Fellowship becoming 2 years

[TableMD]

Agree with above. Comment above inspired me to do a refresher on median nerve, like this image so thought I would share. I do not do Sonex because I think the upper extremity surgeons do excellent work, but I support the interest in it.

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[Lurts]

Thank you all for the great replies. I do feel like I am getting adequate exposure to sonoanatomy and needle guidance in fellowship but was worried about how difficult it would be to incorporate some of this other stuff in future practice once I graduate. Glad to hear it's possible with good foundational skills!

 

[deleted997790]

Agree with above. Comment above inspired me to do a refresher on median nerve, like this image so thought I would share. I do not do Sonex because I think the upper extremity surgeons do excellent work, but I support the interest in it.

This is fantastic. Great post.

 

[Kissmyabjj]

Sick image! Source?

Agree with above. Comment above inspired me to do a refresher on median nerve, like this image so thought I would share. I do not do Sonex because I think the upper extremity surgeons do excellent work, but I support the interest in it.

 

[543vegas10]

As a current resident and who had strong aspirations of doing Sports Medicine... this would be highly deterrent, and potentially change my career path. This would now make post graduate training 6 yrs (PMR)! I predominantly chose PMR for the strong MSK component of primary training and was able to swallow the extra year vs my primary care colleagues for this expertise. I got a family to provide for, loans to pay, would like to buy and home and start saving for retirement... and grey hairs that are only becoming more noticable. That added year must have TONS of value added (as has been mentioned) in order for me to even consider it given the added year of lost attending salary. Those NASS fellowships are looking better and better.

 

[deleted997790]

As a current resident and who had strong aspirations of doing Sports Medicine... this would be highly deterrent, and potentially change my career path. This would now make post graduate training 6 yrs (PMR)! I predominantly chose PMR for the strong MSK component of primary training and was able to swallow the extra year vs my primary care colleagues for this expertise. I got a family to provide for, loans to pay, would like to buy and home and start saving for retirement... and grey hairs that are only becoming more noticable. That added year must have TONS of value added (as has been mentioned) in order for me to even consider it given the added year of lost attending salary. Those NASS fellowships are looking better and better.

I go back and forth on the value of a two year fellowship. Mandatory msk ultrasound plus certification while in fellowship and a high comfort level with advanced procedures, along with extra msk training for the non-PMR guys (this part def sucks if ur PM&R), and mandatory training in PrP/stem cell...u would come out of fellowship excellent instead of “prepared”. No residency or fellowship marks the end of your learning and the idea is to build a basic framework to make the self-motivated excellent within a few years after fellowship. A 2 year fellowship would greatly accelerate that learning path. Learning little keys like the supraspinatus tendon measuring approximately 1.5 CM before it turns into the conjoined tendon with the infraspinatus on ultrasound, for example, is not something all fellows learn while in fellowship (exception of those few great programs out there). You can’t hyper focus on things in a one year fellowship or you’ll miss out on other important things (fracture management, orthopedics, exercise physiology, physical therapy, etc).

I also see the value of letting the fellow learn the basics in one year and then make attending money while they fill in their gaps/weaknesses with self directed studying, conferences, etc.

I go back and forth about this being a good or bad idea. I do like that the field is going to become more difficult to get into and more “prestigious” Bc the # of fellowships will decrease. The only reason I like that is Bc it’s another reason for people to go into family medicine (we need more PCP docs).

 

[door_to_balloon_knot]

I’m surprised more of you guys aren’t outraged at the very obvious lack of value of adding another year of nearly-free labor to the academic system while you could have been earning attending salary. I can almost guarantee that the extra year will not produce any additional skills that will substantially add to your bottom-line which is how much you are paid. Additionally even if you were well versed in seeing where the rotator cuff tendon becomes conjoined on ultrasound... really, who cares? It has no benefit to the patient, your management (unless it’s a complete tear on a younger patient) will likely not change, and you will be essentially wasting your time which has implications if your based on a productivity model. Furthermore, say you learn something esoteric that is not in your wheelhouse like thread mill stress testing. Are you going to be absolutely confident in your results or are you gong to be sending to cardio? Hard to defend a poor outcome when a patient has a missed pathology and you are sitting in court trying to explain that you aren’t a cardiologist by training.

Sorry guys, 2 years is no good for those fellows no matter how you slice it.

 

[deleted997790]

I’m surprised more of you guys aren’t outraged at the very obvious lack of value of adding another year of nearly-free labor to the academic system while you could have been earning attending salary. I can almost guarantee that the extra year will not produce any additional skills that will substantially add to your bottom-line which is how much you are paid. Additionally even if you were well versed in seeing where the rotator cuff tendon becomes conjoined on ultrasound... really, who cares? It has no benefit to the patient, your management (unless it’s a complete tear on a younger patient) will likely not change, and you will be essentially wasting your time which has implications if your based on a productivity model. Furthermore, say you learn something esoteric that is not in your wheelhouse like thread mill stress testing. Are you going to be absolutely confident in your results or are you gong to be sending to cardio? Hard to defend a poor outcome when a patient has a missed pathology and you are sitting in court trying to explain that you aren’t a cardiologist by training.

Sorry guys, 2 years is no good for those fellows no matter how you slice it.

Valid points...

 

[543vegas10]

I’m surprised more of you guys aren’t outraged at the very obvious lack of value of adding another year of nearly-free labor to the academic system while you could have been earning attending salary. I can almost guarantee that the extra year will not produce any additional skills that will substantially add to your bottom-line which is how much you are paid. Additionally even if you were well versed in seeing where the rotator cuff tendon becomes conjoined on ultrasound... really, who cares? It has no benefit to the patient, your management (unless it’s a complete tear on a younger patient) will likely not change, and you will be essentially wasting your time which has implications if your based on a productivity model. Furthermore, say you learn something esoteric that is not in your wheelhouse like thread mill stress testing. Are you going to be absolutely confident in your results or are you gong to be sending to cardio? Hard to defend a poor outcome when a patient has a missed pathology and you are sitting in court trying to explain that you aren’t a cardiologist by training.

Sorry guys, 2 years is no good for those fellows no matter how you slice it.

Yeah I spoke to coresidents today one of whom will be matching this year, other 2 who were kinda on the fence regarding sports fellowship. Both on the fence basically stated uhhh this makes my decision easy, no fellowship. I haven’t heard anyone jumping with joy over this.

 

[sloh]

even if you were well versed in seeing where the rotator cuff tendon becomes conjoined on ultrasound... really, who cares? It has no benefit to the patient, your management (unless it’s a complete tear on a younger patient) will likely not change, and you will be essentially wasting your time which has implications if your based on a productivity model.

This is exactly what I thought when I read "learning little keys like the supraspinatus tendon measuring approximately 1.5 CM before it turns into the conjoined tendon with the infraspinatus on ultrasound, for example, is not something all fellows learn while in fellowship (exception of those few great programs out there)."

A lot of what you guys are talking about in this thread has little to no evidence of benefit and can arguably lead to harm in the long run for patients; and all the mental masturbation over the nitty gritty of pathophysiology and the intricacies you can pick up on imaging do not change management in any meaningful way.

PRP? Stem Cells? Lol. Grift.

The job market and more specifically (poor) compensation is a whole other conversation.

 

[runfastnow]

I’m surprised more of you guys aren’t outraged at the very obvious lack of value of adding another year of nearly-free labor to the academic system while you could have been earning attending salary. I can almost guarantee that the extra year will not produce any additional skills that will substantially add to your bottom-line which is how much you are paid. Additionally even if you were well versed in seeing where the rotator cuff tendon becomes conjoined on ultrasound... really, who cares? It has no benefit to the patient, your management (unless it’s a complete tear on a younger patient) will likely not change, and you will be essentially wasting your time which has implications if your based on a productivity model. Furthermore, say you learn something esoteric that is not in your wheelhouse like thread mill stress testing. Are you going to be absolutely confident in your results or are you gong to be sending to cardio? Hard to defend a poor outcome when a patient has a missed pathology and you are sitting in court trying to explain that you aren’t a cardiologist by training.

Sorry guys, 2 years is no good for those fellows no matter how you slice it.

preach

 

[Kissmyabjj]

Having been an attending now for a whopping four months, I can state that the transition from fellow to attending is way harder than from resident to fellow or from intern to resident. I do EMG’s, ultrasound guided procedures, and lumbar fluoro. The amount I have learned just as a result of being on my own is amazing. So for these basic skills I don’t see the value of an extra year fellowship.

However, developing skills in, to me, essentially novel procedures such as ultrasound guided carpal tunnel release and fasciotomy going to be almost impossible for me at least for the next year or so. This is because I just don’t have the time to go and get trained to do them to a level of competence that I would need to feel comfortable doing them with my license on the line.

I feel the same way about cervical and thoracic spine interventions under fluoro. As a fellow, I had very limited fluoroscopic time. So I had to decide in what I could develop competence within the time constraints of a 1-year fellowship. Of note though, I set up my own fluoro time with a pain physician with permission for my program director. My fellowship was not PM&R based. So maybe it’s possible that if I had been in a PM&R based sports medicine program, I would’ve had much more time in the fluoro suite to become comfortable with cervical and thoracic injections.

I guess what I’m saying is a two-year fellowship, if structured correctly, could definitely significantly improve breadth the procedures you perform and your confidence in performing them. I would imagine with the skill set you would finish fellowship with, you would be able to negotiate for a much higher salary. I’m thinking somewhere between what outpatient MSK PM&R and board-certified pain management get.

 

[deleted997790]

Having been an attending now for a whopping four months, I can state that the transition from fellow to attending is way harder than from resident to fellow or from intern to resident. I do EMG’s, ultrasound guided procedures, and lumbar fluoro. The amount I have learned just as a result of being on my own is amazing. So for these basic skills I don’t see the value of an extra year fellowship.

However, developing skills in, to me, essentially novel procedures such as ultrasound guided carpal tunnel release and fasciotomy going to be almost impossible for me at least for the next year or so. This is because I just don’t have the time to go and get trained to do them to a level of competence that I would need to feel comfortable doing them with my license on the line.

I feel the same way about cervical and thoracic spine interventions under fluoro. As a fellow, I had very limited fluoroscopic time. So I had to decide in what I could develop competence within the time constraints of a 1-year fellowship. Of note though, I set up my own fluoro time with a pain physician with permission for my program director. My fellowship was not PM&R based. So maybe it’s possible that if I had been in a PM&R based sports medicine program, I would’ve had much more time in the fluoro suite to become comfortable with cervical and thoracic injections.

I guess what I’m saying is a two-year fellowship, if structured correctly, could definitely significantly improve breadth the procedures you perform and your confidence in performing them. I would imagine with the skill set you would finish fellowship with, you would be able to negotiate for a much higher salary. I’m thinking somewhere between what outpatient MSK PM&R and board-certified pain management get.

This is what I was trying to say in a convoluted way. It’s not about the “supraspinatus tendon”, it’s about comfort and mastery with procedures. I see both sides of the argument and I’m sitting on a sharp, pointed and painful fence. A one year fellowship is more than sufficient to build a solid framework. You can learn everything on ur own free times while ur making attending salary or u can be a grunt (fellow) and have a higher level of mastery with more procedures and come out of fellowship being more than “sufficient”. Either way, ur gonna end up in 5 years or so with the same skill set if ur motivated enough to learn. You can learn sonex, tenex, ultrasound, nerve ablations and flouro by yourself (my fellowship taught us the first 3 procedures). The AMSSM is pretty much making it mandatory to learn a lot of these procedures (including PrP/stem cell - which I just don’t know why?) and their train of thought is that you learn it while you are a fellow under an attending who is well versed in the procedures and gain a higher level of mastery and comfort with them.

 

[543vegas10]

Having been an attending now for a whopping four months, I can state that the transition from fellow to attending is way harder than from resident to fellow or from intern to resident. I do EMG’s, ultrasound guided procedures, and lumbar fluoro. The amount I have learned just as a result of being on my own is amazing. So for these basic skills I don’t see the value of an extra year fellowship.

However, developing skills in, to me, essentially novel procedures such as ultrasound guided carpal tunnel release and fasciotomy going to be almost impossible for me at least for the next year or so. This is because I just don’t have the time to go and get trained to do them to a level of competence that I would need to feel comfortable doing them with my license on the line.

I feel the same way about cervical and thoracic spine interventions under fluoro. As a fellow, I had very limited fluoroscopic time. So I had to decide in what I could develop competence within the time constraints of a 1-year fellowship. Of note though, I set up my own fluoro time with a pain physician with permission for my program director. My fellowship was not PM&R based. So maybe it’s possible that if I had been in a PM&R based sports medicine program, I would’ve had much more time in the fluoro suite to become comfortable with cervical and thoracic injections.

I guess what I’m saying is a two-year fellowship, if structured correctly, could definitely significantly improve breadth the procedures you perform and your confidence in performing them. I would imagine with the skill set you would finish fellowship with, you would be able to negotiate for a much higher salary. I’m thinking somewhere between what outpatient MSK PM&R and board-certified pain management get.

Then why not pursue an interventional/ msk fellowship vs sports medicine??? The former is predominantly geared for the cervical- lumbar flouro expertise you mention. If there indeed is the switch from 1 to 2 years.... I highly doubt any PMR resident would consider Sports medicine fellowship and instead opt for the ever increasing NASS ISSM options simply from an economics standpoint. You'd be able to do all the spinal stuff without restriction as well as all the peripheral joint stuff, only thing Sports fellowship adds is access to D1/ professional athlete population.

From a PMR perspective I could see the 2 yr fellowship being beneficial if you basically combine these 2 fellowships into one( similar to what Michigan State currently does.)

Regarding increase is salary negotiation. Would the higher salary you can demand be equivalent to the 200-500k in lost income from the added year or from not even doing fellowship at all?? Again what is the actual value here?

 

[runfastnow]

Then why not pursue an interventional/ msk fellowship vs sports medicine??? The former is predominantly geared for the cervical- lumbar flouro expertise you mention. If there indeed is the switch from 1 to 2 years.... I highly doubt any PMR resident would consider Sports medicine fellowship and instead opt for the ever increasing NASS ISSM options simply from an economics standpoint. You'd be able to do all the spinal stuff without restriction as well as all the peripheral joint stuff, only thing Sports fellowship adds is access to D1/ professional athlete population.

From a PMR perspective I could see the 2 yr fellowship being beneficial if you basically combine these 2 fellowships into one( similar to what Michigan State currently does.)

Regarding increase is salary negotiation. Would the higher salary you can demand be equivalent to the 200-500k in lost income from the added year or from not even doing fellowship at all?? Again what is the actual value here?

Hammer meet nail. If over the life time of your career you are unable to make up ~$700k (lost salary, student loan interest, and retirement/investment fund compounding for 30+ years) for a two year fellowship then it likely isn't worth it (unless academics is that much of a draw to you).

The only way I see making up that loss of lifetime financial security is being able to command an extra $50k+ (or 20-25% higher) per year above the typical $200-250k non-op sports salary (+/- a margin of error). To me this means being able to do spine procedures which would only be open to PM&R sports. Cardiac testing and all the other non-sense that other specialists already do are money losers if that's going to be your calling card as a FM sports physician.

If AMSSM wants to have a 2 year option for the academically inclined that want to work in an academic center that doesn't need to be profitable then so be it. But for the rest of us "in the real world" a 2 year fellowship would make no sense unless you got some procedure value add (i.e. spine procedures) to your skill set.

 

[deleted997790]

Hammer meet nail. If over the life time of your career you are unable to make up ~$700k (lost salary, student loan interest, and retirement/investment fund compounding for 30+ years) for a two year fellowship then it likely isn't worth it (unless academics is that much of a draw to you).

The only way I see making up that loss of lifetime financial security is being able to command an extra $50k+ (or 20-25% higher) per year above the typical $200-250k non-op sports salary (+/- a margin of error). To me this means being able to do spine procedures which would only be open to PM&R sports. Cardiac testing and all the other non-sense that other specialists already do are money losers if that's going to be your calling card as a FM sports physician.

If AMSSM wants to have a 2 year option for the academically inclined that want to work in an academic center that doesn't need to be profitable then so be it. But for the rest of us "in the real world" a 2 year fellowship would make no sense unless you got some procedure value add (i.e. spine procedures) to your skill set.

What region are you in that primary care sports medicine is making only $200-$250???

 

[Natremia]

Could anyone comment on going for sports via peds? lm a little hazy on my scope. Is it similar to allergy where I can see all ages when done? I’ve tried googling and searching on sdn but can’t find Jack squat!

That being said, am I at a huge disadvantage applying with a peds background?

Appreciate any fellow/ attending input.

 

[Waterlover]

Do we have an update on if 2 years if happening for fellowship, particularly starting July 2022 lol?

 

[deleted997790]

Do we have an update on if 2 years if happening for fellowship, particularly starting July 2022 lol?

Doesn’t look like it. ACGME isn’t gonna meet until the COVID threat improves. The 2021/2022 and 2022/2023 class look safe...

 

[Waterlover]

Doesn’t look like it. ACGME isn’t gonna meet until the COVID threat improves. The 2021/2022 and 2022/2023 class look safe...

Thank you! Yessss

 

[galactus]

Could anyone comment on going for sports via peds? lm a little hazy on my scope. Is it similar to allergy where I can see all ages when done? I’ve tried googling and searching on sdn but can’t find Jack squat!

That being said, am I at a huge disadvantage applying with a peds background?

Appreciate any fellow/ attending input.

Depends.

If you do a peds sports fellowship...maybe. Like college athletes.
If you matched into a FM sports fellowship, you will get comfortable taking care of adults, do joint injections, deal with osteoporosis, osteoarthritis, etc.

I did a FM sports fellowship. One of the fellows above me and the one after my year in fellowship me were peds trained, and I know they see both children and adults. The ones I know that did a peds sports fellowship primarily only see peds patients.

 

[Natremia]

Depends.

If you do a peds sports fellowship...maybe. Like college athletes.
If you matched into a FM sports fellowship, you will get comfortable taking care of adults, do joint injections, deal with osteoporosis, osteoarthritis, etc.

I did a FM sports fellowship. One of the fellows above me and the one after my year in fellowship me were peds trained, and I know they see both children and adults. The ones I know that did a peds sports fellowship primarily only see peds patients.

Thank you very much for this! I would, ironically, want to see adults. I have no interest in seeing only kids.

I really appreciate your response. I’ve been looking at lots of different sports fellowships and was quite confused at how it broke down. Even more confused on FM vs PM&R based ones; I’m assuming I would not qualify for the latter? I miss doing procedures and miss seeing adults.

Thanks for your time!

 

[runfastnow]

PM&R sports fellowships generally only accept PM&R applicants because they are geared towards more procedures (fluoro spine, EMGs, etc.) that only PM&R have done in residency in addition to the typical sports stuff.

FM tends to be most accepting of any specialty (although some will not take PM&R). You really just have to ask the program coordinator or PD if it is not explicitly stated on the website.

If you are worried about scope of practice I know a current SEC university team physician is peds trained and has seen adults in the past at a prior job - so you don't have to just see kids.

 

[543vegas10]

This is the best option 100%