Deciding on fellowship

[Pablo94]

I am in the beginning of my CA-2 year and still undecided on if I want to pursue fellowship or not. I am considering Pain and cardiac fellowship, I know they are both very different from each other, but each has their pros and cons in my opinion.
Is it a little too late for me to be in this situation? I am worried if I pursue cardiac fellowship that I will be required to have a very tough call schedule for the rest of my life. I would like to do a mix of cardiac and general cases in the future as I enjoy both, but I also don't want to be "pidgeonholed" (whatever that means) into just doing cardiac cases because I have the training and have limited job opportunities.
Regarding Pain, I like the procedures and find flouroscopic epidurals very satisfying for some reason lol. I like the idea of working outpatient sometimes, but after rotating in pain realized the stresses my attending had being a business owner. I know both are very competitive and some people have known they wanted to do either pain or cardiac since there first day of residency. I am not one of these people and do not have any ground breaking research or really any research specific to either field. I have a single publication in a respected journal regarding general anesthesia, but nothing subspecialty specific. Sorry about the rant. But wondering what people with more experience/more wise than me think about this situation.

Would appreciate some input if possible. Thank you.

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[pgg]

I am worried if I pursue cardiac fellowship that I will be required to have a very tough call schedule for the rest of my life.

The lifestyle killers for cardiac anesthesia are transplants, VADs, and ECMO. You don't have to commit to a lifetime of doing them.

There are plenty of jobs out there where the cardiac surgeons do CABGs and valves during daylight hours, and hate to work at night.

Being an underpaid, overworked, academic cardiac anesthesiologist doing BOLTs at 2 AM doesn't have to be your fate. Some people love those cases, and more power to them. I have chosen a path that will never see another lung transplant again as long as I live. You too, can choose wisely.

I would like to do a mix of cardiac and general cases in the future as I enjoy both

Most cardiac anesthesiologists are in practices like this. A minority are doing 100% hearts in either academics or private practice. You could certainly choose whichever you prefer.


Also, to state the obvious - you don't have to do a fellowship immediately after residency. It's the most common path, in part because once you're an attending, the income and lifestyle inflation can make going back to being a trainee unappealing. But there's no reason you can't practice for a while and then go do the fellowship. There are advantages

• you'll already be board certified, so when your co-fellows are doing mock orals with each other, you won't be there
• you'll have the advantage of some independent practice experience - skill, confidence, and experience makes everything a little easier
• you can save some money and live somewhat better than you could as a fellow who just emerged from residency

and disadvantages

• it's hard to hold your tongue sometimes when your fellowship attendings, who know much more than you about cardiac anesthesia, sometimes somehow know much less than you about non-cardiac anesthesia
• GME is a weirdly infantilizing experience, and it can be hard to subject yourself to it again after escaping it and working in a humane and sensible environment

 

[Bertelman]

Pretty much everything pgg said.

I would ask what interests you in cardiac? What about pain? Establish why it is you want to pursue a fellowship. And forget about the research. You do not need research to secure a fellowship. You need good letters of recs, and sometimes a connection or two to a program. So hopefully you are at a residency program where attendings in those specialties like you, and are willing to make a phone call on your behalf.

I had in interest in cardiology during med school. Was maybe the only organ system I felt I truly understood. Could have gone into cardiology, but hated the office, and admissions and rounding. Plus I had experience working with cardiac anesthesiologists. But I realize that is unique. I would discourage you from pursuing a fellowship just to pursue a fellowship. It's just not that hard to find a job as an anesthesiologist right now.

I'm a cardiac doc, take q4 home call, but rarely get called in. Aside from that, no nights, no weekends. I think I work, on average, about the same number of hours as my general colleagues. Just different kind of work, higher acuity. Less blocks. I'll do 200 pump cases this year, but also a fair share of EP, Neuro, Vascular. Some other general stuff sprinkled in. But that's the practice I chose, intentionally. No VADs, no transplants. I prioritized lifestyle over money.

I would caution you against picking a fellowship that you don't love just for the sake of specialization. You will likely never lose the label of being a "cardiac" or "pain" doc. Example: our group used to have dedicated pain docs. Market changed, director retired, etc. Lost the pain clinic. But still have to staff an inpatient chronic pain service. Hospital has forced the 3 anesthesiologists with training in pain to staff that service. Even though they haven't practice pain in years, intentionally. The rest of us that never trained for it have nothing to do with it.

Better love what you do, because you never know where it will take you.

 

[ProPropofol]

Being at an academic center, I can assure you that it is not too late to consider fellowships. I also believe that one publication related to general anesthesia in a respected journal is probably better than most. Besides for our pain fellowship, none of our fellowship spots filled completely and most went completely unfilled for this academic year. Can totally see that happening next year as well since the market is so hot. Even our pain fellowship filled with a lot of people that were not at the top of their list and from specialties outside of anesthesia even though we traditionally only fill with anesthesia folks. If you want to do fellowship, I assure you that there are pain and cardiac programs that would take you as long as you have a pulse, don't have significant red flags, and are a reasonable person. Fellowships for anesthesia are not very competitive recently.

 

[Hoya11]

I am in the beginning of my CA-2 year and still undecided on if I want to pursue fellowship or not. I am considering Pain and cardiac fellowship, I know they are both very different from each other, but each has their pros and cons in my opinion.
Is it a little too late for me to be in this situation? I am worried if I pursue cardiac fellowship that I will be required to have a very tough call schedule for the rest of my life. I would like to do a mix of cardiac and general cases in the future as I enjoy both, but I also don't want to be "pidgeonholed" (whatever that means) into just doing cardiac cases because I have the training and have limited job opportunities.
Regarding Pain, I like the procedures and find flouroscopic epidurals very satisfying for some reason lol. I like the idea of working outpatient sometimes, but after rotating in pain realized the stresses my attending had being a business owner. I know both are very competitive and some people have known they wanted to do either pain or cardiac since there first day of residency. I am not one of these people and do not have any ground breaking research or really any research specific to either field. I have a single publication in a respected journal regarding general anesthesia, but nothing subspecialty specific. Sorry about the rant. But wondering what people with more experience/more wise than me think about this situation.

Would appreciate some input if possible. Thank you.

When I was applying (Yes 10 yrs ago) pain could indeed be tough to get into. Many programs only have a few spots and they all go to candidates at their own program.

My year in pain fellowship was the easiest year of my life. My hours were typically 8-3 as a full day. Often I was done before noon. "Call" was rounding on hospital inpatients for about 2-3hrs a day. I had plenty of free time to study for boards (which you take that year) and get my job situation in order (licenses, moving plans etc)

I liked doing the injections, the fluoro pictures, the theory of pain. I found it very interesting. But then when I got into PP you can see a darker side - and to sum it up I felt like I just wasnt helping people in the way that I wanted to. I didnt want to be the guy that spent 9 years of medical training to give grandma a hip injection or deal with the lowest forms of humans (sure there were some normal people but very few and far between)

To this day I still think it depends on your PERCEPTION of success. If you want to believe that that stimulator or vertiflex is helping grandma, then you can feel good about yourself as helping. I just did not believe that I was truly helping in my gut. I felt like I was just part of an industry.

And you dont have to have your own business, you can work for someone, but production pressure always there in pain.

In the end I stopped doing PP Pain after about a year. Went back to anesthesia and have been way happier and more successful.
I dont look back at that year of my life as completely wasted. I still maintain by BC in Pain. And if anything ever happens to my anesthesia gig pain is an open door for me. Plus, the year of training was complete cake - so nothing really lost ( you could argue a year of salary lost but I felt it necessary to explore my curiosity )

Not exactly the same argument with cardiac. I think you are looking at a TOUGH year in the OR. Probably with surgeons who are not super nice and a lot of call. And the life of the cardiac anesthesiologist at home on call , even if you are rarely called in, no thanks. I personally found cardiac to be a huge amount of effort and technology poured into 70-80 year olds with only a few years to live anyhow.

So I would say if you do anything, do pain, because at lease the year of training will be interesting and not overwhelming. And if you decide you dont like it, not too much lost.

 

[Ronin1]

I worked for a year before doing a pain fellowship mainly because I had no intention of doing a fellowship! I decided I wanted to learn more about pain so went that route. It was a long time ago 1990s when pain was new and fellowships competitive but I got a slot.
I do think I was better prepared having done a year of pp anesthesia and it was quite simply the easiest year of my training life for sure.
I learned a bit and have practiced both pain and anesthesia since that time. Interestingly I have practiced a combo or only one or the other for years at a time.
I would say that pain certification has allowed me to have a very easy lifestyle at this phase of my life when I have a complete outpatient lifestyle practice.

 

[psychbender]

I'll echo what PGG said above. I had a four year gap between residency and CC fellowship, because the government made me take that gap. It had its positives and negatives. It was definitely a weird experience hip checking or overriding my attending once or twice, because I was actually the more experienced person for a given issue.

If you are interested in doing cardiac in your career, so yourself a favor and do the fellowship. Doing hearts straight out of residency is becoming less common, and the echo skills are becoming more important. While you could likely still have a mixed CT/general practice for several years in many parts of the country, I can see the day coming where that is no longer the case (more places listing CT fellowship or APTE cert as requirement).

 

[Bertelman]

Looking at Hoya’s response, that summarizes why I think you should determine who you are, and what you are looking for.

In my experience, the Venn diagram of Pain guys vs. Cardiac guys doesn’t overlap very much.

 

[Gern Blansten]

When I was applying (Yes 10 yrs ago) pain could indeed be tough to get into. Many programs only have a few spots and they all go to candidates at their own program.

My year in pain fellowship was the easiest year of my life. My hours were typically 8-3 as a full day. Often I was done before noon. "Call" was rounding on hospital inpatients for about 2-3hrs a day. I had plenty of free time to study for boards (which you take that year) and get my job situation in order (licenses, moving plans etc)

I liked doing the injections, the fluoro pictures, the theory of pain. I found it very interesting. But then when I got into PP you can see a darker side - and to sum it up I felt like I just wasnt helping people in the way that I wanted to. I didnt want to be the guy that spent 9 years of medical training to give grandma a hip injection or deal with the lowest forms of humans (sure there were some normal people but very few and far between)

To this day I still think it depends on your PERCEPTION of success. If you want to believe that that stimulator or vertiflex is helping grandma, then you can feel good about yourself as helping. I just did not believe that I was truly helping in my gut. I felt like I was just part of an industry.

And you dont have to have your own business, you can work for someone, but production pressure always there in pain.

In the end I stopped doing PP Pain after about a year. Went back to anesthesia and have been way happier and more successful.
I dont look back at that year of my life as completely wasted. I still maintain by BC in Pain. And if anything ever happens to my anesthesia gig pain is an open door for me. Plus, the year of training was complete cake - so nothing really lost ( you could argue a year of salary lost but I felt it necessary to explore my curiosity )

Not exactly the same argument with cardiac. I think you are looking at a TOUGH year in the OR. Probably with surgeons who are not super nice and a lot of call. And the life of the cardiac anesthesiologist at home on call , even if you are rarely called in, no thanks. I personally found cardiac to be a huge amount of effort and technology poured into 70-80 year olds with only a few years to live anyhow.

So I would say if you do anything, do pain, because at lease the year of training will be interesting and not overwhelming. And if you decide you dont like it, not too much lost.

This is an insightful post and I would agree with most of what is stated here. The pain world can be lucrative but can also be a real beat down on your mental state if you don’t really love it. Someone once told me, once you put an implantable device into someone’s body for pain control, you might as well be married to them. It is hard to get away from them and the devices often do not live up to the patient’s expectations and sometimes very bad stuff happens.
Additionally, with the changing climate towards physicians that is occurring, being a pain physician has some new dangers that did not have to be considered in the past. Trying to do the right thing by limiting opioid prescribing for patients can get you a target on your back for a patient population that is either desperate or criminal or both. Pain is a tough business. And it is definitely a business. I’ve seen it change people from caring physicians to callous shrewd business people whose lifestyle always adjusts to meet or exceed their income. I’ve also known a few who morphed over time into the criminal aspect and got in trouble with the law. Pill mills, trading prescriptions for money or illegal drugs or skimming pills off the top to sell on the street. I’ve heard it all. There can definitely be a dark side to a very small percentage of pain practices.

 

[Ezekiel2517]

Cardiac and pain are on completely different ends of the spectrum. Vast majority of the time, the person who wants to do cardiac can't stand pain, and vice versa. You're just starting CA-2 year so if you can't decide b/t the two, you need to rotate through them again. This should not be a complicated decision. "Smart people know what they are."
(Don't worry about being pidgeonholed. There are plenty of folks who did cardiac/pain and now do nothing but straight general. Or you can do 100% cardiac/pain, you can do a mix, etc)

 

[TheLoneWolf]

I am reposting a response I put out in another thread.

financial incentive of procedural stuff does skew things.

I'm saying this without an intent to offend.

This is how the conversation played out as I read it:

@OptionOffense : is pain still lucrative?
@TheLoneWolf : no, reimbursement going down.
@TeslaCoil : well it is lucrative if you perform spine surgery and instrument the spine.

I do not think pain docs are all crackpots. I had EXCELLENT pain docs as mentors (eg presidents of ASRAs, caring physicians, and great anesthesiologists).

But for everyone one of those, I've met 4-5 pain docs that are willing to do anything for money, including people wAcademic pain management (mostly salaried) are a different beast than private practice pain management. PP guys tend to be very procedurally aggressive, upsell procedures, and cognizant of working against large overhead costs. I have met these types at university settings and they quickly consider themselves a poor fit and leave for PP.

The Academic guys have a mantra of most things don't work or provide marginal benefit. They tend to focus heavily physical therapy, psych and coping skills, prudent medication management, cancer pain, addiction management and multidisciplinary therapy. These are, for the most part, lacking in PP settings and considered money losers.

Most Fellows I had met are envisioning doing shots all say and going home at banker hours with little concern for the above issues. Rude awakening when they actually graduate and see what's out there.

Welcome to check out the pain forum and the annual applicants thread where they wish to go to heavily interventional programs without strong consideration of the above matters.

@Planktonmd made a post years ago joking that pain management is patients showing up for procedures in the hopes of you refilling their opioid of choice.

Before my fellowship, I thought the comment was silly, crass and parody of true pain management. It turns out he was describing the pills for shots model so prevalent in PP pain management.

Check out the pain forum for going salaries. There are fully interventional clinics closing because of insufficient revenue.

Another important topic is the co-optation of pain procedures and management in recent years. @Aether2000 had a post regarding this. Essentially, ortho and neurosurgery want to send patients for procedures without interference to their foreseeable and planned surgery. Rather than have your management change or delay these surgeries, it's easier for them to send to a proceduralist with no followup eg IR or in house "block jock".

On the other hand they are more than happy to refer patients who had failed surgery for "optimization of their pain management ".

Caveat Emptor

I don't write this to discourage people from pain but to have an open and honest understanding of what we can offer to chronic pain patients. Just know what you are getting into.

The academics for the most part are legit and have difficult conversations with patients and their referral base and are not reluctant to put their foot down or say no. Doing the same in PP can get you canned (depending on who you work for) or results in your referral base drying up.

BTW I worked in both academic and PP pain settings

 

[TheLoneWolf]

This is an insightful post and I would agree with most of what is stated here. The pain world can be lucrative but can also be a real beat down on your mental state if you don’t really love it. Someone once told me, once you put an implantable device into someone’s body for pain control, you might as well be married to them. It is hard to get away from them and the devices often do not live up to the patient’s expectations and sometimes very bad stuff happens.
Additionally, with the changing climate towards physicians that is occurring, being a pain physician has some new dangers that did not have to be considered in the past. Trying to do the right thing by limiting opioid prescribing for patients can get you a target on your back for a patient population that is either desperate or criminal or both. Pain is a tough business. And it is definitely a business. I’ve seen it change people from caring physicians to callous shrewd business people whose lifestyle always adjusts to meet or exceed their income. I’ve also known a few who morphed over time into the criminal aspect and got in trouble with the law. Pill mills, trading prescriptions for money or illegal drugs or skimming pills off the top to sell on the street. I’ve heard it all. There can definitely be a dark side to a very small percentage of pain practices.

While I agree with most of the above, I would add that nearly ALL of PP pain practices are tempted to join the darkside at some point or another.

It's the only field I am aware of where state specialty society presidents are arrested by the DEA and given long jail sentences.

 

[nimbus]

This is an insightful post and I would agree with most of what is stated here. The pain world can be lucrative but can also be a real beat down on your mental state if you don’t really love it. Someone once told me, once you put an implantable device into someone’s body for pain control, you might as well be married to them. It is hard to get away from them and the devices often do not live up to the patient’s expectations and sometimes very bad stuff happens.
Additionally, with the changing climate towards physicians that is occurring, being a pain physician has some new dangers that did not have to be considered in the past. Trying to do the right thing by limiting opioid prescribing for patients can get you a target on your back for a patient population that is either desperate or criminal or both. Pain is a tough business. And it is definitely a business. I’ve seen it change people from caring physicians to callous shrewd business people whose lifestyle always adjusts to meet or exceed their income. I’ve also known a few who morphed over time into the criminal aspect and got in trouble with the law. Pill mills, trading prescriptions for money or illegal drugs or skimming pills off the top to sell on the street. I’ve heard it all. There can definitely be a dark side to a very small percentage of pain practices.

Locally we’ve had a disproportionate number of pain physicians get mired in criminal legal problems. Can’t say the same about cardiac anesthesiologists.

 

[anaesthetic]

Cardiac and pain are on completely different ends of the spectrum. Vast majority of the time, the person who wants to do cardiac can't stand pain, and vice versa. You're just starting CA-2 year so if you can't decide b/t the two, you need to rotate through them again. This should not be a complicated decision. "Smart people know what they are."
(Don't worry about being pidgeonholed. There are plenty of folks who did cardiac/pain and now do nothing but straight general. Or you can do 100% cardiac/pain, you can do a mix, etc)

Locally we’ve had a disproportionate number of pain physicians get mired in criminal legal problems. Can’t say the same about cardiac anesthesiologists.

I’m a cardiac guy, mama. A heart jockey. We think differently than the pain and regional boys… we’re a different breed.

 

[Beeftenderloin]

I’m a cardiac guy, mama. A heart jockey. We think differently than the pain and regional boys… we’re a different breed.

Took over a case from a regional trained partner a couple weeks ago. Comorbid 90ish yo getting a hemi arthro for hip fracture in lateral. They did it with a spinal and light sedation, because that’s their happy place, fine. The second I took over I’m thinking I do this with a tube 100/100 times, but whatev. Well the light sedation turned into unprotected airway GA when the surgeon ran long and the spinal was wearing off… Nothing warms my heart quite like a tube between the cords and some pressors in line.

 

[TheLoneWolf]

Locally we’ve had a disproportionate number of pain physicians get mired in criminal legal problems. Can’t say the same about cardiac anesthesiologists.

I will share one story from a pain attending in my heavily interventional university fellowship.

Final year well liked resident caught using IV opioids. Already matched to same programs cardiac fellowship. Little time until graduation. Dept had a meeting on whether to fire him, send to rehab, or just let it pass and watch him closely in the fellowship.

They decided the last option was best. He got through the fellowship without issues. Caught a few years later having driven his car into a ditch. EMTs find him unconscious with a hanging IV drip still connected to his arm. Found to be IV midazolam.

Attending followed up and found that he now practices boutique filler and skin care clinic making more money than in cardiac anesthesia.

 

[dchz]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

I would go with that answer. If you practice good fiscal discipline, you're gonna be set financially anyways. Do what is going to make you happy long term.

I loved the anatomy and the chronic pain attendings. I did exactly 9 full days of chronic pain in my residency because I took everyone's call and all the vacation I could after wanting to shoot myself 3 hours into the rotation. It's not a tough decision man, just be honest to yourself.

I would like to do a mix of cardiac and general cases in the future as I enjoy both, but I also don't want to be "pidgeonholed" (whatever that means) into just doing cardiac cases because I have the training and have limited job opportunities.

There is no law that says you HAVE to use your fellowship training. My thumb pushes propofol for colonoscopy just as good as the next person.

Attending followed up and found that he now practices boutique filler and skin care clinic making more money than in cardiac anesthesia.

Man that's either a very lucrative cash paying base or a very ****ty cardiac anesthesia practice. prob combo of both.

I’m a cardiac guy, mama. A heart jockey. We think differently than the pain and regional boys… we’re a different breed.

I think very differently than a chronic pain physician. But I would argue that every practicing anesthesiologist should incorporate regional as much as possible. It's just a better anesthetic.

Not exactly the same argument with cardiac. I think you are looking at a TOUGH year in the OR. Probably with surgeons who are not super nice and a lot of call. And the life of the cardiac anesthesiologist at home on call , even if you are rarely called in, no thanks. I personally found cardiac to be a huge amount of effort and technology poured into 70-80 year olds with only a few years to live anyhow.

So I would say if you do anything, do pain, because at lease the year of training will be interesting and not overwhelming. And if you decide you dont like it, not too much lost.

This is bad logic for a few reasons:

1. My cardiac fellowship was the chillest year of training ever. I had post call days off and home call.

2. The anesthesia performed in cardiac OR is arguably the most mortality reducing anesthesia. Few other surgeries (save liver and kidney transplants) compare in amount of quality-adjusted years of life given to the patient.

3. You just told him how bad it is to do chronic pain and you STILL told him to do Chronic pain simply because of the chill year. without taking into account of the OPPORTUNITY COST of the year of fellowship. The reasonable thing to do if he doesn't like cardiac is to just NOT DO A FELLOWSHIP. It's a great job market out there!

 

[TheLoneWolf]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

I would go with that answer. If you practice good fiscal discipline, you're gonna be set financially anyways. Do what is going to make you happy long term.

I loved the anatomy and the chronic pain attendings. I did exactly 9 full days of chronic pain in my residency because I took everyone's call and all the vacation I could after wanting to shoot myself 3 hours into the rotation. It's not a tough decision man, just be honest to yourself.


There is no law that says you HAVE to use your fellowship training. My thumb pushes propofol for colonoscopy just as good as the next person.



Man that's either a very lucrative cash paying base or a very ****ty cardiac anesthesia practice. prob combo of both.



I think very differently than a chronic pain physician. But I would argue that every practicing anesthesiologist should incorporate regional as much as possible. It's just a better anesthetic.



This is bad logic for a few reasons:

1. My cardiac fellowship was the chillest year of training ever. I had post call days off and home call.

2. The anesthesia performed in cardiac OR is arguably the most mortality reducing anesthesia. Few other surgeries (save liver and kidney transplants) compare in amount of quality-adjusted years of life given to the patient.

3. You just told him how bad it is to do chronic pain and you STILL told him to do Chronic pain simply because of the chill year. without taking into account of the OPPORTUNITY COST of the year of fellowship. The reasonable thing to do if he doesn't like cardiac is to just NOT DO A FELLOWSHIP. It's a great job market out there!

I had a different experience than a few posters pain fellowships. Most days was 8am-5:30 pm seeing the last patients and procedures, then documentation on top of that.

1-2 weeks of continous call per month, quite busy.

Definitely was not a chill year. I think I logged 55+ hours per non call week if I included time for clinical paperwork and charting. 80+ on call weeks. That did not include journal club, device rep meetings, and work on publications.

For comparison, my anesthesia residency, on average, I had logged 74 hours per week which wasalmost purely in the OR.

Well known that some pain fellowships have surgery residency hours eg Rush. Word of mouth is their call week, they log 100+ hours.

 

[pgg]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

As a CA2?

I would text my program director to let him know I wouldn't be in tomorrow.


Actually, I was in the military then. But I'm sure with $10M on hand I could've figured a way to quit without risking a trip to Leavenworth for being a deserter.




Also, obligatory Office Space:

- Our high school guidance counselor used to ask us what you would do if you had a million dollars, didn't have to work. And, invariably, whatever you'd say, that was supposed to be your career.

- If you wanted to fix old cars, then you're supposed to be an auto mechanic.

- So what did you say?

- I never had an answer.

- I guess that's why I'm working at Initech.

- No. You're working at Initech 'cause that question is bull**** to begin with.

- If everyone listened to her, there'd be no janitors because no one would clean **** up if they had a million dollars.

- You know what I would do if I had million dollars? I would invest half of it in low-risk mutual funds and then take the other half of it to my friend Asadulah, who works in securities...

- Samir. Samir, you're missing the point.

- The point of the exercise is that you're supposed to figure out what you would want to do if...

- P.C. load letter? What the **** does that mean?

 

[TheLoneWolf]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

I would go with that answer. If you practice good fiscal discipline, you're gonna be set financially anyways. Do what is going to make you happy long term.

I loved the anatomy and the chronic pain attendings. I did exactly 9 full days of chronic pain in my residency because I took everyone's call and all the vacation I could after wanting to shoot myself 3 hours into the rotation. It's not a tough decision man, just be honest to yourself.


There is no law that says you HAVE to use your fellowship training. My thumb pushes propofol for colonoscopy just as good as the next person.



Man that's either a very lucrative cash paying base or a very ****ty cardiac anesthesia practice. prob combo of both.



I think very differently than a chronic pain physician. But I would argue that every practicing anesthesiologist should incorporate regional as much as possible. It's just a better anesthetic.



This is bad logic for a few reasons:

1. My cardiac fellowship was the chillest year of training ever. I had post call days off and home call.

2. The anesthesia performed in cardiac OR is arguably the most mortality reducing anesthesia. Few other surgeries (save liver and kidney transplants) compare in amount of quality-adjusted years of life given to the patient.

3. You just told him how bad it is to do chronic pain and you STILL told him to do Chronic pain simply because of the chill year. without taking into account of the OPPORTUNITY COST of the year of fellowship. The reasonable thing to do if he doesn't like cardiac is to just NOT DO A FELLOWSHIP. It's a great job market out there!

Um $10 mil is a ton. Most pain docs would walk with less than half that. Again, just check what CMS is doing. I know we as anesthesiologists are ticked about CMS cuts. For pain, CMS proposed annual cuts of...9%. Heavy negotiation with our speciality boards eg ASIPP leads to annual cuts of 4.5%. Such success.

Most PP guys I have met have one eye on the (retirement) door. Academics is tolerable as you can run your shop as you please.

majority of pain guys i know plan on retiring the moment they hit some reasonable number to retire.

Much less commonly, others flirt with the idea of opening a small independent practice and hiring 2-3 new grads to run the place with they keep 40-50% of collections. Currently untenable with the current cuts. New studies questioning current implantables and insurance pushback on coverage as experimental for multiple therapies.

Eg

Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators for Chronic Pain

This comparative effectiveness research study investigates the outcomes of real-world patients with chronic pain treated with spinal cord stimulators vs conventional medical therapy.

jamanetwork.com

Spinal cord stimulation doesn’t help with back pain, says new review

www.cochrane.org

Assuming any of the people I know get something like 3 million or more post tax dollars in a lottery, they would be out the door and out of pain management.

Only guy I could name, who would possibly continue, is a former association president who is salaried and only treats cancer patients. Acts like a palliative care doc, med management and trigger point injections, nothing more.


One final point. Lots of articles in major media are talking about private equity taking over lucrative specialties like ophthalmology and orthopedics as they are safe bets with a long-term reliable future of returns.

Who Employs Your Doctor? Increasingly, a Private Equity Firm.

A new study finds that private equity firms own more than half of all specialists in certain U.S. markets.

www.nytimes.com

I am unaware of major private equity hands in pain practices. On paper, the prevalence and incidence of chronic pain are high (read...tons of patients); the patient base is high resource utilizers and with many, it is a lifelong issue ( read...tons of visits and procedures and ancillaries). I'm sure there are multiple valid reasons they have not invested in pain management practices.

 

[Pablo94]

I appreciate all of your input everyone, you all clearly have more experience and wisdom than I do which is very helpful. I think I am leaning away towards pursuing pain, especially based on many of these comments . Much appreciated.

 

[Hoya11]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

I would go with that answer. If you practice good fiscal discipline, you're gonna be set financially anyways. Do what is going to make you happy long term.

I loved the anatomy and the chronic pain attendings. I did exactly 9 full days of chronic pain in my residency because I took everyone's call and all the vacation I could after wanting to shoot myself 3 hours into the rotation. It's not a tough decision man, just be honest to yourself.


There is no law that says you HAVE to use your fellowship training. My thumb pushes propofol for colonoscopy just as good as the next person.



Man that's either a very lucrative cash paying base or a very ****ty cardiac anesthesia practice. prob combo of both.



I think very differently than a chronic pain physician. But I would argue that every practicing anesthesiologist should incorporate regional as much as possible. It's just a better anesthetic.



This is bad logic for a few reasons:

1. My cardiac fellowship was the chillest year of training ever. I had post call days off and home call.

2. The anesthesia performed in cardiac OR is arguably the most mortality reducing anesthesia. Few other surgeries (save liver and kidney transplants) compare in amount of quality-adjusted years of life given to the patient.

3. You just told him how bad it is to do chronic pain and you STILL told him to do Chronic pain simply because of the chill year. without taking into account of the OPPORTUNITY COST of the year of fellowship. The reasonable thing to do if he doesn't like cardiac is to just NOT DO A FELLOWSHIP. It's a great job market out there!

Lol all I can say is hard disagree on points one and two. Point 3 is not because it was a chill year but to satisfy curiosity

 

[sloh]

Um $10 mil is a ton. Most pain docs would walk with less than half that. Again, just check what CMS is doing. I know we as anesthesiologists are ticked about CMS cuts. For pain, CMS proposed annual cuts of...9%. Heavy negotiation with our speciality boards eg ASIPP leads to annual cuts of 4.5%. Such success.

Most PP guys I have met have one eye on the (retirement) door. Academics is tolerable as you can run your shop as you please.

majority of pain guys i know plan on retiring the moment they hit some reasonable number to retire.

Much less commonly, others flirt with the idea of opening a small independent practice and hiring 2-3 new grads to run the place with they keep 40-50% of collections. Currently untenable with the current cuts. New studies questioning current implantables and insurance pushback on coverage as experimental for multiple therapies.

Eg

Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators for Chronic Pain

This comparative effectiveness research study investigates the outcomes of real-world patients with chronic pain treated with spinal cord stimulators vs conventional medical therapy.

jamanetwork.com

Spinal cord stimulation doesn’t help with back pain, says new review

www.cochrane.org

Assuming any of the people I know get something like 3 million or more post tax dollars in a lottery, they would be out the door and out of pain management.

Only guy I could name, who would possibly continue, is a former association president who is salaried and only treats cancer patients. Acts like a palliative care doc, med management and trigger point injections, nothing more.


One final point. Lots of articles in major media are talking about private equity taking over lucrative specialties like ophthalmology and orthopedics as they are safe bets with a long-term reliable future of returns.

Who Employs Your Doctor? Increasingly, a Private Equity Firm.

A new study finds that private equity firms own more than half of all specialists in certain U.S. markets.

www.nytimes.com

I am unaware of major private equity hands in pain practices. On paper, the prevalence and incidence of chronic pain are high (read...tons of patients); the patient base is high resource utilizers and with many, it is a lifelong issue ( read...tons of visits and procedures and ancillaries). I'm sure there are multiple valid reasons they have not invested in pain management practices.

You should post more often on the underbelly of pain. You’re an absolute wealth of information and it’s a shame you don’t post more

 

[TheLoneWolf]

You should post more often on the underbelly of pain. You’re an absolute wealth of information and it’s a shame you don’t post more

I try to reply as best as I can while juggling other things. Have posted a bunch before as it keeps coming up every couple of months or so. Anyone is free to PM me as well.

 

[GassYous]

I will share one story from a pain attending in my heavily interventional university fellowship.

Final year well liked resident caught using IV opioids. Already matched to same programs cardiac fellowship. Little time until graduation. Dept had a meeting on whether to fire him, send to rehab, or just let it pass and watch him closely in the fellowship.

They decided the last option was best. He got through the fellowship without issues. Caught a few years later having driven his car into a ditch. EMTs find him unconscious with a hanging IV drip still connected to his arm. Found to be IV midazolam.

Attending followed up and found that he now practices boutique filler and skin care clinic making more money than in cardiac anesthesia.

Know someone who was found down and tubed. Claimed to have gotten stuck by a roc syringe. Still graduated and went to pain fellowship. Was caught by a patient stealing their meds.

 

[TheLoneWolf]

Approach it this way:

If you had $10 mil liquid in the bank right now, which fellowship would you do?

I would go with that answer. If you practice good fiscal discipline, you're gonna be set financially anyways. Do what is going to make you happy long term.

I loved the anatomy and the chronic pain attendings. I did exactly 9 full days of chronic pain in my residency because I took everyone's call and all the vacation I could after wanting to shoot myself 3 hours into the rotation. It's not a tough decision man, just be honest to yourself.


There is no law that says you HAVE to use your fellowship training. My thumb pushes propofol for colonoscopy just as good as the next person.



Man that's either a very lucrative cash paying base or a very ****ty cardiac anesthesia practice. prob combo of both.



I think very differently than a chronic pain physician. But I would argue that every practicing anesthesiologist should incorporate regional as much as possible. It's just a better anesthetic.



This is bad logic for a few reasons:

1. My cardiac fellowship was the chillest year of training ever. I had post call days off and home call.

2. The anesthesia performed in cardiac OR is arguably the most mortality reducing anesthesia. Few other surgeries (save liver and kidney transplants) compare in amount of quality-adjusted years of life given to the patient.

3. You just told him how bad it is to do chronic pain and you STILL told him to do Chronic pain simply because of the chill year. without taking into account of the OPPORTUNITY COST of the year of fellowship. The reasonable thing to do if he doesn't like cardiac is to just NOT DO A FELLOWSHIP. It's a great job market out there!

Think OC or Key West. If my memory is correct.

 

[TheLoneWolf]

Know someone who was found down and tubed. Claimed to have gotten stuck by a roc syringe. Still graduated and went to pain fellowship. Was caught by a patient stealing their meds.

Awful

 

[pgg]

Know someone who was found down and tubed. Claimed to have gotten stuck by a roc syringe. Still graduated and went to pain fellowship. Was caught by a patient stealing their meds.

Heard a story somewhere about someone who was diverting fentanyl or sufentanil by carrying it in a syringe with a succinylcholine label. (Think it might have been one of those anti-diversion education videos where the survivor tells his story?) Apparently he got them mixed up one day and gave himself a bolus of succ.

Imagine

Feeling the fasciculations

Knowing what just happened

Doing the math to guess how long you'll be apneic and hypoxic