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[gaspasser127]

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[abolt18]

Hey guys,

I’m a CA-2 and have been struggling with fellowship options. I’ve narrowed it down to pain vs cardiac (yes, i know. They’re extremely different) and am having a hard time deciding. Have talked to a lot of different mentors, senior residents going into both the fellowships, and alumni from my program as well.

In terms of cardiac, I enjoy the academic stuff about it (learning about the procedures, physiology, TEE, etc) and at this stage in my training don’t mind the middle of the night emergencies. i have a few concerns though. Namely, while I don’t mind the high stress, middle of the night emergencies as a resident with great attending back-up, is this something I will end up getting burnt out by and will it still be this fun/exciting without an attending behind me. I genuinely enjoy the OR environment, too. The other concern I have is about fellowship itself. nearly all the mentors I have have trained at Duke for fellowship and they seemed miserable during their training. I don’t want that for myself (even for a year)and I’m curious if all programs are that bad.

When it comes to pain, I love the procedures, I like learning about different pain syndromes, and I really don’t mind clinic or the patient population. The schedule is a huge plus, but what I’m worried about is that we don’t get a huge amount of exposure to pain (especially advanced interventional procedures) so I’m worried I’d be going into pain fellowship somewhat blind. It also feels so different from anesthesiology (which it is) and I worry I’d be leaving a huge knowledge base behind in my career as a pain management physician.

that’s it in a nutshell - thoughts?

You should do pain

-coming from a resident applying to CT

 

[GlowInTheDark]

You should do pain

-coming from a resident applying to CT

You should do cardiac

- coming from a resident applying to pain

 

[abolt18]

You should do cardiac

- coming from a resident applying to pain

No problem! Pain is so far from my realm of interests. You can have it!

 

[deleted162650]

You should skip fellowship and go straight to PP

- coming from an attending that skipped fellowship and went straight to PP.

 

[psychbender]

Not all CT fellowships are Duke, CCF, or otherwise work one to the bone. Not all CT jobs have tons of call with late night cases. There are plenty of jobs out there for the with CT training where cardiac call means that you finish up cases that started in the afternoon, and are at home, available overnight in case of very rare bring backs or other emergencies.

I can't speak much regarding the Pain market, but I do know some that started going back into anesthesia, as they realized that they really didn't care for running a practice and dealing with drug seeking patients. There are several on this forum that I hope will speak up and share their experiences creating practices where treating patients on chronic opioids is a rarity.

Sent from my SM-G930V using SDN mobile

 

[sevoflurane]

You don’t mind clinic/procedures 8-6? Pain may be good.
You may have to be “phone available” to handle your ED visits on some or most weekends depending on your practice. It will become repetitive but a practice you may like. Your day in and day out is very predictable... if you are using a Belmont after pain procedure, something really bad happened (extremely rare). Predictable schedules. I think you can still do very well although reimbursement has been going down while insurance clearance has been getting a little more demanding. Needle jockeying with a good result gives you and your patient a good feeling.

In CT anesthesia, you will see very routine "CABG x2-3" cases to "very complex" cases depending on your situation. Psychbender above has a point though- you are paid (or should be paid) a stipend to be available for 2am cases whether it’s common or not. Call back can be low or 50% of the time depending on the practice (think big transplant center).

As far as CT, you are inherently taking care of really sick patients. Some are attracted to that and a lot of practices offer a mixed cardiac practice that doesn't pigeon hole you into doing the same thing every day. As an example, we have in our practice CT guys that do CT/Regional, CT/OB, CT/ICU, CT/Peds, CT/trauma, or a combination of the above. Really makes for a nice practice IMO. We work hard, but we also have post call days off and 8-10+ weeks of vaca. Later on in your career, you can go 50-60% and still do all the above... which you can't really do in pain. TEE and structural heart is enormously fun IMO. A lot of evolution there which should keep you interested with what will be coming out in the future. But again, you are going to have to take care of that train wreck type A dissection whose eyes roll back while they acutely rupture in pre-op (recent case).

Both are good. Really depends on your personality and long term lifestyle goals.

 

[sevoflurane]

A good perspective on this topic would be @Noyac

 

[dchz]

My views are biased.

I suggest you really get to know the pt population of chronic pain. Going through the same questions a few years back, i recall a poster on here stated that chronic pain is really you bribing your addict patients with candy (opioids) so they let you poke them with a needle. One of my fav attendings who does chronic pain tells me that you can only help about 30% of your pts in chronic pain. On top of all this, i realized quickly that the only way for me to have any longevity in chronic pain is to see my patients as just a number and try to churn through them throughout the day. I was way too idealistic to do that. That was when i realized i was never gonna apply to chornic pain, even though I had it in with the largely interventional pain fellowship attached to my residency.

Cardiac isn't all roses either. You work harder with sicker patients. The cases often don't pay very much because it's all medicare/medicaid. The TEE skills that you work your butt off to visualized every spec of the mitral valve is worth about 100$ per case of reimbursement. You have to come in when someone with a Type A dissects at 2 AM. But I told myself that if i was going to do something for a career, i'm gonna do it well. And to me cardiac anesthesia is the pinnacle of doing anesthesia well. I'm currently 3 months into a CT fellowship. I'm not sure if it'll be worth it in the end. But at this point in my life I think I would have been way happier than if I was 3 months into an interventional pain fellowship.

Also visit this thread: it helped me gain some perspective when i was in OP's shoes.

 

[deleted59964]

you should do neither ... peds is the way forward.

coming from someone who did a peds fellowship

 

[deleted162650]

A good perspective on this topic would be @Noyac

Yes, let’s all hear from the guy that doesn’t do either.



(Yes, yes, I know that 3 lifetimes ago he used to do both - at the same)

 

[sevoflurane]

Yes, let’s all hear from the guy that doesn’t do either.



(Yes, yes, I know that 3 lifetimes ago he used to do both - at the same)

Unique perspective. We have one of those here. Pain/cardiac/peds.

 

[Nivens]

Was in a similar position two years ago and actually completed an application to pain before I woke up. I'm now a very happy CT/ICU fellow (my original post-residency plan). It scares me how close I came to making such an obviously wrong choice (in hindsight, for me). I realized a few things after writing my personal statement and telling a few people I'd decided on pain:

-My interest in pain started with burnout. I didn't like CA-1 year at all: there really wasn't much about it that made me feel like a doctor, which, after loving my very academic internal medicine internship year at a great program, left me looking for a way out. I considered IM -> Cardiology -> interventional/structural heart, but by this point I was a CA-2, and the time cost felt too high.

-I fixated a lot on the idea of running my own practice/being my own boss. I think this is common amongst anesthesia residents who don't find being relegated to the role of ICU nurse-OR transport hybrid to be worth the more predictable schedule (ie, those of us with outsized egos). However, when you look at this a bit closer, it isn't as attractive of an exit strategy as it initially appears. The insurance hassles/patient follow-up/admin stuff aside, to compete in a market as a solo practice, you're probably going to have to play ball when it comes to opioids to some degree. Good luck getting referrals for procedures for your "opioid-free" practice from that PCP desperate to unload his/her dependent panel when there's a practice down the street that will gladly trade candy for procedural reimbursement (For those that have managed to accomplish this, congratulations (really) , but ask yourself if there was something unique about your situation that makes you the exception rather than the rule). Of course, you could always go work for a large practice/academic center/hospital system and carve out that opioid-free existence, but then you give up some of the control you were after in the first place.

-It isn't completely out of the question that procedural pain medicine will all but disappear. The data for much of the needling that is done isn't great, which in itself isn't unsurmountable, but the business model seems to rely on patients not getting better so additional procedures can be prescribed (and billed for), and CMS seems to have noticed. This matches my (admittedly limited) experience as a resident- the patients just didn't seem to derive much, if any, benefit. Of course I enjoyed the physical procedures themselves, but I realized I didn't really believe I was making anyone better. Now, the traditional argument here is that the procedure isn't supposed to be a cure- it's a temporizing measure to allow a patient to get to PT or heal on their own or whatever. And fine, I'll concede that for some small cohort of patients that may be what happens, but I contend it is a vanishingly small proportion. And before someone comes back at me with a comment that starts with "Well my attending, Dr. World-Famous Pain Physician, says...", remember that his/her entire livelihood likely depends on him/her believing what he/she is doing is helping people. If that isn't a potential source of bias, I don't know what is.

-So all of this left me pondering a future where I wasn't as independent as I wanted to be, seeing opioid-dependent patients in clinic trying to make a living on E&M visits, which clearly was enough to crack my conviction and send me running back to the CT ORs. I realize that's a lot about why I didn't choose pain and less about why I choose CT and ICU, but I've procrastinated my real work enough this morning. Suffice it to say that I always preferred doing cardiac and thoracic cases and find the ICU interesting and challenging. In the end I realized I was overthinking things, and really just needed to pick what made me happy at work while trusting the rest of the stuff would work itself out. Couldn't be happier so far.

Good luck.

 

[deleted162650]

Unique perspective. We have one of those here. Pain/cardiac/peds.

Multiple fellowships, or grandfathered in?

 

[Dawkter]

I considered both and chose pain. In my opinion, it was worth a one year investment to allow me the opportunity to explore an option entirely outside of the OR. With pain you can have autonomy, control your schedule, and develop long term relationships with people. These procedures help people if you do them in the right population, especially stim.

I know several people who do both anesthesia and pain in an academic setting which allows for a very diverse and interesting schedule.

If you’re looking to have a skill set that will allow you to practice in a non OR environment as well, ICU is also an option.



Sent from my iPhone using SDN mobile

 

[Ferrismonk]

As a pain trained guy, I can say it really does depend on what you want to do with your life. What do you find yourself reading about? What excites you? I find myself reading about pain syndromes, new procedures, new applications of old procedures, nuances in the opioid epidemic, etc. How do I do that ultrasound guided weird injection again? This all excites me. I also really get significant satisfaction when I see someone who is able to go play baseball who could not, or able to work longer than they thought they were able, or able to get someone off a handful of drugs that were minimally effective. Great moments.

Cardiac? I get bored thinking of a TEE. I don't get a thrill balancing my phenylephrine/NTG pushes. I don't like untangling 6 pumps or repeatedly yelling at the surgeon to put the heart back down. I find no pleasure in placing an emergent Cordis in 12 seconds (other than it may save a life).

With anything you do, whether that be cardiac or pain, it will become routine at some point. Pretend you already know everything about your specialty. What makes you want to read more? Dig a little deeper? That's what you should choose.

 

[sevoflurane]

Multiple fellowships, or grandfathered in?

Grandfathered in all 3.
Dude is like 60 and has been doing all 3 for 30+ years.

 

[Temeraire]

One of our cardiac anesthesia attendings told all the residents (including me) that cardiac fellowship is not worth it, not necessary, and that the only fellowship worth doing is pain.

This is in a highly desirable, high cost of living west coast area, for those wondering.

That’s my n=1 guys

 

[sevoflurane]

One of our cardiac anesthesia attendings told all the residents (including me) that cardiac fellowship is not worth it, not necessary, and that the only fellowship worth doing is pain.

This is in a highly desirable, high cost of living west coast area, for those wondering.

That’s my n=1 guys

Lol... ok.

 

[deleted162650]

One of our cardiac anesthesia attendings told all the residents (including me) that cardiac fellowship is not worth it, not necessary, and that the only fellowship worth doing is pain.

This is in a highly desirable, high cost of living west coast area, for those wondering.

That’s my n=1 guys

Well if you want a job doing hearts at my highly desirable, high COL, West Cost PP you better have a CT fellowship.

 

[nimbus]

One of our cardiac anesthesia attendings told all the residents (including me) that cardiac fellowship is not worth it, not necessary, and that the only fellowship worth doing is pain.

This is in a highly desirable, high cost of living west coast area, for those wondering.

That’s my n=1 guys

There is probably an over abundance of newly graduated cardiac fellows in most desirable areas. Even so, if somebody enjoys doing hearts and wants to continue doing them after residency, they should do a fellowship. The same can be said for pain.

 

[Ferrismonk]

If you look at jobs, there are very few pain jobs and a LOT of Cardiac/TEE jobs.

 

[neutro]

The only real advantage of doing pain is having the ability to have your own practice and not be dependent on any hospital, AMC, group. Maybe that will be important to you At some point in your life, m when you don’t want to take call or work weekends. You can do that in anesthesia also but then you’ll take a bigger pay cut.

That’s about it.

The work environment, type of patients and overall practice In pain is nothing to be excited about. It’s high liability.

 

[T-burglar]

As a pain trained guy, I can say it really does depend on what you want to do with your life. What do you find yourself reading about? What excites you? I find myself reading about pain syndromes, new procedures, new applications of old procedures, nuances in the opioid epidemic, etc. How do I do that ultrasound guided weird injection again? This all excites me. I also really get significant satisfaction when I see someone who is able to go play baseball who could not, or able to work longer than they thought they were able, or able to get someone off a handful of drugs that were minimally effective. Great moments.

Cardiac? I get bored thinking of a TEE. I don't get a thrill balancing my phenylephrine/NTG pushes. I don't like untangling 6 pumps or repeatedly yelling at the surgeon to put the heart back down. I find no pleasure in placing an emergent Cordis in 12 seconds (other than it may save a life).

With anything you do, whether that be cardiac or pain, it will become routine at some point. Pretend you already know everything about your specialty. What makes you want to read more? Dig a little deeper? That's what you should choose.

Imagine being bored by the pinnacle of anesthetic practice but being intrigued by chronic pain that’s untreatable

 

[Ferrismonk]

Imagine being bored by the pinnacle of anesthetic practice but being intrigued by chronic pain that’s untreatable

Imagine being excited watching CRNAs who follow your preferred CABG formula for the millionth time but bored by actual diagnosis and treatment for people that are truly appreciative.

 

[nimbus]

Imagine being bored by the pinnacle of anesthetic practice but being intrigued by chronic pain that’s untreatable

Imagine being excited watching CRNAs who follow your preferred CABG formula for the millionth time but bored by actual diagnosis and treatment for people that are truly appreciative.

And some people enjoy being an accountant.

 

[Twiggidy]

Well if you want a job doing hearts at my highly desirable, high COL, West Cost PP you better have a CT fellowship.

Salty!

 

[Twiggidy]

I'm gonna come out of left field as say......if you want to go into private practice DONT do a fellowship, go hard learning REGIONAL in residency, and get about any job out there.

 

[Twiggidy]

If you look at jobs, there are very few pain jobs and a LOT of Cardiac/TEE jobs.

The problem with a lot of those jobs is WHERE you're working or WHO you're working for.

Edit:
Or what they're paying you

 

[deleted162650]

Salty!

View attachment 283120

Sorry. What I meant to say was: CT fellowship is worthless. Definitely don't need to do it if you wanna do hearts in PP. CT anesthesia is for p**sies anyways. Now that preoperative fellowship - that's where it's at.

 

[2Fast2Des]

Ugh pain, you have to actually talk to people, and people with long pain history, dependencies, and a level of crazy, not even including chasing after insurance and saving your ass from being seen as a dealer. Best part of OR is the ability to limit the interaction part and bizounce once done from pacu

 

[TheLoneWolf]

I'm reposting something I wrote previously as a pain fellow.

Pain fellow

Not superglam

Declining reimbursement over years continued, average difference in pay between pain and anesthesia is much smaller then you can guess. Anesthesia can pay more if thats someones primary concern.

Risk of litigation and DEA monitoring can be stressful

Lots of paperwork that is outside of the clinic hours. It is very busy during clinic, little time to do any paperwork or you will be wayy behind.

Dealing with insurance and prior authorizations.

After hours phone calls that take a lot of time and documentation

Some meds you cant start due to high cost and copays. Unfortunately patients may have to fail the cheaper medications to qualify for better.

20 or more procedures a day expected at many places I interviewed PP. Academics protected but have to teach, lectures, supervise, meetings.

Wearing heavy lead all day will place a lot of strain on your back, hips, knees over the years. Attending I know has to retire in his 50s due to bad back. Did case on an interventional radiologist and his spine barely resembles what you would expect, around same age as the other attending. Little data on long term low dose radiation exposure but is something to consider.

Patient population is not easy and can be demanding or threatening. One of the few fields where you can actually get killed by your patients. Multiple cases you can search. Outburts not uncommon for not starting, continuing, or decreasing meds.

Less vacation time then anaesthesia- across all jobs I looked at

Med management in a good location is expected by most referrers and if you work for someone you might not have a choice. Not everyone prescribes high dose opioids but it is not unusual to see lots on low dose managed by pain management. Cofellows took jobs where they are expected to prescribe.

Lots of shady stuff with medical marijuana, prp, stem cell not supported by much data

Before I went in, someone told me that 1/3 will do great, 1/3 will get some temporary improvement, 1/3 will get no benefits despite everything. Mostly true

Lots of chemical coping, anxiety, depression who either don't want psychiatry, or cant afford

Some neurosurgery and less common ortho referrals may be dumps for meds or after failed procedures.

The number of people on disability and haven't worked in years within the pain clinic was surprising. Some want to get back to work and are motivated but this may not be as common as you would think.

Procedures may help in the short term but patients expect more permanent options. What do you when a person had 10 or more procedures over 2 years and pain scores are not or minimally improved? Some just place a stim then will proceed with pills.

Where I did residency,I know 3-4 who went back to the OR after a few years

on SDN, another 3-4 big names on the threads went back to the OR and say they work less, have more off time and are happier

With all the stuff I mentioned, it can be an excellent option if you work for yourself and have freedom to do what you want in terms of meds and procedures without worrying about your partners expectations of procedure volume or opioid management. Downside is hours and lots of paperwork but may be worth it for select individuals.

Its not all procedures and derm hours.

 

[sevoflurane]

I'm reposting something I wrote previously as a pain fellow.

Pain fellow

Not superglam

Declining reimbursement over years continued, average difference in pay between pain and anesthesia is much smaller then you can guess. Anesthesia can pay more if thats someones primary concern.

Risk of litigation and DEA monitoring can be stressful

Lots of paperwork that is outside of the clinic hours. It is very busy during clinic, little time to do any paperwork or you will be wayy behind.

Dealing with insurance and prior authorizations.

After hours phone calls that take a lot of time and documentation

Some meds you cant start due to high cost and copays. Unfortunately patients may have to fail the cheaper medications to qualify for better.

20 or more procedures a day expected at many places I interviewed PP. Academics protected but have to teach, lectures, supervise, meetings.

Wearing heavy lead all day will place a lot of strain on your back, hips, knees over the years. Attending I know has to retire in his 50s due to bad back. Did case on an interventional radiologist and his spine barely resembles what you would expect, around same age as the other attending. Little data on long term low dose radiation exposure but is something to consider.

Patient population is not easy and can be demanding or threatening. One of the few fields where you can actually get killed by your patients. Multiple cases you can search. Outburts not uncommon for not starting, continuing, or decreasing meds.

Less vacation time then anaesthesia- across all jobs I looked at

Med management in a good location is expected by most referrers and if you work for someone you might not have a choice. Not everyone prescribes high dose opioids but it is not unusual to see lots on low dose managed by pain management. Cofellows took jobs where they are expected to prescribe.

Lots of shady stuff with medical marijuana, prp, stem cell not supported by much data

Before I went in, someone told me that 1/3 will do great, 1/3 will get some temporary improvement, 1/3 will get no benefits despite everything. Mostly true

Lots of chemical coping, anxiety, depression who either don't want psychiatry, or cant afford

Some neurosurgery and less common ortho referrals may be dumps for meds or after failed procedures.

The number of people on disability and haven't worked in years within the pain clinic was surprising. Some want to get back to work and are motivated but this may not be as common as you would think.

Procedures may help in the short term but patients expect more permanent options. What do you when a person had 10 or more procedures over 2 years and pain scores are not or minimally improved? Some just place a stim then will proceed with pills.

Where I did residency,I know 3-4 who went back to the OR after a few years

on SDN, another 3-4 big names on the threads went back to the OR and say they work less, have more off time and are happier

With all the stuff I mentioned, it can be an excellent option if you work for yourself and have freedom to do what you want in terms of meds and procedures without worrying about your partners expectations of procedure volume or opioid management. Downside is hours and lots of paperwork but may be worth it for select individuals.

Its not all procedures and derm hours.

This pretty much sums up why my wife didn’t do pain although she had the fellowship offered to her.

If you like to stomp out pain, you can do plenty of that on an acute pain service. It is majorly rewarding even though it’s temporary. Lots and lots of needle jockeying on a fast ortho/trauma day,

One big thing for me that was mentioned above is that my time is 100% mine when I leave the hospital.

I’ve practiced anesthesia with 700k+ and 12-14 weeks off. Hard to do that in pain, but I am sure it is possible.

I don’t think I’ve ever taken any less than 10 weeks off a year ever since I started doing anesthesia.

Work hard, play hard mentality isn’t for anyone... long nights on call, disaster cases, etc.... My wife came home last night after dealing with a magnum through the chest that exploded the liver plus cardiac injury 30 units of products through a Belmont, median sternotomy, etc.

 

[sevoflurane]

....

 

[sevoflurane]

Pain and Cardiac are complete opposite fields. Spend more time on ea. if u can.

 

[sleepallday]

The only real advantage of doing pain is having the ability to have your own practice and not be dependent on any hospital, AMC, group. Maybe that will be important to you At some point in your life, m when you don’t want to take call or work weekends. You can do that in anesthesia also but then you’ll take a bigger pay cut.

That’s about it.

The work environment, type of patients and overall practice In pain is nothing to be excited about. It’s high liability.

The best reason to do pain imo. Completely dissociate yourself from the hospital and not have to deal with any of the bureaucracy or control that comes with it.

 

[Nivens]

Cardiac? I get bored thinking of a TEE. I don't get a thrill balancing my phenylephrine/NTG pushes. I don't like untangling 6 pumps or repeatedly yelling at the surgeon to put the heart back down. I find no pleasure in placing an emergent Cordis in 12 seconds (other than it may save a life).

Your over-simplification and reductive view of cardiac forces me to admit my impression of pain is likely woefully over-simplified and reductive.

OP: The truth is, it's hard to get a good feel for these subspecialties- both the true depth of what they have to offer, and the disadvantages/downsides- as a resident. It's difficult to really grasp the scope of what we (CT anesthesiologists) can offer, say, in the cath lab, if you don't have a solid understanding of TEE and the limitations of current catheter-based techniques. Most residents just don't get that experience, and I imagine there are analogues in the pain clinic/OR as well. I think it's in our nature when faced with a tough decision to exaggerate the strengths of one choice while understating it's downsides, while doing the opposite for the other option. Complicating factors are all of the external forces (academic momentum, charismatic mentors, burnout, etc) that act to push us one way or another.

At the end of the day, try not to overthink it. I could have saved myself hours of hand-wringing by just be honest with myself about where I was happiest.

 

[agolden1]

I realize this isn't the sole method to make this decision, but another question for the folks with families out in practice. It seems like there is some challenge to having 10-12 weeks off in that it is often hard to coordinate with your partners/AMC around school breaks, weekends, family events. Is it tough? It seems like for the 20-25 years I'd be practicing while my kids are growing up, I'd end up having a great deal of vacation weeks where I'm just bumming around the house while kids are still in school/wife is at work. It's not like I'd be going on great vacays every other month. After they head out to college, life would be more fun... And for the haters, I want to have kids so don't just jump in and say "don't have kids."

Pain sounds kind of the opposite. Easier to coordinate with kiddos while their in school, but then kind of a bummer with the less vacation part after they are in college.

 

[deleted50478]

Imagine being bored by the pinnacle of anesthetic practice but being intrigued by chronic pain that’s untreatable

By pinnacle of anesthetic practice you mean peds cardiac, right? I don’t think OP is considering that

 

[Nivens]

I realize this isn't the sole method to make this decision, but another question for the folks with families out in practice. It seems like there is some challenge to having 10-12 weeks off in that it is often hard to coordinate with your partners/AMC around school breaks, weekends, family events. Is it tough? It seems like for the 20-25 years I'd be practicing while my kids are growing up, I'd end up having a great deal of vacation weeks where I'm just bumming around the house while kids are still in school/wife is at work. It's not like I'd be going on great vacays every other month. After they head out to college, life would be more fun... And for the haters, I want to have kids so don't just jump in and say "don't have kids."

Pain sounds kind of the opposite. Easier to coordinate with kiddos while their in school, but then kind of a bummer with the less vacation part after they are in college.

In all seriousness, this is what I mean by overthinking it.

 

[Nivens]

What worries me about doing cardiac is all the threads about AMCs, supervising CRNAs/the doom and gloom of CRNA takeover, and getting some crappy contract out of fellowship.

1) AMCs/corporations are players in the pain space as well. Admittedly, your potential to flip them off and be independent is greater in pain, but then they become your competition.

2) Midlevels are a threat in pain as well. Also, you need to worry about your reimbursements from CMS.

3) Crappy contracts are offered to all subspecialists- predatory groups don’t discriminate.

My point is this is more or less a wash. You need to figure out what you *like*- this isn’t a decision to make on fear.

Try this: you’re on Saturday call and I’m running the board. We’ve got an aortic dissection in the ED, and they have a full day of overflow from the week booked in the pain clinic and could use some help. I’m giving you the choice- where would you rather spend your Saturday?

Try not to think about the army of zombie CRNAs shambling down the road toward the hospital for now and just answer the question. It’ll tell you a lot.

 

[D P356]

Try this: you’re on Saturday call and I’m running the board. We’ve got an aortic dissection in the ED, and they have a full day of overflow from the week booked in the pain clinic and could use some help. I’m giving you the choice- where would you rather spend your Saturday?

Trick question. Well played. Overflow from pain clinic occurs during next week’s regular office hours.

 

[Nivens]

Trick question. Well played. Overflow from pain clinic occurs during next week’s regular office hours.

hahaha well done, well done

 

[neutro]

The best reason to do pain imo. Completely dissociate yourself from the hospital and not have to deal with any of the bureaucracy or control that comes with it.

Yes sir. Anesthesia overall has more satisfaction than pain. Pain is frustrating and you need to have the right temperament for it.

I am actually starting a pain practice on the side for a few reasons. I work full time as an anesthesiologist but I do have a fellowship in pain. I was doing mix anesthesia and pain working for a hospital but after CDC guidelines came out in 2016, pain practices became a major dumping ground from PCPs because apparently 'they cant write any meds'. I got tired of arguing with the patient that their PCP lied, got tired of PCPs for being lazy and got tired at the environment in pain medicine and the lack of good, reliable, permanent options. PP was never an option when I was starting out as I did not have the means or finances, and eventually I realized hospital employment is not the answer because of bureaucracy and ***** administrators and CEOs at each level.

So with that in background, I just filed for my own corporation, and will start seeing patients hopefully when my credentialing etc is done in January. I don't care about quantity of patients or money - I just want to break even and establish a high quality practice - thats my 6 month goal. And from then, build a reputation, expand and move forward. Hopefully, down the line, I will use that as leverage and sell it to a hospital or merge with another practice on my terms as opposed to being a straight employee. Lets see how it goes...

you know, currently I make close to 500 k with 11 weeks off working FT anesthesia...but the problem is the quality of time off. I worked July 4, will be working thanksgiving and and Christmas day. Essentially either i am on call or working 4 out of 6 holidays a year. Our practice belongs to AMC, but staffing is an issue.
Having two random weeks off in October is not the same as having long weekends and holidays off. When nov and dec schedule came out two weeks ago and I saw my name on the holidays, I had a meeting with my chairman and regional director about this non-sense. Thats one thing I will tell you - if you dont like being told what to do, maybe anesthesia is not the right field for you. Unfortunately the chairman has his hands tied because we have two or three physicians that are not team players so the rest of us have to take the brunt. I was made a promise that next year I will be taking less call on holidays...

Anyways, its quality vs quantity. And if you calculate the amount of time you spend working weekends on call plus back up (I work at least 1 weekend a month in house - either Saturday and Sunday first call and the other weekend day as back up) and at least one friday in house. Sometimes we work 2 weekends a month. So if on average, your'e working 1.5 weekends a month in house, thats 36 hours of additional time per month. Not counting weekday inhouse call or backup. Im being very conservative. Multiply that by 40 hour work week (because my paystub says that I am paid hourly based on 40 hour work week which is bogus - i work close to 55-60), and then 12 months that the pain guy is NOT doing - so that what counts as quality of life. At least for me. Family time is important...my kids are young - i have two boys under 3, and i dont want to miss out more than i already do. And holidays and time off matters. Again depends on the type of person you are.

Im 35 now - my student loans are already paid off, I purchased a house last year, and I just crossed 1M in net worth which i am very grateful about. My goal is 5 Mil of NW. So after a few years, I will re consider options and if I can afford to take a paycut for quality of life, I will either do full time pain or ASC anesthesia or half and half.

So again my friend, decision to do pain vs cardiac is not just based on what you like right now, but what you will like 5, 10 and 15 years down the road...always give yourself the option.

 

[neutro]

Thanks everyone for the feedback and honest responses. I won’t lie - I’m still torn lol. I genuinely am interested in TEE and taking care of sick patients in the OR is fun (hence why I did an anesthesiology residency in the first place). What worries me about doing cardiac is all the threads about AMCs, supervising CRNAs/the doom and gloom of CRNA takeover, and getting some crappy contract out of fellowship.

I also enjoy the procedural aspect of pain medicine and don’t really mind clinic. While at first glance the schedule might seem nicer at first (9-5 M-F, no call), I’m starting to realize that it’s not necessarily like that when you take into consideration all the non-clinical stuff. The less vacation for equivalent pay, also seems less than ideal. But still what’s most attractive about pain medicine is having a skillset outside of OR anesthesia.

and before anyone mentions it - no, i have zero interest in CCM lol

1. There are a lot of 'sick' and 'complicated' patients in pain medicine too. not everything needs to be wham bam thank you ma'am.
2. 5 years out of training, 90% of physicians do not find work that challenging anymore. They find man management, family, time, stressors, health and other issues more challenging. Work just becomes an 'annoyance' at times. Its not that we dont care, its just that by then you have done everything so many times, its not new or sexy anymore.


Whatever you do, if you do choose to do a pain fellowship - try to moonlight in anesthesia during fellowship and then do anesthesia for a little bit when you are starting out your pain practice. This way if you dont like pain, atleast you will not be out of anesthesia for 2-3 years - and then it becomes hard to find a job.

 

[Twiggidy]

@neutro giving good answers, especially that part about long weekends and holidays. You dont need to do pain to get they type of life, you just need a practice that doesn't cover OB. It's easier to give up calls in practices where call is at home or requires a reasonable amount of weekend or night OR work.

 

[deleted171991]

Thanks everyone for the feedback and honest responses. I won’t lie - I’m still torn lol. I genuinely am interested in TEE and taking care of sick patients in the OR is fun (hence why I did an anesthesiology residency in the first place). What worries me about doing cardiac is all the threads about AMCs, supervising CRNAs/the doom and gloom of CRNA takeover, and getting some crappy contract out of fellowship.

I also enjoy the procedural aspect of pain medicine and don’t really mind clinic. While at first glance the schedule might seem nicer at first (9-5 M-F, no call), I’m starting to realize that it’s not necessarily like that when you take into consideration all the non-clinical stuff. The less vacation for equivalent pay, also seems less than ideal. But still what’s most attractive about pain medicine is having a skillset outside of OR anesthesia.

and before anyone mentions it - no, i have zero interest in CCM lol

Forget about all the cowboy things, and think about a ROUTINE day, with routine bread and butter cases, both in the cardiac room and pain clinic. Where would you rather be? Most of your days will be routine, and, as you age, you'll grow to enjoy a routine day more than some adrenaline rush.

Also, somebody mentioned a VERY important thing, especially in the age of encroachment by midlevels and others: what do you find yourself READING about? For example, I don't only like practicing CCM, I love reading about it. I friggin' started reading a neurocritical care book while I was on vacation, and I'm not some maniac; I was just enjoying it. I don't even have NeuroICU patients.

 

[deleted162650]

Forget about all the cowboy things, and think about a ROUTINE day, with routine bread and butter cases, both in the cardiac room and pain clinic. Where would you rather be? Most of your days will be routine, and, as you age, you'll grow to enjoy a routine day more than some adrenaline rush.

Also, somebody mentioned a VERY important thing, especially in the age of encroachment by midlevels and others: what do you find yourself READING about? For example, I don't only like practicing CCM, I love reading about it. I friggin' started reading a neurocritical care book while I was on vacation, and I'm not some maniac; I was just enjoying it. I don't even have NeuroICU patients.

You need help.

 

[deleted171991]

You need help.

Because I like to read, especially when I am on a train with a "view" of soundproofing panels on both sides?

It sounds more like you need education, you little anti-intellectual. Or just some really good books.

 

[neutro]

@neutro giving good answers, especially that part about long weekends and holidays. You dont need to do pain to get they type of life, you just need a practice that doesn't cover OB. It's easier to give up calls in practices where call is at home or requires a reasonable amount of weekend or night OR work.

well you'll definitely be covering a lot of weekends and nights if you wish to do cardiac. or you'll take a pretty significant pay cut...