Cardiac Fellowship - help ranking these 3 programs

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JiPo

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Hi all,

I am done with interviews for the season. I have a pretty good idea about my rank list, but I have trouble ranking these 3 programs.

MGH, Hopkins, BI

They are all clearly very strong programs with great reputations, and I am sure I will receive fantastic training in any of the three places. I liked them all equally on my interview day, which makes it even more difficult to rank.

So, I figured I would ask the board for some advice and input. My ultimate goal is to find the sweet/rare/highly coveted partnership pp gig after fellowship, so I am looking for fellowship programs that will open the most number of doors. Thank you all in advance.

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Then could you provide some insight into my question? I post on SDN decent amount :)

I started writing an answer the day you opened the thread. It began with: You "poor" thing.

Then I stopped, because I realized I don't have pertinent advice, and there are people better-equipped to answer your question. I am not a cardiac anesthesiologist, and all choices sound great to me. I would actually do you a disservice if I commented on something I don't know about.

All I can say is that a lot of people would like to have your "problem".
 
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He's right, it's a good problem to have.

I'd rather live in Boston than Baltimore (for a year ... I wouldn't want to live either place long term).

If you really want to settle and work in one of those two cities, training locally has some advantages. Beyond that, you'll be able to go anywhere. All of those hospitals have alumni everywhere in the country.
 
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I'd rather live in Boston than Baltimore (for a year ... I wouldn't want to live either place this year).

Fixed it for you. Are cardiac fellowships happening this year? Will they give you credit for ICU if that’s the training you receive?

Legitimately curious what people’s thoughts are on the above. I bet OB gets more competitive. I can’t tell if I’m trolling or not.
 
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Never heard of MGH or BI, so i'd pick Hopkins for the name recognition.
 
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I would pick BID out of the ones listed, they are on the cutting edge with 3d printing and often the main speakers at SCA (Dr. Tommy Birch, Dr. Feroze Mehmood)
 
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Never heard of MGH or BI, so i'd pick Hopkins for the name recognition.

I can't tell if you are trolling. :unsure: It's Massachusetts General Hospital and Beth Israel Deaconess, both of which are teaching hospital for Harvard medical school.

Maybe I just didn't get the sarcasm :/
 
I would pick BID out of the ones listed, they are on the cutting edge with 3d printing and often the main speakers at SCA (Dr. Tommy Birch, Dr. Feroze Mehmood)


And you’ll have an in on their interventional echo superfellowship.
 
I can't tell if you are trolling. :unsure: It's Massachusetts General Hospital and Beth Israel Deaconess, both of which are teaching hospital for Harvard medical school.

Maybe I just didn't get the sarcasm :/
It was sarcasm
 
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Beware of choosing a program for any one person - high level national leaders often have minimal ground-floor clinical responsibilities and your exposure may be much less than you anticipated. Also he or she could leave for a promotion elsewhere at anytime, or retirement or illness/leave/sabbatical. I know some folks who have been less-than-enthusiastic about their decisions made like this in the past. As I am sure we all know, there are many “big name” folks who spend the non-critical portions of the case not in the OR teaching but instead in their office revising a manuscript or doing who knows what but not with you.

The overall culture of a place is much more important. Are the cardiac anesthesia guys well-respected for echo or does Cardiology do all the tough/structural stuff? What are the echo numbers? Good experience with hands-on cases as a fellow? All are important.

My personal very biased opinion is BI>JH>MGH.
 
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My personal very biased opinion is BI>JH>MGH.

This is based purely on echo experiences/cardiac anesthesia doing structural heart imaging? It would seem that the breadth of fellow cases exposure at MGH would be vast compared to BI (greater exposure to MCS/transplant).
 
This is based purely on echo experiences/cardiac anesthesia doing structural heart imaging? It would seem that the breadth of fellow cases exposure at MGH would be vast compared to BI (greater exposure to MCS/transplant).

My reasoning is much more nuanced than your assumptions. See the rest of what I wrote. Just because the cases are there doesn’t mean the fellow is directly involved in the diagnostic implications of them.
 
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I assume you mean 3D echo and not printing?

No I mean 3D printing
 
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Completely, absolutely, totally, bonkers level crazy though. Allegedly.

Married a Latin woman did we??

All females are crazy - you just have to find your crazy.
 
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Consider a place that offers expertise as well as volume...one of the three programs you mentioned does not do even basic cardiac cases or transplants.
Do not understand why it is considered so high in your ranking.
 
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Consider a place that offers expertise as well as volume...one of the three programs you mentioned does not do even basic cardiac cases or transplants.
Do not understand why it is considered so high in your ranking.
Sounds like you're calling out BI in that list. What about a list of: Duke > Brigham > CCF > MGH for someone who wants to do their own cases, see sick patients with lots of MCS/transplant, and wind up back in academics?
 
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the reputation of Harvard is no longer a criterion for me to choose a fellowship program. They have proven short in multiple aspects compared to other programs out there. In terms of actual training and skill set I think Duke and CCF are superior by far. The only downside is their size and unless you area superstar to distinguish yourself in the crowd, more likely you will be “lost” but still very marketable. That’s why programs like Vanderbilt, WashU, Columbia and Penn which provide same experience but smaller in size would be my go to. MGH is also great don’t get me wrong but sth about their organization, didactic, support is off. BWH would be at the bottom of my list. Not sure how it’s gonna evolve in a few years from now (after they hired a new cardiac surgery chief) but was not impressed with current data.
 
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You wanna do your own cases?
CCF.

You aren’t allowed to leave the CA2 alone in the room when you’re “supervising” (at least in 2014-15 you couldn’t). You can certainly do a heart transplant, lung transplant and a Type A in one 24h call. You’ll also do angiograms and toe amps at 11 pm.
 
Any response is incomplete without you knowing the strengths of your residency program. If you come from a program where you've been doing Type As, heart transplants, LVADs and massive aortic cases without fellows, why would you go to CCF or THI where you're going to be used as a body to take care of the same sick as **** patients? Go to an "echo" fellowship like PGG likes to call them.

If your program is clinically weak, then you need to go somewhere that will give you stool experience without compromising your echo training. Use a fellowship to compliment your residency, not to replace or duplicate it.
 
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Consider a place that offers expertise as well as volume...one of the three programs you mentioned does not do even basic cardiac cases or transplants.
Do not understand why it is considered so high in your ranking.

Which of these programs doesn’t do basic cardiac cases?
 
Any response is incomplete without you knowing the strengths of your residency program. If you come from a program where you've been doing Type As, heart transplants, LVADs and massive aortic cases without fellows, why would you go to CCF or THI where you're going to be used as a body to take care of the same sick as **** patients? Go to an "echo" fellowship like PGG likes to call them.

If your program is clinically weak, then you need to go somewhere that will give you stool experience without compromising your echo training. Use a fellowship to compliment your residency, not to replace or duplicate it.

I’m sorry but pls allow me to disagree with this. You experience the cases differently as a resident and completely different as a fellow. Why would someone deprive himself/herself from something robust no matter what did they do in residency?!?!
Unless they are totally burnt out and want to play echo during fellowship...
 
I’m sorry but pls allow me to disagree with this. You experience the cases differently as a resident and completely different as a fellow. Why would someone deprive himself/herself from something robust no matter what did they do in residency?!?!
Unless they are totally burnt out and want to play echo during fellowship...

Aside from BI, what about supervisory programs that have better case mix? Would you still recommend programs that are hands-on over those? If the supervisory fellow stays in the room with the resident for the most of the case, what learning is the fellow missing out on, other than doing lines? The fellows make all the decision, and the resident would just follow your decision. Even if you go back and forth between 2 rooms, you are still present during educational moments, and you get double the experience.

I just don't understand the value of physically being in the room, setting up your own room, transporting patients. As a supervisory fellow, you come up with the plan, tell residents what to do, and have luxury of focusing on learning echo, and have double the exposure if you go back and forth between 2 rooms. Does a fellow really need to stay in the room during bypass?
 
Aside from BI, what about supervisory programs that have better case mix? Would you still recommend programs that are hands-on over those? If the supervisory fellow stays in the room with the resident for the most of the case, what learning is the fellow missing out on, other than doing lines? The fellows make all the decision, and the resident would just follow your decision. Even if you go back and forth between 2 rooms, you are still present during educational moments, and you get double the experience

This is the constant debate and the answer is different for everyone. Let me give you a few examples - clearly you will see I was a “sit the stool” type of fellow or as some call it a “CA-4” year.

1) Supervisory setup. When you start in July you are all in, along with go-getter CA-2s trying to impress for LORs. This crowd eats up all your teaching and you stick around a whole lot. But as the weeks go by the residents want more independence or you have the non-cardiac crowd who just wants to get through the day and doesn’t seem interested. Plus you need to finish your echo reports, work on that poster/book chapter and oral boards are looming. You probably haven’t intubated or placed an a-line or CVL in weeks. Maybe the attending staff isn’t comfortable with you directing care, especially early in your fellowship. It’s kinda crowded with 4 people behind the ether screen (you, resident, attending, maybe a med student). It’s pretty easy and attractive to just stroll in, help with the echo, and bounce. How many different echo findings are there for garden-variety AS anyways? By the end of the year you may stay for the pre-bypass echo and be on the beach or on the golf course by the time they are coming off. Or you are cramming for echo boards.

This has been a common refrain from many friends of mine - by the middle of the year their enthusiasm has really waned, and while they feel exceptionally proficient at echo, they wonder if they could be doing something more productive. A good friend of mine spent a year like this at a big name institution and her comment to me was - “what a waste of time.”

2) Sit the stool. Yes, setting your room up in the morning sucks. But you’re probably fresh out of residency and was doing it there anyway. You find yourself getting faster and faster at a-lines and CVLs, you probably have a competition with your co-fellows to see who can line up the quickest. You’re in the room with the surgeon, often they are internationally renowned (particularly at those fellowships) and you form a relationship with them. You start to get a feel, by doing it yourself everyday, what really works coming off pump - what pushes to use and when, what drips to have going, what echo findings you’ll probably see. Lots of this will become intuitive and almost like muscle memory. Since you’re in the room the entire time you see some rare, spur of the moment stuff like a kinked-off bypass graft, clotted ECMO circuit, real-time STEMI, air embolism. You’re halfway through treating it by the time your attending returns. Later that afternoon you care for the same patient who comes back with a postop bleed.

I can’t emphasize enough how the hands-on day-to-day experience positively impacted my anesthesia practice. Even though I’m mostly ACT, those skills prove helpful very frequently. It takes a devoted, constantly engaged fellow to get the most out of a supervisory year. We had a kid halfway through the year (I did a Type A dissection that morning!), and with orals/echo/moving I knew my attention would be divided. Anyways, I’ve been rambling for a while so I’ll sign off. YMMV!
 
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I’m sorry but pls allow me to disagree with this. You experience the cases differently as a resident and completely different as a fellow. Why would someone deprive himself/herself from something robust no matter what did they do in residency?!?!
Unless they are totally burnt out and want to play echo during fellowship...
There are arguments to be made for both sides. It's the Shaq argument that Adam Grant mentions. If you're 95th percentile at a certain skill (premiere center of your time) and 50th percentile at another (free throw shooting), are you better served focusing on marginally improving your weakness or trying to reach the 99th percentile in your strength?

Some residency programs have a ridiculous amount of cardiac exposure as a resident. When you're 1 on 1 in a room with an attending as a CA3, how much different is that then when you're a fellow 1 on 1 with an attending? Each program has its own strengths and weaknesses, but if I'm giving up a year of my life, I sure as hell want to maximize my experience rather than marginally improving on something I know I'm already good at.

Some programs offer a well-rounded experience. But for the most part, programs reach the top percentiles of either clinical experience or cutting edge echo. Pick your path.
 
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Correct...I would recommend then studying echo at home (books, courses you name it) and get an attending salary. By the end of one year you will be theoretically better than the best teacher...
 
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You wanna do your own cases?
CCF.

You aren’t allowed to leave the CA2 alone in the room when you’re “supervising” (at least in 2014-15 you couldn’t). You can certainly do a heart transplant, lung transplant and a Type A in one 24h call. You’ll also do angiograms and toe amps at 11 pm.
I liked CCF and Duke. Both would have me sitting the vast majority of my own cases--which is something I realized I wanted as I started visiting more programs this cycle.

My comparison of CCF vs Duke is that Duke felt a bit more "academic" in that they pushed you hard to complete an academic project (and seemed based on the interview day) and gave you the support to do so; whereas CCF didn't care very much if you were academically productive as a fellow. Didactics seemed potentially stronger at Duke as well.
 
Correct...I would recommend then studying echo at home (books, courses you name it) and get an attending salary. By the end of one year you will be theoretically better than the best teacher...

Are you saying just study echo in your first year out as an attending?

Might be possible, but to get Advanced TEE certified you must complete a cardiac fellowship. It’s listed in the requirements. Anyone (including your random neighbor) can be a testamur.

That being said the NBE has to be the slowest and most inefficient organization out there. Took me 18 months (!!) post-echo boards time receive my advanced certification. Which is why most cardiac-heavy jobs out there require just the fellowship and not the certification.
 
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Are you saying just study echo in your first year out as an attending?

Might be possible, but to get Advanced TEE certified you must complete a cardiac fellowship. It’s listed in the requirements. Anyone (including your random neighbor) can be a testamur.

That being said the NBE has to be the slowest and most inefficient organization out there. Took me 18 months (!!) post-echo boards time receive my advanced certification. Which is why most cardiac-heavy jobs out there require just the fellowship and not the certification.

that was an ironic joke...
 
Since you’re in the room the entire time you see some rare, spur of the moment stuff like a kinked-off bypass graft, clotted ECMO circuit, real-time STEMI, air embolism.
I agree with all of your post.

I chose a non-supervisory fellowship because I wanted the room time and primary responsibility for cases. I was a non-traditional fellow, going back several years after finishing residency. I hadn't touched a TEE probe or done a heart in a very long time. My residency wasn't particularly strong in the CT realm either, with minimal exposure to transplant and big aortic whacks. I suppose someone who was straight out of a heart-heavy residency might have reasonably different goals and needs from fellowship.

However, I have always believed that there's never any substitute for being in the room for lots and lots of hours. We train for rare events, and if you want to see some while you're in training and have experienced backup there to help you, you have got to be present. I got too much of an impression during my interview trail that fellows in supervisory (aka "echo") fellowships gravitated toward being out of the OR.

I don't really mean to disparage echo fellowships - of course those fellows finish the year massively more skilled and capable in the cardiac realm than if they'd just spent the year working. I was just sure that it wasn't for me, and I'm glad I went to a workhorse program that extracted maximal labor out of me, despite not enjoying the grind of every single day.

Also, to another point, I don't entirely agree that there's no need to be in the OR during bypass. Things can happen during that time that affect us. I like to screw around with the echo machine doing pointless stuff while keeping an ear to the field. I'm not a big believer in taking breaks during cases, though of course that's a minority opinion. :)
 
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Might be possible, but to get Advanced TEE certified you must complete a cardiac fellowship. It’s listed in the requirements. Anyone (including your random neighbor) can be a testamur.
Unless something has changed in the last 5 years, that's actually not correct. You have to meet the numbers during a 12-month fellowship dedicated to the care of surgical cardiac patients. Some people, including the ASE, interpret that to include critical care fellowships, especially the way some programs are organized, where the critical care fellows are a few days in the cardiac OR every month.

What I am saying is that there are people who have become certified after a critical care fellowship.
 
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Unless something has changed in the last 5 years, that's actually not correct. You have to meet the numbers during a 12-month fellowship dedicated to the care of surgical cardiac patients. Some people, including the ASE, interpret that to include critical care fellowships, especially the way some programs are organized, where the critical care fellows are a few days in the cardiac OR every month.

What I am saying is that there are people who have become certified after a critical care fellowship.
Holy crap you're right. I had never read the actual requirements but it definitely appears to be possible.
 
Unless something has changed in the last 5 years, that's actually not correct. You have to meet the numbers during a 12-month fellowship dedicated to the care of surgical cardiac patients. Some people, including the ASE, interpret that to include critical care fellowships, especially the way some programs are organized, where the critical care fellows are a few days in the cardiac OR every month.

What I am saying is that there are people who have become certified after a critical care fellowship.

This is brought up a lot. And I understand the NBE etc. is pretty liberal with requirements. It I was in charge, honestly, I wouldn’t approve a typical CCM fellowship as meeting the requirements. I spent my whole year doing solely cardiac cases - doing only cardiac ICU during a CCM year would be suboptimal, you need that medical/neurological ICU experience (and trauma, surgical, etc...). While there are “cardiac conerns” in all these patients you are doing that as a resident as well. Honestly they probably need to just specify that an ACGME ACTA fellowship is required. But again the NBE moves so slowly that few people take it seriously.

Also getting 150 personally performed full TEE exams during a CCM year is not easy. Believe it or not there are some cardiac fellowships out there that struggle to meet this requirement. If you spent a couple of days in the OR you’d have to get probably over 5 exams a day (assuming minimal ICU TEEs) which means you are probably sprinting from room to room doing exams... not great for learners.

Bottom line - would you want a cardiac fellowship grad being a MICU intensivist? Probably not. The same holds true for a CCM grad doing advanced cardiac cases, at least in theory. If you want to do cardiac, just do the darn fellowship.

At some point in the next 10 or so years I’d wager there will be a separate board exam for cardiac like for peds or CCM, so a lot of this discussion will be moot.
 
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The NBE also wants the CCM fellows to pay for their exam. There's no way they'll plug the loophole.

I mean, there's no reason for the Basic periop echo exam and certification to even exist, except to be a product for NBE to sell.
 
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This is brought up a lot. And I understand the NBE etc. is pretty liberal with requirements. It I was in charge, honestly, I wouldn’t approve a typical CCM fellowship as meeting the requirements. I spent my whole year doing solely cardiac cases - doing only cardiac ICU during a CCM year would be suboptimal, you need that medical/neurological ICU experience (and trauma, surgical, etc...). While there are “cardiac conerns” in all these patients you are doing that as a resident as well. Honestly they probably need to just specify that an ACGME ACTA fellowship is required. But again the NBE moves so slowly that few people take it seriously.

Also getting 150 personally performed full TEE exams during a CCM year is not easy. Believe it or not there are some cardiac fellowships out there that struggle to meet this requirement. If you spent a couple of days in the OR you’d have to get probably over 5 exams a day (assuming minimal ICU TEEs) which means you are probably sprinting from room to room doing exams... not great for learners.

Bottom line - would you want a cardiac fellowship grad being a MICU intensivist? Probably not. The same holds true for a CCM grad doing advanced cardiac cases, at least in theory. If you want to do cardiac, just do the darn fellowship.

At some point in the next 10 or so years I’d wager there will be a separate board exam for cardiac like for peds or CCM, so a lot of this discussion will be moot.

But we are talking about an echo certificate, not a cardiac certificate.
 
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But we are talking about an echo certificate, not a cardiac certificate.

The only people needing an advanced echo certification (not just a certificate) are those doing advanced cardiac work.

I guess not enough CCM folks were taking the advanced PTE exam so last year the NBE introduced a new exam meant for ICU POCUS techniques. No clue why they felt this was necessary
 
I guess not enough CCM folks were taking the advanced PTE exam so last year the NBE introduced a new exam meant for ICU POCUS techniques. No clue why they felt this was necessary
Because some greedy intensivists want to limit the right to POCUS in the ICU to people who have been "certified". And some other greedy people want to make a lot of money certifying the obvious, for "quality" reasons of course.

It's disgusting, Just a few decades ago, one could practice most professions without special licenses, except for a handful (like law and medicine). Now one needs a license for a ton of minor stuff. Same for various board-certifications in medicine. And this is supposedly a free market economy. :barf:
 
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The only people needing an advanced echo certification (not just a certificate) are those doing advanced cardiac work.

I guess not enough CCM folks were taking the advanced PTE exam so last year the NBE introduced a new exam meant for ICU POCUS techniques. No clue why they felt this was necessary

There are a small subset of CCM folks who work primarily in the CTICU who might "need" aPTE cert when there's no CT anesthesia nearby. Many of my attendings were dual CT/CCM trained and I did TEEs as a CCM fellow for VA ECMO turndowns, LVAD PI events and suckdowns, persistent LCOS a few hrs after arriving to the unit from the OR, other unexplained shock, codes, etc. Surface echo is definitely more important overall though so I kinda understand why the CC exam was created assuming CCM wants to start billing for these.
 
Surface echo is definitely more important overall though so I kinda understand why the CC exam was created assuming CCM wants to start billing for these.
There is no relationship between certification and billing. In anything, not just in echo. ;)

Any bozo can bill critical care time, for example.
 
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There is no relationship between certification and billing. In anything, not just in echo. ;)

Any bozo can bill critical care time, for example.

I understand (I am only a PTE testamur but I still bill 93312). Hospitals, med exec committee, credentialing committee, and then eventually insurance companies might not see it the same way in the future since currently 99.9% of CCM are not billing for POCUS
 
I understand. Hospitals, med exec committee, credentialing committee, and then eventually insurance companies might not see it the same way in the future since currently 99.9% of CCM are not billing for POCUS
Billing for POCUS is like billing for using a stethoscope. It's ridiculous. It's 2020, and POCUS should be the standard of care in the ICU.
 
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Billing for POCUS is like billing for using a stethoscope. It's ridiculous. It's 2020, and POCUS should be the standard of care in the ICU.

Preaching to the choir, man. But if we insist on a fee-for-service medical system then stupid sht like this is what we get
 
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Preaching to the choir, man. But if we insist on a fee-for-service medical system then stupid sht like this is what we get
We have to get rid of all these bandits from our certification boards.
 
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