a couple CCM folks that moonlighted on the ICU during their vacation weeks told me it was a waste of time (and a pay cut which I was fine with). I was fine with the opportunity costs of the CCM fellowship, but only if I could find something where I could keep my CCM skills sharp and continue MOC. Like nolagas said, if you don't do CCM straight out of fellowship it's likely a waste of your time because the learning curve is so steep and you really need to keep honing your skills immediately. Not to mention you have to do a certain % of CCM each year in order to re-certify through MOC. To help improve my CCM job prospects I even considered doing CCM full time for the first few years and OR moonlighting on the side but almost every PP ICU gig I looked at wanted Pulm/CC so they could share ICU, clinic and floor consults evenly. Ultimately I decided against the CCM fellowship and I couldn't be happier with my PP gig.

It's a tough decision but I'd say if you're 100% sure that academics is for you then consider doing a CCM fellowship because that might be the only good gig you can find that would allow you to practice CCM and OR anesthesia. The market is tight enough without trying to limit your options to one of the rare PP groups that covers the ICU that may or may not be hiring when you finish fellowship. If academics isn't for you and you're dead set on drinking the fellowship cool-aid then you might want to consider something that might be more useful in certain PP groups like peds or cardiac. Best of luck with your decision.

 

[Twiggidy]

Side note: If you get advanced TEE certified (via CV maybe ICU), you can read your echos and bill for that. May not be a HUGE money difference, but it is extra money.

 

[kazuma]

Side note: If you get advanced TEE certified (via CV maybe ICU), you can read your echos and bill for that. May not be a HUGE money difference, but it is extra money.

Please correct me if I'm wrong, but I believe anyone can bill for a TEE interpretation as long as you know what you are doing. What your hospital requires for TEE credentialing and what you are willing to take on in terms of liability are separate issues.

 

[spike7585]

Please correct me if I'm wrong, but I believe anyone can bill for a TEE interpretation as long as you know what you are doing. What your hospital requires for TEE credentialing and what you are willing to take on in terms of liability are separate issues.

From my understanding, if you are not advanced TEE certified, you can only bill for TEE placement (which is at least something!) but not for the report itself.

 

[Twiggidy]

From my understanding, if you are not advanced TEE certified, you can only bill for TEE placement (which is at least something!) but not for the report itself.

Exactly. Trust me, where I work there are peeps more money hungry than I am, and if they could bill for reading their TEEs they would, but they know they can't.....so I read them...and gets paid.

 

[Ezekiel2517]

If you do a cc fellowship and take a 100% OR job, it'll just be a few years before the fellowship become a waste of a year and 300k.

I agree that one should only do a fellowship if they actually like it. That's common sense. But if you are only OR, you can still do CCM per diem as much or as little as you like as these opportunities are plentiful. The pay per hr for some of these gigs is actually more than what you'd get in PP anesthesia. And your initial certification actually lasts 10 years. If you want to stay in PP, having an additional board cert. in CCM will help you get a job in the more competitive groups.
Whatever path you choose, just don't be shortsighted because things can change real quick. That sweet PP partner track gig you signed up for can vanish in the blink of an eye. In uncertain times you gotta protect yourself and be ready for changes. Survival of the fittest.

 

[bashwell]

I don't know Canada but I've heard if you do critical care then it'd help in transferring to their system. No idea if this is true but some people may be interested in finding out more. It's currently not necessary in Australia at least as far as I know though please check for yourself but that said anaesthetics aka anesthesiology residency in Australia is 5 years and 5th year is fellow year which is required of all registrars aka residents.

 

[Fajardo04]

Exactly. Trust me, where I work there are peeps more money hungry than I am, and if they could bill for reading their TEEs they would, but they know they can't.....so I read them...and gets paid.

This is not true. Anyone can bill for a full echo exam as long as it's complete. Even a CRNA can bill for it if they want to. It's the same idea as being a board-certified anesthesiologist - it is absolutely not required to bill for anesthesia services currently. A family practitioner can bill for anesthesia services the same as an anesthesiologist can. Not the smartest idea, but certainly possible. The echo boards have no jurisdiction over billing privileges.

 

[nimbus]

This is not true. Anyone can bill for a full echo exam as long as it's complete. Even a CRNA can bill for it if they want to. It's the same idea as being a board-certified anesthesiologist - it is absolutely not required to bill for anesthesia services currently. A family practitioner can bill for anesthesia services the same as an anesthesiologist can. Not the smartest idea, but certainly possible. The echo boards have no jurisdiction over billing privileges.

Yep. The insurance company is not checking your board status when you submit the bill. You do need a complete report when you bill for a diagnostic exam.

 

[GA8314]

From my understanding, if you are not advanced TEE certified, you can only bill for TEE placement (which is at least something!) but not for the report itself.

This is not true.

 

[G-Man82]

To bring the discussion back on topic, I did a CCM fellowship and I absolutely love it. Life as a fellow and attending in CCM is very different from that as a resident. At both my residency and fellowship hospitals, I felt that the residents got a skewed and inadequate view of what the ICU is - scut work and orders with a healthy dose of fear due to inadequate supervision, patient acuity, or less than helpful surgical attendings. Yeah, as an attending doing daily progress notes again will be a little annoying but it's simply a part of the job. For being in the ICU, I am not on the OR call schedule for nights and weekends (though I will do lates here and there). Plus each ICU week gives me the weekend plus 2 sometimes 3 days post-ICU call. A regular post call day is nice, but these would be normal days free of clinical responsibility where I can do daily life stuff like banking and errands before the place closes. Regular post call days I'm too tired to do anything.

And, this may be skewed because I'm fresh out of fellowship and just doing some per diem work in the OR at my fellowship hospital before moving, but for now at least, I like the ICU more than the OR. Directing CRNAs can get boring. I prefer residents because then I'm more hands on. Go figure. I definitely did not see that coming. Plus, though I'm a month out, I've essentially become like a medical consultant for some of the generalists, especially for add-on ICU cases into their rooms. All curbside stuff, but there is A LOT to be gained in knowledge from one year in the unit. If finances weren't an issue, I'd think that ALL anesthesiologists would benefit from the fellowship regardless of whether or not they intend to practice CCM as an attending.

It was a rewarding year and I definitely learned a lot about how to treat sick patients. And there is a lot about ventilators that I know now that I didn't know or realize as a resident.

 

[seinfeld]

My only issue with CCM anesthesia is that since it's heavy sicu/cticu, I don't know if you can walk in a community micu right off the bat as an attending

You absolutely can!! I did it very easily. Most CCM in PP world is about Vents, pressors, when to start abx, and when to get a consult from other services. In the OR you ARE the medicine attending. Having taken care of 1 COPD exacerbation you have taken care of most all of them. Interesting neuro case, call neurology. Renal Failure call nephrology. Weird arrhythmia or + trop call cards.

Over time you will get a better sense of when to call for a consult and when not to. Surprising to me is that when I take over from the med/pulm guys i find they have consulted people when I never would have.

 

[seinfeld]

PP CCM jobs in anesthesia do exist, the main issues is that we as a specialty haven't reached a critical mass to where groups like mine are easy to find. If you love taking care of sick people then i would do the fellowship. You will never go back to do one. One more year of loan deferral won't change the amount you pay much. There is an opportunity cost that is substantial (first year PP salary - fellowship pay) but given the climate of downtrending reimbursements and CRNA footholds, i see it as an insurance policy with a one time cost.

One thing most don't talk about is the respect and treatment difference you get from a surgeon. It hard to be a dick to you when you are providing referrals (in PP i get to choose who sees my ICU patients unless its after-hours) and also when they are looking to you to make sure their patient don't die in the ICU they listen a lot better to your suggestions in the OR.

 

[G-Man82]

PP CCM jobs in anesthesia do exist, the main issues is that we as a specialty haven't reached a critical mass to where groups like mine are easy to find. If you love taking care of sick people then i would do the fellowship. You will never go back to do one. One more year of loan deferral won't change the amount you pay much. There is an opportunity cost that is substantial (first year PP salary - fellowship pay) but given the climate of downtrending reimbursements and CRNA footholds, i see it as an insurance policy with a one time cost.

One thing most don't talk about is the respect and treatment difference you get from a surgeon. It hard to be a dick to you when you are providing referrals (in PP i get to choose who sees my ICU patients unless its after-hours) and also when they are looking to you to make sure their patient don't die in the ICU they listen a lot better to your suggestions in the OR.

Completely agree. As an ICU attending I have 2 specialties that can overlap, if I do SICU, or can be completely separate, if I take care of MICU or CTICU patients. All for an extra year of training that I believe will be worth the opportunity cost of one year's practice.

As far as the attitudes go, I'm technically at an academic center right now, but this locale is supposed to function as the private practice arm. I'm not doing ICU here, but I am per diem in the ORs, and some of the surgeons know me from my fellowship. There is a palpable difference in the way they speak to me.

My ICU practice will involve some MICU care because they overflow into my unit, and if they're in MY unit, they are mine to treat. It creates a lot of nice variability in my practice that I don't think I would see in a strict OR practice. And besides, it's time more of us entered CCM. The pulm people tend to be too focused on pulm rather than CCM. We would be good.

 

[Random Anesthesiologist]

Last winter I was thinking about fellowship, now I'm certain, mostly for reasons listed already like enjoying working with sick patients and clinical expertise. And, it's the only call I take where my head doesn't hit the pillow. Sometimes involuntary

My ITE is nothing special, just average, but I've only taken it once (not required intern year). So it hopefully will improve. Everything else is normal with great recs so I'm throwing my hat in the ring in Nov. I kinda want to stay at my home institution. I like how the fellowship is set up, the curriculum and the people. They're not a powerhouse like Duke but I have opportunity for advanced TEE. They are strong on resident procedures, so I already know how to place all kinds of lines, chest tubes, do thoracentesis, basic bronch, paracentesis, etc. They offer ID, trauma, and TEE opportunities I wouldn't get as a resident only. And lots of other nuances I like.

My main focus now is getting in, and building up my CV with resident research projects. I just hope I'm on the right path and a good candidate. I'm actually doing it because I like it, not because it's a CRNA fail safe (although that is not a bad reason).

Are there any of you that would be willing to field private questions this fall? I won't pester you now, just wondering who is open to talking more about Anes CCM.

 

[IkeBoy18]

Last winter I was thinking about fellowship, now I'm certain, mostly for reasons listed already like enjoying working with sick patients and clinical expertise. And, it's the only call I take where my head doesn't hit the pillow. Sometimes involuntary

My ITE is nothing special, just average, but I've only taken it once (not required intern year). So it hopefully will improve. Everything else is normal with great recs so I'm throwing my hat in the ring in Nov. I kinda want to stay at my home institution. I like how the fellowship is set up, the curriculum and the people. They're not a powerhouse like Duke but I have opportunity for advanced TEE. They are strong on resident procedures, so I already know how to place all kinds of lines, chest tubes, do thoracentesis, basic bronch, paracentesis, etc. They offer ID, trauma, and TEE opportunities I wouldn't get as a resident only. And lots of other nuances I like.

My main focus now is getting in, and building up my CV with resident research projects. I just hope I'm on the right path and a good candidate. I'm actually doing it because I like it, not because it's a CRNA fail safe (although that is not a bad reason).

Are there any of you that would be willing to field private questions this fall? I won't pester you now, just wondering who is open to talking more about Anes CCM.

im sure @G-Man82 wouldnt mind. He answered all of my PMs regarding CCM with very thorough responses!

 

[amyl]

You usually don't go back to do a fellowship in cc but I am. Three years out and I'm going back.... But I'm special

 

[imfrankie]

I say do it. This anesthesia climate is changing so quickly. It's only a year and you will always be the goto person, able to get a job anywhere. Do it.

 

[G-Man82]

Finding combined Anesthesiology/CCM jobs is still not the easiest, though. I'm leaving my fellowship region for that reason; plain CCM and plain anesthesiology jobs weren't too difficult to come by. Some of the general anesthesiology jobs seemed thrilled to have a CCM-trained doc on board, but still expressed little desire to get involved with critical care. Joining them would have been a waste of my fellowship year, in my opinion, mostly because I actually like the ICU. The plain CCM jobs didn't seem to care that I am an Anesthesiologist, but I didn't ask too many questions of them because I was also against giving up OR practice.

Aside from academics, the PP places that I interviewed at which had dual Anes/CCM practices were all AMCs. The climate for anesthesiology is definitely changing, and the AMCs have also noticed and are adapting. Unfortunately, from my search within this region, I can't really say that about the regular PP groups.

 

[urge]

From my understanding, if you are not advanced TEE certified, you can only bill for TEE placement (which is at least something!) but not for the report itself.

This is true for medicare/medicaid. They will not pay unless you are board certified. They just like any excuse not to pay.

 

[nimbus]

This is true for medicare/medicaid. They will not pay unless you are board certified. They just like any excuse not to pay.

Really? I was paid for my Medicare and Medi-Cal cases before I was board certified in anesthesiology.
It takes surgeons a couple of years to get certified. AFAIK, they get paid too.

 

[urge]

Really? I was paid for my Medicare and Medi-Cal cases before I was board certified in anesthesiology.
It takes surgeons a couple of years to get certified. AFAIK, they get paid too.

It's only for echo.

 

[PainDrain]

Amyl. I sent you a PM.

 

[IkeBoy18]

I think im equally interested in CCM and Cardiac. I guess these next few years will help me make this decision, or not.

 

[deleted171991]

I think im equally interested in CCM and Cardiac. I guess these next few years will help me make this decision, or not.

Do both.

 

[imfrankie]

Do both.

Yeah, Brigham combined.

 

[IlDestriero]

Or go get a high paying job in a smaller city in a fly over state and make hay while the sun shines. 7-10 years from now when you are debt free, have >$1m in you're retirement account, a paid off mortgage, a well funded FU account, and a couple nice toy$, you can reinvent yourself with a fellowship and take a low call, lifestyle faculty job somewhere nice and close out your career in style.
That's what I would do if I was looking at big debt and clouds on the horizon.

 

[Twiggidy]

Or go get a high paying job in a smaller city in a fly over state and make hay while the sun shines. 7-10 years from now when you are debt free, have >$1m in you're retirement account, a paid off mortgage, a well funded FU account, and a couple nice toy$, you can reinvent yourself with a fellowship and take a low call, lifestyle faculty job somewhere nice and close out your career in style.
That's what I would do if I was looking at big debt and clouds on the horizon.

This tho.....especially living somewhere cheap and paying off the mortgage