Dual ct/icu fellowship

[smjsmj]

I'm still a bit unclear how you go about matching/ranking when you want to do a dual. Just rank whichever fellowship you want to do first or do these fall outside the match? I guess its different at each program but any insight from those who have already done this?

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[psychbender]

Those desiring a two-year fellowship (any combination) qualify for an exemption from the SF match. When applying to a program, be sure to express your desire to do both. That way, in interview day, they can schedule it so you meet with staff from both, and both PDs. Because of the extra folk involved, it may be a two-day process. Wash-U has the application process formalized. Other places may have spots essentially set aside for dual-fellowship applicants, but the application process may not be standardized.

If you don't do both consecutively at the same place, you'll do the whole match process twice. Once as a CA2, then for your second fellowship as a CA3. The more common sequence is CC, then CT, but I've met people who have done the reverse.

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[AdmiralChz]

Those desiring a two-year fellowship (any combination) qualify for an exemption from the SF match. When applying to a program, be sure to express your desire to do both. That way, in interview day, they can schedule it so you meet with staff from both, and both PDs. Because of the extra folk involved, it may be a two-day process. Wash-U has the application process formalized. Other places may have spots essentially set aside for dual-fellowship applicants, but the application process may not be standardized.

If you don't do both consecutively at the same place, you'll do the whole match process twice. Once as a CA2, then for your second fellowship as a CA3. The more common sequence is CC, then CT, but I've met people who have done the reverse.

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While you qualify for a match exemption, some programs may still want you to participate in the SF Match along with everyone else and will then reserve a spot for you the next year. You should confirm with each program what their policy is.

Also, don't assume that programs will know you are interested in both by burying it in a single sentence in your PS - make it very clear in your correspondence and application so the program can set up the interview day appropriately (mainly so you can interact with both CCM/CT faculty and fellows). This has already happened twice at my program this year.

 

[partydoc]

I'm still a bit unclear how you go about matching/ranking when you want to do a dual. Just rank whichever fellowship you want to do first or do these fall outside the match? I guess its different at each program but any insight from those who have already done this?

We may be able to guide you better if you told us how far along you are in residency and if you're currently applying

 

[Noyac]

If you are young (or older, it doesn’t matter that much) I would encourage such a fellowship. I would personally find this to be the ultimate anesthesiologist. I was just too dumb, old and eager to make money (truth be told) to pursue something like this.

 

[GA8314]

If you are young (or older, it doesn’t matter that much) I would encourage such a fellowship. I would personally find this to be the ultimate anesthesiologist. I was just too dumb, old and eager to make money (truth be told) to pursue something like this.

Don't beat yourself up too much. Opportunity cost and loan interest are very real concerns. Are you worse off having not done it?

 

[deleted162650]

Don't beat yourself up too much. Opportunity cost and loan interest are very real concerns. Are you worse off having not done it?

No, now he’s just dumb and old - so if my math is correct, he’s like 33% better off.

 

[AdmiralChz]

If you are young (or older, it doesn’t matter that much) I would encourage such a fellowship. I would personally find this to be the ultimate anesthesiologist. I was just too dumb, old and eager to make money (truth be told) to pursue something like this.

If one has the fortitude for it, it's a very strong combination of skills. That being said, getting properly reimbursed for all that training could be hard - we have some new dual-trained staff here at fellowship who bemoan the current job market as you are largely pigeonholed into academics if you truly want to do dual ICU/CT (and typically CTICU at that). You can absolutely get a job in any part of the country for sure, but academic salaries (even for fellowship-trained) can be suboptimal although this might be an over-simplification. My place is more "Priva-demic" which attracts these grads (high-acuity cases and ICUs with relatively high salaries), but I think we are the exception rather than the rule. Just something to consider - if you're OK with that then no problems.

One of the docs joining me in private practice next year is dual trained, despite our group covering no CCM. Different strokes for different docs. I have no stomach for CCM personally but respect those that want to practice it and do it well.

 

[Noyac]

Don't beat yourself up too much. Opportunity cost and loan interest are very real concerns. Are you worse off having not done it?

To be clear, I would not do this in hopes of garnering better compensation. I would only do this to be a better physician. But the call to make money took over. Plus, I didn’t feel the need to to get more cardiac than I did in residency and that proved to be true since I joined a group that had me doing well over 200 hearts a year without any issues.

And there is great risk in being “over qualified”. At least as far as employers see it.

 

[Noyac]

No, now he’s just dumb and old - so if my math is correct, he’s like 33% better off.

Those are two qualities I display regularly.

 

[deleted171991]

If you are young (or older, it doesn’t matter that much) I would encourage such a fellowship. I would personally find this to be the ultimate anesthesiologist. I was just too dumb, old and eager to make money (truth be told) to pursue something like this.

Agree about the ultimate anesthesiologist. Disagree about the encouragement. I think cardiac is enough; CCM is a waste of time and lost wages, unless one already has an academic job that would benefit, or one wants to practice 100% CCM, preferably in a closed ICU. Most surgeons and employers simply don't appreciate the real value of an anesthesiologist-intensivist, and too few OR cases require the level of knowledge of a CCM-trained anesthesiologist.

I love CCM to death, and I will never stop reading about it, but I will probably stick to anesthesia-only for my next job. More positions, easier money. Unfortunately, I've seen this scenario many times before, I just didn't understand it.

 

[Noyac]

Agree about the ultimate anesthesiologist. Disagree about the encouragement. I think cardiac is enough; CCM is a waste of time and lost wages, unless one already has an academic job that would benefit, or one wants to practice 100% CCM, preferably in a closed ICU. Most surgeons and employers simply don't appreciate the real value of an anesthesiologist-intensivist, and too few OR cases require the level of knowledge of a CCM-trained anesthesiologist.

I love CCM to death, and I will never stop reading about it, but I will probably stick to anesthesia-only for my next job. Unfortunately, I've seen this scenario many times before, I just didn't understand it.

Did you rad my follow up post?
I totally agree with you on this.

 

[deleted171991]

Did you rad my follow up post?
I totally agree with you on this.

You mean this one?

Those are two qualities I display regularly.

I wasn't disagreeing with you, just that particular post. I see a number of grads considering CCM, mostly without cardiac, and I always tell them to just go for cardiac and forget CCM, They mostly go for CCM and forget cardiac (which I understand 100%, but it's just a bad career decision).

I had doubts about the value of a CCM fellowship even before I went back for one, but I let this forum convince me that I was wrong. The fellowship did bring me to a different level, but that's only because I too am old and dumb (and was even dumber before it).

 

[deleted162650]

Agree about the ultimate anesthesiologist

Hmmm, what about the dudes that do peds residency, PICU or NICU, the anesthesia residency, then peds fellowship??

I know of those guys. Pretty baller.

 

[nimbus]

Hmmm, what about the dudes that do peds residency, PICU or NICU, the anesthesia residency, then peds fellowship??

I know of those guys. Pretty baller.

They are the ultimate peds anesthesiologists. Different job.

 

[Hamhock]

Hmmm, what about the dudes that do peds residency, PICU or NICU, the anesthesia residency, then peds fellowship??

I know of those guys. Pretty baller.

Yeah, reminds me of the Med-Peds to PICU/adult CCM guy I know.
Kinda a baller, but when some really advanced and specific knowledge/skill is needed, he wasn't the goto.
HH

 

[vector2]

I know of those guys. Pretty baller.

In my experience these guys were baller right up until the point you put them in a difficult case with a patient weighing more than 20 kilos

 

[deleted162650]

Actually, I can’t believe I forgot about the guys that are dual fellowshipped in OB/OR management. Now those are the guys.

 

[Steege305]

You mean this one?

I wasn't disagreeing with you, just that particular post. I see a number of grads considering CCM, mostly without cardiac, and I always tell them to just go for cardiac and forget CCM, They mostly go for CCM and forget cardiac (which I understand 100%, but it's just a bad career decision).

I had doubts about the value of a CCM fellowship even before I went back for one, but I let this forum convince me that I was wrong. The fellowship did bring me to a different level, but that's only because I too am old and dumb (and was even dumber before it).

As someone applying down this path, I can only think "Awww man!" Are you sure it isn't just your current job? I've heard of pretty decent jobs out there for CCM trained anesthesiologists. To be fair, I've also heard of some (even on this forum) that sound draconian.

 

[chocomorsel]

You mean this one?

I wasn't disagreeing with you, just that particular post. I see a number of grads considering CCM, mostly without cardiac, and I always tell them to just go for cardiac and forget CCM, They mostly go for CCM and forget cardiac (which I understand 100%, but it's just a bad career decision).

I had doubts about the value of a CCM fellowship even before I went back for one, but I let this forum convince me that I was wrong. The fellowship did bring me to a different level, but that's only because I too am old and dumb (and was even dumber before it).

Why do you keep saying this? It didn’t work for you, but doesn’t mean it’s a waste of time. There are plenty of people who do this and do both ICU and OR in either private or academics and are happy. A few are on this board. But yeah, you have to be willing to relocate. If you are so stuck on your location, especially overcrowded, underpaid NE, then you may end up wasting time and money.

The jobs are opening up for anesthesia CCM docs as hospitals are realizing the value of intensivists who aren’t just Pulmonologists who won’t have to rush out to clinic during the day.

I personally want to get the heck out of the OR and do CCM solely. At least till I get sick of that too.

 

[chocomorsel]

As someone applying down this path, I can only think "Awww man!" Are you sure it isn't just your current job? I've heard of pretty decent jobs out there for CCM trained anesthesiologists. To be fair, I've also heard of some (even on this forum) that sound draconian.

Don’t listen to him. Do your thing. I am starting in 4 months.

 

[psychbender]

As someone applying down this path, I can only think "Awww man!" Are you sure it isn't just your current job? I've heard of pretty decent jobs out there for CCM trained anesthesiologists. To be fair, I've also heard of some (even on this forum) that sound draconian.

Are you a current CA2 applying and interviewing this cycle? If so, have you been asking the fellows where they're getting jobs? At this point, they should all have something. The market for CCM/Anes is rather small, and mostly confined to academics, but there are non-academic jobs out there (I'm heading to one this summer). You just may have to sacrifice on location, acuity, staffing models, etc, and spend more energy looking than if you wanted a straight anesthesia or CCM job.

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[sunealoneal]

Are you a current CA2 applying and interviewing this cycle? If so, have you been asking the fellows where they're getting jobs? At this point, they should all have something. The market for CCM/Anes is rather small, and mostly confined to academics, but there are non-academic jobs out there (I'm heading to one this summer). You just may have to sacrifice on location, acuity, staffing models, etc, and spend more energy looking than if you wanted a straight anesthesia or CCM job.

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Fingers crossed that the intensivist shortage is enough of a market pressure to make these jobs more available in 4 years.

 

[deleted171991]

OK, let's clear something up: there is NO shortage of anesthesiologist-intensivists. There is only a shortage of intensivists, preferably IM-trained, preferably pulm-CC trained. One should know one's regional anesthesia-CCM market before applying, and preferably have a job lined up before even starting the fellowship.

Sooo... if you want to practice 100% CCM in a MICU (which is basically what most community ICUs are), and give up anesthesia, go for it! That's my dream job, too, once I grow the balls to give up anesthesia (it's not easy to come back after 100% CCM, if I ever need to). If you want to practice both anesthesia and CCM, it won't be that easy to find a good job, meaning one in which you won't have to take more call/work many more hours than a general anesthesiologist, where you are paid more than a 100% general anesthesiologist (CCM and low/intermediate-risk surgery are not the same), where you are not covering 15-20 patients/day with no help or just PGY-1/2 residents etc., and (maybe the first in the list) where the SICU is almost CLOSED and you're not functioning like a glorified surgical midlevel under the watchful eye of the "captain of the ****".

I am sticking to what I said before: it's much easier to find a good anesthesia-only job than a good combined job. This ain't pain. Let's also not forget that anesthesia still makes more money to the employer than CCM (otherwise we'd see a lot of anesthesia groups extending into the ICU, the same way they want the endoscopy center). It's just not worth wasting $150-200K net compounded over 25 years if one won't be able to practice CCM happily in a good place. One doesn't need a CCM fellowship to become a good general anesthesiologist (let's not mention all the anesthesia skills one loses during the CCM fellowship).

And not to minimize what @chocomorsel says, respectfully, she hasn't even started her fellowship yet. The truth is much closer to what @psychbender said in his last post. I love CCM more than anything in anesthesia (except maybe working solo in a good ASC 7-3, Mon-Fri), I am just not drinking the Kool-Aid.

 

[Nivens]

I'm doing a combined CT/CC fellowship at a large academic institution with the intention of staying in academics in a combined job. It was a complex decision, but I sleep better now having committed to this than I did in the 10 months I spent deliberating.

To answer the OPs question, the combined fellowship qualifies you for an exemption from the SF Match. Some will request that you submit a one-program rank list to the match after you commit (either CC or cardiac depending on what you do first, and then again the following year), while some don't seem to care.

 

[sethco]

To be clear, I would not do this in hopes of garnering better compensation. I would only do this to be a better physician. But the call to make money took over. Plus, I didn’t feel the need to to get more cardiac than I did in residency and that proved to be true since I joined a group that had me doing well over 200 hearts a year without any issues.

And there is great risk in being “over qualified”. At least as far as employers see it.

From an employer standpoint, I disagree about being over qualified. Can't speak for other groups, but we have hired people that have done multiple fellowships in the past. It does make them appear to be a well rounded applicant.

The problem is that we don't do any critical care and any time spent away from doing just Anesthesia would not be monetarily beneficial to the group. So, essentially for our group, while you would be a very attractive candidate, it would be a wasted year in terms of future use of that fellowship and lost income from that extra fellowship year. Most, but maybe not all, private groups would probably think the same way. I'm sure there are private groups out there that have arrangements for these dual trained folks that want to do both in practice. It just might take a little more effort to find them

 

[Laryngophed]

I perusing dual ccm/cardiac fellowships and have taken a job in an academic center after completion of the training. You can PM me, however I will state that my situation is unique.

As it is, my program(s) (same institution, lots of crossover in faculty between the two divisions) requested I complete both matches in consecutive years after deciding to agree to the exemption. For posterity sake, I always sent the program a one program rank list after it was finalized and submitted, but was never asked.

 

[OldGregg]

I'm doing a combined CT/CC fellowship at a large academic institution with the intention of staying in academics in a combined job. It was a complex decision, but I sleep better now having committed to this than I did in the 10 months I spent deliberating.

To answer the OPs question, the combined fellowship qualifies you for an exemption from the SF Match. Some will request that you submit a one-program rank list to the match after you commit (either CC or cardiac depending on what you do first, and then again the following year), while some don't seem to care.

I’m in the same boat. It is a complex decision but one that is helping me achieve my career goals. (I’m finishing my CCM fellowship this year, ACTA is next).

As long as you let programs know you want to interview for both beforehand, most of the big shops will exempt you from the match as above.

My road was a little different, I didn’t fully decide to do ACTA until after the CCM match, so I applied and interviewed during CA3 year and went thru the match again. Happy to go on about that through DM if anyone is interested.

If it helps you achieve your career goals, it’s a solid move. I don’t regret my choices one bit. Cheers to the other CCM/ACTA folks, it’s a tough road and I think where our field needs representation. Similarly, cheers to the others keeping it real in the General OR world. We all compliment each other.

 

[deleted171991]

My road was a little different, I didn’t fully decide to do ACTA until after the CCM match

Smart move, if one can stomach the cardiac surgeons.

 

[chocomorsel]

@FFP, like I said, you have to be willing to move. And I am very mobile unlike you. So I think I will be OK. Quite frankly I plan on flying wherever either as a locums or employee for the job. Although I don't have kids I do have my family and would like to spend at least half time with them.

Of course it is easier to do 100% ICU as is my plan.

Yes you are right that it would be easier to find an OR job. But I am looking for a change. Or maybe I just like learning. Could be that too. And I do like to often fly by the seat of my pants as the saying goes. And I am cheap.

 

[Hamhock]

Two of the intensivists at one of my hospitals are ct/CCM. One is mostly OR, but the other is 50/50 OR/ICU.
...and I doubt they "sacrificed location" to live here.
I realize this is just one data point, but my other hospital is community ICU (mostly MICU) and multi-disciplinary intensivists (some still practicing in their primary specialty; but none is an anesthesiologist)
HH

 

[deleted171991]

Two of the intensivists at one of my hospitals are ct/CCM. One is mostly OR, but the other is 50/50 OR/ICU.
...and I doubt they "sacrificed location" to live here.
I realize this is just one data point, but my other hospital is community ICU (mostly MICU) and multi-disciplinary intensivists (some still practicing in their primary specialty; but none is an anesthesiologist)
HH

CT/CCM is not the same as CCM. Groups will make sacrifices for CT/CCM people, including getting them an ICU arrangement with the hospital, if needed, just to get another cardiac anesthesiologist. Also, the CT/CCM people will be useful for CTICU patients, which non-cardiac intensivists are not always trusted with, and who are more important for most hospitals than regular ICU patients. That's why I encourage people to either do both cardiac and CCM, or just cardiac (if they can stomach working with cardiac dinguses surgeons and practice ancient critical care).

 

[psychbender]

Two of the intensivists at one of my hospitals are ct/CCM. One is mostly OR, but the other is 50/50 OR/ICU.
...and I doubt they "sacrificed location" to live here.
I realize this is just one data point, but my other hospital is community ICU (mostly MICU) and multi-disciplinary intensivists (some still practicing in their primary specialty; but none is an anesthesiologist)
HH

Roughly where are you? Anywhere can be a sacrifice, if one would prefer to live in a different part of the country. If I had to move to New York, San Francisco, DC, Chicago, or another major metro area to do this job, I would view that as a huge sacrifice.

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[anbuitachi]

You mean this one?

I wasn't disagreeing with you, just that particular post. I see a number of grads considering CCM, mostly without cardiac, and I always tell them to just go for cardiac and forget CCM, They mostly go for CCM and forget cardiac (which I understand 100%, but it's just a bad career decision).

I had doubts about the value of a CCM fellowship even before I went back for one, but I let this forum convince me that I was wrong. The fellowship did bring me to a different level, but that's only because I too am old and dumb (and was even dumber before it).

In what ways was your ccm training useful in the ors?

 

[vector2]

In what ways was your ccm training useful in the ors?

I work at a level I trauma center alongside a bunch a general guys who either have been out for 10-15 years or who just finished CA3 last year. On average, I have a better grasp on restrictive ventilation and transfusion strategies, TEG/TEM, targeted resuscitation, diagnosing/differentiating types of shock, point of care ultrasound for preop stratification and intraop emergencies, TEE, management of pts coming to surgery who have ACS, pulm htn, restrictive lung disease, sepsis etc.

That being said, I'll be honest, no one really gives two ****s how slick or how evidenced based your anesthetic is as long as the patient wakes up, has adequate pain control, and makes it out of the pacu at a reasonable hour.

 

[deleted171991]

In what ways was your ccm training useful in the ors?

Most of the days, it's not (I work in an academic community hospital). But when it is, it's about:
- being much more confident around really sick patients in the OR
- being much more relaxed about severe coexisting diseases, and how to treat their exacerbations (that's why I always emphasize MICU experience during CCM fellowship)
- being more comfortable with strong cardiovascular medications and what to do when the **** hits the fan
- having a much better perspective about the overall treatment of the patient and not focusing just on getting him alive out of the OR or good-looking numbers (not that anybody who matters gives a **** about the former)
- better relationship with the surgeons who have SICU/stepdown admissions frequently
- better echo skills, especially focused TTE and TEE
- up-to-date knowledge of modern resuscitation (anesthesiology and most surgical literature tend to lag behind) and better knowledge of internal medicine than a generalist.

That's the gist of it, I think.

tl;dr: A CCM fellowship will make you a better doctor, but nobody who matters will care. The difference between a good CCM-trained anesthesiologist and a good non-CCM-trained anesthesiologist is sometimes like the difference between a good anesthesiologist and a good CRNA: it's clearly there in the little details, it's just tough to prove as long as bean counters focus on the wrong outcome measures.

 

[chocomorsel]

CT/CCM is not the same as CCM. Groups will make sacrifices for CT/CCM people, including getting them an ICU arrangement with the hospital, if needed, just to get another cardiac anesthesiologist. Also, the CT/CCM people will be useful for CTICU patients, which non-cardiac intensivists are not always trusted with, and who are more important for most hospitals than regular ICU patients. That's why I encourage people to either do both cardiac and CCM, or just cardiac (if they can stomach working with cardiac dinguses surgeons and practice ancient critical care).

I personally hate cardiac in the OR and can't stand the ass hole surgeons either. Although in Vegas I knew the nicest cardiac surgeon I have ever met, but he is seriously in the minority.
I don't mind doing it in the ICU though. I loved it in residency.

 

[chocomorsel]

I work at a level I trauma center alongside a bunch a general guys who either have been out for 10-15 years or who just finished CA3 last year. On average, I have a better grasp on restrictive ventilation and transfusion strategies, TEG/TEM, targeted resuscitation, diagnosing/differentiating types of shock, point of care ultrasound for preop stratification and intraop emergencies, TEE, management of pts coming to surgery who have ACS, pulm htn, restrictive lung disease, sepsis etc.

That being said, I'll be honest, no one really gives two ****s how slick or how evidenced based your anesthetic is as long as the patient wakes up, has adequate pain control, and makes it out of the pacu at a reasonable hour.

Do you not practice any CCM? If not how come?

 

[McPoyle]

I’m finishing up my CCM year and moving in July to do cardiac. Don’t regret it, have interviews for both academic and community spots in the areas I am interested in. Obviously this training skews much more heavily towards academics however.


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