Cardiac Anesthesiology fellowship a must?

[Cumberland_Doc]

I see several openings for cardiac private practice gigs around the country with no fellowship requirement. In 2018, is this true, or more of an exception? I am wondering because I could just work after residency in this group versus pursuing a fellowship at the cost of a year of pay, if the outcomes would ultimately be the same, especially if the case profile is B&B CABG, valves, and TAVR.

Thanks

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[pgg]

I see several openings for cardiac private practice gigs around the country with no fellowship requirement. In 2018, is this true, or more of an exception? I am wondering because I could just work after residency in this group versus pursuing a fellowship at the cost of a year of pay, if the outcomes would ultimately be the same, especially if the case profile is B&B CABG, valves, and TAVR.

It seems pretty likely that in the next couple decades, all of the good cardiac jobs will go to fellowship trained people. Even if you can secure a job without a fellowship now, in 10 years when you want or need to move, it will be harder if not impossible.

We're training almost 200 adult CT anesthesiologists per year, last I looked. That's a bunch. Already more and more hospitals won't credential non fellowship trained people to do hearts.

There will probably always be undesirable jobs in undesirable locations that will be willing (not happy) to take anyone.

Current, experienced generalists who have gone the extra mile and become Testamurs are probably safe in their current jobs, but may get little love if they have to move.

I am biased but if you think you'll want to make cardiac anesthesia part of your practice in the future, you should do the fellowship.

 

[PeterGriffin]

I see several openings for cardiac private practice gigs around the country with no fellowship requirement. In 2018, is this true, or more of an exception? I am wondering because I could just work after residency in this group versus pursuing a fellowship at the cost of a year of pay, if the outcomes would ultimately be the same, especially if the case profile is B&B CABG, valves, and TAVR.

Thanks

I can't speak for everywhere, but I do recruiting for my group in Austin. If you want to do hearts, do the fellowship. We won't consider anyone for the pedi or heart team without a fellowship or years of experience.

 

[chocomorsel]

I can't speak for everywhere, but I do recruiting for my group in Austin. If you want to do hearts, do the fellowship. We won't consider anyone for the pedi or heart team without a fellowship or years of experience.

How long is your partnership track if you offer one?

 

[GA8314]

off the beaten track is very hard to fill with fellowed cards guys. there are many jobs open for B&B hearts in these areas.

also, often, off the beaten track can be some really nice gigs. big city/tertiary care= cardiac fellowed. otherwise, i'm not so sure.

as Pgg says, they are training up lots of cardiac fellows. the question is, will these fellows be willing to go outside of major city centers. if not, then those jobs will go to those with cardiac proficiency/experience, but not requiring fellowship. once you have an abundance of fellowed guys entering these geographies, i'm sure this can change.

you really need to get out of academia to appreciate the over emphasis on subspecialization. you may be Peds trained at a place that does some peds but also requires you to do lots of regional, B&B hearts, neuro, OB etc. there are tons of groups this size that just can't/will not pay a fellowed person just to do that specialty. because the practice is too diverse case wise. and, the volume of any subspecialty is not such that they can keep that person busy in his/her chosen area of specialization.

you'd be surprised how many places just need good all around docs capable of doing the full gamut of anesthesia.

that said, if you go to a place that is skewed a bit towards needing more peds, or more hearts, then try to cater your CA3 year to doing that. try doing a month of TEE if possible. do an extra couple months of hearts if you plan on going to a place that needs their people to be cardiac proficient......

 

[AdmiralChz]

I am biased but if you think you'll want to make cardiac anesthesia part of your practice in the future, you should do the fellowship.

Yeah, I really agree with this. It’s a really good year and gives you an excellent, applicable skill set to all tough, hemodynamically unstable cases. Is a fellowship REQUIRED to find a job in cardiac? Probably not as those above have illustrated (it is similar to Peds in that respect)...

But the Dunning-Kruger is strong in cardiac - you truly don’t know what you don’t know until it becomes important. I thought I could handle community hearts coming out of residency, but man I was very wrong and my skills exponentially increased during my fellowship year. I was at a high volume center with a huge referral base and saw a lot of complications - I would have been totally lost calling for help if I hadn’t done the year. This goes far beyond TEE as well which is just a tool, you need to put time in on the stool to see the intricacies of the cases and what can go wrong. That’s why myself and others recommend a “sit your own cases” fellowship vs a “TEE/supervisory” fellowship but that’s a separate discussion...

 

[bigdan]

I concur with the group, although I too admit bias.

To answer your question, to get work with those groups listing jobs doing cardiac without a fellowship requirement, sure - you can do cardiac there without a fellowship requirement. I do think a well trained resident who takes an interest in cardiac can safely do most CABG cases. Uncomplicated TAVR is literally a sedation case in my hospital now, including a PACU stay as opposed to ICU admit. Like many things in anesthesiology, there is great value in simply doing the cases; you will get very good by doing a lot of cardiac, fellowship or not.

But I found the year to fellowship training to be immensely rewarding (reflecting on it now, that is - I *hated* doing it) for my entire practice, both for cardiac and non-cardiac surgical cases. Your value, it could be argued, might be even greater as a fellowship trained guy (or gal) at a place that doesn't require fellowship, as you would be "The (wo)man" in the group. And you would "retain" the freedom to move around to places that do require fellowships if you so desired.

If you can stomach another year of training, I would strongly advise doing the fellowship.

 

[T-burglar]

You don’t know what you don’t know.

Do the fellowship if you want to do hearts in 2018. Your understanding of physiology will be next level after a year of intense TEE training.

 

[Man o War]

Here’s my perspective/2 cents:
My last year of training was really heavy on hearts, I went straight out to PP. Worked for many years, made partner, then decided to go back to cardiac fellowship as an “adult learner”. Btw that sucked, just go straight to fellowship if you have any thought you may want to do it.
Prior to fellowship, there were cases coming in that made me really uncomfortable. Perhaps it was just the hospital I was at trying to ramp up their heart program and therefore bringing in surgeons who wanted to do sicker patients. This is what drove me to the extreme of going back to training. I hated that feeling. Very few of my partners wanted to do TAVRs because they didn’t feel comfortable. Now, there is nothing a surgeon could put in front of me that would make me uncomfortable. Cautious, yes. But not uncomfortable.
As a side note, I know of 2 really good PP groups that have been told by the hospital that they have to replace almost their entire cardiac group with advanced TEE certified docs. Doesn’t matter how long they’ve been doing hearts there, they’re out. So that can happen too.
I also recognize, however, that not every practice that does hearts can support maintenance of TEE certification due to lower volume coupled with a large group of docs doing hearts.

 

[ryanjmy]

You can be good at cardiac without a fellowship. You can’t be good at cardiac without TEE expertise.

You can learn TEE without a fellowship but its not easy. The guys that graduated from fellowship In the 90s had to learn echo on the job, so it can be done. You’ll need a local mentor and a lot of self study. You’ll need to pass the advanced echo exams.

Would I recommend it, no. Can it be done. Yes

 

[2Fast2Des]

CRNA's do cardiac cases without residency or fellowship, if they can do it, no excuse a board certified physician with TEE and experience in handling hearts can't do atleast B&B. Do I want to do tertiary care stuff on the regular? Hell no, but I think with our intense cardiac months in residency (high volume center that is), if I can't be trusted to do a basic case without a "fellowship" then its a disgrace to the residency program and my time.

 

[PeterGriffin]

How long is your partnership track if you offer one?

We are part of a AMC, so no true partnership. Associates promote to “partners” after 2 years. Increased pay, profit sharing, increased vacation.

 

[Twiggidy]

CRNA's do cardiac cases without residency or fellowship, if they can do it, no excuse a board certified physician with TEE and experience in handling hearts can't do atleast B&B. Do I want to do tertiary care stuff on the regular? Hell no, but I think with our intense cardiac months in residency (high volume center that is), if I can't be trusted to do a basic case without a "fellowship" then its a disgrace to the residency program and my time.

Correction. They get TOLD how to do a cardiac cases. A lot of “do this” and “do that” from the surgeon

 

[Southpaw]

Correction. They get TOLD how to do a cardiac cases. A lot of “do this” and “do that” from the surgeon

Careful with this. My experience in residency was similar to this. And I’m willing to bet that the ‘culture’ of almost every place was formed by surgeon likes/dislikes.

I think cardiac anesthesia /TEE is awesome - but I found dealing with cardiac surgeons, on the whole, to be awful. Is it like that everywhere? Of course not. But it’s like that in ENOUGH places for me to want to avoid it.

 

[psychbender]

You can be good at cardiac without a fellowship. You can’t be good at cardiac without TEE expertise.

You can learn TEE without a fellowship but its not easy. The guys that graduated from fellowship In the 90s had to learn echo on the job, so it can be done. You’ll need a local mentor and a lot of self study. You’ll need to pass the advanced echo exams.

Would I recommend it, no. Can it be done. Yes

I agree with this. It is possible to learn TEE and do cardiac well without a fellowship. It is just more difficult, and you'll limit yourself to learning and getting comfortable with whatever your practice currently does.

I enjoyed cardiac in residency, did six months (five at high volume civilian centers) for greater exposure and to get down there basics of TEE. I did not do fellowship for several reasons, some related to my obligated work environment (Army). Instead, I went to a place that did a little over a hundred cardiac cases a year (considered rather high volume, for the military). There, I joined the CT team, and tried to get close to half of the cases each year, do an exam on any heart that I wasn't personally doing, and review the recorded studies on any heart I couldn't personally echo. One of the three members of the team was CT fellowship trained, and I had her read my exams, and go over exams from her education file whenever we had hospital training days. I worked hard, studied, and passed the APTE exam. I'm working with my CCM fellowship PD and the NBE to recognize my fellowship as meeting the requirement so that I can officially be certified, rather than the testamur that I currently am.

At the job I start next week, I'm supposed to do cardiac, in addition to general OR and ICU. They are a low-volume center, and attempting to expand, but will still be rather low-volume, if they meet their growth goal. They do B&B CABGs, AVRs, mostly. High-risk patients and complex procedures get referred to the high-volume center less than an hour away.

I fully expect, though, that if I need to move in a few years, then I will not be permitted to do hearts any longer, as that is the direction that most hospitals here are moving toward. At that time, if physician-only practices in my area continue to change to supervision, then I may just go to full time CCM, anyway.

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[Psai]

Careful with this. My experience in residency was similar to this. And I’m willing to bet that the ‘culture’ of almost every place was formed by surgeon likes/dislikes.

I think cardiac anesthesia /TEE is awesome - but I found dealing with cardiac surgeons, on the whole, to be awful. Is it like that everywhere? Of course not. But it’s like that in ENOUGH places for me to want to avoid it.

I'm beginning to appreciate my training program more and more. Our cardiac surgeons can be unpleasant to work but they definitely respect our department and accept our attendings' judgment in determining the surgical plan.

 

[Twiggidy]

I'm beginning to appreciate my training program more and more. Our cardiac surgeons can be unpleasant to work but they definitely respect our department and accept our attendings' judgment in determining the surgical plan.

I get what you guys are saying and I’m glad this is what you’re experiencing but the real world isn’t like academics. One major OR spat over something silly turns into “please don’t have that anesthesiologist in my OR”, which happens in private practice and some academics.

Regarding my post, I’m talking about the CRNAs who “do cardiac so why do a fellowship”. Those CRNAs aren’t discussing a plan. They’re doing what they’re told

 

[Twiggidy]

Careful with this. My experience in residency was similar to this. And I’m willing to bet that the ‘culture’ of almost every place was formed by surgeon likes/dislikes.

I think cardiac anesthesia /TEE is awesome - but I found dealing with cardiac surgeons, on the whole, to be awful. Is it like that everywhere? Of course not. But it’s like that in ENOUGH places for me to want to avoid it.

It’s true. CV surgeons are a special breed and it takes a special person to be able to work with them. They are very particular about how things are doing and I actually like that about the field because I’m particular in how I work as well. It suits me and that’s part of the reason I did the fellowship.

 

[Twiggidy]

And quite honestly.....there’s no such thing as a bread and butter cardiac case. A LOT can go wrong with “just and AVR” or “just a CABG” especially in the wrong hands (on both sides of the drapes)

 

[BLADEMDA]

If you plan on doing hearts, or want to do hearts, the fellowship is a "must" IMHO. This is about the future not the past.

 

[BLADEMDA]

And quite honestly.....there’s no such thing as a bread and butter cardiac case. A LOT can go wrong with “just and AVR” or “just a CABG” especially in the wrong hands (on both sides of the drapes)

You bet. I've seen unidentified moderate MR, incorrect Aortic Valve evaluation by Cardiology, etc doing routine cases. You are not a technician but a Physician so act like one and do the right thing: that means a fellowship for all current residents who want to do hearts.

Older MDs should get certified themselves (they are grandfathered in) or step aside for the new fellowship trained graduates.

 

[GA8314]

Blade, that all sounds really great. But, the reality is that there aren't enough to go around. Or, they aren't willing to leave the larger metropolitan "cultural centers". But, there are plenty of places doing "light cardiac", like 1 heart/day or so. Even if they do recruit a cardiac trained doc, he/she has to take vacation, have PC days off (hopefully) etc. So, others without fellowship will be doing hearts. Like it or not. I don't see this changing anytime soon, at least at the locations I'm describing.

The cardiac fellowed docs I've known are mostly the major metropolitan types of folks. I just don't see the interest in moving even 2 hours off the beaten track, as good as those jobs can indeed be.

 

[Modanq]

Cardiac folks are also making in roads to doing the TEE for cards ...TAVR, mitral clip, LAA occlusion and also EP cases.

Lots of annoying offsite but good cases that need CV anesthesia.

 

[psychbender]

And quite honestly.....there’s no such thing as a bread and butter cardiac case. A LOT can go wrong with “just and AVR” or “just a CABG” especially in the wrong hands (on both sides of the drapes)

Yeah, I know things can go wrong in any case. That's hardly news. I've had surgeons lacerate the RV on a re-do CABG, then struggle to cannulate from the groin, take forever on pump, struggle to come off, and end up on ECMO. I've seen them burn holes in the LA during pulm vein isolation, leading the LA to rupture after decannulating. I've told surgeons to go back on, as their nice new aortic valve occluded both coronaries. I've also told them to change surgical plans based on my echo. None of this is rocket science, and non fellowship-trained anesthesiologists that are motivated to learn can handle these situations, particularly if the higher risk cases are referred to the high volume center with only CT fellowship trained anesthesiologists and highly skilled surgeons.

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[T-burglar]

Cardiac folks are also making in roads to doing the TEE for cards ...TAVR, mitral clip, LAA occlusion and also EP cases.

Lots of annoying offsite but good cases that need CV anesthesia.

Yes cardiology doesn’t want to spare a body to image these cases. Our group at my hospital is doing all the structural TEE. These are well reimbursed cases and should get even more well reimbursed once structural TEE becomes reimbursed.

 

[sevoflurane]

Funny how little reimbursement we get for a complicated mitral clip(s). That procedure is 95% TEE driven.

 

[sevoflurane]

As to the original question, if you want to do hearts with any regularity, then a fellowship is probably the way to go.

As always, there are exceptions based on training, location and cardiac volume. You can’t expect to have 4 Fellows in a program that does 100 bread and butter hearts a year.

 

[sevoflurane]

... and even then q4 24 hour heart call is kinda lame. Need more bodies or a sizable stipend.

 

[T-burglar]

Funny how little reimbursement we get for a complicated mitral clip(s). That procedure is 95% TEE driven.

Clips make me want to shoot myself though. TMVR valve in native annulus will hopefully be a less painful procedure to guide

 

[deleted697535]

CRNA's do cardiac cases without residency or fellowship, if they can do it, no excuse a board certified physician with TEE and experience in handling hearts can't do atleast B&B. Do I want to do tertiary care stuff on the regular? Hell no, but I think with our intense cardiac months in residency (high volume center that is), if I can't be trusted to do a basic case without a "fellowship" then its a disgrace to the residency program and my time.

Are you a resident?

 

[2Fast2Des]

Are you a resident?

Just finished residency

 

[GA8314]

As to the original question, if you want to do hearts with any regularity, then a fellowship is probably the way to go.

As always, there are exceptions based on training, location and cardiac volume. You can’t expect to have 4 Fellows in a program that does 100 bread and butter hearts a year.

There are plenty of hospitals doing 100-250 hearts per year. I don't think residents understand that when in the midst of academia doing 800-1200/year with huge emphasis on subspecialization.

It is not only unrealistic to expect these groups to hire multiple cardiac fellowed docs, but it may even be self defeating UNLESS that cardiac guy/gal is also deft at doing all types of non-cardiac cases. You won't have the choice to "not do OB" at such groups. You need to be deft (fast) at Regional at many groups with substantial Ortho business etc etc.

This in no way excludes the cardiac fellowed folks, but at such places you simply will not be able to do mostly cardiac. You can be the "go to" cardiac person however. Even then, I'm not sure a fellowship mandates that you will necessarily be the best at doing cardiac. That is up to the individual.