Advanced TEE..no cardiac fellowship

[Maverikk]

Is a cardiac fellowship required to do hearts in private practice? If I get my basic during residency and shoot for an advanced during a CCM fellowship would I be able to do hearts?

---

Members don't see this ad.

 

[nimbus]

It depends on the practice.

When I joined our practice, a fellowship was not required to do hearts and most of the people doing hearts did not have fellowships. Beginning 4 years ago, we started to require a fellowship for any new hire who wants to do hearts. The landscape is changing. You should do a fellowship if you want to do hearts. You will have more choice.

 

[Man o War]

It depends on the practice.

When I joined our practice, a fellowship was not required to do hearts and most of the people doing hearts did not have fellowships. Beginning 4 years ago, we started to require a fellowship for any new hire who wants to do hearts. The landscape is changing. You should do a fellowship if you want to do hearts. You will have more choice.

Same. My place requires advanced TEE and cardiac fellowship.

 

[dutchmaster]

It depends on the acuity of the hearts and the expectations of the anesthesiologists and surgeons in the practice you join. My practice requires advanced TEE certification for all valves. Our cardiac surgeons will request the TEE docs for difficult CABGs as well

If you're serious about cardiac anesthesia and TEE, do a cardiac anesthesiology fellowship. I don't care how motivated you are, you cannot substitute the TEE training in a cardiac anesthesia fellowship with self study/basic exam. You will be unable to get advanced certification from the NBE without doing a cardiac anesthesia fellowship - plus i highly doubt the exposure you could obtain in a CCM fellowship would be adequate to provide the proficiency required in a cardiac OR.

 

[urge]

Is a cardiac fellowship required to do hearts in private practice? If I get my basic during residency and shoot for an advanced during a CCM fellowship would I be able to do hearts?

In the boonies only. The window of opportunity keeps closing everyday.

 

[pgg]

Is a cardiac fellowship required to do hearts in private practice? If I get my basic during residency and shoot for an advanced during a CCM fellowship would I be able to do hearts?

I don't believe it is possible to qualify for advanced cert via a CCM fellowship. (Not since July 1, 2009 anyway.)

The requirement is:

Applicants must have a minimum of 12 months of clinical fellowship training dedicated to the perioperative care of surgical patients with cardiovascular disease. Training obtained during the core residency (anesthesiology, internal medicine, or general surgery) may not be counted toward this requirement. Fellowship training in cardiothoracic or cardiovascular anesthesiology must be obtained at an institution with an ACGME or other national accrediting agency accredited fellowship in cardiothoracic anesthesiology.

There's no CCM fellowship out there that's going to be 12 months of perioperative care of surgical patients with CV disease.

http://www.echoboards.org/sites/default/files/AdvPTE Cert App_0.pdf

 

[fakin' the funk]

I don't believe it is possible to qualify for advanced cert via a CCM fellowship. (Not since July 1, 2009 anyway.)

The requirement is:

There's no CCM fellowship out there that's going to be 12 months of perioperative care of surgical patients with CV disease.

http://www.echoboards.org/sites/default/files/AdvPTE Cert App_0.pdf

It is a little complicated.

Anyone can take either the basic or advanced perioperative TEE exam and, if you pass, become "testamur" status.

To become certified in either basic or advanced TEE you have to jump through the hoops of minimum numbers of exams performed, exams reviewed, etc. And to be certified in advanced TEE you have to have done cardiac anesthesia fellowship.

 

[sethco]

Count me in on my group also requiring new hires that want to do cardiac to be TEE certified (I.e. Completed a Cardiac fellowship). However, my group does a ton of cardiac. Still, If you want to do cardiac in private practice, do a cardiac (not ICU) fellowship. Just my two cents

 

[kazuma]

Reportedly it is possible to become TEE boarded/certified through CCM (not just testamur), however it's exceedingly rare and difficult to do. Perhaps even frowned upon by many CCM fellowships as they feel it takes your focus away from the unit. At least that's the impression I got during CCM interviews.

Technically most CCM fellowships qualify as 12 months of perioperative care of surgical patients with CV disease. The problem is getting time in the OR doing enough exams to get your required numbers. Duke and maybe Michigan were the only programs that offered a pathway to TEE certification via CCM when I was interviewing 2 years ago. I'm not sure if that's changed now. Like many have mentioned, if you really want to do hearts then do CT, CCM won't give you enough street cred at most shops without TEE boards.

 

[pgg]

I don't see how a CCM fellowship could possibly spin a MICU month (surely there's at least one of those?) into the "perioperative care of surgical patients" ... but if some programs are able to get away with wink-nudge-hammering a bunch of square non-surgical CHF and COPD exacerbation pegs into that round hole, good on 'em, I guess. 🙂

 

[kazuma]

I don't see how a CCM fellowship could possibly spin a MICU month (surely there's at least one of those?) into the "perioperative care of surgical patients" ... but if some programs are able to get away with wink-nudge-hammering a bunch of square non-surgical CHF and COPD exacerbation pegs into that round hole, good on 'em, I guess. 🙂

Not sure how they do it either, but programs told me that occasionally a motivated fellow had done it. Perhaps the wink/nudge is why all the programs I visited frowned upon TEE certification.

 

[seinfeld]

I disagree that a cardiac fellowship is required to do TEE and big excellent at it. Its physics but not rocket science. The practical ability to learn to diagnose valvular issues is easy, deciding if its P1 or P2 can get more complicated, but a good surgeon relies more on what he sees in vivo than the TEE. Myself and all of my cardiac Anesthesia colleagues have learned TEE in practice and have passed the advanced exam. The decisions on whether to replace or repair a mitral or when to ring the TV in the setting of Mitral disease are currently being tested in the literature and have nothing to do with ones ability to acquire an image. Having asked for a second opinion from a cardiologist on rare occasions have proved less than useful as they are often even less skilled at TEE than we are.

IN my opinion the certification rule regarding needing to do a fellowship was only to give weight to the fellowship. Every surgeon over 50 has had to learn while in practice how to do new things i.e. robotics, laparoscopic colectomies, TAVR. Not one of them went back to do a formal fellowship.

Also what is a cardiac anesthesia fellowship really? It a year when you spend reading, doing hundreds 0f exams and having mentors to bounce questions off of. Sounds like how my first couple of years of working in private practice.

Anesthesia has created a standard which will only serve to push older providers out, when they decline to pursue the pursuit of paperwork. We , modern america, seem more focused on documentation of purported skill than actual skill. Although the trend is moving toward looking at clinical outcomes.

 

[nimbus]

I disagree that a cardiac fellowship is required to do TEE and big excellent at it. Its physics but not rocket science. The practical ability to learn to diagnose valvular issues is easy, deciding if its P1 or P2 can get more complicated, but a good surgeon relies more on what he sees in vivo than the TEE. Myself and all of my cardiac Anesthesia colleagues have learned TEE in practice and have passed the advanced exam. The decisions on whether to replace or repair a mitral or when to ring the TV in the setting of Mitral disease are currently being tested in the literature and have nothing to do with ones ability to acquire an image. Having asked for a second opinion from a cardiologist on rare occasions have proved less than useful as they are often even less skilled at TEE than we are.

IN my opinion the certification rule regarding needing to do a fellowship was only to give weight to the fellowship. Every surgeon over 50 has had to learn while in practice how to do new things i.e. robotics, laparoscopic colectomies, TAVR. Not one of them went back to do a formal fellowship.

Also what is a cardiac anesthesia fellowship really? It a year when you spend reading, doing hundreds 0f exams and having mentors to bounce questions off of. Sounds like how my first couple of years of working in private practice.

Anesthesia has created a standard which will only serve to push older providers out, when they decline to pursue the pursuit of paperwork. We , modern america, seem more focused on documentation of purported skill than actual skill. Although the trend is moving toward looking at clinical outcomes.

I agree with everything you say. On the job training with experienced mentors is a legitimate way to learn and even excel. But for current residents thinking of doing cardiac, it's better and sometimes mandatory to do a fellowship. And even after fellowship you will still benefit from continued study and on the job training.

 

[pgg]

I don't disagree that ongoing learning and self-improvement via practice and apprenticeship with one's colleagues is one way to get there.

Full disclosure for my bias - I finished residency in 2009, exactly one day before the practice pathway to full TEE certification closed, so I'm grandfathered into the group that could get there without fellowship. I still think I need to do the fellowship to be the anesthesiologist I want to be. Starting in July.

 

[Man o War]

I disagree that a cardiac fellowship is required to do TEE and big excellent at it. Its physics but not rocket science. The practical ability to learn to diagnose valvular issues is easy, deciding if its P1 or P2 can get more complicated, but a good surgeon relies more on what he sees in vivo than the TEE. Myself and all of my cardiac Anesthesia colleagues have learned TEE in practice and have passed the advanced exam. The decisions on whether to replace or repair a mitral or when to ring the TV in the setting of Mitral disease are currently being tested in the literature and have nothing to do with ones ability to acquire an image. Having asked for a second opinion from a cardiologist on rare occasions have proved less than useful as they are often even less skilled at TEE than we are.

IN my opinion the certification rule regarding needing to do a fellowship was only to give weight to the fellowship. Every surgeon over 50 has had to learn while in practice how to do new things i.e. robotics, laparoscopic colectomies, TAVR. Not one of them went back to do a formal fellowship.

Also what is a cardiac anesthesia fellowship really? It a year when you spend reading, doing hundreds 0f exams and having mentors to bounce questions off of. Sounds like how my first couple of years of working in private practice.

Anesthesia has created a standard which will only serve to push older providers out, when they decline to pursue the pursuit of paperwork. We , modern america, seem more focused on documentation of purported skill than actual skill. Although the trend is moving toward looking at clinical outcomes.

I don't necessarily disagree with this...the problem is what happens when you go to look for a job with fellowship and advanced cert vs without? I interviewed with one group whose hospital system told them they didn't care how long some of their anesthesiologists had been doing heart cases/TEE, starting that following year they would no longer be allowed to since they couldn't check the boxes. So here you had a handful of guys who had been doing cardiac their whole careers and with one administration decision they couldn't anymore. I think that sucks, but something residents need to be thinking about when deciding what they want to do. And as a side note, these were not incredibly sick cardiac cases being done so I was surprised the hospital took such a hard line.

 

[deleted162650]

I don't necessarily disagree with this...the problem is what happens when you go to look for a job with fellowship and advanced cert vs without? I interviewed with one group whose hospital system told them they didn't care how long some of their anesthesiologists had been doing heart cases/TEE, starting that following year they would no longer be allowed to since they couldn't check the boxes. So here you had a handful of guys who had been doing cardiac their whole careers and with one administration decision they couldn't anymore. I think that sucks, but something residents need to be thinking about when deciding what they want to do. And as a side note, these were not incredibly sick cardiac cases being done so I was surprised the hospital took such a hard line.

This sort of thing is only becoming more and more common whether we like it/think it's appropriate or not. My current group would like to have more people in the pediatric call pool - a role I would be happy to fill, but the hospital requires peds fellowship to do any case on kids under 2yo so I can't.

 

[seinfeld]

The last 2 posts illustrate my point. The creation of the certification ( resume building fellowships ) process has created the need to do the fellowships. Some how we are losing sight of the fact that experience and skill are the most important factors not box checking resumes. Its all a snow ball process which is based on good intentions. Look at what being board certified has become. No longer a step up above the rest but a requirement for employment in most circumstances.

Same thing with jobs that used to require high school diploma now requiring bachelors. Pharmacists and physical therapists with PhDs.

 

[pgg]

This sort of thing is only becoming more and more common whether we like it/think it's appropriate or not. My current group would like to have more people in the pediatric call pool - a role I would be happy to fill, but the hospital requires peds fellowship to do any case on kids under 2yo so I can't.

I agree things have gone too far in that direction. Case in point:

I was on call last night (it's in-house call with two residents and a CRNA). Around 6 PM as things were winding down, a patient came in a couple weeks s/p AVR, symptomatic from a pericardial effusion vs tamponade. Stable, but our CT surgeon decided he ought to get his pericardial window & drain done then vs waiting until the next day.

I hope all of us here would agree that this is a case any anesthesiologist ought to be able to do.

But the cardiac call team had to stay to do it. So I literally ordered some take out buffalo wings and had a snack in the lounge while they did the case. Just silly.

 

[bigdan]

Regarding the exact "qualifications" for advanced TEE certification, page 7 of the Advanced PTExAM pdf on the echoboards.com site says: "Applicants that finished their core residency training after June 30, 2009, can ONLY qualify for certification by completing cardiothoracic or cardiovascular anesthesiology fellowship training at an ACGME accredited fellowship program" I was surprised to see things this exact, and was under the impression that you could get certified via a CCM pathway - I'm 100% sure Duke used to promote this on their website in years past, but, looking for it now, the website no longer says you'll get certified for Advanced TEE upon completion of the Duke CCM fellowship. I did CCM at Michigan, and can tell you that no one in the 2014 graduating class got advanced TEE certified through the ICU training.

You can - anyone can - take the Advanced exam, and pass, and be a testamur - a CA2 resident I know took (and passed) the Advanced exam, and (I just checked) he is a Advanced PTExAM testamur.

Regarding "needing" a CT fellowship to do hearts, it's probably all in the eye of the beholder. I'm just out of training, so I admit my naivety; I did both Cardiac and CCM. I don't think I could do what I do now in an OR without the CT year. I've seen a few attendings say the year of hearts isn't necessary - but have never heard that from someone who's done the year. Likewise, I work with a guy who's "100% sure" he could do ICU after his CT fellowship. I'm biased since I did both, and I think both were very beneficial to what I do now, but I'm also not a natural genius.

Either way, there will ALWAYS be hoops to jump through - you have to decide if the hoop-jumping is worth it.

 

[urge]

Regarding the exact "qualifications" for advanced TEE certification, page 7 of the Advanced PTExAM pdf on the echoboards.com site says: "Applicants that finished their core residency training after June 30, 2009, can ONLY qualify for certification by completing cardiothoracic or cardiovascular anesthesiology fellowship training at an ACGME accredited fellowship program" I was surprised to see things this exact, and was under the impression that you could get certified via a CCM pathway - I'm 100% sure Duke used to promote this on their website in years past, but, looking for it now, the website no longer says you'll get certified for Advanced TEE upon completion of the Duke CCM fellowship. I did CCM at Michigan, and can tell you that no one in the 2014 graduating class got advanced TEE certified through the ICU training.

You can - anyone can - take the Advanced exam, and pass, and be a testamur - a CA2 resident I know took (and passed) the Advanced exam, and (I just checked) he is a Advanced PTExAM testamur.

Regarding "needing" a CT fellowship to do hearts, it's probably all in the eye of the beholder. I'm just out of training, so I admit my naivety; I did both Cardiac and CCM. I don't think I could do what I do now in an OR without the CT year. I've seen a few attendings say the year of hearts isn't necessary - but have never heard that from someone who's done the year. Likewise, I work with a guy who's "100% sure" he could do ICU after his CT fellowship. I'm biased since I did both, and I think both were very beneficial to what I do now, but I'm also not a natural genius.

Either way, there will ALWAYS be hoops to jump through - you have to decide if the hoop-jumping is worth it.

I think you can get proficient at hearts without a fellowship but it will take you several years to get there. In the mean time, your patients are the ones who pay the price. It is not optimal.

 

[caligas]

I think you can get proficient at hearts without a fellowship but it will take you several years to get there. In the mean time, your patients are the ones who pay the price. It is not optimal.

That's no more true than saying that it will take years in PP to get proficient at neuro, ob, peds...

I did 6 months of cardiac as a CA-3 including 2 dedicated months of echo. I was doing 100+ open hearts per year right out of residency and was beyond proficient.

But it's sort of a moot point now that the practice pathway is gone.

 

[urge]

That's no more true than saying that it will take years in PP to get proficient at neuro, ob, peds...

I did 6 months of cardiac as a CA-3 including 2 dedicated months of echo. I was doing 100+ open hearts per year right out of residency and was beyond proficient.

But it's sort of a moot point now that the practice pathway is gone.

Versus a fellowship? Yes.

You likely come out of fellowship with more experience than someone doing one heart a week for 5 years.

Think of a fellowship as fastracking you into 5 years, at least, of experience.

 

[urge]

That's no more true than saying that it will take years in PP to get proficient at neuro, ob, peds...

I did 6 months of cardiac as a CA-3 including 2 dedicated months of echo. I was doing 100+ open hearts per year right out of residency and was beyond proficient.

But it's sort of a moot point now that the practice pathway is gone.

You also have to consider that the incidence of adverse outcomes is much higher in cardiac than neuro ob and healthy peds (no fellowship job).

What might go unnoticed in these other cases might turn into a mortality in cardiac.

 

[DrBeaker]

I won't get certified as I haven't done an accredited fellowship. I agree with Seinfeld in that experience and skill are more important than checking a box. Just because you do a cardiac fellowship doesn't mean you were given enough experience and learned enough skill to be proficient at hearts and TEE. What do the hospitals hope to have in someone that is certified? I think those fellowships get you pretty good at one (care of CV patients) and passable in another (TEE).

 

[urge]

I won't get certified as I haven't done an accredited fellowship. I agree with Seinfeld in that experience and skill are more important than checking a box. Just because you do a cardiac fellowship doesn't mean you were given enough experience and learned enough skill to be proficient at hearts and TEE. What do the hospitals hope to have in someone that is certified? I think those fellowships get you pretty good at one (care of CV patients) and passable in another (TEE).

Correct. Hospitals want experienced people. They don't want you to gain experience on the job anymore. That means only old anesthesiologists who lived thru the olden days can claim experience (which might not be enough, just as you claim it is for the fellowships), or the young ones with a fellowship.

Times have changed. There is no way around it.

 

[deleted162650]

anesthesiologista

Is that what they call us in Italy?

 

[urge]

Is that what they call us in Italy?

Google translation says anestesista.

 

[sevoflurane]

Agree with Seinfeld. You don't need a fellowship to become proficient at CT or TEE. But it requires a tremendous amount of dedication to get there and it begins early in your residency training. If you are not going to do a fellowship, go to a strong CT program that graduates it's residents with big numbers and allows you to do dedicated echo/CT senior rotations. If you are graduating with the bare minimum, you need to do a fellowship. Times are changing and mere numbers might not be good enough in a large program- fellowship or advanced cert. could be required. Plan accordingly.

I think the advanced PTEeXAM was one of the hardest tests I've taken. I studied tons for it (over studied actually).
That along with the other requirements of meeting certification criteria (CME, 350+ hearts in 4 years), was no easy task.
It is my favorite diploma on the wall.

Now TEE has been moving fast over the last 5 years. The phillips i33 is a game changer IMO.
3D TEE is one of the most fun things I do on a day to day basis. The level of interrogation of valves is on a whole different level.

2D is just not good enough anymore. If you are doing valves, you need to be good at both.

Just my opinion.

 

[seinfeld]

Love this discussion so far.

So as many of you know I am a boarded CCM anesthesiologist but spend 70% of my time in either the ICU or Cardiac ORs. I did take and pass the advanced exam and did graduate just prior to the cut off. My group does 1200+ hearts a year, last year 1000 Pump cases and 200+ TAVRs. We recently, November, hired our first CV trained anesthesiologist. So a couple issues that I have with making fellowship the standard for doing PP hearts.

1. Some groups are losing contracts or being forced to spend time and money getting certified, or paying high starting wages for new grads (most attendings recognize that in PP a cardiac anesthetic is a money loser most often). Unfortunately the more cost is driven up without an increase in payment means more reliance on hospital subsidy or the taboo selling to an AMC, not the global win a new grad might think it is.

2. DATA- I would doubt to find a statistical difference in outcomes between my group of non-fellowship trained cardiac attendings and a group of fellowship trained attendings. I would find it most important that a smaller group of people do cardiac than to actually be fellowship trained.

3. As far as TEE advancing at a rapid pace, well you can't do a fellowship for infinity. At some point your fellowship will be history and your ability to evolve and learn new things on the job will become just as imperative to you, a fellowship trained person, as a non-fellowship trained person.

I worry what the "standards" are forcing upon PP. The fight against MOCA was based on lack of evidence that it did improve outcomes, where is the evidence here? If there are articles please forward them along.

 

[urge]

Love this discussion so far.

So as many of you know I am a boarded CCM anesthesiologist but spend 70% of my time in either the ICU or Cardiac ORs. I did take and pass the advanced exam and did graduate just prior to the cut off. My group does 1200+ hearts a year, last year 1000 Pump cases and 200+ TAVRs. We recently, November, hired our first CV trained anesthesiologist. So a couple issues that I have with making fellowship the standard for doing PP hearts.

1. Some groups are losing contracts or being forced to spend time and money getting certified, or paying high starting wages for new grads (most attendings recognize that in PP a cardiac anesthetic is a money loser most often). Unfortunately the more cost is driven up without an increase in payment means more reliance on hospital subsidy or the taboo selling to an AMC, not the global win a new grad might think it is.

2. DATA- I would doubt to find a statistical difference in outcomes between my group of non-fellowship trained cardiac attendings and a group of fellowship trained attendings. I would find it most important that a smaller group of people do cardiac than to actually be fellowship trained.

3. As far as TEE advancing at a rapid pace, well you can't do a fellowship for infinity. At some point your fellowship will be history and your ability to evolve and learn new things on the job will become just as imperative to you, a fellowship trained person, as a non-fellowship trained person.

I worry what the "standards" are forcing upon PP. The fight against MOCA was based on lack of evidence that it did improve outcomes, where is the evidence here? If there are articles please forward them along.

1 Cardiac makes loads of money for the hospital. That's why there is so much competition and the hospitals always want to keep growing. Professional fees for anesthesiologists are not good, which means a stipend is needed. No way around it either. No cardiac anesthesiologists, no cardiac program.

2 I would not jump into conclusions without the data. I think you are missing the point. I doubt anyone would question that a new grad from fellowship will have better outcomes than a new grad from residency. That's why hospitals don't want the new grad from residency. Whether fellowship gives you an advantage 10 years down the line over non fellowship trained people is harder to tell. You would assume that eventually they would catch up.

3 Agree. A good foundation makes it easier.

 

[Nivens]

To me the far more egregious thing is the hospital that forces people who have been doing hearts for ages to either pursue the certificate or stop doing hearts. That isn't better for patients- in fact it's worse because many experienced attendings are going to say hellll no. I have less of an ossue with hiring only new grads w CT fellowship to do hearts, but agree it's a slippery slope.

 

[periopdoc]

If you are a current trainee, and want to do hearts in the current environment (and in any reasonable predictable future environment) do the cardiac anesthesia fellowship. Right or wrong, this is simply a simple acknowledgment of where things are headed.

If you want to be ICU boarded, talk to programs about the potential for an 18 month fellowship that might give you the necessary hours in the in the ICU to pursue ICU board certification as well the necessary hours in the OR to pursue advanced PTE certification.

More and more hospitals are and will be requiring certification for all new members of cardiac anesthesia teams. We currently require basic certification, but I would strongly argue against allowing any new member on our team who is not at least Testamur Advanced with experience. Of course I am certified so I have a bias.

Nothing I have said should be construed to claim that I am arguing for cutting experienced anesthesiologists due to lack of certificate. I am strictly talking about new members of heart teams.

-pod

 

[urge]

If you want to be ICU boarded, talk to programs about the potential for an 18 month fellowship that might give you the necessary hours in the in the ICU to pursue ICU board certification as well the necessary hours in the OR to pursue advanced PTE certification.

I don't think that is possible in 18 months.

Everyone I know has done 24 months.

 

[secants]

^which is basically the combined CC and cardiac fellowship that a few programs havw already

 

[psychbender]

^ which really isn't a combined fellowship at all, it's just doing both fellowships back to back with a single application/interview process.

Sent from my SM-G920V using SDN mobile

 

[nimbus]

If you are a current trainee, and want to do hearts in the current environment (and in any reasonable predictable future environment) do the cardiac anesthesia fellowship. Right or wrong, this is simply a simple acknowledgment of where things are headed.

If you want to be ICU boarded, talk to programs about the potential for an 18 month fellowship that might give you the necessary hours in the in the ICU to pursue ICU board certification as well the necessary hours in the OR to pursue advanced PTE certification.

More and more hospitals are and will be requiring certification for all new members of cardiac anesthesia teams. We currently require basic certification, but I would strongly argue against allowing any new member on our team who is not at least Testamur Advanced with experience. Of course I am certified so I have a bias.

Nothing I have said should be construed to claim that I am arguing for cutting experienced anesthesiologists due to lack of certificate. I am strictly talking about new members of heart teams.

-pod

This is how it is where I work. All the old guys are either advanced testamur or boarded. All the young guys have fellowship and are boarded. Despite this, we still have a couple of true echo geeks who we rsend clips to when we have questions.

 

[urge]

This is how it is where I work. All the old guys are either advanced testamur or boarded. All the young guys have fellowship and are boarded. Despite this, we still have a couple of true echo geeks who we rsend clips to when we have questions.

You send the clips outside your group?

 

[nimbus]

You send the clips outside your group?

No to my partners

 

[OB1🤙]

We are similar to POD.

I do a fair bit of adult congenital, and I would otherwise have been kinda lost during these cases were it not for fellowship. Between stuff like that and VADs, I really think you need a fellowship to operate in a modern, fully-functional cardiac anesthesiology service.

Plus it helps to have been through a year's worth of exposure to horrendous redos, triple valves, dealing with LV/RV failure, knowing which mode of mechanical circulatory support is best when, etc.

Keep in mind this is a community shop, not academics.

For a place that only does bread and butter CABG and avr and punts everything else, fellowship is much less important, and either experience OR true motivation to learn are fine.

 

[periopdoc]

I don't think that is possible in 18 months.

Everyone I know has done 24 months.

Only because there is no incentive for programs to get creative, and recent grads aren't pushing for it.

Current ACGME CT Anesthesia fellowship requirements are minimum 12 months of training, at least 6 of which must be clinical (OR) experience, at least one of which must be in the adult CT ICU, and at least 2 months of clinical (non-OR) electives.

Current ACGME Anesthesthesia CCM requirements are minimum 12 months of training, at least nine of which must be in the ICU setting.

So, the absolute bare minimum length would be the mandatory 6 months cardiac OR time plus the mandatory 9 months of ICU time for a total of 15 months. All non-core months in each fellowship would be covered by the core time in the other.

If I was interested in a combined fellowship, I would try to work out an 18 month arrangement at a busy institution. If they insisted on a 24 month arrangement, I would negotiate for 6 months of the time to be spent and paid as a junior attending in the OR, and I would want that time equally divided throughout the 24 months.

This would more than fulfill all the PTEexam cert requirements.

-pod

 

[urge]

Only because there is no incentive for programs to get creative, and recent grads aren't pushing for it.

Current ACGME CT Anesthesia fellowship requirements are minimum 12 months of training, at least 6 of which must be clinical (OR) experience, at least one of which must be in the adult CT ICU, and at least 2 months of clinical (non-OR) electives.

Current ACGME Anesthesthesia CCM requirements are minimum 12 months of training, at least nine of which must be in the ICU setting.

So, the absolute bare minimum length would be the mandatory 6 months cardiac OR time plus the mandatory 9 months of ICU time for a total of 15 months. All non-core months in each fellowship would be covered by the core time in the other.

If I was interested in a combined fellowship, I would try to work out an 18 month arrangement at a busy institution. If they insisted on a 24 month arrangement, I would negotiate for 6 months of the time to be spent and paid as a junior attending in the OR, and I would want that time equally divided throughout the 24 months.

This would more than fulfill all the PTEexam cert requirements.

-pod

Sounds reasonable, but why would the programs pass on the cheap labor for the extra 6 months?

Especially since the good cardiac and ccm programs are on the match. There are other 10 guys vying for your spot. I don't think there is much negotiating power.

What you propose might be possible in a program that has a hard time recruiting. But, do you really want to go there? I don't think 6 months is worth going to a nameless program.

 

[periopdoc]

The programs are passing on cheap labor if they don't let you fulfill the junior attending role for those six months. ACGME fellows aren't cheap labor due to the ACGME rules. Non-ACGME fellows (and junior attending a) can totally be abused for cheap labor, thus the proliferation of non-ACGME fellowships. For those 6 months, you would essentially be a non-fellow.

There is always room to negotiate. If you approach them professionally to work together to come up with novel solutions, most will be open to trying to work with you. If they aren't, that might be your clue to stay away from that specific institution.

-pod

 

[urge]

The programs are passing on cheap labor if they don't let you fulfill the junior attending role for those six months. ACGME fellows aren't cheap labor due to the ACGME rules. Non-ACGME fellows (and junior attending a) can totally be abused for cheap labor, thus the proliferation of non-ACGME fellowships. For those 6 months, you would essentially be a non-fellow.

There is always room to negotiate. If you approach them professionally to work together to come up with novel solutions, most will be open to trying to work with you. If they aren't, that might be your clue to stay away from that specific institution.

-pod

I think you are wrong. ACGME fellows are just like residents. They are a profit for the department, due to ACGME stipend being like 3 times their salary.

If you are an acgme fellow, you cannot do the junior attending thing during the program.

Why would I want to hire you for 6 months after your 18 month fellowship? And even if I did, how is that cheap if I'm paying you attending salary?

If you come to my place, the first thing we would ask is *who the f does this guy think he is?" That's it. You are done. You wasted your time and travel money.

 

[sethco]

Correct me if I am wrong but I thought that people you do a CT fellowship at a non ACGME accredited place would not be eligible for TEE certification. Could sit for the exam and get testamur status, though

The programs are passing on cheap labor if they don't let you fulfill the junior attending role for those six months. ACGME fellows aren't cheap labor due to the ACGME rules. Non-ACGME fellows (and junior attending a) can totally be abused for cheap labor, thus the proliferation of non-ACGME fellowships. For those 6 months, you would essentially be a non-fellow.

There is always room to negotiate. If you approach them professionally to work together to come up with novel solutions, most will be open to trying to work with you. If they aren't, that might be your clue to stay away from that specific institution.

-pod

 

[psychbender]

Doing both fellowships back-to-back is becoming more common. When I interviewed at Wash-U for CCM, most of my interview group were interested in the dual-fellowship track. With increasing interest in the current product, programs have no incentive to invent creative solutions that only benefit the applicant. I would love to do an 18 month dual fellowship, and save six months, but that's not going to happen now.

This thread is rather depressing, by the way. When I was a resident, quite a few of my attendings at the three hospitals where I did CT rotations were not CT fellowship trained, but just had a strong interest or did six months as resident, like I did. I thought that was the norm, and that practice model would still be open when I got out. I've spent the last three years, and a fair bit of money, teaching myself a new skill, and getting better at doing hearts on my own, but the general consensus here is that it's all for naught. If I want to keep cardiac as part of my practice when I leave the Army, I'll have to do a second fellowship.

Sent from my SM-G920V using SDN mobile

 

[Nivens]

Part of me wonders how much of this fellowship arms race we find ourselves in is a consequence or side-effect of relatively short, 1-year fellowships. I don't know much about EM training, but I can't imagine how they manage to fill a whole year of "Ultrasound" with value. Seems to me the fellowships with the biggest value are those that train you to be a totally different kind of doctor, broadening your skills rather than narrowing them. For me, critical care and pain are the "top tier" under this criteria, cardiac and peds are next given that, while they do "narrow" your focus, they give you comfort with a subset of patients that you might not have right out of residency (sick neos, mechanical support, etc) as well as providing opportunities for TEE cert. Last in my mind are the fellowships the may enhance some basic skills taught in residency but really exist more for those looking to establish themselves as academic experts or enhance their hire-ability in PP (OB, regional).

That being said, I'd still take our training time over that of an interventional cardiologist or pediatric surgeon. I have zero desire to celebrate the big 4-0 in training.

 

[nimbus]

Part of me wonders how much of this fellowship arms race we find ourselves in is a consequence or side-effect of relatively short, 1-year fellowships. I don't know much about EM training, but I can't imagine how they manage to fill a whole year of "Ultrasound" with value. Seems to me the fellowships with the biggest value are those that train you to be a totally different kind of doctor, broadening your skills rather than narrowing them. For me, critical care and pain are the "top tier" under this criteria, cardiac and peds are next given that, while they do "narrow" your focus, they give you comfort with a subset of patients that you might not have right out of residency (sick neos, mechanical support, etc) as well as providing opportunities for TEE cert. Last in my mind are the fellowships the may enhance some basic skills taught in residency but really exist more for those looking to establish themselves as academic experts or enhance their hire-ability in PP (OB, regional).

That being said, I'd still take our training time over that of an interventional cardiologist or pediatric surgeon. I have zero desire to celebrate the big 4-0 in training.

I would add that every new orthopedist, every new radiologist, and over 90% of the general surgeons that have joined the staff at my hospital in the last 10years has had a fellowship in something. And these are not academic departments.

 

[urge]

Doing both fellowships back-to-back is becoming more common. When I interviewed at Wash-U for CCM, most of my interview group were interested in the dual-fellowship track. With increasing interest in the current product, programs have no incentive to invent creative solutions that only benefit the applicant. I would love to do an 18 month dual fellowship, and save six months, but that's not going to happen now.

This thread is rather depressing, by the way. When I was a resident, quite a few of my attendings at the three hospitals where I did CT rotations were not CT fellowship trained, but just had a strong interest or did six months as resident, like I did. I thought that was the norm, and that practice model would still be open when I got out. I've spent the last three years, and a fair bit of money, teaching myself a new skill, and getting better at doing hearts on my own, but the general consensus here is that it's all for naught. If I want to keep cardiac as part of my practice when I leave the Army, I'll have to do a second fellowship.

Sent from my SM-G920V using SDN mobile

The 2 fellowship trend is baffling to me. I get why you would want to do cardiac, but ccm i don't.

Why would anyone want to do a fellowship where they teach you how to do work an intern can do? All questions of medicine get consulted to ID, neurology, cardiology, hematology, GI, and pulmonology. Even endocrinology gets consulted for diabetes!

The only thing they do on their own is order seroquel and haldol.

 

[psychbender]

You and I had very different ICU experiences, Urge.

 

[Nivens]

I would add that every new orthopedist, every new radiologist, and over 90% of the general surgeons that have joined the staff at my hospital in the last 10years has had a fellowship in something. And these are not academic departments.

My favorite are the "transition to practice" fellowships that are popping up for general surgeons.