OB or Regional?

[rakotomazoto]

I still don't buy the argument that more training = safety from midlevel creep or other specialty-wide threats. Our training is already longer and more rigorous, doesn't seem to be doing anything to stop the problem.

If the sky really is falling, seems better to me to go make hay while the sun shines rather than missing out on an entire year of attending-level salary because it MIGHT be beneficial when the world comes crashing down. I figure it's better to make money, pay off debts, and be in a more stable/sound financial position so that an unexpected personal or specialty-level crisis doesn't put me in a terrible financial position. Also, if you are fortunate enough to have a partner-track job, the sooner you put in your time, the sooner you are not the easiest person to screw in the group. If you do fellowship and join group and are anywhere one year or less away from making partner and the group sells, then not only did you miss out on one year of full salary (plus interest if you continued to live like a resident and invested the difference), but you just missed whatever the buyout for partners was and you are left holding the bag. This is a real risk, not hypothetical. I personally know 3 people who had this happen to them in different groups.

Only do a fellowship if you love it and it provides tangible benefits, not some hypothetical protection from bad times. Bad times will come, but I just remain unconvinced that fellowship will be this magical life preserver that some people seem to believe in. Don't drink the kool aid, residency programs have a strong incentive to talk the best and brightest into signing up for one more year. If fellowship does not align with your own self interest, don't do it. If you went to a good residency program, trust your training and skills and go to work.

So from the limited IQ and perspective of a guy who is one month into a great PP job fresh out of residency with no fancy fellowship, think long and hard before applying. Of course, there are plenty of solid fellowship-trained people here on SDN and in my new group, clearly their perspective is different. But who would admit that they did an extra year of training for essentially nothing? Not sure anyone would want to admit that, even if it were true for some. Especially on the internet. No need to feed the sharks who patrol these waters.

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[neutro]

^ couple of points..

1) More training does often result in a higher pay actually. In fact, many groups automatically reward fellowship training at $10-25k/ year of additional pay. I have seen cardiac guys make 50K additional per year plus extra stipend for cardiac call.
So over one's career, if you compare non fellowship trained vs fellowship trained, the difference can be substantial. In fact for pain, the difference used to be 2x or even 3x if you own the practice compared to salary for anesthesia, but that number has come down. Who knows, 5 years down the road ir may return again. Everything in anesthesia seems to be cyclical, so I wont rule that out.

2) Secondly, there is definitely a midlevel creep. Fellowship does prevent against this in my experience. I have worked at several hospitals already as an attending, not counting my residency and fellowship training. I have yet to see a CRNA doing TEE or interventional pain. Infact, the post on this thread was the first time I head about this. For perspective, I have only lived in small to medium size towns, and I haven't seen this. So unless you are in the boonies, this CRNA creep has to be rare. I do not know if a referring physician really trusts a CRNA doing a pain block (which you do after you evaluate a patient), or worse yet, interpret a TEE. Places where this happens must really be under served where no anesthesiologist wants to work.

3) Again, just because you did not happen to do a fellowship, does not mean that acquisition of knowledge is a bad thing...not everything in life is about money. I am very happy that I did my fellowship, learned a lot - made important connections, got boarded in it as well and have the option to practice outside of OR without any call or weekend work, do my billing, hire and fire my own staff if I want. I have the option to exercise this whenever I want. To me that is worth its weight in gold.

4) You just started your career and are one month into PP. I wouldn't call any group "great" yet...Everyone's looking to make money. The guys that hired you obviously did because their profit minus your pay = still a positive number. Rarely you would know about your own worth because the numbers, time to partnership and billing will always be fudged...been there, done that...no thanks

 

[deleted162650]

Rarely you would know about your own worth because the numbers, time to partnership and billing will always be fudged...been there, done that...no thanks

Well I'm sorry that you have never been part of a stand-up group, because this part simply isn't true. Plenty of groups out there - mine included are completely transparent.

 

[Arch Guillotti]

Rarely you would know about your own worth because the numbers, time to partnership and billing will always be fudged...been there, done that...no thanks

Not always.

 

[neutro]

Well I'm sorry that you have never been part of a stand-up group, because this part simply isn't true. Plenty of groups out there - mine included are completely transparent.

yeah plenty aren't.

what does that tell you...

 

[neutro]

Not always.

i wont disagree with you.

infact just this weekend I was negotiating with a group, and this is what is happening:

1) they wont tell me what is the average/median compensation after 4-5 years. they are saying its propreitary information and cant disclose it. i am expected to sign up without knowing my compensation. ok boss.
2) starting salary is 1/2 as much as i am earning right now and there is a "2 year partnership track which makes me eligible for RVU pay". Dont know how is that a good deal when i am eligible fro RVU starting day 1 at my current hospital based gig.
3) there is no PTO. i have the "opportunity" to use my PTO to work.
4) i pay for my own malpractice, benefits. malpractice i can pay for, but with the rising healthcare cost, having benefits would be nice.
5) i asked them about equity. there is no equity. just "profit sharing" - whatever that means. profit sharing from what? a whole pie of pizza? or ASC? I dont know. they wont tell me.

And they introduced themselves as a "premier" private practice group where they rarely have an opening. They are trying to hire me because the last guy left because "his commute was too long". they wont disclose this person so i can talk to him.

they also will not let me credential with them so i can do locums/working interview WITHOUT pay (which I offered during my vacation time) so to see if i am a good fit for them and vise versa. they are saying that they dont credential people unless they are in contract. thats a first for me since its usually its the other way around.

these are your "private practice" groups. wonderful.

i am waiting for a few days to send them a polite decline.

 

[pgg]

i am waiting for a few days to send them a polite decline.

Why wait? I'm not sure I could have even finished the meeting.

 

[neutro]

Why wait? I'm not sure I could have even finished the meeting.

Just practicing some tact my friend.

 

[by604]

It seems everyone here is basically against every fellowship. But serious question, every attending at my program is essentially fellowship trained--I figure it's this way at many major academic centers. If you desire to work in this setting, wouldn't a fellowship in anything be worthwhile?

 

[nimbus]

It seems everyone here is basically against every fellowship. But serious question, every attending at my program is essentially fellowship trained--I figure it's this way at many major academic centers. If you desire to work in this setting, wouldn't a fellowship in anything be worthwhile?

No I think most everyone agrees if you want to do peds, pain, or cardiac you need to do a fellowship.

 

[Twiggidy]

No I think most everyone agrees if you want to do peds, pain, or cardiac you need to do a fellowship.

Exactly. Definite for academic practice. Arguable but more likely "yes" also in private practice.

 

[GA8314]

CRNAs do TEE, and just googling that will turn up quite a few providers that talk about how the MDAs are teaching them as well . Trans-esophageal Echocardiography [Archive] - WWW.NURSE-ANESTHESIA.ORG

I can't read this as I know what it will say and I will want to f.cking puke.

That said, I have always said that we are the only ones putting all of these barriers onto one another by subscribing to the fellowship or parish philosophy (pushed by our academic "leadership"). Meantime, the CRNA's put no such barriers onto one another.

So, given that, do you think at some point it could be totally feasible that a CRNA doing TEE day in and day out, could be perceived as having more value (in cardiac) than an MD who's colleagues pushed him/her out of the heart room because they didn't do a fellowship? I can.

We keep upping the ante via credentialing and they keep making a virtual mockery of us. And this is why I think that fellowships will only very marginally protect someone from encroachment.

One partial solution is to have strong anesthesia presence and leadership in the credentialing process.

 

[GasAllDay]

Exactly. Definite for academic practice. Arguable but more likely "yes" also in private practice.

Groups in more desirable cities seemed to want a fellowship-trained person depending on their needs (cardiac, peds, ICU, pain), but only typically only ask for "strong regional skills" or mention "high OB volume." Not all residencies provide the training to be strong in regional.
Of course, having fellowship training in OB or regional and staying in academics has it's obvious advantages. Especially if you don't want to be in the call pool for some of the other types of cases, right?

But re: private practice. I'm not in PP. However, I see people hired in private practice for "director of OB anesthesia" position or "director of regional anesthesia" to build up their regional service or build their acute pain service. Those groups had that need at that time, and if that's something you might be interested in, why not consider the fellowship

 

[Mman]

No I think most everyone agrees if you want to do peds, pain, or cardiac you need to do a fellowship.

I believe for pain you need to have completed an accredited fellowship to be eligible for reimbursement for those procedures. Older docs got grandfathered in.

 

[Dejavu]

God, I hated OB.

Sorry, that didn’t help, but it felt good.

 

[gassyPants]

Here is the deal:
OB anesthesia is not really a sub-specialty, it is basically about doing more spinals and epidurals than GA because they teach you to be so scared of doing GA on pregnant women.
.

Having done an OB fellowship, I respectfully disagree. If anything, I am more comfortable and have a lower threshold for doing GA on my pregnant ladies than most of my peers here.

I got more than enough training on spinals and epidurals during my residency, they can be a pain in the butt, but like any procedure they are a monkey skill. Do I maybe understand subtle nuances better? Sure, but that comes with anyone who has done enough of them.

I am involved in (and better geared) toward teaching and training our residents, am better able to keep up (and understand the background of) current literature and am therefore able to also teach and keep my partners updated and use this evidence to develop local protocols. I serve as an OB anesthesia consultant to my larger group in my health network. My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.

And yes, if you want to work at a hospital that does high risk OB, they may well only hire, or prefer to hire, fellowship trained docs.

So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

The bottom line is that a knowledgeable anesthesia team can positively and aggressively contribute to the function and safety of a labor and delivery unit, and that is the advantage of an OB fellowship.

 

[Planktonmd]

Having done an OB fellowship, I respectfully disagree. If anything, I am more comfortable and have a lower threshold for doing GA on my pregnant ladies than most of my peers here.

I got more than enough training on spinals and epidurals during my residency, they can be a pain in the butt, but like any procedure they are a monkey skill. Do I maybe understand subtle nuances better? Sure, but that comes with anyone who has done enough of them.

I am involved in (and better geared) toward teaching and training our residents, am better able to keep up (and understand the background of) current literature and am therefore able to also teach and keep my partners updated and use this evidence to develop local protocols. I serve as an OB anesthesia consultant to my larger group in my health network. My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.

And yes, if you want to work at a hospital that does high risk OB, they may well only hire, or prefer to hire, fellowship trained docs.

So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

The bottom line is that a knowledgeable anesthesia team can positively and aggressively contribute to the function and safety of a labor and delivery unit, and that is the advantage of an OB fellowship.

Not trying to underestimate your fellowship but all these things that you mentioned should be pretty much learned in residency, provided they have a good volume of OB cases. But if you are in a residency program with limited OB exposure then maybe the extra year is needed.
As for your partners coming to you to handle the crappy cases, that might be a disadvantage, since you end up doing the disasters that no one wants to do.

 

[MoMoGesiologist]

Having done an OB fellowship, I respectfully disagree. If anything, I am more comfortable and have a lower threshold for doing GA on my pregnant ladies than most of my peers here.

I got more than enough training on spinals and epidurals during my residency, they can be a pain in the butt, but like any procedure they are a monkey skill. Do I maybe understand subtle nuances better? Sure, but that comes with anyone who has done enough of them.

I am involved in (and better geared) toward teaching and training our residents, am better able to keep up (and understand the background of) current literature and am therefore able to also teach and keep my partners updated and use this evidence to develop local protocols. I serve as an OB anesthesia consultant to my larger group in my health network. My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.

And yes, if you want to work at a hospital that does high risk OB, they may well only hire, or prefer to hire, fellowship trained docs.

So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

The bottom line is that a knowledgeable anesthesia team can positively and aggressively contribute to the function and safety of a labor and delivery unit, and that is the advantage of an OB fellowship.

I'm really not sure how doing any of that requires a fellowship... sorry!

 

[San Marzano]

Having done an OB fellowship, I respectfully disagree. If anything, I am more comfortable and have a lower threshold for doing GA on my pregnant ladies than most of my peers here.

I got more than enough training on spinals and epidurals during my residency, they can be a pain in the butt, but like any procedure they are a monkey skill. Do I maybe understand subtle nuances better? Sure, but that comes with anyone who has done enough of them.

I am involved in (and better geared) toward teaching and training our residents, am better able to keep up (and understand the background of) current literature and am therefore able to also teach and keep my partners updated and use this evidence to develop local protocols. I serve as an OB anesthesia consultant to my larger group in my health network. My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.

And yes, if you want to work at a hospital that does high risk OB, they may well only hire, or prefer to hire, fellowship trained docs.

So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

The bottom line is that a knowledgeable anesthesia team can positively and aggressively contribute to the function and safety of a labor and delivery unit, and that is the advantage of an OB fellowship.

Sounds like you’ve done a great job of marketing your fellowship to yourself.

 

[nimbus]

My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.



So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

Any real life examples? I’m still curious what you get out of OB fellowship that you can’t get by working on a busy OB service for a few months.

 

[Mman]

Any real life examples? I’m still curious what you get out of OB fellowship that you can’t get by working on a busy OB service for a few months.

man if we had someone with an OB fellowship I'd love to play dumb and let the expert take care of the epidural or c-section for me.

On a more serious note, I think 99.9% of difficult OB anesthesia stuff is pre-eclampsia/eclampsia, HELLP, and complicated cardiac patients. But it's something a board certified anesthesiologist should be able to handle just fine. We get every complex pregnant patient from a referral base of almost 2M people and have never had anyone with an OB fellowship and I don't think our care is lacking in any way.

 

[deleted162650]

It’s been said before but:

The reeeeeaaallly scary OB patients are actually cardiac patients. If you wanna take care of the truly high risk OB cases, then do a cardiac fellowship. Then at the end of the day you’ll also have a skill (TEE) that is actually worth something.

 

[GravelRider]

Maybe we’ll get to a point where only those who did an OB fellowship can do OB like we have seen with cardiac. One can only dream that day will come...

 

[Mr.S]

My two bits: Cardiac fellowships make sense because you will acquire skill sets that are not taught through traditional residency programs. Peds fellowships make sense only if you plan on limiting your job to pediatrics and ICU babies. ICU fellowships never made sense to me....if you want to be a flea, then be a flea and don't enter ICU from anesthesiology: internal med makes far more sense. Regional fellowships are only infrequently useful since regional anesthesia is becoming limited by insurance considerations, and sufficient experience is often obtained for primary blocks in residency. Pain fellowships make no sense at all in this day and age given collapsing scope of practice, limitations by insurance, increasing limitations on standard procedures, and the penchant of many pain physicians to offer experimental treatments not taught in fellowship. OB fellowships are not reasonable unless you plan to limit your practice to OB, and even then, a fellowship offers you only a limited enhancement of skills obtained during anesthesia residency.

In other words, stay away from medicine since a flea or a nurse can and will do it in the future!!

My 2 cents.. Icu or pain.. the others youre just another more of the same anesthesia doc

 

[dannyboy1]

Having done an OB fellowship, I respectfully disagree. If anything, I am more comfortable and have a lower threshold for doing GA on my pregnant ladies than most of my peers here.

I got more than enough training on spinals and epidurals during my residency, they can be a pain in the butt, but like any procedure they are a monkey skill. Do I maybe understand subtle nuances better? Sure, but that comes with anyone who has done enough of them.

I am involved in (and better geared) toward teaching and training our residents, am better able to keep up (and understand the background of) current literature and am therefore able to also teach and keep my partners updated and use this evidence to develop local protocols. I serve as an OB anesthesia consultant to my larger group in my health network. My partners usually come to me when they want to better understand complex situations. I am able to effectively communicate with the OB teams without things degrading into sheer frustration - a longstanding problem here. Instead of being reactive and appearing only on the OB floor when the residents call for an epidural or there's an emergency operative delivery, I can be proactive, predict problems coming down the line and coordinate teams appropriately. I am integrally involved in L&D operations both pertaining to anesthesia and not. Having managed an extremely busy and large L&D unit as part of my fellowship, I am also able to be very creative with rearranging my staffing so that the floor can keep moving - something that is highly valued at any busy high risk site.

And yes, if you want to work at a hospital that does high risk OB, they may well only hire, or prefer to hire, fellowship trained docs.

So, while OB anesthesia may be a niche market, there is a lot more value in it than just being able to do an epidural. I am routinely surprised by what my partners don't know about what they don't know and it's this exact problem that gives and OB anesthesia fellowship a bad reputation. It's always this kind of thinking that results in undervaluation of any field or specialty.

The bottom line is that a knowledgeable anesthesia team can positively and aggressively contribute to the function and safety of a labor and delivery unit, and that is the advantage of an OB fellowship.

Small needle, big needle, or ETT. You don’t need a fellowship for that.....

 

[Guillemot]

Everyone knows that once one's income exceeds approximately $70,568 that they become incapable of learning. Hence, why OB and regional fellowships are critical. And also why those residencies that actually care about their resident's education don't allow moonlighting. Gotta get that extra knowledge in before you are financially capable of starting to pay back those student loans. Its not like you could read and learn more about these or other topics while being an attending. Am I right?

 

[nimbus]

Everyone knows that once one's income exceeds approximately $70,568 that they become incapable of learning. Hence, why OB and regional fellowships are critical. And also why those residencies that actually care about their resident's education don't allow moonlighting. Gotta get that extra knowledge in before you are financially capable of starting to pay back those student loans. Its not like you could read and learn more about these or other topics while being an attending. Am I right?

If you’re on a truly busy OB deck, you can make $70,568 in a month and learn while you’re at it.