Pp cardiac

[anes121508]

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hey everybody....for those of you who did a cardiac fellowship (or even those of you that didn't) and are doing pp hearts with some general, how many heart cases a year are you doing? For those of you who did a fellowship, how many cases a year do you think would be the minimum to keep up your skills and feel proficient? Obviously this depends on how long you have been practicing, but just wanted some opinions. Thanks!

 

[caligas]

hey everybody....for those of you who did a cardiac fellowship (or even those of you that didn't) and are doing pp hearts with some general, how many heart cases a year are you doing? For those of you who did a fellowship, how many cases a year do you think would be the minimum to keep up your skills and feel proficient? Obviously this depends on how long you have been practicing, but just wanted some opinions. Thanks!

I had no fellowship, doing about 50 hearts/year. My group lets folks do more if they wish to.

 

[sethco]

My group (for those that do cardiac) range from 70-400/year. Most of those people are not fellowship trained, but have been doing private practice hearts for years. New hires are now required to be fellowship trained. I am probably around 250-300/year in an MD only practice. I would think for a fresh fellow grad, the minimum is 50/year. The reason I say this is a lot of fellowship don't give you that much autonomy until the end, so you want a higher volume for those first couple of years so you get to be comfortable handling the sick patients on your own without any backup.

 

[deleted87051]

I agree 50/yr is a minimum. But more is better for the reason sethco gives.

 

[confusingleaf]

starting as an attending 7/18 after finishing cardiac fellowship....and i would agree that you definitely want to be doing more than 1 heart a week EVEn if you've done fellowship. i know there will be a bit of adjustment for me getting used to having no backup...what if i can't get the echo probe in? the central line is difficult? a renal failure patient with no good site for an a line?

key to that is picking a good place to start out. i am staying at the institution where i completed fellowship for at least a couple years, if not for my career...knowing i have that backup available to call if I need it gives me a good amount of confidence.

 

[Noyac]

I did btw 800 and 1000 hearts in just under 3 yrs in my first gig out of training. I felt pretty proficient and was rapidly becoming one of the "go to" guys for the service. Even with all of those cases I still had some doubts. I felt like I could still learn more. I could slam in a swan in no time, dig a pt out of the gutter gracefully without over shooting, predict the next three moves before they happened, etc etc. But I still remember the one case I really struggled to get off the pump. I used all my tricks and was still struggling. It was a dose of reality. Sometimes you just get handed a bag of ****. I found hearts to be very routine. The best surgeons operated that also. It made things easy. But if you have a bunch of surgeons that try to reinvent the wheel on every case then you will never feel completely comfortable.
I remember interviewing for my first job in Austin and the anesthesiologist extubated the heart at the end of the case. I thought that was absolutely nuts and was pretty sure I would never do that. At the end of my first year of PP I was doing it on occasion. I got so much more comfortable in that room so fast. But every once in a while you get a gut punch. The only other one I remember well was a partner of mine who was doing a 4V CABG on a 38 yo female. She coded and we never got her back. He was good and had been doing hearts for about 15 yrs. That one opened my eyes.

So I may or may not have answered your question but the point is, you will get very comfortable in the cases but there is no number that will eliminate the occasional feeling that you need more experience. Hearts are very routine right up u til they aren't.

 

[anes121508]

I did btw 800 and 1000 hearts in just under 3 yrs in my first gig out of training. I felt pretty proficient and was rapidly becoming one of the "go to" guys for the service. Even with all of those cases I still had some doubts. I felt like I could still learn more. I could slam in a swan in no time, dig a pt out of the gutter gracefully without over shooting, predict the next three moves before they happened, etc etc. But I still remember the one case I really struggled to get off the pump. I used all my tricks and was still struggling. It was a dose of reality. Sometimes you just get handed a bag of ****. I found hearts to be very routine. The best surgeons operated that also. It made things easy. But if you have a bunch of surgeons that try to reinvent the wheel on every case then you will never feel completely comfortable.
I remember interviewing for my first job in Austin and the anesthesiologist extubated the heart at the end of the case. I thought that was absolutely nuts and was pretty sure I would never do that. At the end of my first year of PP I was doing it on occasion. I got so much more comfortable in that room so fast. But every once in a while you get a gut punch. The only other one I remember well was a partner of mine who was doing a 4V CABG on a 38 yo female. She coded and we never got her back. He was good and had been doing hearts for about 15 yrs. That one opened my eyes.

So I may or may not have answered your question but the point is, you will get very comfortable in the cases but there is no number that will eliminate the occasional feeling that you need more experience. Hearts are very routine right up u til they aren't.

Great insight. I guess that goes for just about everything.

At 50/yr I'm still hesitant...no matter how amazing fellowship is, no way I'm going to know everything once I graduate. I feel that a whole lotta clinical maturity and growth occurs over those first few years as an attending. Heck i bet it does every year no matter how long you have been out. Just such a steep slope those first 5 years or so....what do you all think?

Is 50/year enough?

For those of you who do hearts + general stuff how does your practice break down week by week? 1 day a week hearts? 2-3days a week hearts? What do you like and dislike about your setup?

My gut feeling tells me that I'll enjoy myself a whole lot more doing a solo heart case over supervising 4:1. Variety is good and a break from the cardiac room to do blocks/ob/neuro ect sounds nice. Not sure what is best though. Maybe 2-3 days cardiac a week?

 

[deleted171991]

Your gut is probably right. There is no fun in supervising CRNAs. Although there is no fun dealing with entitled cardiac surgeons either.

 

[Noyac]

Great insight. I guess that goes for just about everything.

At 50/yr I'm still hesitant...no matter how amazing fellowship is, no way I'm going to know everything once I graduate. I feel that a whole lotta clinical maturity and growth occurs over those first few years as an attending. Heck i bet it does every year no matter how long you have been out. Just such a steep slope those first 5 years or so....what do you all think?

Is 50/year enough?

For those of you who do hearts + general stuff how does your practice break down week by week? 1 day a week hearts? 2-3days a week hearts? What do you like and dislike about your setup?

My gut feeling tells me that I'll enjoy myself a whole lot more doing a solo heart case over supervising 4:1. Variety is good and a break from the cardiac room to do blocks/ob/neuro ect sounds nice. Not sure what is best though. Maybe 2-3 days cardiac a week?

You have heard that it takes 10,000 hrs to master something haven't you? I don't recall who wrote it but someone here will chime in. Athletes, artists, etc all fall in this catagory. There is no reason medicine wouldn't either. I also read something years ago that mentioned that most physicians peaked at 10-15 yrs of practice. I was skeptical but I now believe it. I am much smoother and safer now than I was earlier. I have seen more and done more over and over again.

So 50/yr is a good number as far as I can tell. But more is better. I liken it to new grads and the programs they come from. The ones that come from heavy fellowship programs or ivory towers "seem" to have actually done less cases. They must shadow more or something. The ones that come from busy programs with many cases under their belts seem to do better in the first couple years. Just my observation. I wouldn't pass on either one if they were a good fit. But time in the chair makes a big difference.

Typical week for me (every practice is different) was 1-3 days in heart room and usually averaged 3 cases/day.
1-2 days in other areas like neuro or even ambulatory center. I also did some pain management which was 1/2 a day once or twice a week. But many times I would do regular cases or pain then go to the heart room in the afternoon. So a heavy heart week could be 11+ cases. That was rare tho. Probably more like 5+.

 

[Noyac]

"What do you like and dislike about your setup?"

In my first three years, I did everything even pain management. I had 4-6 weeks vacation. I was paid barely more than the CRNA's. I was dumb in business but good at anesthesia. I loved the job. But was exhausted at times. By the time I reached partnership (3yrs) I was slightly angry at my group but still liked every single one of the partners. I realized how much money I had made for them. It was somewhat fair tho. I signed the contract. They setup the practice, signed the hospitals, developed the reputation with the surgeons, staff and administration. I just walked in one day needing a job. I didn't expect to be equal and I was ok with that, for a while. But I was working harder than the other new hires I felt. I brought in more $$$. I had to be the highest grossing person, partner or associate for those three years. That started to weigh on me some and I wasn't happy in my location completely. So I walked, one month prior to partnership.

That's probably not what you were asking tho. I like the diversity of the group that does it all. I couldn't see myself doing the same thing everyday. I like outpt stuff as much as I like inpt ICU stuff. I love the trauma but I could be happy never doing another c/s. I don't mind labor epidurals tho. So my perfect setup (which is what I tried to create at my current gig) is one that does everything. We don't do hearts any more tho. Where everyone is equal from day one.

 

[confusingleaf]

thanks, noyac, for your words and expertise in this thread. as I get down to the wire of finishing fellowship and starting as an attending, i am, to put it bluntly, petrified. i realize there is no way i have learned in one year how to handle all the cases that my counterparts with 10 years of experience can. and i still have that sucker punch case every so often right about when i think i know what i'm doing and can handle what comes my way 🙂

so i guess i'll be logging cases and volunteering to do as much by myself as i can (i will also be supervising residents...and i have learned in fellowship how f*&cking scary that is) and just slog through those 10k hours!

 

[sevoflurane]

Nice thread. Noy always brings something good to the table.

I think the more hearts the better in the short term. Had an AV rupture recently. Always tough cases that pose serious clinical challenges.

In the long term, develop your practice into areas you are most interested in. If it's mostly hearts... then bingo.

Example:

For me, it's always been cardiac and regional. These cases take up most of my time and they are busy days- 3 hearts this Monday. Regional days involve lots of SS/catheters, early morning starts, calling patients at home, etc. Its busy, but I'm at home when I'm in these rooms.

Sometimes I need a break from both and am 100% content doing general cases, neuro (prefer brains to backs), OB, peds, trauma, etc. Just nice to mix it up- keeps me thinking.

I'm an inpatient kind of guy. Never scheduled at the surgery centers, but that's how I like it. Noy doesn't like Ob much and I am deathly allergic to eyeballs and cystos.

So I guess the big picture is... what do you have the most fun doing? Do you want to do it all? Hearts only? A little of this and a little of that?

Nothing wrong doing 50 hearts a year. It allows you to pursue other areas of interest. If you are doing 200-300 hearts a year then that is what you will mostly be doing in you career. I think burnout might be a bit higher in this setting, IDK- hearing Noy stating that we was a bit exhausted during his heart days means a lot to me as I know this guy is a tank.

I would urge you to think about what you want to do for the rest of your career and choose a practice that way.

 

[confusingleaf]

Noyac and Sevoflurane and really anyone else with more clinical experience than I--would you be willing to share your top pearls of cardiac that you wish you'd known or done when first starting out?

 

[Noyac]

Noyac and Sevoflurane and really anyone else with more clinical experience than I--would you be willing to share your top pearls of cardiac that you wish you'd known or done when first starting out?

Sevo will have much more input here than I will. It's been 10yrs now since I've done hearts.
But my one piece of advice is ask for help early. Don't let the case go down the drain before asking. If you can't get a line, ask for help. If you can't come off pump, get help. There is no room for pride. And if it bothers you to ask (which it shouldn't) just member that if you work in one place long enough you will undoubtedly get the opportunity to return the favor.

I actually called for help last week. I can't remember the last time that happened. When my partners heard it was me, they came running. (Sevo, Al came running saying "oh no, that's Noy's room, it's for real🙂) It was an airway. Luckily I got it in before he got there. The pt came with a Difficult Airway Letter and everything so I was prepared. Moral here is that after all these years I still knew when to call for help. It wasn't a pride thing.

 

[sevoflurane]

When my partners heard it was me, they came running. (Sevo, Al came running saying "oh no, that's Noy's room, it's for real🙂) It was an airway. Luckily I got it in before he got there. The pt came with a Difficult Airway Letter and everything so I was prepared. Moral here is that after all these years I still knew when to call for help. It wasn't a pride thing.

He prolly came charging in with his socks and front wheel up ... looked around for a second and before he focused his attention on the patient, snuck one of these into your anesthesia cart in ninja like fashion

and then was like, $hait, that's Noy, why did I even come in here...

 

[anes121508]

"What do you like and dislike about your setup?"

In my first three years, I did everything even pain management. I had 4-6 weeks vacation. I was paid barely more than the CRNA's. I was dumb in business but good at anesthesia. I loved the job. But was exhausted at times. By the time I reached partnership (3yrs) I was slightly angry at my group but still liked every single one of the partners. I realized how much money I had made for them. It was somewhat fair tho. I signed the contract. They setup the practice, signed the hospitals, developed the reputation with the surgeons, staff and administration. I just walked in one day needing a job. I didn't expect to be equal and I was ok with that, for a while. But I was working harder than the other new hires I felt. I brought in more $$$. I had to be the highest grossing person, partner or associate for those three years. That started to weigh on me some and I wasn't happy in my location completely. So I walked, one month prior to partnership.

That's probably not what you were asking tho. I like the diversity of the group that does it all. I couldn't see myself doing the same thing everyday. I like outpt stuff as much as I like inpt ICU stuff. I love the trauma but I could be happy never doing another c/s. I don't mind labor epidurals tho. So my perfect setup (which is what I tried to create at my current gig) is one that does everything. We don't do hearts any more tho. Where everyone is equal from day one.

You all are awesome for sharing this type of insight, guidance and advice.

you walked 1 month prior to partnership!?!?! did this turn out to be a good decision?

 

[anes121508]

Nice thread. Noy always brings something good to the table.

I think the more hearts the better in the short term. Had an AV rupture recently. Always tough cases that pose serious clinical challenges.

In the long term, develop your practice into areas you are most interested in. If it's mostly hearts... then bingo.

Example:

For me, it's always been cardiac and regional. These cases take up most of my time and they are busy days- 3 hearts this Monday. Regional days involve lots of SS/catheters, early morning starts, calling patients at home, etc. Its busy, but I'm at home when I'm in these rooms.

Sometimes I need a break from both and am 100% content doing general cases, neuro (prefer brains to backs), OB, peds, trauma, etc. Just nice to mix it up- keeps me thinking.

I'm an inpatient kind of guy. Never scheduled at the surgery centers, but that's how I like it. Noy doesn't like Ob much and I am deathly allergic to eyeballs and cystos.

So I guess the big picture is... what do you have the most fun doing? Do you want to do it all? Hearts only? A little of this and a little of that?

Nothing wrong doing 50 hearts a year. It allows you to pursue other areas of interest. If you are doing 200-300 hearts a year then that is what you will mostly be doing in you career. I think burnout might be a bit higher in this setting, IDK- hearing Noy stating that we was a bit exhausted during his heart days means a lot to me as I know this guy is a tank.

I would urge you to think about what you want to do for the rest of your career and choose a practice that way.

This really hits home with me. Thank you.

I have my allergies too (endo, cysto, eyeballs, peds) 🙂

Most at home in the heart room. Even if it's an earlier morning start and going home and hour or so later, I'm happier throughout the day.

I'm like you, second to hearts is regional. Absolutely love a busy day of blocks. Regional, like cardiac is a hobby to me that I enjoy .

I like that you bring up the burn out doing too many hearts, I've noticed in months where I take a ton of back up cardiac call and volunteer to stay late for heart cases, I need to come up for a breather and really enjoy doing something different. Can't imagine how I'd feel after 20 years of practice (I like to think of myself as a tank like Noy, but I'm probably a wimp in comparison)

Thinking about it, my ideal set up would be 2 days hearts, 1 day blocks, 2 days general (without my allergies)

 

[anes121508]

on a side note....when I was an intern we had an "E-ICU" at night....this forum has been like my "E-mentor/advisor", so thank you

 

[Noyac]

did this turn out to be a good decision?

For me it was. My life is much more full.

I make less money than I would have if I'd stayed but one thing I've learned as well, the more money you make the money you need. Wealth comes in many ways. Not all of it is money.

 

[confusingleaf]

well said, Noy. I've always maintained that i'd rather work a little less and enjoy my life a lot more. I see many of my classmates who graduated and started PP last year spent a ton of money on new cars, new houses, etc. only to never enjoy any of it because they have to work all the time to pay for it. very circular.

 

[sevoflurane]

For me it was. My life is much more full.

I make less money than I would have if I'd stayed but one thing I've learned as well, the more money you make the money you need. Wealth comes in many ways. Not all of it is money.

I learned this the hard way (as you know). I'm not a huge spender and I agree.
A major part of my "wealth" is really based on life experiences I am able to accumulate as I transition from here to there (wherever there might be).