Is fellowship a MUST for Anesthesia in 2020?

[Man o War]

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.

Cardiac anesthesia is heavily subsidized. You will find locums rates higher for cardiac vs general typically.

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[Nivens]

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.

If we require more ICU months as part of training there are more residents per CA year in the ICU at any given time. This would allow for more heirarchial structure you describe.

 

[kidthor]

I was under impression that Peds doesn't pay that well because medicaid.

True that peds reimbursement in isolation is very poor due to medicaid. Medicaid is overwhelmingly the insurer for kids, much more so than adults (and there are more kids on medicaid than there are adults on medicare too).

Sometimes it evens out with blended units if in PP, and/or with stipends. In academia it can be less of an issue due to fuzzy finances.

If you're in an "eat what you kill" non-blended PP practice then peds pays very poorly. And that tells you how awful health insurance incentives are in the USA.

 

[CopaceticOne]

If we require more ICU months as part of training there are more residents per CA year in the ICU at any given time. This would allow for more heirarchial structure you describe.

Critical care training isn't about hierchy. It is about knowledge.

 

[Nivens]

If the regulations change to reflect this we are fu(ked.

Make no mistake, they will. The economic pressures are too strong, and the nurses are too popular/numerous (more votes -> politician influence). Training to take care of patients too sick for the average CRNA + a SD or two is the only real job security for a 20+ year career.

 

[Nivens]

Critical care training isn't about hierchy. It is about knowledge.

Except if you want fellows acting as attendings overseeing senior residents leading interns through rounds, you need a heirarchy. It can and should be a heirarchy of knowledge, but the structure needs to be there.

 

[dannyboy1]

Make no mistake, they will. The economic pressures are too strong, and the nurses are too popular/numerous (more votes -> politician influence). Training to take care of patients too sick for the average CRNA + a SD or two is the only real job security for a 20+ year career.

I always thought they would, but that it would take enough time that I could have a nice career. Unfortunately COVID may have sped up the timeline a bit. We shall see....

 

[chocomorsel]

If we require more ICU months as part of training there are more residents per CA year in the ICU at any given time. This would allow for more heirarchial structure you describe.

Depends on the place. For example where I did my residency rotating through the ICU is total bull****. It was competition between the surgical residents and the anesthesia residents. And we were the second class citizens.

But where I did my fellowship the anesthesiologists ran the ICUs. And it was set up the way it should be. Where the senior residents/fellows were in charge and led and guided the junior residents. Much better experience.

You got to go to a place where the anesthesiologists have a very strong presence in the ICUs or run the ICUs to get a good experience.

 

[nimbus]

True that peds reimbursement in isolation is very poor due to medicaid. Medicaid is overwhelmingly the insurer for kids, much more so than adults (and there are more kids on medicaid than there are adults on medicare too).

Sometimes it evens out with blended units if in PP, and/or with stipends. In academia it can be less of an issue due to fuzzy finances.

If you're in an "eat what you kill" non-blended PP practice then peds pays very poorly. And that tells you how awful health insurance incentives are in the USA.

Kids need to hire better lobbyists.

 

[kidthor]

Kids need to hire better lobbyists.

Yes. For now they're essentially paid by the pound.

 

[MoMoGesiologist]

Depends on the place. For example where I did my residency rotating through the ICU is total bull****. It was competition between the surgical residents and the anesthesia residents. And we were the second class citizens.

I have experienced this as well unfortunately. Sucks but unfortunately anesthesia departments are not interested in participating in ICUs. All about maximizing profits and getting am/lunch/pm breaks.

 

[deleted500612]

I am happy my son isn't in your shoes - I'd make him do the cardiac fellowship for sure

As oppose to letting him choose his own fellowship as a 30+ year old man?

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.

People have been saying for 30 years that "A few years from now CRNAs will be everywhere and anesthesiologists will be lucky to have a job. Beware! Do a fellowship, or better yet get out of this doomed specialty!". Yet the world continues to turn and anesthesiologists, including generalists in states with CRNA independence, are still doing fine. So color me skeptical about the supposedly imminent stormy showers the weathermen have been predicting for 30 years that still haven't come. Doesn't mean they will never come, it means people suck at predicting the weather.

 

[Man o War]

As oppose to letting him choose his own fellowship as a 30+ year old man?



People have been saying for 30 years that "A few years from now CRNAs will be everywhere and anesthesiologists will be lucky to have a job. Beware! Do a fellowship, or better yet get out of this doomed specialty!". Yet the world continues to turn and anesthesiologists, including generalists in states with CRNA independence, are still doing fine. So color me skeptical about the supposedly imminent stormy showers the weathermen have been predicting for 30 years that still haven't come. Doesn't mean they will never come, it means people suck at predicting the weather.

Yep. And anyone who lived through the 90s as an anesthesiologist is even more weary of the sky is falling camp.

 

[dchz]

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.

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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While i do agree with your general sentiment, no worth doing a fellowship if you don't enjoy the fellowship. I have said this before. In order to not regret a fellowship, two condition must be met:

1). You would do the area of specialization for the same pay.

2). Your fellowship year must give you skills you cannot gain otherwise.


Lastly, what is "above par" echo training? or learning TEE "very well"? You are looking at a muscle with ultrasound. There is only so much you can learn about it. There are def cardiac fellowships out there not worth going to. But I always wonder what would be a good example of teaching TEE very well.

 

[dchz]

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.

Valve, singular, as in the aortic valve, mostly through a trans arterial approach. Would you really let someone do your mitral/tricuspid/pulmonic valve repair without a CT fellowship?

I know of a case in residency where the CCM attending without CT fellowship missed an aortic PVL, and the pt died from direct complications of that.

The problem with what you're proposing is the same problem with CRNAs practicing independently. Without regulation, you can't expect the whole population to act like the top 5%tile of the population, there will be a regression to the mean. Sure, very top tier CCM Anesthesiologist will be adequate for CABGs if they go through and do 50 CABGs and TEEs under the guidance of another qualified CT anesthesiologist. But what happens when a CCM guy that can't hack it in anesthesia wants to do cardiac for the money?? It's a slippery slope to a bad place.

 

[Nivens]

While i do agree with your general sentiment, no worth doing a fellowship if you don't enjoy the fellowship. I have said this before. In order to not regret a fellowship, two condition must be met:

1). You would do the area of specialization for the same pay.

2). Your fellowship year must give you skills you cannot gain otherwise.


Lastly, what is "above par" echo training? or learning TEE "very well"? You are looking at a muscle with ultrasound. There is only so much you can learn about it. There are def cardiac fellowships out there not worth going to. But I always wonder what would be a good example of teaching TEE very well.

There definitely is a spectrum. One one end there’s the “squeezing/not squeezing, leaking/not leaking, effusion present/absent”, on the other is the advanced structural heart stuff like guiding non-standard mitral clips, tricuspid clips, and PVL closure with hybrid/fusion imaging.

Now, we can debate the clinical utility of the more advanced stuff for your average anesthesiologist today, but it’s tough to predict what we’ll be called upon to do in the future. I’m happy I’m getting a thorough education in it now should it become relevant at some point in the future.

 

[dchz]

There definitely is a spectrum. One one end there’s the “squeezing/not squeezing, leaking/not leaking, effusion present/absent”, on the other is the advanced structural heart stuff like guiding non-standard mitral clips, tricuspid clips, and PVL closure with hybrid/fusion imaging.

Now, we can debate the clinical utility of the more advanced stuff for your average anesthesiologist today, but it’s tough to predict what we’ll be called upon to do in the future. I’m happy I’m getting a thorough education in it now should it become relevant at some point in the future.

As far as mitraclip guidance, one needs to be facile at understanding, locating, and orienting the clip in 2d and 3d. Are you noticing a difference between the CT anesthesiologists after they've gone through the Abbott training?

I am ignorant of the hybrid/fusion imaging. Would be cool to see in fellowship, wonder what % of fellowships have that.

 

[secretasianman]

We need the ASA to become more politically active and less neutered, more so than we need need ppl to go into fellowships..

 

[vector2]

Valve, singular, as in the aortic valve, mostly through a trans arterial approach. Would you really let someone do your mitral/tricuspid/pulmonic valve repair without a CT fellowship?

I know of a case in residency where the CCM attending without CT fellowship missed an aortic PVL, and the pt died from direct complications of that.

The problem with what you're proposing is the same problem with CRNAs practicing independently. Without regulation, you can't expect the whole population to act like the top 5%tile of the population, there will be a regression to the mean. Sure, very top tier CCM Anesthesiologist will be adequate for CABGs if they go through and do 50 CABGs and TEEs under the guidance of another qualified CT anesthesiologist. But what happens when a CCM guy that can't hack it in anesthesia wants to do cardiac for the money?? It's a slippery slope to a bad place.

Even though I am one of the CCM trained doing cardiac people you’re talking about (and to be fair a missed PVL could potentially happen to even a CT trained person for a variety of reasons), I tend to agree with your sentiment. How many CCM trained doing CT are going to be like me, I.e. 3 months of cardiac and 1 month of TEE in residency, 3 months of dedicated TEE in fellowship with 100+ read and 90+ performed with CT staff, 4 months+ of CTICU in fellowship working with many dual trained attendings and doing almost daily TTE and occasional TEE in the unit including stuff like ECMO turndowns and LVAD PI diagnoses etc, almost a year of echo studying during fellowship, 90+%ile on aPTE, and a decent size TEE log I’ve built up in practice? My guess would be 1-2% of purely CCM trained folks, if that.

However, the flip side of that in my personal experience is that I work with hustler PP CT surgeons who have good pt selection (too selective imo), are fast, have been in practice for 15 yrs, and who work at 4 different hospitals including mine. They do some complex cases occasionally but they are mostly community surgeons, which means many of the hospitals in which they work (including mine) don’t have CT fellowship trained anesthesia. To boot, cardiology is frequently awful (will not even bother to show sometimes, some are really bad echocardiographers, many with no NBE cert, come in for 2 min prepump, 2 min postpump, oftentimes miss things etc). This combination of things has led them to do a ton of surgeries without echo. When I am there, I TEE anyone and everyone getting a sternotomy because that’s what I would want for me or my family member. When I’m on vacation though, they pretty much only request cards TEE for mitral valve repairs, ASD repairs, septal myectomy, and the very occasional sick or complex MVR. Yep, every other CABG (even Ef 20% with iabp), MVR, AVR, bentall with composite valve replacement etc is done without TEE and with general anesthesiologists, and believe it or not, their pump times are better than 90% of other surgeons I’ve seen and I’ve only had 2 bringbacks with them in 3 yrs (granted, overall cardiac volume is low compared to most tertiary centers). They have certainly challenged my notion of how necessary CT anesthesia is *in community practice* if the surgeon has flawless technique, meticulous suture lines and hemostasis, uses del nido plegia, and almost never has a pump time long enough to require redosing or a complication that requires going back on....

 

[deleted697535]

Even though I am one of the CCM trained doing cardiac people you’re talking about (and to be fair a missed PVL could potentially happen to even a CT trained person for a variety of reasons), I tend to agree with your sentiment. How many CCM trained doing CT are going to be like me, I.e. 3 months of cardiac and 1 month of TEE in residency, 3 months of dedicated TEE in fellowship with 100+ read and 90+ performed with CT staff, 4 months+ of CTICU in fellowship working with many dual trained attendings and doing almost daily TTE and occasional TEE in the unit including stuff like ECMO turndowns and LVAD PI diagnoses etc, almost a year of echo studying during fellowship, 90+%ile on aPTE, and a decent size TEE log I’ve built up in practice? My guess would be 1-2% of purely CCM trained folks, if that.

However, the flip side of that in my personal experience is that I work with hustler PP CT surgeons who have good pt selection (too selective imo), are fast, have been in practice for 15 yrs, and who work at 4 different hospitals including mine. They do some complex cases occasionally but they are mostly community surgeons, which means many of the hospitals in which they work (including mine) don’t have CT fellowship trained anesthesia. To boot, cardiology is frequently awful (will not even bother to show sometimes, some are really bad echocardiographers, many with no NBE cert, come in for 2 min prepump, 2 min postpump, oftentimes miss things etc). This combination of things has led them to do a ton of surgeries without echo. When I am there, I TEE anyone and everyone getting a sternotomy because that’s what I would want for me or my family member. When I’m on vacation though, they pretty much only request cards TEE for mitral valve repairs, ASD repairs, septal myectomy, and the very occasional sick or complex MVR. Yep, every other CABG (even Ef 20% with iabp), MVR, AVR, bentall with composite valve replacement etc is done without TEE and with general anesthesiologists, and believe it or not, their pump times are better than 90% of other surgeons I’ve seen and I’ve only had 2 bringbacks with them in 3 yrs (granted, overall cardiac volume is low compared to most tertiary centers). They have certainly challenged my notion of how necessary CT anesthesia is if the surgeon has flawless technique, meticulous suture lines and hemostasis, uses del nido plegia, and almost never has a pump time long enough to require redosing or a complication that requires going back on....

Yeah no, sorry that's not a thing. It doesn't matter how you dress it up. The fact that you're using residency to fluff the numbers gives me a headache. That entire post means I'm going to have to have another double rum here.

Mvr without tee in 2020. Generalists doing hearts. Surgeons holding your hand with case selection.

I need to drink more

 

[vector2]

Yeah no, sorry that's not a thing. It doesn't matter how you dress it up. The fact that you're using residency to fluff the numbers gives me a headache. That entire post means I'm going to have to have another double rum here.

Mvr without tee in 2020. Generalists doing hearts. Surgeons holding your hand with case selection.

I need to drink more

Not a thing? To whom, you? You frequently make a lot of bizarre, incoherent anesthesia proclamations and join in discussions with US anesthesiologists around here even though you’re some UK trainee on an 8? year track with no real firsthand knowledge of how US residency, fellowship training, or CT surgery practice function. So sure, have another drink and keep moving pal.

 

[bigdan]

Vec -

Your points about an experience based (or at least not-formal-CT-Anesthesiology-fellowship based) TEE training are well taken. The "numbers" have always seemed someone nebulous. Some folks seem to "get it" MUCH MUCH faster than others, and some seem to still be missing something even after many more TEE than the NBE minimum numbers of exams.

Regarding doing hearts without a cardiac fellowship, my assumption (I have no numbers or published literature on this) is that most cardiac surgical cases in the USA get done without a cardiac anesthesiologist staffing the case. And I suspect the overwhelming majority of cases do great. Planned CABG is not a Class 1 indication for intraop TEE, so there's no harm/no foul there, at least by indication. While I too provide TEE for every single cardiac surgical case I do, I do not know that it is absolutely mandatory, despite what we see in residency/fellowship. I remember an interview I had at a tiny PP place I interviewed for as I left cardiac fellowship - an older CT surgeon asked me if I would have a problem not doing TEE for CABG cases. I told him no, as per the aforementioned guidelines, but asked him if he was worried if he would miss something that wasn't appreciated on preop workup. He told me that he consents them for CABG, not anything else. Fine, I guess. Not exactly what I would want, but that's what this guy's patients got. There's a study from late 2000s that looked at something like 10K patients undergoing cardiac surgery with TEE and almost 10% of all cases had some form of surgical plan change based on intraop TEE findings. That's less than one case changed per month if your shop does 100 cases/yr, but it's a couple per week if you do 1000 cases/yr. I understand that an outstanding surgeon really makes all the difference in the world. But some of the data on what we (the surgeons) should be doing with (as a couple of examples among many possible issues) moderate MR, or with functional TR (when found during cardiac surgery for other indication) doesn't make much of a difference to come off CPB, or on POD#1 or 2. But it makes a mortality difference later. I certainly cannot command a surgeon to open the R heart when he's trying to do a quick CABG, but, again, the surgeon can't consider it if he doesn't know about it. At my place, our guys are actually pretty considerate of our TEE discussions.

Anyways, I realize I'm getting into the weeds a little bit. But one of the things I hope to be true is that we anesthesiologists are part of improving outcomes for the very sick patients we encounter. It's rarely good enough to just "get 'em outta the room" anymore, and I think we can/should be part of making their intraoperative, in-hospital, 30-day, 6 month, and 1 year (and more) M&M better than it would have been without us. That's prolly a bit pollyanna, but still...

 

[vector2]

Vec -

Your points about an experience based (or at least not-formal-CT-Anesthesiology-fellowship based) TEE training are well taken. The "numbers" have always seemed someone nebulous. Some folks seem to "get it" MUCH MUCH faster than others, and some seem to still be missing something even after many more TEE than the NBE minimum numbers of exams.

Regarding doing hearts without a cardiac fellowship, my assumption (I have no numbers or published literature on this) is that most cardiac surgical cases in the USA get done without a cardiac anesthesiologist staffing the case. And I suspect the overwhelming majority of cases do great. Planned CABG is not a Class 1 indication for intraop TEE, so there's no harm/no foul there, at least by indication. While I too provide TEE for every single cardiac surgical case I do, I do not know that it is absolutely mandatory, despite what we see in residency/fellowship. I remember an interview I had at a tiny PP place I interviewed for as I left cardiac fellowship - an older CT surgeon asked me if I would have a problem not doing TEE for CABG cases. I told him no, as per the aforementioned guidelines, but asked him if he was worried if he would miss something that wasn't appreciated on preop workup. He told me that he consents them for CABG, not anything else. Fine, I guess. Not exactly what I would want, but that's what this guy's patients got. There's a study from late 2000s that looked at something like 10K patients undergoing cardiac surgery with TEE and almost 10% of all cases had some form of surgical plan change based on intraop TEE findings. That's less than one case changed per month if your shop does 100 cases/yr, but it's a couple per week if you do 1000 cases/yr. I understand that an outstanding surgeon really makes all the difference in the world. But some of the data on what we (the surgeons) should be doing with (as a couple of examples among many possible issues) moderate MR, or with functional TR (when found during cardiac surgery for other indication) doesn't make much of a difference to come off CPB, or on POD#1 or 2. But it makes a mortality difference later. I certainly cannot command a surgeon to open the R heart when he's trying to do a quick CABG, but, again, the surgeon can't consider it if he doesn't know about it. At my place, our guys are actually pretty considerate of our TEE discussions.

Anyways, I realize I'm getting into the weeds a little bit. But one of the things I hope to be true is that we anesthesiologists are part of improving outcomes for the very sick patients we encounter. It's rarely good enough to just "get 'em outta the room" anymore, and I think we can/should be part of making their intraoperative, in-hospital, 30-day, 6 month, and 1 year (and more) M&M better than it would have been without us. That's prolly a bit pollyanna, but still...

You make excellent points, and unfortunately part of my surgeons' selectivity, overly conservative approach, and apathy toward TEE is likely based on them knowing what they would actually have to fix according to ACC/AHA guidelines if the diagnostic information was right in front of their faces. It hasnt happened often, but I have had cases with them where I've seen clearly severe functional MR during CABG and they've left it alone, or obvious TV annular dilatation with TR due to left heart disease and they haven't banded it. And obviously historically for them, if there is no TEE and no TEE report then letting that MR slide and punting to cards for a (likely less durable and worse for the pt) clip is easier to justify.

On the other hand, where I do locums, those guys are so responsive to the pre-exam that I have to pull a 180 and be extremely judicious, because they are going to go after every borderline severe lesion that meets an indication. Their revascs are frequently 4-5+ vessels because if there is even a hint of a target and enough vein they're doing it. They cut out and oversew every appendage. I even have to watch whether I tell them about a PFO I see during a pre CABG exam because they'll do bicaval and an atriotomy to sew it even if it's 2mm, non aneurysmal, and the pt is totally asymptomatic.

 

[GA8314]

I don't think fellowship is a must. It's hard to say it will hurt you, and will help you in certain jobs in competitive markets. Also, if you really want to do mostly that particular subspecialty. Also, highly tertiary care type stuff it is warranted for sure in my opinion (neonates, complex cardiac etc). But, that's not the majority of anesthesia being done out there. There are plenty of generalist jobs out there, and the real need are for folks that can hustle and be an asset to patient flow through the OR's. That generates money and makes everyone happy. If you are good, you will have a decent career.

 

[deleted171991]

I don't think fellowship is a must. It's hard to say it will hurt you, and will help you in certain jobs in competitive markets. Also, if you really want to do mostly that particular subspecialty. Also, highly tertiary care type stuff it is warranted for sure in my opinion (neonates, complex cardiac etc). But, that's not the majority of anesthesia being done out there. There are plenty of generalist jobs out there, and the real need are for folks that can hustle and be an asset to patient flow through the OR's. That generates money and makes everyone happy. If you are good, you will have a decent career.

Translation: you're not only the ACT firefighter and scapegoat anymore, you're also the "facilitator" monkey.

But, hey, you will have a "decent" career. Because all those surgical delays are because of you, not the slow surgeons. And what better way to save money than flog the anesthesia staff about saving 10-15 minutes on turnover. Why should any anesthesiologist not feel like they are working in a sweatshop?

If one thinks one needs a fellowship for future success in anesthesia, maybe one should consider just going back for a residency in a better specialty, one in which a doctor is more than just somebody else's monkey.

 

[GA8314]

Translation: you're not only the ACT firefighter and scapegoat anymore, you're also the "facilitator" monkey.

But, hey, you will have a "decent" career. Because all those surgical delays are because of you, not the slow surgeons. And what better way to save money than flog the anesthesia staff about saving 10-15 minutes on turnover. Why would any anesthesiologist not feel like they are working in a sweatshop, for a moment?

If one thinks one needs a fellowship for future success in anesthesia, maybe one should consider just going back for a residency in a better specialty, one in which a doctor is more than just somebody else's monkey.

We all answer to someone. Not understanding this dynamic is a setup for disappointment. I have found that surgeons appreciate anesthesiologists who take their time seriously. And, there is no reason you can't also do this sitting cases solo.

My experience has been that respect is given to those who earn it. In the rare case that it's not, then one simply needs to shrug it off versus getting all butt hurt.

 

[deleted171991]

We all answer to someone. Not understanding this dynamic is a setup for disappointment. I have found that surgeons appreciate anesthesiologists who take their time seriously. And, there is no reason you can't also do this sitting cases solo.

My experience has been that respect is given to those who earn it. In the rare case that it's not, then one simply needs to shrug it off versus getting all butt hurt.

Someone very wise once said that anesthesia is like prostitution: the better you work, the more you work. As an employee with no real participation to profit, which most of us are, that's a losing proposition. People will work themselves to death, literally.

I learned long ago that there is EXACTLY one form of respect that matters: money. Talk is cheap; that's why shrewd employers give all kinds of pompous titles to employees, instead of properly raising their salaries. And anybody who expects dumb people to recognize a good doctor when they see one had better not hold their breath. All the world's a stage...

 

[dannyboy1]

If one thinks one needs a fellowship for future success in anesthesia, maybe one should consider just going back for a residency in a better specialty, one in which a doctor is more than just somebody else's monkey.

That’s the point isn’t it. Anesthesia is not a profession for those who want to be “doctors”. I hate talking to patients, their families, long term follow up, rounding ect. I’m happy for someone to do the all that legwork and me being able to show up, put em to sleep, wake em up and leave. As a plus, I get paid well. Those who want to be the “doctor” are invariably miserable in anesthesia.

 

[psychbender]

Valve, singular, as in the aortic valve, mostly through a trans arterial approach. Would you really let someone do your mitral/tricuspid/pulmonic valve repair without a CT fellowship?

I know of a case in residency where the CCM attending without CT fellowship missed an aortic PVL, and the pt died from direct complications of that.

The problem with what you're proposing is the same problem with CRNAs practicing independently. Without regulation, you can't expect the whole population to act like the top 5%tile of the population, there will be a regression to the mean. Sure, very top tier CCM Anesthesiologist will be adequate for CABGs if they go through and do 50 CABGs and TEEs under the guidance of another qualified CT anesthesiologist. But what happens when a CCM guy that can't hack it in anesthesia wants to do cardiac for the money?? It's a slippery slope to a bad place.

That's the attitude of someone who has yet to leave the ivory tower and see that motivated, educated individuals can learn the skills necessary (echo and anesthetic management) for those cases. Without doing it all day every day with great mentors, it may take a few years, rather than just one, to accumulate a similar skill and comfort level, but it is entirely possible. Now, it also means that there will be things such physicians have never seen before (I've never done a pulmonic valve repair or replacement, nor any peds cardiac), but the same can be said of graduates of many CT fellowship programs that do very little to no congenital, mechanical circulatory support, interventional/hybrid lab procedures, etc. The argument is nothing like the CRNA independence argument, as the difference in training between a CRNA and physician are deep and vast, with education differences spanning years. The difference between a general anesthesiologist and a CT fellowship trained anesthesiologist are small and focal, with only a single year separating the two. I am not saying let everyone just do whatever the hell they feel like. However, qualified physicians should not be locked out by some national push to limit practice to just CT fellowship-trained anesthesiologists. This is where groups and hospital credentialing committees come in, and set standards to practice these skills. If your academic center or private practice doesn't want to chance it, then fine. Others are more open-minded.

Additionally, your anecdote is just an anecdote. Anyone can miss something. I have an anecdote about a CT fellowship trained anesthesiologist that missed a giant saddle PE in an emergent CABG that had more right-sided dysfunction than could be explained by the known coronary disease.

 

[KENY1]

Guys this is not supposed to be a fight between practicing CT fellowship-trained people and non-fellowship trained ones. This was an advice for a young anesthesiologist how to best assure job security in the next 20- 30 years.
It's a question of anticipating the future. To me if in the last couple of months the VA system and the State of Arizona opted out of physician supervision of CRNAs this is a trend. A trend like this may be simmering and it may burst: a sudden new fashion that everyone follows. That is what the danger is for current and more so for future physician anesthesiologists please do not fool yourself - that is the main danger no doubt. A fellowship may save the physician from being pushed aside or paid less in a specialty where lower-cost laborers are likely soon going to be pouring in.

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[CCM-MD]

Do something that can get you out of the hospital, like Pain (if you can tolerate it).

 

[GA8314]

Someone very wise once said that anesthesia is like prostitution: the better you work, the more you work. As an employee with no real participation to profit, which most of us are, that's a losing proposition. People will work themselves to death, literally.

I learned long ago that there is EXACTLY one form of respect that matters: money. Talk is cheap; that's why shrewd employers give all kinds of pompous titles to employees, instead of properly raising their salaries. And anybody who expects dumb people to recognize a good doctor when they see one had better not hold their breath. All the world's a stage...

Look. There is no perfect system. No perfect career. Imagine the spine surgeon whom administration may genuflect towards. He/she probably has been sued multiple times, threatened to be sued many more times than that, has to deal with exhausting pre-op/surgical expectation setting, and has to deal with patients constantly asking for pain meds.

We all answer to someone. Sure, anesthesia is beyond it's heyday. But, so is much of medicine. The grass isn't always greener. Headaches are probably more across the board. I don't disagree with that.

 

[deleted171991]

Look. There is no perfect system. No perfect career. Imagine the spine surgeon whom administration may genuflect towards. He/she probably has been sued multiple times, threatened to be sued many more times than that, has to deal with exhausting pre-op/surgical expectation setting, and has to deal with patients constantly asking for pain meds.

We all answer to someone. Sure, anesthesia is beyond it's heyday. But, so is much of medicine. The grass isn't always greener. Headaches are probably more across the board. I don't disagree with that.

If you're trying to lead with "the grass is always greener...", you won't convince me. Been there done that. It's about the same level of argument as "if you think you have it bad, think about Africa". Or "millionaires have problems too". Anesthesiologists seem to get less respect than even hospitalists, almost everywhere I look. Even the good ones. The way I compensate for it is that I think about being relatively well-paid for my current low stress job. I am lucky because I don't have educational loans or expensive habits, I have a working spouse, and we are both frugal.

The question here is whether a fellowship is worth it, at least for job safety. If I had to do another year of fellowship for job safety, I would just do my missing 2 years of internal medicine instead, but that's me. For the average graduate, the way to think is what's the future value, in 30 years, of the 300K they are wasting on that fellowship year.

Besides cardiac anesthesia, I really don't see the point of a fellowship. Even with cardiac, if everybody does a fellowship (like with the pediatric mania when it became a boarded subspecialty), there won't be enough jobs for all the subspecialty-trained people. What this country needs is more great generalist anesthesiologists, not subspecialists. Pain may be the only other fellowship worth doing, but only if the person has the entrepreneurial spirit. Otherwise they will just end up being somebody's bitch, as in anesthesia.

A vast majority of the things that differentiate an anesthesiologist from a CRNA are taught during medical school and residency. It's not like most fellowships are necessary for the average OR practice of a good graduate, as mentioned by wise people above.

 

[dchz]

That's the attitude of someone who has yet to leave the ivory tower and see that motivated, educated individuals can learn the skills necessary (echo and anesthetic management) for those cases. Without doing it all day every day with great mentors, it may take a few years, rather than just one, to accumulate a similar skill and comfort level, but it is entirely possible. Now, it also means that there will be things such physicians have never seen before (I've never done a pulmonic valve repair or replacement, nor any peds cardiac), but the same can be said of graduates of many CT fellowship programs that do very little to no congenital, mechanical circulatory support, interventional/hybrid lab procedures, etc. The argument is nothing like the CRNA independence argument, as the difference in training between a CRNA and physician are deep and vast, with education differences spanning years. The difference between a general anesthesiologist and a CT fellowship trained anesthesiologist are small and focal, with only a single year separating the two. I am not saying let everyone just do whatever the hell they feel like. However, qualified physicians should not be locked out by some national push to limit practice to just CT fellowship-trained anesthesiologists. This is where groups and hospital credentialing committees come in, and set standards to practice these skills. If your academic center or private practice doesn't want to chance it, then fine. Others are more open-minded.

Additionally, your anecdote is just an anecdote. Anyone can miss something. I have an anecdote about a CT fellowship trained anesthesiologist that missed a giant saddle PE in an emergent CABG that had more right-sided dysfunction than could be explained by the known coronary disease.

Again, my criticism is meant to be constructive and non-confrontational. I certainly do not come from an ivory tower. I can't control what people do. I might even have done CT w/o fellowship if I didn't get a spot. But what I do know is that I've learned a lot of skill and knowledge that I don't think most people can get without fellowship. Notice I have not mentioned one thing about TEE. TEE doesn't make a fellowship, it's a tool just like the linear probe, being able to picture the heart doesn't make you a CT anesthesiologist, it's barely the minimum requirement. Furthermore, if it takes you YEARS to just meet the basic requirement of proficiency, do you want your loved ones to be one of those patients during those years?

Their revascs are frequently 4-5+ vessels because if there is even a hint of a target and enough vein they're doing it. They cut out and oversew every appendage. I even have to watch whether I tell them about a PFO I see during a pre CABG exam because they'll do bicaval and an atriotomy to sew it even if it's 2mm, non aneurysmal, and the pt is totally asymptomatic.

Do you really believe 4-5 vessel bypass helps the pt in the long term? my understanding is that arterial grafts to the left side are the only thing that has a proven moRtality benefit This might be left over from billing or may be they do get paid by the graft.

I'm gonna stop fueling the debate on forum on who's peepee is bigger. It's just not constructive.

 

[deleted171991]

Do you really believe 4-5 vessel bypass helps the pt in the long term? my understanding is that arterial grafts to the left side are the only thing that has a proven moRtality benefit This might be left over from billing or may be they do get paid by the graft.

That darn intensivist deep inside you spoke up again.

Repeat after me: anesthesiologists are not supposed to behave as if they were physicians, anesthesiologists are not supposed to behave as if they were physicians...

 

[dchz]

That darn Physician deep inside you spoke up again.

Fixed that for ya.

What's his name? did he use lube??

 

[psychbender]

Again, my criticism is meant to be constructive and non-confrontational. I certainly do not come from an ivory tower. I can't control what people do. I might even have done CT w/o fellowship if I didn't get a spot. But what I do know is that I've learned a lot of skill and knowledge that I don't think most people can get without fellowship. Notice I have not mentioned one thing about TEE. TEE doesn't make a fellowship, it's a tool just like the linear probe, being able to picture the heart doesn't make you a CT anesthesiologist, it's barely the minimum requirement. Furthermore, if it takes you YEARS to just meet the basic requirement of proficiency, do you want your loved ones to be one of those patients during those years?

I'm gonna stop fueling the debate on forum on who's peepee is bigger. It's just not constructive.

If your aim was to be nonconfrontational, you fell a bit short of the mark. You came right out and claimed that a good chunk of your colleagues are clinically inferior and incapable of doing some rather straightforward cases, using an anecdote as evidence. Further, you did mention TEE when you discussed how only the best CCM anesthesiologists could even be allowed to do a CABG, and in your anecdote. Echo is just a tool used to gather information, and it is up to the physician to determine how best to use that information, and act on it. Without facility with the tool, information cannot be obtained (as in your PVL example), yet without experience and judgement to interpret and images and clinical situation, facility with the tool is meaningless.

As for the time remark, it is a matter of how long it takes to accumulate enough cases, "oh ****" moments, and eventually comfort. That caselog and comfort level builds up rapidly when every day is spent doing cardiac cases, with structured didactics and mentoring built in. Although I did a lot of cardiac in residency, doing only one or two a week as an attending, while going through textbooks, conferences, review courses, and finding a mentor with whom to discuss cases, means that it naturally took longer to reach a similar endpoint. I do not feel bad that it took more time to become comfortable, as it would be the pinnacle of ignorant arrogance to assume that it took the same or less. My patients received good care, and I would feel comfortable had the roles been reversed, and it was my parent being cared for by someone else in my same situation.

Agreed, this discussion is not constructive. If you did not want to have a penis measuring contest, maybe you should not have opened with stating how much bigger yours is than that of your colleagues.

 

[KENY1]

Wow....u guys r funny indeed...but...
we have very experienced and very smart people here but please tone it down..it's a waste of time to argue and be angry all the time...counterproductive..it's funny but it's not smart..let's all get back to our best behavior pls...can we ? Please ?

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[Status Sciaticus]

Wow....u guys r funny indeed...but...
we have very experienced and very smart people here but please tone it down..it's a waste of time to argue and be angry all the time...counterproductive..it's funny but it's not smart..let's all get back to our best behavior pls...can we ? Please ?

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[deleted171991]

Wow....u guys r funny indeed...but...
we have very experienced and very smart people here but please tone it down..it's a waste of time to argue and be angry all the time...counterproductive..it's funny but it's not smart..let's all get back to our best behavior pls...can we ? Please ?

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Yes, mother.

 

[MirrorTodd]

Wow....u guys r funny indeed...but...
we have very experienced and very smart people here but please tone it down..it's a waste of time to argue and be angry all the time...counterproductive..it's funny but it's not smart..let's all get back to our best behavior pls...can we ? Please ?

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I swear to God, you were channeling like an alternate universe of Trump there. Lol

 

[ProRealDoc]

I don't think fellowship is a must. It's hard to say it will hurt you, and will help you in certain jobs in competitive markets. Also, if you really want to do mostly that particular subspecialty. Also, highly tertiary care type stuff it is warranted for sure in my opinion (neonates, complex cardiac etc). But, that's not the majority of anesthesia being done out there. There are plenty of generalist jobs out there, and the real need are for folks that can hustle and be an asset to patient flow through the OR's. That generates money and makes everyone happy. If you are good, you will have a decent career.

 

[dchz]

Valve, singular, as in the aortic valve, mostly through a trans arterial approach. Would you really let someone do your mitral/tricuspid/pulmonic valve repair without a CT fellowship?

I know of a case in residency where the CCM attending without CT fellowship missed an aortic PVL, and the pt died from direct complications of that.

The problem with what you're proposing is the same problem with CRNAs practicing independently. Without regulation, you can't expect the whole population to act like the top 5%tile of the population, there will be a regression to the mean. Sure, very top tier CCM Anesthesiologist will be adequate for CABGs if they go through and do 50 CABGs and TEEs under the guidance of another qualified CT anesthesiologist. But what happens when a CCM guy that can't hack it in anesthesia wants to do cardiac for the money?? It's a slippery slope to a bad place.

If your aim was to be nonconfrontational, you fell a bit short of the mark. You came right out and claimed that a good chunk of your colleagues are clinically inferior and incapable of doing some rather straightforward cases, using an anecdote as evidence. Further, you did mention TEE when you discussed how only the best CCM anesthesiologists could even be allowed to do a CABG, and in your anecdote. Echo is just a tool used to gather information, and it is up to the physician to determine how best to use that information, and act on it. Without facility with the tool, information cannot be obtained (as in your PVL example), yet without experience and judgement to interpret and images and clinical situation, facility with the tool is meaningless.

As for the time remark, it is a matter of how long it takes to accumulate enough cases, "oh ****" moments, and eventually comfort. That caselog and comfort level builds up rapidly when every day is spent doing cardiac cases, with structured didactics and mentoring built in. Although I did a lot of cardiac in residency, doing only one or two a week as an attending, while going through textbooks, conferences, review courses, and finding a mentor with whom to discuss cases, means that it naturally took longer to reach a similar endpoint. I do not feel bad that it took more time to become comfortable, as it would be the pinnacle of ignorant arrogance to assume that it took the same or less. My patients received good care, and I would feel comfortable had the roles been reversed, and it was my parent being cared for by someone else in my same situation.

Agreed, this discussion is not constructive. If you did not want to have a penis measuring contest, maybe you should not have opened with stating how much bigger yours is than that of your colleagues.

You are obviously triggered. I apologize for making you angry.

But if you read my quote. No where did I say "ONLY the best CCM anesthesiologists could even be allowed to do a CABG" I simply stated that the top tier anesthesiologist are more than capable to learn without formal education. It was a lead-in to the problem of having no regulation. Whether you agree with the analogy or not, I know you are offended by the CRNA reference, I apologize.

Furthermore, I did not "opened with stating how much bigger yours is than that of your colleagues." I think at this point you are reading into things without context. If anything, I would have done CT without fellowship if I didn't get a spot, the same way you did. So our penile masses would be somewhat equivalent. But when I contemplated doing that, I knew there would be a difference (I think most of us agree with the discrepancy, but I see that you are offended by the comparison). There was, again, no attempt at condescension from me at all, sorry again about that.

 

[BLADEMDA]

There will always be a need for Generalists in Anesthesiology. They will be easier to find, easier to replace and lower paid than their fellowship trained colleagues in certain subspecialties.

As the AANA gains more ground in the drive for independence the generalist is the first one on the chopping block to be fired or coerced into a 1:6 model known as Collaborative care.

So, if you were looking at a 20+ career in a heavily dominated nursing specialty what would you do? IMHO, the smart ones like Nivens obtained Advanced training way beyond the skill/knowledge of an Advanced practice Nurse. Like another poster said if you can stomach the PAIN then go that route. If not, there is Cardiac, CCM or Peds. For those considering an academic career any fellowship is valuable to your advancement.

This field is not like it was just 10 years ago. The opportunities are fewer and the job market for the best positions is very tight. Some on here keep arguing that there is lost income due to the fellowship year. I would counter with there are lost opportunities over a 20 year career without it. The future of this specialty is NOT rosy despite what a fortunate few post on SDN. For those that decide to skip the fellowship networking is likely the best way to find a good private practice job.

There really is a big, bad wolf out there just waiting to devour your specialty and your career.

Library of Congress Aesop Fables

read.gov

 

[MoMoGesiologist]

There really is a big, bad wolf out there just waiting to devour your specialty and your career.

Library of Congress Aesop Fables

read.gov

that is a cool link, thanks!

 

[psychbender]

You are obviously triggered. I apologize for making you angry.

But if you read my quote. No where did I say "ONLY the best CCM anesthesiologists could even be allowed to do a CABG" I simply stated that the top tier anesthesiologist are more than capable to learn without formal education. It was a lead-in to the problem of having no regulation. Whether you agree with the analogy or not, I know you are offended by the CRNA reference, I apologize.

Furthermore, I did not "opened with stating how much bigger yours is than that of your colleagues." I think at this point you are reading into things without context. If anything, I would have done CT without fellowship if I didn't get a spot, the same way you did. So our penile masses would be somewhat equivalent. But when I contemplated doing that, I knew there would be a difference (I think most of us agree with the discrepancy, but I see that you are offended by the comparison). There was, again, no attempt at condescension from me at all, sorry again about that.

Sorry for getting into it. I had just had a similar conversation with an old colleague who was basically ****ting on everyone that didn't do fellowship from his program, and read too much into what you wrote. I know we tend to agree on things from past posts. I guess as long as we have peens of similar mass, all is well.

 

[victor le cube]

The alternative to fellowship is BFE. I was sick of residency and decided to be a generalist. By the end, residency call was like a sweat shop, with lots of autonomy, so I felt ready to move on. Many of the good private practice jobs are in the overlooked locations that most millennials would never want to live (I am a millennial). But, if you are willing to spread a wider net than just the larger cities you can find jobs where you do good work, get paid well(higher than most numbers I see on here), and have plenty of time off (15 weeks for me this year). I also made partner last year, while many of my residency colleagues were in groups in large cities that sold out while they were still on the partnership track. We have a collegial/respectful relationship with our surgeons and I have never felt disrespect from them. This is much different than the academic hospital I trained at. But, the hard part is living in BFE, and finding a fair group to work with. Many are not willing (and I get it, it can be a little boring in BFE). Hopefully I’ll get out after we save >50% of our income for a few more years.

 

[MirrorTodd]

The alternative to fellowship is BFE. I was sick of residency and decided to be a generalist. By the end, residency call was like a sweat shop, with lots of autonomy, so I felt ready to move on. Many of the good private practice jobs are in the overlooked locations that most millennials would never want to live (I am a millennial). But, if you are willing to spread a wider net than just the larger cities you can find jobs where you do good work, get paid well(higher than most numbers I see on here), and have plenty of time off (15 weeks for me this year). I also made partner last year, while many of my residency colleagues were in groups in large cities that sold out while they were still on the partnership track. We have a collegial/respectful relationship with our surgeons and I have never felt disrespect from them. This is much different than the academic hospital I trained at. But, the hard part is living in BFE, and finding a fair group to work with. Many are not willing (and I get it, it can be a little boring in BFE). Hopefully I’ll get out after we save >50% of our income for a few more years.

That's exactly the kind of job I'm looking for once I peace out from the Army. The only benefit to city/large town living is the ability to eat out, but **** the city life. I cant stand it.

 

[victor le cube]

That's exactly the kind of job I'm looking for once I peace out from the Army. The only benefit to city/large town living is the ability to eat out, but **** the city life. I cant stand it.

Yeah it does have its benefits. Twice the pay, and twice the vacation as the big city job offer I had. Also I only work at 2 facilities versus the 12+ facilities they would have had us driving between. It’s a simpler life.

 

[KENY1]

A fellowship as opposed to no fellowship: look at the equivalent difference in internal medicine between hospitalists - generalists and specialists - cardiology, pulmo, GI: it's huge. Hospitalists jobs are being taken over by NPs and PAs as an equivalent to CRNAs.

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