Regional Fellowship

[sevoflurane]

To be clear, I def. think that a year doing regional is absolutely NOT necessary if you went to a residency that has a regional program- most now days do.

---

Members don't see this ad.

 

[deleted162650]

Didn't say that. It was a response to the idea that regional fellows refuse to do big cases, which is BS. similarly, there are plenty of people that feel comfortable doing cardiac coming out of residency (and do in pp). Is cardiac fellowship useless then?

CT fellowship gives you advanced TEE cert which is almost unattainable outside the fellowship (emphasis on almost). That's the difference - oh and it's ACGME which means something as well.

I do feel that in this day and age if you want a career doing hearts or taking care of little and or sick kids then you should do the associated fellowship. I do not feel that way about regional. We're talking about finding a structure of interest on U/S and then putting a needle there - it's not really that difficult and it is a monkey skill. The same cannot be said for the knowledge base that goes along with sick cardiac and non-bread/butter peds.

 

[sevoflurane]

CT fellowship gives you advanced TEE cert which is almost unattainable outside the fellowship (emphasis on almost). That's the difference - oh and it's ACGME which means something as well.

I do feel that in this day and age if you want a career doing hearts or taking care of little and or sick kids then you should do the associated fellowship. I do not feel that way about regional. We're talking about finding a structure of interest on U/S and then putting a needle there - it's not really that difficult and it is a monkey skill. The same cannot be said for the knowledge base that goes along with sick cardiac and non-bread/butter peds.

Agree. As some of the older guys that have been doing hearts for 20 some years (and don't have advanced TEE certification) retire from the heart team, we will be replacing them with fellowship trained candidates. At the moment we have 50/50 that have the advanced TEE cert. There are about 12 of us. The ones that don't have the certification do CABGs and the ones that have advanced cert. do almost exclusively valves and structural heart interventions.

 

[nimbus]

Why take on big cases when you are paid the same? More stress, more work, more risk, same everything else.

More fun. And the way my practice is set up, more $$.

 

[deleted171991]

More fun. And the way my practice is set up, more $$.

I wonder whether you would still be doing it just for fun, for the same money, especially in a state with no malpractice caps.

 

[deleted162650]

especially in a state with no malpractice caps.

Are big cases associated with a higher likelihood of getting sued? I don't know, but my hunch is no.

 

[deleted171991]

Are big cases associated with a higher likelihood of getting sued? I don't know, but my hunch is no.

It depends. If the patient has been sick for a while, then the answer is no. If the surgery is urgent/emergent with just a short prelude, and anything bad happens, the family is still in the "it must have been malpractice" mindset, especially if they weren't involved before the surgery.

That's actually one of the reasons I like the ICU much more than the OR: patients and their families (even of those who die) are waaaay more grateful for their care.

 

[deleted162650]

It depends. If the patient has been sick for a while, then the answer is no. If the surgery is urgent/emergent with just a short prelude, and anything bad happens, the family is still in the "it must have been malpractice" mindset, especially if they weren't involved before the surgery.

That's actually one of the reasons I like the ICU much more than the OR: patients and their families (even of those who die) are waaaay more grateful for their care.

Is there any data to support this from the ASA closed claims databse, or is this pure opinion??

 

[deleted171991]

Is there any data to support this from the ASA closed claims databse, or is this pure opinion??

This is pure opinion. The part that is based on data AFAIK is that intensivists are sued less than anesthesiologists.

One of the reasons for the latter, I think, it's a longer and more meaningful patient/family-doctor relationship in the ICU. When families see one's hard work every day, it's much easier to accept a bad outcome.

 

[Robotic Wis-Hipple]

Pretty sure Anesthesiologists are sued more for MAC cases these days than anything else other than perhaps OB (though these may be included in the MAC umbrella).

 

[Mman]

One of the reasons for the latter, I think, it's a longer and more meaningful patient/family-doctor relationship in the ICU. When families see one's hard work every day, it's much easier to accept a bad outcome.

Or maybe it's because the patient was already in such bad shape they were being admitted to the ICU before you ever got involved. In the OR, patients can often walk in from home and families might not appreciate the severity of their comorbidities

 

[facted]

Pretty sure Anesthesiologists are sued more for MAC cases these days than anything else other than perhaps OB (though these may be included in the MAC umbrella).

Wouldn't be suprised by this. I tell my colleagues all the time. If I was going under, just put a freakin tube in if I need any sedation.

 

[Timeoutofmind]

Really agree 100%. I guess from a hiring perspective, how do you weed out the ones that come out of residency ready to hit the road vs. the ones that really shouldn't be doing a regional day due to lack of skill and inefficiency? Not easy, unless you are picking from a known basket with known references.

IMO, there are lots of residencies that produce graduates that are not capable of dealing with a heavy day of regional. It is becoming less common I will admit, but it's still out there in not so small quantities a some may think. Now if we are talking about some of the "old guys" who are transitioning to a different job... now that can be a big problem as there is a set of mid 40's to end of time candidates that may not posses the necessary skills.

From a resident point of view, only interview at programs with strong regional. It will help you succeed- especially if you are not planning on peds or cardiac.
Graduate with 50 blocks and you will be struggling. 300-400 blocks sounds about right for a 4 year program including catheters and the less "prime time" blocks-( pecs, genicular, LPB, BP terminal nerve blocks, supracapular, PVTs, etc.) If you know how to do those blocks and been trained well, you can put catheters in them. Not hard, but it requires a certain foundation and comfort. Also, lets not forget about pediatric blocks. Caudals, epidurals, PVNBs, and other peds blocks under GA.

Hard to really tell proficiency on an interview unless you know where they are coming from.

Just my 2cents.

U r doing geniculars peri-op?

With US?

for TKAs or what?

Could u share pics/technique?

 

[sevoflurane]

U r doing geniculars peri-op?

With US?

for TKAs or what?

Could u share pics/technique?

I haven't done a ton of ipacks, but I have done some. This does a good job of explaining what to do:

 

[sevoflurane]

Very easy to do... but with LIA and a good orthopod that injects in the right places... it's rarely needed.

 

[BLADEMDA]

Conclusions I can draw from this, and other, threads:

You need a fellowship, preferably something that goves you a broadened skillset, BUT:

Cardiac: saturated market, dwindling volume, more and more interventional procedures
Regional: waste of time
OB: waste of time
Peds: shrinking market, do you really need it to do T&As?
Pain: reimbursement dropping like a stone, but youre the boss. On the other hand, youre the boss...
Critical care: more work for less money

With academic pay (after 5-6 years) equaling AMC pay then any of these fellowships would be a good choice IMHO. I've seen good academic jobs where the position REQUIRED a fellowship in both Cardiac and ICU to be considered for the position. These jobs pay well and will likely exceed AMC pay over the duration of a career.

IMHO the best path is to do a fellowship in the area of interest and then get an academic position; if, you find a great PP gig during this process or after 1-2 years as an attending then jump ship for that dream job. But, for most the fellowship is a path to an academic career which over 20-30 years is far better than an AMC.

 

[hankbb02]

Why not do cardiac and split your time between cardiac and regional once in pp? It's basically what I do 80% of the time. 20% would be other areas like OB/trauma/neuro brain/spine /general.

Good mix and not stuck doing one thing.

This is exactly the setup I am looking for once I finish CT fellowship.

 

[mmag]

Consider that cRNa's are doing the same fellowship, would go towards picking up as much regional experience during residency and rethink fellowship.

 

[Maverikk]

You're going to be spending a lot of your time at work, so pick a specialty based on what you like, that one year of lost salary will be made up a lot more by doing what you enjoy even if it's regional/OB/perioperative or something negative nellies on here say are useless. Doing that fellowship will fast track you on to a pathof a more enjoyable job. Could you do it without the fellowship? yeah, but the fellowship will put you in a more likely path.

As for regional you should go to program that will prepare you to set up an acute pain service that is fast, efficient and available, this will be useful for a hospital and you will be valuable. I've done regional at shops where they had a good and bad setup and it makes a difference. You walk into the pre-op and the nurse has already primed the patient about what to expect for a block and why we do it. The patient is positioned and the ultrasound is in the right area, the nurse knows how to stim, what too much resistance feels like vs. being the first person to tell them about the block (our good surgeons tell them in their office but some don't but expect a block) and having to position, get the bed ready, family out etc. Having a program where you know how to troubleshoot catheters over the phone and more importantly who not to put catheters in.

Knowing how and what it takes to get an efficient program set up is more important than doing the blocks, as long as you know how to do the blocks. If you don't have>400 blocks coming out of residency you probably need more/getting some supervision to become efficient. You should be able to do interscalene/supra,infraclav/femoral/pop and you'll cover 95% of needs. Yes it is just finding an image and putting a needle, if it's easy. It's the harder patients that separate the good from the bad: I've done axillary on renal failure patients with more collateral veins around the axillary artery than their fingers and toes, interscalenes on old fatties with slits for interscalene muscles, choosing to do retroclavs on the giant pec body builder with hand injuries.

 

[mmag]

During fellowship make sure you learn the business side of setting up an acute pain service not just the logistics. If not you aren't even getting a cRNa level fellowship.
"Fellows will learn innovative techniques including multimodal and interventional therapies to manage acute surgical pain, while developing business management proficiency."
Acute Surgical Pain Management Fellowship - MTSA

 

[Blockdoc22]

Don’t listen to all the Debbie Downers on this forum about how to spend your extra year after residency. They’re the ones who didn’t do a fellowship, so of course they’re going to say these things to justify their decision of not doing a fellowship. Ultimately, do what you’re passionate about. If you’re going into PP and had a lot of regional experience during residency, there’s no need to do a regional fellowship. You also won’t get a pay increase for doing this fellowship compared to a generalist. However, if you have a strong interest in academics, leading the field in research, speaking at national meetings, receiving invitations to speak at grand rounds, and teaching at national workshops, completing a regional fellowship at a reputable program will certainly open many opportunities for you. Do a fellowship in what you love, and it’ll pay off in your professional career down the road. Good luck with your decision making!

 

[deleted171991]

Opportunity Cost and ROI of Fellowships | The White Coat Investor - Investing And Personal Finance for Doctors

"One of the common misconceptions of opportunity cost when choosing a fellowship is to simply determine your first year’s salary (including benefits such as quarterly or annual bonuses) as an attending and subtract that from your fellowship salary. It may look something like this in my field, Anesthesiology:

(Wrong perception)
Opportunity Cost = 1st Year Attending Salary – Fellowship Salary
Opportunity Cost = $250,000 – $60,000 = $190,000"

"So, now combining the three numbers above, in this anesthesiology scenario, your opportunity cost for pursuing a fellowship is $531,166. Now THAT is a big number. If your fellowship is more than one year, you can double or triple that number. Can you ever really catch up on that and break even for an “adequate” ROI?"

https://thephysicianphilosopher.com/wp-content/uploads/2018/05/Opportunity-Cost-Calculator-1.xlsx

Love,
Debbie

 

[Arch Guillotti]

Opportunity Cost and ROI of Fellowships | The White Coat Investor - Investing And Personal Finance for Doctors

"One of the common misconceptions of opportunity cost when choosing a fellowship is to simply determine your first year’s salary (including benefits such as quarterly or annual bonuses) as an attending and subtract that from your fellowship salary. It may look something like this in my field, Anesthesiology:

(Wrong perception)
Opportunity Cost = 1st Year Attending Salary – Fellowship Salary
Opportunity Cost = $250,000 – $60,000 = $190,000"

"So, now combining the three numbers above, in this anesthesiology scenario, your opportunity cost for pursuing a fellowship is $531,166. Now THAT is a big number. If your fellowship is more than one year, you can double or triple that number. Can you ever really catch up on that and break even for an “adequate” ROI?"

https://thephysicianphilosopher.com/wp-content/uploads/2018/05/Opportunity-Cost-Calculator-1.xlsx

Love,
Debbie

Too simplistic. If doing a fellowship means getting a "good" job that pays you twice as much as the crappy local AMC all the numbers become meaningless.

 

[deleted171991]

Too simplistic. If doing a fellowship means getting a "good" job that pays you twice as much as the crappy local AMC all the numbers become meaningless.

There are very few jobs that pay double the local AMC. If anything, most academic jobs pay the same or less. Plus there are a ton of fellowships which don't mean squat in PP, unless they translate into special skills/certifications that a generalist doesn't have and the group needs.

My previous post applies to most (but not all) fellowships, those which don't add significant measurable value (for the employer, and thus the employee).

My own CCM fellowship made me a much better anesthesiologist, as a side effect. Was the opportunity cost worth it financially? Yes, if I end up as partner in PP because of it (very unlikely), no in pretty much any employed situation. What it has done was to maybe put my name on the top of the pile of resumes.

I would also add that any residency program that requires one to do a "minor" fellowship (i.e. one that doesn't teach special skills, such as OB or regional), just to compensate for the lack of proper training during residency, should be outed on this forum, and avoided like the plague.

People should waste a year only on cardiac, and maybe pain. CCM only if they want 100% CCM, and probably the same is true about pain (which is probably worth doing only as a partner). Anything else, big question mark. Peds? I'll let the peds people comment on that, but there are only so many sick kids and major surgeries that require a subspecialist. Anything else just for resume-padding mostly.

 

[AdmiralChz]

Arch and FFP are both right in their own way. I’m sure this is said above but most are non-ACGME so fellows are paid as semi-junior faculty often 120-150, which helps soften the blow/opportunity cost (plus call incentives). That is changing with mandatory ACGME accreditation so I expect interest overal to plummet.

 

[waterbottle10]

I still OFTEN hear attendings tell me that I should do a fellowship after graduation (almost regardless of what it is), just so i can put it on my resume since it's only one year and it will last thru my entire career. Their reason being that it opens doors. The example being that often times fellowship trained anesthesiologist can bring more to the table than a general anesthesiologist. So if the MBA guy is going to pay 200k for a generalist vs regional trained , they'd rather have the regional trained since the fellowship trained may bring in more money in billing. If the generalist can bill 1M on his 200k salary, that's 800k that the MBA is seeing. But if the regional trained guy can bring in 1.1M by doing all sort of blocks for post op pain, the MBA guy may see 900k on top of the regionalists 200k salary.

I think in the end, sure you can have a great regional training in residency, heck most of these blocks can be taught by looking at youtube videos, but it may be harder to convince an employer if you say you are great at regional without a fellowship, and another applicant says that after being fellowship trained. I feel like these days, employers get tens if not hundreds of applicants per job opening, so you for sure will be competing against fellowship trained grads

 

[nimbus]

If the generalist can bill 1M on his 200k salary, that's 800k that the MBA is seeing. But if the regional trained guy can bring in 1.1M by doing all sort of blocks for post op pain, the MBA guy may see 900k on top of the regionalists 200k salary.

On what basis are you making this assumption? In most situations it would be incorrect. Sometimes the opposite is true and a generalist is generating more revenue than someone with a fellowship. Some people love to do blocks and do a lot of them, some don’t. But a fellowship has no bearing on that. In real life everyone does all the blocks they need to do and you don’t need a fellowship to learn them. You just need one guy who knows what he’s doing to show you. Then you practice.

If anyone is still in training, take advantage of your teachers and make sure to learn the blocks. There’s no reason to do a regional fellowship unless you want to have an academic career as regional faculty.

 

[waterbottle10]

On what basis are you making this assumption? In most situations it would be incorrect. Sometimes the opposite is true and a generalist is generating more revenue than someone with a fellowship. Some people love to do blocks and do a lot of them, some don’t. But a fellowship has no bearing on that. In real life everyone does all the blocks they need to do and you don’t need a fellowship to learn them. You just need one guy who knows what he’s doing to show you. Then you practice.

If anyone is still in training, take advantage of you teachers make sure to learn the blocks. There’s no reason to do a regional fellowship unless you want to have an academic career as regional faculty.

None. I'm just restating what one of my attending mentioned. He said it's one of the reasons why employers will pretty much always pick fellowship trained over generalist at same pay.

 

[deleted171991]

None. I'm just restating what one of my attending mentioned. He said it's one of the reasons why employers will pretty much always pick fellowship trained over generalist at same pay.

So you'd give up a potential 300-500k in lifetime income for that? Of course one will pick the most qualified candidate for the same money.

The main reasons to do a fellowship are:
- to make more money for the same or less work
- a better job (including location, lifestyle etc.), especially if money is not an issue
- to practice mostly or exclusively a subspecialty that makes one happy
- a cacademic career.

 

[Ronin786]

Opportunity Cost and ROI of Fellowships | The White Coat Investor - Investing And Personal Finance for Doctors

"One of the common misconceptions of opportunity cost when choosing a fellowship is to simply determine your first year’s salary (including benefits such as quarterly or annual bonuses) as an attending and subtract that from your fellowship salary. It may look something like this in my field, Anesthesiology:

(Wrong perception)
Opportunity Cost = 1st Year Attending Salary – Fellowship Salary
Opportunity Cost = $250,000 – $60,000 = $190,000"

"So, now combining the three numbers above, in this anesthesiology scenario, your opportunity cost for pursuing a fellowship is $531,166. Now THAT is a big number. If your fellowship is more than one year, you can double or triple that number. Can you ever really catch up on that and break even for an “adequate” ROI?"

https://thephysicianphilosopher.com/wp-content/uploads/2018/05/Opportunity-Cost-Calculator-1.xlsx

Love,
Debbie

Ironically, the author did a regional fellowship.

 

[deleted171991]

Ironically, the author did a regional fellowship.

To be honest, he also feels he got his money's worth, because of academic incentives where he works (although he estimates his opportunity cost to $591K).

If one makes an extra 20-25K/year due to the fellowship, it's probably not a loss. Although, even then, not all fellowships are made equal, especially for PP.

 

[ItBurnsInMyHand]

I'll be doing a regional fellowship once I graduate at a non-ACGME accredited facility where I will be in a junior faculty position. I would say I really enjoyed regional compared to other rotations. Pretty good bread and butter block experience in my residency. Part of what I am looking forward to is a year to learning to supervise residents/ CRNAs. I'm not saying I would be unable to do this had I pursued a job straight out of residency. If my training has taught me anything, it is that I can rise to an occasion. However, the opportunity to be able to learn some of the nuances involved with supervising is something I'm looking forward to and having people around that are still willing to help or provide insight/ideas definitely appeals to me. It is also a level one trauma center, so I am anticipating exposure to some cases that I may not have seen during residency. Call me a chicken; I just think the more experience I have under my belt, the more comfortable I will be once I am truly on my own. Not wanting to pursue cardiac or ccm (the only other fellowship I considered was peds), this seemed like a great transition to anesthesia adulthood while also being able to hone my skills in something I enjoy!

 

[facted]

I'll be doing a regional fellowship once I graduate at a non-ACGME accredited facility where I will be in a junior faculty position. I would say I really enjoyed regional compared to other rotations. Pretty good bread and butter block experience in my residency. Part of what I am looking forward to is a year to learning to supervise residents/ CRNAs. I'm not saying I would be unable to do this had I pursued a job straight out of residency. If my training has taught me anything, it is that I can rise to an occasion. However, the opportunity to be able to learn some of the nuances involved with supervising is something I'm looking forward to and having people around that are still willing to help or provide insight/ideas definitely appeals to me. It is also a level one trauma center, so I am anticipating exposure to some cases that I may not have seen during residency. Call me a chicken; I just think the more experience I have under my belt, the more comfortable I will be once I am truly on my own. Not wanting to pursue cardiac or ccm (the only other fellowship I considered was peds), this seemed like a great transition to anesthesia adulthood while also being able to hone my skills in something I enjoy!

I did a regional fellowship and I thought it was well worth it and I was very comfortable doing blocks out of residency. Since then, I've gotten jobs at two different practices that were only looking for regional fellowship trained people at the time I was hired. Granted, I work in the NE which is quite a crowded work environment.

With that being said, doing any fellowship to learn to supervise residents and CRNA's is just a big NO. You should be doing a great fellowship that will sharpen your block skills, not one that puts you in a role to supervise residents and CRNA's.

 

[facted]

So you'd give up a potential 300-500k in lifetime income for that? Of course one will pick the most qualified candidate for the same money.

The main reasons to do a fellowship are:
- to make more money for the same or less work
- a better job (including location, lifestyle etc.), especially if money is not an issue
- to practice mostly or exclusively a subspecialty that makes one happy
- a cacademic career.

I think it depends entirely on where you're looking to work. In a great job market area, doing a fellowship and giving up 400k income may not be worth it. But if you're in a tougher job market, a fellowship (even regional) can set you apart and help you get a job that otherwise would go to someone else. And in those markets, an entry-level gig is ~350k anyway. If you did a non-ACGME fellowship and made decent 150kish money, you're looking at $200k loss, and that assumes no increased salary from a fellowship. But if that's what you need to do to get a top job in your area, then so be it.

 

[CubsDynasty]

The main reasons to do a fellowship are:
- to make more money for the same or less work
- a better job (including location, lifestyle etc.), especially if money is not an issue
- to practice mostly or exclusively a subspecialty that makes one happy
- a cacademic career.[/QUOTE]

^^My reasons for doing OB fellowship. I'm one of those people who wants to practice mostly OB, I know multiple jobs I am interested in will not take anyone without it. Will be moving to a competitive market. Wife is a higher earner.