Some questions about regional

[Mr FancyPants]

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Hi all, current intern starting CA-1 in July...couldn't find many recent threads on regional anesthesia and had a couple of Q's...

Do most people enter this (or other non-accredited felloships for that matter) mainly to open opportunities in academia? How competitive has regional been in recent years, particularly in the desirable big cities?

I like sticking needles into people - for those currently practicing, what proportion of your time is spent doing actual acute pain procedures? Does one typically do general as well?

Thanks guys/gals!

 

[Lonestar]

I didn't do a fellowship. Just did 4 months of regional during my CA3 yr.

In our practice, we do lots of regional everyday. We also do lots of general.

We do fem/sciatics, axillary, infraclavicular, interscalenes and spinals for ortho cases with propofol infusions. Has worked well for us. We also use blocks for AV fistulas. I have enjoyed doing them.

 

[Mr FancyPants]

Thanks for the reply lonestar, any one else care to chime in? I realize I'm a total noob and this thread isn't about guns or our profession's demise but...any thoughts are appreciated!

 

[periopdoc]

Most of the practices that I talked with were not interested in hiring regional fellows. The thought was that the residents who go into regional are generally weaker (though not as weak as the ones who do OB).

The fellowships that count most in PP are the big ones... ICU, Peds, Cardiac, and debatably Pain.

However, you will likely be expected to know a good amount of regional once you get into practice. The hardest part IMHO is that there are few residencies or fellowships who will train you to do non-ultrasound based techniques, even though this is the predominant technique in the majority of practices that I know of. Perhaps this will change as u/s becomes increasingly cheaper.

Unless you are in a really weak residency, the opportunities to do blocks are there if you look for them and take advantage of them when they present themselves. If there are blocks that your residency doesn't do, try to do an away rotation to improve your skillset. I was lucky enough to get a 2-month stint at Virginia Mason and spend an elective month doing pain/ regional at Harborview.

Good Luck

- pod

 

[Tuohy]

Wow-I think you are mistaken as there are about 10 really good regional fellowships. The competition is quite fierce at the top regional fellowship programs as I have been on the selection committe at one of these programs. I have heard of 50 legitimate applications for 2 spots. Obviously, there is a wide range in quality of fellowship programs but I think you need to be careful when you think that regional fellows are the weaker residents. I happened to be chief resident at a top program and top 5 in my med. school class. And I had several ASC medical director offers right out of fellowship with very impressive compensation packages.

 

[mid|ine]

I would not recommend a regional fellowship. Just make sure you get as much regional exposure in your residency as you can. As long as your are proficient with epidural, spinal, fem, sciatic, interscalene and axillary blocks you can do 99.9% of what you will need.

 

[periopdoc]

Wow-I think you are mistaken...

Not sure how a person's experience can be "mistaken"...

As I said,

Most of the practices that I talked with

We all have different perspectives and experiences, thus the value of this board in gathering a variety of both. I have similar credentials and I seriously considered a regional fellowship. I ended up in cardiac due to circumstances in my life unrelated to medicine. So, I don't personally have a beef with the quality or competitiveness of the top 5-10 regional fellowships, but many of the people that I interviewed with did.

I stand by my statement that the fellowship is unnecessary unless you are planning on an academic career, are looking at specific jobs that require the fellowship (I don't personally know of any of these), or your residency is particularly weak. The same could probably be said for the cardiac fellowship that I did, although I did get several offers specifically because of the training.

If you are the type of person to really push the envelope on regional, you can easily learn it on your own just like the people who developed the regional techniques in the first place. If you are not the type of person to push the envelope, your residency training is sufficient and time spent in the regional fellowship is wasted.

On a financial level, you have to wonder if you will ever be able to recoup the year of lost wages, especially if the doomsayers are right and we only have 5-10 years before a drastic downward adjustment in compensation.

Personally I believe that at this point, for the anesthesiologist headed into general private practice in the United States, the only fellowships worth doing are ones that will secure you a future outside of the OR (ICU and Pain). You will be very lucky to recoup the year of lost wages in any fellowship.


- pod

 

[Planktonmd]

I am not sure why you need a fellowship to do regional?
In private practice you are expected to do a few simple blocks, do them fast and with minimal help.
These are: Interscalenes, maybe Supraclaviculars, some axillaries, Femorals and Sciatics.
Everything else is rare and masturbatory in nature!
That's it!
You should learn these blocks as a resident and demand from your attending to allow you to do them with and without ultrasound.

 

[epidural man]

The thought was that the residents who go into regional are generally weaker (though not as weak as the ones who do OB).

The fellowships that count most in PP are the big ones... ICU, Peds, Cardiac, and debatably Pain.

- pod

Holy crap! I completely disagree. People go into what they enjoy and want to do - how strong they are has nothing to do with it.

I think that fellowships that take you out of the OR will be the most useful in the future - given the current practice trends as discussed at length on this board.

Everything else is rare and masturbatory in nature!

HAHAHA! Love it. Probably true.....

Having said that, have you tried to learn TAP blocks (under ultrasound)? This has become a very useful and once learned, fast and safe block for me. I love doing it. I think the patients benefit as well.

Blocks can be sucky to. (Where are the SARA guys?) I (well the resident....) did an axillary block today - under a time pressure. Plan was to use it for the primary anesthetic. The arm was completely weak, and sensory blocked almost completely, except for the stupid patch on the dorsum of the hand - right where they needed to cut. I didn't have time to do a radial touch up block - which would have been easy enough. I was a little perturbed at the CRNA doing the anesthesia since they could have just asked the surgeon to give some local to the area, or a ring-type block at the wrist (hind sight - i should have done that) - and the patient ended up LMA-ized.

 

[350Z]

I recently did a regional anesthesia fellowship and loved it. There were about 8-10 applicants for each spot. When I was done I was recruited by several practices in highly desirable areas. They were mostly interested in my ability to setup and lead an acute pain service. Since finishing fellowship I have also done consulting for several private groups that continue to hire me to teach them advanced techniques (ie US blocks for lumbar plexus, thoracic epidurals, stellate ganglion (for the pain guys) etc....)

While I can block much more than a IS, SC, Fem, and Sciatic the fact is 99% of practices require only these basic blocks. So dont do a fellowship if just want to learn how to do blocks do it if you want to be a leader in the field.

 

[Mman]

I interviewed at a few places for a regional fellowhip and was offered spots, but declined after thinking more about it.

I think it is very useful if you want to work in the academic world. It looks good on a CV. In private practice, it honestly has very little use. I mean I can't really think of anything I could bring to my current gig that I can't already do (although I think I did get top notch regional training as a resident). I already teach the older guys how to do stuff with the ultrasound and have never met a block I couldn't perform fairly deftly, although I admit to taking my time just a little more with the thoracic paravertebrals (I think it's worth not moving at warp speed with those).

 

[sevoflurane]

Having said that, have you tried to learn TAP blocks (under ultrasound)? This has become a very useful and once learned, fast and safe block for me. I love doing it. I think the patients benefit as well.

I also dig 'em. What kind of cases are you TAP 'n?

Most useful in the emergent OB case that gets a tube and nothing else. Bilateral TAP blocks are perfect for these cases.

http://www.ncbi.nlm.nih.gov/pubmed/18165577