Regional Fellowship

[aimedicine]

I’m considering doing regional fellowship but have been told it’s a waste and that no one is really looking for a Regional trained anesthesiologist, I would like to hear more thoughts from you guys about this.

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[Lecithin5]

While there are other threads addressing this question, I think most would say that if you feel like you need some extra experience and/or desire to secure some sort of academic position related to that subspecialty, then it can’t hurt. Of course there may be an opportunity cost. Most people don’t end up doing it, as it should be part of residency training, and do fine in private practice. You will get better in private practice the more you do it. One of the weaknesses in my residency was regional, and within a few weeks of doing lots of blocks at my gig, I became very good and confident in my abilities.

 

[aimedicine]

See that’s the thing I have no interest in academics and more I think about it the more I’m leaning towards just foregoing fellowship...will I regret this decision?

 

[Lecithin5]

See that’s the thing I have no interest in academics and more I think about it the more I’m leaning towards just foregoing fellowship...will I regret this decision?

Go with your gut. I don’t think you’ll regret the decision of not pursuing a regional fellowship. But if you ever get the itch later on for whatever reason, you can always go back.

 

[Aether2000]

There is rarely any differential pay increase for regional trained anesthesiologists. If you can do US guided adductor canal blocks, pop, TAP, Pecs I and II, ax, and interscalene blocks, you will have covered 97% of the blocks you need in clinical practice. Not all surgery centers have US, and those that do not rarely perform anything other than interscalene or ax blocks with stimulation. Some other blocks are so time consuming using stim only that they are not practical in surgery centers, and therefore are only infrequently employed.

What you would gain by foregoing a fellowship is a minimum extra $165,000 at retirement (with a $30,000 pension contribution with 5% growth over 35 years).

 

[Mman]

There is rarely any differential pay increase for regional trained anesthesiologists. If you can do US guided adductor canal blocks, pop, TAP, Pecs I and II, ax, and interscalene blocks, you will have covered 97% of the blocks you need in clinical practice.

I'd venture a guess that interscalene/supraclavicular, femoral/adductor canal, and popliteal sciatic will be nearly everything you need at the overwhelming majority of jobs you will ever look at.

 

[facted]

Biased as I did a regional fellowship but I do not at all regret doing it as the two places I've worked since were both SPECIFICALLY looking for regional fellowship people. Would not have gotten either job without it and I was plenty good at regional in residency at a big busy place. But sometimes, that extra libe on your resume opens doors. I would recommend it, especially if A) you're actually interested in it and B) you're want to work in a place with a tighter job market (ie: NE for example).

 

[facted]

I'd venture a guess that interscalene/supraclavicular, femoral/adductor canal, and popliteal sciatic will be nearly everything you need at the overwhelming majority of jobs you will ever look at.

There's a lot of interest now in abdominal blocks as well, and doing a paravertebral (or serratus, Pec, etc) or a good thoracic epi doesn't hurt either. But the other blocks are the building blocks for sure. Also, IPack block for TKR is becoming a thing as places move towards outpt TKR.

 

[Mman]

There's a lot of interest now in abdominal blocks as well, and doing a paravertebral (or serratus, Pec, etc) or a good thoracic epi doesn't hurt either. But the other blocks are the building blocks for sure. Also, IPack block for TKR is becoming a thing as places move towards outpt TKR.

while there are all kinds of other things you can do (and I personally do since I love my U/S machine), the bread and butter stuff is simple basic things and that will make you competent to work at almost any job out there.

 

[AdmiralChz]

There's a lot of interest now in abdominal blocks as well, and doing a paravertebral (or serratus, Pec, etc) or a good thoracic epi doesn't hurt either. But the other blocks are the building blocks for sure. Also, IPack block for TKR is becoming a thing as places move towards outpt TKR.

Ugh, we were starting to do iPack blocks when I finished residency. In my limited experience, such an inferior block compared to sciatic. Almost all the knees came out with significant posterior pain, which almost never happened with sciatic. I know foot drop is a concern, but it seems like femoral with a good posterior capsule field block is much better tolerated by the patient.

Agree with the above about regional, Would maybe add TAP to the list of more commonly-seen blocks. Only on SDN have I seen Serratus anterior block mentioned, but I am quite far removed from being a regional expert. PEC easily replaced by a good field block.

 

[facted]

Ugh, we were starting to do iPack blocks when I finished residency. In my limited experience, such an inferior block compared to sciatic. Almost all the knees came out with significant posterior pain, which almost never happened with sciatic. I know foot drop is a concern, but it seems like femoral with a good posterior capsule field block is much better tolerated by the patient.

Agree with the above about regional, Would maybe add TAP to the list of more commonly-seen blocks. Only on SDN have I seen Serratus anterior block mentioned, but I am quite far removed from being a regional expert. PEC easily replaced by a good field block.

Sciatic for a outpatient TKR is a non starter in my opinion. IPACK can be helpful.

Novel Regional Techniques for Total Knee Arthroplasty Promote Reduced Hospital Length of Stay: An Analysis of 106 Patients.

 

[BLADEMDA]

Total Knee Arthroplasty and Anesthesia

I rarely do a Sciatic or Popliteal block for a TKR these days. They simply aren't needed and are in fact a detriment to early ambulation with the goal of discharge POD1.

 

[BLADEMDA]

I’m considering doing regional fellowship but have been told it’s a waste and that no one is really looking for a Regional trained anesthesiologist, I would like to hear more thoughts from you guys about this.

Tough decision. The Fellowship in Regional is best for an academic career. Perhaps, certain elite or high volume practices may have a need for fellowship trained Regional Anesthesiologists but this is the exception and not the rule. I have seen ads requesting this fellowship for private practice jobs from time to time so it's not a complete waste of time.

In the end, you need to make the decision just how much this fellowship will help secure you a job outside academia.

 

[nimbus]

For those who’s goal is PP I wonder if a 4-6 month fellowship would be more than adequate. How long does it really take to become expert at those blocks? Is a fellowship high yield for the entire year? Maybe some programs can offer a PP track. And remember you can keep learning after fellowship or residency, especially if you have an interest and a high volume practice. A significant number of regional fellowship directors and faculty are self taught.

 

[Ronin786]

For those who’s goal is PP I wonder if a 4-6 month fellowship would be more than adequate. How long does it really take to become expert at those blocks? Is a fellowship high yield for the entire year? Maybe some programs can offer a PP track. And remember you can keep learning after fellowship or residency, especially if you have an interest and a high volume practice. A significant number of regional fellowship directors and faculty are self taught.

You mistake the goal of most academic and fellowship programs out there. Their main goal is utilizing a BE anesthesiologist as cheap labor for a year. They have no incentive to forego 6 months of slave labor.

 

[BLADEMDA]

Inaugural ACGME-Accredited RAAPM Fellowships Announced

Sure, look for a non accredited fellowship so you can moonlight as a junior attending. Maybe, 6 months salary as a junior attending ($125K) and 6 months as a fellow ($30k). This option will likely be closing in just a year or two as all the fellowship programs seek formal ACGME status.

ACGME accredited Regional Anesthesia and Acte Pain Medicine Fellowship

 

[facted]

Inaugural ACGME-Accredited RAAPM Fellowships Announced

Sure, look for a non accredited fellowship so you can moonlight as a junior attending. Maybe, 6 months salary as a junior attending ($125K) and 6 months as a fellow ($30k). This option will likely be closing in just a year or two as all the fellowship programs seek formal ACGME status.

ACGME accredited Regional Anesthesia and Acte Pain Medicine Fellowship

Depending on the place and how much call you take, you can make more than that (made over 200,000 myself). Totally right that this will disappear with accreditation

 

[The Physician Philosopher]

I thought regional was a waste of time if going PP but then had co-fellows get great offers because they did one where a practice was spefically looking for a regional person to be the "block-doc."

That said, I do feel like it is more helpful for academics, which is where I stayed.

In terms of opportunity cost, I actually have a post coming out on White Coat Investor in a couple of months on that exact subject. Can't share the details but sufficr it to say after figuring out the math it cost me over $500k to do a fellowship. I'll make that back, but in PP would be tough since you don't get paid more the skill set. (Unless you got a higher paying gig at an altogether different practice that you wouldn't have gotten without it).

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[dhb]

I thought regional was a waste of time if going PP but then had co-fellows get great offers because they did one where a practice was spefically looking for a regional person to be the "block-doc."

That said, I do feel like it is more helpful for academics, which is where I stayed.

In terms of opportunity cost, I actually have a post coming out on White Coat Investor in a couple of months on that exact subject. Can't share the details but sufficr it to say after figuring out the math it cost me over $500k to do a fellowship. I'll make that back, but in PP would be tough since you don't get paid more the skill set. (Unless you got a higher paying gig at an altogether different practice that you wouldn't have gotten without it).

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I'm not pro regional fellowship but you have to admit that a lot of people out there have no concept of regional anesthesia: just look around you at the big meetings; as a patient i'd be weary of 90% of those guys.
So to those people, you come out with a shinny paper saying you're an expert and they'll suck your D.

 

[The Physician Philosopher]

I'm not pro regional fellowship but you have to admit that a lot of people out there have no concept of regional anesthesia: just look around you at the big meetings; as a patient i'd be weary of 90% of those guys.
So to those people, you come out with a shinny paper saying you're an expert and they'll suck your D.

Ultrasound in significant use has only been around for 10 years or so. That means there are twenty years of docs that learned it in practice, and many of them still rely on anatomic regional because it's easier than learning a new skill (or don't offer it to their patients).

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[Lecithin5]

Ultrasound in significant use has only been around for 10 years or so. That means there are twenty years of docs that learned it in practice, and many of them still rely on anatomic regional because it's easier than learning a new skill (or don't offer it to their patients).

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Yeah, some of the older docs in my group clearly try their best not to offer blocks because of their lack of comfort in the skill (be it anatomical or u/s). It’s too bad, because it is a disservice to patients. And blocks are continue to be more important than ever in this day in age where patients are getting fatter (ie avoid GA) and/or on so much chronic opioids that no amount of periop narcotics or non-opioid adjuncts would help.

 

[Aether2000]

In the 12 locations I have been in during the last year doing locums, none of these used regional anesthesia instead of general. They used it in addition to general. Patients are indeed getting fatter, and anatomical landmarks are practically useless.

 

[facted]

In the 12 locations I have been in during the last year doing locums, none of these used regional anesthesia instead of general. They used it in addition to general. Patients are indeed getting fatter, and anatomical landmarks are practically useless.

Billing? Regional as post op analgesia can often bill extra.

 

[Lecithin5]

In the 12 locations I have been in during the last year doing locums, none of these used regional anesthesia instead of general. They used it in addition to general. Patients are indeed getting fatter, and anatomical landmarks are practically useless.

At least your docs are offering/doing it!

 

[aimedicine]

For those of you who did Regional fellowship, what are some of the good ones out there?

 

[facted]

For those of you who did Regional fellowship, what are some of the good ones out there?

HSS, Pitt, Stanford for starters.

 

[The Physician Philosopher]

HSS, Pitt, Stanford for starters.

Would add Virginia Mason, Wake, Duke.

I think HSS is not good because it is strictly Ortho. Had an applicant recently who had done very few truncal blocks and less than 20 thoracic epidurals. They also follow the patient to the room instead of staying in block area.

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[abolt18]

Would add Virginia Mason, Wake, Duke.

I think HSS is not good because it is strictly Ortho. Had an applicant recently who had done very few truncal blocks and less than 20 thoracic epidurals. They also follow the patient to the room instead of staying in block area.

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I did >20 thoracic epidurals in my one month of acute pain last month. I'm an intern. (We do a few months of anesthesia integrated into intern year)

 

[The Physician Philosopher]

I did >20 thoracic epidurals in my one month of acute pain last month. I'm an intern. (We do a few months of anesthesia integrated into intern year)

How many TEA's do you think you need to be pretty good at them?

 

[GA8314]

I'm not pro regional fellowship but you have to admit that a lot of people out there have no concept of regional anesthesia: just look around you at the big meetings; as a patient i'd be weary of 90% of those guys.
So to those people, you come out with a shinny paper saying you're an expert and they'll suck your D.

LOL

 

[abolt18]

How many TEA's do you think you need to be pretty good at them?

I don't think I've done enough to answer that question. What's "pretty good?"

While I've been very successful with them, and I feel pretty comfortable and proficient doing them, I think I've got lots of learning to do. I'm still learning a lot every time I do an epidural and run into new anatomical problems that I have to troubleshoot. I'm still gaining confidence in the tactile feedback I get through the needle with every epidural.

I have only used the harpoon once (BMI 75) but I got too freaked out when I was at 10cm and still hadn't hit any landmarks so I had my attending take over, who got loss at 11cm and continued on my same trajectory without ever hitting bone. I also haven't tried any other techniques like paramedian approach to troubleshoot someone with a tight spine.

Basically, I just feel like I haven't done enough to really be comfortable when I run into challenges that can't be easily troubleshooted by moving the needle up or down 1-3cm.

 

[BLADEMDA]

I don't think I've done enough to answer that question. What's "pretty good?"

While I've been very successful with them, and I feel pretty comfortable and proficient doing them, I think I've got lots of learning to do. I'm still learning a lot every time I do an epidural and run into new anatomical problems that I have to troubleshoot. I'm still gaining confidence in the tactile feedback I get through the needle with every epidural.

I have only used the harpoon once (BMI 75) but I got too freaked out when I was at 10cm and still hadn't hit any landmarks so I had my attending take over, who got loss at 11cm and continued on my same trajectory without ever hitting bone. I also haven't tried any other techniques like paramedian approach to troubleshoot someone with a tight spine.

Basically, I just feel like I haven't done enough to really be comfortable when I run into challenges that can't be easily troubleshooted by moving the needle up or down 1-3cm.

If you have not performed a paramedian Thoracic Epidural then you have not done enough.

 

[abolt18]

If you have not performed a paramedian Thoracic Epidural then you have not done enough.

I agree completely. I was mostly sharing my experience (or lack thereof) and demonstrating that I haven't done enough, so the applicant previously mentioned with <20 obviously hadn't done enough. I did more than 20 in a single month as an intern, but I'd say I'm still at amateur level, so the number required to be proficient is likely quite a few more. Whether that's double or triple or quadruple etc, I don't know.

 

[nimbus]

If you have not performed a paramedian Thoracic Epidural then you have not done enough.

Was thinking the same thing. How do you get over 20 without doing a single paramedian? They must have a uniquely ideal patient population.

 

[Lecithin5]

Was thinking the same thing. How do you get over 20 without doing a single paramedian? They must have a uniquely ideal patient population.

Or more likely, a high lumbar epidural under the guise of a (low) thoracic

 

[AdmiralChz]

I agree completely. I was mostly sharing my experience (or lack thereof) and demonstrating that I haven't done enough, so the applicant previously mentioned with <20 obviously hadn't done enough. I did more than 20 in a single month as an intern, but I'd say I'm still at amateur level, so the number required to be proficient is likely quite a few more. Whether that's double or triple or quadruple etc, I don't know.

Your program allows interns to do thoracic epidurals... ? Good for your program allowing interns to do that I guess, I won’t be next year myself (nor does anyone else there) - ample lumbar experience is needed first IMO, preferably on OB if possible. Thoracic epidural isn’t where I’d start with an inexperienced needle jockey, there’s not much room for error and if you aren’t comfortable with that loss of resistance feels like it could spell disaster for the patient. I’d be nervous if I was supervising, honestly. Then again I as I type this know of colleagues allowing CRNAs to do this routinely, even on kids, so what do I know?

Did you do any other regional blocks in your one month? That’s a big block to jump to right off the bat...

 

[deleted697127]

lol How many IVs have you even placed? That’s odd if you’ve done more thoracic epidurals than IVs.

 

[abolt18]

Your program allows interns to do thoracic epidurals... ? Good for your program allowing interns to do that I guess, I won’t be next year myself (nor does anyone else there) - ample lumbar experience is needed first IMO, preferably on OB if possible. Thoracic epidural isn’t where I’d start with an inexperienced needle jockey, there’s not much room for error and if you aren’t comfortable with that loss of resistance feels like it could spell disaster for the patient. I’d be nervous if I was supervising, honestly. Then again I as I type this know of colleagues allowing CRNAs to do this routinely, even on kids, so what do I know?

Did you do any other regional blocks in your one month? That’s a big block to jump to right off the bat...

We have a pretty busy acute pain service. Interns are the ones doing most of the procedures on our APS. Upper levels start out by showing you the ropes, but they quickly step back to a more supervisory role and fill in the gaps when more than one procedure needs to happen at the same time.

Interscalenes (ss and catheter), lots of fem/sci blocks with frequent femoral catheters, and got to do popliteal, lateral, and infragluteal approaches to sciatic. TAP blocks and catheters. PEC blocks. Did an ankle block, a lateral femoral cutaneous nerve block, and an obturator nerve block.I did ~65 blocks myself (all supervised by an attending, of course)

Most of my epidurals were thoracic because our thoracic, colorectal, GYN/onc, and surg-onc surgical services are all very busy and they almost always want epidurals pre-op. Occasionally we'll get one for rib fractures.

There is obviously graduated responsibility. You start out just putting gloves on and helping set up the kit and feeling the loss of resistance when it's achieved or feeling what it's like when you are engaged/advancing in the ligamentum flavum. Your first few that you actually do, an attending or upper level throws on gloves and helps intermittently. Plenty of practice on models all the while. And that responsibility only increases if you demonstrate competence. Not counting those first ones where I wasn't the primary person doing it, I did 23 thoracic epidurals in the month.

Perhaps our program is set up in a unique manner, but I'm appreciative that I got to do and learn so much this early in my training.

 

[deleted697127]

Interscalene catheter eh?

 

[abolt18]

Interscalene catheter eh?

Indeed. We used through-the-needle catheters for interscalenes and over-the-needle ones for the femoral catheters.

 

[pgg]

That's an impressive residency program that gets 65 blocks (including some thoracic epidurals) to a CA-0. I'm going to go out on a limb and guess that you're not going to "need" a regional fellowship to be proficient.

 

[abolt18]

That's an impressive residency program that gets 65 blocks (including some thoracic epidurals) to a CA-0. I'm going to go out on a limb and guess that you're not going to "need" a regional fellowship to be proficient.

I can only hope so!

 

[The Physician Philosopher]

If you have not performed a paramedian Thoracic Epidural then you have not done enough.

All of our thoracic epidurals are performed paramedian, initially.

Your residency sounds very interesting. It sounds akin to letting a CA1 carry the emergency code/airway bag.

We do a bunch of TEAs, too, and because our regional and acute pain rotation are so popular some of our ca3s can't get a fourth rotation if they want to... Which often means most of the three months Are obtained as a ca-2 and ca-3.

(We have other months with regional techniques like ambulatory rotations, but this isn't taught by our regional faculty).

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[Psai]

All of our thoracic epidurals are performed paramedian, initially.

Your residency sounds very interesting. It sounds akin to letting a CA1 carry the emergency code/airway bag.

We do a bunch of TEAs, too, and because our regional and acute pain rotation are so popular some of our ca3s can't get a fourth rotation if they want to... Which often means most of the three months Are obtained as a ca-2 and ca-3.

(We have other months with regional techniques like ambulatory rotations, but this isn't taught by our regional faculty).

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Whats wrong with a ca1 carrying the airway bag?

 

[POW16]

Everything.

 

[deleted162650]

Everything.

Disagree. At my program, CA-1’s regularly carried the airway pager. Early in the year a senior resident or staff would tag along, but late in the year it wasn’t uncommon for a CA-1 to respond alone with a “call if it looks hairy” blessing from the attending. A late CA-1 has better airway skills than just about any other non-anesthesia personnel in the hospital. I would have hated training a hand holding, baby the juniors type of program.

 

[The Physician Philosopher]

Whats wrong with a ca1 carrying the airway bag?

There is certainly a minimal amount of airway experience that should allow you to carry the airway bag. You and I apparently differ on what that amount of experience is.

Would you want a CA1 being the expert on scene to intubate you in a dead or dieing situation?

Historically, our program has done this in the past many years ago. Now this is one of the primary responsibilities of the CA-3 on call, which is much better for everyone involved.


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[norwood]

Whats wrong with a ca1 carrying the airway bag?

Depends if he's fast enough to keep up with the CA3/fellow/attending who will actually be using its contents...

 

[Ashers]

I did a regional fellowship because I was not comfortable with blocks when I finished residency. I went to the University of New Mexico for my fellowship, and it was very well rounded (peripheral, neuraxial, acute pain, peds, inpatient, and outpatient). Initially, after fellowship, I went home to do private practice, and one reason I was hired was because of my regional fellowship. I came back to a hospital associated with UNM (after leaving my 1st job), where they wanted to make sure that each attending is proficiency with blocks. I am absolutely glad I did a regional fellowship.

 

[POW16]

Disagree. At my program, CA-1’s regularly carried the airway pager. Early in the year a senior resident or staff would tag along, but late in the year it wasn’t uncommon for a CA-1 to respond alone with a “call if it looks hairy” blessing from the attending. A late CA-1 has better airway skills than just about any other non-anesthesia personnel in the hospital. I would have hated training a hand holding, baby the juniors type of program.

We can agree to disagree. As a CA-1, especially early in the year you still worry about putting the tube in. Even though you see a fair amount of sick patients,you are nowhere close to being ready to decide on an induction plan for sick patients requiring an ETT. I am not talking about coding patients (that don't require any drugs) but decompensating patients on the floor or the ICU. We routinely bring the CA-1s on call to intubate but they're always supervised by a CA-3 who pushes drugs and acts as a backup.