Is fellowship a MUST for Anesthesia in 2020?

[ChasingMavericks]

Title says it all.
What do you guys think about this?

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[2Fast2Des]

CCM is job security today

 

[dannyboy1]

I would think peds. If volume continues to be low the ability for one doc to do all cases is invaluable.

 

[bigdan]

On the surface: no. Many anesthesiologists make a great income doing great work without fellowship training. I suspect this will continue to be the case.

On deeper dive: you should just do whatever you want. We plan, God laughs. We have A LOT of naysayers, cynics and clairvoyants on this board, and none predicted a pandemic. I did fellowship, and it so happens that in this unpredictable, bizarre environment, I didn’t have the pay cut or furlough experiences that some of my buddies doing mainly outpatient work experienced. But I did what I wanted, and I have a niche that works for me and my employer. I don’t think everyone NEEDS a fellowship, but you should do one if you want to, and don’t if you don’t want to.

 

[AdmiralChz]

On the surface: no. Many anesthesiologists make a great income doing great work without fellowship training. I suspect this will continue to be the case.

On deeper dive: you should just do whatever you want. We plan, God laughs. We have A LOT of naysayers, cynics and clairvoyants on this board, and none predicted a pandemic. I did fellowship, and it so happens that in this unpredictable, bizarre environment, I didn’t have the pay cut or furlough experiences that some of my buddies doing mainly outpatient work experienced. But I did what I wanted, and I have a niche that works for me and my employer. I don’t think everyone NEEDS a fellowship, but you should do one if you want to, and don’t if you don’t want to.

Very much agree with this. I was more in the “fellowship is job security camp” ... then the pandemic came along. I was a big proponent of cardiac (strongly biased of course), but our volume is down a staggering 90% and those that were 100% cardiac were basically out of a job for the better part of 6 weeks.

Other subspecialties fared much better, particularly CCM, but until (more of a murky if) market forces pay them the same (preferably more) as a general anesthesiologist it will continue to be unpopular. I imagine chronic pain took a massive hit as elective procedures were halted, and the prospect of future waves in the fall make it a somewhat troubling time in the field. Telehealth restrictions help, though, and even we are jumping on as an anesthesia group.

More than ever, the importance of a diversified practice has been illustrated in this period. High paying cosmetic procedures are gone and won’t be back for a while (depending on how desperate your surgeons and your group is), and even cardiac volume is only back to 25-50%.

As Big Dan says, pursue a fellowship if you are interested. Don’t play the crystal ball game of what you think will earn more.

 

[dannyboy1]

Very much agree with this. I was more in the “fellowship is job security camp” ... then the pandemic came along. I was a big proponent of cardiac (strongly biased of course), but our volume is down a staggering 90% and those that were 100% cardiac were basically out of a job for the better part of 6 weeks.

So your cardiac guys don’t have the ability to do general cases?
I would think with low volume the guy who can do cardiac + general + peds is the most valuable. More cases, less personnel

 

[JiPo]

So your cardiac guys don’t have the ability to do general cases?
I would think with low volume the guy who can do cardiac + general + peds is the most valuable. More cases, less personnel

Why not make it cardiac + general + peds + ccm? 😉

 

[KENY1]

For me I did cardiac and ccm and I do general and peds and it certainly paid off job security wise as well as financially. There is a also a massive CRNA influx and u should have something they don't for sure. Definitely do it even though there aren't many cases. By having a cardiac fellowship u will be more or less bound to hospitals if that's ok with u.
Also heart surgeons seem to still have a choice ehobthey prefer to work with and love to blame their disasters on us.
Pain fellowship gives u independence from surgeons and it will tie u to surgery centers but I'm hearing there's little money in it now and tons of work and paperwork plus dealing with difficult patients.
Correct me where u think I'm wrong everyone.

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[Man o War]

For me I did cardiac and ccm and I do general and peds and it certainly paid off job security wise as well as financially. There is a also a massive CRNA influx and u should have something they don't for sure. Definitely do it even though there aren't many cases. By having a cardiac fellowship u will be more or less bound to hospitals if that's ok with u.
Also heart surgeons seem to still have a choice ehobthey prefer to work with and love to blame their disasters on us.
Pain fellowship gives u independence from surgeons and it will tie u to surgery centers but I'm hearing there's little money in it now and tons of work and paperwork plus dealing with difficult patients.
Correct me where u think I'm wrong everyone.

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I agree. Our surgeons and ICs are awesome to work with, they are rain makers so they get what they want...they will never allow nurses to be at the head of the bed. They have single handedly kept them out of the ORs for even training. My locums gigs are the same. As difficult as heart surgeons can be, they know the difference between a doc and a nurse for anesthesia.

 

[DrZzZz]

There is a also a massive CRNA influx and u should have something they don't for sure.

While I hear variations of this statement often, I'm sick of hearing it. He/she WILL have something CRNAs don't. They'll have a medical degree and a residency. I get that hospitals don't necessarily see the difference there and you can argue that as a reason to do a fellowship. I know you know the difference between a non-fellowship trained anesthesiologist and a CRNA thanks to their difference in training, but I don't like your wording which suggests otherwise.

 

[AdmiralChz]

So your cardiac guys don’t have the ability to do general cases?

The short answer is no.

The longer answer - No, it was their choice to only be credentialed there. They adamantly refuse to help us with General/trauma/OB/vascular/call/etc so when they had no business they were hosed. They aren’t really part of our PP, per se. Fairly complicated arrangement.

 

[Man o War]

While I hear variations of this statement often, I'm sick of hearing it. He/she WILL have something CRNAs don't. They'll have a medical degree and a residency. I get that hospitals don't necessarily see the difference there and you can argue that as a reason to do a fellowship. I know you know the difference between a non-fellowship trained anesthesiologist and a CRNA thanks to their difference in training, but I don't like your wording which suggests otherwise.

Also agree with this. No comparison, and most of my interactions with CRNAs was back when they were much better than the degree mill graduates they produce now.

 

[KENY1]

Guys...I understand what you are saying and I agree with you if course and I apologize, didn't mean to say a medical degree and a residency are the same as a short 2 year CRNA training. But.. just be realistic, many hospitals don't wanna see that difference and then its' safer to have a fellowship under your belt.

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[zizzer]

Let me just cover what I see as three bad reasons to do a fellowship:

1. To differentiate yourselves from CRNAs
As others have pointed out, you already are differentiated from CRNAs. But let's just assume the worst-case scenario: that hospitals view physicians and nurses as interchangeable. At the same price, the MD would get the job. CRNAs would drive themselves out of jobs, not physicians. It would be reasonable to assume that the end salary offered for a CRNA/MD would meet somewhere between where the two are now, and CRNAs already make more than primary care physicians.

2. Because you don't think you'll have enough training after 8 years
You're deciding to do a fellowship in CA-1 year or early CA-2 year. You will feel much more comfortable in your training as a CA-3, especially if you approach the CA-3 year with the mindset of, "****, I better get my skills and knowledge locked down before I have to be on my own" rather than banking on having one more year (fellowship). Besides, do you think 9 years vs 8 will make all the difference? Actually, that's not even an unfair comparison because the first year on the job as a nonfellowship attending will be a year of learning as well (arguably more than a fellowship year). It's fairer to compare where you would be with regards to skills and knowledge after at the end of the first year as an attending, not the beginning.

3. To make more money
You might command a bit more income as a fellowship-trained physician, but is it enough to make up for the opportunity cost of a year of attending salary (and the money that will accrue over your career on the money you put in savings)? Maybe, but not likely.

If you want to do a fellowship for some other reason, it's probably worth it.

 

[BLADEMDA]

Title says it all.
What do you guys think about this?

Yes. It’s a must going forward. Glorified CRNA if you don’t do a fellowship. No guarantees even if you do one but as both providers reach parity in the O.R. The fellowship will help distinguish you from the Doctor Nurses.

All you will hear from those not willing to do a fellowship is the lost money. What matters most over 30 years is not 1 year of lost income but rather job satisfaction and career advancement. I’d argue you are more likely to obtain both after a fellowship.

 

[sevoflurane]

No

 

[JiPo]

I am (hopefully) doing cardiac fellowship, so I am clearly biased. I think fellowship is worth it if the year of investment gives you a skill set you otherwise would not have without the fellowship, so think beyond "another line on your resume" when choosing a fellowship.

There are a lot of BS fellowships that really don't teach enough to make the year of investment worth it (ex. cardiac fellowships that only do bread and butter with subpar echo training, regional fellowships that only do bread and butter blocks, etc. - These "fellowships" are basically looking for cheap labors in return for a certificate.

 

[Dantrolene FC]

Yes. It’s a must going forward. Glorified CRNA if you don’t do a fellowship. No guarantees even if you do one but as both providers reach parity in the O.R. The fellowship will help distinguish you from the Doctor Nurses.

All you will hear from those not willing to do a fellowship is the lost money. What matters most over 30 years is not 1 year of lost income but rather job satisfaction and career advancement. I’d argue you are more likely to obtain both after a fellowship.

I have a question about your logic here:

Let's assume you do a cardiac fellowship. Are you practicing as a true anesthesiologist when doing a cardiac case, but still only practicing as a glorified CRNA when doing an OB case, regional block, or abdominal case, etc? If that's the case, then should I do a fellowship in general anesthesiology so I can be a true anesthesiologist?

 

[dannyboy1]

Yes. It’s a must going forward. Glorified CRNA if you don’t do a fellowship. No guarantees even if you do one but as both providers reach parity in the O.R. The fellowship will help distinguish you from the Doctor Nurses.

All you will hear from those not willing to do a fellowship is the lost money. What matters most over 30 years is not 1 year of lost income but rather job satisfaction and career advancement. I’d argue you are more likely to obtain both after a fellowship.

Not sure what you mean about this “career advancement”. the vast majority of us will only be doing cases or signing charts from day 1 of being an attending until the day we retire, weather they are general, peds or cardiac cases. The regulations surrounding CRNA’s and the overall surgical demand will determine our income and working conditions....

 

[UnoMas]

I have decided that I won't be doing any fellowship. If my 8 years of formal education really doesn't mean anything to society/the bean counters then it's pretty silly to waste another extra year of my life. The current problem we have is not the lack of expertise but a problem of lack of respect for the expertise. Extending training won't solve that.

My goal for the next few years is to make the best of my residency to become the best GENERALIST/glorified CRNA there is. Get out a year early, make hay while the sun still dimly shines. Save aggressively. Maybe that will allow me to shave a couple working years off the back-end.

 

[Southpaw]

Yes. It’s a must going forward. Glorified CRNA if you don’t do a fellowship. No guarantees even if you do one but as both providers reach parity in the O.R. The fellowship will help distinguish you from the Doctor Nurses.

All you will hear from those not willing to do a fellowship is the lost money. What matters most over 30 years is not 1 year of lost income but rather job satisfaction and career advancement. I’d argue you are more likely to obtain both after a fellowship.

SARS-COV2 has done a real number on you.

 

[KENY1]

Guys..gentlemen, doctors: nobody is saying if u don't have a fellowship u're not better then a CRNA ! Were trying to help a young colleague have the best chances in his career. As CRNAs are getting to work independently now in the VA system, in Arizona etc they will be gaining ground and taking away employment opportunities from the DOs and MDs. It's going to be worse than it is now ! And likely even harder in 5-10-15 years !
There is going to be fewer jobs for non-fellowship trained anesthesia doctors ! Very little doubt this is not going to happen. A peds fellowship is good for doing neonates, sick neonates etc. Cardiac is good. CCM - few opportunities and competition frompulmonologists. It's also really a different specialty, it's not really anesthesia. OB fellowship only if u wanna do academic work. Pain is separate, not much money in it any longer I hear ?
Choose a fellowship where u will learn TEE very well. Cardiologists who are doing more and more invasive work like Watchman, TAVR, MV clipping will be doing more such procedures and will ask for you if u get TEE board certification ! Financially it doesn't even compare - u will get 25-30% more than others - u can calculate the amount yourself. I am happy my son isn't in your shoes - I'd make him do the cardiac fellowship for sure - in 10 yrs there will be CRNAs everywhere and u will b lucky if they let u sign charts. However painful this sounds to many it is the truth. And even if it's not gonna happen that fast it will still make u feel more protected.

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[Justice4all]

There are pros and cons to either camp. But I would say, you should not pigeonhole yourself to a fellowship. Continue case complexity and diversity wherever you decide to practice. Outside of sick neonates and cardiac procedure requiring advanced TEE skills, an anesthesiologist should be game for anything but that's not the reality.

 

[MoMoGesiologist]

Do a periop medicine fellowship! CRNAs are not gonna replace you at preop clinic

 

[UnoMas]

Guys..gentlemen, doctors: nobody is saying if u don't have a fellowship u're not better then a CRNA ! Were trying to help a young colleague have the best chances in his career. As CRNAs are getting to work independently now in the VA system, in Arizona etc they will be gaining ground and taking away employment opportunities from the DOs and MDs. It's going to be worse than it is now ! And likely even harder in 5-10-15 years !
There is going to be fewer jobs for non-fellowship trained anesthesia doctors ! Very little doubt this is not going to happen. A peds fellowship is good for doing neonates, sick neonates etc. Cardiac is good. CCM - few opportunities and competition frompulmonologists. It's also really a different specialty, it's not really anesthesia. OB fellowship only if u wanna do academic work. Pain is separate, not much money in it any longer I hear ?
Choose a fellowship where u will learn TEE very well. Cardiologists who are doing more and more invasive work like Watchman, TAVR, MV clipping will be doing more such procedures and will ask for you if u get TEE board certification ! Financially it doesn't even compare - u will get 25-30% more than others - u can calculate the amount yourself. I am happy my son isn't in your shoes - I'd make him do the cardiac fellowship for sure - in 10 yrs there will be CRNAs everywhere and u will b lucky if they let u sign charts. However painful this sounds to many it is the truth. And even if it's not gonna happen that fast it will still make u feel more protected.

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What's happening to the general anesthesiologists in the 27 opt out states now? Do the CRNAs have to collect the full 50 states to start their morphing time?

 

[Man o War]

What's happening to the general anesthesiologists in the 27 opt out states now? Do the CRNAs have to collect the full 50 states to start their morphing time?

They are doing more than fine.

 

[KENY1]

They're doing fine now. There's a lot of jobs for anesthesia doctors in California for instance even in LA or SF, more than ever before in the last 20 years. But we're talking trends...5 yrs, 10 yrs. U don't think the high CRNA salaries are attracting more and more people..?

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[deleted162650]

In 2020 a fellowship is not a MUST. There are plenty of generalist jobs available all over the country. It’s not like a few years ago in rads where no one could get a job without 1 or 2 fellowships - that was a MUST situation. Not remotely close to that in anesthesia right now. Down the road - who knows???

 

[deleted171991]

A fellowship is like an MBA. Unless done at one of the top 10-20, and/or really useful in one's job (e.g. cardiac), it's just an expensive piece of paper.

 

[KENY1]

Arizona just became the 18 th state to opt-out of the CRNA supervision requirement, one could see a trend in that. No doubt it diminishes the numbers of positions for physician anesthesiologists as we're not increasing the number of surgeries, minimally invasive procedures are flooding medicine everywhere.



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[KENY1]

I agree in 2020 a fellowship is not a must but we are talking about 2025...2030..

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[deleted171991]

I agree in 2020 a fellowship is not a must but we are talking about 2025...2030..

You'll see (and should decide) in 2025-2030 then. 😉

I went back to do my fellowship years after graduation, when I was 100% convinced that it would at least make me happier, regardless of the finances. It did, still does.

Doing a fellowship years after residency makes for a better fellowship. A board-certified attending, with a few years of real life under the belt, knows much better what s/he wants/ could get out of it.

 

[KENY1]

Very few people go back..it's a rarity.

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[KENY1]

It's now or never.

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[deleted171991]

Very few people go back..it's a rarity.

If I were a smart PD, interested in excellence, I wouldn't hire new grads unless I had no choice, or they were geniuses. Even a few years of attending-level practice make for a world of difference.

If I were a lazy PD, looking for cheap scared monkeys to do the work and create minimal problems, I would do what we do today, absolutely.

People who are truly passionate would do a fellowship anytime. I would go back and do a second year of CCM fellowship in a top program tomorrow, if it changed my skills and career outlook significantly. I am not a fan of some of the stuff I do in the ICU, but, beyond that, it's tap dancing to work. That's how a subspecialty should feel; it should make one HAPPY.

Unfortunately, our CME system is a capitalist joke, geared toward the wrong things (e.g. profit), not educational performance. We should have mini-fellowships that are 3-6 month-long, and teach people particular skills (e.g. echo, regional, OB etc.), not 12 months of indentured servitude.

 

[deleted162650]

I agree in 2020 a fellowship is not a must but we are talking about 2025...2030..

Pretty sure the thread title specifically says “2020”.

 

[nimbus]

In 2020 a fellowship is not a MUST. There are plenty of generalist jobs available all over the country. It’s not like a few years ago in rads where no one could get a job without 1 or 2 fellowships - that was a MUST situation. Not remotely close to that in anesthesia right now. Down the road - who knows???

Same with ortho. I haven’t seen a new orthopedist without a fellowship in 15 years.

 

[deleted171991]

Same with ortho. I haven’t seen a new orthopedist without a fellowship in 15 years.

But they can mostly choose what surgeries they want to do. 😉

We have people with fellowship who practice outside of their subspecialty 80-90% of the time. That's just a royal waste for a 300K year.

 

[KENY1]

..yes a fellowship is done in 2020 but it stays with you and will be more important in 2025 and later because of the influx of CRNAs. I have done a fellowship and there was always a need for some cardiac work. I always got better money and was always needed for my knowledge of TEE.
Whoever can do a fellowship and doesn't do it is foolish - it's just 12 months and u can usually get in a good name program, Cleveland Clinic etc.
I'm not sure if doing a regional fellowship is any good, most people learn blocks by themselves from YouTube these days and most residents without a fellowship can do blocks already.

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[deleted171991]

..yes a fellowship is done in 2020 but it stays with you and will be more important in 2025 and later because of the influx of CRNAs. I have done a fellowship and there was always a need for some cardiac work. I always got better money and was always needed for my knowledge of TEE.
Whoever can do a fellowship and doesn't do it is foolish - it's just 12 months and u can usually get in a good name program, Cleveland Clinic etc.
I'm not sure if doing a regional fellowship is any good, most people learn blocks by themselves from YouTube these days and most residents without a fellowship can do blocks already.

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So then plead for a CARDIAC fellowship, not just any. Nobody will contradict you about that.

I remember exactly the "genius" who kept advising people to do a CCM fellowship (among others) years ago, because it swayed me, too, back when I knew even less than the nothing I know now. I loved my fellowship, hate the job market.

 

[KENY1]

Totally, i actually did a one and a half year of CCM fellowship and I learned a lot about sick patients it's a whole new world but I have never used it later as a source of income, just knew more.

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[Zekchar]

There are a lot of BS fellowships that really don't teach enough to make the year of investment worth it (ex. cardiac fellowships that only do bread and butter with subpar echo training, regional fellowships that only do bread and butter blocks, etc. - These "fellowships" are basically looking for cheap labors in return for a certificate.

That certificate is often your only ticket in. I'd make the case that peds hearts and advanced cardiac make a difference in terms of clinical skill. Everything else, you should be good enough to do once graduating from a decent residency. No ticket = no entry. That's the price of doing business and this will only escalate once CRNA's gain their independence.

 

[BLADEMDA]

So then plead for a CARDIAC fellowship, not just any. Nobody will contradict you about that.

I remember exactly the "genius" who kept advising people to do a CCM fellowship (among others) years ago, because it swayed me, too, back when I knew even less than the nothing I know now. I loved my fellowship, hate the job market.

I know CCM Anesthesia docs doing hearts. Quite a few actually. I would argue that for some practices a CCM trained MD is more than adequate to do Cabg and Valves.

The fact that the ABA wastes time during the residency process is the reason every resident can’t be CCM boarded. I’d argue to change the program to include CCM as part of the 4 year residency like in Europe. Despite the blow back on this board I’d argue that a 5 year program which includes CCM and a subspecialty like peds or Cardiac is exactly what this profession needs. That extra year gives you the option of both CCM boards and another subspecialty. We should stop watering the field down with outpatient cases and ridiculous electives and refocus on what it is important.

 

[KENY1]

In Europe anesthesiologists are the predominant physicians in ICUs as opposed to the US. No point in doing the CCM fellowship if u don't get a job in ICU.

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[JiPo]

I know CCM Anesthesia docs doing hearts. Quite a few actually. I would argue that for some practices a CCM trained MD is more than adequate to do Cabg and Valves.

The fact that the ABA wastes time during the residency process is the reason every resident can’t be CCM boarded. I’d argue to change the program to include CCM as part of the 4 year residency like in Europe. Despite the blow back on this board I’d argue that a 5 year program which includes CCM and a subspecialty like peds or Cardiac is exactly what this profession needs. That extra year gives you the option of both CCM boards and another subspecialty. We should stop watering the field down with outpatient cases and ridiculous electives and refocus on what it is important.

I agree with this sentiment, but many, if not most, ICU experience for ca 1-3 is basically doing intern work. Doing more “intern level work” in icu wont prepare anesthesiologists to be able to cover ccm.

icu experience for anesthesiology residents should change to mirror IM residents’ experience. You do intern level work as intern, and you take on senior role as senior, overseeing all of the patients, and making appropriate decisions. Only very few anesthesiology residency give this icu experience to residents.

 

[JiPo]

That certificate is often your only ticket in. I'd make the case that peds hearts and advanced cardiac make a difference in terms of clinical skill. Everything else, you should be good enough to do once graduating from a decent residency. No ticket = no entry. That's the price of doing business and this will only escalate once CRNA's gain their independence.

i dont know. Job market may be different with covid, but if I cant match at great fellowship program that I can learn something and walk away with new skills from, I would just go straight to job market and not lose 300k, which could be a huge difference later on. I went on a bunch of interviews this season, and I am not ranking several programs for this reason.

 

[CopaceticOne]

I agree with this sentiment, but many, if not most, ICU experience for ca 1-3 is basically doing intern work. Doing more “intern level work” in icu wont prepare anesthesiologists to be able to cover ccm.

icu experience for anesthesiology residents should change to mirror IM residents’ experience. You do intern level work as intern, and you take on senior role as senior, overseeing all of the patients, and making appropriate decisions. Only very few anesthesiology residency give this icu experience to residents.

The thought is good, however don't forget that IM folks must do 2-3 years of fellowship to be CCM board eligible. So during this extra year of anesthesia residency the individual will need to actually be treated as and given the responsibilities of a fellow. Until they aren't H&P and progress note monkeys the extra year is just a way of extending residency.

 

[vector2]

I agree with this sentiment, but many, if not most, ICU experience for ca 1-3 is basically doing intern work. Doing more “intern level work” in icu wont prepare anesthesiologists to be able to cover ccm.

icu experience for anesthesiology residents should change to mirror IM residents’ experience. You do intern level work as intern, and you take on senior role as senior, overseeing all of the patients, and making appropriate decisions. Only very few anesthesiology residency give this icu experience to residents.

It's unfortunate your ICU experience is like that. When I'm staffing interns, I expect an intern note and presentation during rounds. When I staff PGY-2s and especially 3s, I expect them to actually put some thought into the plan and not just regurgitate pt data back to me in the hopes that I simply tell them what to do.

This is more of a systems issue, but it would also help if in academics it wasn't usually just one attending for a 15-20 pt census. I'm sympathetic to how long rounds take especially when there are procedures or scut to do after rounds, so I usually have to rush a bit more than I would like. If I had 10 pts...that would certain give me more time to do more relaxed, thorough teaching rounds and let senior residents incrementally take the lead.

 

[linkin06]

I was under impression that Peds doesn't pay that well because medicaid. And Cardiac doesn't pay that well because medicare? But I'm not in either of those fields to know. I hated cardiac and do not enjoy those tertiary referral peds cases, so I'm just generalist. I do feel poorly for the overall future and hence saving aggressively.

 

[dannyboy1]

I was under impression that Peds doesn't pay that well because medicaid. And Cardiac doesn't pay that well because medicare? But I'm not in either of those fields to know. I hated cardiac and do not enjoy those tertiary referral peds cases, so I'm just generalist. I do feel poorly for the overall future and hence saving aggressively.

As more and more of us become employed that really makes no difference. Your employer will to the tough peds and heart cases at the facility so money can be made off elective Ortho and plastics. My feeling is that independent CRNA’s can ( unfortunately) cover the bread and butter cases safely enough overall...
If the regulations change to reflect this we are fu(ked.