Our CA-3 class this year

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Nivens

Nivens

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Received this email last week and figured I'd share how our graduating CA-3 class breaks down in terms of fellowship/jobs this year. Major academic hospital in the Northeast.

Job- 8
Pain- 7
Cardiac- 8
Regional- 7
Peds- 4
 
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Interesting. I'm surprised so many still go into pain.
And I still have no idea why anyone would do a regional fellowship. Do you not get enough regional in 3yrs?
 
Where are the jobs located? Salary, weeks vaca, supervision ratios, etc?
 
Noyac said:
Interesting. I'm surprised so many still go into pain.
And I still have no idea why anyone would do a regional fellowship. Do you not get enough regional in 3yrs?
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We meet all of our numbers, but whether or not that translates into "getting enough" to feel comfortable, as a CA-1 it's tough for me to say. Many of the residents getting jobs rotate at some of our ambulatory sites to get extra block experience.

As for pain, in talking to some of those who pulled the trigger, it seems that there is still a decent cohort that tires of "table-up-table-down" and is willing to do just about anything to get out of the OR, at least part of the time. We also have a very interventional-heavy department that sells it well, despite sort of a nightmarish clinic experience (from what I hear, and have seen on a very limited scale).
 
Carbocation1 said:
Where are the jobs located? Salary, weeks vaca, supervision ratios, etc?
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My friend, you severely over-estimate the amount of leg-work I'm willing to do for this post ; P

All joking aside, the little I know is most of the people getting jobs are going to very specific geographic locations for family reasons.
 
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75% doing fellowships? Anybody know what the national average is like?
 
Nivens said:
My friend, you severely over-estimate the amount of leg-work I'm willing to do for this post ; P

All joking aside, the little I know is most of the people getting jobs are going to very specific geographic locations for family reasons. All are PP groups, with the exception of one who I know is passing up a 400k-ish PP job with 10 weeks vacation a year and a 4:1 ratio working 60-65 hrs/wk for an academic job in the 300s with 4 weeks vacation but better hours and less driving (the PP group covers a large geographic area).
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Smart guy. It's also less work and stress, at probably 2:1. 400K at 4:1 and 65 hours is not at all a great job. The 10 weeks of vacation are for not burning out. This is worse than a regular 3:1 job with 5-6 weeks of vacation.

Just calculate the number of cases per year, based on the rooms covered:
2:1 = 2N times 48 weeks = 96N (where N is the average number of cases per OR per week)
4:1 = 4N times 42 weeks = 168N.

Get it? They should pay him 500+K for the PP job to be comparable with the academic one (and I bet the PP job has much worse benefits). 😉
 
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Nivens said:
Received this email last week and figured I'd share how our graduating CA-3 class breaks down in terms of fellowship/jobs this year. Major academic hospital in the Northeast (I won't say "top program"- made that mistake all-too-recently...😉)

Job- 6
Pain- 5 (1 staying at home institution, 4 going to other programs)
Cardiac- 4 (all 4 staying)
Combined Cardiac/ICU- 2 (1 staying, 1 leaving)
Regional- 5 (3 staying, 2 leaving)
Peds- 2 (both staying)
Click to expand...

Your program is a top national program (my ranking has it in top 3 while others may have it at number 4 or 5). This means any "fellowship" is a good idea for an academic career. These days why kill yourself making $600K in Private practice when a good academic job pays $375-$400k (typically after 5 years) with much better benefits? The taxes alone could be 47% on those earnings over $450K anyway. The better plan is to get a lot of deferred benefits like in a sweet academic gig with a nice $400K salary to go along with it.
 
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It is interesting to note how many people are doing regional. If you exclude the combined folks, regional > cardiac.
 
Nivens said:
It is interesting to note how many people are doing regional. If you exclude the combined folks, regional > cardiac.
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But, you can't exclude the combined folks. Those people are planning on an academic career or maybe, a top Private practice doing Cardiac if the pay is $600K plus.
The combo fellowship of CCM/Cardiac is a good investment in your academic career which for many is 30+ years. At my age you begin to realize that health matters more to your income productivity over 30 years than the 1-2 years lost in fellowship. So, if those fellowships get you a sweet gig with lots of perks, time off, time to exercise daily, etc. the odds favor that individual over the others who went straight into a grueling private practice (no fellowship) working 60 hours per week or more.

https://smartasset.com/taxes/income-taxes
 
Nivens said:
It is interesting to note how many people are doing regional. If you exclude the combined folks, regional > cardiac.
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It's extremely important for PP. The so-called "top" programs usually suck at regional. If you're doing fewer than 2-300 blocks in residency, you're not doing enough. That goes for neuraxial, too.
 
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FFP said:
It's extremely important for PP. The so-called "top" programs usually suck at regional.
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I'm not sure the degree to which my program "sucks" at regional, but imagine we are somewhere to the left of the curve at worst and "uneven" at best. And in an n =1 example, I spoke to a partner in one of the last PP groups in my (Florida) hometown a few weeks ago, who encouraged me to do a fellowship. When I asked him to rank the top three if I wanted to be hired by his group (hypothetically), he answered "Regional, regional, cardiac".
 
Nivens said:
I'm not sure the degree to which my program "sucks" at regional, but imagine we are somewhere to the left of the curve at worst and "uneven" at best. And in an n =1 example, I spoke to a partner in one of the last PP groups in my (Florida) hometown a few weeks ago, who encouraged me to do a fellowship. When I asked him to rank the top three if I wanted to be hired by his group (hypothetically), he answered "Regional, regional, cardiac".
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I quoted some numbers for you. I would almost bet that you guys graduate with under 100.
 
BLADEMDA said:
But, you can't exclude the combined folks. Those people are planning on an academic career or maybe, a top Private practice doing Cardiac if the pay is $600K plus.
The combo fellowship of CCM/Cardiac is a good investment in your academic career which for many is 30+ years. At my age you begin to realize that health matters more to your income productivity over 30 years than the 1-2 years lost in fellowship. So, if those fellowships get you a sweet gig with lots of perks, time off, time to exercise daily, etc. the odds favor that individual over the others who went straight into a grueling private practice (no fellowship) working 60 hours per week or more.

https://smartasset.com/taxes/income-taxes
Click to expand...


Oh I know, but writing "Regional almost equals cardiac!" wasn't quite as controversial of a headline as "Regional exceeds cardiac alone!" 😉
 
Nivens said:
Oh I know, but writing "Regional almost equals cardiac!" wasn't quite as controversial of a headline as "Regional exceeds cardiac alone!" 😉
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For people who haven't had good regional training in residency, it does. Open heart surgery is slowly dying, while ortho is flourishing.

When you train in a top program, with sick patients and tough surgeries left and right, you tend to forget that B&B profits are 40% ortho and 30% GI.
 
Nivens said:
Oh yeah, I'd be shocked if we were higher than that.
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I know. Mine were around 60-70 each. You're kind of like the foreigner who speaks English with an accent (you'll get better with practice, except that PPs want you to hit the ground sprinting, not just running.) 😉

I would also bet that you don't get much if any TEE training at your "top" program. Where I trained, the whole concept of being able to do a CABG without a fellowship was inconceivable.

There are very few balanced programs in this country. One should do a fellowship in two kinds of things: 1. what one likes and 2. what the market wants and one can't offer. If one is lucky, 1=2. If one is smart, he does 1+2.
 
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Current Ca-3 in southeast.

Peds - 3 (1 staying)
Cardiac - 3 (1 staying)
CCM - 2 (1 staying)
Cardiac/CCM combo - 2 (elsewhere)
CCM/Neruo combo - 1 staying
Regional - 3 or 4 (all staying)
Pain - 2 (1 staying)
PP - 6

So in line with Nivens program. We usually hover around 50-60%, this was an unusual year.
 
FFP said:
I would also bet that you don't get much if any TEE training at your "top" program. Where I trained, the whole concept of being able to do a CABG without a fellowship was inconceivable.
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Hard to argue with this. The new cardiac fellows from outside programs are more experienced in TEE than our homegrown fellows, in part because we are discouraged as residents from focusing too much on echo if we plan on doing cardiac fellowship, and are instead told to concentrate on things we WON'T learn later (such as blocks).
 
Nivens said:
Hard to argue with this. The new cardiac fellows from outside programs are more experienced in TEE than our homegrown fellows, in part because we are discouraged as residents from focusing too much on echo if we plan on doing cardiac fellowship, and are instead told to concentrate on things we WON'T learn later (such as blocks).
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Blocks are much more important than TEE. But you still have to speak TEE/TTE at basic level, if you ever want to do serious cases, or just be able to put a probe preop on somebody's chest, to clear him/her for high-risk surgery. It's one of the things that will make you stand out when compared to a CRNA. Ultrasound (of all kinds) is the new stethoscope.

What I am trying to say is that the world is much different and rapidly changing outside of the ivory towers, and many top programs are preparing graduates for yesterday's market. That's why people end up doing fellowships, because they are just not great all-around anesthesiologists anymore, not at the level expected by today's PPs (who are managers and employees, not partner-owners like in the past, so they have little interest to invest time and effort in filling your gaps and growing you).
 
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I didn't appreciate the true generalist at all (in any specialty) until I started as a CA-1. We have a handful, and they are incredible physicians to learn from.

FFP said:
That's why people end up doing fellowships, because they are just not great all-around anesthesiologists anymore, not at the level expected by today's PPs (who are managers and employees, not partner-owners like in the past, so they have little interest to invest time and effort in filling your gaps and growing you).
Click to expand...

Eh, I think that's part of it, but remember the advice we get about developing a niche to "differentiate yourself" from CRNAs. I think while it's foolish to become a super-specialist at the expense of developing your general skills, since at the end of the day those are the foundation, we exist in a healthcare environment that has and will continue to favor the niche player. It is in the generalist spirit my program discourages us from doing a ton of cardiac or echo electives if we are going to do cardiac fellowship anyway. The degree to which it is enough is up for debate.
 
CA-3. Half fellowship at my program.

No one doing regional in my class .

We do at least 200 blocks each, probably many, many more but I quit logging them. And we do so many, I've been basically independent for the last year. Huge perk of our program.

I'm going to work in PP. Every interview regional skills were heavily stressed as a requirement and folks were impressed with my experience.

However, all of our new regional hires do have a fellowship, fwiw.
 
Sorry, but regional fellowship is still a waste of time. Nobody in PP does the "exotic" blocks. It doesn't take a fellowship to be deft at the 4-5 basic blocks you will use on a regular basis. If you can do a SS block, then you can place a catheter which gradually seem to be falling outta favor.

Keep in mind that fresh grads that were actually trained to do USG regional in residency are lightyears better than the mid-career guys who 1/2 the time have no interest in doing blocks anyways. Just by virtue of completing residency in the last 5 years will make you a "go-to" regional guy in your practice.

My group is currently interviewing. A few have been regional fellows and we all sorta snicker when we see that on the CV and ask each other why the F somebody would spend a year doing that.
 
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Almost every resident in my class did a fellowship....each year there is 1 to a handfull that don't for various reasons. Popular choices are cardiac, peds, pain, with some CCM and regional. Most residents in my program did hundreds of blocks....I did ~400 and I didn't do many regional electives my ca3 year like some people.

FWIW---the people that went into regional were almost universally clinically weaker and frankly, lazy. Maybe ~20% of those applicants truly had a passion for regional anesthesia and were pretty good, but they were less common. Regional was seen as an extremely easy fellowship year on the path to easy weeks/better hours on service as the pain attending. The strongest residents went into peds, cardiac, and pain.
 
Libertas said:
Almost every resident in my class did a fellowship....each year there is 1 to a handfull that don't for various reasons. Popular choices are cardiac, peds, pain, with some CCM and regional. Most residents in my program did hundreds of blocks....I did ~400 and I didn't do many regional electives my ca3 year like some people.

FWIW---the people that went into regional were almost universally clinically weaker and frankly, lazy. Maybe ~20% of those applicants truly had a passion for regional anesthesia and were pretty good, but they were less common. Regional was seen as an extremely easy fellowship year on the path to easy weeks/better hours on service as the pain attending. The strongest residents went into peds, cardiac, and pain.
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I've noticed this phenomenon too.
 
SaltyDog said:
Sorry, but regional fellowship is still a waste of time. Nobody in PP does the "exotic" blocks. It doesn't take a fellowship to be deft at the 4-5 basic blocks you will use on a regular basis. If you can do a SS block, then you can place a catheter which gradually seem to be falling outta favor.

Keep in mind that fresh grads that were actually trained to do USG regional in residency are lightyears better than the mid-career guys who 1/2 the time have no interest in doing blocks anyways. Just by virtue of completing residency in the last 5 years will make you a "go-to" regional guy in your practice.

My group is currently interviewing. A few have been regional fellows and we all sorta snicker when we see that on the CV and ask each other why the F somebody would spend a year doing that.
Click to expand...
I tend to agree, but I am not an employer. I used to snicker, too. But that has changed recently, because most employers in my area want one to be highly proficient from the first day. It's something like: we have this guy who is OK but has done a ton of regionals, and we have this guy who sounds better but has done just enough (but he's probably slower)... so we're going with the former. They just don't want to wait for people to gain a bit of experience, like partners used to. Reason being they are not partners anymore, they are managers, and they just want another body to fill the place at the assembly lane.

They make too much money from ortho to risk alienating the surgeons.
 
Libertas said:
Almost every resident in my class did a fellowship....each year there is 1 to a handfull that don't for various reasons. Popular choices are cardiac, peds, pain, with some CCM and regional. Most residents in my program did hundreds of blocks....I did ~400 and I didn't do many regional electives my ca3 year like some people.

FWIW---the people that went into regional were almost universally clinically weaker and frankly, lazy. Maybe ~20% of those applicants truly had a passion for regional anesthesia and were pretty good, but they were less common. Regional was seen as an extremely easy fellowship year on the path to easy weeks/better hours on service as the pain attending. The strongest residents went into peds, cardiac, and pain.
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SaltyDog said:
I've noticed this phenomenon too.
Click to expand...
Some do it because they feel that their regional training was underpar, in an otherwise good residency. I know multiple people like that, and I wouldn't call any of them clinically weak or lazy.

It's like with CCM: some do it because they suck at anesthesia, some do it because they couldn't do any other fellowship, and some just love it.
 
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Libertas said:
Almost every resident in my class did a fellowship....each year there is 1 to a handfull that don't for various reasons. Popular choices are cardiac, peds, pain, with some CCM and regional. Most residents in my program did hundreds of blocks....I did ~400 and I didn't do many regional electives my ca3 year like some people.

FWIW---the people that went into regional were almost universally clinically weaker and frankly, lazy. Maybe ~20% of those applicants truly had a passion for regional anesthesia and were pretty good, but they were less common. Regional was seen as an extremely easy fellowship year on the path to easy weeks/better hours on service as the pain attending. The strongest residents went into peds, cardiac, and pain.
Click to expand...

I have noticed a similar trend as well. The ones who went on to do a regional fellowship are the same ones who avoided doing the cardiac and pediatric electives as a CA3. While I understand that high acuity is not for everyone, it should be during residency. Although, I haven't completely concluded that a regional fellowship is a total waste because I have seen some good jobs where a regional fellowship is required. I probably did somewhere between 300 and 400 blocks and even more neuraxial procedures during residency, but I have been told that certain places were looking for a regional trained anesthesiologist for certain jobs. In the end, people like seeing a certificate.
 
FFP said:
Some do it because they feel that their regional training was underpar, in an otherwise good residency. I know multiple people like that, and I wouldn't call any of them clinically weak or lazy.

It's like with CCM: some do it because they suck at anesthesia, some do it because they couldn't do any other fellowship, and some just love it.
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Well now that the regional fellowship is becoming more popular, you will see less and less residents who are able to get good numbers during residency. Now any program can open up a regional "fellowship" to get another year of cheap labor out of people. Any place where there are regional fellows, resident block numbers are going to suffer. It will evolve into a situation where you have no choice but to do a fellowship just to get a reasonable amount of block numbers. Or just watch YouTube...

There is one other type I've seen in CCM...super type-A personalities. In the ICU, you can be the "master of your domain."
 
7/11
2 Cardiac
2 CCM
3 Peds

Our regional numbers are outstanding for all residents. 300-400+ by graduation if you're doing it right. Not including neuraxial. We could do better there but still not bad. TEE education is pretty good too, especially if you take a 3rd month of hearts as an elective.
 
my program has been 80-90% fellowship for the last 2 years, mostly pain, cardiac, peds. i'm sure that 50% doing fellowship nationally number is a severely lagging indicator
 
vector2 said:
my program has been 80-90% fellowship for the last 2 years, mostly pain, cardiac, peds. i'm sure that 50% doing fellowship nationally number is a severely lagging indicator
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Nah, I bet it's like the election, more rural/small programs graduating generalists vs big city/big academic centers tending towards fellowship training.
 
Nivens said:
Hard to argue with this. The new cardiac fellows from outside programs are more experienced in TEE than our homegrown fellows, in part because we are discouraged as residents from focusing too much on echo if we plan on doing cardiac fellowship, and are instead told to concentrate on things we WON'T learn later (such as blocks).
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So why the hell is your program such a "Top Program" anyway according to you and Blade? Sounds almost below average if not weak. What kind of top notch experience do you get in training that makes you stand out? Makes you a stronger candidate than your colleagues interviewing for the same job? The snooty sounding name of your school?

The elitisism in medicine is astounding.
 
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chocomorsel said:
The snooty sounding name of your school?
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Yep.
The elitisism in medicine is astounding.
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Because patients are stupid and get wet from certain brands, and employers like to hire grads from those brands to look good.

It's the same reason anesthesiologists don't get referrals. People are dumb and don't realize that a brand doesn't mean ****, that every person/doctor is different.
 
chocomorsel said:
So why the hell is your program such a "Top Program" anyway according to you and Blade? Sounds almost below average if not weak. What kind of top notch experience do you get in training that makes you stand out? Makes you a stronger candidate than your colleagues interviewing for the same job? The snooty sounding name of your school?

The elitisism in medicine is astounding.
Click to expand...

It has a great atmosphere. Not being sarcastic.
 
Psai said:
It has a great atmosphere. Not being sarcastic.
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WTH does this even mean? Ambiance?
Full of puppies, cotton candy and ice cream?
Great PD who doesn't abuse the residents?
No mean attendings?
No sexism or racism?
No overworked residents? No SRNAs,? Nice CRNAs?
What exactly?
 
chocomorsel said:
WTH does this even mean? Ambiance?
Full of puppies, cotton candy and ice cream?
Great PD who doesn't abuse the residents?
No mean attendings?
No sexism or racism?
No overworked residents? No SRNAs,? Nice CRNAs?
What exactly?
Click to expand...

That pretty much describes where I trained to a T. Well maybe not the puppies and cotton candy but everything else is spot on.
 
SaltyDog said:
That pretty much describes where I trained to a T. Well maybe not the puppies and cotton candy but everything else is spot on.
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I concur though one year there was an otherwise nice attending who made the comment that the residents might look more professional if they didn't skateboard to m+m in flip flops.

I was there way before Peter or Saltydog. It was a great program then and I have heard it has only gotten better since. Well loved and respected chair and PD. Great regional and echo training. Faculty, residents, crna's are all there because they want to be there and that makes a huge difference.
 
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SaltyDog said:
No, Pete was 2 years ahead of me. He was a good guy, but a little immature - almost like he never really grew up.
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So you did do your residency in Neverland. 🙂

I am glad there are still places like that. It's the people, not just the leadership. My fellowship was also somewhere close to Neverland.
 
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