What is the best fellowship path?

[DetectiveAlonzo]

Do you hate call, weekends, and being told what to do in the OR? --------> Pain fellowship
Do you like rounding? --------> Critical care
Do you like the OR and want to be invaluable to your group? --------> Peds and Cardiac
Do you like academics and have extra time to kill? --------> Regional
Do you have extra time to kill period!? --------> The other exotic fellowships which will not be named.

how competitive is a cards fellowship?

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[Machinery]

how competitive is a cards fellowship?

Anyone half way serious about getting one will get it. I am not sure any of the fellowships are that competitive these days.

 

[deleted171991]

Peds is less and less invaluable to groups. I would slowly put regional above peds, unless one had great regional training in residency. Otherwise Blade's list is correct.

Oh, and critical care is almost worthless for many PPs. They will actually look down on your year off, and suspect that you would leave at some point for a combined academic position (especially since PP jobs for new grads kind of suck in certain parts of the country).

So, for PP, my order is. Cardiac, Pain, Regional, Peds, possibly OB or Neuro.

 

[deleted171991]

how competitive is a cards fellowship?

More and more. Match numbers at about 80% now, have been decreasing for the last few years. Expect 70% next year etc. Cardiac is the new pain.

 

[deleted162650]

Peds is less and less invaluable to groups. I would slowly put regional above peds, unless one had great regional training in residency. Otherwise Blade's list is correct.

I'm really gonna have to disagree with you on this part. I realize it may be somewhat practice dependent, but many hospitals are now requiring peds fellowship training if you want to get credentialed to take care of sick or little (<2yo) kids or peds trauma.

I've never heard of a hospital requiring regional fellowship training to do blocks (at least not yet anyways).

Add to that the fact that going to a solid residency program will allow you to block as good as any regional fellow (excepting for maybe the real exotic blocks that no one wants/does in PP anyways) but residency alone will not adequately prepare you to take care of a sick/syndromic neonate.

 

[deleted171991]

I'm really gonna have to disagree with you on this part. I realize it may be somewhat practice dependent, but many hospitals are now requiring peds fellowship training if you want to get credentialed to take care of sick or little (<2yo) kids or peds trauma.

I've never heard of a hospital requiring regional fellowship training to do blocks (at least not yet anyways).

Add to that the fact that going to a solid residency program will allow you to block as good as any regional fellow (excepting for maybe the real exotic blocks that no one wants/does in PP anyways) but residency alone will not adequately prepare you to take care of a sick/syndromic neonate.

There just won't be enough peds cases for all the peds anesthesiologists; it will be a bad market for them, unless they will do 90% adults. Most of them go into peds because they don't like adults, and that's exactly the message they are sending to potential employers. How many pediatric anesthesiologists does this country need? There are way too many fellowship positions, as in cardiac. In 10-15 years, peds will be just a nice thing on the resume, like CCM and others. A lot of people got grandfathered in; it's not like suddenly we needs tons of board-certified people.

I did say regional only for people who were not trained well in residency. Regional anesthesia is becoming more and more popular with surgeons, especially in outpatient, where the money is. It's not the fancy stuff that matters; it's the ability to do blocks fast and well. That's why pain people still have a job in the OR, even when not practicing pain.

 

[deleted162650]

There just won't be enough peds cases for all the peds anesthesiologists; it will be a bad market for them, unless they will do 90% adults. Most of them go into peds because they don't like adults, and that's exactly the message they are sending to potential employers. How many pediatric anesthesiologists does this country need? There are way too many fellowship positions, as in cardiac. In 10-15 years, peds will be just a nice thing on the resume, like CCM and others. A lot of people got grandfathered in; it's not like suddenly we needs tons of board-certified people.

I did say regional only for people who were not trained well in residency. Regional anesthesia is becoming more and more popular with surgeons, especially in outpatient, where the money is. It's not the fancy stuff that matters; it's the ability to do blocks fast and well. That's why pain people still have a job in the OR, even when not practicing pain.

I fully agree we don't really "need" that many peds people. There are only so many sick kids and so many dedicated children's hospitals out there. The problem is that at least in urban areas, the trend is towards only letting fellowship trained docs touch kids period, regardless of whether it's a case that could be handled by a generalist. You're seeing the same thing with cardiac. You wanna do B&B cardiac in an urban area, you're gonna need that fellowship cert. I think this will "artificially" keep the demand for CT fellows high despite the declining volume of CT surgeries.

 

[Man o War]

I fully agree we don't really "need" that many peds people. There are only so many sick kids and so many dedicated children's hospitals out there. The problem is that at least in urban areas, the trend is towards only letting fellowship trained docs touch kids period, regardless of whether it's a case that could be handled by a generalist. You're seeing the same thing with cardiac. You wanna do B&B cardiac in an urban area, you're gonna need that fellowship cert. I think this will "artificially" keep the demand for CT fellows high despite the declining volume of CT surgeries.

Agree. One of the groups I interviewed with was told by the hospital they had a certain amount of time to replace all their heart docs with docs that had advanced cert. Some of these guys and gals had been doing hearts there for years.
I've heard from new fellows looking for jobs that they have encountered this at different places as well.

 

[deleted171991]

What I am trying to say is that most fellowships will become as common and underappreciated as generalists are today. It's a matter of supply and demand, and we are overproducing most graduates. At my previous academic job, the chair had a waitlist of 10 monkeys for pediatrics. Plus, as I said, there are all the grandfathered people (which was easier than with cardiac).

 

[caligas]

Reproductive endocrinology. B'c Self-determination, cash pay, and no nights or weekends.

Actually our R.E. transferred our embryo (she's 2 now) on thanksgiving day. You're right about the cash though, we forked it over happily.

 

[anes121508]

Agree. One of the groups I interviewed with was told by the hospital they had a certain amount of time to replace all their heart docs with docs that had advanced cert. Some of these guys and gals had been doing hearts there for years.
I've heard from new fellows looking for jobs that they have encountered this at different places as well.

I echo this. At multiple places the administration and CT surgeons want to replace the non TEE cert docs with those who have formal training. What I'm finding though is that there isn't much volume. 500-600 hearts a year split 10-12 ways. Does that keep up your skills?

 

[anes121508]

As open heart declines, those looking for fellowship should find a place that has a presence in the cath lab doing the echo for structure heart cases (as opposed to turning the dial up and down while the cardiologists and fluoro arm crowd your space). A solid knowledge of catheter based procedures and skills to guide the proceduralist with live 3-D skills/knowledge brings value.

 

[deleted171991]

I echo this. At multiple places the administration and CT surgeons want to replace the non TEE cert docs with those who have formal training. What I'm finding though is that there isn't much volume. 500-600 hearts a year split 10-12 ways. Does that keep up your skills?

Why is it split 10 ways? Why aren't 3-4 cardiac anesthesiologists enough (one on vacation)? Because now everybody and their mother are getting a cardiac fellowship?

I doubt anybody will pay a significant premium for a cardiac anesthesiologist when there are 3 times more than needed in the group.

 

[Man o War]

I echo this. At multiple places the administration and CT surgeons want to replace the non TEE cert docs with those who have formal training. What I'm finding though is that there isn't much volume. 500-600 hearts a year split 10-12 ways. Does that keep up your skills?

I don't think so. Maybe it depends on your years of experience though. So if you spent a couple decades doing TEEs and tough cases you could spend the last 10 years of your career doing more bread and butter and be fine?

 

[Man o War]

Why is it split 10 ways? Why aren't 3-4 cardiac anesthesiologists enough (one on vacation)? Because now everybody and their mother are getting a cardiac fellowship?

I doubt anybody will pay a significant premium for a cardiac anesthesiologist when there are 3 times more than needed in the group.

It's ideal for case coverage for sure but the call burden would be a tough sell.

 

[psychbender]

The fellowship trend is kind of becoming ridiculous. When I was interviewing for CCM this past year, one of my interviewers was dual CT-CCM, but was only CCM at the university hospital because they had too many cardiac guys already (volume 500-600 cases annually). He did CT at the local VA, instead. When discussing experience, he made the passing comment that he actually did fewer hearts than I did the previous year, as the volume and acuity at his VA is lower than at my current hospital.

A residency classmate of mine just told me that at his "privademic" hospital that is part of a big name academic network, only the regional fellowship trained guys are allowed to do blocks.

 

[caligas]

A residency classmate of mine just told me that at his "privademic" hospital that is part of a big name academic network, only the regional fellowship trained guys are allowed to do blocks.

(Including CRNAs with an online regional fellowship)

 

[GravelRider]

Of course there are going to be cycles where peds and cardiac anesthesiologists are in oversupply. Right now they are the "hot" fellowship choices for anesthesiologists because the job market is slightly better. However, that won't last forever. It can't. Everything cycles in medicine. We are seeing an uptick in interest in primary care because the pay has gotten better when 5-10 years ago no one wanted to do primary care. Choosing a fellowship based purely on the job market is unwise. You have to at least like what you do.

I also think most med students have to come to the realization that the days of banging out bread & butter cases all day and bringing your paycheck home in a wheelbarrow are gone. Despite all the cheery attitudes about how great private practice is, the reality is that private practice...for all physicians...is a dying breed. The vast majority of people entering medical school now will never get a job offer from a PP. Current medical students will be employed by a much larger entity...academics, large hospital system, private equity company, etc... These organizations will be looking for "value" when they hire someone. People with additional skills can provide that value. That's why I think a fellowship is a good idea. I think ranking fellowships now based on current market conditions is foolish. Rather, I think residents should decide which area of anesthesia they enjoy the most and then do the fellowship. If you really enjoy OB then do the extra year. Forget about the year of lost income. You have a whole career ahead of you and the purpose is to position yourself so that you can provide "value" to these large entities. The suits that run these entities like to see certificates because the truth is that they have no idea what our training is like. They also don't want to be the only organization in a region without a certain specialty. You can't have hospitalists rounding in the ICU when every other hospital in the region has intensivists.

 

[deleted171991]

@GravelRider, you are one of my favorite posters, but I disagree. First of all, the vast majority of people entering medical school now, or finishing it, should never consider anesthesia, period, unless they can't get anything better. Now about the people already stuck with a residency...

People have to train for a particular regional market, at least for whatever they can foresee in its future. It will bring them so much more more happiness. Forget about passions, make hay while the sun still shines. The best job is the one that makes you more than enough money and allows for a lot of time off. That's the secret. It's almost always a partner job. Just read this forum if you don't believe me; most unhappy people are stuck in a bad employed position, and the other way round. Don't just follow your heart, passions and other BS. If the market rewards blue anesthesiologists with partnerships big time, go drink ink till you turn blue if you have to.

They say one should follow one's passions because it's much easier to do work that one likes. Guess what: people like to do stuff they are good at, so get good at what the market wants, not at what you want. One should do whatever is rewarded by the market with partnerships, meaning the subspecialties where demand dwarfs supply. Right now it's cardiac, and maybe pain, so that's what any intelligent person should do. Try to get into a great program and get good at your job, and do maintain all your general anesthesiologist skills for life. Happiness will follow. Just don't expect it to be permanent; this business is cyclical, and every cycle burns some people.

 

[Nivens]

@GravelRider, you are one of my favorite posters, but I disagree. First of all, the vast majority of people entering medical school now, or finishing it, should never consider anesthesia, period, unless they can't get anything better. Now about the people already stuck with a residency...

People have to train for a particular regional market, at least for whatever they can foresee in its future. It will bring them so much more more happiness. Forget about passions, make hay while the sun still shines. The best job is the one that makes you more than enough money and allows for a lot of time off. That's the secret. It's almost always a partner job. Just read this forum if you don't believe me; most unhappy people are stuck in a bad employed position, and the other way round. Don't just follow your heart, passions and other BS. If the market rewards blue anesthesiologists with partnerships big time, go drink ink till you turn blue if you have to.

They say one should follow one's passions because it's much easier to do work that one likes. Guess what: people like to do stuff they are good at, so get good at what the market wants, not at what you want. One should do whatever is rewarded by the market with partnerships, meaning the subspecialties where demand dwarfs supply. Right now it's cardiac, and maybe pain, so that's what any intelligent person should do. Try to get into a great program and get good at your job, and do maintain all your general anesthesiologist skills for life. Happiness will follow. Just don't expect it to be permanent; this business is cyclical, and every cycle burns some people.

For all those new to the board, this is the new, optimistic, positive FFP ;P

 

[GravelRider]

@GravelRider, you are one of my favorite posters, but I disagree. First of all, the vast majority of people entering medical school now, or finishing it, should never consider anesthesia, period, unless they can't get anything better. Now about the people already stuck with a residency...

People have to train for a particular regional market, at least for whatever they can foresee in its future. It will bring them so much more more happiness. Forget about passions, make hay while the sun still shines. The best job is the one that makes you more than enough money and allows for a lot of time off. That's the secret. It's almost always a partner job. Just read this forum if you don't believe me; most unhappy people are stuck in a bad employed position, and the other way round. Don't just follow your heart, passions and other BS. If the market rewards blue anesthesiologists with partnerships big time, go drink ink till you turn blue if you have to.

They say one should follow one's passions because it's much easier to do work that one likes. Guess what: people like to do stuff they are good at, so get good at what the market wants, not at what you want. One should do whatever is rewarded by the market with partnerships, meaning the subspecialties where demand dwarfs supply. Right now it's cardiac, and maybe pain, so that's what any intelligent person should do. Try to get into a great program and get good at your job, and do maintain all your general anesthesiologist skills for life. Happiness will follow. Just don't expect it to be permanent; this business is cyclical, and every cycle burns some people.

I agree, most med students should consider other specialties at the moment...at least until anesthesia figures itself out. In fact, I think that most college students should stay away from medical school and seriously consider nursing school instead. Unless you want to be involved in research, nursing school provides a much better entry into the practice of clinical medicine. Unfortunately, most people reading this are at the point of no return.

My point is that private practice is not an option for the vast majority of students/residents. Yes, it is ideal to be able to find a PP job, but we have to come to terms with the fact that it is not a reality for most people. Most residents will move and settle in the known popular markets where the private practices that still do exist are either failing or a target for an imminent sale/takeover. The private practice dream is just not a reality anymore. If you are a physician in training right now, in all likelihood you will be employed. Ownership in your work is obviously ideal, but it just becoming such a rarity nowadays.

Your career is also a long term investment. Speculating that a certain specialty will give you the most money right now will likely result in long term unhappiness. If you hate being in the heart room, but cardiac anesthesia is in demand in the region you want to live, does it make sense to do a cardiac fellowship?

Do I think residents should choose a fellowship without any understanding of the market? Absolutely not. In fact, knowledge of the market will help set expectations. Doing a critical care fellowship and thinking it will help you step into a sweet private practice job banging out 12 knee scopes a day is unrealistic. Doing a critical care fellowship knowing you will likely end up in academics or a larger employed hospital system is an appropriate level of expectation. A critical care fellowship will help you get a job in Philadelphia, but might not help you get a job in Montana.

I also think doing a fellowship might position a physician with "creating" a job within an organization. This may be the next best thing beyond private practice ownership. You do an OB fellowship and approach the gigantic hospital system in your hometown and say "hey, you're not advertising a job for an OB anesthesiologist, but if you were thinking about expanding your Women's Health Services, I'd love to join your organization and help you grow."

I guess the takeaway point is this: Doing cardiac anesthesia because it is in demand now is an overly simplistic recommendation. If you love cardiac anesthesia then by all means, go for it. No matter how you look at it, you are going to be spending an awful lot of time at work until you are 60 years old, so you better at least like what you do.

 

[deleted171991]

For all those new to the board, this is the new, optimistic, positive FFP ;P

It's much better if I don't post at all. People don't like bad news, even if rooted in a collective experience. Some people always like to make their own mistakes, even if warned. I can walk through fire, I will not get burnt, the laws of the Universe don't apply to me...

 

[Nivens]

It's much better if I don't post at all. People don't like bad news, even if rooted in a collective experience. Some people always like to make their own mistakes, even if warned. I can walk through fire, I will not get burnt, the laws of the Universe don't apply to me...

I was only being half-sarcastic- your posts have a different feel post-fellowship. A little less Consig, a little more Blade.

 

[deleted171991]

Your career is also a long term investment. Speculating that a certain specialty will give you the most money right now will likely result in long term unhappiness. If you hate being in the heart room, but cardiac anesthesia is in demand in the region you want to live, does it make sense to do a cardiac fellowship?

Oh man/woman, you're a beautiful mind! But the answer to your question is a resounding Yes (coming from a person who didn't do cardiac exactly because of the atmosphere in the rooms). And the reason is family. One works to live, not lives to work. Hence one is at work to make money and get out asap. If the cardiac room allows one to make more hay with more time off while closer to family and having easier OR days, it's more than enough sugar for the rest of the lemonade. Even the electron knows to choose the pathway of least resistance.

Obviously, if one has a deep passion for a subspecialty, one should go for it. Like I went for CCM. But it has to be deep, because the passion may end up being most of the sugar in that lemonade. One can be an Artusio, and it wouldn't matter, if all the market needs are CRNAs. The market is king; know the market, train for the market.

That should kind of answer your entire post. Funny thing is that I too used to be a strong believer in "do what you like" but, as I get older, I think "like what you do" should be put first.

 

[deleted171991]

I was only being half-sarcastic- your posts have a different feel post-fellowship. A little less Consig, a little more Blade.

Is that good or bad?

 

[Nivens]

Oh man/woman, you're a beautiful mind! But the answer to your question is a resounding Yes (coming from a person who didn't do cardiac exactly because of the atmosphere in the rooms). And the reason is family. One works to live, not lives to work. Hence one is at work to make money and get out asap. If the cardiac room allows one to make more hay with more time off while closer to family and having easier OR days, it's more than enough sugar for the rest of the lemonade. Even the electron knows to choose the pathway of least resistance.

Obviously, if one has a deep passion for a subspecialty, one should go for it. Like I went for CCM. But it has to be deep, because the passion may end up being most of the sugar in that lemonade. One can be an Artusio, and it wouldn't matter, if all the market needs are CRNAs. The market is king; know the market, train for the market.

That should kind of answer your entire post. Funny thing is that I am also a strong believer of do what you like but, as I get older, I think like what you do should be put first.

The issue with making decisions this way is you wind up chasing the market- there's no way to know how close to the peak your buying that stock. Cardiac might be hot now, but as you pointed out above there are some concerning market trends with declining open cardiac surgical procedures and increasing percutaneous intervention that doesn't seem to require us. It's nearly impossible to predict where this will find a level, especially when you factor in the increasing prevalence of cardiac disease and overall unhealthiness and the impending "Silver Surge". So whereas a cardiac fellowship might seem like a great bet today, if you are lukewarm on the heart room but go do a fellowship anyway, following the market, you are really going to be kicking yourself if the tides turn. I suspect this is the reasoning behind some of the regurg of pain trained folks back into general anesthesiology- they were expecting to do injection on injection, making money by the wheelbarrow, and the market changed (namely the reimbursement structure).

I have always wondered how quickly medical students would suddenly decide bones and moles aren't that fascinating after all if the floor fell out from those salaries...

 

[Nivens]

Is that good or bad?

On balance, I would say good!

 

[anes121508]

Why is it split 10 ways? Why aren't 3-4 cardiac anesthesiologists enough (one on vacation)? Because now everybody and their mother are getting a cardiac fellowship?

I doubt anybody will pay a significant premium for a cardiac anesthesiologist when there are 3 times more than needed in the group.

What I've encountered are groups with 15-20 docs. All of them do hearts. Some like it it, some don't. Some have taught themselves TEE, some couldn't care less. The 2-4 CT fellowship trained people don't wan't the call burden. So they take the guys/gals in the group that have more of an interest or function at a very high level in the cardiac room and make a dedicated team (8-12 docs). The folks with non formal TEE training in this group do some sort of education to improve their skills and make the surgeons/administration happy.

Some offer a bit more for the fellowship, some don't. The small bit more is nowhere near what you sacrifice during the year of fellowship. For the groups that don't offer premium, it isn't because they already have a bunch of TEE cert people. It's because they have large number of docs that already do complex cardiac cases and feel they are only hiring CT fellows because their hand is being forced.

 

[nimbus]

Oh man/woman, you're a beautiful mind! But the answer to your question is a resounding Yes (coming from a person who didn't do cardiac exactly because of the atmosphere in the rooms). And the reason is family. One works to live, not lives to work. Hence one is at work to make money and get out asap. If the cardiac room allows one to make more hay with more time off while closer to family and having easier OR days, it's more than enough sugar for the rest of the lemonade. Even the electron knows to choose the pathway of least resistance.

Obviously, if one has a deep passion for a subspecialty, one should go for it. Like I went for CCM. But it has to be deep, because the passion may end up being most of the sugar in that lemonade. One can be an Artusio, and it wouldn't matter, if all the market needs are CRNAs. The market is king; know the market, train for the market.

That should kind of answer your entire post. Funny thing is that I am also a strong believer of do what you like but, as I get older, I think like what you do should be put first.

Admittedly the call burden is high but our heart rooms have the best sense of camraderie, collegiality and teamwork of the entire OR. The atmosphere is not the same everywhere.

 

[Machinery]

Admittedly the call burden is high but our heart rooms have the best sense of camraderie, collegiality and teamwork of the entire OR. The atmosphere is not the same everywhere.

Those are unique heart rooms you got there. The ones I am familiar with attract some strong abrasive personalities. There are people I know who don't like doing hearts for that exact reason.

 

[IlDestriero]

Admittedly the call burden is high but our heart rooms have the best sense of camraderie, collegiality and teamwork of the entire OR. The atmosphere is not the same everywhere.

That doesn't seem like the norm from my limited experience.


--
Il Destriero

 

[nimbus]

Those are unique heart rooms you got there. The ones I am familiar with attract some strong abrasive personalities. There are people I know who don't like doing hearts for that exact reason.

That doesn't seem like the norm from my limited experience.


--
Il Destriero

Yes my residency experience was quite the opposite, although I hear it is better there now than it was 20years ago. I'm glad that didn't dissuade me from doing something I love.

 

[Nivens]

Yes my residency experience was quite the opposite, although I hear it is better there now than it was 20years ago. I'm glad that didn't dissuade me from doing something I love.

My residency program has the opposite "problem". We are warned not to go into cardiac believing that our surgeons- who are notoriously very nice- are typical.

 

[sethco]

I had a bad experience in residency, good in fellowship, and great in private practice. My practice is about 80-90% solo Cardiothoracic and I think our surgeons greatly appreciate us. I think for some reason the worse personalities are attracted to academic institutions

 

[pgg]

I can't believe people are shying away from cardiac because of the surgeons' personalities.

In any case, for my N=1, I've had more run ins with peds surgeons and neurosurgeons than cardiac.

 

[Man o War]

I can't believe people are shying away from cardiac because of the surgeons' personalities.

In any case, for my N=1, I've had more run ins with peds surgeons and neurosurgeons than cardiac.

Agree with neuro/spine and I'd add ortho to the list.
Very few issues with cardiac and thoracic surgeons. I've seen people who are what they deem to be slow or inefficient have lots of issues with them though- applies to nurses, techs, PAs, and anesthesia.
It's fine if they mess up but not if you do.

 

[deleted171991]

I can't believe people are shying away from cardiac because of the surgeons' personalities.

In any case, for my N=1, I've had more run ins with peds surgeons and neurosurgeons than cardiac.

Neuro is another well-known group of prima donnas. You can add plastics, too. Cardiac is definitely up in the top; they think they are the smartest in the room. Generally, the more a surgeon makes the smarter he thinks he is.

It's absolutely normal to shy away from bad personalities. The surgeon is one of the main modifiers of the atmosphere in the OR. I used to work with a very serious, demanding and unpleasant to work with surgeon, whom the OR staff was afraid of, until I discovered by chance that, when you put on her favorite music, she started smiling and telling stories. Before that, any imperfection was a huge stressor for most of us.

I realized how much of a stressor surgeons are especially when I worked in the MICU, during my fellowship. What a breath a fresh air...

 

[Hoya11]

Neuro is another well-known group of prima donnas. You can add plastics, too. Cardiac is definitely up in the top; they think they are the smartest in the room. Generally, the more a surgeon makes the smarter he thinks he is.

It's absolutely normal to shy away from bad personalities. The surgeon is one of the main modifiers of the atmosphere in the OR. I used to work with a very serious, demanding and unpleasant to work with surgeon, which the OR staff was afraid of, until I discovered by chance that, when you put on her favorite music, she started smiling and telling stories. Before that, any imperfection was a huge stressor for most of us.

I realized how much of a stressor surgeons are especially when I worked in the MICU, during my fellowship. What a breath a fresh air...

Completely Agree with FFP about the atmosphere in cardiac rooms - very unpleasant everywhere I have worked. The people who dont find this room unpleasant are either lucky to be working with nice surgeons (unusual) or just not aware of what unpleasant actually is (and may be unpleasant themselves).

I personally am always amazed at the level on intensity/seriousness and hours and hours of effort and stress (not to mention resources) poured into the elderly cardiac folks with poor long term outcomes despite any intervention, and diseases that they have brought upon themselves. One of the areas for improvement in our healthcare system for sure. TAVRs are a step in the right direction. But i can remember MANY old crumping (dying) grandmas and grandpas where you would think the life of a 20 year old was on the line in the OR. Too intense for no reason/low yield IMO.

 

[pgg]

It doesn't make sense to me. You can't really avoid people who are annoying in the OR. You might as well be doing something you like.

 

[pgg]

One of the areas for improvement in our healthcare system for sure. TAVRs are a step in the right direction.

I think TAVRs actually cost more than SAVRs at this point ... surely that will change in time, but right now I don't think anyone's saving any money there.

In any case, it's not expensive health care we should look to first for rationing, but futile health care.

And futility lives, thrives, and spends in the ICU, not the OR.

But i can remember MANY old crumping (dying) grandmas and grandpas where you would think the life of a 20 year old was on the line in the OR. Too intense for no reason/low yield IMO.

That's the story of every second bed in every ICU in the US.

 

[deleted171991]

It doesn't make sense to me. You can't really avoid people who are annoying in the OR. You might as well be doing something you like.

Agree. But I can also understand shying away from cardiac. It took me years to get over my very unpleasant ICU experience in residency (after a great one as a medical intern).

In many academic cardiac rooms, the anesthesiologist is almost like a nurse, no offense. I would hate to be told what pressors I should start the patient on, especially if I disagree. That's one of my problems with cardiac ICUs, too.

We love to say that we anesthesiologists are consultants. In the OR, that can't be further from the truth. In reality, and in the eyes of the law, we are the ones responsible for maintaining the patient's homeostasis during surgery, so in the OR we are as "primary" as the surgeon is. I don't tell him what suture to use, he shouldn't tell me what medication to give. He may ask... but what I have usually witnessed were instructions, as to a subordinate, not questions. And that's not OK, especially when he's wrong.

Of course, respect is earned, yada yada yada, and other BS. Not with the way most of the surgeons are trained, to look down on us.

 

[Nivens]

Agree. But I can also understand shying away from cardiac. It took me years to get over my very unpleasant ICU experience in residency (after a great one as a medical intern).

In many academic cardiac rooms, the anesthesiologist is almost like a nurse, no offense. I would hate to be told what pressors I should start the patient on, especially if I disagree. That's one of my problems with cardiac ICUs, too.

We love to say that we anesthesiologists are consultants. In the OR, that can't be further from the truth. In reality, and in the eyes of the law, we are the ones responsible for maintaining the patient's homeostasis during surgery, so in the OR we are as "primary" as the surgeon is. I don't tell him what suture to use, he shouldn't tell me what medication to give. He may ask... but what I have usually witnessed were instructions, as to a subordinate, not questions. And that's not OK, especially when he's wrong.

Of course, respect is earned, yada yada yada, and other BS. Not with the way most of the surgeons are trained, to look down on us.

Unlikely this can be avoided completely in any aspect of anesthesiology with the exception of Pain, but then you have to be willing to listen to those patients 30-50 times per day.

 

[nimbus]

I had a bad experience in residency, good in fellowship, and great in private practice. My practice is about 80-90% solo Cardiothoracic and I think our surgeons greatly appreciate us. I think for some reason the worse personalities are attracted to academic institutions

In general I think cardiac surgeons have a greater appreciation for what we do than most other surgeons.

 

[GravelRider]

I'll take a mean, cranky, ornery surgeon who is skilled, efficient, and knowledgeable over a happy and friendly surgeon who is slow and s*cks any day. It's the bad surgeons who are cranky and mean that annoy the cr@p out of me.

I think TAVRs actually cost more than SAVRs at this point ... surely that will change in time, but right now I don't think anyone's saving any money there.

In any case, it's not expensive health care we should look to first for rationing, but futile health care.

And futility lives, thrives, and spends in the ICU, not the OR.




That's the story of every second bed in every ICU in the US.

I agree with you, but I think there is more to it than just saying ICU care is futile. Once a patient makes it to the ICU, the chance to prevent futile care has been lost. Either a primary care doctor didn't discuss end of life decisions appropriately, or an oncologist did not set expectations appropriately, or a surgeon took on a case that should have been avoided. If we are going to solve the delivery of futile care in the ICU then we have to prevent it in the first place.

 

[deleted171991]

I agree with you, but I think there is more to it than just saying ICU care is futile. Once a patient makes it to the ICU, the chance to prevent futile care has been lost. Either a primary care doctor didn't discuss end of life decisions appropriately, or an oncologist did not set expectations appropriately, or a surgeon took on a case that should have been avoided. If we are going to solve the delivery of futile care in the ICU then we have to prevent it in the first place.

I deleted a post on this subject, to not deviate the thread. I just want to point out that the reason ICU expenses are much lower in Europe is mainly because their intensivists (can) refuse ~40% of the admissions (including irreversible disease/futile care), because nobody gets to sue them for every little stupid thing. So GravelRider is correct.

 

[BLADEMDA]

In general I think cardiac surgeons have a greater appreciation for what we do than most other surgeons.

That's one perspective. My General surgeons, Ortho, Colo-Rectal, etc are more appreciate of my skills than the Cardiac Surgeons. Can anyone remember the last time an Orthopod or Gynecologist told you what lines to place for their cases?

I agree that the CV surgeons appreciate our Echo skills and abilities more than most hospital administrators do.

 

[pgg]

Can anyone remember the last time an Orthopod or Gynecologist told you what lines to place for their cases?

Not to be too snarky, but most ortho and gyn surgeons don't volunteer opinions on what we should do because they haven't the foggiest idea what we're doing in the first place.

Cardiac surgeons might be a little bossy about which inotrope to start, but at least they know something about the heart beyond its ability to move Ancef (ortho) or cause bleeding (gyn).

 

[deleted171991]

Not to be too snarky, but most ortho and gyn surgeons don't volunteer opinions on what we should do because they haven't the foggiest idea what we're doing in the first place.

Cardiac surgeons might be a little bossy about which inotrope to start, but at least they know something about the heart beyond its ability to move Ancef (ortho) or cause bleeding (gyn).

That still doesn't mean that they know more about resus than the guy at the head of the bed. Most surgeons, even if intensivists, don't bother reading up on the pharmacology of everything they use. It's how they are programmed (plus there is so much one can learn while leading a normal life). There are few and between who are the exception.

 

[pgg]

I don't disagree, I'm just making the counter-argument to Blade's suggestion that that non-cardiac surgeons are nicer / more polite / more appreciative. They have less to say about our management in the first place, and that's why they meddle less.

 

[kidthor]

I've had only reasonable / good interactions with peds surgeons... which is why I'm doing a peds fellowship currently (and this holds true both at my fellowship and residency hospitals).