Anesthesia vs IM

Discussion in 'Anesthesiology' started by msmith83, Feb 25, 2014.

  1. sevoflurane

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    Just depends on the person. Allergy doc for me would be.... :vomit:... soooo boring. :sleep::sleep::sleep::sleep::sleep:

    I love the ORs... there is a very fun and social aspect to the ORs and we are at the forefront of a lot of great action.

    Mitral clips and Watchmen procedures have been the latest thing in my little corner of the universe. Just so completely reliant on our echo skills to get these procedures done well. When you go from systolic reversal in the pulmonary veins to a normalized pattern you KNOW you've done something very meaningful for that patient. NOT boring... ever evolving and making the most of our new technology.

    [​IMG]

    I love stomping out pain with needles... but that's another story.

    Had a friend request me for his AVR/aortic aneurysm. Placed an intuity valve and noticed a significant leak when we came off CPB. Surgeon could not see it. Showed him a Color flow 3D en face view of exactly where it was after I cropped down on it... asked him to put some stitches in the NCC location. Came off the second time with zero leak and I feel like I made a significant difference for my friend.

    I am definitely NOT built for clinic. :sleep::sleep::sleep:

    Love the ORs. You just see so much stuff... it's the only place I can practice medicine.
     
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  3. anbuitachi

    anbuitachi ASA Member

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    Here for the Mitral clips, the cardiologist does the TEE =(.

    Is your place doing Lariat procedure for A fib? If so how have they been going?
     
  4. magicdock

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    We should push for anesthesia public awareness and for pts being able to choose who puts them under so anesthesiologist dare more valuable to hospitals too


    Sent from my iPhone using Tapatalk
     
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  5. sevoflurane

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    We quit doing lariat procedures about 2 years ago. They were fine most of the time, but did have a couple of bleeders.
     
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  6. MEN2C

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    Man, some of the specialties on that list are pretty low down on the list of physician satisfaction scores. Many of them would see Anesthesia as the amazing perfect specialty if you asked them.

    Physician career satisfaction within specialties

    No one is THAT satisfied overall (but probably true for most careers). But top ten in this survey are 1) Pedi EM 2) Geriatrics 3) Dermatology 4) Pediatrics 5) IM & Peds 6) 'Other' ped subspecialty 7) Neonatology 8) A&I 9) Child psych 10) Rad onc.

    NSG is dead last and ortho is in the bottom third (though they don't break out spine specifically). This survey didn't have Anesthesiology.

    Another survey, slightly older (Physician Career Satisfaction Across Specialties) also has Geriatrics, Dermatology, Neonatology and pediatrics in the top five. So a somewhat stable set of specialties.

    Derm is derm but most of the rest aren't particularly at the top of the income scale (if anything, towards the bottom) and only moderately competitive (Average step score for Peds is 230, IM is like 233. For comparison, Anesthesiology is 232. Essentially the same.*) Just interesting, that's all.

    *Source: NRMP Outcomes in the match for US allopathic seniors
     
    #255 MEN2C, Mar 4, 2018
    Last edited: Mar 4, 2018
  7. OutRun

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    If you could go back would you do IM?

    This post scares me.
     
  8. skankhunt42

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    I will try to be succint because people on these forums can be negative and rambling.

    The day of Physician only Anesthesia is long gone. But I feel firmly that the value of a MD anesthesiologist is in taking care of sicker, more complex patients.

    My advice is to do a fellowship. You should never be in the position where a CRNA can walk into a room and argue they are just as good. To me, this means doing CV, Crit Care (or Peds/ Peds CV).
     
  9. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    This is not true. Many parts of the Midwest and the vast majority of the Western US are still MD only. There’s not a PP group within several hundred miles of me that’s an ACT practice.
     
  10. skankhunt42

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    Sorry- I was trying to be brief. You are of course right, many Anesthesiologists still work 1:1 bedside. But I do feel that you should not train specifgically for a 1:1 lollipop job. Now more than ever the incentives and safety you get with a fellowship is big. Take that extra year and try to learn skills that sets you apart. Do if the sky every truly does fall with CRNAs, you're protected (some).
     
  11. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    I think that’s good advice.
     
  12. agammaglobulin

    agammaglobulin ASA Member

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    Are you saying CRNAs don't do 'specialty' anesthesia? Because I've seen CRNAs at Children's hospitals, CRNAs doing CT cases, and NPs working in the ICU. I would argue, it isn't about finding a subspecialty with less risk of midlevel encroachment, but rather we as anesthesiologists should be protecting our field. Something the older generation did not do. I.e. stop hiring and training CRNAs/NPs like they are residents.
     
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  13. gasman2014

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    This. I don't know how it is everywhere else, but our NPs and CRNAs already call their "clinicals" residency. I've even seen a few of them complain when residents are given the sickest patients in the OR/ICU, instead of the SNPs/RNAs, because it's "not fair." Seriously....mind boggling. It's up to us to try and right this ship...if we can.
     
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  14. agammaglobulin

    agammaglobulin ASA Member

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  15. Psai

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    The **** do they get off thinking they deserve what we do
     
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  17. FFP

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    To me this only means CV. Critical care doesn't mean crap for most OR cases. Same goes for Peds (how many difficult peds cases are there, how many children's hospitals?). People should do peds because they like children, not for job safety.

    Besides cardiac, the only fellowship worth it is pain, IF one has a good post-fellowship pathway/market.
     
    #265 FFP, Apr 16, 2018
    Last edited: Apr 16, 2018
  18. FFP

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    As a FMG, maybe. As an AMG, with a good chance for a fellowship, definitely.

    Whatever you do, try to avoid becoming your employer's bitch. The only way for that is to have your own stable of chronic patients that would drive 10-20 miles more to see you elsewhere, and to be irreplaceable by midlevels.

    Most (but not all) people who choose anesthesia nowadays do it for the lack of better choice, regardless of what they lie to others. It can seem like a decent compromise.

    Last, but not least (au contraire): if you are NOT an extrovert, you have NO business being in anesthesia.
     
    #266 FFP, Apr 16, 2018
    Last edited: Apr 16, 2018
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  19. ERRES2288

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    Care to elaborate ?
     
  20. gasman2014

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    As someone whose number 1 choice was anesthesiology and is not an introvert, maybe FFP means we tend to have too many people willing to just rollover for surgeons, crnas, nps, admins, rns, etc etc and forget that they are, indeed, physicians, with a very intimate role to play in a patients care.
     
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  21. FFP

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  22. anbuitachi

    anbuitachi ASA Member

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    Just curious, if mid west and west are mostly MD only, and the pay is similar to East coast, why is east coast using so many CRNAs? Clearly it's doable with just MD only as shown by the west side of the country..
     
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  23. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay

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    Yes. Very doable. The reason plain and simple is greed.

    ACT at low ratio is really no more profitable than MD only. You have to run at least 3:1 and ideally 4:1. At that point you do make more in an ACT model.

    A bigger difference is scheduling. In an ACT practice, you need less docs to run the same number of rooms. Typically the call burden may be more frequent, but on the flip side, you will have less late days and be able to take more vacation than working MD only.

    Also, with less docs, there’s less ways you have to split up that stipend pie.
     
    #271 SaltyDog, Apr 17, 2018
    Last edited: Apr 17, 2018
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  24. chocomorsel

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    And that is the real deal. All these people who keep saying that we can't function without CRNAs are busy drinking the cool aid and stuffing their pockets.

    Most anesthesiologists work in ACT models not because they necessarily believe in it, but because they have no choice due to location and family ties, want to make more money or don't like being in a room all day. The ones who say they believe it's the best model for patients are lying to themselves.
     
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  25. anbuitachi

    anbuitachi ASA Member

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    I can see the attraction to covering 1:2, good balance between in and out of OR. Good case load/procedures. More just sound like torture. I imagine a huge chunk of the day once you get to 1:4 will be spent pre opping/post opping, and jumping into rooms to induce/extubate, give breaks.. not cool. How much more do you make anyway on average with 1:3 to 1:4..? I can't believe so many people sold themselves to this model
     
  26. Man o War

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    Yes and don’t forget bailing out CRNAs from dumb [email protected]@t they do in your absence, not to mention things they just can’t handle properly.
    It’s truly miserable to cover too many, and I’ll retire before I will do it.
     
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  27. W19

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    Unfortunately, this is true... Some people will include IM as well, but inpatient IM might be too tricky for midlevels to handle.
     
  28. Psai

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    Nah everytime you can't handle something, either you scan everything nearby hoping for a radiologist to bail you out or consult someone who actually knows what they're doing. We cover for their inadequacies all the time.
     
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  29. GA8314

    GA8314 Regaining my sanity

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    A disgusting reality is that CRNA's are currently doing "Peds Fellowships" at one major tertiary center that I know of...... They will also be taking more and more US guided regional, and I'm sure TEE courses in the future.
     
  30. AdmiralChz

    AdmiralChz ASA Member

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    I’m inclined to agree, and that’s why I would suggest doing a fellowship that emphasizes higher-level management and evidence-based practice. In layman’s terms - using your brain.

    Peds, cardiac both accomplish this. CCM and Pain is a separate practice environment with their own individual issues but also fit the bill. In my honest opinion I don’t see regional accomplishing this - it’s not really higher-level anesthetic management just experience in placing (often esoteric) blocks. That can be taught to anyone off the street as FFP alludes.
     
  31. GA8314

    GA8314 Regaining my sanity

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    I don't think fellowships are that protective. There are only so many super tertiary care places with the sickest and most advanced cases. Most of anesthesia is NOT done in such places. I think we simply need to be vigilant and active politically to protect our interests. As others have said, CRNA's are being taught that NOTHING is off limits to them. Literal equivalency.

    For those in ACT models, don't ever ever let your OR skills diminish. While this is not as likely as one would think, I've seen it among some older docs. Never let that happen, and it's actually easy to maintain those skills. There will always be a job for good "anesthesia" folks even if we lose political battles.
     
  32. Psai

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    The problem is that we teach them. If we didn't teach them how to do the cases, the problem would stop there.
     
  33. resp228

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    As a current MS3 I will admit it is quite disheartening to hear attendings warn students not to enter their specialty. At the same time, I appreciate all the honest feedback as it leads me to a more informed decision. I understand the concern with CRNA's and I recognize that in the future physicians will likely be employees. However, throughout my rotations I have noticed these trends throughout all of the specialties. The vast majority of my class actually would prefer to be an employee, although I would prefer to be in private practice.

    Like the earlier poster, I am looking to choose between IM and Anesthesiology. Part of me feels like I am choosing between a career where I would love my work, but have a worse employment outlook (Anesthesiology) versus a field where I can tolerate the work, but have better job prospects (IM subspecialty).

    I would appreciate any more thoughts on Anesthesia vs IM and the future of having a fulfilling career in Anesthesiology.
     
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  34. spacegun

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    I’m exactly where you are too.

    First I guess it depends what IM subspecialties we would want. I’d probably take anesthesia over most except maybe not GI, maybe not cards, pulm/cc is equivocal I love the ICU however, I don’t know much about hem/onc but I hear they do well if you can stand cancer patients so maybe, but the rest of the fellowships and also general IM I’d prefer anesthesia instead.

    Second do you like OR or clinics more. I don’t know if I can stand clinics, maybe I can tolerate clinics, I’d prefer not having to deal with patients expecting me not only to treat or manage their medical issues, but also social work, a lot more paperwork, calling other physicians, referrals, etc. That is a pain. But on the other hand, I have heard attendings say if you have your own patients, then you are directly bringing in money and hospitals and everyone else will like and respect that, so you have more clout in the community I guess, while unfortunately a lot of places sometimes see anesthesia as more of a grudging necessity or expense in order to facilitate surgery.

    Third do you like working alongside surgeons or would you prefer to be more independent and your own boss and set your own schedule, not be at the mercy of when surgeons start and finish their cases. But the good side is you are also not tied to a pager (unless on call), so you go home when the job is done, no patient followups and all that, good separation between work and life.

    Just some thoughts, I’d be eager to hear more too however.
     
  35. shepardsun

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    I did peds before I did anesthesia, so I can break down some of the more subtle training/lifestyle differences between the inpatient/outpatient/rounding/long notes/methodical and cerebral style of peds/medicine vs. the procedural, fast-paced, dynamic world of the OR if anyone is interested.

    I was never a clinic person so I hated that element of peds, but did enjoy the inpatient wards/ICU atmosphere a lot. I will say I "feel" more like a physician when I'm in the OR- even though I'm still a resident, I'm directly manipulating the physiology and anatomy of the patient in a way I never did as a peds resident- there was always a mass of nurses, fellows, and attendings standing between me and those types of decisions and actions. I don't intend that to be a perjorative to anybody else in those types of specialties- it's a personal thing. But there's a satisfaction in doing a case where the attending is in the room at the start and at the end for a total of two minutes and you otherwise get the patient through a surgical procedure by yourself ending up better than when they started that for me, beat any of the sense of accomplishment I felt in my peds training.

    Went straight from peds residency to anesthesia residency, so I can't say whether that would change if I were a peds attending, but unless they were an ICU or EM attending it never really felt like the ones I worked with during residency had full ownership of their patients either.
     
  36. FFP

    FFP Grunt, body, pompous ass, pissant, buzzkill, jaded
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    Maybe this will help: I went into critical care after anesthesia because I wanted the patient-doctor relationship. Few things in anesthesia are as rewarding as your patient's face lighting up when he sees you. That's how one should think about clinic, too.

    If one is a clever thinker, one should do IM. No monkey see monkey do anesthesia will come close to the intellectual orgasm of IM. What anesthesia (followed by a CCM fellowship) does is gives one the knowledge of applied physiology and pharmacology to be both a thinker and a doer in the MICU (not worth it for SICU). But otherwise it's mostly monkey see, monkey do.
     
    #284 FFP, Apr 25, 2018
    Last edited: Apr 29, 2018
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  37. LunchMD

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    I want to chime in for the med students cosidering the IM subspecialties. My SO is an IM resident applying to one. If you want to do GI, Cards, or Pulm/CC, just know that these fields have all become very very competitive. Of my 4 IM friends I know (who went to top college/med school/residences, and are awesome ppl), they are all applying to the above. They are all taking extra years after residency to do a combination of hospitalist/research/brown nose to have a better chance at matching. Except one who is going to be a chief resident.

    They are all great fields, but just something to be aware of. Make sure you are going to be a very strong candidate if you hate general IM but want to do the above 3.
     
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  38. FFP

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    All the good stuff in life is very competitive. That applies to the good stuff in anesthesia, too.

    When a residency or fellowship is less competitive, easier to get into, one should wonder what one's missing in the picture.
     
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  39. Psai

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    Pulm cc is not competitive
     
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  40. spacegun

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    I looked this up because I was curious. You are right! 288/320 US grads matched pulm cc.

    Cards 514/571 US grads matched.

    Even the most competitive, GI, 304/373 US grads matched.

    [​IMG]
     
  41. LunchMD

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    I'm not sure how reliable using US grads is at this point. Cards has a 70% match rate, GI 64%, and PulmCC 71%. Think back to med school. ENT and Ortho had higher match rates than that.

    My prior evidence may be anecdotal, but suffice to say I believe them. If you hate general IM, but want the those 3 specialties, I would just be prepared to gun hard for them, even for PulmCC. I've seen good people fail to match (in med school to other fields). Life will kick you right in the nuts if you aren't prepared
     
  42. str8cashhomie

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    I am also struggling between IM and anesthesia. Heart says cardiology because I loved the cath lab and the idea of greater satisfaction with it. However, my head says anesthesia because I don't like clinic, enjoyed the OR, enjoy more procedure based stuff, and like the separation of life and work. Hard to think of doing 3 years of IM which I really did not enjoy (pt non compliance, med list of 100, notes for days, smokers) just to get to cardiology. But also don't want to get to anesthesia and wish I had more pt contact or doing something more satisfied. I need help with this.
     
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  43. pgg

    pgg Laugh at me, will they?
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    You can't take "percent matched" and make meaningful statements on how competitive a specialty is, because there is enormous self-selection in the applicant pool.

    The things to look at are board scores, US vs IMG grads, even DO vs MD stats for people who match.
     
  44. FFP

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    It sounds like you enjoy procedures more than thinking, so why even consider IM? There is a huge chance you will not get into an interventional cardiology fellowship. If you think about all the possible outcomes (including subspecialty training), I would guess there is a much higher probability of being happy in anesthesia, where it's not so difficult to get into a cardiothoracic anesthesia fellowship.

    IM is for thinkers, period. Anesthesia is NOT for thinkers. Introvert? IM. Extrovert? Anesthesia. FMG with small chances for a good IM fellowship? Anesthesia. Enjoy being captain of the ship, feeling and being treated like a real doctor, elitist? IM. Better lifestyle? IM (with fellowship).

    Hating clinic should not be a criterion. Why? Because clinic as an attending is different than the resident version, due to much better continuity.
     
    #292 FFP, Apr 26, 2018
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  45. FFP

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    For the students debating whether to choose anesthesia: this is exactly how an extrovert sounds. And that's one of the main reasons why he's very happy practicing anesthesia. Don't ignore your personality when choosing a specialty.

    Also, while an introvert has more attention to detail and may provide better care for most cases, s/he is worse at multitasking and prioritizing, which are essential in anesthesia emergencies. An extrovert will thrive on the adrenaline rush, while the introvert will just increase his/her chances of dying young. Many introverts end up practicing pain (hard to get into, declining reimbursements, most jobs involve some OR anesthesia) or critical care (truly rewarding only in MICUs and other closed ICUs, bad lifestyle).
     
    #293 FFP, Apr 26, 2018
    Last edited: Apr 26, 2018
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  46. anbuitachi

    anbuitachi ASA Member

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    Pain salary is going down???
     
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  47. FFP

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    I don't know about salaries, but reimbursements have been.
     
  48. sevoflurane

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    While I do believe that your personality has a lot to do with the specialty you choose, intro/extrovert is like splitting. Its not so black or white. Lots of shades in the middle for sure. I know lots of introverts that excel in the specialty, but they are def. quiet types. As a matter of fact, my wife was probably one of those @ one time. Way smarter than me, but always quiet and reserved. Fast forward into 10 years of PP however and she definitely has a different personality than when we were presenting patients on rounds during 3/4th year of medical school or residency.

    Personalities evolve with experience and confidence.

    One thing is for sure. Anesthesia is very much a social specialty- can’t get around that part. You see patients all day, speak to surgeons and staff, schedulers/board runners, etc.
     
    #296 sevoflurane, Apr 26, 2018
    Last edited: Apr 26, 2018
  49. AdmiralChz

    AdmiralChz ASA Member

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    These stats (and those for residency) don’t count the applicants that apply, get no interviews, and then don’t go through with the Match - at least to my knowledge. This happened several times for low-scoring IM residents applying for GI at my home program.
     
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  50. spacegun

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    Thanks, definitely will be prepared to work hard for those subspecialties if I do IM! But I thought it made a big difference even for fellowship if you are a US citizen and don't need a visa vs. you need a visa (IMG's)?

    Board scores still matter!?! I guess I'm OK but still didn't know fellowships still care about USMLE's. Is it the same for anesthesia fellowships?
     
  51. LunchMD

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    My thought process is there is a large pool of IMG in IM, and the ones that match are probably studs. Also if we use the %US grad metric, then palliative care would be about the same competitiveness as cards which doesn't seem right. But yes I imagine if you are IMG you have to be that much better than the US grads to match
     
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  52. pgg

    pgg Laugh at me, will they?
    Moderator Physician Faculty

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    When I applied for fellowship, programs wanted my USMLE and ITE scores. Since I was a few years out of residency I also provided my actual written exam results too. I didn't get the impression that they cared much about my USMLE scores, but that might just be because my scores were 15+ years old at that point. They definitely commented on my ITEs.
     
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