Fellowship advice

[tombola]

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CA-1 here. Obviously thinking about fellowships already as we have to apply so early.

My question is essentially, would doing a cardiac fellowship make me a better all around anesthesiologist and better suited for handling everything? Or is cardiac so specialized? What fellowship would help?
I am fairly set on a fellowship as I would like to stay academic, just want the one which will give me best bang for buck in regards to my skills and applicability.

 

[hununuh]

How did you get exposed to all the subspecialties as a CA-1 in just 4 months? Im still doing mostly ENT and general surgery cases

 

[pocafx]

Yeah lol. He mentioned ob regional and trauma...

 

[tombola]

How did you get exposed to all the subspecialties as a CA-1 in just 4 months? Im still doing mostly ENT and general surgery cases

Haven't done them all but my categorical program has us in the ORs during PGY1. Have done regional and OB months. Trauma is just from being on call. Still have my fair share of ENT and other general stuff also.

 

[kidthor]

CA-1 here. Obviously thinking about fellowships already as we have to apply so early. So far I have enjoyed all of my rotations, and can really see my future career as a generalist, doing some general OR, trauma, transplant, OB, regional, if thats feasible.

My question is essentially, would doing a cardiac fellowship make me a better all around anesthesiologist and better suited for handling everything? Or is cardiac so specialized now that it is really just for coming off and on pump, doing valves and TEE? What fellowship would help?
I am fairly set on a fellowship as I would like to stay academic, just want the one which will give me best bang for buck in regards to my skills and applicability.

You have a long way to go. But, you do need to think about fellowships early - so good mindset.

Don't do a fellowship to make yourself a better all around anesthesiologist for marketing purposes. You'll a good all around anesthesiologist if you're in a good program. And sure - cardiac anesthesiologists are usually quite good with most (adult) cases. Broken hearts are among the illest.

But, only do a fellowship if you really, really like a field and want to do a deep dive into it. And love it.

Don't worry about "bang for buck". The future will change. It can't be gamed. And you will be fine with whatever.

Just do what you love. Trust me.

 

[DrN2O]

Too early for OP to tell.

I wish cardiac anesthesia is just go on and off pump and play with TEE.

I also "love" fellowships that require no board certification and anybody does it when they are on call.

"Bang for" the department on your "buck".

 

[BLADEMDA]

OP expressed a desire to do academics. He/She should do a fellowship.

 

[Drangue]

How did you get exposed to all the subspecialties as a CA-1 in just 4 months? Im still doing mostly ENT and general surgery cases

This.

 

[deleted697535]

This fellowship stuff has been debated forwards and back for ages on here... There are only about 4/5 fellowships worth doing overall where you actually gain a skill you wouldn't otherwise have...

Cardiac peds pain ICU are it probably.

But the harsh truth is that for a lot of people (I don't have exact numbers but of my friends probably over half) they don't end up even using their fellowship 2 or 3 years after completing it.

 

[deleted171991]

This fellowship stuff has been debated forwards and back for ages on here... There are only about 4/5 fellowships worth doing overall where you actually gain a skill you wouldn't otherwise have...

Cardiac peds pain ICU are it probably.

But the harsh truth is that for a lot of people (I don't have exact numbers but of my friends probably over half) they don't end up even using their fellowship 2 or 3 years after completing it.

EXACTLY! Which is the main reason why most people should not do Pain, CCM, or possibly even peds.

 

[Aether2000]

Cardiac definitely needs a fellowship but only if you plan to apply to jobs with cardiac programs. Peds fellowships are useful if you work in a pediatric hospital. I would not recommend pain since it has been coopted by radiology, CRNAs, and surgeons. Regional or OB are useful only if you are in academics. Critical care is a waste of time unless you plan on practicing in the ICU. Anesthesiology residency is already 4 years- you don't need 5 or 6 years of training unless there are very specific indications.

 

[kidthor]

EXACTLY! Which is the main reason why most people should not do Pain, CCM, or possibly even peds.

It's worth thinking about this fact, at least. I did a peds fellowship and do mostly peds... and wouldn't want it any other way. However, plenty of my fellowship class ended up in PP jobs where they do mostly adult anesthesia. They don't regret doing the fellowship though.

I think a subsidiary yet major point is that doing multiple fellowships really can be a waste of time, given that doing one fellowship can be a sort of overkill for some. The market broadly speaking wants lots of generalists. And we shouldn't give up generalist anesthesia as a core of our jobs (e.g. give the midlevels all the "healthy" patients and then have the actual anesthesiologists care for the "sick" patients).

All said and done people should just do what they're interested in and go from there.

 

[BLADEMDA]

The fellowship is a defacto requirement for academia. For competitive markets and very desirable areas a fellowship may open doors.

For less desirable areas and rural American fellowship not very useful.

Right now a primo job is posted for Louisville but a Cardiac Fellow is preferred.

I remember what it’s like as a CA3 just wanting to be done and not do another year. All I can tell you is that the fellowship is worth it IMHO over a 25-35 year career.

 

[Aether2000]

Another view: In my area, fellowship training is required only in cardiac (for reasons of experiences not gained during residency) and pain (insurance carriers are not uncommonly requiring pain certification that is usually obtained via fellowship). Outside that, NO JOB in the area requires a fellowship. Those that completed fellowship training in other areas effectively sacrificed $300,000 income and a year of their lives (professional and personal) to obtain skills that many state are not being used or at most, made them slightly more comfortable with skills. Also consider who profits the most by fellowship training programs- hint: it isn't the fellow.

 

[deleted171991]

Another view: In my area, fellowship training is required only in cardiac (for reasons of experiences not gained during residency) and pain (insurance carriers are not uncommonly requiring pain certification that is usually obtained via fellowship). Outside that, NO JOB in the area requires a fellowship. Those that completed fellowship training in other areas effectively sacrificed $300,000 income and a year of their lives (professional and personal) to obtain skills that many state are not being used or at most, made them slightly more comfortable with skills. Also consider who profits the most by fellowship training programs- hint: it isn't the fellow.

That being said, most people don't regret doing a fellowship in a subspecialty they are PASSIONATE about, even if they end up not using it much.

Pain and regional will give one better regional anesthesia and non-opiate pain management skills, critical care (in the right program) will make one a much better doctor, peds will make the T&As fun, OB will make one look forward to the emergent/complicated C-sections most of us run away from etc.

When in doubt, just skip the fellowship until you're sure. Don't do it because that's the latest fashion, because of social pressure, because your "academic advisor" says so.

 

[26B]

Also consider who profits the most by fellowship training programs- hint: it isn't the fellow.

I think this is a great point, and probably one that more residents should at least consider.

 

[slippery_when_wet]

Cardiac definitely needs a fellowship but only if you plan to apply to jobs with cardiac programs. Peds fellowships are useful if you work in a pediatric hospital. I would not recommend pain since it has been coopted by radiology, CRNAs, and surgeons. Regional or OB are useful only if you are in academics. Critical care is a waste of time unless you plan on practicing in the ICU. Anesthesiology residency is already 4 years- you don't need 5 or 6 years of training unless there are very specific indications.

what do you mean coopted?

 

[vector2]

what do you mean coopted?

I honestly don't know enough about the procedure volumes or economics to comment whether the statement is true nationally, but what he means is that there are many hospitals (such as mine) where ortho and neurosurg send patients to IR for various pain procedures because a referral to pain would require going outside the system and/or be less convenient.

 

[Aether2000]

Yes, that and the self-referral by radiologists who read the MRI then self refer for procedures.

Radiology in one of the hospitals in my area routinely does SI injections, geniculate nerve ablations, ESI, kyphoplasties, etc. In some cases, the MRI is ordered by the pain physician, the patient goes to the hospital and has the MRI, the radiologists read the MRI then contact the patient's PCP asking if they want them to treat the problem, then they schedule the patient to come back to the IR department to have the block/kyphoplasty/RF before the patient ever returns to the pain physician who ordered the MRI.

In other cases, PCPs order the MRI/CT and without ever examining the patient, the radiology departments schedule them for injections, even if they already have a pain physician.

Also, neurosurgeons and orthopedic surgeons are not infrequently (poorly) doing their own ESI, RF, etc.
NASS has training courses for surgeons for exactly that purpose.

I am also aware of neurosurgery and ortho groups that hire CRNAs, PAs, and NPs to do their fluoroscopically guided injections and procedures including SCS trials. In some cases, radiology technicians do these spine injections without the radiologist being anywhere near the patient.

 

[deleted87051]

In all fairness, in my area it can be like pulling teeth to get chronic pain doctors to come to the hospital for inpatient consults.

 

[deleted697127]

Yes, that and the self-referral by radiologists who read the MRI then self refer for procedures.

Radiology in one of the hospitals in my area routinely does SI injections, geniculate nerve ablations, ESI, kyphoplasties, etc. In some cases, the MRI is ordered by the pain physician, the patient goes to the hospital and has the MRI, the radiologists read the MRI then contact the patient's PCP asking if they want them to treat the problem, then they schedule the patient to come back to the IR department to have the block/kyphoplasty/RF before the patient ever returns to the pain physician who ordered the MRI.

In other cases, PCPs order the MRI/CT and without ever examining the patient, the radiology departments schedule them for injections, even if they already have a pain physician.

Also, neurosurgeons and orthopedic surgeons are not infrequently (poorly) doing their own ESI, RF, etc.
NASS has training courses for surgeons for exactly that purpose.

I am also aware of neurosurgery and ortho groups that hire CRNAs, PAs, and NPs to do their fluoroscopically guided injections and procedures including SCS trials. In some cases, radiology technicians do these spine injections without the radiologist being anywhere near the patient.

Wow. That is blatantly unethical. I am not a pain doc but if that happened to me I would 100% report that to medical boards.

 

[slippery_when_wet]

Yes, that and the self-referral by radiologists who read the MRI then self refer for procedures.

Radiology in one of the hospitals in my area routinely does SI injections, geniculate nerve ablations, ESI, kyphoplasties, etc. In some cases, the MRI is ordered by the pain physician, the patient goes to the hospital and has the MRI, the radiologists read the MRI then contact the patient's PCP asking if they want them to treat the problem, then they schedule the patient to come back to the IR department to have the block/kyphoplasty/RF before the patient ever returns to the pain physician who ordered the MRI.

In other cases, PCPs order the MRI/CT and without ever examining the patient, the radiology departments schedule them for injections, even if they already have a pain physician.

Also, neurosurgeons and orthopedic surgeons are not infrequently (poorly) doing their own ESI, RF, etc.
NASS has training courses for surgeons for exactly that purpose.

I am also aware of neurosurgery and ortho groups that hire CRNAs, PAs, and NPs to do their fluoroscopically guided injections and procedures including SCS trials. In some cases, radiology technicians do these spine injections without the radiologist being anywhere near the patient.

Honestly, IR has all the skills sets to do the pain procedures, if not more.

Pain docs self refer patients to themselves right? Why can't radiology?

 

[deleted171991]

Honestly, IR has all the skills sets to do the pain procedures, if not more.

Pain docs self refer patients to themselves right? Why can't radiology?

Because the patient already has a pain doctor (the one who referred him for an MRI in the first place)? 🙄

 

[slippery_when_wet]

Because the patient already has a pain doctor (the one who referred him for an MRI in the first place)? 🙄

I was referring to primary care docs that order the MRI

 

[deleted171991]

I was referring to primary care docs that order the MRI

As long as the patient already has a pain specialist (whether s/he ordered the MRI or not), it's still hugely unethical in my book. Unless it's the patient (or the pain doc) who asks specifically.

Why? Because one should do what's best for the patient, not the pocketses. And what's best for the patient is continuity of care.

 

[kidthor]

I've seen IR do many of these procedures on inpatients - and they barely even follow up with the patient. Certainly they don't route them to any multi disciplinary sort of pain care. They just do the (lucrative) procedure and ship the patient back to wherever. Overall I don't think it's good care.
If someone getting pain procedures they absolutely need ongoing longitudinal care, ideally in a good pain clinic.

As an analogy could you imaging if ortho did a total hip on an ED patient, never did a post op visit, never sent the patient to PT/OT, never managed any post op meds/care, never answered any questions, and just basically sent them back to the ED? That's the level of non-involvement I've seen from IR when they do pain procedures...

 

[deleted697535]

As an analogy could you imaging if ortho did a total hip on an ED patient, never did a post op visit, never sent the patient to PT/OT, never managed any post op meds/care, never answered any questions, and just basically sent them back to the Ed

I thought that was exactly what Ortho did?

 

[kidthor]

I thought that was exactly what Ortho did?

I mean, we like to joke that ortho doesn't care... but I think they have a good interest in making sure their patients do well post op. Ortho cares that their procedure worked for its intended purpose. But IR doing a pain procedure? It's hazier. It's as if they placed a PICC and need no follow up.

Now IR does a great job with some of the complicated stuff that they have a more vested interest in - like aneurysm coiling.

Basically pain and all pain procedures need to go to a legit good pain doctor.

 

[ToKingdomCome]

That being said, most people don't regret doing a fellowship in a subspecialty they are PASSIONATE about, even if they end up not using it much.

Pain and regional will give one better regional anesthesia and non-opiate pain management skills, critical care (in the right program) will make one a much better doctor, peds will make the T&As fun, OB will make one look forward to the emergent/complicated C-sections most of us run away from etc.

When in doubt, just skip the fellowship until you're sure. Don't do it because that's the latest fashion, because of social pressure, because your "academic advisor" says so.

Would you recommend a fellowship if you feel that your training program didn’t provide adequate training?

 

[deleted171991]

Would you recommend a fellowship if you feel that your training program didn’t provide adequate training?

It's probably worth being more specific about the type of fellowship and the lack of training.

 

[deleted697127]

Would you recommend a fellowship if you feel that your training program didn’t provide adequate training?

Which area are you feeling deficient in?

The only one i would consider in this scenario is regional. You just don’t have to do the others if you don’t want to (cardiac, icu, peds, pain).

 

[PieOHmy]

Which area are you feeling deficient in?

The only one i would consider in this scenario is regional. You just don’t have to do the others if you don’t want to (cardiac, icu, peds, pain).

you can easily learn regional on yourself

 

[Neopolymath]

you can easily learn regional on yourself

On yourself or by yourself?

 

[deleted697127]

you can easily learn regional on yourself

Oh yeah? Just do the online fellowship and call it a day?

I’m sure it’s possible but I’m not sure it’s as easy as many people who were taught regional would like you to believe it would have been had they learned it on their own as an attending. I just don’t believe it. There are plenty of people who aren’t comfortable with blocks. I don’t think it’s a bad idea to address deficiencies with formal training if it’s something you intend on being part of your career.

 

[psychbender]

Would you recommend a fellowship if you feel that your training program didn’t provide adequate training?

If you don't think your training in a given area is adequate, and you seek to continue practicing those skills, then force your attendings to spend more time with you in those areas. If you're already out, then find a colleague at your new job that can bring you up to speed. Don't spend an extra year making a pittance doing something just because you think your residency did a **** job teaching you.

Sent from my SM-G930V using SDN mobile

 

[deleted87051]

Oh yeah? Just do the online fellowship and call it a day?

I’m sure it’s possible but I’m not sure it’s as easy as many people who were taught regional would like you to believe it would have been had they learned it on their own as an attending. I just don’t believe it. There are plenty of people who aren’t comfortable with blocks. I don’t think it’s a bad idea to address deficiencies with formal training if it’s something you intend on being part of your career.

Remember that regional fellowships are relatively new and many current regional faculty are actually self taught.

 

[deleted697127]

Remember that regional fellowships are relatively new and many current regional faculty are actually self taught.

That is a valid point. Plus, hopefully even the worst regional experience in residency gives you the background to make learning on your own less painful.

I just think it would be well worth the effort to seek out regional if it’s a deficiency in your training while you’re still a resident within your program or by asking for elective time outside of your hospital to avoid the need for on the job training or an unnecessary fellowship. People tend to get things they ask for. I stand by my point that it’s a reasonable career choice to work on your deficiencies with formal training.

Personally, I would prefer being able to market myself in regional. I like working with ortho. I like making a good first impression with my partners, nursing staff, the surgeons, and my patients. I personally would prefer to see common methods of troubleshooting and complications of regional while in a training program rather than out in the real world. I like knowing that if I’m on call and a surgeon asks for a block, I know how to do it. It definitely didn’t start out easy my first day of regional in residency. I would not want to start a new job hoping for hand holding.

 

[deleted87051]

That is a valid point. Plus, hopefully even the worst regional experience in residency gives you the background to make learning on your own less painful.

I just think it would be well worth the effort to seek out regional if it’s a deficiency in your training while you’re still a resident within your program or by asking for elective time outside of your hospital to avoid the need for on the job training or an unnecessary fellowship. People tend to get things they ask for. I stand by my point that it’s a reasonable career choice to work on your deficiencies with formal training.

Personally, I would prefer being able to market myself in regional. I like working with ortho. I like making a good first impression with my partners, nursing staff, the surgeons, and my patients. I personally would prefer to see common methods of troubleshooting and complications of regional while in a training program rather than out in the real world. I like knowing that if I’m on call and a surgeon asks for a block, I know how to do it. It definitely didn’t start out easy my first day of regional in residency. I would not want to start a new job hoping for hand holding.

In my opinion it’s fine to ask for a little hand holding at your first job out of residency. With rare exception, the learning curve is still pretty steep during the first 5 years of practice. Any good practice will understand this. Ask the old folks questions and I’m sure you’ll have things to teach them too.

Learn as much as you can during residency but the learning doesn’t stop after residency. Much of it is a matter of interest and motivation.

 

[Aether2000]

So...questions to ask before considering a fellowship:
1. Will it benefit me financially? (cardiac, pain)
2. Is it an area of specialization that anesthesiologists frequently practice (pain, regional, neuroanesthesia, cardiac, peds, OB) or is dominated by other base residencies (sleep, hospice and palliative, critical care, neurocritical care)
3. Is it an area in which I plan to specialize and have an intense interest?
4. Is it a requirement for the job (academia, cardiac, pain, pediatric anesthesia)?
5. Is it a marketable training that will afford greater job opportunities? (cardiac, pain)
6. Is the specialty viable and stable (cardiac, peds, CCU, OB) or is it a fellowship that is relatively new? (regional, neurocritical care)
7. Does it have associated board certification (pain, critical care, peds, hospice and palliative, sleep medicine, neurocritical care 2021) OR NOT (regional, neuroanesthesia, cardiac, OB)
8. Is my primary reason for doing a fellowship is because I feel weak in a particular area and do not believe I have the ability to achieve the skills to practice in that area without an extra year of training?

 

[deleted171991]

So...questions to ask before considering a fellowship:
1. Will it benefit me financially? (cardiac, pain)
2. Is it an area of specialization that anesthesiologists frequently practice (pain, regional, neuroanesthesia, cardiac, peds, OB) or is dominated by other base residencies (sleep, hospice and palliative, critical care, neurocritical care)
3. Is it an area in which I plan to specialize and have an intense interest?
4. Is it a requirement for the job (academia, cardiac, pain, pediatric anesthesia)?
5. Is it a marketable training that will afford greater job opportunities? (cardiac, pain)
6. Is the specialty viable and stable (cardiac, peds, CCU, OB) or is it a fellowship that is relatively new? (regional, neurocritical care)
7. Does it have associated board certification (pain, critical care, peds, hospice and palliative, sleep medicine, neurocritical care 2021) OR NOT (regional, neuroanesthesia, cardiac, OB)
8. Is my primary reason for doing a fellowship is because I feel weak in a particular area and do not believe I have the ability to achieve the skills to practice in that area without an extra year of training?

#3 should be the first question and veto-type.

If one is not passionate about the subspecialty (i.e. doesn't spend a lot of time just reading about it), then one should just skip the fellowship.