CCM Fellowship Dilemma

Started by OldGregg
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OldGregg

OldGregg

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Hey gang,

CA2 here on the tail end of the ACCM interview trail. I'm at a residency program on the west coast and would prefer to stay in this geographic area long term.

I've had a lot of great interviews and I'm excited about my options. The dilemma: a heavy hitter program has offered me a spot outside of the match (really caught me off guard mid-interview) The problem: they aren't on the west coast.

While I feel pretty good about my odds getting into a solid west coast program, I can see the argument to go with the "sure thing" for a year and hope to hop back to the coast. Just wasn't sure about it since I've heard it helps to do fellowship where you intend to stay long term.

Any thoughts are appreciated!
 
I guess it depends. For example, if you want to end up in the SF Bay Area, this is a region with 2 of the most reputable programs in the country in Stanford and UCSF. Obviously it would be in your favor to train at one of these places. But if the "heavy hitter" program you're talking about is an MGH, Brigham type of place, I'm sure you'll have no problem ending up wherever you want to be. So we would need more detailed info to provide a good answer.
 
Brigham is not a heavy hitter in CCM, no offense. But it's a nice brand to have on the resume. 😉

My advice: heavy hitter or no, don't choose a workhorse program, where you are a resident, not a fellow. Otherwise, chances are you'll get a pretty good education anywhere the fellow is treated and functions as the junior attending.
 
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FFP said:
Brigham is not a heavy hitter in CCM, no offense. But it's a nice brand to have on the resume. 😉

My advice: heavy hitter or no, don't choose a workhorse program, where you are a resident, not a fellow. Otherwise, chances are you'll get a pretty good education anywhere the fellow is treated and functions as the junior attending.
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I am aware. IMO, BID has the best CCM program in Boston . But when it comes to looking for a job, especially outside of academics, the Brigham name alone will carry its weight, even if not as strong as other programs . As you probably know , perception has significance in this specialty.
 
How is it that a program offered you a spot? Don't they have to go through the match first before offering outside spots? Assuming you aren't a resident there, of course since you said you're on the coast.
 
Random Anesthesiologist said:
How is it that a program offered you a spot? Don't they have to go through the match first before offering outside spots? Assuming you aren't a resident there, of course since you said you're on the coast.
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I don't have a great answer to that question. From my n=1 experience programs have been pretty point blank about "we have all of our spots in the match" or not. The way it was presented was "we would like to offer you a spot outside of the match, upon signing you would withdraw from the formal match." Not my home institution, I was equally surprised. Hence the dilemma.
 
Thanks FFP and Ezekiel, your replies are appreciated. I think I'm going to go through the match after all given that advice. Will let you know how it turns out. 🙂
 
nycitygas said:
It doesn't matter what program you go to, within a year or two you'll be practicing 100% anesthesia (like everybody else I know )
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Really? In my experience, it's almost the exact opposite. Nearly everyone I know who did CC fellowship is doing a substantial amount of CCM. Everyone from my fellowship class (one of the largest programs in the country) is doing CCM and most are doing it the vast majority of the time.
 
Ezekiel2517 said:
Really? In my experience, it's almost the exact opposite. Nearly everyone I know who did CC fellowship is doing a substantial amount of CCM. Everyone from my fellowship class (one of the largest programs in the country) is doing CCM and most are doing it the vast majority of the time.
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Agree. The main reason people end up not practicing critical care is because there aren't enough combined anesthesia-CCM jobs, and it's much tougher to maintain anesthesia practical skills over time. Also people used to give up critical care for a much more lucrative PP partner job. That's not really in the books anymore. Within 5-10 years, CCM will probably be the better paid one, on an hourly and workload basis, for employed physicians.

If offered a combined job, my own preference would be 75% CCM. After CCM, anesthesia looks... way less interesting. I smile when I wake up in the morning and remember that I have to go to work. Let's just say that anybody who voluntarily gives up CCM after fellowship shouldn't be in the specialty. 😉
 
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FFP said:
Agree. The main reason people end up not practicing critical care is because there aren't enough combined anesthesia-CCM jobs, and it's much tougher to maintain anesthesia practical skills over time. Also people used to give up critical care for a much more lucrative PP partner job. That's not really in the books anymore. Within 5-10 years, CCM will probably be the better paid one, on an hourly and workload basis, for employed physicians.

If offered a combined job, my own preference would be 75% CCM. After CCM, anesthesia looks... way less interesting. I smile when I wake up in the morning and remember that I have to go to work. Let's just say that anybody who voluntarily gives up CCM after fellowship shouldn't be in the specialty. 😉
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I loved my critical care rotations, it was a nice respite from the OR environment.
I also really liked interventional pain too lol
 
I thought the only exceptions to the match were for active duty military, internal applicants, and combined/dual-fellowship contracts?

OP, it sounds like you are making the right decision to stick with the match. If you're good enough for a strong program to offer you a direct contact, you're likely good enough to be highly ranked by your top programs.

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OldGregg said:
I don't have a great answer to that question. From my n=1 experience programs have been pretty point blank about "we have all of our spots in the match" or not. The way it was presented was "we would like to offer you a spot outside of the match, upon signing you would withdraw from the formal match." Not my home institution, I was equally surprised. Hence the dilemma.
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Looking at the SF match guidelines this looks like a violation. I would go through the match. If you don't match (unlikely) there will be after match spots.
 
CCM is still a "buyer's market". Most people have high chances of matching into one of their top choices. I wouldn't count on post-match though. There are only a few good programs remaining at that time, and they sell out fast.

Getting an offer from a good program suggests that the candidate has a strong application and has a high likelihood of matching into one of his/her top 3 choices.
 
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Random Anesthesiologist said:
Looking at the SF match guidelines this looks like a violation. I would go through the match. If you don't match (unlikely) there will be after match spots.
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I don't think it's a violation for the applicant. The applicant does not commit to the match unless they submit a ranking list. If anything, it's possibly a violation for the program, but I bet that they go around it by keeping a few slots "out of the match" every year. NRMP used to allow this, years ago, and my guess is that programs use SF Match exactly because it allows "out of match" positions.
 
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I was offered and accepted a CT spot outside the match, but it was contingent upon ACGME approving a temporary complement increase for the program. While that was an unknown, I continued to keep doors open at other programs. (I am military so there are other considerations for me.)

I would caution anyone considering an outside the match spot in this newish era of fellowship match systems, to look at the fine print and reassure themselves that the spot really exists in the ACGME's eyes. It would be unfortunate to withdraw from the match only to find out in March that ACGME didn't approve the extra spot. Then you're either left with nothing, or an unaccredited spot that may affect eligibility for subsequent board exams.

My program was confident the complement increase would be approved, but even so I was sweating it a bit until the day ACGME signed off on it.
 
nycitygas said:
It doesn't matter what program you go to, within a year or two you'll be practicing 100% anesthesia (like everybody else I know )
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That's the unfortunate reality I faced and the reason I didn't do my CCM fellowship and went straight in to PP. I trained at a good program so my OR skills were strong, I was looking for a skill set I could use out of the OR and I couldn't make it happen outside of academics in the region I desired. In hindsight I might be able to make it work now at my current gig, but that wasn't an option a couple years ago.
 
psychbender said:
So do it now.

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I might consider it depending on what the near future brings. I have a sweet set up/dream job right now but if things change then I may reconsider. I'd probably have to do an out of match position because I'm probably banned from the SF match after dropping out of the fellowship.
 
Eh, SF match probably forgot...That program probably didn't. I heard the bitterness in the voices of a few PDs, as they mentioned that they were down a fellow this year, because one of their prospective fellows broke the match agreement for a job.

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kazuma said:
I might consider it depending on what the near future brings. I have a sweet set up/dream job right now but if things change then I may reconsider. I'd probably have to do an out of match position because I'm probably banned from the SF match after dropping out of the fellowship.
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Oh man, what are you going to tell the programs you apply to next time around?

I'm sure you're a great guy (or gal) but if I were a fellowship PD it would take quite a story for me to risk a spot on someone who bailed for a job once before and left a program hanging.
 
pgg said:
Oh man, what are you going to tell the programs you apply to next time around?

I'm sure you're a great guy (or gal) but if I were a fellowship PD it would take quite a story for me to risk a spot on someone who bailed for a job once before and left a program hanging.
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He would be crazy to tell them. 😉
 
pgg said:
Surely they'd want to know why he was banned from the match and had to look for an out-of-match spot ...
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There is an easy solution to that. He applies late in the cycle, after the interviews are basically done. Or jumps on a last minute opening.

The problem with either is that it's highly dependent on luck. Most good programs fill during the Match, and never lose a fellow afterwards. The only real chance is finding an otherwise good program in an unpopular location, which doesn't fill.

Also there is a chance that the programs will require an SF Match application package even for a post-match position. 😉
 
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pgg said:
Oh man, what are you going to tell the programs you apply to next time around?

I'm sure you're a great guy (or gal) but if I were a fellowship PD it would take quite a story for me to risk a spot on someone who bailed for a job once before and left a program hanging.
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Agreed.
Honestly though, if a gig like he's describing came along once in a blue moon, I'd probably do the same thing too. He's a great guy, I've gotten to know him some and I'm sure he had his reasons.
 
pgg said:
I don't really blame him for taking a great job. In the end you've got to do what's best for you and it's not like I've never in my life burnt a bridge. 🙂 Burned bridges tend to stay burnt though ... absolutely a wrinkle if he ever decides to try again.
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Agree.
I probably wouldn't look at pursuing a fellowship if I had such a job. I've found a nice gig where I'll be starting when I finish residency. I've burned some bridges during this job hunt, but I knew fully well if I ever did burn those bridges, I'll never be looking to ever consider those options in the future so I was okay with that.
 
I don't disagree with any of the above. As for what I'd tell them, I'd tell them the same thing I told the program I bailed on. The pp market for CCM trained anesthesiologists is ****ty and I would only do a fellowship if I had a decent chance of getting a combined job afterwards. H I'd already have a CCM job lined up at my shop.

But this is all highly theoretical. It would be very tough to go back for fellowship and if I did, I would likely try to work something out with the fellowship at my residency program. It must be fairly common. I know 2 other people who bailed on CCM for PP my application year.
 
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Absolutely, burnt bridges stayed burned. I wouldn't attempt to reapply to that program which sucks because it's a good program. The opportunity costs were too high and I didn't have any interest in doing academics.

I really like my gig and I don't have any regrets nor plans to go back to CCM anytime soon. I likely wouldn't have got this job had I done the fellowship and waited a year. It's everything I wanted in a PP job in a highly respected group and I've been doing well from the feedback my partners give me. I don't have to deal with the disrespect and BS that so many folks complain about on this board especially since I don't supervise nurses. I get to do a diverse range of cases that helps keep my skills sharp. Everything from ortho/blocks, thoracic, neuro, peds and neonates, OB, trauma, etc. Basically everything but hearts and transplants. Our surgeons are fast and great to work with and many of them socialize outside of work with us. Great recreation close to home. I seriously can't complain, sometimes it feels like I won the lottery when I hear folks complain about their jobs on this board.
 
kazuma said:
Absolutely, burnt bridges stayed burned. I wouldn't attempt to reapply to that program which sucks because it's a good program. The opportunity costs were too high and I didn't have any interest in doing academics.

I really like my gig and I don't have any regrets nor plans to go back to CCM anytime soon. I likely wouldn't have got this job had I done the fellowship and waited a year. It's everything I wanted in a PP job in a highly respected group and I've been doing well from the feedback my partners give me. I don't have to deal with the disrespect and BS that so many folks complain about on this board especially since I don't supervise nurses. I get to do a diverse range of cases that helps keep my skills sharp. Everything from ortho/blocks, thoracic, neuro, peds and neonates, OB, trauma, etc. Basically everything but hearts and transplants. Our surgeons are fast and great to work with and many of them socialize outside of work with us. Great recreation close to home. I seriously can't complain, sometimes it feels like I won the lottery when I hear folks complain about their jobs on this board.
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Stay put man. We often underestimate the skills (intestinal fortitude) required to be a good general anesthesiologist. If you are working in such a setting, you are for sure being challenged. Put a pain guy who hasn't done anesthesia in even a few short years and he/she will be hurting..... Same with CCM if they've not been in the OR a lot.

We all know it doesn't take too long to lose that "anesthesia edge". I've heard it from really good former attendings being off for even a few weeks and they weren't right out of residency.

The demand for anesthesia services is growing. Sure, other services are growing too, and doctor shortfalls will be met with foreign grads and even APN's/CRNA's, but there will always be work if you are good. Hopefully, you're working towards some equity. If not, I no longer think it's the end of the world as long as the overall job is a good one and you are happy.
 
kazuma said:
Absolutely, burnt bridges stayed burned. I wouldn't attempt to reapply to that program which sucks because it's a good program. The opportunity costs were too high and I didn't have any interest in doing academics.

I really like my gig and I don't have any regrets nor plans to go back to CCM anytime soon. I likely wouldn't have got this job had I done the fellowship and waited a year. It's everything I wanted in a PP job in a highly respected group and I've been doing well from the feedback my partners give me. I don't have to deal with the disrespect and BS that so many folks complain about on this board especially since I don't supervise nurses. I get to do a diverse range of cases that helps keep my skills sharp. Everything from ortho/blocks, thoracic, neuro, peds and neonates, OB, trauma, etc. Basically everything but hearts and transplants. Our surgeons are fast and great to work with and many of them socialize outside of work with us. Great recreation close to home. I seriously can't complain, sometimes it feels like I won the lottery when I hear folks complain about their jobs on this board.
Click to expand...

You made the right choice. The CCM year made me an all round better physician and got me a job in competitive market that I needed to be in. However, two years later, I am done with it. Any job with more than 25% CCM isn't sustainable for the long term (>5 years). All of the PP OR/CCM folks I know are transitioning to full time OR and the ones in academics wish they could. CCM was fun and exciting and I will miss the feeling of being in charge but after a while telling families their loved one died or coding gomers gets old.

I still plan on moonlighting in the ICU to keep my skills/credentials but my warning to the residents is that for most, a critical care fellowship is a waste of a year.
 
My disclaimers: So I'm coming from an academic center with a strong anesthesia leadership, I'm in my first year out of fellowship, and I don't do my own cases. I'm at a major academic center and my split is 50-50; but all vacation, nonclinical and ICU post call time comes out of my OR time.

The OR can get a little boring and monotonous. Not to mention catering to surgeons and their ridiculous non-evidenced based demands. A few of them stamp their feet and throw a temper tantrum when I question them and their requests. A lot are actually very happy that I notice things that others don't, or that I'm a little less scared to take an otherwise optimized pulmonary cripple to the OR and not cancel the case and actually extubate at 7 pm rather than take tubed to the ICU.

Those same surgeons are even more grateful when I save their patient in the icu and avoid the trach/peg/ LTAC route. The icu I'm involved in also gets a lot of ARDS and general medical patients and is the only unit to accept and manage ecmo patients. We even cannulate on our own. Placing a 23F hose into someone's IJ or a 29F into the groin is a humbling experience.

To say the CCM year is a waste isn't really accurate. There's a lot we can offer to the CCM and anesthesia worlds, and in all honesty, it improves upon our general medical knowledge. Have you listened to some CA-3s "report" to you on the phone the night before? If the acgme didn't have such a hold on resident treatment and feelings, I'd fail a lot of them due to their lack of overall knowledge, and I'm talking cardiopulmonary problems. It's sometimes getting harder to distinguish them from our AA and CRNA counterparts, despite all our efforts.

PP jobs exist, but I do agree that in the current climate, it may be tough to sustain. I'm academic but we also staff the ICU's in our community affiliates. So I do both and I do OR in both settings as a result. While the Pulmonologists are cheaper, I don't think they're any better than I am in the ICU, and time will only tell, but I think CCM time is going to become more valuable. Where I did fellowship, 100% PP CCM was already paying more than 100% PP general anesthesiology.


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nycitygas said:
You made the right choice. The CCM year made me an all round better physician and got me a job in competitive market that I needed to be in. However, two years later, I am done with it. Any job with more than 25% CCM isn't sustainable for the long term (>5 years). All of the PP OR/CCM folks I know are transitioning to full time OR and the ones in academics wish they could. CCM was fun and exciting and I will miss the feeling of being in charge but after a while telling families their loved one died or coding gomers gets old.

I still plan on moonlighting in the ICU to keep my skills/credentials but my warning to the residents is that for most, a critical care fellowship is a waste of a year.
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So you state the fellowship got you the great job you wanted, then literally a few sentences later state that the fellowship is a waste of a year. Interesting. I am pretty sure that is the precise reason many people are doing fellowships in the first place. Most of the cardiac people in our group never do hearts at all. Most of the peds people are hardly ever doing peds.
 
nycitygas said:
You made the right choice. The CCM year made me an all round better physician and got me a job in competitive market that I needed to be in. However, two years later, I am done with it. Any job with more than 25% CCM isn't sustainable for the long term (>5 years). All of the PP OR/CCM folks I know are transitioning to full time OR and the ones in academics wish they could. CCM was fun and exciting and I will miss the feeling of being in charge but after a while telling families their loved one died or coding gomers gets old.

I still plan on moonlighting in the ICU to keep my skills/credentials but my warning to the residents is that for most, a critical care fellowship is a waste of a year.
Click to expand...

Couldnt disagree more
my icu fellowship was an invaluable year of learning - would encourage any Anesth residents who went into Gas because they love physiology and taking care of super sick pts to consider it- not only will you learn a lot and gain new/invaluable skills but you will also open another door and career path - never hurts to have options
these days hospitals want 24/7 intensivist coverage and in order to do so more and more jobs opening to any ICU background in PP now and not just exclusively pulm/crit anymore
personally I am currently 95% ICU and 5% Gas in PP and couldnt be happier
As far as coding gomers, knowing which patients may benefit from CCM and knowing which patients would benefit more from comfort measures is part of the job and one I find not ever to be easy or enjoyable but very important since you are assisting pts at the end of life when they need your expertise the most and is a privilege imho, sure many families may still have unreasonable expectations despite your best efforts but it is what it is
 
What are the heavy hitters? I know it's a small pool so some programs with a brand name for anesthesia might not have a great CCM program and vice versa, good anesthesia programs might be a great CCM programs. Just wondering peoples thoughts now that interview season is winding down
 
Well, therein lies the problem. Just as there is no clear "best" residency program (as evidenced by the fact that everyone on here claims that their training was "second to none"), there is no clear best fellowship. Some will have great name recognition, despite not offering great training (or off fairly malignant training). Others will give you fantastic cardiac ICU training, but are weaker in Neuro, Trauma, or general Surgical critical care. Some are SICU powerhouses, but give minimal training in other units. There is also something to be said about where a program falls on the Work/Life/Service triangle. Each of us here have our own opinions on what constitutes a great program, so you will unlikely find consensus. As far as the opinion of outsiders and academicians, they'd likely rely more on name recognition ("Oh, you're from Hopkins!") and research reputation to determine the best.

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Maverikk said:
What are the heavy hitters? I know it's a small pool so some programs with a brand name for anesthesia might not have a great CCM program and vice versa, good anesthesia programs might be a great CCM programs. Just wondering peoples thoughts now that interview season is winding down
Click to expand...

I would cast a vote for any of the fellowship programs which offer a diverse exposure to different ICUs. There are several programs which have you almost exclusively in CVICU for your 9 core months of fellowship. I won't argue that's where anesthesiology providers shine, but I think in order to be a good intensivist and to get the most out of a fellowship year you need plenty of rich MICU/neuro exposure with a little trauma (maybe) sprinkled in. Something beyond exclusively babysitting hearts postoperatively.

I think it's also worth mentioning that departments with traditionally strong anesthesiology departments are well represented "at the table" of hospital politics. Having good backing from the department and higher ups as a fellow is a good thing,
 
Talking to people at my shop your name can get you into places more than the strength of your program if it doesn't have a name. PP gigs that pay a lot more where you'd do some ICU are out there and that's where brand names count. Going into academics is a different game, ie do you like research, are you going to like the reimbursement when you know you could OR only for 2x the salary. One of the guys at my place who finished from a top name institution gave the advice to think about what you want to do and what's worth it to you/your family. He does all OR, a lot of endo, said he gets paid almost 2x what the fellows who stayed at his fellowship program get and they're on the bottom rung and have to produce research or they'll stay there, he's pretty happy even with the endo. These things have been weighing on my mind
 
Talking to people at my shop your name can get you into places more than the strength of your program if it doesn't have a name. PP gigs that pay a lot more where you'd do some ICU are out there and that's where brand names count. Going into academics is a different game, ie do you like research, are you going to like the reimbursement when you know you could OR only for 2x the salary. One of the guys at my place who finished from a top name institution gave the advice to think about what you want to do and what's worth it to you/your family. He does all OR, a lot of endo, said he gets paid almost 2x what the fellows who stayed at his fellowship program get and they're on the bottom rung and have to produce research or they'll stay there, he's pretty happy even with the endo and he was offered a spot at his fellowship home. These things have been weighing on my mind, may be better to get a good brand name
 
Oh, another factor to bring up is the alumni network. Places that graduate a lot of intensivists each year (CCF, Columbia, Vanderbilt, etc) for many years have a broad network for job placement. This was something that was brought up by a few PDs at my interviews ("You know, just last month I got a call from the department chair at X asking if I had any more fellows that wanted to work there," where X was a major university hospital near where my wife wants to relocate after fellowship, and one of their recent grads is there now).

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psychbender said:
Oh, another factor to bring up is the alumni network. Places that graduate a lot of intensivists each year (CCF, Columbia, Vanderbilt, etc) for many years have a broad network for job placement. This was something that was brought up by a few PDs at my interviews ("You know, just last month I got a call from the department chair at X asking if I had any more fellows that wanted to work there," where X was a major university hospital near where my wife wants to relocate after fellowship, and one of their recent grads is there now).
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Since you brought up some big names, I was wondering what people thought about Vanderbilt, UPMC and CCF. I'm very interested in all 3 and really having a difficult time ranking them in top 3. Any pros/cons appreciated!
 
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SGC2015 said:
Since you brought up some big names, I was wondering what people thought about Vanderbilt, UPMC and CCF. I'm very interested in all 3 and really having a difficult time ranking them in top 3. Any pros/cons appreciated!
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Seems fairly easy....where do you want to live? For me it would be Vandy, UPMC, Cleveland.
 
SGC2015 said:
Since you brought up some big names, I was wondering what people thought about Vanderbilt, UPMC and CCF. I'm very interested in all 3 and really having a difficult time ranking them in top 3. Any pros/cons appreciated!
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Well, what is most important to you? Nothing has the name recognition like CCF. Even lay people who's only medical knowledge is gleaned from WebMD and Dr Oz know of CCF. CCF also spends more time in the general SICU, and has a low overnight call responsibility, so if those are chief in your thoughts, then go with CCF. Vanderbilt is also well-known, but not to the extent of CCF, and has a more varied ICU experience with more time spent in CVICU, Trauma, and Burn units in addition to the regular SICU (and VA SICU). You will definitely work harder for your training there, however, with a lot more time in house at night and often longer days. You will get excellent training at both. I did not interview UPMC, so I do not know where they fall in this mix.
 
psychbender said:
Well, what is most important to you? Nothing has the name recognition like CCF. Even lay people who's only medical knowledge is gleaned from WebMD and Dr Oz know of CCF. CCF also spends more time in the general SICU, and has a low overnight call responsibility, so if those are chief in your thoughts, then go with CCF. Vanderbilt is also well-known, but not to the extent of CCF, and has a more varied ICU experience with more time spent in CVICU, Trauma, and Burn units in addition to the regular SICU (and VA SICU). You will definitely work harder for your training there, however, with a lot more time in house at night and often longer days. You will get excellent training at both. I did not interview UPMC, so I do not know where they fall in this mix.
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Are you joking about UPMC? They're unbelievable for CCM.
 
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