Regional Fellowship

[TIVAking]

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I was thinking of doing a regional fellowship next year after I finish. However, everyone (and I mean everyone) I have spoken to about this has tried to talk me out of it. They say that most regional fellowship (like HSS in NYC) are really an "orthopedic" fellowship where the fellows are used as slave labor for one year. They argue that if you really enjoy regional anesthesia to join a practice that has a lot of regional and you will learn as much or more in a year from your partners than in a fellowship - and make $300,000 more in that year. What does everyone else think? Would it be valuable or is it just a marketing ploy to have some cheap labor?

PS - The one good program I heard about was Dartmouth, since you get 1/2 the faculty salary. In that manner, the difference between salary as a "fellow" and a faculty is much smaller. Would that be a more wise choice?

 

[Noyac]

Why in the world would you want 1/2 salary?

A regional fellowship is a complete waste of time.

I got very little regional training in residency. Just enough to know how to do most blocks but not enough to be proficient. I went to PP and learned very quickly. Probably faster than if I would have done a fellowship and made coin in the process.

 

[Anes2009]

My residency program is very weak in regional, but I would NEVER, EVER consider doing a regional fellowship. You can learn regional on the job, if that's the type of job you ultimately take. Think about it. You're giving up hundreds of thousands of dollars to do a few blocks per day? The job market is getting tighter and tighter every year. The best paying, best location jobs are increasingly hard to find. It was not that way 5 years ago. So, you may be giving up a year of your life to earn a misinscule salary in an UNACCREDITED fellowship (unlike cardiac or pain) and might find, in a year, that the job market is even tighter. Sounds like a raw deal to me! I thought about it (briefly) but so many people told me what a scam it was that I quickly moved on.

 

[New2Midwest]

I think you should do whatever you like. I am currently a regional fellow and I really enjoy it. You will learn every block you could imagine both with stim. and ultrasound guided. I was told by many people not to do the fellowship (people shouldn't do fellowships for money anyways)-if money concerns you as priority #1, go into PP out of residency. I really enjoy what I am learning-there is so much more to regional and blocks than just sticking a needle near a nerve (contrary to what most PP guys think). Basic blocks are one thing but it also depends on what your exposure to regional was as a resident. PM if you have further questions....

 

[Noyac]

I don't think people should do fellowships that don't have an accrediting board. If you can't get an additional board cert then why do it? Cardiac gives you TEE, Pain has a board cert as does CCM. You see my point?

 

[New2Midwest]

A lot of people want to make credentialing/board certification with US guided regional. Just do a fellowship if you really enjoy doing it.

 

[Jeff05]

i disagree.

the job market is tightening in and around metro areas. so competition for good jobs is increasing.

you have 2 candidates for a job. everything else being equal...
1. just finished ca3 year. is ok with basic blocks.
2. another just finished a good regional fellowship. can do ALL blocks, quickly, with great success rates. knows how to work with ortho surgeons. can use ultrasound profficiently. can do femoral, IS, IC catheters in 10 min. your practice can now advertise to patients and surgeons that you have a regional specialist.

whom would you hire?

what if you want to do academics - and during your regional fellowship (research is a part of fellowship) you published some regional papers? you are definitely more competitive for academic spots - which in cities are, again, becoming more difficult to land.

most regional places will give you about 120-150k/yr for the fellowship. so you lose 100-150k, over a career, but you gain an edge, that in my opinion will be very useful in the upcoming years.

 

[Anes2009]

I think that in an increasingly tight job market, you either need to do a fellowship that leads to a certification (pain, TEE) or get out there in the real world and learn hands-on.

Most of the PP people I've spoken with have told me it was a waste of time. I applied for pain, then briefly considered regional. Now, after so many people have strongly discouraged a regional fellowship, I'm going to look for jobs.

One of the guys I met at an interview was at HSS a few years back and just hated it. He said he would routinely work till 6-7 pm. They don't have a block room, so you only get to do the blocks for you cases that day. He said he would often get put into a spine room, where there wasn't any regional. He said they didn't do any catheters and he was very comfortable doing all the basic blocks after 4 weeks. He said for the rest of the 11 months he learned nothing additional, worked harder than he ever has in private practice, earned a mere $55,000 (which is nothing in NYC) and found that when it came to looking for jobs his options were no better than someone coming right out of residency. He said that you can learn all blocks (if your practice even does them) within a few weeks/months.

Ultimately, in anesthesia most fellowships are money-losing endeavors. The only possible exception is pain (or possibly cardiac, but that one is close). A regional fellowship doesn't really make you more marketable, and unless you end up at an ortho only practice (which are rare), you might start to lose a lot of your other anesthesia skills in that year (labor epidurals, thorasic epidural, double lumen tubes, neuro...etc). Just not worh it in my opnion.

 

[New2Midwest]

Dude, every regional fellowship is set up differently-at HSS, you are in an OR every day thus 3-5 blocks max per day. Some regional fellowships are designed so you are never in an OR; you just hang out and do blocks in the block area all day. Whereas others are somewhere in between. PP guys will invariably tell you that it's a waste of time. I would also argue that right now, regional fellowship positions are among the most competitive to acquire. I think the best advice in a tight job market is to make yourself stand out; there is always room at the top.

 

[Noyac]

Dude, every regional fellowship is set up differently-at HSS, you are in an OR every day thus 3-5 blocks max per day. Some regional fellowships are designed so you are never in an OR; you just hang out and do blocks in the block area all day. Whereas others are somewhere in between. PP guys will invariably tell you that it's a waste of time. I would also argue that right now, regional fellowship positions are among the most competitive to acquire. I think the best advice in a tight job market is to make yourself stand out; there is always room at the top.

How is this better?
I would think it would be better to place the block and continue the case throughout and even into the pacu. There's more to regional anesthesia than just placing blocks.

BTW, how competitive are regional fellowships?

 

[Gator05]

Applying for the regional fellowship at UF. Similar to Dartmouth, opportunity to significantly increase your income above a PGY-5 level by working as an OR attending 1 day/week..

As for arguments about a "non-accreddited fellowship", this was true for peds and CV just a few years ago.

I agree it's a poor fellowship if you're looking to maximize your income. If you're interested in academics or a hybrid practice between general OR and inpatient consults for acute pain, I think it's great. Aside from it just being fun. Our fellows are quite happy. The number of residents who have applied for the UF fellowship, both from within our residency and outside, speaks for the popularity.

Looking towards the future, I see a time where TKA, THA and TSA are outpatient procedures dependent upon indwelling catheters. Add to this the upcoming data about regional in prostate and breast cancer, and I think there is a lot to be excited about.

If you're interested enough, and are ok with the financial implications, I say go for it!

 

[zippy2u]

Gator, for what it's worth, I hope that fellowship is teaching you how to block an eye. I've run across a lot of these whiz bangers out of residency and ya tell um to throw in a peri/retrobulbar block and ya get that deer in headlights look with rubbery legs. Sure as shiit, they can tell ya the dna sequence of all the subunits of a cholinergic receptor but ya hear every excuse in the book as to why they can't put some LA around an eyeball. I just ain't got no time for all that monkeyshine---same for anything else but propofol for endoscopies. Regards, ----Zippy

 

[Noyac]

Gator, for what it's worth, I hope that fellowship is teaching you how to block an eye. I've run across a lot of these whiz bangers out of residency and ya tell um to throw in a peri/retrobulbar block and ya get that deer in headlights look with rubbery legs. Sure as shiit, they can tell ya the dna sequence of all the subunits of a cholinergic receptor but ya hear every excuse in the book as to why they can't put some LA around an eyeball. I just ain't got no time for all that monkeyshine---same for anything else but propofol for endoscopies. Regards, ----Zippy

Dude, I ain't never dun one of dem retrobulbar blocks.

But I've not seen one done in over 5 yrs either. It's not necessary.

 

[bellandross]

Applying for the regional fellowship at UF. Similar to Dartmouth, opportunity to significantly increase your income above a PGY-5 level by working as an OR attending 1 day/week..

As for arguments about a "non-accreddited fellowship", this was true for peds and CV just a few years ago.

I agree it's a poor fellowship if you're looking to maximize your income. If you're interested in academics or a hybrid practice between general OR and inpatient consults for acute pain, I think it's great. Aside from it just being fun. Our fellows are quite happy. The number of residents who have applied for the UF fellowship, both from within our residency and outside, speaks for the popularity.

Looking towards the future, I see a time where TKA, THA and TSA are outpatient procedures dependent upon indwelling catheters. Add to this the upcoming data about regional in prostate and breast cancer, and I think there is a lot to be excited about.

If you're interested enough, and are ok with the financial implications, I say go for it!

THere is no way the Total joint patients (maybe TSA) will ever be outpts. I agree that regional anesthesia and PN catheters will shorten hospital stay, but because of the post op complications that are still seen in this population, i.e DVT/PE, MI, etc..., they will need to be observed for at least 48hrs. There is data out there by a guy out of UCSD that I remember hearing at a lecture at ASRA on this topic

 

[zippy2u]

I'll agree with ya on that point. If it were my eye, topical all the way. 65 y/o old skool ophtho goat, 80 cases /month, yup, Zip's guilty of bein' a yessir man when money on da table. I betcha ya got your ***** over to da hospital for that 3AM epidural like lickity split. Ya could throw a lil' muscle on the scene and issue a memo stating epidural service only from 7AM-10PM. Regards, ----Zippy

 

[Noyac]

I'll agree with ya on that point. If it were my eye, topical all the way. 65 y/o old skool ophtho goat, 80 cases /month, yup, Zip's guilty of bein' a yessir man when money on da table. I betcha ya got your ***** over to da hospital for that 3AM epidural like lickity split. Ya could throw a lil' muscle on the scene and issue a memo stating epidural service only from 7AM-10PM. Regards, ----Zippy

I can read b/w the lines here zip. Sorry, I don't kiss ass as well as you do.

Why don't you just do the topical for him?

And the 7a-10p epidural service is already in the works.

 

[zippy2u]

'cause Big Daddy likes a "quiet eye" and I like to put needle to skin any chance I can. Regards, ----Zippy

 

[Planktonmd]

there is so much more to regional and blocks than just sticking a needle near a nerve (contrary to what most PP guys think).

Really??
Like what??

 

[pgg]

Dude, I ain't never dun one of dem retrobulbar blocks.

But I've not seen one done in over 5 yrs either. It's not necessary.

I got all excited and twitchy one day because the ophthalmologist told me he wanted to do the case under a retrobulbar block.

Then the bastard wouldn't let me anywhere near the needle. He did the block himself. I pushed a whoppin' 0.5 mg of midazolam then sat there trying to stay awake while he did whatever it was ophthalmologists do.

 

[jwk]

THere is no way the Total joint patients (maybe TSA) will ever be outpts.

Wanna bet?

 

[Noyac]

THere is no way the Total joint patients (maybe TSA) will ever be outpts.

Would yo consider a unicondylar knee a total joint due to the invasiveness of the case?

 

[Gator05]

THere is no way the Total joint patients (maybe TSA) will ever be outpts. I agree that regional anesthesia and PN catheters will shorten hospital stay, but because of the post op complications that are still seen in this population, i.e DVT/PE, MI, etc..., they will need to be observed for at least 48hrs. There is data out there by a guy out of UCSD that I remember hearing at a lecture at ASRA on this topic

His name in Brian Ilfeld. With proper patient selection, and if your surgeon is good enough with (relatively) minimal blood loss, then pain control becomes the big confounder. Enter the ambulatory nerve block. Already movement to make TSA outpatient, with THA/TKA d/c POD1. And this is just with current procedures. With how much money Ortho rakes in, this area is booming when it comes to surgical progress...

 

[toughlife]

I got all excited and twitchy one day because the ophthalmologist told me he wanted to do the case under a retrobulbar block.

Then the bastard wouldn't let me anywhere near the needle. He did the block himself. I pushed a whoppin' 0.5 mg of midazolam then sat there trying to stay awake while he did whatever it was ophthalmologists do.

You dropped the ball on this one. When pt is in preop area and "eye man" tells you he wants a retrobulbar block, you should immediately push some barbs into the patient and proceed to do retrobulbar block.

 

[urge]

THere is no way the Total joint patients (maybe TSA) will ever be outpts.

A friend of mine who only does office/asc anesthesia is already doing a few of them. I thought it was crazy. Anyway, the only thing that will come out of it is decreased reimbursement.

 

[Noyac]

A friend of mine who only does office/asc anesthesia is already doing a few of them. I thought it was crazy. Anyway, the only thing that will come out of it is decreased reimbursement.

What do you mean "a few of them"? TKA's, THA's, or unicondylars?

 

[pgg]

You dropped the ball on this one. When pt is in preop area and "eye man" tells you he wants a retrobulbar block, you should immediately push some barbs into the patient and proceed to do retrobulbar block.

Heh, if only it was that simple. I'm as aggressive as I can be when it comes to getting procedures and cases. When the eye guy said a case for the next day was going to be under a retrobulbar block, I prepared to do it. In the morning, he made it clear he was going to do it and that I was going to watch.

I don't know how your hospital works, but at mine a resident doesn't do a procedure against the wishes of an attending unless he wants to get fired. 🙂

 

[toughlife]

Heh, if only it was that simple. I'm as aggressive as I can be when it comes to getting procedures and cases. When the eye guy said a case for the next day was going to be under a retrobulbar block, I prepared to do it. In the morning, he made it clear he was going to do it and that I was going to watch.

I don't know how your hospital works, but at mine a resident doesn't do a procedure against the wishes of an attending unless he wants to get fired. 🙂

well, let's just say that our opthalmic anesthesiologist is a pimp on retrobulbar blocks and he wrote the chapter in Miller. He has enough clout to get you the whatever optho block you wish to do despite what the 'eye doc' wants. He will even hold your hand while you're doing it. I got to do about 10 of them in less than 2 weeks.

 

[zippy2u]

Bah, You'll be a pimp cubed if ya read Ophthalmic Anaesthesia by Smith, Hamilton and Carr--2nd Edition. Not enough info in Miller to hang your hat on. The Brits know their shiit when it comes to eyeball anesthesia or rather anaesthesia. Regards, ---Zip

 

[Bertelman]

well, let's just say that our opthalmic anesthesiologist is a pimp on retrobulbar blocks and he wrote the chapter in Miller. He has enough clout to get you the whatever optho block you wish to do despite what the 'eye doc' wants. He will even hold your hand while you're doing it. I got to do about 10 of them in less than 2 weeks.

You mean the Eye, Ear, Nose, Throat chapter?

Before this thread, I didn't realize there was such a thing as an Ophthalmic Anesthesiologist. Frankly, I look at the cover of Barash curiously, wondering if half of the residents reading that text will ever perform the block so prominently displayed on the cover.

 

[RussianJoo]

thought it would be better to bring this thread up than starting a new one...


So 2.5 years later do people still feel the same way about doing a regional fellowship?

 

[nap$ter]

we have regional fellows where i work - i do far more blocks as a new attending (supervising 1:2) than they do in their year. most regional fellows have to pay their salary by working as an attending some percentage of the time, and don't do blocks most of those days.

so i do twice as many blocks as they do in a year and get paid more than twice as much... and nobody tells me which block i can and can't do - so i do em all - LP, fascia iliaca, fem, scia (all approaches), ankle, iliohg/ilioing, TAP, all b plexus blocks...etc

i think regional fellowships are for people who aren't confident doing the stuff residency prepares you to do, or who think it will help them get a better job - and i don't think this is true - most pp folks just care that you can DO regional efficiently and safely...

my .02$