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Man if only your residency had like ridiculous amount of hearts and not that many fellows. 😉
Any attendings out there regret not doing a fellowship?
- Thread starter propofabulous
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Man if only your residency had like ridiculous amount of hearts and not that many fellows. 😉
D
deleted171991
He's 100% right. Think about it like a business person: you have a candidate who didn't practice most of general anesthesiology for a year. Most ACGME fellowships don't allow for enough moonlighting to maintain one's skills in everything, even if the fellows had the energy and will to work even more hours.
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Hey, they just increased the fellowship positions by 100% (all the way up to 2 per year). And they just brought in another CT surgeon with plans to get another transplant/LVAD guy (as if we weren't busy enough).
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Despite all the "apparent" pessimism around ACCM, I actually enjoy my time in the ICU. My only qualm against cards was exactly what abolt18 mentioned. I enjoy most facets of anesthesia and do not intend on giving that up. I will hope to find a mixed anesth-CCM job, hope. But I will ultimately be flexible given job offerings with pay and geography.
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deleted171991
Most intensivists enjoy their time in the ICU. That's seldom the issue. People who hate ICU don't even consider it, since it's not "prestigious", like cardiac. But a fellowship can be waste of time and money, if unused.
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Yes and no. While I feel like my CCM fellowship made me a much smoother operator with crumping patients, I just cant justify missing out on the 650k I would have gotten had I went straight into practice. At my shop the pay cut for CCM is extreme, as in a 40% pay cut, so again can't justify doing it here outside of picking up occasional locums at outlying facilities to keep my skills up.
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Is that a double brag or a brag/humblebrag? Can't get my head around that sentence.
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I’m not understanding the “lost skills” argument against fellowship. In the heart room we get access, induce, intubate, manage hemodynamics, and resuscitate every day. Can someone explain to me which part of a crani, exlap, or laparoscopic case is so complicated I need to be worried about getting rusty? Extubation? We do ultrasound guided blocks on almost all of our sternotomies now, so maybe labor epidurals? What am I missing here?
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ortho blocks. and maybe efficiency for smaller cases?
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deleted697535
The only consistent theme through all of this is money. Are you willing to give up 400k approx for a year's fellowship? It might seem like a lot right now but over a 30 year career it's not really...
At the end of the end we are fabulously well paid. Maybe not top 1% but definitely top 2%.if we're frugal we could all retire by 50. But some people myself included don't want that. I love working. I love being the guy that knows stuff and can do stuff. I don't want to work 90 hours a week but I do want to work around 40 to 50. For a long time if not forever. I'm cool with that. I'm a better more productive person, husband etc when I'm busy. I'm useless to the world when I'm lying on a beach somewhere. That's not for me
So I don't mind doing the extra year or two now as long as I'm getting ok money, not killed with hours, can see my family and do my thing. It's fine.
At the end of the end we are fabulously well paid. Maybe not top 1% but definitely top 2%.if we're frugal we could all retire by 50. But some people myself included don't want that. I love working. I love being the guy that knows stuff and can do stuff. I don't want to work 90 hours a week but I do want to work around 40 to 50. For a long time if not forever. I'm cool with that. I'm a better more productive person, husband etc when I'm busy. I'm useless to the world when I'm lying on a beach somewhere. That's not for me
So I don't mind doing the extra year or two now as long as I'm getting ok money, not killed with hours, can see my family and do my thing. It's fine.
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We ....get access induce intubate and manage hemodynamics and resuscitate all the time as a generalist. Though I do not claim to know TEE well enough I think the hospitals have pushed a culture
of fellowships... any sane board certified anesthesiologist knows there limits and asks for help or knows where the help will be if put in a case they haven't done in a while.
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deleted171991
Blocks (neuraxial and peripheral), pedi, OB, turnover speed, extubation skills, MAC skills (not that you'll have a lot after a good residency) etc.
This is of course nothing like the loss of skills in a pain or CCM fellowship, but one year is a long time. It's tough enough to be a new attending.
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Of course you do, but the assertion I was refuting was that by doing a CT fellowship I somehow am "losing" skills. I'm not claiming a good generalist can't do those things, just that I can every bit as well.
As I mentioned, we do ultrasound guided blocks for almost every sternotomy, and I did enough supraclavs/infraclavs/IS and LE blocks in residency to be comfortable with the anatomy. We extubate patients in thoracics (and do thoracic epidurals) and the cath lab. As for rapid turnover, I'll give you that, but only because I work in an ivory-tower academic institution where nothing is "rapid".
I remain unconvinced.
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While I agree with the sentiment of your post, that people should do a fellowship because the genuinely enjoy a subspecialty and will have a more fulfilling and enjoyable career because they did the fellowship, we should be realistic about the financial part. It's not like you just lop $400k off your net worth at the end of your career. You lose both that initial cash as well as the time value of money. Even if you put half of that 400K into index funds for 30 years (per Dr. Google the average inflation-adjusted S&P 500 return rate has been about 7% over the past 30 years), that 200k is worth about 1.5 million when you retire. Still maybe not a deal-breaker if you're passionate about your chosen subspecialty, but certainly worth considering.
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The skills loss for blocks and epidurals isn't that bad if your residency training was good. After CCM I shook off the rust almost immediately after the first two or three because the muscle memory runs so deep if you've done hundreds of blocks and neuraxial in residency. Plus, my ultrasound skills got better in fellowship as I did a ton of vascular access, central lines, a-lines, TTE, lung scanning for US assisted thoracentesis, etc.
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I work in a busy private practice. I certainly don't think you "lose" general anesthesia skills during a year of fellowship, but you certainly get rusty. Depends on the fellowship and what exactly you did during that year (moonlighting, etc). I think the further you are from the OR (pain, CCM, sleep, palliative) the rustier you are when you get out. This is per report of friends/colleagues who did fellowships then went on to general OR jobs. They all also report that they got back in the groove pretty quickly (a few weeks), so overall it's probably irrelevant.
Now being away from some facet of anesthesia (OR in general, OB, peds, hearts, whatever) for several YEARS can lead to skill loss that's tough to get back. Not impossible, but requires serious effort/education to get your sea legs back. We hired a guy who did peds cardiac at an academic place for 12 years, and he (per his own report) struggled a bit with blocks/epidurals/etc when he first started with us. He was successful, and is totally up to par with the rest of the group at this point, but it took time and effort on his part to get there.
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I did a cardiac fellowship and do not regret it. I would not have the job I currently have were it not for the fellowship. My pay is about 50k more because of the fellowship. My specific request, which was honored, was to have a blend of cardiac with regional/general cases. I found that coming out of fellowship I did not have atrophy of regional/neuraxial skills that I expected.
I became better with ultrasound during fellowship and this ultimately translated to me being much faster with blocks than when I was resident. Neuraxial I was more worried about, but fortunately a year away wasn’t enough to really make a difference.
In terms of high turnover and workflow, I was definitely not among the fastest of residents when I graduated or among the fastest of fellows. Surprisingly though I am probably among the fastest of Attendings where I work when I am doing regional or general (it is academics though). The cardiac fellowship usually either makes people OCD and super detail oriented or makes them view things in a larger context and not sweat the small stuff in simpler cases on healthy patients (I became the latter) and this definitely sped me up significantly. Also from where I did fellowship I was used to having to place the a-line, introducer (with or without PA), induce and start the TEE exam in around 20min so when I am doing general or regional it feels like I am already done with initiating the case before I even think I have got started.
That all being said, I would personally avoid any jobs where I had to be full cardiac, it’s just too much of the same thing.
I became better with ultrasound during fellowship and this ultimately translated to me being much faster with blocks than when I was resident. Neuraxial I was more worried about, but fortunately a year away wasn’t enough to really make a difference.
In terms of high turnover and workflow, I was definitely not among the fastest of residents when I graduated or among the fastest of fellows. Surprisingly though I am probably among the fastest of Attendings where I work when I am doing regional or general (it is academics though). The cardiac fellowship usually either makes people OCD and super detail oriented or makes them view things in a larger context and not sweat the small stuff in simpler cases on healthy patients (I became the latter) and this definitely sped me up significantly. Also from where I did fellowship I was used to having to place the a-line, introducer (with or without PA), induce and start the TEE exam in around 20min so when I am doing general or regional it feels like I am already done with initiating the case before I even think I have got started.
That all being said, I would personally avoid any jobs where I had to be full cardiac, it’s just too much of the same thing.
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I dont think the fellowships matter as much as the day to day case load you are doing...I dont do hearts but if i came out of residency doing them I would be comfortable doing them with some advice from senior partners. If you dont do OB and try to go back it will be hard to get some of that rust off but I dont think fellowships make you set apart with other employers as much as day to day case load. Nobody can market themselves as very comfortable with every aspect of anesthesia after being in a comfortable practice that does x,,y and not z for 5yrs. Will your skills come back for Z after 5 yrs? Not sure and thats maybe where a fellowship can come in handy.
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A pediatric cardiac anesthesiologist is about as subspecialized as an anesthesiologist can get, representing some fraction of a percent of fellowship-trained anesthesiologists out there. Any difficulty that individual had adjusting to your group probably had as much or more to do with the transition from a very academic setting to a PP environment than being fellowship trained. I suspect- but cannot prove- that any of our academic generalists would struggle with the production pressure of a busy PP in the beginning.
I maintain that the average PP or academic CT-trained anesthesiologist taking care of cardiac, thoracic, and vascular patients on a daily basis would have no difficulty doing the work of their generalist partners, controlled for practice setting. While there are certainly generalists for whom the reverse is true, in my short experience they tend to be the exception rather than the rule. Of course, I certainly know CT trained folks I wouldn't let near me or my family. These are generalities. Fellowship isn't going to turn a turd into rockstar- there is no such magic.
In my mind you should only do a fellowship in something you really like, because the other stuff is impossibly difficult to anticipate, and it's all liable to change in the future anyway.
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I'm don't really need to troll an internet forum to convince people I can do regional blocks as well as the next guy. So i'm going to do something constructive. For those residents thinking about applying to a fellowship:
1). The fellowship should be in the subspecialty you love. The type of thing you'd love to do without making extra money.
2). The fellowship should vastly improve your skill set in the said subspecialty. e.g. if you are a needle ninja in residency, a regional fellowship might truly be a waste of your year.
As many posters have echoed (pun intended), if both conditions don't apply, your chances of regretting the year spent in fellowship is high.
Did a regional fellowship. glad i did but its definitely not necessary and not for everyone. im married with no kids, wife makes good money. Did my fellowship in boston which was a wonderful experience. chill year, explored boston and the rest of new england. got to put a big academic name on my resume. My group does pay fellowship trained grads a little more than non-fellowship. it isnt a big enough difference over the 3 years to partner to cover the loss of 1 year of attending salary but thats ok.
i know everyone craps on regional, and everything thinks theyre great at it. but i probably get consulted by a partner at least once a week for either help with a block or suggestions for how regional can help their anesthetic. its nice to have a niche within a big group.
i would do the same thing all over again. but to all the residents out there, do a fellowship because you want to. dont buy the BS that you need to have a fellowship to be a competitive applicant to groups.
i know everyone craps on regional, and everything thinks theyre great at it. but i probably get consulted by a partner at least once a week for either help with a block or suggestions for how regional can help their anesthetic. its nice to have a niche within a big group.
i would do the same thing all over again. but to all the residents out there, do a fellowship because you want to. dont buy the BS that you need to have a fellowship to be a competitive applicant to groups.
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I think many of these subspecialties, including regional, have different levels. I think many people leave residency thinking they could “do hearts” because the could get a patient through a CABG with attending backup. That isn’t the same as advising a surgeon about mitral repair vs replacement, or doing clips in the structural lab. Similarly, my comfort with a healthy 3 year old tonsil doesn’t really extend to a fresh CDH, and my proficiency with supraclavs doesn’t mean I can invent blocks on the fly in complex traumas the way some of the regional folks at my shop can.
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deleted171991
The beginning of true knowledge is knowing one's limits.
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I would also add: don’t do an OB fellowship. Just don’t.
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While I agree that the time value of money must be considered, you're overstating things a bit. No one is investing $200K out of a $400K income their first year out of residency. That's what, $200K after taxes and $56K of pretax 401(k) savings? There isn't another $150K there to save in a taxable account while living, eating, and probably paying student loans.
A realistic set of numbers might be an extra $80K saved, maybe by an exceptionally disciplined person, invested with perhaps 5% real returns over the next 30 years, totaling $350K. Reasonable people can quibble over likely real returns in the next 3 decades, but in my opinion the #1 problem with retirement dreams and plans these days are overly optimistic stock market returns.
There are other confounders, too.
1) If that fellowship earns you an extra $25K or $50K per year compared to what you'd earn as a generalist, you'll pull ahead of your direct-to-PP colleague in the first half of that 30 year time frame.
2) If that fellowship opens doors to practices that wouldn't have been available to you as a generalist, the possibilities sure favor the fellowship.
3) On the flip side, an extra year in training is an extra year for student loans to compound while you're not saving. Depends how much you owe.
Few things in life pay off better than useful education. Even useless education for the sake of self-betterment has its rewards. I think a $1.5M shortfall is a gross overstatement of the likely opportunity cost of a fellowship year.
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Sorry to bump this - don't most CCM docs do week on/week off? So you should really be comparing the pay ratio of 10 days of anesthesia to 7 days of ICU?
In other words, one day in ICU would have to pay 1.43x what one day in anesthesia does.
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many fellows here moonlight on top of their fellowships and make good money. like 300k total comp
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in one thread we got paramedics practicing anesthesia in Florida. Then over here, we debate whether a fellowship is worth it. What the hell…
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Glad I didn’t do one.
Reasons to do a fellowship- 1. Want to stay in academia 2. Love something lots
Sometimes cards and peds make more $ but often it’s not significantly different $.
Reasons to do a fellowship- 1. Want to stay in academia 2. Love something lots
Sometimes cards and peds make more $ but often it’s not significantly different $.
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My ratio is actually a good bit more than that.
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Didn't do a fellowship and thankful for not wasting a year and 6 figure loss of income for that. Unless you are really dedicated to being all in to a subspecialty or academic then it is a waste. Plenty of general jobs out there
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I actually regret not doing a fellowship. Not that I am entirely unhappy with my life at present, but I it would have been enjoyable to further my knowledge and practice subspecialty anesthesiology.
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I've had one anesthesiologist who was making good money doing 100% OB anesthesia say he regretted not doing a peds fellowship... Only person I've heard say they regret not doing one.
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Pretty much hit the nail on the head. I like cardiac and had thoughts of staying in academia. At my facilities being part of the cardiac team has it advantages and disadvantages (I still think it works more into my favor at the moment).
It all depends on what one wants to do. As much as I enjoy cardiac, if I knew I was joining a private practice group that had no requirement for fellowship to do cardiac, Im not sure if I would have done one.
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I am glad you did.
Not because I thought the thread was that interesting, but because SEVOFLURANE's response to PGG made me laugh out loud. I love to laugh. (It was funny partly because PGG's response was spot-on, and the meme nailed it).
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I got kind of close to those numbers.
Income was 400K July to June from my employer and $60K signing bonus early this year from my future employer.
In that first 12 months out of residency, I saved $156K in retirement accounts (if you include the 10% employer match, which was ~$34.5K). 104K of that was in Roth savings. Then an additional 65K in cash earmarked for specific purposes, and 10K in a taxable account.
I'm helped by the fact that my income went way back down this summer as I returned to do fellowship, so lower tax rate. (This is part of the reason for hoarding cash, to supplement income during fellowship)
Of my income I saved, it amounted to 196,500 of the 460,000. Add in the employer match (which one would do if 1099) and it's 231,000/496,500.
I was pretty aggressive saving that 12 months. It would definitely be hard to do 50% of gross (though, easier if my savings weren't so much in Roth). I also tithe 10% of my income so... That affects the maximum I can save.
It makes me acutely aware of how much money I'm NOT earning/saving currently. But I am loving fellowship and so glad I'm doing it.
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10% employer match? Wow. That's great!
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Nope, I did cardiac, and I am very happy I did. The base is marginally higher, but the way my shop structures cardiac home calls, I think I end up making $40-50k more than generalists in call pay while sleeping in my own bed when I am not called in.
Cases are by far more interesting, to me anyways.
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104k in Roth? 65k in specific purposes? These are tax exempt savings?
How were you able to save 185,000 tax free (assuming you subtract the 10k you said went into a taxable account)
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Yea, same question future partner. How did you manage to save that much into roth?? That's amazing!
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It appears you may have misunderstood.
First, the first 12 months of practice is the last half of 2021 and first half of 2022, so I maxed out retirement contributions for all accounts twice during those 12 months.
The 65K was cash, not tax exempt. Knowing I was returning to fellowship in summer of 2022, we just saved a bunch of cash to supplement income during fellowship instead of moonlighting, and as a "car fund" to fix or replace our cars if they give up the ghost, as they're 17 and 20 yrs old.
104K in Roth:
Roth 403b: 2021 - $19,500, 2022 - $20,500 => $40K
Roth 457b: 2021 - $19,500, 2022 - $20,500 => $40K
My Backdoor Roth IRA: 2021 - $6,000, 2022 - $6,000 => $12K
Wife Backdoor Roth IRA: 2021 - $6,000, 2022 - $6,000 => $12K
So in that 12 months, 80K into Roth 403b and Roth 457b and 24k into Backdoor Roth IRAs. it was a total of $104K. All of this was POST-tax (hence, Roth).
The other $52K in PRE-tax, tax-protected accounts is from mandatory employee 5% contribution and employer 10% contribution. Salary was $343K for the first 9 months, but bumped up to $357K for the last 3 months after board certification.
343 * 0.75(9months) * 0.15 = $38,587
357* 0.25 * 0.15 = $13,387
Those added together equal just shy of $52K
Make sense?
First, the first 12 months of practice is the last half of 2021 and first half of 2022, so I maxed out retirement contributions for all accounts twice during those 12 months.
The 65K was cash, not tax exempt. Knowing I was returning to fellowship in summer of 2022, we just saved a bunch of cash to supplement income during fellowship instead of moonlighting, and as a "car fund" to fix or replace our cars if they give up the ghost, as they're 17 and 20 yrs old.
104K in Roth:
Roth 403b: 2021 - $19,500, 2022 - $20,500 => $40K
Roth 457b: 2021 - $19,500, 2022 - $20,500 => $40K
My Backdoor Roth IRA: 2021 - $6,000, 2022 - $6,000 => $12K
Wife Backdoor Roth IRA: 2021 - $6,000, 2022 - $6,000 => $12K
So in that 12 months, 80K into Roth 403b and Roth 457b and 24k into Backdoor Roth IRAs. it was a total of $104K. All of this was POST-tax (hence, Roth).
The other $52K in PRE-tax, tax-protected accounts is from mandatory employee 5% contribution and employer 10% contribution. Salary was $343K for the first 9 months, but bumped up to $357K for the last 3 months after board certification.
343 * 0.75(9months) * 0.15 = $38,587
357* 0.25 * 0.15 = $13,387
Those added together equal just shy of $52K
Make sense?
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What is your Roth strategy going forward? Will you only do the backdoor after fellowship and you are back to attending earnings or do you have a different plan? I'm trying to decide when I say enough is enough with aggressive Roth savings and then just do the backdoor alone. I personally think post tax savings are a little under utilized. My IPS position was to accumulate 500k post tax (started way before this career so not impressive) and then do back door only.
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Will do Roth conversion of that pretax 403b money next year as I finish fellowship. That'll give me a solid 200K+ in Roth IRAs. That, plus backdoor Roth IRAs yearly going forward feels like enough at this stage in my life. Unencumbered and getting reasonable returns, it'll likely be close to $2M when I retire.
Otherwise, during full attending years, I plan to max out all pre-tax accounts, backdoor Roths, and then just use taxable accounts for the remainder of my investing/saving.
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Are you doing fellowship at the same institution? Or was this institution a state institution? How are you not being forced to take distribution of your 457?
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I am very grateful I did CCM, even though I have only practiced actual ICU medicine for less than half of my <10yr attending life. The calculus for me on the intellectual and practical benefits even "just" as a general anesthesiologist, balanced against the opportunity cost, supported the fellowship at the time of the decision and now as well.
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