IM/Anes --> Cardiac --> CC?

[NotYY4U]

Just heard an attending talking about how if you really love anesthesia, cardio and CCM the way to go would be a combined IM/Anesthesia residency (or even just anesthesia) then do a CC Fellow along with a cardiac anesthesia Fellowship. You would be a master of physio in regards to CC (due to the combined residency with IM) along with the procedures of Anesthesia. With the cardiac fellowship you can do nearly any anesthesia case and then man the CICUor even just ICU.

Biggest drawback is obviously length (6-7 years).
5 years - IM/Anestheisa / 4 years - Anesthesia
1 year - CC
1 year - Cardiac Anesthesia

What do you all think of this?

I am just a pre-med and have no desire to pick any specialties obviously but this sounded interesting as a bystander during the convo! Was just hoping to hear from the pros!

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[okayplayer]

And lose out on 1.5mm in lifetime earnings.

 

[psychbender]

Why not tack on two more years for Pulm to REALLY know the lungs and vent? Or two more for ID, to be a sepsis bad ass?

What you describe is hardly needed to function competently in the CVICU. It's not even necessary in order for one to be really good in the ICU. If you want to do cardiac anesthesia, then anesthesiology residency plus CT fellowship is all that you really need. If you want to do CCM, then anesthesiology residency plus CC fellowship is all that you really need. Yes, the combination of CC/CT fellowships is becoming more popular, and if you want to work in both the cardiac OR and the ICU, is pretty much necessary in this day and age, but that is the only real reason to do both. Training in two specialties and two subspecialties will not turn one into a Grand Master. If you are after doing all of those, you probably would have been one, anyway. I have met plenty of general anesthesiologists that can do damn near any case (they're all over SDN, just ask any of us).

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[Modanq]

Anesthesia/CCM/CV anesthesia. 1 year intern, 3 years anesthesia, 1 year CCM, 1 year CV. 6 years total. Comparatively Cardiology is 3 IM, 3 Cardiology, 1-2 Super fellowship CHF, Intervention, or EP. There are pros and cons to both pathways not only financially but also scope of practice, length of training, what your job looks like in 10 - 30 years from now.

 

[Psai]

You don't need to do a fellowship to be a master in physiology.

 

[pgg]

Just heard an attending talking about how if you really love anesthesia, cardio and CCM the way to go would be a combined IM/Anesthesia residency (or even just anesthesia) then do a CC Fellow along with a cardiac anesthesia Fellowship. You would be a master of physio in regards to CC (due to the combined residency with IM) along with the procedures of Anesthesia. With the cardiac fellowship you can do nearly any anesthesia case and then man the CICUor even just ICU.

Biggest drawback is obviously length (6-7 years).
5 years - IM/Anestheisa / 4 years - Anesthesia
1 year - CC
1 year - Cardiac Anesthesia

What do you all think of this?

I am just a pre-med and have no desire to pick any specialties obviously but this sounded interesting as a bystander during the convo! Was just hoping to hear from the pros!

It's so ******ed that attending should be wearing a helmet.


edit - Owned by the filter again, which reminds me of an Australian anesthesiologist I met in Afghanistan, who gasped with shock the way we uncouth Americans would use the word r e t a r d e d interchangeably with stupid. Apparently it's a very offensive word down under. And on SDN too, apparently. I hope I have not offended anyone.

 

[ButterButter]

Pretty sure that attending was just trolling you.

 

[Ezekiel2517]

If you do all that, you won't be a master of anything. You'll just be a master at whatever it is you end up doing everyday.

 

[lverbmb]

This is my path- i do think the duo training has added a lot to my clinical skills- others, who are more seasoned may disagree, but im very happy with my training and its only an extra year in my combined program- ive already made tons of sacrifices (im another RN almost to crna but then dropped that path and switched to medicine) so another year which i feel is well spent is worth it to me. If i were to re enter the match I would choose combo im/anesth again in a heart beat.

 

[deleted697127]

Thats a lot of recertification exams in your future.

 

[nimbus]

That’s a lot of clinic time....too much for most people who like anesthesia.

 

[acidbase1]

 

[acidbase1]

Just heard an attending talking about how if you really love anesthesia, cardio and CCM the way to go would be a combined IM/Anesthesia residency (or even just anesthesia) then do a CC Fellow along with a cardiac anesthesia Fellowship. You would be a master of physio in regards to CC (due to the combined residency with IM) along with the procedures of Anesthesia. With the cardiac fellowship you can do nearly any anesthesia case and then man the CICUor even just ICU.

Biggest drawback is obviously length (6-7 years).
5 years - IM/Anestheisa / 4 years - Anesthesia
1 year - CC
1 year - Cardiac Anesthesia

What do you all think of this?

I am just a pre-med and have no desire to pick any specialties obviously but this sounded interesting as a bystander during the convo! Was just hoping to hear from the pros!

Poor little guy hasn’t had the life beat out of him yet... reality will set it soon

 

[lverbmb]

That’s a lot of clinic time....too much for most people who like anesthesia.

Agree, clinic is not my strong suit- but there are people who decide to go to pain which does demand a certain amount of clinic, and for me pain clinic is infinitly more painful (no pun intended) then my primary care clinic...

 

[NotYY4U]

Thanks for all the responses! He wasn't even talking to me but rather a resident, perhaps he was trolling him lol?

It sounded like a lot to me as well, ESPECIALLY the combined IM/Anesthesia residency adding on an extra year alone.

 

[NotYY4U]

This is my path- i do think the duo training has added a lot to my clinical skills- others, who are more seasoned may disagree, but im very happy with my training and its only an extra year in my combined program- ive already made tons of sacrifices (im another RN almost to crna but then dropped that path and switched to medicine) so another year which i feel is well spent is worth it to me. If i were to re enter the match I would choose combo im/anesth again in a heart beat.

Have you done both fellowships as well or just the combined residency?

 

[lverbmb]

Have you done both fellowships as well or just the combined residency?

The combined residency is relatively new - its only been going on for 4 years. I am in the first group recruited to my program so I'm near the end of my PGY4 year - so just now applying to fellowship with the plan to do cardiac and critical care. Honestly i wasn't planning on doing cardiac but after doing my cardiac rotation and a rotation in the CVICU I sort of knew that it was right for me. I still have quite a bit of bandwidth and am quite the minority. I do know a sizable amount of my residency class is over training and ready to just get a job. While I'd love to get a job soon, I'm honestly quite happy training. It does help that this is my second career and I was able to save up for medical school before I started so financially I don't feel strapped which definitely can be a big deal- I also realize I'm missing skill sets that I need in order to have the career I want - so I'm ok with taking a longer path.

A year longer in the grand scheme of things to me isn't that long - especially if you're aiming to do academics. I compare myself to my medicine co-residents who can take a chief year, then sign up for 3 years of fellowship.. do an extra year of research.. and then do a super fellowship. Many jobs like EP are quite saturated - so just cause people go through those training paths it doesn't necessarily mean they'll end up with a plethora of options. In the end you gotta do you - I totally understand many people think I'm nuts for my training path but to me it makes perfect sense and I'm so happy with all the choices I've made so far.

 

[deleted171991]

Doing IM just to go into cardiac anesthesia is a royal waste.

Doing IM to be a better intensivist after anesthesia? Worth it (for the ego, not the wallet).

 

[nimbus]

I also realize I'm missing skill sets that I need in order to have the career I want - so I'm ok with taking a longer path.

The best and only reason to take extra training, whether it’s a fellowship, research year or another residency.

 

[LunchMD]

The combined residency is relatively new - its only been going on for 4 years. I am in the first group recruited to my program so I'm near the end of my PGY4 year - so just now applying to fellowship with the plan to do cardiac and critical care. Honestly i wasn't planning on doing cardiac but after doing my cardiac rotation and a rotation in the CVICU I sort of knew that it was right for me. I still have quite a bit of bandwidth and am quite the minority. I do know a sizable amount of my residency class is over training and ready to just get a job. While I'd love to get a job soon, I'm honestly quite happy training. It does help that this is my second career and I was able to save up for medical school before I started so financially I don't feel strapped which definitely can be a big deal- I also realize I'm missing skill sets that I need in order to have the career I want - so I'm ok with taking a longer path.

A year longer in the grand scheme of things to me isn't that long - especially if you're aiming to do academics. I compare myself to my medicine co-residents who can take a chief year, then sign up for 3 years of fellowship.. do an extra year of research.. and then do a super fellowship. Many jobs like EP are quite saturated - so just cause people go through those training paths it doesn't necessarily mean they'll end up with a plethora of options. In the end you gotta do you - I totally understand many people think I'm nuts for my training path but to me it makes perfect sense and I'm so happy with all the choices I've made so far.

I'm jealous, I didn't know about the combined programs until after I matched. I would have totally done one. Just curious why you/your cooresidents chose to do it? I would have done it bc I liked both Pulm/CC and Anes(/SICU), so I'd have all options available (and other IM specialties) once I had more experience to really decide. Also seems like it would make you a better doc no matter what you end up in.

 

[deleted162650]

I’m waiting for the combined IM/Anes/GenSurg residency to pop up.

 

[deleted171991]

I’m waiting for the combined IM/Anes/GenSurg residency to pop up.

That's for nurse practitioners.

 

[LunchMD]

I’m waiting for the combined IM/Anes/GenSurg residency to pop up.

Is it bad that I would probably have done that residency too? Haha. Depending on how many extra years we talking

 

[deleted171991]

I'm jealous, I didn't know about the combined programs until after I matched. I would have totally done one. Just curious why you/your cooresidents chose to do it? I would have done it bc I liked both Pulm/CC and Anes(/SICU), so I'd have all options available (and other IM specialties) once I had more experience to really decide. Also seems like it would make you a better doc no matter what you end up in.

Anything will probably make one a better doc. It's a matter of personal gains vs losses. Society definitely does not reward long training anymore; if anything, it's the contrary (see APRNs, PAs, CRNAs). So my advice is to think long and hard before getting into any combined training.

There is that ageless anecdote about the talented young woman who was both a singer and a dancer and couldn't get a job, one audition after another useless audition. She didn't understand why, until one employer told her: "For a singer you are a pretty good dancer, and for a dancer you sing very well. But you're neither a good singer or a good dancer, and that's what I need."

Btw, that's what people practicing anesthesia-critical care or pulm-critical care remind me of.

 

[MoMoGesiologist]

Does anyone else feel like the more fellowships and certificates and letters people collect after their name, the less likely they are to be good in the OR?If I saw someone who had IM/Anes/CCM/Cardiac after their name, I would assume that person would struggle to actually do a case. I'd rather take the person who has been out doing their own cases, but maybe that's just me

 

[pgg]

Does anyone else feel like the more fellowships and certificates and letters people collect after their name, the less likely they are to be good in the OR?If I saw someone who had IM/Anes/CCM/Cardiac after their name, I would assume that person would struggle to actually do a case. I'd rather take the person who has been out doing their own cases, but maybe that's just me

I would just assume they wanted a particularly competitive job in academia.

 

[GravelRider]

Does anyone else feel like the more fellowships and certificates and letters people collect after their name, the less likely they are to be good in the OR?If I saw someone who had IM/Anes/CCM/Cardiac after their name, I would assume that person would struggle to actually do a case. I'd rather take the person who has been out doing their own cases, but maybe that's just me

As someone boarded in both IM and anesthesia, I take exception to that.

Actually, I kind of agree. At some point the ultimate goal of all this is to get a job and provide for a family, right? I think these combined IM/Anes programs are a complete waste of time for the vast majority of people. There is maybe a small subset of people in academia who would benefit from this training...but that is a very small subset.

In a perfect world, IM/anes/CCM would probably be better training for pure critical care jobs over just IM+CCM or anes+CCM and probably even better than the IM/pulm/CCM route. However, the majority of community ICUs (and thus the majority of jobs) are looking for pulm/CCM.

I think I could listen to an argument saying that IM/anes is good prep for a career in critical care, but if you want to spend significant time in the cardiac ORs then don’t waste your time with the IM. If you want to spend time doing outpatient then don’t waste your time with anesthesia and do the IM/pulm/CCM. If you are not sure what you want to do then just do IM and convince yourself to do Allergy so you can hit the golf course after your last 3pm patient.

 

[lverbmb]

I'm jealous, I didn't know about the combined programs until after I matched. I would have totally done one. Just curious why you/your cooresidents chose to do it? I would have done it bc I liked both Pulm/CC and Anes(/SICU), so I'd have all options available (and other IM specialties) once I had more experience to really decide. Also seems like it would make you a better doc no matter what you end up in.

Some disclaimers - this is just my experience doing a duo residency - im not preaching that this path is for everyone or even for a majority.

First most of my classmates aren't super big fans of pulm thats why we choose to do anesth/med -> CCM at first. Could you do pulm/ccm after the residency? of course - but i think being a GOOD pulmonologist/CCM/Anesthesiologist will be very very difficult. For me i plan to keep abreast on most of my medicine background related to ccm and realize that once im done with residency my broad medicine base will slowly shrink overtime.

I don't think this path should be taken just because you want more time to figure out your career path - if you want to be a cardiologist - just do internal medicine, if you want to be a cardiac anesthesiologist, just do anesthesia.

Lastly i don't think a program necessarily makes you a better doctor. I think the program gives you training opportunities that if you are motivated enough you will benefit from. On the interview trail a lot of people asked me what I gained from duo training - i think most of it is a differing perspective then I would gain from a single specialty. For instance glucose control in the ICU - lots of new literature about it surrounding type 2 diabetics.. i think a lot of my co-pure anesthesia folks aren't familiar with nor with the background of where the magic (or not so magic) "180" goal came from - and also new Car-t therapy - a lot of the ccm guys think it is such a waste of resources and time - but from working with these patients on an acute heme service i feel a little differently... i'll leave it at that.

From my class all of us wanted to do CCM and Anesth,the funny thing is now we are all planning to do CTICU and cardiac anesth. We tend to be a group that LIKES micu and not sicu - i know most people here can't stomach micu so i'll leave it at that. One of the reasons i really liked the cticu is i get to follow the patients that i initially met as a medicine person - whether that be a patient with end stage lung disease in the micu or end stage heart disease in the ccu or both - and one day we can actually cure their chronic disease (WOAH!) with a transplant (or two!) if we can get them through it. Getting them through their transplant is rewarding to me, the lung patients in my experience tend to have a more tenuous course then hearts, obviously these patients usually come with all their co-morbidities that brought them to needing a transplant and I feel really comfortable taking care of those with a medicine background but also feel comfortable with the transplant side of things from the anesthesia stand point. Mechanical support devices is also fascinating for me for some of the same reasons above.. i don't considered them cured tho the way a transplant can but it definitely is a life changer for some patients... and now new indications for ecmo. I struggled with doing cardiac in all honesty - it wasn't part of my "plan" but as i've said before doing my 2 months of cardiac in the ORs and 1 month of CVICU sealed the deal for me.

Lastly to become "good" I realize it may take me a bit longer doing both things then if i focused on one (aka just anesthesia/cardiac anesthesia or just ccm) - but for my career longevity i do like doing both. I realize to be able to do the job I want I'd likely stay in academics and thats fine with me, I do have academic interests that I wouldn't mind continuing to pursue.

If anyone wants to truly know more feel free to pm me. I don't want to feel like I have to defend the combined programs they are just what they are - but i do want to say that I'm truly happy with my choice for the reasons i've stated previously.

 

[B-Bone]

This may not apply to the combined IM/anesthesia residency program for a host of reasons, but my experience training with several people who did IM prior to anesthesia was that they had much more of an "IM" attitude/timeline, particularly with regard to critically ill patients. They tended to be less aggressive in the OR/ICU, and would do things like "give a 250 cc fluid bolus and want to check labs before trying a different strategy" for hypotension (as an example). This is probably a self-selection thing, as all the people I knew who did this (n=5 over my residency time) did not plan to do anesthesia from the start and were thus "IM people". Two of them had some gap between their two residencies where they practiced IM, and seemed even more ingrained in this way of thinking.

I think that if you kind of toggled back and forth between the two specialties for five years, knowing you planned to practice anesthesia and/or ICU afterwards, the IM knowledge could really add something and make you a better doc with less risk of the above. Do you need it? Absolutely not. Is there a huge opportunity cost? Definitely. Is it a reasonable choice? That's for you to decide.

 

[lverbmb]

This may not apply to the combined IM/anesthesia residency program for a host of reasons, but my experience training with several people who did IM prior to anesthesia was that they had much more of an "IM" attitude/timeline, particularly with regard to critically ill patients. They tended to be less aggressive in the OR/ICU, and would do things like "give a 250 cc fluid bolus and want to check labs before trying a different strategy" for hypotension (as an example). This is probably a self-selection thing, as all the people I knew who did this (n=5 over my residency time) did not plan to do anesthesia from the start and were thus "IM people". Two of them had some gap between their two residencies where they practiced IM, and seemed even more ingrained in this way of thinking.

I think that if you kind of toggled back and forth between the two specialties for five years, knowing you planned to practice anesthesia and/or ICU afterwards, the IM knowledge could really add something and make you a better doc with less risk of the above. Do you need it? Absolutely not. Is there a huge opportunity cost? Definitely. Is it a reasonable choice? That's for you to decide.

Honestly i don't want to drag on this post but i just need to say that it was probably just the people you met and not a product of their training. At my program we have many double boarded people and they definitely don't match your description... our chair was actually IM -> pulm/crit and on faculty with the medicine department for years before going back to do anesthesia. He is probably the longest standing chair currently and is also probably still the most clinically active especially for the size and reputation of the program he is chair of- the guy is a total role model for why i did a combined residency. Does mainly cardiac anesthesia including frequent 24 hour call plus attends in the MSICU and CVICU. i've come to the conclusion i will probably never be as clinically brilliant as he is but if i can be 50% as good as him when im done training I'd be a total boss. There are many different personality types and styles in anesthesia. I think that is more a reflection of the person necessarily their path of training.

 

[deleted171991]

I would just assume they wanted a particularly competitive job in academia.

I wouldn't, unless the fellowships are highly-related (e.g. CCM and cardiac).

 

[deleted171991]

@lverbmb, you sound a lot like rationalizing your decision.

As somebody who loves IM, I can see very few reasons to do a combined residency (e.g. to become a better intensivist).

 

[Laryngophed]

I would just assume they wanted a particularly competitive job in academia.

Never forget self-loathing. It might be the number one factor for me.