Didn't Match into Cardiac Fellowship.....Thoughts and Advice?

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As I saw in fellowship, TEE exposure and training greatly varies across programs. Some of my co-fellows when they started barely knew a few basic views, much less the full exam and what to look for. That’s fine for them because they very quickly were brought up to speed. I was basically the only one who could do a full (but not very good) exam and could name almost all the basic structures, but I also went after cardiac cases and did a TEE elective (highly recommended).

After what I saw in fellowship and the minimal exposure the residents I worked with got to TEE, I’d be pretty reluctant to take a new grad onto our cardiac team unless they can prove some sort of TEE proficiency. The training out there is way, way too heterogenous.

Side note, the structural stuff is pretty overrated. There’s been some talk about restructuring TEE reimbursement led by the ASE (right now, it’s embarassingly low especially from CMS), and if that happens expect Cardiology to come and bill for those exams. When actual money is on the line, there will be no shortage of folks coming out of the woodwork. This is why we focus our efforts in the OR rather than the cath lab.
 
Man o War said:
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.
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where i work they do sedation for the tavr and if they do echo its another cardiologist
 
PieOHmy said:
where i work they do sedation for the tavr and if they do echo its another cardiologist
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It's never been like that anywhere I've worked, trained, or moonlit. Those guys/gals don't want to sit around and wait for a cardiologist when they have an anesthesiologist sitting right there who can do it. I suppose it's a function of how busy everybody is, but that seems terribly inefficient.
 
OP, have you thought about a transplant fellowship? Those are big cases. Also, it’s not an ACGME fellowship so you can be paid more to be an attending half the year. Just something to consider.
 
pgg said:
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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Interventional pain is dying - maybe a new procedure will keep it alive a little longer with regenerative therapies but who knows. Pain treatment that really works won’t ever get covered (intensive outpatient rehab programs) so what is the value of a the future pain physician? It’s looking dismal.
 
Man o War said:
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.
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That's what we said in the initial days of EP and IC, and now those procedures are done with CRNAs.
 
Yeah how many EP and IC cases require very specialized TEE guidance though?

Structural interventions will explode, it is the growth area in medicine , and CT anes will provide the TEE guidance at reputable shops .

If your cardiologists are doing the TEEs for these, it’s because the anesthesia offering was so inadequate that the cardiology department decided they would eat the cost just to have good image guidance
 
T-burglar said:
Yeah how many EP and IC cases require very specialized TEE guidance though?

Structural interventions will explode, it is the growth area in medicine , and CT anes will provide the TEE guidance at reputable shops .

If your cardiologists are doing the TEEs for these, it’s because the anesthesia offering was so inadequate that the cardiology department decided they would eat the cost just to have good image guidance
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I honestly don't know the reasons, but this is how it's done at my program. Structural heart stuff, TEE is done by the cardiologist.

Also almost all our TAVRs are done with a light MAC and under fluoroscopy.
 
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So CCM/CT is much less competitive than CT alone? I probably want to do CCM alone but CT also sounds interesting. That said 2 years of fellowship sound like suicide
 
ToKingdomCome said:
So CCM/CT is much less competitive than CT alone? I probably want to do CCM alone but CT also sounds interesting. That said 2 years of fellowship sound like suicide
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I am in the same boat as you with the exact same thoughts. Hope we make the most valid decision when the time comes, in 4 months for me
 
AdmiralChz said:
After what I saw in fellowship and the minimal exposure the residents I worked with got to TEE, I’d be pretty reluctant to take a new grad onto our cardiac team unless they can prove some sort of TEE proficiency. The training out there is way, way too heterogenous.
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Would you be willing to take a fresh grad w/ no fellowship onto your heart team if they passed the advanced PTE exam? To give the residents out there a better picture. What kind of practice are you in? big city/small city? VADs and heart failure?
 
abolt18 said:
Also almost all our TAVRs are done with a light MAC and under fluoroscopy.
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There are some big name places doing straight-forward medium and low-risk TAVRs with RN fentanyl/versed sedation with zero anesthesia involvement. I thoroughly enjoyed doing a big general TEE TAVR case in residency and fellowship but those are going the way of the dodo. Now a cardiologist comes in and does a minimal TTE to check for PVL and done.
 
dchz said:
Would you be willing to take a fresh grad w/ no fellowship onto your heart team if they passed the advanced PTE exam? To give the residents out there a better picture. What kind of practice are you in? big city/small city? VADs and heart failure?
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My practice: Mid-sized city suburban PP. Pseudo-academic hospital, VADs, HF and heart transplants (no lungs or livers) but honestly it's at least 75% straight-forward CABGs and valves. Structural cases (Clips, Watchman) have TEEs done by Cardiology. Some of our very old surgeons don't even want a TEE for their aortic valves.

So yeah, we would definitely consider taking a fresh grad onto our team but most politely decline or run for the hills when we talk about it at the interview. Probably half of us have done a true ACTA fellowship (the rest just did a 3-6 month mini-fellowship at the end of residency as was common in the 1990s when Anesthesia expanded by a year). It's a rare thing to see a new grad take the advanced PTE exam, it would definitely help but if I was in charge I'd want to 1) see your TEE log to check for numbers and case variety and 2) Ask someone in your program about your TEE skills and exposure. I think it would show pretty quickly if he or she didn't have the skills and we'd quickly act to get you off the team or send you to a review course, depending on our staffing.
 
AdmiralChz said:
Probably half of us have done a true ACTA fellowship (the rest just did a 3-6 month mini-fellowship at the end of residency as was common in the 1990s when Anesthesia expanded by a year).
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I think anesthesia expanded to 3 years in the mid 1980s and those finishing in 1988 or 1989 were the first class to complete a required CA-3 year.
 
AdmiralChz said:
There are some big name places doing straight-forward medium and low-risk TAVRs with RN fentanyl/versed sedation with zero anesthesia involvement. I thoroughly enjoyed doing a big general TEE TAVR case in residency and fellowship but those are going the way of the dodo. Now a cardiologist comes in and does a minimal TTE to check for PVL and done.
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Now that's crazy to me. Just last week we were doing TAVRs. Last one of the day went from going fine to acute tamponade in moments. No one but me and my attending were paying attention to her or her vitals. My attending immediately took control of the room, demanded the sonogropher come in the room, told the cardiologist to stop what he was doing and do a pericardial drain. After the drain just kept dumping and dumping bright red blood, they put her on ECMO, we tubed her and were managing hemodynamics. Near the end, my attending guided the decision-making in a way that I believe optimized her chances of a good outcome.

She was walking around the ICU last night, getting ready to go to the step down unit. Having only a sedation nurse there, she would not have had the same outcome, of that I feel quite certain.
 
abolt18 said:
Now that's crazy to me. Just last week we were doing TAVRs. Last one of the day went from going fine to acute tamponade in moments. No one but me and my attending were paying attention to her or her vitals. My attending immediately took control of the room, demanded the sonogropher come in the room, told the cardiologist to stop what he was doing and do a pericardial drain. After the drain just kept dumping and dumping bright red blood, they put her on ECMO, we tubed her and were managing hemodynamics. Near the end, my attending guided the decision-making in a way that I believe optimized her chances of a good outcome.

She was walking around the ICU last night, getting ready to go to the step down unit. Having only a sedation nurse there, she would not have had the same outcome, of that I feel quite certain.
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This is exactly why our cardiologists don’t do it that way.
Sometimes pushing the envelope on these things is not a great idea.
If I were having a TAVR, I sure as heck wouldn’t want it done with a sedation nurse.
 
abolt18 said:
Now that's crazy to me. Just last week we were doing TAVRs. Last one of the day went from going fine to acute tamponade in moments. No one but me and my attending were paying attention to her or her vitals. My attending immediately took control of the room, demanded the sonogropher come in the room, told the cardiologist to stop what he was doing and do a pericardial drain. After the drain just kept dumping and dumping bright red blood, they put her on ECMO, we tubed her and were managing hemodynamics. Near the end, my attending guided the decision-making in a way that I believe optimized her chances of a good outcome.

She was walking around the ICU last night, getting ready to go to the step down unit. Having only a sedation nurse there, she would not have had the same outcome, of that I feel quite certain.
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It also depends on the skill of cardiologists. I also come from a place where the cardiologists like to poke holes in the heart...

But imagine if the cardiologist never pokes a hole in the heart. like ever.
 
T-burglar said:
Redouble your efforts and try to get into fellowship one more time if you love cardiac.



Exactly.

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



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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So just because I'm not fellowship trained outside of ICU, I can't learn anything else.... Currently I do clips, watchman's, all valves and Arch work...... I'm sorry physicians can learn to expand their knowledge Base
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It ultimately depends on who does the echo at institutions. As structural heart gains a larger share of case volume, cardiac trained anesthesiologists comfortable with somewhat advanced 3D imaging will be a premium at institutions where anesthesiologists do the perioperative TEE for these cases. At institutions where this is not the case, the relevance will likely go down.
 
FFP said:
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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I have to say that I respect and listen to your opinions a lot but I utterly disagree with you on critical care.

The saviour of anesthesia in the fight against nurses is our value in icu, cardiac and peds. I firmly believe icu is better when we are there.

And our lot is better when we are entrenched in the power levels of hospitals such as icu, bed mgt and putting manners on surgeons.

So I say do ICU and buddy it with cardiac and in 10 years time when your job is secure you may be glad you did. We are not technicians.
 
Newtwo said:
I have to say that I respect and listen to your opinions a lot but I utterly disagree with you on critical care.

The saviour of anesthesia in the fight against nurses is our value in icu, cardiac and peds. I firmly believe icu is better when we are there.

And our lot is better when we are entrenched in the power levels of hospitals such as icu, bed mgt and putting manners on surgeons.

So I say do ICU and buddy it with cardiac and in 10 years time when your job is secure you may be glad you did. We are not technicians.
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I couldn't agree more. Unfortunately, the bean counters (including anesthesia department chiefs) disagree, and don't see the value of anesthesiologist-intensivists, especially now that the periop surgical home has quietly died off. Hence (good) ICU jobs are scarce, mostly academic and surgical (especially CT, which is a no-no if you don't like cardiac surgical egos). And, in many places, critical care is paid less for the same/more labor (one of the reasons I still practice anesthesia).

Most ICUs are MICUs, and pulmonologists are holding on to their turf (which American anesthesiologists have given up, idiotically, unlike most other countries). Many community hospitals won't let one practice in the MICU if not IM-boarded, especially if they have a residency program with its ridiculous RRC requirements (apparently you're too dumb to teach IM geniuses if you're boarded in critical care through something else than ABIM). Our professional organizations don't do much if any work on this front (I'm looking at you, SOCCA), so nothing will change. Why give up a year of attending salary, compounded over 20+ years, for this?

My wife was just telling me about a newspaper article saying that doctors work 40% more than a decade ago, for the same money. So not only did our salaries stagnate (my colleagues used to make 300k for solo mommy track in 2009 - now it's 250), despite inflation, but we are also dealing with more crap. Apparently, there are now 10 leeches administrative employees for every single physician. Why waste hundreds of thousands of dollars on training with poor return on investment, like most anesthesia fellowships? Anesthesiologists should work their butts off while still young, invest all that money early, and focus on compounding, passive income and retiring early. Study FIRE, not critical care.
 
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Could be a blessing in disguise OP. If you find the right job, you may have just earned an extra 300-400k in earnings.
 
What does a liver transplant fellowship look like? I’m imagining 50% pay. 75% home call. 110% breakgiver?

Something to ask yourself when considering fellowships. How would you feel about being told you’re going to do more of that specialty in your eventual practice? Where do you plan on practicing ultimately? Are there a lot of people to split the call pool with? If joining a small call pool, what happens when someone leaves or goes on vacation? Maybe this means more easy home call that pays well? Maybe it means you’re on call until your partner gets back from vacation or hospital administration pays more than you actually get for spotty locums coverage. (Cough parents cough) If ICU bills less and all of the sudden there is a shortage of coverage, is that going to be you whether you like it or not. I’m all for learning to be a better doctor and the clinical exposure you’d get from an ICU fellowship, but i really like anesthesia and the variety of being a generalist.

Can you stay on as junior staff at your residency program and work on your application while getting over new attending jitters of being on your own in a familiar environment with a backup system you understand?
 
dchz said:
Would you be willing to take a fresh grad w/ no fellowship onto your heart team if they passed the advanced PTE exam? To give the residents out there a better picture. What kind of practice are you in? big city/small city? VADs and heart failure?
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I will say that from my experience with the Advanced PTE Exam, it is not much of a reflection at all of your ability to perform a dynamic TEE. Someone who is competent with TEE should be able to pass the exam, but someone who can pass the exam is not necessarily at all competent with TEE.

Interpreting images (even bad ones) is infinitely easier than being able to competently acquire them.
 
DM27 said:
I will say that from my experience with the Advanced PTE Exam, it is not much of a reflection at all of your ability to perform a dynamic TEE. Someone who is competent with TEE should be able to pass the exam, but someone who can pass the exam is not necessarily at all competent with TEE.

Interpreting images (even bad ones) is infinitely easier than being able to competently acquire them.
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Completely agree, hence my question.
 
FFP said:
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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Where I practice, the trend is very different than what you describe. CT surgery generates solid revenue for most of the hospitals. CABG referrals seem to be ramping up. I am part of a group (PP) that does about 350-ish hearts per year and the numbers are going up. The cardiologists are stenting more and more of the baby boomers and getting their fill. They have no interest in doing high risk or even complex PCI cases and our CT surgeons are busy as heck. CT will lose some valve cases to interventional but open heart isn't going anywhere in our lifetime. Just like coronary work, there will be a chunk of valve work taken away by cardiology but people will always need open heart surgery.

On that note, CT surgeons in my area want CT anesthesia more than ever. When new surgeons come in they want CT anesthesia only. They want echo. They want guys who know what's going on when **** hits the fan. I know several hospitals in my area that are now requiring CT fellowship and NBE certification. The bean counters care about bringing in case volume and keeping the surgeons happy, more than anything.

Also, the difference in pay between CT and general in my area is only around 15-25k....
 
Echo33 said:
Where I practice, the trend is very different than what you describe. CT surgery generates solid revenue for most of the hospitals. CABG referrals seem to be ramping up. I am part of a group (PP) that does about 350-ish hearts per year and the numbers are going up. The cardiologists are stenting more and more of the baby boomers and getting their fill. They have no interest in doing high risk or even complex PCI cases and our CT surgeons are busy as heck. CT will lose some valve cases to interventional but open heart isn't going anywhere in our lifetime. Just like coronary work, there will be a chunk of valve work taken away by cardiology but people will always need open heart surgery.

On that note, CT surgeons in my area want CT anesthesia more than ever. When new surgeons come in they want CT anesthesia only. They want echo. They want guys who know what's going on when **** hits the fan. I know several hospitals in my area that are now requiring CT fellowship and NBE certification. The bean counters care about bringing in case volume and keeping the surgeons happy, more than anything.

Also, the difference in pay between CT and general in my area is only around 15-25k....
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Wait. So what you are saying is that even though CT anesthesiologists are required for such “complex” cases or with new surgeons, their pay is only 15-25k more than generalists?
 
Echo33 said:
Where I practice, the trend is very different than what you describe. CT surgery generates solid revenue for most of the hospitals. CABG referrals seem to be ramping up. I am part of a group (PP) that does about 350-ish hearts per year and the numbers are going up. The cardiologists are stenting more and more of the baby boomers and getting their fill. They have no interest in doing high risk or even complex PCI cases and our CT surgeons are busy as heck. CT will lose some valve cases to interventional but open heart isn't going anywhere in our lifetime. Just like coronary work, there will be a chunk of valve work taken away by cardiology but people will always need open heart surgery.

On that note, CT surgeons in my area want CT anesthesia more than ever. When new surgeons come in they want CT anesthesia only. They want echo. They want guys who know what's going on when **** hits the fan. I know several hospitals in my area that are now requiring CT fellowship and NBE certification. The bean counters care about bringing in case volume and keeping the surgeons happy, more than anything.

Also, the difference in pay between CT and general in my area is only around 15-25k....
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I have also experienced a similar trend to this. Two different places where I worked started doing more high-risk cath (utilizing Impella etc.) and quickly seemed to decide it wasn't worth the time with their overall high volume. As a result, we continued to have a steady increase in CABG referrals which seems against the prior national trend. Where I am working now the same thing just happened, there was an initial uptick in high-risk cath utilizing augmentation devices such as Impellas, then after a few months they seemed to come to the same conclusion and our CABG numbers have increased from the prior year.

At most academic places I have interviewed in the past the difference between CT and Non-CT pay is also minimal to non-existent, the main difference is being CT actually GETS you the job.
 
Dam272 said:
Wait. So what you are saying is that even though CT anesthesiologists are required for such “complex” cases or with new surgeons, their pay is only 15-25k more than generalists?
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Really hard to generalize between groups. As an example, in our group the difference between a Generalist partner vs CT is around 125k. Every group is going to be different depending on how they want to set up their compensation model
 
Dam272 said:
Wait. So what you are saying is that even though CT anesthesiologists are required for such “complex” cases or with new surgeons, their pay is only 15-25k more than generalists?
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Yes this is very often the case, on the surface.

The longer answer is that most groups negotiate higher rates for cardiac call and a lot of people take a lot of it - so cardiac attendings can make substantially more $ but also work substantially more. On a per hour worked basis, minimal difference. The field attracts workaholics for sure - it’s not unreasonable to say I’d do just as well being a full generalist. But I enjoy what I do so that’s worth it for me.

You should do no fellowship (or residency for that matter) just to chase money, that’s a fool’s errand. Particularly in modern times - see Radiology, Diagnostic. Do something you enjoy and can see yourself doing for a career.

TEE reimbursement is, on average, abysmal. You can do all the advanced modeling 3D strain 8D printing of a mitral valve, but won’t net you much. It’s a very academic, esoteric practice once you get beyond the basics of 2D and live 3D imaging.
 
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Dam272 said:
Wait. So what you are saying is that even though CT anesthesiologists are required for such “complex” cases or with new surgeons, their pay is only 15-25k more than generalists?
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He’s right. You shouldn’t do a CT anesthesia fellowship for the money. You do it because you like CT anesthesia.
 
AdmiralChz said:
Yes this is very often the case, on the surface.

The longer answer is that most groups negotiate higher rates for cardiac call and a lot of people take a lot of it - so cardiac attendings can make substantially more $ but also work substantially more. On a per hour worked basis, minimal difference. The field attracts workaholics for sure - it’s not unreasonable to say I’d do just as well being a full generalist. But I enjoy what I do so that’s worth it for me.

You should do no fellowship (or residency for that matter) just to chase money, that’s a fool’s errand. Particularly in modern times - see Radiology, Diagnostic. Do something you enjoy and can see yourself doing for a career.

TEE reimbursement is, on average, abysmal. You can do all the advanced modeling 3D strain 8D printing of a mitral valve, but won’t net you much. It’s a very academic, esoteric practice once you get beyond the basics of 2D and live 3D imaging.
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Exactly

Although I'm not making a ton more than my patterns, I there are still perks

- I'm covering slightly less rooms per day than my colleagues and focusing more on tougher cases.
- I'm doing cases that interest me. Very little eyeball and GI stuff
- I'm compensated with a bit more vacation for the extra cardiac call
- I like my job. I like where I work. The only job opening was for cardiac so without it, I wouldn't have this job

But I agree, you do the fellowship because it interests you. It's going to take some time to make up for that lost year of salary. In my area, the major benefit of cardiac is job security.
 
Twiggidy said:
If you’re in this game for the money you’re better off doing hips, shoulders, lap cases, and ear tubes ...all which will have relatively healthier patients.
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All politics are local. Our shop the cardiac guys enjoy a nice differential, also our schedule revolves around theirs.
 
FFP said:
I couldn't agree more. Unfortunately, the bean counters (including anesthesia department chiefs) disagree, and don't see the value of anesthesiologist-intensivists, especially now that the periop surgical home has quietly died off. Hence (good) ICU jobs are scarce, mostly academic and surgical (especially CT, which is a no-no if you don't like cardiac surgical egos). And, in many places, critical care is paid less for the same/more labor (one of the reasons I still practice anesthesia).

Most ICUs are MICUs, and pulmonologists are holding on to their turf (which American anesthesiologists have given up, idiotically, unlike most other countries). Many community hospitals won't let one practice in the MICU if not IM-boarded, especially if they have a residency program with its ridiculous RRC requirements (apparently you're too dumb to teach IM geniuses if you're boarded in critical care through something else than ABIM). Our professional organizations don't do much if any work on this front (I'm looking at you, SOCCA), so nothing will change. Why give up a year of attending salary, compounded over 20+ years, for this?

My wife was just telling me about a newspaper article saying that doctors work 40% more than a decade ago, for the same money. So not only did our salaries stagnate (my colleagues used to make 300k for solo mommy track in 2009 - now it's 250), despite inflation, but we are also dealing with more crap. Apparently, there are now 10 leeches administrative employees for every single physician. Why waste hundreds of thousands of dollars on training with poor return on investment, like most anesthesia fellowships? Anesthesiologists should work their butts off while still young, invest all that money early, and focus on compounding, passive income and retiring early. Study FIRE, not critical care.
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Best advice ever! No need to kill yourself to impress your colleagues or administrators. No one will care when you're 70 y/o. Just work hard, make and save as much as you can and call it.
 
ProRealDoc said:
Aren't most fellowships?
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I just feel like the main reason for doing a liver transplant fellowship is to give an indication to that particular institution that you want to stay there as faculty and do livers. While it may be attractive in a private practice candidates CV I’m not sure that particular risk is worth the reward
 
ProRealDoc said:

Liver Transplant Fellowship – Johns Hopkins Anesthesiology & Critical Care Medicine

anesthesiology.hopkinsmedicine.org anesthesiology.hopkinsmedicine.org

my.clevelandclinic.org

Liver Transplant Anesthesia Fellowship | Cleveland Clinic

The Anesthesiology Institute at Cleveland Clinic offers two positions in a one-year non- ACGME accredited fellowship in Liver Transplant Anesthesia.
my.clevelandclinic.org my.clevelandclinic.org
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Hm basic echo certification? Do you place TEEs for liver? I’m not sure what it tells you that’s worth the risk of placement with varices. If not, how would you manage to perform 50 TEE exams required for the basic certification without cardiac cases? If this is elective time bouncing between cardiac rooms for TEE experience while paid as a fellow why not at least aim for the advanced?
 
ProRealDoc said:
Aren't most fellowships?
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To some degree yes, but liver especially. The pathway that one would take for that fellowship is likely staying on as faculty. Not enough livers to do them every day, and you'd likely be supervising residents. Also likely working part time as a regular attending. Im sure one would learn a lot, but it just sounds like more of a job than a fellowship.
 
Echo33 said:
. They want guys who know what's going on when **** hits the fan. I know several hospitals in my area that are now requiring CT fellowship and NBE certification.....
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1. They want guys who know what's going on when **** hits the fan but they are not willing to pay for it. same old story
 
SnapperRocks said:
Hm basic echo certification? Do you place TEEs for liver? I’m not sure what it tells you that’s worth the risk of placement with varices. If not, how would you manage to perform 50 TEE exams required for the basic certification without cardiac cases? If this is elective time bouncing between cardiac rooms for TEE experience while paid as a fellow why not at least aim for the advanced?
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I know they place TEE for most of our livers without them bleeding to death from exploded varices.
 
The point of the liver fellowships is that it provides an alternative avenue for someone coming from a lower tier residency program with little-to-no exposure to complex cases to gain an extra set of skills and enable them to be an active participant in PP cardiac group. I wouldn't look down on someone who can do an open TAAA (without the luxury of CPB back-up), thoracic or major vascular cases because they lack a CTA fellowship or advanced TEE certification.

See the Hopkins curriculum below and tell me someone out there couldn't benefit from the extra practice these cases would provide? Most everyone is not trained like the SDN rockstars present in this forum.

Fellows will advance their medical knowledge through a number of didactics. Fellows will be required to participate in Resident lecture series (given by faculty and fellows every two weeks), in monthly quality assurance/quality improvement meetings dedicated to transplant patients, attend at least monthly the Liver Transplant Selection Committee held weekly, and complete the transesophageal echocardiogram curriculum and quality improvement along with the Cardiac Anesthesia Fellows.
Patient Care
Fellows will spend time assisting in management of complex anesthesia cases including but not limited to liver transplantation, vascular and thoracic cases. Fellows will also take liver transplant anesthesia call in which they will sometimes provide direct supervision to rotating residents. The educational objectives during this time include:
  • Improvement in procedural skills (arterial catheter, central line insertion, pulmonary artery catheter, flexible fiberoptic intubation, and transesophageal echocardiography)
  • Establish proficiency in the evaluation and management of end-stage-liver disease including
    • Preoperative assessment
    • Anesthetic management
    • Post-operative recovery
  • Establish proficiency in administration of anesthesia for liver transplantation including:
    • Operating room set-up for cadaveric liver transplants, living liver donor and living donor liver transplantation
    • The stages of the case and their implications on patient management
    • Reperfusion management
    • Hepatopulmonary syndrome
    • The association of pulmonary hypertension with ESLD and its management implications
    • Hepatorenal syndrome
    • Rapid infuser use
    • Management of patients with complications of cirrhosis, including portal hypertension, hemodynamic alterations, cirrhotic cardiomyopathy, hepatopulmonary syndrome, portopulmonary hypertension, and hepatorenal syndrome
    • Management of patients with acute liver failure
  • Establish proficiency in administration of anesthesia for:
    • Open thoracic and thoracoscopic (VATs) cases including esophagectomy cases
    • Vascular cases including thoracoabdominal aortic aneurysm cases
    • Simultaneous liver and kidney transplantation
    • Pancreas transplantation
    • Kidney transplantation
  • Achieve certification in basic TEE
  • Establish proficiency in management of coagulopathy, in the selection and use of the various available blood products and their associated potential complications.
 
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Some places will almost always place TEE for livers. We place them rarely, I would say maybe 1 out of 25 has hemodynamic issues following reperfusion to a degree that we ultimately place a TEE. It is similar to PA catheters, some places will place a PA catheter for all livers, some will place them situationally, some will never place them.
 
That a particular fellowship's justification for existence is to compensate for poor residency training is hardly a ringing endorsement of its inherent value as a fellowship.

Of course a year spent doing complex cases is going to be good for you, and your marketability. And maybe being someone's bitch at a particular location for a while will get your foot in the door. Doing it at 1/4 your market value is the thing that raises eyebrows.
 
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