Cardiac vs Critical care

[bigfootisreal]

Looking for any insight anyone might have regarding pursuing fellowship in either of these and specifically comparing practice options. I am not particularly interested in academics which I understand may make crit care more difficult. Cardiac is intriguing because I enjoy TEE and the complexity of the cases, but not sure how thrilled I would be to do a fellowship just to spend a majority of my time doing routine lap appys with some CT cases mixed in. Crit care appeals because of the change of pace and also makes for a more comprehensive knowledge and skill base. Plus gives me practice options for the future. Hoping to end up in the NE for family purposes. Thanks everyone.

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[Pharmado]

Go to gaswork and troll any random states job board. You'll see that there are a lot of available cardiac positions that pay very well. I'm not familiar with the job market for ICU jobs, but I don't think that it is nearly as easy to find a job nor is it as financially lucrative. Just my two cents since I do neither.

 

[psychbender]

Only do a fellowship if you truly enjoy the subspecialty, and not just to be more well-rounded or knowledgeable. Think, "would I be content if I NEVER practiced this subspecialty for the rest of my career?" If you would be fine without it, then don't bother giving up a year of time and income to potentially limit your prospects.

I really enjoy the practice of critical care medicine, but the unit can be utterly exhausting at times. It also does not pay as well as anesthesiology on a per hour basis, and there are far fewer private practices that also cover the ICU. It does allow for some interesting options, though, like 0.5FTE ICU (12-13 weeks a year) for basic benefits and home base, then locums anesthesiology for however many weeks you want.

Regarding your concerns of doing garden variety cases and only rare cardiac, that's up to you. You can join a group doing exclusively cardiac and cardiac-adjacent cases (EP, structural heart, thoracic), or have a more varied practice, but still do hearts a couple days a week. There are a lot of options out there.

 

[bigfootisreal]

Only do a fellowship if you truly enjoy the subspecialty, and not just to be more well-rounded or knowledgeable. Think, "would I be content if I NEVER practiced this subspecialty for the rest of my career?" If you would be fine without it, then don't bother giving up a year of time and income to potentially limit your prospects.

I really enjoy the practice of critical care medicine, but the unit can be utterly exhausting at times. It also does not pay as well as anesthesiology on a per hour basis, and there are far fewer private practices that also cover the ICU. It does allow for some interesting options, though, like 0.5FTE ICU (12-13 weeks a year) for basic benefits and home base, then locums anesthesiology for however many weeks you want.

Regarding your concerns of doing garden variety cases and only rare cardiac, that's up to you. You can join a group doing exclusively cardiac and cardiac-adjacent cases (EP, structural heart, thoracic), or have a more varied practice, but still do hearts a couple days a week. There are a lot of options out there.

Thanks for the advice. By the sounds of it, you do critical care. I am just curious how your average year shakes out splitting time between the two. Also, do you feel like as you reach the end of your career you will value the ability to pursue one versus the other? thanks!

 

[Katheudontas parateroumen]

Good choices. Have you (gulp) thought about doing both fellowships? I agree that only do a fellowship if you’re absolutely passionate about it. At this point, jobs are plentiful for everyone. This is likely for what I’ve been told by my department chair for 10-15 years due to staffing shortages. I wouldn’t count on that long, but it is definitely good right now.

I, for one, am thankful for my critical care fellowship. Although per hour it pays less and work is definitely harder, I definitely know I could do either OR or CCM if anything were to happen. Also, I do enjoy teaching and the change of pace and knowledge base. I’m constantly consulted by my peers (for better or for worse lol). Crazy, but during the pandemic, I heard plenty of stories of anesthesiologists not being paid or getting back paid because there weren’t any cases to be done. Anything can happen I guess, best to protect yourself if that’s worth anything.

 

[bigfootisreal]

Good choices. Have you (gulp) thought about doing both fellowships? I agree that only do a fellowship if you’re absolutely passionate about it. At this point, jobs are plentiful for everyone. This is likely for what I’ve been told by my department chair for 10-15 years due to staffing shortages. I wouldn’t count on that long, but it is definitely good right now.

I, for one, am thankful for my critical care fellowship. Although per hour it pays less and work is definitely harder, I definitely know I could do either OR or CCM if anything were to happen. Also, I do enjoy teaching and the change of pace and knowledge base. I’m constantly consulted by my peers (for better or for worse lol). Crazy, but during the pandemic, I heard plenty of stories of anesthesiologists not being paid or getting back paid because there weren’t any cases to be done. Anything can happen I guess, best to protect yourself if that’s worth anything.

I’ve given it some thought but not sure doing both would fit my goals of wanting to be in the private sector (although that could change). I agree with you though, I realize the job market is on fire right now but I also like the idea of hedging my skill set so that when things do change, I’m not left without options. How do you feel the critical care outlook is for anesthesiologists? I’ve never met someone crit care trained who isn’t thankful for their extra training

 

[PpfSuxTube]

I do cardiac and cover the csicu. 80% of my work is cardiac. Love it.
Gen surg icu is so slow and morbid in comparison in my opinion.

That could be an option. Do a cardiac fellowship for one year then cover the csicu afterwards... you won't get the breath of icu illnesses or complexity in a cvicu but who needs that anyways.

Pls don't try do cardiac without a fellowship... unless you work with dinosaurs and only do simple cabg you will forever be behind the 8 ball

 

[aneftp]

In general especially if u are good at talking BS. A critical care fellowship followed with some hybrid anesthesia and icu work can lead to job promotions better.

You aren’t stuck in OR duties while in icu.

Depends on the end game. The money is better in anesthesia and cardiac fellowship gives you even more opportunities financially.

 

[livefree1212]

I do cardiac and cover the csicu. 80% of my work is cardiac. Love it.
Gen surg icu is so slow and morbid in comparison in my opinion.

That could be an option. Do a cardiac fellowship for one year then cover the csicu afterwards... you won't get the breath of icu illnesses or complexity in a cvicu but who needs that anyways.

Pls don't try do cardiac without a fellowship... unless you work with dinosaurs and only do simple cabg you will forever be behind the 8 ball

I always love when people who have done a one year fellowship in hearts try to gatekeep like this.

I have no fellowship training and routinely assist surgeons in providing anesthesia for CABG surgery (including low LVEF with IABP, planned or unplanned LV assist devices or ECMO), aortic/mitral valve cases, MAZE/convergent ablations, and other not straight forward cases.

My residency program was very cardiac heavy and truthfully the main benefit a fellowship would have provided is echocardiography expertise which can also be gained through alternative pathways. Many hospitals who do under a certain number of pump cases can’t attract CV fellowship boarded anesthesiologists because they simply don’t have the volume to attract these folks.

I have no doubt you are better at interpreting echo than I in structural heart or OR settings, but I don’t feel as though I am “behind the 8ball”. I have, however, worked an additional year as an attending and got paid a real salary instead of a meager fellowship stipend.

 

[Steege305]

I initially chose CCM because i really enjoyed the medicine and wanted a pathway out of the OR if I got bored with it. I left CCM because the number of nights was way more physically and mentally taxing then being on call in the OR, and even though I had a block schedule I was getting home just before my kids were going to bed on my ICU weeks. Life is too short. It’s one thing to know it intellectually, but it’s another to see it in action all the time. I love the medicine, but I love my family more.

That being said, I would 100% do a CCM fellowship again. It was easily the most educational and rewarding year of my training.

 

[pgg]

The opportunity cost is very high for doing both CCM and ACTA fellowships. These days more than ever.

It's not likely to ever be a job requirement outside of a few high powered academic places. I know some places are only hiring dual CCM/ACTA people to their cardiac divisions.

For a brief while I explored doing CCM after my ACTA year. I probably could've arranged to stay at my fellowship institution but I was still on active duty and probably couldn't have gotten the Navy to OK it.

In the grand scheme of things I think I learned much more medicine during my CCM months in residency and fellowship. While ACTA absolutely added important skill sets and experience that I use daily now, I think a CCM fellowship would've made me a better doctor.

In speaking with the few CCM anesthesiologists I know it's apparent they have a depth and breadth of knowledge that I don't. And I sort of wish I had that, even though I get by just fine in my OR-only practice.

I'm pretty sure I wouldn't enjoy ICU practice (hours, multitasking, consults, speaking to many more awake humans), but there's a part of me that wishes I'd done a CCM year, just to be a better doctor.

 

[nimbus]

Around here cardiac locums is 400/hr. General locums is 250-300/hr. In our production based PP, cardiac averages around 100k more per year. But also much more home call. Nobody does exclusively hearts. No new or recent grads can do hearts without a fellowship. We have made exceptions for people with 15-20yrs experience. Whatever one may think of “gatekeeping”, it is a reality in most places unless they are desperate.

 

[JiPo]

In speaking with the few CCM anesthesiologists I know it's apparent they have a depth and breadth of knowledge that I don't. And I sort of wish I had that, even though I get by just fine in my OR-only practice.

I totally echo this sentiment. There are days I wish I had this knowledge just to be a better physician, but I don't want it badly enough to sacrifice a year of attending salary, especially in the current market. I am happy with the type of anesthesiologist I turned out to be, and the skill that I would've gained from doing additional year of ICU fellowship would've been a very expensive cherry on top that I am okay with not having.

 

[Bertelman]

The lost wages of my cardiac fellowship year have paid off handsomely by providing an entire career of no in-house call. As mentioned, the salary can be higher as well.

I’m not saying every cardiac job provides that, but they aren’t hard to find.

 

[POW16]

I do CCM and anesthesia. CCM for me scratches a different itch. Continuity with the patients, true multidisciplinary approach to problems, communicating with other teams, etc. It's much more intellectually stimulating than the OR.

 

[Ronin786]

I do cardiac and cover the csicu. 80% of my work is cardiac. Love it.
Gen surg icu is so slow and morbid in comparison in my opinion.

That could be an option. Do a cardiac fellowship for one year then cover the csicu afterwards... you won't get the breath of icu illnesses or complexity in a cvicu but who needs that anyways.

Pls don't try do cardiac without a fellowship... unless you work with dinosaurs and only do simple cabg you will forever be behind the 8 ball

I don't get it, are you in the same sentence saying he should cover the ICU with only a cardiac fellowship but avoid doing cardiac without a cardiac fellowship?


It is by far easier to do cardiac anesthesia without fellowship than it is to manage any ICU without a fellowship.

That said, I tell my trainees that if you do CCM, resign yourself to a job in academics. I know there are a few jobs out there, but if you want to be in a PP you're making your life much more difficult with a CCM fellowship.

 

[nimbus]

I do CCM and anesthesia. CCM for me scratches a different itch. Continuity with the patients, true multidisciplinary approach to problems, communicating with other teams, etc. It's much more intellectually stimulating than the OR.

I’m a simp so wordle scratches that itch for me

 

[PpfSuxTube]

I always love when people who have done a one year fellowship in hearts try to gatekeep like this.

I have no fellowship training and routinely assist surgeons in providing anesthesia for CABG surgery (including low LVEF with IABP, planned or unplanned LV assist devices or ECMO), aortic/mitral valve cases, MAZE/convergent ablations, and other not straight forward cases.

My residency program was very cardiac heavy and truthfully the main benefit a fellowship would have provided is echocardiography expertise which can also be gained through alternative pathways. Many hospitals who do under a certain number of pump cases can’t attract CV fellowship boarded anesthesiologists because they simply don’t have the volume to attract these folks.

I have no doubt you are better at interpreting echo than I in structural heart or OR settings, but I don’t feel as though I am “behind the 8ball”. I have, however, worked an additional year as an attending and got paid a real salary instead of a meager fellowship stipend.

Well done.

I don't get it, are you in the same sentence saying he should cover the ICU with only a cardiac fellowship but avoid doing cardiac without a cardiac fellowship?

Not cover a regular icu, but rather a cvicu. Very, very different.

 

[luckybuck]

Is pain still the most lucrative

 

[NVO]

Is pain still the most lucrative

No. General anesthesia is the most lucrative

Especially taking into account the 1 year of attending pay over doing any fellowship

 

[ToKingdomCome]

I do cardiac and cover the csicu. 80% of my work is cardiac. Love it.
Gen surg icu is so slow and morbid in comparison in my opinion.

That could be an option. Do a cardiac fellowship for one year then cover the csicu afterwards... you won't get the breath of icu illnesses or complexity in a cvicu but who needs that anyways.

Pls don't try do cardiac without a fellowship... unless you work with dinosaurs and only do simple cabg you will forever be behind the 8 ball

pls dont try to do csicu without a icu fellowship

 

[PpfSuxTube]

pls dont try to do csicu without a icu fellowship

I am icu boarded. From my residency. It was icu heavy

 

[psychbender]

I am icu boarded. From my residency. It was icu heavy

I see what you did there with that comment.

However, I'm actually ok with it. We need to stop thinking of our subspecialties as competed distinct fields that we've mastered in the one year of added training that separated us from our colleagues. If a CT fellowship trained person gets a job where they're doing a split of CT surgery and CVICU work, have a CCM mentor guiding them in the fine points of critical care, regularly attends major SCCM and related conferences, devours CCM CME and textbooks, and really puts in the time to learn and understand not only the medicine, but the social and logistic aspects of the ICU, I have no problem calling them an intensivist and allowing them to be boarded. I think ABA actually still has a pathway for this.

We cannot forget that we share the same medical school and residency foundation. Our fellowships are only a year, and these two have a lot of overlap. Learning does not end with our formal training, and we can continue to pick up and develop skills after training, if we have the drive and support from our colleagues. I am CCM trained, but passed both the Advanced TEE board and the new cardiac anesthesiology board. I spend as much time in the CVORs as my CT fellowship-trained colleagues, and am part of our structural heart team. I alternate my CME focus between CCM, echocardiography, and cardiac anesthesiology, getting 20-30hrs a year in those fields. I would be a ****ing hypocrite if I did not apply the same logic to someone doing CCM from a CT anesthesiology background. Fellowship is not the end of learning, it is just the beginning.