is it worse to apply for pain after working as anesthesiology attending?

phillyfornia

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i'm going to be starting my CA-1 year in a couple of months and i'm trying to figure out what i want to do with my life afterward. i think that i will enjoy working as an anesthesiologist but i'm not sure that i want to pass gas for the rest of my life. pain medicine sounds really interesting too but i'm not sure if i'm ready to settle down and start a practice right after residency.

so, one thing that i'm considering is finishing residency and then working as an anesthesiologist for a few years. i'm considering locums because i'd like my work schedule to be very flexible. after a few years, i would then like to do a pain fellowship and then settle down in a city, develop a practice, and live happily ever after.

i was wondering if not applying for a pain fellowship right after residency makes you less competitive? i personally don't know anyone who has done this but i've always figured that it was because people get accustomed to money and being an attending that they can't get themselves to do a fellowship. if i was willing to take the cut in pay and status (i.e. attending-->fellow), would applying for a pain fellowship after working as an attending decrease my chances of matching?
 

Jeff05

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being a fellow after being an attending may suck more than anything...

it's 1 year. get it done and then do locums..
 

joshmir

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this is a great topic, and i would love to hear the regulars here commenton this...i will be speaking on a panel at the fall asra meeting on topics related to this...

i have heard one PD from a prestigious NYC program tell me he was not interested in the applications of people who were not coming straight out of residency...he opined that these applicants were probably being asked to get credentialing by another party...he didn't explain why this was bad...

i've heard the brigham likes to take people who have already been out practicing pain as fellows...but just hearsay...please correct me if i'm wrong...

it is not clear to me why a program would *not* want someone as a fellow who has been out there practicing pain....i would think they would bring so much more to the table....in reference to someone who has been practicing anesthesia, not sure what advantage that would have to the pain program....but depending on how hard you're working as an attending, i could see doing a fellowship as an easy lifestyle transition (maybe a difficult financial one)

what do you guys think?
 

Pain_doc

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I practiced anesthesia for over a decade. I actually became somewhat bored with the routine and missed the patient-physician relationship. (Ironic, as part of the reason I went into anesthesia was to avoid the "clinic" and the chronic medical conditions). As it was so long since my residency, I felt the best approach for me would be to complete a formal pain fellowship. I didn't feel completing a few weekend courses and observing some colleagues would provide me with the best preparation. After having the support of my wife, I took the year off, completed a formal ACGME approved fellowship and now practice pain exclusively. Yeah, the 95% pay cut was not pretty. Most people said I f---- crazy. But, I believe it was for the best. It's a difficult choice that only gets harder with each year.
 

drusso

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I had a former anesthesia attending in my fellowship class. He was on staff where he did the fellowship. He said that it was tough to make the transition back down the food-chain, and I sensed that his former colleagues took some enjoyment in scutting him, but overall I think it worked out well...it might really give you a unique perspective on the residency/fellowship after being an independent practitioner for a while.
 

mille125

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I dont understand why you wouldnt just do the fellowship after practice? It is only one year as previously mentioned. Personally, if I had to go back now and do more training (even one yr), I think that I would consider quitting.


I dont think that most fellowships penalize good applicants for choosing to apply for pain several years after training. However, I think that most directors would ask themselves: "Why didnt this applicant take the "traditional route?" Is he or she an impaired physician or does he have some personal issues that he was sorting through. I think that it is natural to wonder about these things (especially in a specialty that has a high incidence of substance abuse and impaired physicians). I just do not see any real advantage to postponing a fellowship just to do locums if you really have your mind set on pain. Just my two cents......
 

mille125

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If a fellowship interviewer asked you to explain why you didnt go directly into fellowship, how would you answer it?
 
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phillyfornia

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I dont understand why you wouldnt just do the fellowship after practice? It is only one year as previously mentioned. Personally, if I had to go back now and do more training (even one yr), I think that I would consider quitting.


I dont think that most fellowships penalize good applicants for choosing to apply for pain several years after training. However, I think that most directors would ask themselves: "Why didnt this applicant take the "traditional route?" Is he or she an impaired physician or does he have some personal issues that he was sorting through. I think that it is natural to wonder about these things (especially in a specialty that has a high incidence of substance abuse and impaired physicians). I just do not see any real advantage to postponing a fellowship just to do locums if you really have your mind set on pain. Just my two cents......
i'm thinking about working for a bit before fellowship because i think that working as a general anesthesiologist would be fun. i think that it would be an interesting experience to have. locums sounds cool too because it is flexible. i can work as much/little as i want without being tied down to a practice.

perhaps i'm wrong (i probably am), but my impression is that the best thing to do after finishing a pain fellowship is to start practicing pain full-time. if that is the case, i would feel like i missed out on the experience of working as an anesthesiologist attending.
 

Jeff05

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you can finish pain and then work just in anesthesia. or do a mixed practice. you don't have to do committ to 100% pain after fellowship.
 
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phillyfornia

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you can finish pain and then work just in anesthesia. or do a mixed practice. you don't have to do committ to 100% pain after fellowship.
do people do that a lot (work just anesthesia)? if you do that for a few years and then look for a pain position after would it be more difficult to find a job? i figure that you might lose your pain "skills" if you start working in ust anesthesiology for too long after fellowship. excuse my noobie questions and thanks for the replies.
 

Jeff05

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people either do a mixed practice - pain and anesthesia from the beginning and then, after a while to just pain. sometimes it's mixed, then on to just anesthesia after realizing that pain is not for them. sometimes it's right to pain. rarely, i know 1 example, it's from pain to just anesthesia.

as far as skills are concerned...you may be rusty, but you won't lose them, not after a year or 2.

the important point is that at this time (pre ca1) you should have NO idea what you want to do. because you have really, NO idea what it is to 1. do anesthesia every day 2. do pain. stop worrying. you don't have to apply for fellowships until spring of ca2 year. and they are not that competitive.

my advice, if you think you want to do pain and do electives during residency and are still undecided, just do the fellowship. it's 1 year (for now it is) - 1 month of vacation - a couple of months of electives. if you hate it, just do anesthesia only after you finish. you probably did a year of medicine prelim which you hated, but still learned a lot...
 

jsaul

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people either do a mixed practice - pain and anesthesia from the beginning and then, after a while to just pain. sometimes it's mixed, then on to just anesthesia after realizing that pain is not for them. sometimes it's right to pain. rarely, i know 1 example, it's from pain to just anesthesia.

as far as skills are concerned...you may be rusty, but you won't lose them, not after a year or 2.

the important point is that at this time (pre ca1) you should have NO idea what you want to do. because you have really, NO idea what it is to 1. do anesthesia every day 2. do pain. stop worrying. you don't have to apply for fellowships until spring of ca2 year. and they are not that competitive.

my advice, if you think you want to do pain and do electives during residency and are still undecided, just do the fellowship. it's 1 year (for now it is) - 1 month of vacation - a couple of months of electives. if you hate it, just do anesthesia only after you finish. you probably did a year of medicine prelim which you hated, but still learned a lot...
i have seen 3 docs do that in the last 9 months here. one because the money and benefits were better if he just joined a gen anesthesia group to do 100%gas, one because he could not stand dealing with this patient population, and the other one was a combo of both
 

mille125

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i'm thinking about working for a bit before fellowship because i think that working as a general anesthesiologist would be fun. i think that it would be an interesting experience to have. locums sounds cool too because it is flexible. i can work as much/little as i want without being tied down to a practice.

perhaps i'm wrong (i probably am), but my impression is that the best thing to do after finishing a pain fellowship is to start practicing pain full-time. if that is the case, i would feel like i missed out on the experience of working as an anesthesiologist attending.


Personally, I think that you should just get "on with it". After the fellowship you can do anything that you choose without amercement. This include locums, mixed pain/anesthesia, 100% pain or 100% anesthesia. To be honest I think that your anesthesia skills have a higher chance of degrading than your pain skills...
 

mille125

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oh, i just reread your first post and see that you are a pre-CA-1...just relax man...you may not even like pain when you do the rotation...........i wouldnt worry about all of this stuff until you have some real life experience in anesthesia, pain, ICU, etc. Focus on reading miller and taping your tubes for now..........