Best ultrasound fellowships at the moment?

[EMhawkeye]

It seems for the two-year UCLA fellowship program you have to graduated from a 4 year program lol

That is universal for all their fellowship programs from what I hear as they expect for fellows to be able to supervise Pgy4’s

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[Jabbed]

lol @ 6 years of training for EM + US.

The $1M+ mistake.

 

[BoardingDoc]

lol @ 6 years of training for EM + US.

The $1M+ mistake.

Seriously, if I'm doing 6 yrs of training, I'm gonna be a cardiologist, not an EM US director.

 

[GonnaBeADoc2222]

Seriously, if I'm doing 6 yrs of training, I'm gonna be a cardiologist, not an EM US director.

Peds has entered the chat.

 

[GonnaBeADoc2222]

That is universal for all their fellowship programs from what I hear as they expect for fellows to be able to supervise Pgy4’s

This is a nice thing actually.

Opposite of my program that was so insistent on "EM requires 4 years of training!!!" And then hired pgy4 fellows.

What a slap in the face.

 

[Waterlover]

Another issue with US fellowship is that even if you wanted to use it in the community, you're bogged down with all these metrics and over-slammed with patients, no time to do US on everyone realistically and it's easier to just order the formal study.

 

[sylvanthus]

Some animals have to live in the zoo.

Academics havent learned to survive in the wild. Best to keep them in their cage where they are safe.

 

[emergentmd]

U/S fellowship sounds about as useful as a fellowship in Abscess I&D. I guess this would allow me to drain all abscess that comes to the ER.

 

[Mount Asclepius]

The challenge of this question to this forum is that most here seemingly practice in the community like most EPs do. An US fellowship seems only beneficial if wanting to pursue academics. Most end up going into community medicine though. There is a chance if you jump into a fellowship now that later on you’ll decide it was a waste once you leave academics for the community.

When I was in residency a few of my sub-specialty EM faculty advised me to go into community EM first before pursuing a subspecialty EM fellowship if undecided.

They advised three benefits. 1) Gain financial independence. Makes the opportunity cost of decreased fellowship pay tolerable. 2) Find out if you can stomach community EM better or worse than most. 3) Allow for a little more time to develop your passion. Gives more credence when applying and gave them a leg up on their competition.

On the flip side, the longer out from residency you are the harder it is to go back to train. Your drive diminishes, lifestyle creep occurs, and your priorities shift. It’s not impossible though if it’s what you truly want or need. @Birdstrike took the plunge. Many of the rest of us are still on the sidelines. It’s never off the table though.

 

[Apollyon]

Academics havent learned to survive in the wild. Best to keep them in their cage where they are safe.

No, they haven't. My entire statement is: "Some animals have to live in the zoo, because they can't survive in the wild". Any of the stupid $hit that some (most?) of the academics do would get a solid punch in the face, or worse. And none - bar none - could take the a$$ kicking.

 

[CoolDoc1729]

No, they haven't. My entire statement is: "Some animals have to live in the zoo, because they can't survive in the wild". Any of the stupid $hit that some (most?) of the academics do would get a solid punch in the face, or worse. And none - bar none - could take the a$$ kicking.

Maybe 1/4 of my residency attendings could do my community job. And not the ones that were persnickety, bedside US for everything, consults for everything, rectal exam for everyone with a rectum 🙄 pelvic exam for every woman with pain below the neck 🙄 etc etc. I’m so glad I only had to practice like that for 3 years!

 

[Brigade4Radiant]

For six years I would rather do a radiology residency. Most academic attendings also look down on community docs just see what comments are made when their colleagues go into the community "I'm so disappointed." lol

 

[Birdstrike]

You have to decide what you want to get out of a fellowship.


1) Do you want a new skill to use within EM?

2) Do you want a fellowship to add an entirely second specialty outside of EM, with a totally different practice setting and lifestyle, to your skill set?

3) Do you want one that makes you a more desirable applicant in an academic setting?

4) Do you want one that allows you to run a fellowship or department, or in some other way work less (but not zero) ED shifts?


To me, #2 was most important.

 

[Brigade4Radiant]

Man to even think that US is considered a true fellowship is crazy. Why can’t we do sleep?

 

[Tiger26]

Y’all aren’t answering OP’s question.

Best US fellowships in the country: highland, Denver, Penn, mgh

Ucla and Stanford are good but they’re two year fellowships which brings down the competitiveness and is less palatable.

2 year ultrasound fellowships???

 

[skougess]

2 year ultrasound fellowships???

Do you think I could open and fill a 3 year “community medicine” fellowship where a board certified EM doc just works my shifts for me for $70k/yr under the guise of education?

I actually bet I could.

 

[AlvinKamara]

Do you think I could open and fill a 3 year “community medicine” fellowship where a board certified EM doc just works my shifts for me for $70k/yr under the guise of education?

I actually bet I could.

Lmao. You absolutely could

 

[RuralEDDoc]

There’s nothing wrong with ultrasound fellowships other than the oversupply. If there were 10 great fellowships, there wouldn’t be an issue here. How many are there? More than 60? 50+ of those grads will have no ROI. The other 10 will be ultrasound directors with some associated income.

 

[thegenius]

There’s nothing wrong with ultrasound fellowships other than the oversupply. If there were 10 great fellowships, there wouldn’t be an issue here. How many are there? More than 60? 50+ of those grads will have no ROI. The other 10 will be ultrasound directors with some associated income.

There's nothing wrong, and the standard US training we get in residency is more than sufficient for community and academic ER. Unless one really gets a stiffy doing US, I really don't see the point and agree with everyone else.

 

[gruemd]

There's nothing wrong, and the standard US training we get in residency is more than sufficient for community and academic ER. Unless one really gets a stiffy doing US, I really don't see the point and agree with everyone else.

Then you can use those skills to do an US-guided dorsal penile block and drain the priapism, 2 birds 1 stone.

 

[DeadCactus]

Maybe I'm the crazy one but it seems to me most of the people here don't actually understand what an ultrasound fellowship is for. If you just want to be good at doing various POCUS scans, there is no point in doing an ultrasound fellowship. There are plenty of more expeditious ways to get good at POCUS. The point of the fellowship (as with many fellowships) is academic and administrative leadership. The point is learning the entire ultrasound ecosystem to incorporate POCUS into your local institution's practice in a way that makes sense for that specific setting. The point is to be able to speak with authority and expertise to administrators and peers on what machines to buy, on how to set up billing and QI, on what scans makes sense in the local workflow, on training and credentialing requirements, etc.

This whole thread is the equivalent to someone asking about doing a Clinical Informatics fellowship and getting a bunch of nonsense about how residency trains you to use an EMR good enough for community practice. There are specific career goals where an ultrasound fellowship makes sense (as is true with every fellowship). There is plenty of room for discussions about oversupply, realistic expectations, alternative options, and nuanced career guidance but that's not what is happening here.

 

[JacobMcCandles]

Maybe I'm the crazy one but it seems to me most of the people here don't actually understand what an ultrasound fellowship is for. If you just want to be good at doing various POCUS scans, there is no point in doing an ultrasound fellowship. There are plenty of more expeditious ways to get good at POCUS. The point of the fellowship (as with many fellowships) is academic and administrative leadership. The point is learning the entire ultrasound ecosystem to incorporate POCUS into your local institution's practice in a way that makes sense for that specific setting. The point is to be able to speak with authority and expertise to administrators and peers on what machines to buy, on how to set up billing and QI, on what scans makes sense in the local workflow, on training and credentialing requirements, etc.

So basically worthless in the community. A fellowship should be valuable in most practice settings, not just at an academic place.

 

[DeadCactus]

So basically worthless in the community. A fellowship should be valuable in most practice settings, not just at an academic place.

A fellowship should be valuable for the specific career goals of the people entering that fellowship. A skill needed in most practice settings should be part of residency training; which is exactly what we have now. Residents learn FAST and procedural ultrasound. Fellows learn skills needed for academic and administrative leadership.

You're so desperate to **** on this you're really going to pretend there are no large community practices with a robust POCUS program that includes credentialing, billing, QI, and training warranting a fellowship trained Ultrasound Director?

 

[thegenius]

Then you can use those skills to do an US-guided dorsal penile block and drain the priapism, 2 birds 1 stone.

See here's the thing. If you need US to drain a priapism then you really have some problems.

 

[JacobMcCandles]

A fellowship should be valuable for the specific career goals of the people entering that fellowship. A skill needed in most practice settings should be part of residency training; which is exactly what we have now. Residents learn FAST and procedural ultrasound. Fellows learn skills needed for academic and administrative leadership.

You're so desperate to **** on this you're really going to pretend there are no large community practices with a robust POCUS program that includes credentialing, billing, QI, and training warranting a fellowship trained Ultrasound Director?

I'm ****ing on it because it's a waste of time for the majority of people who do it.

 

[Brigade4Radiant]

So a community program with ultrasound? Why would they do that? So the ER doctors are reading the ultrasound and doing QI in the community?

Billing?

 

[bougiecric]

A fellowship should be valuable for the specific career goals of the people entering that fellowship. A skill needed in most practice settings should be part of residency training; which is exactly what we have now. Residents learn FAST and procedural ultrasound. Fellows learn skills needed for academic and administrative leadership.

You're so desperate to **** on this you're really going to pretend there are no large community practices with a robust POCUS program that includes credentialing, billing, QI, and training warranting a fellowship trained Ultrasound Director?

You make a good point. I'll grant you that the point of an US fellowship isn't solely to make you better at bedside US. For those going into the community, it's supposed to be an entry point to becoming a community US director (more typically for a hospital system as opposed to a single facility site).

My criticism of this pathway is twofold. It is true that these positions exist. All of the large hospital/staffing companies in my region have an US trained ED physician who gets a stipend for performing this role. I've declined this position in the past because the stipend in no way makes up for the money you'd get by simply working more shifts. The amount of time doing administrative tasks is better spent doing shifts. Granted (much like academics), many folks find gratification and value in doing US administration and feel the decrease in pay is worth it.

...

My second criticism of this path is... none of the community docs care and there is no way to make them care. I've been around long enough to see every which way community docs are encouraged to do more ultrasounds. None of it ever works. I have never once seen a simple way to save and documents scan. Even the ubiquitous FAST exam is a PITA to save and document on a trauma activation. People have tried everything. Barcode scanners, dot phrases, wifi archiving, canned text for charting. The truth of the matter is, when your hospital expects you to meet DTG and PPH metrics, futzing with the US machine is by far the last thing on anybody's mind.

I used to be an acolyte. I was involved in streamlining workflows to make scanning easier. After seeing multiple US administrators in multiple hospital systems try to make this easier, I've come to the conclusion that it never will be. ER docs are hyperaware of even little disruptions to our flow. Pop up asking you why you're giving an antibiotic? You immediately adapt to bypassing this as fast as possible. Same goes for US. Your average community doc immediately see this as minimally useful clinically, and it comes with multiple roadblocks to flow. I admit I'm a pessimist, but I do not ever see bedside US being accepted by community ER docs without a significant overhaul to how ERs operate.

Yes, there are robust community programs with everything you list. A director who does QI, manages archiving, and make sure billing occurs. But it's smoke and mirrors. These programs exist, but nobody is really doing US. In my personal experience, 80-90% of ER docs don't even touch the machine. A handful will use it for FAST and procedures. A tiny percentage (probably former fellows; I include myself in this category) will use it for more. By far the the people who touch the machines the most are techs and nurses placing IVs.

It used to be thought it was an age/training issue. I.e. older docs who didn't understand wouldn't use it, but all the new grads would. This is false. The younger docs don't touch it either. They probably liked it in residency and know many of it's applications, but (like everyone else) as soon as they're thrown into the pit with 20 in the waiting room and fires left and right, they realize that it's nearly impossible to reasonably incorporate into practice.

 

[CliveStaples]

I do think there is a niche, both in academics and in large community practices, for an US trained physician who understands that their real value is in RVU generation, to build an infrastructure for ease of recording and documentation of bedside ultrasound.

My group (academic practice, but an "eat what you kill" model for department funding in terms of RVU tracking) has an US director who presents quarterly on what we have billed for bedside ultrasound documentation and justifies his stipend, additional US trained faculty, and the costs of infrastructure this way. I know one of our recent fellows joined for a large private group and pays down part of her clinical time by building the exact same infrastructure in the hospitals her groups staffs, reporting financially on revenue that the group was otherwise leaving on the table.

Now, whether any of this is taught in most academic emergency ultrasound fellowships is another thing entirely.

 

[Siggy]

My group (academic practice, but an "eat what you kill" model for department funding in terms of RVU tracking) has an US director who presents quarterly on what we have billed for bedside ultrasound documentation and justifies his stipend, additional US trained faculty, and the costs of infrastructure this way. I know one of our recent fellows joined for a large private group and pays down part of her clinical time by building the exact same infrastructure in the hospitals her groups staffs, reporting financially on revenue that the group was otherwise leaving on the table.

Granted, it's harder now because CMS now requires completed 30 minute blocks for a 99232 (so first 99232 is at 104 minutes), but outside of US guided vascular access for CVCs and image guidance for paras and thoras (which I imagine are rare for EM anyways), how often does the legwork for documenting and billing US exams work out instead of folding them into critical care time? I've always figured it was easier to justify and bill extra time than dealing with documenting and archiving a limited echo or limited US of the chest.

 

[CliveStaples]

Granted, it's harder now because CMS now requires completed 30 minute blocks for a 99232 (so first 99232 is at 104 minutes), but outside of US guided vascular access for CVCs and image guidance for paras and thoras (which I imagine are rare for EM anyways), how often does the legwork for documenting and billing US exams work out instead of folding them into critical care time? I've always figured it was easier to justify and bill extra time than dealing with documenting and archiving a limited echo or limited US of the chest.

I'd say a majority of my group's billed ultrasounds are not in critical care patients or are being billed in conjunction with the 30+ minutes of critical care time for critical care patients. They're limited bedside echos, FAST exams for traumas, RUSH exams for hypotension, ocular exams for vision loss, USGIV access primarily.

Again the key value added process our US guys do is by having an easy system for recording and attaching scans to the patient's chart and having an easy template for documentation. We just drop an order for a bedside ultrasound in EPIC, it shows up on the ultrasound work queue, we record the scan under that order, and then do a quick templated procedure note. I'd say it's a bit more work than an EKG interpretation and documentation, for a bit more RVU billing.

 

[RustedFox]

Nevermind the absolute Royal Rumble that you're going to cause with your radiology department regarding billing for these studies.

We tried. We lost.

Psst: The hospital likes "them" better. That's rads, in case you were wondering.

 

[CliveStaples]

Nevermind the absolute Royal Rumble that you're going to cause with your radiology department regarding billing for these studies.

We tried. We lost.

Psst: The hospital likes "them" better. That's rads, in case you were wondering.

This is a perspective I haven't heard yet.

POCUS is being performed and not being billed at all unless we interpret them. Unless you're saying that at your shop Radiology actually interprets the images that are being performed by the EM docs and are being uploaded? I mean, why on earth would the EM docs record the studies, then?

For perspective, I'm at a shop where the ED doesn't bill EKGs because Cardiology reads them over the next day. The fight wasn't worth it for us (under the new billing codes we just use it as an added layer of complexity in our MDMs so they aren't always wasted, either). But in the case of POCUS, I am not sure how EM would lose this fight - you can just throw the baby out with the bathwater.

 

[RustedFox]

This is a perspective I haven't heard yet.

POCUS is being performed and not being billed at all unless we interpret them. Unless you're saying that at your shop Radiology actually interprets the images that are being performed by the EM docs and are being uploaded? I mean, why on earth would the EM docs record the studies, then?

For perspective, I'm at a shop where the ED doesn't bill EKGs because Cardiology reads them over the next day. The fight wasn't worth it for us (under the new billing codes we just use it as an added layer of complexity in our MDMs so they aren't always wasted, either). But in the case of POCUS, I am not sure how EM would lose this fight - you can just throw the baby out with the bathwater.

We wanted to interpret and bill our own studies for small things (gallbladder, early OB, etc).

We lost fast.

 

[Brigade4Radiant]

We wanted to interpret and bill our own studies for small things (gallbladder, early OB, etc).

We lost fast.

Would rads prefer formal ones? What was their argument?

 

[RustedFox]

Would rads prefer formal ones? What was their argument?

"That's our money, lolz"

 

[Brigade4Radiant]

"That's our money, lolz"

I see yeah this is also another thing Doing the study then billing. They would probably wouldn’t have a fit if we started doing US paras and thoras

 

[Siggy]

My argument for allowing EM and CCM bill POCUS exams would be, “I’m either going to order the formal echo regardless or not going to order the formal exam anyways (eg FAST, lung US, etc). So we’re building our own pot, not carving up someone else’s.

The only pot I’m taking from IR are thoras and paras… which they’re more than happy to give up anyways.

 

[emergentmd]

Academics, I have no idea but makes sense. Go for it.

Community even if you can bill, have Admin/Rad support, have efficient system..... explain me how the pit Er doc can make more money?
How much do you get reimbursed for a beside U/S on average (not bill), how many can you do a shift, how long does it take all in for an U/S from setting up to charting.

I bet even the most efficient U/S ER doc would make more money seeing extra patients than doing U/S. The avg U/S Er doc for sure would be net negative in a strict RVU pay scale.

 

[BoardingDoc]

Academics, I have no idea but makes sense. Go for it.

Community even if you can bill, have Admin/Rad support, have efficient system..... explain me how the pit Er doc can make more money?
How much do you get reimbursed for a beside U/S on average (not bill), how many can you do a shift, how long does it take all in for an U/S from setting up to charting.

I bet even the most efficient U/S ER doc would make more money seeing extra patients than doing U/S. The avg U/S Er doc for sure would be net negative in a strict RVU pay scale.

We bill for our bedside US's at my shop. You are 100% correct that doing any sort of time consuming US is not profitable if there is another patient to be seen. The majority of the time I'm doing an US these days is if I'm placing a central line, if I'm doing an LP on a morbidly obese person, or if I'm doing an abscess I+D. In all of these cases the US saves me time (or makes little to no difference in total time) and increases billing by ~30% and ~20% respectively for the latter two. I don't know the delta for CVL access w/wo US use as I haven't done a CVL without US since residency so haven't bothered to look.