Dual fellowship programs - thoughts?

[Drangue]

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I was just talking to a buddy and he was thinking about dual Cardiac-Critical Care fellowship. I don't get how these work.

Anyone know how these work? Is this 1 year of intense cardiac and ICU stuff or is it still 2 years just at the same program?

 

[pgg]

I was just talking to a buddy and he was thinking about dual Cardiac-Critical Care fellowship. I don't get how these work.

Anyone know how these work? Is this 1 year of intense cardiac and ICU stuff or is it still 2 years just at the same program?

It's two separate fellowships. Sometimes at the same institution, sometimes not. I think the applicants may be eligible for an exception to the SF ACTA match to coordinate the years?

Doing both fellowships certainly provides an opportunity to be a top tier rock star anesthesiologist, something we all aspire to be, though the economic return on that time investment is questionable. I'm not sure it really opens many employment doors, beyond a handful of renowned academic practices which have made noises about requiring both for new hires.

 

[AdmiralChz]

I think the applicants may be eligible for an exception to the SF ACTA match to coordinate the years?

True, if the program agrees to it. SF Match is less formalized than NRMP so many programs (including my fellowship) just rank to guarantee match for these folks.

There are a few truly integrated dual fellowships where the two years are weaved in by few month blocks. These are the exception, most are separate years.

But quality applicants for dual “combined” programs are honestly in short supply. The majority of what we saw this past year on the application front were poorly-competitive applicants who added a CCM fellowship to be more attractive for their main goal - a cardiac fellowship. It could lead to a great academic career if one is interested and flexible geographically (you’d be able to get a job anywhere but that doesn’t mean it’s a good one) but the opportunity cost is really quite immense.

Most departments have these programs, formalized or not, to increase interest in CCM. Nearly every fellowship has open spots after the match every year, or they have to fill with applicants from other specialties like ER.

 

[OneTyme]

There are a very few select combined programs in the country for various specialties. (IE both specialties are intertwined and completed at the end of 2 years.)

The advantages are; knowing where you’ll be for 2 years, only going through one interview season/traveling, and the training is more akin to what you want your professional life to look like.

The down sides; loss of attending income, and inability to sit for either subspecialty board until your entire 2 years are finished. So, if you decide to get out of dodge and quit your dual fellowship early, you aren’t eligible to sit for either sub specialty board.

Personally, I chose a dual program because I liked the fit and it helped out with having stability for my growing family.

 

[bigdan]

There are a very few select combined programs in the country for various specialties. (IE both specialties are intertwined and completed at the end of 2 years.)

The advantages are; knowing where you’ll be for 2 years, only going through one interview season/traveling, and the training is more akin to what you want your professional life to look like.

The down sides; loss of attending income, and inability to sit for either subspecialty board until your entire 2 years are finished. So, if you decide to get out of dodge and quit your dual fellowship early, you aren’t eligible to sit for either sub specialty board.

Personally, I chose a dual program because I liked the fit and it helped out with having stability for my growing family.

Unless there is some new requirement, the bolded statement above is not true.

I completed my CCM board exam during August of my cardiac year, and cardiac anesthesiology doesn't have a subspecialty board. If you mean "echo boards", you don't even have to be finished with residency to take that exam. You need a valid medical license.

Who told you that?

 

[bigdan]

I should have also added, in a broader sense, that doing both fellowships was a great choice for me. I feel I am a better physician for having done both, and I am extremely happy professionally with the work I currently do.

I did the fellowships at separate places, which was inconvenient but worked out (in hindsight) to be great. There is, obviously, a huge difference in the salaries paid to the fellowship trainee and the attending anesthesiologist, so the opportunity cost can be high. Some centers will endeavor to reward the extra training/skill set that the CT-CCM anesthesiologist brings, but they are hard to find. Very hard. In fact, let me know if you find one.

 

[OneTyme]

Unless there is some new requirement, the bolded statement above is not true.

I completed my CCM board exam during August of my cardiac year, and cardiac anesthesiology doesn't have a subspecialty board. If you mean "echo boards", you don't even have to be finished with residency to take that exam. You need a valid medical license.

Who told you that?

I thought the OP was asking about combined fellowships in general, looking back I think I was mistaken and maybe he just meant CT/CCM.

I was speaking in a broader sense about combined programs (not just CCM and CT).

I’m doing a combined Peds and Pain fellowship over two years. It is truly combined, I can switch back and forth week to week between the two specialties but every week is credited to either the ACGME Pain Fellowship or the ACGME Pediatric Anesthesia Fellowship. Due to this I will not have a full 12 months in either specialty until I complete the full 24 months of training.

I cannot sit for either board until I complete the full two years.

I can’t speak to CCM or CT, I know didly squat about that.

 

[2Fast2Des]

Boy I wish I loved something so much to lose atleast 600k income over 2 years with a smile

 

[Drangue]

I thought the OP was asking about combined fellowships in general, looking back I think I was mistaken and maybe he just meant CT/CCM.

I was speaking in a broader sense about combined programs (not just CCM and CT).

I’m doing a combined Peds and Pain fellowship over two years. It is truly combined, I can switch back and forth week to week between the two specialties but every week is credited to either the ACGME Pain Fellowship or the ACGME Pediatric Anesthesia Fellowship. Due to this I will not have a full 12 months in either specialty until I complete the full 24 months of training.

I cannot sit for either board until I complete the full two years.

I can’t speak to CCM or CT, I know didly squat about that.

Yeah, sorry. I was just referring to CT and CCM but I don't mind having information on other dual fellowships for anesthesiology.

 

[abolt18]

I thought the OP was asking about combined fellowships in general, looking back I think I was mistaken and maybe he just meant CT/CCM.

I was speaking in a broader sense about combined programs (not just CCM and CT).

I’m doing a combined Peds and Pain fellowship over two years. It is truly combined, I can switch back and forth week to week between the two specialties but every week is credited to either the ACGME Pain Fellowship or the ACGME Pediatric Anesthesia Fellowship. Due to this I will not have a full 12 months in either specialty until I complete the full 24 months of training.

I cannot sit for either board until I complete the full two years.

I can’t speak to CCM or CT, I know didly squat about that.

Peds AND pain? These seem totally and completely unrelated in my mind. How does a career look after such training?

 

[AKMD_1984]

Boy I wish I loved something so much to lose atleast 600k income over 2 years with a smile

++

 

[Mman]

Peds AND pain? These seem totally and completely unrelated in my mind. How does a career look after such training?

Pediatric pain service in a children's hospital.

 

[abolt18]

Pediatric pain service in a children's hospital.

I guess I didn't consider, is this a chronic pain fellowship? Cause that's what I was imagining when it just said "pain'. Not an acute pain/regional fellowship.

 

[Mman]

I guess I didn't consider, is this a chronic pain fellowship? Cause that's what I was imagining when it just said "pain'. Not an acute pain/regional fellowship.

My answer would be the same no matter what. There aren't enough chronic pain kids in any place to run an outpatient chronic peds pain clinic so if you are doing pediatric pain, it's essentially always in an inpatient setting.

 

[deleted925573]

My answer would be the same no matter what. There aren't enough chronic pain kids in any place to run an outpatient chronic peds pain clinic so if you are doing pediatric pain, it's essentially always in an inpatient setting.

When I was a fellow the peds pain guy ran an inpatient pain service and had an outpatient pain clinic as well. As you said, the clinic wasn’t busy enough for a FTE, but I think a few hours of clinic and a bit of inpatient pain coverage was a pretty sweet gig, for him anyway.

I think you could have an adult pain job and take peds pain appointments, but you’d have to just be committed to peds pain because your income would suffer.

 

[chocomorsel]

I know a friend who does peds and pain. Of course he works in Academics and does a little bit of each with a focus on meds pain.

 

[Ronin786]

Knew someone that did peds and pain. Wasn't able to create enough of a pediatric pain practice and ended up having to move to a regional children's hospital. You can make it work, but you're not going into a market with ton of demand IMO.

 

[OneTyme]

Peds AND pain? These seem totally and completely unrelated in my mind. How does a career look after such training?

The fellowship I’m doing is two years, and I’ll be board certified in pediatric anesthesia and chronic pain. The pain training will have a large adult component (like typical pain fellowships) but it will have a focus on pediatric pain clinic/procedures.

I think there are a lot more pediatric chronic pain patients than most people realize.

Many of the major academic institutions were represented at the last Peds pain meeting I went to. Nearly all of them were looking for dual fellowship trained people (some had been looking for years).

My practice will almost certainly be in academics. I hope to spend my time split evenly between OR, Acute/Inpatient Pain, and Pain Clinic.

While it would be almost impossible to have a private practice job with that setup, there are ways to make it happen.

For example, I could do private practice Peds and then find a way to set up a Peds clinic a few days a month on the weekends.

This would be difficult to do and the clinic portion would at best be revenue neutral, or even cost me $ out of my own pocket.

That would be fine with me. I’m clearly not in it for the money.

 

[bigdan]

Boy I wish I loved something so much to lose atleast 600k income over 2 years with a smile

Most places, I presume, will see dual-trained anesthesiologists compensated in the same (or similar) manner to the generalists or those whom have done one fellowship. But if the service is desired, the compensation will be very, very good.

Supply and demand.

 

[abolt18]

The fellowship I’m doing is two years, and I’ll be board certified in pediatric anesthesia and chronic pain. The pain training will have a large adult component (like typical pain fellowships) but it will have a focus on pediatric pain clinic/procedures.

I think there are a lot more pediatric chronic pain patients than most people realize.

Many of the major academic institutions were represented at the last Peds pain meeting I went to. Nearly all of them were looking for dual fellowship trained people (some had been looking for years).

My practice will almost certainly be in academics. I hope to spend my time split evenly between OR, Acute/Inpatient Pain, and Pain Clinic.

While it would be almost impossible to have a private practice job with that setup, there are ways to make it happen.

For example, I could do private practice Peds and then find a way to set up a Peds clinic a few days a month on the weekends.

This would be difficult to do and the clinic portion would at best be revenue neutral, or even cost me $ out of my own pocket.

That would be fine with me. I’m clearly not in it for the money.

Thank you for the clarifications. Thé concept of those two fellowships together was outside anything I had ever thought about and I wasn't visualizing how you would apply it clinically.

 

[OneTyme]

Thank you for the clarifications. Thé concept of those two fellowships together was outside anything I had ever thought about and I wasn't visualizing how you would apply it clinically.

Yeah, Peds Pain is a rarity. By my count there are only 5 programs.

Peds anesthesia fellowships, in general, are moving towards becoming a mandatory 2 years (aka “super fellowship”). The governing body wants people doing a year of General Peds followed by a year of Peds CT, Peds Pain, Research, Peds Regional, etc.

I think everything will be game for the second year except maybe OB...

 

[Psai]

Yeah, Peds Pain is a rarity. By my count there are only 5 programs.

Peds anesthesia fellowships, in general, are moving towards becoming a mandatory 2 years (aka “super fellowship”). The governing body wants people doing a year of General Peds followed by a year of Peds CT, Peds Pain, Research, Peds Regional, etc.

I think everything will be game for the second year except maybe OB...

Makes sense since CRNAs are doing peds without a single extra day of training.

 

[2Fast2Des]

Makes sense since CRNAs are doing peds without a single extra day of training.

But they will continue to do so, so what does the extra gain (financially, etc) over the current situation?

 

[Psai]

But they will continue to do so, so what does the extra gain (financially, etc) over the current situation?

That's what I'm saying

 

[OneTyme]

But they will continue to do so, so what does the extra gain (financially, etc) over the current situation?

That's what I'm saying

The answer is probably twofold:

1. I think it’s an effort to widen the gap between mid level providers and MDs.

2. I think it’s an effort to decrease the number of pediatric fellowship graduates to a more sustainable level. As it is, a relatively low percentage of fellows go into full or part time Peds jobs.

I’m not saying either is right.

I’m just repeating what programs said when I was interviewing. Which has also been echoed here:
Peds Anesthesia Fellowship to be Two Years?

For me it comes down to having the ability to do what I want to do with my life. I’m ok with losing income in order to make it happen.

 

[DM27]

I loved my fellowship, but when that year finished I was DONE and very very ready to finally work. If you had asked me about my thoughts on a dual fellowship my CA-2 and CA-3 year I would've said it sounds great and I am considering it. Ask me now and I can't say hell no quick enough.

 

[mmag]

If there's an oversupply of pediatric anesthesiologists, why is there any demand for pediatric CRNAs?

There is no gap to the public when CRNAs do pediatric hearts.
Childrens Hospital at Vanderbilt

The answer is probably twofold:

1. I think it’s an effort to widen the gap between mid level providers and MDs.

2. I think it’s an effort to decrease the number of pediatric fellowship graduates to a more sustainable level. As it is, a relatively low percentage of fellows go into full or part time Peds jobs.

I’m not saying either is right.

I’m just repeating what programs said when I was interviewing. Which has also been echoed here:
Peds Anesthesia Fellowship to be Two Years?

For me it comes down to having the ability to do what I want to do with my life. I’m ok with losing income in order to make it happen.

 

[AdmiralChz]

If there's an oversupply of pediatric anesthesiologists, why is there any demand for pediatric CRNAs?

There is no gap to the public when CRNAs do pediatric hearts.
Childrens Hospital at Vanderbilt

I rotated at a high-level place with dedicated pedi heart CRNAs. Most of the time they sat other procedures like EP, MRI but when they did big open heart cases they did little more than intubate as the staff there was 1:1 and hyper vigilant. While they are employed, let’s not pretend they are doing anything resembling independence as they would like you to believe (at least in this realm).

 

[mmag]

I rotated at a high-level place with dedicated pedi heart CRNAs. Most of the time they sat other procedures like EP, MRI but when they did big open heart cases they did little more than intubate as the staff there was 1:1 and hyper vigilant. While they are employed, let’s not pretend they are doing anything resembling independence as they would like you to believe (at least in this realm).

Anesthesiologists don't pretend because we know the truth. Institutional webpages do like to muddy the waters. Likely the public and definitely the AANA believe they could be unsupervised if only given the opportunity.

 

[Psai]

I rotated at a high-level place with dedicated pedi heart CRNAs. Most of the time they sat other procedures like EP, MRI but when they did big open heart cases they did little more than intubate as the staff there was 1:1 and hyper vigilant. While they are employed, let’s not pretend they are doing anything resembling independence as they would like you to believe (at least in this realm).

That's true and it is same for us. But still.

 

[Man o War]

I rotated at a high-level place with dedicated pedi heart CRNAs. Most of the time they sat other procedures like EP, MRI but when they did big open heart cases they did little more than intubate as the staff there was 1:1 and hyper vigilant. While they are employed, let’s not pretend they are doing anything resembling independence as they would like you to believe (at least in this realm).

That’s all they do at any heart program with fellows I’ve observed. That, and basically function as an extra set of trained hands. It’s actually laughable for me to imagine them working independently at any of those places, the leash was short. They were so out of their league in those cases anyway.

 

[OneTyme]

If there's an oversupply of pediatric anesthesiologists, why is there any demand for pediatric CRNAs?

There is no gap to the public when CRNAs do pediatric hearts.
Childrens Hospital at Vanderbilt

I don’t know that the difference to the public matters as much as the actual difference in skill and ability. No Peds CT Attending will every worry about mid level encroachment on their territory.

I won’t ever worry about mid level practitioners taking my Peds pain role (not that anyone really wants it anyways).

However, the general anesthesia MDs of my “generation” might start to feel that pressure, if it isn’t felt already.

 

[nimbus]

(not that anyone really wants it anyways).

This is key. If you enjoy doing something nobody else wants or likes, then you will have job security. Beauty is in the eye of the beholder.

 

[mmag]

Even general peds anesthesiologists are feeling the pressure from CRNAs. Studies that show there is an oversupply and the subsequent response to lengthen fellowship to reduce supply. However many children's hospitals employ CRNAs. So there are not enough procedures and jobs for pediatric anesthesiologists yet CRNAs do have many opportunities in pediatrics. The argument that CRNAs are there to fill anesthesiologists shortages does not hold. Therefore CRNAs are taking the jobs of pediatric anesthesiologists.

A peds fellowship trained anesthesiologist (let alone a general anesthesiologist) can not join the peds CT team even if it's to just do Cath lab/EP, MRI, or be a second set of hands but a CRNA can with some on the job training.

The Pediatric Anesthesiology Workforce: Projecting Supply... : Anesthesia & Analgesia

I don’t know that the difference to the public matters as much as the actual difference in skill and ability. No Peds CT Attending will every worry about mid level encroachment on their territory.

I won’t ever worry about mid level practitioners taking my Peds pain role (not that anyone really wants it anyways).

However, the general anesthesia MDs of my “generation” might start to feel that pressure, if it isn’t felt already.

 

[Man o War]

Even general peds anesthesiologists are feeling the pressure from CRNAs. Studies that show there is an oversupply and the subsequent response to lengthen fellowship to reduce supply. However many children's hospitals employ CRNAs. So there are not enough procedures and jobs for pediatric anesthesiologists yet CRNAs do have many opportunities in pediatrics. The argument that CRNAs are there to fill anesthesiologists shortages does not hold. Therefore CRNAs are taking the jobs of pediatric anesthesiologists.

A peds fellowship trained anesthesiologist (let alone a general anesthesiologist) can not join the peds CT team even if it's to just do Cath lab/EP, MRI, or be a second set of hands but a CRNA can with some on the job training.

The Pediatric Anesthesiology Workforce: Projecting Supply... : Anesthesia & Analgesia

Because the CRNA is being supervised. While I get the gist of what you’re saying, the role of a CRNA vs a peds anesthesiologist is totally different in this scenario.
This is apples and oranges.

 

[mmag]

A peds anesthesiologist would rather have no job than take a job doing peds EP, cath, MRI with CT peds anes available as backup or be the second anesthesiologist in an open heart?

Because the CRNA is being supervised. While I get the gist of what you’re saying, the role of a CRNA vs a peds anesthesiologist is totally different in this scenario.
This is apples and oranges.

 

[Man o War]

A peds anesthesiologist would rather have no job than take a job doing peds EP, cath, MRI with CT peds anes available as backup or be the second anesthesiologist in an open heart?

We have always been held to a higher standard than CRNAs. That’s why no hospital I would actually want to have surgery in (or have my kid have surgery in) has unsupervised CRNAs working there. Their training just is not as good, and the quality decreases each year IMO.
I don’t think a General peds anesthesiologist should be doing peds hearts. I don’t think I should be doing peds hearts, I did an adult cardiac fellowship, not peds. The buck stops with the doctor, not the CRNA. I also don’t think CRNAs should be in those rooms unless it’s 1:1, which really makes no sense financially.
But it seems the almighty dollar trumps patient safety and well being these days, so my opinion doesn’t really mean much.

 

[OneTyme]

This is key. If you enjoy doing something nobody else wants or likes, then you will have job security. Beauty is in the eye of the beholder.

Yes my friend, it is a beautiful thing indeed.

 

[chocomorsel]

Yes my friend, it is a beautiful thing indeed.

In anesthesia that would be CCM and maybe OB. And join an OB only practice.

 

[Psai]

In anesthesia that would be CCM and maybe OB. And join an OB only practice.

I'd like to wait until I die before I go to hell

 

[AdmiralChz]

In anesthesia that would be CCM and maybe OB. And join an OB only practice.

Yeah I’d rather be raked over hot coals. Or do IR all day everyday.

 

[G-Man82]

I'd like to wait until I die before I go to hell

I'm in academics: Anesthesiology + CCM. This year, I'm cutting my OR time in half and increasing my CC time. Why? As one has mentioned, it's all about perspectives. I get paid the same either way and I enjoy the ICU more than the OR. Life in the ICU is not as bad as you guys make it out to be. Attending life is much nicer than Resident ICU life. If the money factor diverged a lot in favor of OR, then I'm not sure what I would do. I can't see myself giving up either specialty.

The ICUs that I work in include: MICU (a non-IM resident one), CVICU, and eICU.

I like the OR, but these days, at least in academics, it's riddled with BS. It could just be life in academics, but going to PP, I'd hate to manage 4 rooms at a time. So, there are multiple tradeoffs depending on your preferences and locale. In my opinion, the ICU just has less BS to deal with as an Attending.

 

[jthedestroyr]

I'm in academics: Anesthesiology + CCM. This year, I'm cutting my OR time in half and increasing my CC time. Why? As one has mentioned, it's all about perspectives. I get paid the same either way and I enjoy the ICU more than the OR. Life in the ICU is not as bad as you guys make it out to be. Attending life is much nicer than Resident ICU life. If the money factor diverged a lot in favor of OR, then I'm not sure what I would do. I can't see myself giving up either specialty.

The ICUs that I work in include: MICU (a non-IM resident one), CVICU, and eICU.

I like the OR, but these days, at least in academics, it's riddled with BS. It could just be life in academics, but going to PP, I'd hate to manage 4 rooms at a time. So, there are multiple tradeoffs depending on your preferences and locale. In my opinion, the ICU just has less BS to deal with as an Attending.

This is why i picked ccm.

I felt like an outsider bec everyone at my program does either pain or peds, but i generally like being in the unit way more than the OR.

The Militant APRN arent nearly anywhere close to miliant crna and we have both at my program. At least in the sicu even the miliant APRN dont profess to be equal.

Side note, Ive been surprised bt how many recruiting emails I have been getting for anesth-ccm and not just academics, but private places also. It may help we arent geographically limited other than opting for no NE/midwest states.