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

[deleted697127]

I know they place TEE for most of our livers without them bleeding to death from exploded varices.

Complications related to intraoperative transesophageal echocardiography in liver transplantation

Intraoperative transesophageal echocardiography (TEE) has commonly been used for evaluating cardiac function and monitoring hemodynamic parameters during complex surgical cases. Anesthesiologists may be dissuaded from using TEE in orthotopic liver transplantation ...

www.ncbi.nlm.nih.gov

This is the data for TEE placement complications vs utility at Mayo. Apparently performed in 12% of their liver transplants from 2003-2013. 1/232 had an acute variceal bleed with blood noted in the mouth during probe placement which required intraop banding. I personally still wouldn’t do it routinely and would think hard before doing it emergently depending on preop variceal history.

Causing a complication requiring emergent consult and intervention is not a small consideration.

---

Members don't see this ad.

 

[Dam272]

Are there jobs out there in private after dual fellowships that let you practice CC in the ORs and CC-CCM ICU as well? Or after dual, in private one sticks to the OR primarily?

 

[ToKingdomCome]

Maybe

Are there jobs out there in private after dual fellowships that let you practice CC in the ORs and CC-CCM ICU as well? Or after dual, in private one sticks to the OR primarily?

I think it’s mostly academics. Unreasonable to make > 300k in east coast academics doing CCM/anesthesia?

 

[deleted171991]

Maybe


I think it’s mostly academics. Unreasonable to make > 300k in east coast academics doing CCM/anesthesia?

You can make even 500K, I bet, if you never leave the hospital.

So you're asking the wrong question. The right question also includes the workload.

 

[T-burglar]

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.

Yeeeeaaahhh this fellowship wouldn’t get you into any sought after cardiac PP groups. In 2019 private hospitals want certified advanced and for good reason. It’s kind of baffling to me that you think basic certification qualifies you to do valves and structural.

People in our specialty love to say that livers are “the most complicated case in anesthesia.” That is a sentiment left over from when anesthesia didn’t have the entire field of echocardiography in its purview.

 

[ToKingdomCome]

You can make even 500K, I bet, if you never leave the hospital.

So you're asking the wrong question. The right question also includes the workload.

Well the problem is, aren’t most if not all academics salary so your basically going to be capped in terms of annual income?

 

[deleted162650]

Well the problem is, aren’t most if not all academics salary so your basically going to be capped in terms of annual income?

Usually you can pick up additional calls for more money. Depending on the department, the call structure, and your sub specialty, you can actually do pretty well in academics.

 

[ToKingdomCome]

Usually you can pick up additional calls for more money. Depending on the department, the call structure, and your sub specialty, you can actually do pretty well in academics.

Why does it get such a bad rap then in terms of income? Sure, dealing with med students, politics, coming up with curriculum probably aren’t ideal but it seems like you could carve out a decent career financially which is contrary to what most people say on this board

 

[AdmiralChz]

Why does it get such a bad rap then in terms of income? Sure, dealing with med students, politics, coming up with curriculum probably aren’t ideal but it seems like you could carve out a decent career financially which is contrary to what most people say on this board

All things being equal, you’d make way more in an average PP working extra shifts than an equivalent amount in academics. True you can do well in some departments, but you’ll be working a crap ton. For the 2 large ivory towers in my state, It’s pretty much impossible to get to 50th percentile type income until you’re a division chief even with extra shifts. There’s a reason it’s so hard for departments to recruit.

 

[blockstar]

at our hospital cardiothoracic surgical icu requires triple boarded cardiac/ccm anes

 

[deleted171991]

at our hospital cardiothoracic surgical icu requires triple boarded cardiac/ccm anes

Academic hospitals do that. It's dumb. It's mostly so that the surgeons work with the same people in the ICU as in the OR.

 

[Dam272]

Academic hospitals do that. It's dumb. It's mostly so that the surgeons work with the same people in the ICU as in the OR.

Is that the future? Even in pp?

 

[psychbender]

Is that the future? Even in pp?

No. Not enough demand for this.

 

[psychbender]

Why does it get such a bad rap then in terms of income? Sure, dealing with med students, politics, coming up with curriculum probably aren’t ideal but it seems like you could carve out a decent career financially which is contrary to what most people say on this board

Academic jobs in my part of the country start people off around $270-300k (plus ok benefits worth maybe $50k). Extra call or late shifts at $150/hr can push it up a bit. Private groups in the same area are making $350-500k, with the lower ones maybe having a lower salary because they are benefits-heavy (>$100k benefits packages). Overall number of hours in the hospital are often similar between the two, so to close the pay gap, the academic folk have to work much harder.

Also, when I was interviewing at some academic practices, they had the attitude of you are there working a shift, often 7-5p, M-F, except for call. Even if you're not actively working, you are still there until 5pm, just in case. In the private realm, if you're done, you can often go home. Some groups employ a number system dictating who leaves in what order, so some days may end before noon.

A lot of the latter is culture, and other parts of the country are different regarding pay. A colleague of mine is killing it at a university in the midwest.

 

[ToKingdomCome]

Academic jobs in my part of the country start people off around $270-300k (plus ok benefits worth maybe $50k). Extra call or late shifts at $150/hr can push it up a bit. Private groups in the same area are making $350-500k, with the lower ones maybe having a lower salary because they are benefits-heavy (>$100k benefits packages). Overall number of hours in the hospital are often similar between the two, so to close the pay gap, the academic folk have to work much harder.

Also, when I was interviewing at some academic practices, they had the attitude of you are there working a shift, often 7-5p, M-F, except for call. Even if you're not actively working, you are still there until 5pm, just in case. In the private realm, if you're done, you can often go home. Some groups employ a number system dictating who leaves in what order, so some days may end before noon.

A lot of the latter is culture, and other parts of the country are different regarding pay. A colleague of mine is killing it at a university in the midwest.

Ugh. Thanks. This is frustrating for me since I want to do CCM and gas. Doubt this is even in the realm of possibility but what if I did anesthesia full time with private practice and then moonlighted in the ICU every now and then? That would give me the best of both worlds while also making me not miss out on income

 

[Dam272]

Ugh. Thanks. This is frustrating for me since I want to do CCM and gas. Doubt this is even in the realm of possibility but what if I did anesthesia full time with private practice and then moonlighted in the ICU every now and then? That would give me the best of both worlds while also making me not miss out on income

Good question. I am too in the same boat as you.

 

[psychbender]

Ugh. Thanks. This is frustrating for me since I want to do CCM and gas. Doubt this is even in the realm of possibility but what if I did anesthesia full time with private practice and then moonlighted in the ICU every now and then? That would give me the best of both worlds while also making me not miss out on income

The key is how much time off will you have, and will you do enough CCM to maintain skills and certification. Say you join a private anesthesia group with ten weeks of vacation, taking one weekend OR call per month. Are you going to spend eight of those vacation weeks in the unit? So much for time off. Only do five to six weeks, but throw an extra weekend per month in (assuming you can find a place to only cover an occasional weekend)?

There are a handful of private groups that also cover the ICU. These groups are rare, but exist. Other options include doing full time CCM (week on/off model) and doing part-time anesthesia during those off weeks. Or, find a place that both needs a good anesthesiologist, and an intensivist, and see if the group and the hospital are willing to work out a deal so that the hospital compensates the group for the time you are out of the OR (that's the setup at my current practice).

 

[rakotomazoto]

There are a couple of partners in my group who also work in the unit. To make it do-able, they are "part-time", doing about 0.6 to 0.7 FTE's plus their time in the unit. Average time off for us is 8 weeks among "full time" partners. Everyone seems quite happy with this arrangement, but from what I hear this type of gig is hard to find. Unfortunately, we are not hiring right now. But this type of set up does exist.

 

[ProRealDoc]

Yeeeeaaahhh this fellowship wouldn’t get you into any sought after cardiac PP groups. In 2019 private hospitals want certified advanced and for good reason. It’s kind of baffling to me that you think basic certification qualifies you to do valves and structural.

People in our specialty love to say that livers are “the most complicated case in anesthesia.” That is a sentiment left over from when anesthesia didn’t have the entire field of echocardiography in its purview.

Not sure what you mean by sought-after but I presume you mean jobs in large cities which are mostly AMC/academic jobs which are no longer big money jobs anyway. Most PP cardiac groups don't do mitral clips, TAVRs, watchman devices exclusively. They are a mixed bag of thoracic, cardiac, cathlab and possibly vascular cases. As result, having someone with a not-so-sexy liver fellowship, can still be an asset as they can be assigned to the less echo-heavy cases in your practice which I venture to say are >50%. Perhaps I'm more inclined to make efficient use of every member of the practice.

 

[DM27]

Ultimately, I think the liver fellowship basically buys you the sentiment of "this guy/gal probably will require less hand holding their first attending year than someone straight out of residency". The few people I know who have a role in hiring basically consider a fellowship year roughly equivalent to a year of prior job experience unless the fellowship is relating directly to the opening they are being hired for (cardiac fellow for cardiac team, etc.).

 

[AdmiralChz]

We aren’t hiring for cardiac, but if we were and I saw a liver transplant fellow my first question would by why are you applying to my group (that doesn’t do livers) and then they’d get put in the “fresh grad” pile. I wouldn’t consider it AT ALL a reasonable substitute for ACTA. TEE is an important tool, but there’s much more to those cases than that.

 

[T-burglar]

Not sure what you mean by sought-after but I presume you mean jobs in large cities which are mostly AMC/academic jobs which are no longer big money jobs anyway. Most PP cardiac groups don't do mitral clips, TAVRs, watchman devices exclusively. They are a mixed bag of thoracic, cardiac, cathlab and possibly vascular cases. As result, having someone with a not-so-sexy liver fellowship, can still be an asset as they can be assigned to the less echo-heavy cases in your practice which I venture to say are >50%. Perhaps I'm more inclined to make efficient use of every member of the practice.

I just think you have a nascent understanding of cardiac cases. There aren’t any that are “light echo” unless it’s an already screened CABG where the surgeon literally doesn’t even want to hear about the TEE findings except how nasty the aorta is. It’s totally inappropriate to ask a liver fellow to report an analysis of the mitral apparatus, in a mitral repair, to the surgeon. Diagnostic Imaging of valve disease is a massive and specialized skillset. Like admiralChz said, even beside the echo there’s a massive skillset to master revolving around cardiopulmonary bypass and cardiac surgery. If a liver fellow approached our group about joining our cardiac team we would think he needed to be investigated for diversion.

Just like if I walked into a children’s hospital and asked to join the team that takes care of complex neonates.

 

[deleted162650]

You cardiac guys like playing with those black snakes more than Kim Kardashian.

 

[Twiggidy]

You cardiac guys like playing with those black snakes more than Kim Kardashian.

Pay me enough I'll touch a dudes.....wait, what?

 

[DM27]

Outside of CABG there are really no cases I would consider even close to echo-lite. Even for our CABGs there is an expectation from the surgeons that the patients get a full exam just in case something was missed.

 

[pgg]

Not sure what you mean by sought-after but I presume you mean jobs in large cities which are mostly AMC/academic jobs which are no longer big money jobs anyway. Most PP cardiac groups don't do mitral clips, TAVRs, watchman devices exclusively. They are a mixed bag of thoracic, cardiac, cathlab and possibly vascular cases. As result, having someone with a not-so-sexy liver fellowship, can still be an asset as they can be assigned to the less echo-heavy cases in your practice which I venture to say are >50%. Perhaps I'm more inclined to make efficient use of every member of the practice.

Did you do a liver fellowship?

 

[ProRealDoc]

Did you do a liver fellowship?

No I didn't.

 

[ProRealDoc]

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.

How about we edit your sentence above,
Bean counters are not stupid. If they can get away with NPs and PAs doing ICU, they will not pay extra for the fellowship-trained guy.

 

[Southpaw]

Pretty sure PRD did cardiac at a big name place. I’m following along sort of peripherally. I hated cardiac in residency bc the surgeons were straight primas and I watched some real smart cardiac anesthesiologists fall into ‘our culture’ (which is basically whatever the surgeons want, bc regardless of how hardline you hold to ‘your plan’ in the OR the surgeons will do whatever they want post-op) which seemed to me a waste of the fellowship year.

I highly respect the extra year of training but I can’t help but feel some of you are overstating it a bit due to the demand currently out there. In my PP world cardiologists are doing the echo for all structural work and our TEE boarded folks who do the cardiac, however smart they are, fall in line with the old guard and do the same ‘our culture’ anesthesia that I’ve seen everywhere else if for no other reason than to ‘get along’ and be labeled as ‘team players’. But maybe they’re giving less fentanyl. And my n is small so disregard if you want.

My point is that I certainly wish the ACTA meant something more, but for that to be the case the cardiac anesthesiologists would need to be managing the patients post op and that’s awful rare.

 

[T-burglar]

There’s something majorly wrong if the anesthetists are constantly coming up with “a plan” by themselves that they want to stick to that the surgeons later have to “veto” . The plan for a case should be jointly developed. Many anesthetists think “I don’t tell you how to do surgery so you don’t tell me how to do anesthesia” which is ridiculous in all ORs , because you share the patient and the physiology, but especially in the cardiac OR. It stems from some idea that surgeons don’t “understand anesthesia or physiology”. Well, let me update you, CT surgeons understand anesthesia and physiology. They have input and it’s valuable input. On the flip side, CT anes is frequently the authority in the room, more so than the surgeon, on imaging of the diseased valve or other structure in the closed chest beating heart, and surgeons rely on us to show them what’s wrong and discuss fixes. It’s a collaboration.

 

[psychbender]

I'd argue that CT surgeons possess a very specialized knowledge of physiology, which gives them the illusion that they understand all of their patients' physiology. Of all of the kinds of surgeons I work with in the units, CT surgeons tend to be the most aggressively confident in their ignorance. I have yet to meet another type of surgeon demand bicarb for a mild, predominantly respiratory acidosis. Nor are most other surgeons trying to direct fluid resuscitation based on CVP. Just yesterday, one of the CT surgeons was demanding an amp of bicarb and an albumin bolus for an immediately post-op pt on very low dose norepi with a pH of 7.3, PCO2 47, BE about -3, and CVP of 5.

This attitude is not necessarily universal, though. At one of my previous hospitals, the surgeons trusted the three of us that did their cases, allowed us to properly manage their medical issues in the OR, and followed our initial recommendations when we delivered them to the unit. They were also the first surgeons to go along with the intensivists when they made the unit a closed one. I would love to work with them again.

Periop care of cardiac surgical patients is a team effort, but many cardiac surgeons still think the responsibility is solely theirs, and they are the only ones that actually know what's going on.

 

[T-burglar]

Yeah well sure if you travel the US I’m sure you can find some CT or other surgeons that have strange ideas. But I think as a whole they are on point with hemodynamics and the circulation

 

[deleted171991]

How about we edit your sentence above,
Bean counters are not stupid. If they can get away with NPs and PAs doing ICU, they will not pay extra for the fellowship-trained guy.

Much harder than you think, the same way not anybody can do a more complex heart case.

 

[deleted171991]

There’s something majorly wrong if the anesthetists are constantly coming up with “a plan” by themselves that they want to stick to that the surgeons later have to “veto” . The plan for a case should be jointly developed. Many anesthetists think “I don’t tell you how to do surgery so you don’t tell me how to do anesthesia” which is ridiculous in all ORs , because you share the patient and the physiology, but especially in the cardiac OR. It stems from some idea that surgeons don’t “understand anesthesia or physiology”. Well, let me update you, CT surgeons understand anesthesia and physiology. They have input and it’s valuable input. On the flip side, CT anes is frequently the authority in the room, more so than the surgeon, on imaging of the diseased valve or other structure in the closed chest beating heart, and surgeons rely on us to show them what’s wrong and discuss fixes. It’s a collaboration.

Mmm hmmm.

 

[deleted171991]

Just yesterday, one of the CT surgeons was demanding an amp of bicarb and an albumin bolus for an immediately post-op pt on very low dose norepi with a pH of 7.3, PCO2 47, BE about -3, and CVP of 5.

There is a reason they don't call them doctor in the UK (and other countries).

I wish they would fine all the protocolized drones who overtreat/-diagnose their patients.

 

[Ronin786]

Yeah well sure if you travel the US I’m sure you can find some CT or other surgeons that have strange ideas. But I think as a whole they are on point with hemodynamics and the circulation

Completely disagree. Most CT surgeons hemodynamics and circulation revolve around the CVP and nothing else. The newer ones are better, but their hubris in the ICU stems from their society automatically considering them qualified to practice ICU back in the day with no extra training.

Lots going on in this thread, but some comments:

1) If your program was so bad that you needed a liver fellowship to become comfortable with sick patients, that's an argument to close down your program. Not for a fellowship.

2) Cardiac anesthesia is a great fellowship, but for those banking on structural disease being the saving grace of CT anesthesia I'd think again. If reimbursement ever becomes worthwhile the cardiologists will be all over those TEEs. Why would they give money to somebody outside of their own group when they can collect on their own?

3) On a similar note, structural heart is one of the worst things in CTA. Nothing more stimulating than a glorified internist with absolutely zero technical skill pretending to be a surgeon. They have zero concept of what an OR environment is like and do very poorly with direction.

4) Cardiac anesthesia is fun, but it's way too contingent on the department you're joining. If you're practicing with dinosaurs, you're going to have very little say in anything. If your department has proven their salt and the surgeons care then it can be very rewarding. Good luck discerning that upfront though.

5) Personally, I'd be very worried about cardiac anesthesia reimbursement down the line. Bread and butter CABGs and AVRs are going away. Mitral valves will follow pretty closely. Surgeons are going to be left with the lower volume and higher acuity multivessel CABGs and device implantation. Going to be a lot more work, a lot less volume and questionable reimbursement. I mean, with the most recent SAVR vs TAVR data, there's almost no indication for an isolated AVR in any patient and that's long been cardiac bread and butter.

 

[T-burglar]

That’s an interesting experience you have there. Our surgeons are excellent physicians and physiologists. And our structural cardiologists are excellent technicians with a surgical mindset that get **** done fast and efficient. Our TAVRs take 45 mins from holding to PACU. I’m sorry your cath lab blows.

People have been predicting the end of cardiac surgery for decades it seems like. We do more than a thousand pump cases a year at my shop and that number hasn’t changed in decades. Endocarditis, elective aortic work, emergent aortic work, LVADs, ECMO, thoracotomy TAVR, thoracotomy TMVR, adult congenital, simple mitral repairs that TMVR would be innapropriate for, the list goes on.

Structural heart is great, It’s an area that’s poised to explode and requires extensive TEE imaging. Everyone keeps saying this damn **** about cardiology coming to take the 7 units for the 93355. Take a look at how much a cardiologist generates sitting in the reading room while you’re in the structural case. They aren’t coming to take the god damn probe from you. Unless you’re incapable of doing the imaging.

I will give you that Medicare pays garbage for a unit and so technically the ASC makes more money for your group than the cardiac service. But any group that includes a cardiac team that isn’t insurance blind is garbage.

 

[Ronin786]

That’s an interesting experience you have there. Our surgeons are excellent physicians and physiologists. And our structural cardiologists are excellent technicians with a surgical mindset that get **** done fast and efficient. Our TAVRs take 45 mins from holding to PACU. I’m sorry your cath lab blows.

People have been predicting the end of cardiac surgery for decades it seems like. We do more than a thousand pump cases a year at my shop and that number hasn’t changed in decades. Endocarditis, elective aortic work, emergent aortic work, LVADs, ECMO, thoracotomy TAVR, thoracotomy TMVR, adult congenital, simple mitral repairs that TMVR would be innapropriate for, the list goes on.

Structural heart is great, It’s an area that’s poised to explode and requires extensive TEE imaging. Everyone keeps saying this damn **** about cardiology coming to take the 7 units for the 93355. Take a look at how much a cardiologist generates sitting in the reading room while you’re in the structural case. They aren’t coming to take the god damn probe from you. Unless you’re incapable of doing the imaging.

I will give you that Medicare pays garbage for a unit and so technically the ASC makes more money for your group than the cardiac service. But any group that includes a cardiac team that isn’t insurance blind is garbage.

They're not taking the probe because it's not profitable. The second it does become profitable (and there's writing on the wall), they're going to be sitting in your OR while you turn the dial.

Also your shop sounds great. It sounds like where I did fellowship. Strong cardiac anesthesia division with a great relationship with surgeons who are pushing the envelope. Huge presence that's going to be very difficult to remove. And while everybody on SDN works with the most gifted surgeons who also apparently listen to whatever their cardiac anesthesiologists offer up, know that there is a large number of shops out there that are nowhere near that.

 

[T-burglar]

The writing isn’t on the wall though. At present 93355 will never be more than a cardiologist can make by sitting in the reading room. Even If rebecca Hahn gets her way and somehow spawns an entire subspecialty called “interventional echocardiography” with its own pay structure , I just don’t see how CMS would reimburse it in a way that even approaches competing with even a basic clinic cardiologists’ pay.

I want people to stop parroting this idea that cardiologists will ever drag their asses out of the reading room to do structural because you would have to take 93355 and multiply it by like 25+ for it to be profitable for them.

93355 is meant to compensate anesthesiologists who cover the IC cases, and the unit value reflects that.

 

[AdmiralChz]

I want people to stop parroting this idea that cardiologists will ever drag their asses out of the reading room to do structural because you would have to take 93355 and multiply it by like 25+ for it to be profitable for them.

Never underestimate the power of money, especially if that increased reimbursement is being taken from elsewhere. In an age where CMS dollars are more and more rare that’s how it is. A riff on Field of Dreams: “If you build it (pay for it), they will come.”

As far as CT surgery like the above have said it’s been doom and gloom predictions since the 1980s (sounds familiar?). The glory days of 30-40 pump cases a day with Cooley’s group are certainly gone, but there’s still a place for these surgeons going forward. That being said, the community hospital which did maybe 100-200 pump cases a year will probably scale back or fully cancel their cardiac program with cases being siloed in high-volume centers. And that is probably for the best. One of my sites used to do 200 just 10 years ago now will be lucky to break 30, that’s less than 3 heart cases a month. Just how it goes.

 

[T-burglar]

How do I make this clearer. 93355 is not just free money there for whoever wants it, unless you schedule your structural cases st night after everything else is done and work overtime. As a cardiologist , To cover a IC case, you have to STOP doing whatever other more profitable thing you were doing, like clinic or reading images. So you LOSE MONEY BY COVERING STRUCTURAL.. LOSE IT.. DECREASE YOUR PROFITS OVERALL.. MAKE LLLEEEESSSS MONEY THAN IF YOU CHOSE NOT TO COVER THOSE CASES


*blows brains out*

 

[AdmiralChz]

How do I make this clearer. 93355 is not just free money there for whoever wants it, unless you schedule your structural cases st night after everything else is done and work overtime. As a cardiologist , To cover a IC case, you have to STOP doing whatever other more profitable thing you were doing, like clinic or reading images. So you LOSE MONEY BY COVERING STRUCTURAL.. LOSE IT.. DECREASE YOUR PROFITS OVERALL.. MAKE LLLEEEESSSS MONEY THAN IF YOU CHOSE NOT TO COVER THOSE CASES


*blows brains out*

Why can't a Cardiologist who is reading exams come between exams likely down the hall and do your structural exam? Right now the economics might not favor it, but ASE wants that to be changed (not that CMS really cares what they have to say). If it does change, the above will happen. Or will come between clinic patients (more and more being seen by NP and PAs anyways).

There are already large academic shops that do that now. Including both of the large university centers in my state, so it's hardly out of the ordinary to suggest these things.

 

[psychbender]

And while everybody on SDN works with the most gifted surgeons who also apparently listen to whatever their cardiac anesthesiologists offer up, know that there is a large number of shops out there that are nowhere near that.

A big issue with people in general is that they tend to downplay what they have (particularly the more successful). They may think that their skill and knowledge is slightly more than that of their peers, or that their work environment is only a little more ideal than others. They'll overestimate the average, and think that everyone else is working with what they have. Unfortunately, there are a lot of cardiac surgeons still practicing 1980s critical care, and plenty of CT anesthesiologists that had little exposure to structural heart in fellowship, outside of lectures. Not everyone gets to practice in T-burgler's shop.

 

[T-burglar]

Why can't a Cardiologist who is reading exams come between exams likely down the hall and do your structural exam? Right now the economics might not favor it, but ASE wants that to be changed (not that CMS really cares what they have to say). If it does change, the above will happen. Or will come between clinic patients (more and more being seen by NP and PAs anyways).

There are already large academic shops that do that now. Including both of the large university centers in my state, so it's hardly out of the ordinary to suggest these things.

Because outside of TAVRs you can’t just pop in and do a quick study. You’re there for the duration of the case from start to finish doing procedural guidance. That’s an hour for some things or multiple hours for others. Multiple hours spent for ONE 93355 bill, when you could have spent multiple hours banging out studies for much more than 1 instance of 93355.

93355 would have to be worth like 30 units or more for a cardiologist to not LOSE money staffing labor intensive cases. And he’ll would freeze over before that happens because suddenly CT anesthesia could bill 45 units for one watchman procedure lol.

 

[T-burglar]

Even the quickest procedure like a transcatheter PFOclosure is still not enough revenue per unit time to be worth it. It just isn’t

 

[vector2]

Tburg is right. Some IC procedures take 3 hrs+. The fastest TAVRs are still like 45-60 min. Mitraclip just started at my shop and the first few took 6 hrs, most of that time spent dicking around on a difficult septal puncture. Even if interventional echo reimburses triple TTE, the cardiologists I know can read and fully document a TTE in like 8-9 minutes.

 

[psychbender]

Agree with Vector and T-burg regarding Cards choosing the reading room over the interventional suite. I spent some time in the reading room with the Imaging guys during fellowship, and they can churn through an echo like there's no tomorrow. If any cardiologists were to start guiding the procedure, it would likely be those guys, but they could generate so much more billable work in the reading room, maybe squeezing in a couple TEEs throughout the day.

 

[sleepallday]

Because outside of TAVRs you can’t just pop in and do a quick study. You’re there for the duration of the case from start to finish doing procedural guidance. That’s an hour for some things or multiple hours for others. Multiple hours spent for ONE 93355 bill, when you could have spent multiple hours banging out studies for much more than 1 instance of 93355.

93355 would have to be worth like 30 units or more for a cardiologist to not LOSE money staffing labor intensive cases. And he’ll would freeze over before that happens because suddenly CT anesthesia could bill 45 units for one watchman procedure lol.

The culture at my place is for cards to bring in their own guy to do the echo. Initially they would complain the entire case about how they are not getting reimbursed. So what did they do- they took their complaints to the hospital admin and asked for a subsidy so that they can continue to do these cases. Problem solved. Besides, my personal experience with these cases is that it may be less then ideal to do both the anesthesia and the echo simultaneously, unless of course, you have a resident or CRNA. But at my place its MD only in CV rooms.

 

[deleted171991]

The culture at my place is for cards to bring in their own guy to do the echo. Initially they would complain the entire case about how they are not getting reimbursed. So what did they do- they took their complaints to the hospital admin and asked for a subsidy so that they can continue to do these cases. Problem solved. Besides, my personal experience with these cases is that it may be less then ideal to do both the anesthesia and the echo simultaneously, unless of course, you have a resident or CRNA. But at my place its MD only in CV rooms.

Bingo! There's the solution and the beginning of cardiac anesthesia's nightmare. The hospital doesn't care whom they pay a subsidy, anesthesia or cardiology, as long as they have their money-making cardiac interventions. It makes perfect sense.

 

[T-burglar]

Our team went to the hospital to get a subsidy to pay for a “float” CT guy who does the perioperative TEEs in cath lab and the OR too. Lol

The subsidy is equal to an “average” days work in the OR. This wasn’t even our idea at first, one of our more vocal surgeons wanted a dedicated CT anes guy for echos and was the person to initially bring it to the administration

That’s just our arrangement though. The point stands that if a stipend can’t be secured cardiology will pull the eject lever from the cath lab if they can. The only reason they’d stay without being subsidized is if the anesthesiologists can’t really handle the imaging