Fellowship...Or not?

[Stillwater45]

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Now in the middle of my CA-2 year im feeling a lot of pressure to pick a sub-specialty. I always thought I would do a fellowship. But now that it comes down to it... Im not sure I want to anymore. I like everything, don't love anything, and don't hate anything (Cardiac, Peds, Regional, +/- Pain). When it comes down to it, don't like anything enough to justify getting paid like a resident for another year, or being pigeon holed into doing primarily one thing. But if it's looking like we all need to do fellowships - I wouldn't mind doing one, Im just not excited about it.

Is it OK to not do a fellowship these days? What is the general consensus in private practice world? Does it matter?

 

[pgg]

Is it OK to not do a fellowship these days?

I'd have to say, of course it's OK. Take a step back and look at the pool of anesthesiologists out there. Most haven't, most won't. There aren't enough fellowship slots available for everyone to do one even if the demand and desire was there.

I'm planning to, because
- I like doing those cases a lot
- at present I'm dissatisfied with my inability to do certain things as well as I want to, and there's a ceiling to what I can self-teach myself
- I like the thought of having extra options that may be helpful at some unspecified point in an uncertain economic future

Besides, my whole professional life has been one year of delayed gratification after another, one more won't kill me. Even so, if I fall into the right offer and the right place a couple years from now ... maybe not.

 

[nycitygas]

I'd have to say, of course it's OK. Take a step back and look at the pool of anesthesiologists out there. Most haven't, most won't. There aren't enough fellowship slots available for everyone to do one even if the demand and desire was there.

I'm planning to, because
- I like doing those cases a lot
- at present I'm dissatisfied with my inability to do certain things as well as I want to, and there's a ceiling to what I can self-teach myself
- I like the thought of having extra options that may be helpful at some unspecified point in an uncertain economic future

Besides, my whole professional life has been one year of delayed gratification after another, one more won't kill me. Even so, if I fall into the right offer and the right place a couple years from now ... maybe not.

What fellowship are u considering pgg? Cardiac?

 

[pgg]

What fellowship are u considering pgg? Cardiac?

Yes. Sorry, didn't mean to be deliberately vague in that post. I'm serving out a military obligation now. There is no projected need for additional cardiac anesthesiologists in the next few years, so the Navy will not allow any of us to do fellowships for the forseeable future. I'm free to go anywhere July 2014. Eyeballing the California programs, so we won't have to move the family (with 3 highschool aged kids) for that single year.

 

[desflurane]

There are plenty of threads on this and many strong opinions one way or the other. Like most complicated issues...it depends.

If you are doing this whole thing for the money then don't do a fellowship. In that case find a private practice in a good payor mix area, become a partner and churn out cases till you die. Even if things go bad in the job market you'll most likely have made enough to cover yourself.


Having seen what goes on in the private practice world, I would say do one in the area you like the most. Cardiac is good even if volume is going down. You will generally be the go to guy for big cases even if you do no hearts. That's valuable. Peds is good because private practices love to use that as a marketing tool for parents and surgeons even if you are just doing ears and tonsils. Regional is good if you want to be block master. Its amazing how much cred you actually get in private practice for that one year. Nobody can take those credentials from you once you have them. I've been doing blocks for years and the one year fellowship guy is now our "block jockey".

I guess it depends how you feel about insurance. Consider the fellowship your insurance policy against irrelevance in the face of midlevel incursions. The lost income is your premium. Do the math and decide if its worth it for you.

 

[Mman]

You don't have to do a fellowship. It helps open some doors that otherwise wouldn't be opened. I was on the fence about doing one, but found an opening at a great group that is rarely hiring. They needed me and I'm confident I could never find a better job even with a fellowship so I took the job.

A fellowship can't hurt and it might help. But it does have the opportunity cost of lost income for that year, which can be a decent amount of money and can compound for a long period of time.

 

[gtb]

The fellowship environment is also something to consider. Some universities use atypical fellowships (thoracic, regional, OB, neuro, trauma, transplant) as little more than cheap labor. They were called faculty-fellows, and while making about $100K/year, they really mostly functioned as attendings without any significant subspecialty training.

 

[HalO'Thane]

You don't have to do a fellowship. It helps open some doors that otherwise wouldn't be opened. I was on the fence about doing one, but found an opening at a great group that is rarely hiring. They needed me and I'm confident I could never find a better job even with a fellowship so I took the job.

A fellowship can't hurt and it might help. But it does have the opportunity cost of lost income for that year, which can be a decent amount of money and can compound for a long period of time.

I do think that a fellowship can limit you in certain situations. There may be a really desirable anesthesia group or hospital that does not require your subspecialty. e.g. a lucrative general anesthesia practice that does not do hearts, peds, or critical care. You may convince them that you are O.K. not practicing your subspecialty but to me it would look fishy as a prospective employer and to the fellow it would be a complete waste of a year. You may also lose much of the skills and knowledge that you acquired during your fellowship after several years of not practicing your subspeciality.

Having said that you should do what makes you happy. I don't think you should feel pressured to do a fellowship if there is nothing that you love or if you enjoy doing a little of everything.

 

[Frank Rizzo]

You don't have to do a fellowship. It helps open some doors that otherwise wouldn't be opened. I was on the fence about doing one, but found an opening at a great group that is rarely hiring. They needed me and I'm confident I could never find a better job even with a fellowship so I took the job.

A fellowship can't hurt and it might help. But it does have the opportunity cost of lost income for that year, which can be a decent amount of money and can compound for a long period of time.

Sounds like my situation exactly. Was going to do cardiac, then a great job fell in my lap... decision was easy.

 

[Frank Rizzo]

The fellowship environment is also something to consider. Some universities use atypical fellowships (thoracic, regional, OB, neuro, trauma, transplant) as little more than cheap labor. They were called faculty-fellows, and while making about $100K/year, they really mostly functioned as attendings without any significant subspecialty training.

This is more common than most people think.

 

[DrN2O]

The fellowship environment is also something to consider. Some universities use atypical fellowships (thoracic, regional, OB, neuro, trauma, transplant) as little more than cheap labor. They were called faculty-fellows, and while making about $100K/year, they really mostly functioned as attendings without any significant subspecialty training.

These non-ACGME fellowships are mostly for people interested in staying in academia that may let them to stay in the same institutions or move to somewhere similar. Not sure how that distinguishes you from others for most other jobs.

 

[IlDestriero]

The fellowship environment is also something to consider. Some universities use atypical fellowships (thoracic, regional, OB, neuro, trauma, transplant) as little more than cheap labor. They were called faculty-fellows, and while making about $100K/year, they really mostly functioned as attendings without any significant subspecialty training.

You really don't need a fellowship to do any of that if you went to a good residency program. Possibly excepting regional, I think they're a total scam.
If you feel deficient, instead of a $100k pseudo fellowship, join a good academic faculty for a couple years at $250k+/yr and become an expert. All you have to do is ask, the "grey hairs" are happy to help mentor Jr. faculty. You could try to make it a condition of your employment. You can also knock back a few paid CME trips focusing on your new pseudo-specialty. Academic programs love their go-to specialty faculty, they want you to become an expert in something. (neuro, OB, regional, trauma, etc)
Then go get your dream job with real marketable experience under your belt and some $$ in the bank.👍

 

[nycitygas]

My personal take on fellowships
Of the non ACGME accredited fellowships, I've heard that an OB fellowship done at the right place can open doors-every big hospital would like to have one on faculty (Those Director of OB Anesthesia come from somewhere).
I'm doing a critical care fellowship. Although I enjoy cardiac cases, dealing with cardiac surgeons everydays seems tiresome. And the case load nationwide is going downhill and in my program, I feel as if the cardiac anesthesiologists are constantly getting dumped on. Peds has a great job market and is interestering but but sick kids scare me. I had an infant die a few days after a large surgery last year-and It definitely affected me. Much more than say a 70 year old with HTN DM CHF CAD x 3 would. I loved the procedures in pain and though clinic was okay. The problem with pain is that I notice many groups are honestly too money focused. A friend in fellowship told me many groups he's interviewed want a "needle jockey" (they used this phrase in the interview).
I settled on critical care after loving my SICU month. I also liked the experience many of the top programs give ie ECHO, running CTICUs that will (I think at least) give me cred in PP. I also like the idea of having the chance to become a different sort of physician if necessary later in life if I burnout from the OR or develop a physical impairment. And at worst, They are in high demand in academics. The Critical Care Anesthesiologists always seemed the brightest to me as well (No offense hah)

 

[vector2]

I settled on critical care after loving my SICU month. I also liked the experience many of the top programs give ie ECHO, running CTICUs that will (I think at least) give me cred in PP. I also like the idea of having the chance to become a different sort of physician if necessary later in life if I burnout from the OR or develop a physical impairment. And at worst, They are in high demand in academics. The Critical Care Anesthesiologists always seemed the brightest to me as well (No offense hah)

I've heard from a couple anesthesia CCM attendings at home and on the interview trail that they still get offers from private groups, but what is the national job market really like for these guys? I'm not really getting what sort of true demand there is for critical care anesthesia when, from my understanding, the vast majority of ICUs outside of academics are staffed by pulm/cc...

 

[kazuma]

I've heard from a couple anesthesia CCM attendings at home and on the interview trail that they still get offers from private groups, but what is the national job market really like for these guys? I'm not really getting what sort of true demand there is for critical care anesthesia when, from my understanding, the vast majority of ICUs outside of academics are staffed by pulm/cc...

This is my understanding as well. I've had several attendings and PD's tell me that CC is in high demand. But I haven't seen or heard of any ICU's in PP staffed by anesthesiologists.

 

[seinfeld]

Want a job doing critical care and anesthesia? If you're a reasonable person and somewhat normal I would hire you in a second.

Critical Care anesthesia is in that problem place where more are needed but until more of us exist finding a group like mine, where you can truly practice both under one umbrella, is not easy.

Most anesthesia groups want to be single specialty, Anesthesia. Most don't have a pain segment, and even more rare is to find a group with a critical care segment.

In my situation the pulm guys would rather not take call, rather not deal with sick patients who are dying, dont know how to put lines in or to intubate. Plus they make more money doing clinic, sleep labs, etc than doing CCM. We dont bill, the hospital does and they contract us to provide the MD coverage and oversight. We dont get 100% of what an anesthesiologist's annual salary would be but what we loose in dollars we make up for in leverage at the bargaining table.

Also the lifestyle as an attending is no where near as painful and stressful as it was being a resident or fellow. I have a 24/7 NP/PA staff which take care of the pain of dictating, calling consults, replacing electrolytes. I get to do all the higher level thinking, talking with families about prognosis and doing procedures. Remember, do it enough, and even ARDS and MODS becomes routine.

PS: sorry to highjack the thread and turn it into a Pro - ICU thread

 

[kazuma]

Want a job doing critical care and anesthesia? If you're a reasonable person and somewhat normal I would hire you in a second.

Critical Care anesthesia is in that problem place where more are needed but until more of us exist finding a group like mine, where you can truly practice both under one umbrella, is not easy.

Most anesthesia groups want to be single specialty, Anesthesia. Most don't have a pain segment, and even more rare is to find a group with a critical care segment.

In my situation the pulm guys would rather not take call, rather not deal with sick patients who are dying, dont know how to put lines in or to intubate. Plus they make more money doing clinic, sleep labs, etc than doing CCM. We dont bill, the hospital does and they contract us to provide the MD coverage and oversight. We dont get 100% of what an anesthesiologist's annual salary would be but what we loose in dollars we make up for in leverage at the bargaining table.

Also the lifestyle as an attending is no where near as painful and stressful as it was being a resident or fellow. I have a 24/7 NP/PA staff which take care of the pain of dictating, calling consults, replacing electrolytes. I get to do all the higher level thinking, talking with families about prognosis and doing procedures. Remember, do it enough, and even ARDS and MODS becomes routine.

PS: sorry to highjack the thread and turn it into a Pro - ICU thread

Thanks for sharing. With uncertain times ahead it seems like being more integrated into a hospital by covering the ICU would be of great benefit to an anesthesiology group when contract renewal comes around. Perhaps making it more difficult for an AMC to come in and boot your group out.

 

[nycitygas]

Want a job doing critical care and anesthesia? If you're a reasonable person and somewhat normal I would hire you in a second.

Critical Care anesthesia is in that problem place where more are needed but until more of us exist finding a group like mine, where you can truly practice both under one umbrella, is not easy.

Most anesthesia groups want to be single specialty, Anesthesia. Most don't have a pain segment, and even more rare is to find a group with a critical care segment.

In my situation the pulm guys would rather not take call, rather not deal with sick patients who are dying, dont know how to put lines in or to intubate. Plus they make more money doing clinic, sleep labs, etc than doing CCM. We dont bill, the hospital does and they contract us to provide the MD coverage and oversight. We dont get 100% of what an anesthesiologist's annual salary would be but what we loose in dollars we make up for in leverage at the bargaining table.

Also the lifestyle as an attending is no where near as painful and stressful as it was being a resident or fellow. I have a 24/7 NP/PA staff which take care of the pain of dictating, calling consults, replacing electrolytes. I get to do all the higher level thinking, talking with families about prognosis and doing procedures. Remember, do it enough, and even ARDS and MODS becomes routine.

PS: sorry to highjack the thread and turn it into a Pro - ICU thread

Thanks for the post Seinfeld. I'm interviewing at Michigan next month-you're in depth post regarding its training got me into it. Mind if a I pm you in a few weeks with questions?

 

[seinfeld]

PM anytime

 

[CrazyJake]

Kinda in the same situation, like everything, don't love anything specific to do it potentially daily and lose another year of income. If I did anything, toward PP, I'd probably do Regional or Peds - for points mentioned below.

Have been talking to PP groups casually (Ca2) and if you've gone to a good training program there doesn't seem to be a HUGE need or focus for the fellowship. Have asked specifically about Cardiac (they say #s are dwindling), Peds (most PP folks can do bulk of Peds and if kids are super sick they're getting sent to the academic ctr), Regional (great skill set, but PP doesn't do/run catheter service) and SICU (PP people have laughed so hard b/c that's the last thing they want to run or be apart of!).

Seinfeld - I'd happily do a SICU year..you'd be fantastic after it and as Blade has said - you could market yourself as being able to take care of 'the sickest of the sick.' But, honestly...there just aren't PP groups covering the ICU's. With the talk of the Surgical Home concept, maybe it's the best fellowship to potentially do...but things don't match currently with our system, way we get paid, etc. Not knocking anyone for doing it, have thought long and hard myself, but just doesn't seem to lead to great PP jobs at the moment.

Tough decision...kinda hard to guess what Medicine/Anesthesia will look like in 20 years. Who knows??

If a GREAT job comes along, it would be hard to pass that up for another year...

CJ

 

[studentologist]

Could a Critical Care fellowshipped Anesthesiologist work in a PP group that doesn’t run an ICU and work in an ICU staffed by PP Pulm/CC docs?

 

[Doctor4Life1769]

Kinda in the same situation, like everything, don't love anything specific to do it potentially daily and lose another year of income. If I did anything, toward PP, I'd probably do Regional or Peds - for points mentioned below.

Have been talking to PP groups casually (Ca2) and if you've gone to a good training program there doesn't seem to be a HUGE need or focus for the fellowship. Have asked specifically about Cardiac (they say #s are dwindling), Peds (most PP folks can do bulk of Peds and if kids are super sick they're getting sent to the academic ctr), Regional (great skill set, but PP doesn't do/run catheter service) and SICU (PP people have laughed so hard b/c that's the last thing they want to run or be apart of!).

Seinfeld - I'd happily do a SICU year..you'd be fantastic after it and as Blade has said - you could market yourself as being able to take care of 'the sickest of the sick.' But, honestly...there just aren't PP groups covering the ICU's. With the talk of the Surgical Home concept, maybe it's the best fellowship to potentially do...but things don't match currently with our system, way we get paid, etc. Not knocking anyone for doing it, have thought long and hard myself, but just doesn't seem to lead to great PP jobs at the moment.

Tough decision...kinda hard to guess what Medicine/Anesthesia will look like in 20 years. Who knows??

If a GREAT job comes along, it would be hard to pass that up for another year...

CJ

Hey bro! Thanks for writing this up. Maybe you could elaborate on the Surgical Home concept? Hope things are going well with you... still appreciate the help you gave me. Things are going well thus far, can't wait till to start in 5-6 months.

 

[CrazyJake]

I think you could, definitely...but from what my PP groups have said to me is that logistically it would be hard to schedule shifts, call, early-late guy, vacation, etc.
They have also said they want their Anesthesiologists in the OR working b/c that's where the money is at. I would imagine an ICU would want you to cover at least a week q 4-6 weeks, maybe more....Billing has also been mentioned as a challenging point b/c ICU's often don't make $$ - so whose going to pay for that week you're gone?? As Seinfeld described, their payment method sounds like it works.

Maybe Seinfeld or other guys doing ICU in PP can offer a more real-life perspective.
Seinfeld - would you care to add what part of the country you're in and if you think people doing CCM years are going to be able to find PP jobs in the years to come. This is was a hot topic at ASA for sure. Most that I know who are interested in ICU don't want to do it daily, but maybe a week a month and covering nights/weekends occasionally.

Don't know a ton about the surgical home concept, but from what I can gather it essentially would mean a bundled payment for the entire course (being evaluated by surgeon, preop stuff, the surgery, post op course) and 1 physician would be the gate-keeper who oversees everything. Anesthesiologists make great sense for this b/c we're good at getting folks ready for surgery, getting them thru the surgery safely and after a solid residency should be comfortable managing postop pt's. The issue seems to be in that 1) we don't bring the pt to the hospital/OR, 2) surgeons are more valuable to a hospital in the eyes of most hospital administration, and 3) I don't see surgeons giving up the bulk of pt mgmt to us. At our SICU fellowship, the surgery residents are lining up left and right to get into that 1 year so if the above happens (probable), then they can claim that the found the pt, decided they needed surgery, did the actual surgery and then managed them postop and hence deserve the majority of that bundled payment...leaving us to fight for the scraps with the hospital, pharmacy, and everyone else. There's probably a ton more to it, but that's my impression. Please correct me, if wrong.

I know the ASA and thought leaders are advocating for us to become this gate-keeper and perioperative physicians, but with our current system just not sure how it's gonna work??

Again, not bashing the idea of a CCM year - sounds fantastic, but PP jobs aren't everywhere.

CJ


Doc4Life - let me know if you need anymore help - only a few more months!

 

[imfrankie]

Another point to consider: if you can afford it, a fellowship just might make you a better doctor.

 

[Doctor4Life1769]

Thanks CJ! Very much appreciate it! 👍👍

 

[orangballoon123]

what is the reimbursement like for the different anes fellowships? does fellowship mean higher salary in private practice or is it more a leverage to get the offer from a competitive group? if leveraging tool, which fellowship is highest demand?

 

[VentdependenT]

what pulmonar/cc trained doc doesnt KNOW how to tube someone or put in a line?

 

[WholeLottaGame7]

what pulmonar/cc trained doc doesnt KNOW how to tube someone or put in a line?

I dunno, but I had an interventional pulm fellow ask me if she could intubate a patient post-rigid bronch because she had never intubated someone before. I mean, there's no way she could have done a full IM residency and then a pulm/CC residency without intubating someone, could she? Or maybe some places RTs do all the ICU intubations? Genuinely curious if she was telling the truth or lying just so I would let her intubate.

 

[Stellar Clouds]

I dunno, but I had an interventional pulm fellow ask me if she could intubate a patient post-rigid bronch because she had never intubated someone before. I mean, there's no way she could have done a full IM residency and then a pulm/CC residency without intubating someone, could she? Or maybe some places RTs do all the ICU intubations? Genuinely curious if she was telling the truth or lying just so I would let her intubate.

I would think that if someone were lying in order to convince you to let them intubate that they wouldn't say that they've NEVER done it. Wouldn't give me much confidence to let them intubate. I think they would be more likely to say that they've done it a handful of times but could really use the practice.

However, it does strike me as odd that someone with that much training has never intubated. Aren't IM residents required to spend time on anesthesia learning to intubate? I know at my home program that they have to, and I sincerely doubt our anesthesia department lets the IM residents in the OR if they didn't have to.

 

[WholeLottaGame7]

I would think that if someone were lying in order to convince you to let them intubate that they wouldn't say that they've NEVER done it. Wouldn't give me much confidence to let them intubate. I think they would be more likely to say that they've done it a handful of times but could really use the practice.

However, it does strike me as odd that someone with that much training has never intubated. Aren't IM residents required to spend time on anesthesia learning to intubate? I know at my home program that they have to, and I sincerely doubt our anesthesia department lets the IM residents in the OR if they didn't have to.

We have EM and ENT residents rotate through occasionally, but never IM. I think they just get their numbers in the unit when they can. The interventional pulm attending was in the room, so it wasn't an issue of confidence. Plus, we let med students try to intubate all the time and I have very little confidence in a fair number of them.

 

[DreamMachine]

Not

 

[VentdependenT]

IM residents must rotate through anesthesia here. i wouldnt say it inspires confidence in them and medicine dudes shouldnt be go to airway dudes anyways.

However you cannot do three years of PulmCC and not be confident with airway skills. you do so many F'N procedures that its inconcievable. Sheaut you can tube over a bronchoscope even if you dont feel good with DL but glidescope has taken the balls of intubation. nearly any idiot can tube with that thing.

Every CCM-pulm dude Ive ever met is solid with intubation, lines, chest tubes, thora, para, etc. you cannot avoid being inundated with procedure and especially emergency airway management. Fer cryen out loud as a lowly crusty medicine resident Ive put in over 100 centrals. friggen doin US guided subclavians now.

Glidescope and ultrasound have been revolutionary and have leveled the playing field for the most part.