Jan 8, 2019
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Hi All,
New CA-3, Applied for Cardiac last year, Got 5 interviews at excellent programs, sent love letters. And didn't match.

Been applying to private practice/academic jobs and have had a good response. Just trying to focus on getting a job now. But I know that after a few yers the cardiac itch is going to come back. Anyone have any experience with a situation like this. Any advice?

Thanks.
 

AdmiralChz

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You need to take a retrospective on your application and see what was deficient and try to address it. Cardiac is competitive, per SF Match it has about a 75% match rate that leaves a quarter of the applicants short. Perhaps you could sit down with your PD or a faculty member to discuss?

5 interviews I think is a little low. There are a few things that are important in a fellowship app: main residency program (clearly out of your control, but a high level university applicant gets farther on average), ITE scores, cardiac research and leadership positions. Work this year on getting that ITE score up and be sure to present an abstract at SCA.

Once your out in practice, especially if not in academics it will be difficult to improve your application. That being said the forums are full of people who went back to fellowship after a few (or many) years of practice, they probably have some good insight!
 
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psychbender

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Going back in to fellowship after being in practice for some time has both pluses and minuses. On the plus side, programs see that you are actually very interested in the subspecialty, since you are willingly giving up attending salary that you already have in order to go back into training making peanuts. They also know that they are getting someone with more experience and maturity, who is already board certified, and thus can focus entirely on learning the new subspecialty.

On the minus side, you may not be eligible for federal funding, so your salary and benefits would come straight from the department (less of a deal if that was already true, as not all GME spots are federally funded). Additionally, those who have been out for a while are less likely to tolerate bull**** and mistreatment. It also creates since awkward situations where your attendings may be younger and less experienced in anesthesia than you. Finally, you may have "bad habits" that will need to be unlearned to do things the University way.

Overall, I think the pluses outweigh the minuses, but a few year's experience won't necessarily turn a poor applicant into a stellar one, and some few places may just not interview those already out in practice.
 

Man o War

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I went back to cardiac fellowship after being in practice. I should’ve done it right out of training, but I was young and not thinking with the long term picture in mind. Sounds like you know you want to do it, that’s unlikely to change.
Does your home program have a cardiac fellowship? That’s your best bet if you’re going from attending back to fellowship.
Go to the SCA meeting every year and network. Most of the people you need on your side if you’re going to do this will be there. Make a good impression on them.
I would look for a job where you’re doing cardiac- this will make you less of a “risk” skill wise, you can tell them you’ve been doing some hearts. Possibly think about getting an academic job as a generalist at a program that has a cardiac fellowship, and work your tail off to make a good impression on the cardiac chair and attendings so you can slide into a spot there.
 
May 28, 2019
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Hi All,
New CA-3, Applied for Cardiac last year, Got 5 interviews at excellent programs, sent love letters. And didn't match.

Been applying to private practice/academic jobs and have had a good response. Just trying to focus on getting a job now. But I know that after a few yers the cardiac itch is going to come back. Anyone have any experience with a situation like this. Any advice?

Thanks.
Cases are too darn long and you work with the same crotchety surgeons all the time. pump runs are long and its the same recipe all the time... and the same plan GETA post op ventilation art line swan tee.
go out in practice make money. There are enough cases for general anesthesiologist to go around
 

Newtwo

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Cases are too darn long and you work with the same crotchety surgeons all the time. pump runs are long and its the same recipe all the time... and the same plan GETA post op ventilation art line swan tee.
go out in practice make money. There are enough cases for general anesthesiologist to go around
A days cardiac is a hell of a lot easier than say a day doing 5 or 6 shoulders on 'healthy ' 70 year olds in the beach chair. Or 12 to 14 tonsils with your resident trying to kill each of them.

To each their own.
There does exist the odd cardiac job where you can take a days general every now and again to break the cycle.
And having a years cardiac makes you very employable as generalist in good places...

Diff strokes for diff folks man
 

dchz

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I thought about writing up a preemptive response to this situation, but personal life got in the way. Glad someone brought this up. I'm choosing to be semi anonymous but if you feel like you need me to reach out to you in the PMs I will do so. I was in your shoes last year. I remember the day like it was yesterday. Here is my advice/story:

First, and most important:
You need to take care of your mental health. Everyone on SDN is a super star, so it's hard to get empathy but the fact of the matter is nearly 25% of the people that apply to CT anes do not match. Your job now is to make sure that you know you're still an awesome anesthesiologist. You're literally competing against some of the best in the nation and there is no shame in not matching. despite me typing this, you're going to feel shame. That's just part of being human. The next steps is to step away from things and gather yourself. I remember i consciously made myself take personal time away from anesthesia just to have some me time.

Understand the game:
We really were nothing but professional students until residency, and some of us still don't see the big picture. Getting fellowships involve more about connections than merit. The match rate is 75%. but the match rate for someone without a fellowship attached to the residency is WAY lower. It doesn't matter if you score the 95 percentile on the ITE, PDs rather take a mediocre 70% ITE guy that they've worked with for 3 years. Oh this guy looks mediocre on paper, but my buddy from residency tells me he's God's gift to anesthesia. Then i'm gonna take him over this guys that looks great on paper. It's not unfair or unethical, it's just way it is.

Reassess your situation:
As @FFP often alludes, fellowship year comes with its own opportunity costs. Are you in a position where you can let your debt sit 1 more year and do fellowship next year? Is cardiac such a big deal in your life that you either become a CT anesthesiologist or you won't be happy in life? Take some time away reassess your own situation. Like @Consigliere said, it could be a blessing in disguise. Do you have red flags that you can't overcome?? Or was it something minor like you now have better letters of recommendation?

Possible paths from here:
-Reapply while keeping your eyes out for new opportunities:
You can re apply as a CA3. Perhaps you've made better connections since the first time? Perhaps you've signed up to take the advanced PTE and it's gonna look really good as a CA3 that passed the advanced PTE exam? @AdmiralChz once gave me advice that there will be a non-insignificant # of spots that will open up (this advice was invaluable. thank you again @AdmiralChz ). Email the places you've interviewed and keep an eye on SF match. In the last year, 4 spots publicly opened for newly approved fellowships spots (and many more unofficially because they got plugged internally or outside of SF match). But this path is not without its risks. You could be out weeks of vacation, thousands of dollars in traveling. It could be all for nothing in the end. After that, you get settled in a job for 1 year and then you're moving again if you match in the 2021-2022 fellowship year.

-Find a job that allows you to do cardiac:
These jobs are harder to find, but if you have a calling to do CT cases there are jobs out there that allows you to do them without a fellowship (most of them are farther away from big cities but I have a buddy that found a job in houston that allows him to do cardiac). But know that on paper, you will be less appealing than someone that did a fellowship, even if you have all the clinical skills in the world.

-Enjoy life
Those CT people are jokers anyways. Sitting and doing bread and butter or supervising CRNAs could be just as fun.
 
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Modanq

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Think dual. Get an open ICU spot and then cardiac. Hard road but many places allow you to moonlight.
 
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Nivens

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Think dual. Get an open ICU spot and then cardiac. Hard road but many places allow you to moonlight.
This 100%. Tons of open ICU spots around. Find an unmatched spot at a place you’d like to do CT, and work the connections from there.
 
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FFP

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Think dual. Get an open ICU spot and then cardiac. Hard road but many places allow you to moonlight.
OP, find an open ICU spot which will give you good CTICU and/or TEE training. Then emphasize that next time you apply for ACTA. My guess is that you will become very popular. ;)
 
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dannyboy1

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Find an open ICU spot which will give you good CTICU and TEE training. Then emphasize that next time you apply for ACTA. My guess is that you will become very popular. ;)
Umm. Give up over 300k income to improve his application so he might get a spot. And then give up another 300k to do the actual training??!!!. Fu(k that. OP, get a job, make some money, and enjoy life. You can always apply later (though at that point you will probably realize that it isn’t worth it)
 

FFP

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Umm. Give up over 300k income to improve his application so he might get a spot. And then give up another 300k to do the actual training??!!!. Fu(k that. OP, get a job, make some money, and enjoy life. You can always apply later (though at that point you will probably realize that it isn’t worth it)
Cardiac is the ONLY fellowship that's actually worth the year of lost income, occasionally even two. S/he'll make the money back in the first 3-5 years of practice.

Another alternative would be to choose a PP job where non-cardiac people can do cardiac cases, then apply again in 1-2 years. That's harder and less helpful, IMO, even if more mature and financially wiser.
 
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Everything here is good advice. Only thing I’ll add is to really do some soul searching. Do you HAVE to be a cardiac Anesthesiologist for you to be content/happy? Or did you want to do it because you think it’s cool or you think it will make you a better doctor?

If you don’t think you’ll be happy without doing cardiac then the choice is easy. If it’s the other scenario I’d say go get a job and move on. Once you do cardiac you will be typecast. Most places you’ll be doing hearts most days of not everyday. The days you aren’t doing hearts you’ll have the sickest patients or biggest rooms and that’s regardless of whether you go private or academic. Just know that. If that excites you I think that leads you back to doing the fellowship, while if your mind goes; “eh, I’d like to have a couple days of ortho rooms or general cases to break things up” I think that’s a sign it may be s blessing in disguise.

In the end, I wouldn’t go do CCM just to make yourself more marketable to Cardiac PDs if you weren’t already in love with CCM. I’d go take a job in a complex practice that does everything, ideally a decent number of cardiac cases but not so many that they hire half their group as cardiac trained, and live the life for a bit. That would give you the info you need; do you miss cardiac cases? Do you like your “easy” days? Do you just like the variation? Etc. It will be harder to go back to training with every year out in practice but if you decide to do it I think it’s fair to say you are doing it because you really want to be cardiac.
 

sethco

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I thought about writing up a preemptive response to this situation, but personal life got in the way. Glad someone brought this up. I'm choosing to be semi anonymous but if you feel like you need me to reach out to you in the PMs I will do so. I was in your shoes last year. I remember the day like it was yesterday. Here is my advice/story:

First, and most important:
You need to take care of your mental health. Everyone on SDN is a super star, so it's hard to get empathy but the fact of the matter is nearly 25% of the people that apply to CT anes do not match. Your job now is to make sure that you know you're still an awesome anesthesiologist. You're literally competing against some of the best in the nation and there is no shame in not matching. despite me typing this, you're going to feel shame. That's just part of being human. The next steps is to step away from things and gather yourself. I remember i consciously made myself take personal time away from anesthesia just to have some me time.

Understand the game:
We really were nothing but professional students until residency, and some of us still don't see the big picture. Getting fellowships involve more about connections than merit. The match rate is 75%. but the match rate for someone without a fellowship attached to the residency is WAY lower. It doesn't matter if you score the 95 percentile on the ITE, PDs rather take a mediocre 70% ITE guy that I've worked with for 3 years. Oh this guy looks mediocre on paper, but my buddy from residency tells me he's God's gift to anesthesia. Then i'm gonna take him over this guys that looks great on paper. It's not unfair or unethical, it's just way it is.

Reassess your situation:
As @FFP often alludes, fellowship year comes with its own opportunity costs. Are you in a position where you can let your debt sit 1 more year and do fellowship next year? Is cardiac such a big deal in your life that you either become a CT anesthesiologist or you won't be happy in life? Take some time away reassess your own situation. Like @Consigliere said, it could be a blessing in disguise. Do you have red flags that you can't overcome?? Or was it something minor like you now have better letters of recommendation?

Possible paths from here:
-Reapply while keeping your eyes out for new opportunities:
You can re apply as a CA3. Perhaps you've made better connections since the first time? Perhaps you've signed up to take the advanced PTE and it's gonna look really good as a CA3 that passed the advanced PTE exam? @AdmiralChz once gave me advice that there will be a non-insignificant # of spots that will open up (this advice was invaluable. thank you again @AdmiralChz ). Email the places you've interviewed and keep an eye on SF match. In the last year, 4 spots publicly opened for newly approved fellowships spots (and many more unofficially because they got plugged internally or outside of SF match). But this path is not without its risks. You could be out weeks of vacation, thousands of dollars in traveling. It could be all for nothing in the end. After that, you get settled in a job for 1 year and then you're moving again if you match in the 2021-2022 fellowship year.

-Find a job that allows you to do cardiac:
These jobs are harder to find, but if you have a calling to do CT cases there are jobs out there that allows you to do them without a fellowship (most of them are farther away from big cities but I have a buddy that found a job in houston that allows him to do cardiac). But know that on paper, you will be less appealing than someone that did a fellowship, even if you have all the clinical skills in the world.

-Enjoy life
Those CT people are jokers anyways. Sitting and doing bread and butter or supervising CRNAs could be just as fun.
If you don't mind me asking, how did it work out for you?
 
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Ezekiel2517

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Most of the people I know who did a cardiac fellowship are doing nothing but straight general cases
 
OP
Ketafol1:5
Jan 8, 2019
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5
Hey y'all,

Thanks again for all of this support. There is a spot at UCSF that I've thrown my hat in the ring for, but it will be months till they decide per the program director. As of now I am treating that spot like one job opportunity of the many that I am applying to. I've try to hit up some academic groups that have a cardiac fellowship in house with the mindset that if I still want to go do this in a few years I'll have an inherent connection.

Thanks again to @dchz for the support. I think cardiac anesthesia is baller, but I like thoracic and transplant too. I'll see how I feel in a few years once I have a job and a more stable financial situation. My main priority right now is making sure I can provide for my family and give them a modicum of certainty and financial stability.

As for critical care. It's a viable option...but for me hell no. 4 months of the SICU as a resident very nearly broke my will to live as well as my liver. Doing a year of that just to have a possible better chance of getting a cardiac fellowship is well beyond what I am willing to myself and my family through.
 

dchz

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Everything here is good advice. Only thing I’ll add is to really do some soul searching. Do you HAVE to be a cardiac Anesthesiologist for you to be content/happy? Or did you want to do it because you think it’s cool or you think it will make you a better doctor?

If you don’t think you’ll be happy without doing cardiac then the choice is easy. If it’s the other scenario I’d say go get a job and move on. Once you do cardiac you will be typecast. Most places you’ll be doing hearts most days of not everyday. The days you aren’t doing hearts you’ll have the sickest patients or biggest rooms and that’s regardless of whether you go private or academic. Just know that. If that excites you I think that leads you back to doing the fellowship, while if your mind goes; “eh, I’d like to have a couple days of ortho rooms or general cases to break things up” I think that’s a sign it may be s blessing in disguise.

In the end, I wouldn’t go do CCM just to make yourself more marketable to Cardiac PDs if you weren’t already in love with CCM. I’d go take a job in a complex practice that does everything, ideally a decent number of cardiac cases but not so many that they hire half their group as cardiac trained, and live the life for a bit. That would give you the info you need; do you miss cardiac cases? Do you like your “easy” days? Do you just like the variation? Etc. It will be harder to go back to training with every year out in practice but if you decide to do it I think it’s fair to say you are doing it because you really want to be cardiac.
+1

This 100%. Tons of open ICU spots around. Find an unmatched spot at a place you’d like to do CT, and work the connections from there.
This could work. But this would be likely a 3 year plan, because you won't make the connections until you get there and if it works well you'd be getting a spot 2 years from then. this is a true Long Con if you're up for it.

OP, find an open ICU spot which will give you good CTICU and/or TEE training. Then emphasize that next time you apply for ACTA. My guess is that you will become very popular. ;)
I got this advice a lot. I disagree with this advice. First, you won't be doing the CCM fellowship until after your CA-3 year. Second, the CCM fellowship isn't a competitive one. I don't think that many people will be impressed when you're a CA-3 interviewing and your only selling point is that you plugged into a spot that was open and unmatched anyways. I think the idea of going to do CCM at a place with many spots would be a better strategy (Columbia, THI, etc) because you will have connections at those places, but that's a long con in itself.
 

FFP

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I got this advice a lot. I disagree with this advice. First, you won't be doing the CCM fellowship until after your CA-3 year. Second, the CCM fellowship isn't a competitive one. I don't think that many people will be impressed when you're a CA-3 interviewing and your only selling point is that you plugged into a spot that was open and unmatched anyways. I think the idea of going to do CCM at a place with many spots would be a better strategy (Columbia, THI, etc) because you will have connections at those places, but that's a long con in itself.
Seriously? :rofl:

The selling point is that, by the time OP would start the fellowship (more or less), s/he will be a CCM grad with a lot of TEE and/or post-op sick cardiac experience (and possibly also board-certified in anesthesia and critical care). Trust me, any of those runs circles around the regular CA-2 applicant. (The only caveat is keeping up the OR skills by moonlighting occasionally during the CCM fellowship.)

Why do you think you got this advice a lot, if it's bad?

Applying again as a CA-3, or after some non-cardiac PP experience, is like expecting a successful intubation on the second try, while doing the exact same things as for the failed one. Also, one of the things faculties are afraid of is having to deal with the attending mindset in a trainee, so they are reluctant to take people who've been out of training, unless they bring something to the table.

Anyway, the OP hated his residency ICU experience (stay in line, buddy, I was first), so whatever... The number one reason to do anything should be because one likes it.
 
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bigdan

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I agree with dchz on his post, and have advised our residents who did not Match to avoid doing CCM first as a "means" to get into CT fellowship.

Many (most?) anesthesiologists greatly dislike the idea of doing a full year of critical care, and even more dislike the idea of 2 years of fellowship. I advise our trainees (and all ACTA applicants) to avoid the "CCM first" plan UNLESS you truly want to do both fellowships from the outset. It just seems like pure torture, and if you are doing it at a place that has not guaranteed you the CT spot, you might STILL miss out.
 

bigdan

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FFP -

The CCM training is minimally valued. Not by me (of course) but by the ACTA program directors. Look at this manuscript (attached), in which the ACTA PDs were surveyed about what is important in consideration of the applicant attributes...CCM board certification was deemed less important than ANY other factor they asked about.

I'm profoundly biased, and I personally think that CCM + ACTA allows for the best positioning for excellent periop care of the compromised cardiovascular and/or thoracic surgical patient, but: 1) most health systems don't want/need that, 2) most physicians don't want to do the training, and 3) most places won't make it worth the while (in terms of time to do the work, money for the effort and work, and respect for the work). You have to be in a niche practice for it to truly matter, and that's putting a LOT of eggs in one basket to bet you can get that type of job. So for someone that really just wants to Match into a cardiac anesthesia fellowship, it simply ain't worth it to do both (probably).
 

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whats wrong with going out and getting a job as soon as humanly possible?
what is with all the fellowhship talk..
The cardiac guy at my place, I dont envy him!! I make more than him and he gets to sit in 5 hour boring cases with the same D**k surgeon.
I would do Critical care a million x over cardiac.
 

Man o War

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whats wrong with going out and getting a job as soon as humanly possible?
what is with all the fellowhship talk..
The cardiac guy at my place, I dont envy him!! I make more than him and he gets to sit in 5 hour boring cases with the same D**k surgeon.
I would do Critical care a million x over cardiac.
How is this possible? There’s one cardiac guy and he’s making less than the general guys/gals while taking all the cardiac call I assume?
 

dr doze

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You don’t have a call stipend? He should be making more if he takes more call.....call is the worst part of the job.
Call intensity is hugely important.
 

epidural man

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Hi All,
New CA-3, Applied for Cardiac last year, Got 5 interviews at excellent programs, sent love letters. And didn't match.

Been applying to private practice/academic jobs and have had a good response. Just trying to focus on getting a job now. But I know that after a few yers the cardiac itch is going to come back. Anyone have any experience with a situation like this. Any advice?

Thanks.
No great advice here - just offering support.

Sorry Man. That sucks. I have had a few rejection letters in my day (first round of medical school applicants). Every letter I opened was like getting kicked in the balls.

Actually, I have a quick story - a zen/budda kinda thing.

A man in a village had his horse run away. The villagers came and let him know how sorry they were and said "this is so sad. This is the worst thing that could happen to you!" And the wise man said "good or bad, I don't know. I can't read the future. How do you know this is a bad thing?"

The next day, his horse came back with a new wild stallion. The villagers came and said "Horray for you! You now are the richest man in the village." the wise man said "good or bad, I don't know. I can't read the future. How do you know this is a good thing?"

The next day, the man's son who was taming the horse, fell off the wild stallion and breaks his leg. The villagers came and said "this is the worst thing that could happen. With no help to harvest your crops, you will likley starve this winter!" The wise man replied "good or bad, I can't say. How do you know this is a bad thing?"

The next day, war breaks out in the land, and soldiers came through gathering all eligible young men to fight - and they were all killed. The man's son didn't go because he had a broken leg.


Point is - and this has happened to me many many times - that life often forces us down a path that we don't want to go...we go screaming, clawing at the walls to keep us in our comfortable spot...but then after some time - we often look back and say "holy cow. This was the best thing that happened to me. I can't believe how lucky I am that I was forced in this direction."
 

pgg

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whats wrong with going out and getting a job as soon as humanly possible?
what is with all the fellowhship talk..
The cardiac guy at my place, I dont envy him!! I make more than him and he gets to sit in 5 hour boring cases with the same D**k surgeon.
I would do Critical care a million x over cardiac.
Has it occurred to you that different people can be happy doing different things?

The cardiac surgeons I work with are great people. Excellent surgeons. The thought of doing gyn or ortho all day with someone who loses 1500mL of blood in a five hour hysterectomy, or who refuses regional for his patients because a block will slow down his day, or some 15-banger colo/EGD assembly line GI day in a basement room smelling of poo ... man, give me the 5 hour "boring" case with an interesting echo, real professional dialogue with the surgeon, and the same tight knit team of people who are on their game every day.

Enjoy your hernias and c sections.
 

epidural man

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Has it occurred to you that different people can be happy doing different things?

The cardiac surgeons I work with are great people. Excellent surgeons. The thought of doing gyn or ortho all day with someone who loses 1500mL of blood in a five hour hysterectomy, or who refuses regional for his patients because a block will slow down his day, or some 15-banger colo/EGD assembly line GI day in a basement room smelling of poo ... man, give me the 5 hour "boring" case with an interesting echo, real professional dialogue with the surgeon, and the same tight knit team of people who are on their game every day.

Enjoy your hernias and c sections.
Haha.

This is funny. I love being in the robot prostate room. Takes forever - nothing happens...I can play craps on my phone all day long.
 

OTCAwesome

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Cardiac isn't rocket science, no need for fellowship if your market doesn't require it. I'm only boarded in Crit Care and have my basic TEE. Would way rather do a sick AF cardiac patient any day of the week over the Ortho trauma 98 yo hip fracture. Plus when we're not doing an off pump case, you have time to get stuff done or nap while on pump.

I do however agree by being a cardiac person you can get hosed occasionally, but for the CV team in my group it's more of a personal pride thing.
 

T-burglar

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Redouble your efforts and try to get into fellowship one more time if you love cardiac.

Has it occurred to you that different people can be happy doing different things?

The cardiac surgeons I work with are great people. Excellent surgeons. The thought of doing gyn or ortho all day with someone who loses 1500mL of blood in a five hour hysterectomy, or who refuses regional for his patients because a block will slow down his day, or some 15-banger colo/EGD assembly line GI day in a basement room smelling of poo ... man, give me the 5 hour "boring" case with an interesting echo, real professional dialogue with the surgeon, and the same tight knit team of people who are on their game every day.

Enjoy your hernias and c sections.
Exactly.

The only days I like going to work are my CT and structural days, on my general days I watch the clock.

Cardiac isn't rocket science, no need for fellowship if your market doesn't require it. I'm only boarded in Crit Care and have my basic TEE. Would way rather do a sick AF cardiac patient any day of the week over the Ortho trauma 98 yo hip fracture. Plus when we're not doing an off pump case, you have time to get stuff done or nap while on pump.

I do however agree by being a cardiac person you can get hosed occasionally, but for the CV team in my group it's more of a personal pride thing.
It’s amazing to me that anesthesiologists will say “you don’t know what you don’t know” when shaking their heads at nurses thinking they are as good as doctors at anesthesia, then turn around and scoff at formal training in state of the art cardiac
 
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DM27

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The ACTA fellowship process is a very fickle one. Most of the fellowships are on the smaller side (<5 spots) and there is a large trend towards filling internally. I remember having to somewhat reorganize my rank list and who I was emailing based on some (ultimately correct) rumors about a few places filling internally.

You ultimately need to play a numbers game and even a good number of interviews can mean little if most are at programs who usually fill most spots internally. If you’re coming from a program without a fellowship it totally removes that safety net of sorts and also removes you from the very important fellowship PD connection network that sometimes is all that really matters when it comes to getting that spot.


Getting an ICU spot and then trying to match ACTA after it is a reasonable strategy but with a high risk of an extra year without attending income and is also contingent on if you like critical care. There are quite a few ACTA programs out there that are basically forced to take accepted ICU fellows who dual apply so that is one strategy. ICU is currently much less competitive and I know of one or two people who used the ICU fellowship part of the dual application to basically strong arm their way into a normally region-locked or internal applicant dominated ACTA spot.
 

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It’s amazing to me that anesthesiologists will say “you don’t know what you don’t know” when shaking their heads at nurses thinking they are as good as doctors at anesthesia, then turn around and scoff at formal training in state of the art cardiac
Yeah ...

On the flip side, there are a lot of cardiac practices that aren't state of the art. One of the places I moonlight has just one cardiac surgeon, and nearly all of the cases he does are normal EF CABGs. I've done about 25 or 30 CABGs with him, one valve replacement (endocarditis). No VADs or transplants. I sometimes cover the cath lab there or push drugs for cardiologists doing TEEs or cardioversions, but they aren't doing TAVRs, clips, etc.

The first day I worked there, the tech and nurses were surprised when I asked for the ECG cables for the echo machine. They had to go find them, because no one had ever used them before. They didn't understand why echo machines had ECG cables, and apparently neither did any of the anesthesiologists who worked there previously.

When people say things like "cardiac isn't rocket science" ... these are the places they're talking about, where (almost) anyone can at least limp through the cases.
 

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The ACTA fellowship process is a very fickle one. Most of the fellowships are on the smaller side (
You ultimately need to play a numbers game and even a good number of interviews can mean little if most are at programs who usually fill most spots internally. If you’re coming from a program without a fellowship it totally removes that safety net of sorts and also removes you from the very important fellowship PD connection network that sometimes is all that really matters when it comes to getting that spot.


Getting an ICU spot and then trying to match ACTA after it is a reasonable strategy but with a high risk of an extra year without attending income and is also contingent on if you like critical care. There are quite a few ACTA programs out there that are basically forced to take accepted ICU fellows who dual apply so that is one strategy. ICU is currently much less competitive and I know of one or two people who used the ICU fellowship part of the dual application to basically strong arm their way into a normally region-locked or internal applicant dominated ACTA spot.
Talking about strong arming. Icu first years and then applying for cardiac again? Or applying for dual?
 
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ICU is a better fellowship to do anyway. You are a whole different physician as an icu doc. With cardiac and peds and ob etc etc you are another anesthesiologist. pain and Icu is where it's at.
 

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Thoughts about doing cardiac with icu to be a better icu doc in a cardiac settting?
 
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Thoughts about doing cardiac with icu to be a better icu doc in a cardiac settting?
Just go to a CCM fellowship that includes plenty of cardiac ICU and echo training, if that's your goal (plenty to choose from). One doesn't have to be trained in CT anesthesia to be good in the CVICU. Having a closer working relationship with the surgeons may be helpful, but in the end, what's going to make it break your patients is your critical care knowledge.
 

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Thoughts about doing cardiac with icu to be a better icu doc in a cardiac settting?
IMO the only way this makes sense is if you want to do academics. Even then, the 2 guys I know who have done this spend like 1 day a week in the OR. This isn’t really enough to stay proficient IMO for the high level cases. There is very little utility for the dual fellowship in PP unfortunately. You would do very little ICU. They want you in the OR cranking out RVUs.
I’m sure there are places that my generalizations would not apply, but my comments are based on what I’ve seen out here in practice
 
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Do not waste time on a critical care fellowship unless your heart is in it, especially if it is a means to an end. Even then, be very skeptical. Better do a regional fellowship, if you lack excellent skills; it will have a better return on investment.

Nobody gives a rat's ass about ICU docs being better anesthesiologists than the average generalist. Bean counters want just good enough (see CRNAs). The only reason to do critical care is to (almost) give up anesthesia and practice critical care. Same for pain.

This is something nobody told me before my fellowship. I see all these idealistic graduates going into CCM in a market that doesn't care, and I wonder WTF are their mentors doing? All those ivory tower wiseguys, who have not practiced a day in PP, should not be allowed to mentor.

But then the country is still full of fools going into anesthesiology residency, even when they have better choices, instead of heeding @Consigliere's advice. So why would fellowship decisions be smarter?
 
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It’s amazing to me that anesthesiologists will say “you don’t know what you don’t know” when shaking their heads at nurses thinking they are as good as doctors at anesthesia, then turn around and scoff at formal training in state of the art cardiac
Well, unlike the nurses, all anesthesiologists have a shared eight years of medical training. Many also had upwards of six months of cardiac anesthesia, maybe with additional echo rotations during residency. That all makes the gap in knowledge and experience between an interested generalist and a newly graduated fellow rather narrow. Add to that a job that includes good mentors with formal training, SCA and ASE conferences, and other CME, and getting more practice with mentors providing feedback, and a similar degree of competence with TEE can be obtained, thus narrowing the gap even further.

At my current practice, we have about eight of us on the cardiac team, taking cardiac call. I believe three are CT fellowship trained, and they make up the structural sub-team. They do the TAVRs, mitra-clips, perc-mitrals, and will be doing the VADs when that program gets started. One surgeon will further request that only two of them do his more complex valves (for some reason, he just doesn't like the third guy). The rest of us do the on or off-pump CABGs, single valves, aortic cases, etc. Our chief of cardiac, though, wants to expand the structural team, and train up those of us on the general cardiac team that have demonstrated a high level of proficiency both with echo (APTE testamurs) and taking care of sick patients. It is possible to continue to learn new things after completing residency or fellowship.
 

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Talking about strong arming. Icu first years and then applying for cardiac again? Or applying for dual?
When you dual apply you interview for both cardiac and ICU during the same interview season, and often the same day at some institutions. I do not know the specifics of how the order is decided for starting, but all of the people I knew did ICU with the Cardiac start date deferred to the next year.

The “strong arming” I mentioned is basically you interviewing at a program where you like the ICU and Cardiac and the ICU program likes you back etc. You make it clear that you don’t want to move again etc and you want to do both fellowships at the same place. This results in the ICU PD strongly requesting the Cardiac PD to consider you. Assuming you’re objectively a good applicant this can often result in getting interviews at places, and possibly matching, at somewhere that otherwise may only consider applicants from specific regions or internally simply by virtue of how much easier it is to get your foot in the door on the ICU side.

The added advantage of the deferring the Cardiac year to the following cycle, is basically you are matching into a future cycle where the eligible residents are currently barely known CA-1s and likely there have been no implicit agreements yet.
 
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ICU is a better fellowship to do anyway. You are a whole different physician as an icu doc. With cardiac and peds and ob etc etc you are another anesthesiologist. pain and Icu is where it's at.
I won't argue that ICU and pain will make you a different kind of physician. Whether the market does, or will continue to, or will ever, reward that differentiation is another issue. Life isn't fair and neither is the job market.

I wonder about pain especially. A lot of that lucrative interventional work is on thin ice with regard to actual efficacy, and eventually someday payers will probably stop paying for stuff that doesn't work. Opiate rx pill mills are gone.

RIght or wrong, the market is rewarding the hell out of cardiac trained people right now. Will that continue? I hope so. ;)
 

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I definitely felt that Cardiac was the overall most useful of fellowships, mainly because even if you ultimately don’t do cardiac for a living, the ultrasound/echo skills, familiarity with very advanced pathology, and repetitive line placement are all training that will serve you well. Also you get (accurately or not) stereotyped into being able to “do anything” once you’ve done the fellowship.

The other fellowships we can do, while very useful, do not seem to translate into especially strong sentiments about skills outside the purview of unrelated cases.
 

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Honestly, cardiac anesthesia has more of a mythical standing than anything else. Mostly because people who suffer through the tougher cardiac fellowships are a select group (many top and chief residents). I don't think there is much they learn during the fellowship that would really make a big difference for 98% of non-cardiac cases, when compared to a good generalist coming from a good residency (but I'm open to be contradicted). What I am trying to say is that many cardiac anesthesiologists are good because they were good anesthesiologists even before the fellowship.

Inducing a low EF patient (or other ASA 4 patient) is not rocket science. Placing lines, same. Doing a trauma, same. Thoracic with a good surgeon, same. Vascular, unless open AAA or intrathoracic, same. Most of it is a matter of experience, not specialized knowledge (e.g. TEE).

Once open-heart surgery goes down the toilet, so should cardiac anesthesia (as a fellowship). The main reason to do a cardiac fellowship is to do complex open-heart and intrathoracic surgeries (e.g. lung transplants).

Bean counters are not stupid. If they can get away with generalists doing "healthy" CABGs, they will not pay extra for the fellowship-trained guy. Just look at regional.
 
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Man o War

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Honestly, cardiac anesthesia has more of a mythical standing than anything else. Mostly because people who suffer through the tougher cardiac fellowships are a select group (many top and chief residents). I don't think there is much they learn during the fellowship that would really make a big difference for 98% of non-cardiac cases, when compared to a good generalist coming from a good residency (but I'm open to be contradicted). What I am trying to say is that many cardiac anesthesiologists are good because they were good anesthesiologists even before the fellowship.

Inducing a low EF patient (or other ASA 4 patient) is not rocket science. Placing lines, same. Doing a trauma, same. Thoracic with a good surgeon, same. Vascular, unless open AAA or intrathoracic, same. Most of it is a matter of experience, not specialized knowledge (e.g. TEE).

Once open-heart surgery goes down the toilet, so should cardiac anesthesia (as a fellowship). The main reason to do a cardiac fellowship is to do complex open-heart and intrathoracic surgeries (e.g. lung transplants).

Bean counters are not stupid. If they can get away with generalists doing "healthy" CABGs, they will not pay extra for the fellowship-trained guy. Just look at regional.
Except that catheter based stuff is the wave of the future....and the interventional cardiologists rely heavily on us for those procedures. I think cardiac anesthesia will still be in demand, the training may just evolve with the advances in IC.