Critical Care plus Cardiac Fellowship

[MDAforthewin]

I have multiple contacts who are currently in anesthesia residents. It has been said by contacts that a critical care fellowship in combination with a cardiac fellowship would be useful for academic critical care (more so than only critical care). The argument is that with cardiac you would be TEE certified and be even more valuable/marketable with your critical care fellowship. However, it seems that more and more Gas critical care programs are incorporating enough TEE cases to be eligible to sit for certs (Duke for instance). What else about cardiac would make an academic practitioner more attractive that I'm missing?

I would appreciate any pros/cons concerning this pairing in light of wanting to be in academics. I'm also interested how it would affect a person if they decided to go to private practice instead.

I don't necessarily disagree with this notion. I actually think it would be cool combo because not only would you be exposed to many different cases but you would experience them (at least presumably) multiple times which would hopefully drive those experiences into your brain forever. However I don't know if that means its worth an extra year or two of lost income and career advancement. At the moment I want to do critical care and go into academics so I'm planning on at least one year post-residency.

Thanks as always for all the great insights.

---

Members don't see this ad.

 

[DrBeaker]

You don't have to do either to pass the basic or advanced tee exams. I took and passed the advanced pte exam in July of ca3 year. Just have to be motivated.

Cardiac fellowship won't necessarily get you tee certified either. I know of a few big name fellowships where the fellows get no probe time.

 

[Dwindlin]

You can't get the advanced certification without fellowship as of end of academic year 2009.

 

[Stank811]

In order to be an accredited cardiac fellowship the following requirement must be met:

"Additional clinical experience within the full one-year fellowship
must include successful completion of advanced preoperative
echocardiography education according to the training objectives
from the American Society of Echocardiography and the Society
of Cardiovascular Anesthesiologists’ “Guidelines for Training in
Perioperative Echocardiography”.

So if fellows are not getting probe time they are not accredited fellowships

 

[Stank811]

Just in case you were curious what the Guidelines for Training in Peri-operative Echocardiography say as far as numbers:

"This will include the study of 300 complete perioperative
echocardiographic examinations, of which at least 150 are
comprehensive intraoperative TEE examinations
performed, interpreted, and reported by each fellow."

 

[MalloryWeiss]

I'm really interested in this pathway as well. I too have heard that it's a super marketable combo for academics, and makes for a truly baller anesthesiologist/intensivist. I'm barely starting PGY-1 in a few months, so I have little perspective regarding the cost/benefit of this track. However I am currently really motivated to do something like this, but who knows how I'll feel after enduring the gauntlet of residency -- not to mention, student loans continuing to accrue interest.

I would love to hear more perspectives from the seasoned anesthesiologists that frequent this forum. If I'm not mistaken, @BLADEMDA has previously written in support of the dual fellowship track. Would anyone else mind commenting on the marketability + cost/benefit + job security + bad-ass'ness of cardiac/crit-care? Private Practice? Academics?

Thanks in advance.

 

[secants]

I've come across several academic centers that either have a combined CC/Cardiac track or one where you can apply at once for both to do them back to back at the same place. I was thinking pain/CC just to diversify skills to the ICU and outside the OR; I know practicing both might not happen but it's just for insurance at this point.

 

[sevoflurane]

Just got back from putting in a couple of lines in the ICU (call guy tonight). BMI 60, quad, septic, renal failure, SIRS/ARDS, etc. A-line goes in and pressure reads 60/30. Make sure you like critical care. It is very differnt from the ORs (not knocking it of course). Make sure you know the job...and if you truly like it then go for it. That should be #1.

Gonna have to cut this one short...Beeper just went off... GSW to the chest and abdomen.
Different environments all together. 🙄

 

[nycitygas]

Very few critical care programs will have enough TEE exposure to let you sit for the boards. The only ones I can think of are UMich and Duke (which is like a mini cardiac fellowship).

Combined cardiac/ccm is awesome if you can stomach an extra year of fellowship while your friends from residency are out buying range rovers and vacationing in St. Lucia.

FYI, the academic ccm job market isn't as great as it used to be. Most (if not all) program are filling these days and there are alot more of us out there each year.

 

[MaximusD]

Just got back from putting in a couple of lines in the ICU (call guy tonight). BMI 60, quad, septic, renal failure, SIRS/ARDS, etc. A-line goes in and pressure reads 60/30. Make sure you like critical care. It is very differnt from the ORs (not knocking it of course). Make sure you know the job...and if you truly like it then go for it. That should be #1.

Gonna have to cut this one short...Beeper just went off... GSW to the chest and abdomen.
Different environments all together. 🙄

GSW survive?

 

[nimbus]

Depends on what you want to do with your career. If you want to be critical care faculty who also does cases in the heart room, I think a cardiac fellowship would be mandatory. If you don't want to do hearts then it's not necessary. The days of on the job training and grandfathering are dwindling.

 

[Mac4]

First of all, these two fellowships are hard-working fellowships and the career path they lead to might be much more demanding than other subspecialities. Please make sure you are really interested before you jump in.

If you like both, do both. If you were to do one, cardiac is helpful to find a good PP job while CCM will open doors for you in academics.

 

[pjl]

Why not also do peds, ob, regional, neuro and pain to become truly sought after?
You should be able to get cc and echo in just a year. Any good program should let you customize at least to that degree. Intensivist lifestyle leaves a lot to be desired.

 

[sevoflurane]

Why not also do peds, ob, regional, neuro and pain to become truly sought after?
You should be able to get cc and echo in just a year. Any good program should let you customize at least to that degree. Intensivist lifestyle leaves a lot to be desired.

Don't forget the trauma and orthopedic fellowships... arrr....

Pretty soon everyone is gonna be fellowship trained... we'll need a new "general" fellowship.

I kid... I kid.

 

[invitro]

If you want to stay in academics do it man. You will be a bad ass attg that can drop a ton of knowledge on hungry residents. Plus you could probably be in the running to head up cardiac anesthesia at midsize to smaller academic program. If you can afford the opportunity cost (at least 400k) I think it's a good move. Otoh if private practice is your deal just cardiac or possibly no fellowship is probably better.

 

[urge]

If you are young and money is not an issue, go for it.

 

[Dwindlin]

Planning on doing both myself, unless I can find a ICU program that will allow flexibility enough to get the numbers for the advanced cert.

 

[dutchmaster]

Pretty sure the only way to get Advanced Perioperative TEE certification is to do a Cardiothoracic Anesthesiology Fellowship; unless you graduated from residency in 2009 or earlier. You can't get advanced certification through CCM. Plus, the fellowship must be ACGME certified - those doing non-accredited CT fellowships cannot get certification either.

From the NBE website: "Applicants that finished their core residency training after June 30, 2009 can ONLY qualify for certification by completing cardiothoracic or cardiovascular anesthesiology fellowship training at an ACGME accredited fellowship program."

Doesn't mean that those with proper training cannot have the skills to preform a quality TEE exam. However, i feel that TEE skills necessary to actually be proficient and safe in the cardiac OR are much more advanced than most realize.

 

[pjl]

 

[pjl]

sorry

 

[pjl]

 

[yasawa]

If you want to do academics, then I would do both. During residency, all of the new ICU hires ( 7 attendings) did both. I think our chair actually stopped hiring people who were only cardiac trained. She made exceptions for people who only did ICU AND did residency at my program. Based on how our department runs the ICUs, you really need to do both cardiac and CC.

 

[secants]

Any thoughts on doing both CC/Pain? Is it practical? If you happen to be hospital employed, can one work out some deal doing 1wk ICU and the rest outpatient pain?

 

[DrBeaker]

I understand I'm not a diplomate of the NBE. Technically I'm a testamur. I'm certified in TEE. I can perform, interpret, and read my own studies. I make decisions in the OR based on my echo, as my attending looks on since I'm still a resident for 2 months.
My comment regarding fellowships not necessarily getting you to pass the test are based on my research and past fellows who have done cardiac. One month of echo isn't much. I did more than that by midway through my CA2 year.

 

[sevoflurane]

Well done Beaker.
Big step forward.

 

[scudrunner]

So is there a minimum number of cases needed to actually take the test and become testamur status?

 

[psychbender]

So is there a minimum number of cases needed to actually take the test and become testamur status?

For certification,150 for basic (50 performed, 100 reviewed), 300 for advanced (not sure on the split). Getting 150 exams in residency is doable.

 

[neusu]

Just got back from putting in a couple of lines in the ICU (call guy tonight). BMI 60, quad, septic, renal failure, SIRS/ARDS, etc. A-line goes in and pressure reads 60/30. Make sure you like critical care. It is very differnt from the ORs (not knocking it of course). Make sure you know the job...and if you truly like it then go for it. That should be #1.

Gonna have to cut this one short...Beeper just went off... GSW to the chest and abdomen.
Different environments all together. 🙄

I lined a BMI of 80. Worst night ever. Not just because of that, but that certianly helped..

 

[gasdoc77]

I lined a BMI of 80. Worst night ever. Not just because of that, but that certianly helped..

80??? Wow! Double amputee??

 

[Random Anesthesiologist]

I lined a BMI of 80. Worst night ever. Not just because of that, but that certianly helped..

Mother of God. This is every day for me, it seems.

 

[neusu]

Well, since you asked.. We PLIF'd her. Yes, we actually performed surgery on her. She had ?urinary retention, foot drop, and a lumbar disc that may explain it. It was oddly fulfilling to do the case. She couldn't be extenuated, ended up in the unit with lines. Got extenuated and did well. Last I heard she's still heavy and continent. Yay us!

 

[dutchmaster]

Split for advanced certification is 150 performed, 150 reviewed, 300 total. You need to complete a CT anesthesiology fellowship to be CERTIFIED (along with passing the PTEeXAM). You can take the test at any time and be "testamur" status; even if you've never done a TEE exam in your life.

Testamur's are not certified

For certification,150 for basic (50 performed, 100 reviewed), 300 for advanced (not sure on the split). Getting 150 exams in residency is doable.

 

[scudrunner]

I understand I'm not a diplomate of the NBE. Technically I'm a testamur. I'm certified in TEE. I can perform, interpret, and read my own studies. I make decisions in the OR based on my echo, as my attending looks on since I'm still a resident for 2 months.
My comment regarding fellowships not necessarily getting you to pass the test are based on my research and past fellows who have done cardiac. One month of echo isn't much. I did more than that by midway through my CA2 year.

Split for advanced certification is 150 performed, 150 reviewed, 300 total. You need to complete a CT anesthesiology fellowship to be CERTIFIED (along with passing the PTEeXAM). You can take the test at any time and be "testamur" status; even if you've never done a TEE exam in your life.

Testamur's are not certified

These statements seem to contradict each other regarding "certified." Can someone clarify?

 

[psychbender]

These statements seem to contradict each other regarding "certified." Can someone clarify?

Advanced certification requires fellowship, the 300 cases, and the Advanced test. You can be Basic certified, but an Advanced testamur without the fellowship. Basic certified requires primary board certification, 150 exams, and the Basic test. Advanced or Basic testamur (not certified) just requires the Advanced or Basic test. So, a resident can be a non-certified testamur only. At least, that was my interpretation from reading the NBE website, and comments about this in previous years.

 

[dutchmaster]

Psychbender has it exactly right. For purposes of TEE certification, the NBE has set up two types of echo certification, basic and advanced. Basic certification is available to all anesthesiologists who have passed their anesthesiology boards, completed the requisite number of exams as outlined in previous posts, and passed the basic exam administered by the NBE. The NBE is pretty clear that basic certification should allow the echocardiographer the tools/knowledge to use TEE as a physiologic monitor. The basic certification should NOT be used to allow the echocardiographer to make diagnostic decisions regarding cardiac surgical interventions.

Advanced certification is available to board certified anesthesiologists who completed a ACGME accredited fellowship in CT or Cardiovascular anesthesiology, completed the requisite number of exams as outlined in previous posts, and passed the advanced echo exam. The advanced certification is meant to verify the competence of an echocardiographer to act in a full consultant role during cardiac surgical and interventional cardiology procedures.

IMHO if you plan to do cardiac anesthesia in a busy surgical practice and you really want to know what you're doing in a TEE sense...this is the level of expertise you need. By the time you do the number of exams required in a CT Anesthesiology fellowship, you are reaching the amount of examinations that a level II/level III cardiology fellow will get in their fellowship.

You can take the NBE exams at any time as long as you hold a license to practice medicine. If you pass the exams, you can be "testamur" status until you have the prerequisites to apply for certification. Again, you can take the exams without doing any TEEs and be a "testamur", but you cant be certified until you meet the other requisites mentioned above.

During my job search this past summer/fall, most groups that advertise they want "TEE certified anesthesiologists" to act as cardiac anesthesiologists, they are usually referring to the advanced certification. IMHO, I think it's a stretch to think that at the conclusion of an Anesthesiology residency you have the sophistication to make accurate, tough echo decisions (adequacy of valve repair, EXACT location of perivalvular leaks, nature of mitral regurgitation, should i repair/replace this mitral valve, etc...) in cardiac ORs. Most cardiac anesthesia fellows spend an entire year doing TEE exams during their cases, and many fellowships have 3-5 months of exclusive TEE/TTE rotations as well. It's hard to duplicate that during your anesthesiology residency while fulfilling all the other requirements (OB, peds, neuro, regional, etc...).

 

[Jay K]

arrr....

This cracked me up. That is all.