Regional Fellowship

[The Physician Philosopher]

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.

Agree with you. The "about to code" patient is not a place for a CA-1 to learn the hard lessons involved in putting a tube in that patient.

That said, our CA-3s get a ton of autonomy with airway experiences and so there is not a "handholding, baby" experience. I think CA-1 year is too early for that kind of autonomy.

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[Arch Guillotti]

Whats wrong with a ca1 carrying the airway bag?

It's sort of stupid.

 

[Ronin786]

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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I agree. Doing that many blocks is fine and all, but I question the utility of a CA0 that has no real idea of what each surgery entails or the applicability of the blocks to the case. Granted their program may be designed in a way to facilitate that, but there's a lot more to regional anesthesia than just doing the procedure.

 

[abolt18]

I agree. Doing that many blocks is fine and all, but I question the utility of a CA0 that has no real idea of what each surgery entails or the applicability of the blocks to the case. Granted their program may be designed in a way to facilitate that, but there's a lot more to regional anesthesia than just doing the procedure.

Agreed that it's more than just learning how to do the procedure, and there are multiple structured avenues for learning during and before the rotation in our program including modules on anesthesia toolbox, recorded lectures, recommended reading, and regular faculty teaching. I mean honestly, putting the needle in the right place is not technically difficult if you have a bit of hand-eye coordination and some practice with the ultrasound. Knowing who/what/when/why or why not for each block is what makes that skill useful, effective, and safe.

 

[Aether2000]

All easily learned during residency. Also you will find that your medical decision-making on when a block is appropriate is trumped by local politics of the hospital and surgeon preferences in the real world. In that sense, a regional fellowship could actually be detrimental, giving a physician a false sense of reality, colored by the pedagogy of the academic world that may be a non-sequitur in clinical practice. Also, just how many years are necessary to create an anesthesiologist? I find the tacking on of any fellowship to an already bloated educational track, now totaling 9-10 years after undergraduate studies, to be excessive compared to some other western countries training, and especially compared to the 2-3 years training of a CRNA that are being trained to do exactly the same thing. Some physician led workshops and some CRNA programs train nurses to do regional anesthesia techniques. Our system of educating physician anesthesiologists in the US seems to be driven more by outdated academic BS and manpower needs in the OR than any consideration of the thousands of extra man-years of training/slave labor each year in anesthesiology and its ever burgeoning add-on fellowships.

 

[Psai]

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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If I were in a dead or dying situation, I would want people to let me go peacefully

 

[GA8314]

Agreed that it's more than just learning how to do the procedure, and there are multiple structured avenues for learning during and before the rotation in our program including modules on anesthesia toolbox, recorded lectures, recommended reading, and regular faculty teaching. I mean honestly, putting the needle in the right place is not technically difficult if you have a bit of hand-eye coordination and some practice with the ultrasound. Knowing who/what/when/why or why not for each block is what makes that skill useful, effective, and safe.

Fair points, but the physician model of training (med school and 4 years of residency) teaches us that we need to know the who/what/when/why and why not before undertaking any endeavor.

 

[GA8314]

All easily learned during residency. Also you will find that your medical decision-making on when a block is appropriate is trumped by local politics of the hospital and surgeon preferences in the real world. In that sense, a regional fellowship could actually be detrimental, giving a physician a false sense of reality, colored by the pedagogy of the academic world that may be a non-sequitur in clinical practice. Also, just how many years are necessary to create an anesthesiologist? I find the tacking on of any fellowship to an already bloated educational track, now totaling 9-10 years after undergraduate studies, to be excessive compared to some other western countries training, and especially compared to the 2-3 years training of a CRNA that are being trained to do exactly the same thing. Some physician led workshops and some CRNA programs train nurses to do regional anesthesia techniques. Our system of educating physician anesthesiologists in the US seems to be driven more by outdated academic BS and manpower needs in the OR than any consideration of the thousands of extra man-years of training/slave labor each year in anesthesiology and its ever burgeoning add-on fellowships.

I largely agree with you. I too feel that the push towards fellowship, almost any fellowship, has gotten a bit out of control. Cutting edge cardiac, neonates and sick peds being a strong exception. ICU and pain are basically different specialties. But, it does seem like we are shooting ourselves in the foot a bit doesn't it? This excessive push is mostly being led by academia with a good deal of self interest involved.

As technology and techniques evolve, our profession needs to be flexible enough to allow for the acquisition of such skills just as much as any surgical subspecialty allows for the adoption of new techniques, technology, and procedures. Almost always this does not require going back to do, or doing, a fellowship.

I've found a nice practice as a good general anesthesiologist doing a wide array of cases. I do not regret my own decision. Quite the opposite. I respect that of others to pursue certain fellowships (listed above), but just ANY fellowship does not make much sense to me and the reality of the marketplace as well as personal economics (opportunity cost) suggests as much.

Residents need to hear the other side of things as well, because they are almost certainly being inundated with a very pro-fellowship agenda while in training.

 

[Aether2000]

In a perfect world, where we could jettison the ABA board, replacing them with clinicians instead of academics, and fundamentally alter ACGME entrenched training protocols, it would be possible to design an anesthesia residency program of 4 years, with the last year being a specialization year in pain, cardiac, peds, critical care, regional, neuro, etc. Of course this would require a sea change in both the philosophy and implementation of the residency programs to be more physician-centric rather than institution-centric. Even more radical would be to eliminate the sequence of BS followed by MD degrees, and make all programs a 5-6 year MD degree after high school, that included a broad swath of courses relevant to medicine but also with courses broad enough to include humanities, communication, etc. while eliminating many courses required for the BS that have no relevance in the practice of medicine. Those wanting to do research would then go on to the PhD after the MD degree. These combined changes would trim years and billions of dollars of unnecessary educational pathways that have evolved by academic tradition rather than by pragmatic design.

 

[anbuitachi]

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.

Which residency is this? Do you guys have a fellowship? It sounds like you guys have a ton of blocks. I may be applying for regional fellowship and looking at different programs now..

 

[abolt18]

Which residency is this? Do you guys have a fellowship? It sounds like you guys have a ton of blocks. I may be applying for regional fellowship and looking at different programs now..

Our acute pain faculty are adamant that we will not have a regional fellowship, for the sake of our residents. They don't want to take any of the opportunities from us, despite having the numbers to probably have a fellowship.

 

[Mehd School]

especially compared to the 2-3 years training of a CRNA that are being trained to do exactly the same thing. Some physician led workshops and some CRNA programs train nurses to do regional anesthesia techniques.

Your experiences have likely been different from mine, but many of the CRNA's I've worked with love to go down to the well regarded workshop at UNT and work on cadavers. They do crap blocks before they leave, and come back afterwards doing crap blocks confidently. It's bizarre to me that you're essentially equating that to an accredited fellowship.

 

[Mehd School]

Residents need to hear the other side of things as well, because they are almost certainly being inundated with a very pro-fellowship agenda while in training.

This is an interesting perspective and I thank you for sharing it. I interviewed at over a dozen programs this year and 90% of them hammered home that we should do a fellowship, and rank lists were a large part of their sales pitch.

Two programs jump out to me that said that they train us to be competent general anesthesiologists first, and if we decide to subspecialize, so be it. I intend to do a fellowship (obviously very subject to change) because early in my career (and likely beyond) I want to be doing all or most of my own cases. Attendings and programs abroad have hammered into me that jobs are becoming more and more rare for MD/DO only general anesthesia.

 

[nimbus]

Attendings and programs abroad have hammered into me that jobs are becoming more and more rare for MD/DO only general anesthesia.

Talk to some MD/DO only PP docs and ask them what their actual needs are. We have more than a few fellowship trained people who do exactly the same thing that everyone else does. Same schedule, same cases, same pay, same everything. A great general anesthesiologist is nothing to sneeze at. The need for a fellowship in actual practice may be overblown in academics.

 

[GA8314]

Talk to some MD/DO only PP docs and ask them what their actual needs are. We have more than a few fellowship trained people who do exactly the same thing that everyone else does. Same schedule, same cases, same pay, same everything. A great general anesthesiologist is nothing to sneeze at. The need for a fellowship in actual practice may be overblown in academics.

Indeed. Residents simply need to consider the other side of the story and find out what the actual NEEDS of PP groups are. We had a Peds fellowed guy do Locums for us. We had zero interest in even hiring him on full time/offering a partner track and most certainly would not pay him a premium for the year of Peds training. We do some bread and butter T&A's and dental. Otherwise healthy peds. It's a relatively small part of our practice.

For similar above examples, I don't think our group is alone. The other thing to consider is that as fellowed grads enter the workforce and fill specialty roles, there very well could be ample opportunities (increase?) for generalists. It's not like "generalists" are just doing cake walk cases all day long. They are doing all sorts of cases, including difficult off-site cases, neuro, frequently even CV and B&B peds (but not always), regional, trach/pegs on trainwrecks from the ICU, and your average OB/GYN with BMI>50.... To list just a few examples....

Don't knock the challenge of good general cases. Or the future demand for them.

That said, doing a fellowship does not preclude you from these cases, but if you go to a larger tertiary care center, you'll likely be doing mostly subspecialty cases I presume.

 

[anbuitachi]

Hijacking the thread sort of but recently accreditation for regional program came out and i believe 11 programs already received accreditation, may be more now. I'm not sure what improvements if any accreditation will bring to the program... but do jobs even care if you graduated from an accredited vs non accredited regional program.. eg for jobs that say they prefer regional fellowship trained.. do you think itd specifically want ACGME accredited fellowship trained?

 

[The Physician Philosopher]

Hijacking the thread sort of but recently accreditation for regional program came out and i believe 11 programs already received accreditation, may be more now. I'm not sure what improvements if any accreditation will bring to the program... but do jobs even care if you graduated from an accredited vs non accredited regional program.. eg for jobs that say they prefer regional fellowship trained.. do you think itd specifically want ACGME accredited fellowship trained?

No. Accreditation only brings the bad programs up. It rarely improves the good programs. I don't think anyone who knows anything about this sort of thing would prefer an accredited fellow over a non-accredited. In fact, they may do the opposite.

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[Psai]

Regional fellowship is a scam. Life is too short.

 

[The Physician Philosopher]

Regional fellowship is a scam. Life is too short.

Lol. Completely depends on what you want to do with your life. If you are doing academics and want to study regional (like I did) you don't have a choice. Also know several people who did a fellowship and landed a great gig to be "the regional" person at their respective group or to create an acute pain service.

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[deleted697535]

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 held it as ca1s and it was fine for.most of us. Except for one who might have tubed the goose during a code and got written up for it and almost kicked off the scheme.

 

[deleted697535]

Am I reading this right? Someone has done more thoracic epidurals than peripheral ivs?

What the ****? I don't even know where to start...

 

[anbuitachi]

Am I reading this right? Someone has done more thoracic epidurals than peripheral ivs?

What the ****? I don't even know where to start...

I think an average program resident graduate with <10 thoracic epidurals...

 

[Psai]

Am I reading this right? Someone has done more thoracic epidurals than peripheral ivs?

What the ****? I don't even know where to start...

I am writing a proposal to my pd as we speak.

 

[anbuitachi]

I am writing a proposal to my pd as we speak.

Proposal to do more IV s?

 

[Mman]

I think an average program resident graduate with <10 thoracic epidurals...

huh? I'm too far removed to remember the exact case minimums but there are some number of thoracic surgical procedures you need to do of which they can't all be VATS wedge resections that don't need an epidural. Throw in some whipples and what not and I'd find it hard to believe the median number of thoracic epidurals for graduating residents across the country is < 40. And I'm including shady programs that try to skirt by the bare minimums. Any normal residency is probably at least 50-100.

 

[pgg]

huh? I'm too far removed to remember the exact case minimums but there are some number of thoracic surgical procedures you need to do of which they can't all be VATS wedge resections that don't need an epidural. Throw in some whipples and what not and I'd find it hard to believe the median number of thoracic epidurals for graduating residents across the country is < 40. And I'm including shady programs that try to skirt by the bare minimums. Any normal residency is probably at least 50-100.

Well, technically a T10 epidural for something in the belly is a "thoracic" epidural, but really that's no different than a lumbar epidural in terms of technique or difficulty. Often easier in fact because there's less butt fat in the way, the patients tend to be skinnier (cancer, elderly), and the spinous processes are still pretty horizontal.

When I think "thoracic epidural" I imagine something mid thoracic that deserves a paramedian approach. If you don't pad the numbers with low thoracic chip shots for belly crap, I bet 10 per resident isn't all that far off the truth. I bet our program's residents are in the range of 10 of those thoracic epidurals. My CT fellowship, at a reputable place, included 2 months of thoracic. I took some vacation during that time, so I probably only got 6 or 7 weeks of dedicated thoracic time. Even so, maybe I did 15? Not sure off the top of my head. It wasn't something we logged. I don't think I did a lot.

Also, a lot of cases that used to get thoracic epidurals, e.g. VATS lobectomies etc, are getting intercostal blocks from the surgeons. They squirt some bupiv or Exparel in between a few ribs and call it a day. And hospital stays are shorter ... the last thoracic epidural I put in, they pulled on POD 1 ... not sure I'll bother next time. It wouldn't surprise me if our residents finished up with 10 of them.

 

[AdmiralChz]

We didn’t put any T Epi’s in for VATS only thoracotomies, and since those are fairly rare we didn’t put a ton in. We put some in for Whipples, like pgg said like T10.

Ive probably done 10 max in residency, much more in fellowship. Still don’t get letting an intern without much needle skills do them but hey, to each program their own. Maybe my residency sucked, I dunno. Doesn’t bother me much.

 

[Mman]

Well, technically a T10 epidural for something in the belly is a "thoracic" epidural, but really that's no different than a lumbar epidural in terms of technique or difficulty.

I learned to do all thoracic epidurals paramedian as a resident, T6 or T10, does that mean they are more comparable? I find no difference in difficulty for a mid thoracic paramedian approach compared to a lumbar midline approach. It's all the same, just a slightly different angle of approach. But even if you take out the low ones, all the ones for traumatic rib fractures, lung transplants, thoracotomies, VATS pneumonectomies and lobectomies, etc I'd bet it still ends up averaging more than 10 for most places.

 

[McPoyle]

10 seems exceedingly low... this is a procedure we should all be comfortable with after training. Who is doing these for VATS??? We did tons of paravertebrals.


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[Lecithin5]

10 seems exceedingly low... this is a procedure we should all be comfortable with after training. Who is doing these for VATS??? We did tons of paravertebrals.


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I wish we did some paraverebrals during training. Nobody did them at our residency- just wasn’t a thing. Unfortunately at times too much group-think lol

 

[AdmiralChz]

10 seems exceedingly low... this is a procedure we should all be comfortable with after training. Who is doing these for VATS??? We did tons of paravertebrals.


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I guess I didn’t go to the average SDN program where residents get advanced TEE certs, 100+ Thoracic and cervical blocks, opportunities to join the Legion of Doom, all score >99th percentile on ITE, $300/hr after 3 PM. I’ll choose better next time...

But seriously, different strokes out there. We did tons of paravertebrals too... not a block I’ll be replicating in my own practice, personally (more labor intensive compared to standard epidurals in my limited experience),

 

[anbuitachi]

I guess I didn’t go to the average SDN program where residents get advanced TEE certs, 100+ Thoracic and cervical blocks, opportunities to join the Legion of Doom, all score >99th percentile on ITE, $300/hr after 3 PM. I’ll choose better next time...

But seriously, different strokes out there. We did tons of paravertebrals too... not a block I’ll be replicating in my own practice, personally (more labor intensive compared to standard epidurals in my limited experience),

I haven't done a single cervical epidural!

Or paravertebral... I dont think we really do them here, the risks are significant and there are better alternatives.. Paravertebral is deep so if you do a paravertebral, might as well do a epidural...

 

[GA8314]

paravertebrals with US aren't that tough once you do a couple. A bit of a learning curve but not so bad. We do single shots with decadron for our VATS/Thors. They do a good job. PECS 2 blocks for mastectomies with axillary node dissection and for reconstructions. Safer/Easier than paravertebrals. We should probably go back to Thoracic epidurals for some of our Thors but that's another story. We still do them for the larger open abdominal cases.

 

[deleted697535]

Yeah in fairness to pvb with USS it's not that difficult and the complication rate is pretty low. Even if you give them a pneumo it's really rare to need a chest tube

I'd say pvb is faster than epidural

 

[deleted697535]

I haven't done a single cervical epidural!

Or paravertebral... I dont think we really do them here, the risks are significant and there are better alternatives.. Paravertebral is deep so if you do a paravertebral, might as well do a epidural...

Pvb risks? I have it in my head as a fairly low risk block. An article I read a while ago even said pneumos caused by it we're usually.self resolving

 

[The Physician Philosopher]

Yeah in fairness to pvb with USS it's not that difficult and the complication rate is pretty low. Even if you give them a pneumo it's really rare to need a chest tube

I'd say pvb is faster than epidural

Arrogant comment of day....

It depends on who is doing it. A TEA shouldn't take longer than a few minutes in experienced hands. Time to set up iltrasound get image, prep and drape, ultrasound cover, get image again and then do procedure takes longer than a few minutes no matter who you are.

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[anbuitachi]

I find even erector spinae to be hard and its supposed to be a easier paravertebral. When everyone is obese it's hard to get good images

 

[deleted697535]

Arrogant comment of day....

It depends on who is doing it. A TEA shouldn't take longer than a few minutes in experienced hands. Time to set up iltrasound get image, prep and drape, ultrasound cover, get image again and then do procedure takes longer than a few minutes no matter who you are.

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That's even what the articles on pvbs say not me

 

[anbuitachi]

That's even what the articles on pvbs say not me

They probably had someone set up everything and positioned the patient and all they did was come in and inject!

 

[StudyAnesthesiology]

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.

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.

A regional fellowship is pretty unnecessary if you're headed to private practice! Not to mention an extra year of not making any money....

 

[anbuitachi]

A regional fellowship is pretty unnecessary if you're headed to private practice! Not to mention an extra year of not making any money....

It's like a 150k difference here. Which is like 75k after tax. Regional fellow get like almost 90k I think if there's overtime or moonlighting, compared to 200 to 250k for attendings.

 

[facted]

A regional fellowship is pretty unnecessary if you're headed to private practice! Not to mention an extra year of not making any money....

Both my current job and prior job were only hiring regional fellowship trained positions when I got the job(both private practice) but it definitely depends on the job market. In the NE, you have to differentiate yourself.

Not to mention I made close to 200k with moonlighting, though that's going away with accreditation.

 

[nimbus]

Both my current job and prior job were only hiring regional fellowship trained positions when I got the job(both private practice) but it definitely depends on the job market. In the NE, you have to differentiate yourself.

Not to mention I made close to 200k with moonlighting, though that's going away with accreditation.

What role did you play in the new jobs? What did you do that the generalists did not do? Are you teaching your current partners the blocks you mastered during fellowship? I could see that as one plausible reason why a PP group would specifically want a regional fellow as a new hire.

 

[facted]

What role did you play in the new jobs? What did you do that the generalists did not do? Are you teaching your current partners the blocks you mastered during fellowship? I could see that as one plausible reason why a PP group would specifically want a regional fellow as a new hire.

In my old gig, I did a lot of blocks that no one was doing (adductor, truncal blocks, serratus) and quickly became I've of the go to guys for blocks. A few others were doing lots of blocks but in a relatively large group (60+ attendings), I'd say maybe 10 or so were comfortable doing all the blocks. I did lots of Ortho there, and frequently called to help others with blocks (which I mostly liked).

Current gig, we do lots of Ortho and most everyone is comfortable with blocks, nothing crazy we're doing but both I and the guy they fired right after me are both regionally trained.

 

[Dr3mc6tchr]

HSS trained fellow here, after they started adding MSK and I highly recommend the program. Anesthesiology residency is growing in terms of subspecialty requirements and residents aren't getting as much regional/ICU/cardiac/peds to be able to all these things well without a fellowship. HSS/MSK positioned me to hit the ground running with my current job (privademic) and overall it was an awesome year. Fellows choose tracks so some went to Ghana or India for global health, some went to Austria. Between HSS/MSK, there is not a block you won't be able to do. Not as many catheters so you'll have to push for that/learn them on your own.

 

[nimbus]

HSS trained fellow here, after they started adding MSK and I highly recommend the program. Anesthesiology residency is growing in terms of subspecialty requirements and residents aren't getting as much regional/ICU/cardiac/peds to be able to all these things well without a fellowship. HSS/MSK positioned me to hit the ground running with my current job (privademic) and overall it was an awesome year. Fellows choose tracks so some went to Ghana or India for global health, some went to Austria. Between HSS/MSK, there is not a block you won't be able to do. Not as many catheters so you'll have to push for that/learn them on your own.

I’m sure regional experience depends on the residency. Our new hires without fellowship are very good at blocks they need to know. Which blocks do you do now that you couldn’t do at the end of residency? Just curious.


The international experience sounds worthwhile but that’s probably not happening in the next few years.

 

[Mman]

I’m sure regional experience depends on the residency. Our new hires without fellowship are very good at blocks they need to know. Which blocks do you do now that you couldn’t do at the end of residency? Just curious.


The international experience sounds worthwhile but that’s probably not happening in the next few years.

i seriously question a regional fellowship that doesn't train you with significant catheter experience. I mean what's the point???

 

[dhb]

i seriously question a regional fellowship that doesn't train you with significant catheter experience. I mean what's the point???

Catheters are mostly a thing of the past, each time i try to find an indication i can't find any.

 

[Mman]

Catheters are mostly a thing of the past, each time i try to find an indication i can't find any.

we send our total knee and shoulder patients home and get longer analgesia and higher patient satisfaction than with any single shot technique. But from a fellowship point of view??? You can learn just about every single shot technique you will ever need in residency and out on the job.

 

[dhb]

we send our total knee and shoulder patients home and get longer analgesia and higher patient satisfaction than with any single shot technique. But from a fellowship point of view??? You can learn just about every single shot technique you will ever need in residency and out on the job.

Really? Is the difference enough to justify the trouble? Are the knees ambulatory? A total knee with a single shot technique will have a comfortable first 24h needing on average 10mg of morphine, the next 24h are not as great but on average they're at 30-40mg of morphine over the first 3-4 days so i'm not placing a catheter to save them from taking 3-4 10mg oxy.