Help With Fellowship Choice

[RussianJoo]

I am having a really hard time deciding between Critical Care and Cardiac.

Everyone I spoke to said my original plan of doing both was a waste of time, unless of course I wanted to go into academics which I don't at first but might want to do once I am older and much much more experienced. The guys without fellowships say that I should go into Critical Care since you don't need to do a fellowship to do hearts, however, I know that at any well respected group you'll be required to do a fellowship, especially if you're just starting out.

The cardiac guys say do a cardiac fellowship. The critical care guys say do a critical care fellowship and that if you do a critical care fellowship and make an effort to learn TEE you won't need to do a cardiac fellowship. A new critical care guy at my place said he was recruited to do hearts at other places, even though he was only critical care trained, and that groups know that if you're critical care trained you'll be able to take care of really sick patients in the OR without a problem. This same guy also said that you can get advanced TEE certified from either cardiac or critical care, is this true?

My goal is to be the best anesthesiologist I can be. I want to be the go to guy to take care of the sickest patients in my future group. I don't mind leaving the OR for a a week or two a month to round in the unit but I don't want to leave the OR for good.

What I like about Cardiac Anesthesia is the fact that if I can do a heart I can also do a major vascular or thoracic case. I like the lines, the epidurals, the paravertibral blocks, and the TEE.

What I like about critical care is that I can leave the OR sometimes (very rarely it's nice being outside the OR), I like taking care of sick patients, and love the power you get when working in a closed unit.

Also many say that doing a critical care fellowship will make me a much better anesthesiologist than doing a cardiac fellowship.

My fear is if I do a critical care fellowship, the group I want to work for might not cover the unit and thus my fellowship will go to waste or I might not even get hired because the group wouldn't be able to provide the type of work I'd be looking for and tell me that "we don't think you're the right fit for the job because we don't cover the icu"

If I do a cardiac fellowship, I would still be able to be hired by a group even if they don't do hearts, because I would just be the go to guy for difficult cases and really sick patients, and taking care of healthy patients will be very easy for me.


At the end I would still be willing to do both fellowships, if a top notch institution offered me a spot only if I accepted to do both.


As for location, I don't care where I train, I just want to get into the best place I can, eventually I would like to live somewhere warm, more on the west coast than the east, but once again none of that is really important since I am single and would be willing to live where my future currently non-existant significant other wants to live.

I also feel like critical care is slightly less competitive thus allowing me to get into a much better program than cardiac. I am an extremely hard worker and my evaluations reflect that, however, my ITE scores aren't that great.


Any advice or suggestions are welcome and thanks in advance.

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[BobBarker]

Cardiac. Easier to get a PP job than critical care.

 

[RT2MD]

Very interested in this thread. Just a 3rd year student now, but leaning towards the same path as the OP... I know I won't make any decisions on this for quite some time but figured I'd follow along for now!

 

[tennisballs]

If money, location, and time are less important, I think you should do both. Since you are single, you have the leisure to pursue both without your significant other nagging about the factors listed above. Others on the board may disagree, but doing both will definitely get you towards your goal; doing one or the other may or may not get you towards your goal.

 

[RussianJoo]

Cardiac. Easier to get a PP job than critical care.

Yeah that's what I was thinking all along, but talking with one of my critical care attendings he made some very good points for picking critical care. But then again that might be part of his job, to convince residents to go into critical care. Don't get me wrong I really like critical care and that was going to be my back up plan if I didn't get into anesthesia (IM -->CCM), however, I like being in the ER a lot more.

 

[RussianJoo]

If money, location, and time are less important, I think you should do both. Since you are single, you have the leisure to pursue both without your significant other nagging about the factors listed above. Others on the board may disagree, but doing both will definitely get you towards your goal; doing one or the other may or may not get you towards your goal.

Even though money isn't as important, I am not getting any younger and would like to eventually have a family, so spending a year doing something that would theoretically make me a better physician in the short term but not really in the long term, would be a waste of roughly $350K and a year of my life. There are a few CA-3's in my program who were very gung-ho about doing fellowships during the CA2 year who decided that it really wasn't worth it financially and are simply looking for work, one already signed a contract.

For me however, the only way I won't be doing a fellowship is if I don't get accepted, which is always a possibility.

 

[countingdays]

Cardiac

 

[Dejavu]

Doing a Fellowship will personally cost you $200,000 or so in lost income for that year.

Make sure that you factor that into your decision-making process.

 

[imfrankie]

Doing a Fellowship will personally cost you $200,000 or so in lost income for that year.

Make sure that you factor that into your decision-making process.

You bring nothing special without the fellowship. Also factor in the possibility the fellowship will enable you to keep a chair if the music ever stops.

I say go critical care and stop worrying about the market. You'll be one of the best trained anesthesiologists out there. Find a place that will let you get TEE certification. Modern critical care medicine is using a lot more echo for bedside diagnosis also. Spend a lot of time in the CCU if you're worried about getting a job doing cardiac.

Don't know the details and there may be exceptions, but my understanding is that if I wanted to practice in a lot of other parts of the world--where anesthesiologists in training must spend a year in the unit--I would need to do some more training.

Go critical care man. (who cares if you work in the unit later? Point is, you'll be a better doctor, and you gain the ability to work in the unit if you ever want or need to. Trust me, you will be just as marketable for a cardiac anesthesia position if you spend a year at CCF doing CCM than any guy thats done 150 pump cases in the OR doing cardiac all year)

 

[RussianJoo]

You bring nothing special without the fellowship. Also factor in the possibility the fellowship will enable you to keep a chair if the music ever stops.

I say go critical care and stop worrying about the market. You'll be one of the best trained anesthesiologists out there. Find a place that will let you get TEE certification. Modern critical care medicine is using a lot more echo for bedside diagnosis also. Spend a lot of time in the CCU if you're worried about getting a job doing cardiac.

Don't know the details and there may be exceptions, but my understanding is that if I wanted to practice in a lot of other parts of the world--where anesthesiologists in training must spend a year in the unit--I would need to do some more training.

Go critical care man. (who cares if you work in the unit later? Point is, you'll be a better doctor, and you gain the ability to work in the unit if you ever want or need to. Trust me, you will be just as marketable for a cardiac anesthesia position if you spend a year at CCF doing CCM than any guy thats done 150 pump cases in the OR doing cardiac all year)

you sound just like one of my attendings...

 

[seinfeld]

You bring nothing special without the fellowship. Also factor in the possibility the fellowship will enable you to keep a chair if the music ever stops.

I say go critical care and stop worrying about the market. You'll be one of the best trained anesthesiologists out there. Find a place that will let you get TEE certification. Modern critical care medicine is using a lot more echo for bedside diagnosis also. Spend a lot of time in the CCU if you're worried about getting a job doing cardiac.

Don't know the details and there may be exceptions, but my understanding is that if I wanted to practice in a lot of other parts of the world--where anesthesiologists in training must spend a year in the unit--I would need to do some more training.

Go critical care man. (who cares if you work in the unit later? Point is, you'll be a better doctor, and you gain the ability to work in the unit if you ever want or need to. Trust me, you will be just as marketable for a cardiac anesthesia position if you spend a year at CCF doing CCM than any guy thats done 150 pump cases in the OR doing cardiac all year)

Being a critical care anesthesiologist who practices mostly ICU and Cardiac i must agree with the above.

questions that i asked myself 4.5 years ago

-Would i prefer to be 2 different kinds of doctors or a specialized type of 1?
-Whats more likely to happen, CRNAs take over the OR or NPs/PAs take over the ICU
-Do i like the challenge of diagnosing IgG defeinceny, legionella PNA, or EEE
-I considered discussing end of life issues with family a noble task and not a waste of my time.
-Critical care gave me more options down the road for flexibility
- I can do cardiac with a critical care fellowship but can't do critical care with a cardiac fellowship
- I liked interacting with people outside the OR
- Big downside to Critical care is that the memory of a patient follows you home. Sometimes it does happen in cardiac but not nearly as often

I couldn't be happier with my choice

Having said all that my wife thinks i should have done Pain, at least while reimbursement are good.

 

[countingdays]

Being a critical care anesthesiologist who practices mostly ICU and Cardiac i must agree with the above.

questions that i asked myself 4.5 years ago

-Would i prefer to be 2 different kinds of doctors or a specialized type of 1?
-Whats more likely to happen, CRNAs take over the OR or NPs/PAs take over the ICU
-Do i like the challenge of diagnosing IgG defeinceny, legionella PNA, or EEE
-I considered discussing end of life issues with family a noble task and not a waste of my time.
-Critical care gave me more options down the road for flexibility
- I can do cardiac with a critical care fellowship but can't do critical care with a cardiac fellowship
- I liked interacting with people outside the OR
- Big downside to Critical care is that the memory of a patient follows you home. Sometimes it does happen in cardiac but not nearly as often

I couldn't be happier with my choice

Having said all that my wife thinks i should have done Pain, at least while reimbursement are good.

Well, since even doctors who know how to do tee can't get certified, it's not likely that ct anesthesia will be taken over by nurses in the near future.

 

[seinfeld]

I did not intend to turn this into a CRNA debate, merely stating that the average patient, from my experience, cares more to talk to directly with the ICU doc then the Anesthesiologist. In the ICU I never have had a patients family ask when is the "Doctor" coming in when referring to the surgeon. In the ICU they call me Doctor and call the surgeon "surgeon".

 

[OB1🤙]

Question to ask yourself: do you miss the OR when you're rotating in the unit? I did, and even though I enjoyed the challenge of the ICU, I found myself happier on my days in the heart room. So I did cardiac.

If you don't miss the OR at all when you're in the unit, then ICU would be a great call.

To each their own.

I would state this bit of the obvious: you'll be more comfortable when things go to shit during a cardiac case after a cardiac fellowship. Sure, you'll be capable of handling it after an ICU fellowship, but having seen these issues time and time again *in the same setting,* it'll be easier after CV.

That said, the statement above that you can do cardiac after ICU but can't do ICU after cardiac is obviously also true.

Good luck. Can't go wrong either way.

 

[countingdays]

I did not intend to turn this into a CRNA debate, merely stating that the average patient, from my experience, cares more to talk to directly with the ICU doc then the Anesthesiologist. In the ICU I never have had a patients family ask when is the "Doctor" coming in when referring to the surgeon. In the ICU they call me Doctor and call the surgeon "surgeon".

Also not trying to debate. Just don't choose icu out of fear of nursing politics if you want to do ct anesthesia. Choose critical care if you want to do icu.

 

[G0S2]

Agree, ultimately choose what you love. It was a hard decision for me but I chose CCM. My best attendings are CCM trained and do hearts like champs. Personally, the unit is so different from the OR and I love "getting away" to the ICU to really think about complex patient issues. I fully believe a CCM fellowship will make me a stud in the OR.

I passed the advanced PTEeXAM and spoke to the echo boards and asked if the guidelines for advanced certification will change, nope. She did say that as long as I got my 300 TEEs during my fellowship year it would count. That, however, is near impossible with a CCM fellowship and they know that. There are some CCM programs with great TEE experience (Duke) so you may want to consider them if pursuing CCM. Keep in mind that TTE is going to be the mode of cardiac imaging in the unit and courses are popping up at every CCM conference.

 

[bluewater]

Money lost during fellowship is big; however, I did a CV fellowship and was highly recruited coming out of fellowship. With that being said, I also loved CCM and debated doing a second fellowship.... however, my wife would have killed me. At some point you will have to start making a few dollars. I will say that even though I did CV, I am one of the best CC minded physicians at my hospital.

My final piece of advice-- do not trade long term goals for short term gains- because once you go into practice and start making money it will be nearly impossible to go back if you made a poor decision in choosing a fellowship the first time around.

- BW

 

[BLADEMDA]

Agree, ultimately choose what you love. It was a hard decision for me but I chose CCM. My best attendings are CCM trained and do hearts like champs. Personally, the unit is so different from the OR and I love "getting away" to the ICU to really think about complex patient issues. I fully believe a CCM fellowship will make me a stud in the OR.

I passed the advanced PTEeXAM and spoke to the echo boards and asked if the guidelines for advanced certification will change, nope. She did say that as long as I got my 300 TEEs during my fellowship year it would count. That, however, is near impossible with a CCM fellowship and they know that. There are some CCM programs with great TEE experience (Duke) so you may want to consider them if pursuing CCM. Keep in mind that TTE is going to be the mode of cardiac imaging in the unit and courses are popping up at every CCM conference.

 

[RussianJoo]

Thanks, but you guy aren't making my decision any easier.

 

[IveGotTwins]

Can a CT trained anesthesiologist cover a CVICU or is that cardiology/CT surgeon territory?

 

[DrN2O]

I believe you can get more out of the training with a CCM than a CV fellowship, even though I'm doing the latter. CV is more competitive however. Also I know for a fact that if you are a good candidate, some programs will offer you a spot in their CV fellowship once you commit to a CCM year, so you can do both.

In the end, you have to be honest with yourself about what you WANT to do versus what you CAN do. Covering the unit is not everyone's cup of tea, so more power to you. You are right, if you have to have ICU in your practice, it will limit your options.

 

[BLADEMDA]

Thanks, but you guy aren't making my decision any easier.

With Obamacare or Socialized medicine in the future I believe you are better off with ICU. Forget the BS PP which you see today. Think ACO or Group practice where you play a valuable role.

Do ICU and try to get a one month elective in TTE/TEE or cardiology. Unlike many on this board I firmly believe we need more qualified Anesthesiologist Intensivists. Plus, basic TEE exam is sufficient for most practices (to do hearts) and ICU.

 

[2win]

Thanks, but you guy aren't making my decision any easier.

I understand. I am CCM - happy with my choice.
I love what I do - it is very interesting. Fits my personality.
Soon we gonna have a split between anesthesia and critical care. Anesthesia only envy us....There are multiple reasons. We can have a discussion about that later. It is similar with the "conflict" anesthesia vs pain medicine. Truth is that we gonna be paid better than anesthesia only. Especially with OBYcare ( doesn't mean that I like the "change")...
Also - you can work at any time as a hospitalist ( if u can take care of the sickest of the sicj , you'll be able to take care of the less sick). Means flexibility.
The hospitalist salary - 15 shifts is around 200k. Gaswork anesthesia jobs 230k.
Overall - take all of this in consideration, speak with people that you trust and go for it.
2win

 

[MiracleforMD]

I understand. I am CCM - happy with my choice.
I love what I do - it is very interesting. Fits my personality.
Soon we gonna have a split between anesthesia and critical care. Anesthesia only envy us....There are multiple reasons. We can have a discussion about that later. It is similar with the "conflict" anesthesia vs pain medicine. Truth is that we gonna be paid better than anesthesia only. Especially with OBYcare ( doesn't mean that I like the "change")...
Also - you can work at any time as a hospitalist ( if u can take care of the sickest of the sicj , you'll be able to take care of the less sick). Means flexibility.
The hospitalist salary - 15 shifts is around 200k. Gaswork anesthesia jobs 230k.
Overall - take all of this in consideration, speak with people that you trust and go for it.
2win

Do you mean 15 shifts a month is around 200K/year?

 

[2win]

Do you mean 15 shifts a month is around 200K/year?

Yes - I do.

 

[secants]

I understand. I am CCM - happy with my choice.
I love what I do - it is very interesting. Fits my personality.
Soon we gonna have a split between anesthesia and critical care. Anesthesia only envy us....There are multiple reasons. We can have a discussion about that later. It is similar with the "conflict" anesthesia vs pain medicine. Truth is that we gonna be paid better than anesthesia only. Especially with OBYcare ( doesn't mean that I like the "change")...
Also - you can work at any time as a hospitalist ( if u can take care of the sickest of the sicj , you'll be able to take care of the less sick). Means flexibility.
The hospitalist salary - 15 shifts is around 200k. Gaswork anesthesia jobs 230k.
Overall - take all of this in consideration, speak with people that you trust and go for it.
2win

How true is this in reality? Can't you extrapolate that and say you can also do outpatient IM as well since people are less sick? I'm contemplating between IM and Anesthesia atm and this would definitely help in the decision process.

 

[nycitygas]

I believe its quite easy to get CCM jobs set up like hospitalist schedule (7 days on 7 days off) for 250k a year, but I had no idea one could actually work as a medicine hospitalist.

RJ, I was a in a similar spot last year. I think what would fit you best is either sucking it up and doing the combined ccm/cardiac fellowship or doing a CCM year with heavy CTICU experience.
From worth of mouth, I've heard Mich/Duke/Cleveland Clinic have a pretty established pathway to obtaining advanced TEE certification. My future program Wash U has excellent CTICU experience and I hope to get at least the basic cert during my fellowship year.

It is also much easier to get a CCM spot than a cardiac spot at a top institution, the cardiac fellowship market is very competitive.

Good luck bud!

 

[smgilles]

I believe its quite easy to get CCM jobs set up like hospitalist schedule (7 days on 7 days off) for 250k a year, but I had no idea one could actually work as a medicine hospitalist.

RJ, I was a in a similar spot last year. I think what would fit you best is either sucking it up and doing the combined ccm/cardiac fellowship or doing a CCM year with heavy CTICU experience.
From worth of mouth, I've heard Mich/Duke/Cleveland Clinic have a pretty established pathway to obtaining advanced TEE certification. My future program Wash U has excellent CTICU experience and I hope to get at least the basic cert during my fellowship year.

It is also much easier to get a CCM spot than a cardiac spot at a top institution, the cardiac fellowship market is very competitive.

Good luck bud!

I agree with the above. Getting a CV spot is much much more difficult than CCM. CCM requires a pulse and the ability to sign your name to be accepted. I am doing both fellowships and feel CCM will probably be more marketable in the future as long as you can acquire strong echo skills - TTE or TEE.

I have finished the CV fellowship and am certified in TEE and currently in my CC fellowship. I think they complement each other well but CCM is much more painful because it's so closely related to medicine. I feel like I could take care of any patient acutely with the CV skills, but you need the CCM training to truly provide EBM in the ICU's and care for people beyond that 72-hour window post-op.

My biased opinion of course.

 

[imfrankie]

I'm not worthy