Time to choose a Fellowship: Peds vs Pain

[Dawkter]

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PEDS:
Pros- Rewarding, broad variety of cases with unique niches including pain/cardiac, desirable fellowship for competitive job markets, generally collegial environment and pleasant surgeons

Cons- Can be high stress at times (laryngospasm/cardiac defects), may be stuck with the sickest patients if you are the only peds guy in your group, neonates scare EVERYONE

PAIN:
Pros- Great skill set outside of the OR, may have diversity of practice if you split time between the OR and pain, fun procedures, patient contact, no call/weekends, great pay

Cons- Unknown future with reimbursements, difficult patients, may lose OR skills if practicing 100% pain, midlevel encroachment


I could honestly see myself being very happy with either of these options. I really do like being in the clinic setting and appreciate that pain gives you an avenue to practice medicine outside of an OR setting if you feel like changing up the pace. I do not think I would be happy doing 100% pain as I definitely enjoy my time in the OR as well.

Any thoughts or advice? Any other residents debating between these two options?

 

[PainDrain]

My choice was between pain and critical care. I went with pain for a little better lifestyle and I had issues with keeping dead patients alive by artificial means for their family's comfort.

Anyway here are my thoughts on pain. I love the procedures and getting to actually help people get some relief from their chronic pain, but the types of patients you get in an academic setting and those you get in the "real world" are totally different. In academics you typically get straightforward chronic pain patients and you may actually have the resources to offer them a procedure or treatment plan that will help them. In the real world, most insurance plans suck and make patients jump through hoops for procedures. Also in private practice, if you prescribe you will get over run with drug seekers and problems. The sweet little grandmother will become a raging psycho when you tell her you aren't going to prescribe to her the Oxy 40 QID her PCP had been giving her for her vague pain complaints. You become the dumping ground for other people's problems. The PCP's patient with fibro who insists on getting narcotics....send them to pain. The ortho spine doc who did a 6th revision-fusion on a 45 yo and left the guy in agony...send him to pain. The psychiatrist who has a bipolar former heroin addict/alcoholic with a bad back....send him to pain. If it were up to me my practice would be procedures and med consults only but it's tough to stay alive without prescribing to some people. Some states are even mandating that pain management be involved in all patients who are on chronic narcs. Don't get me wrong, I like what I do but you have to really make sure you can stomach it.

 

[Random Anesthesiologist]

I went into peds with the goal of being comfortable handling sick babies. Now I really love it. I'm doing ccm but have thought about a second year with peds if certain future plans with my spouse play out. The only downside for me would be income lost, something to think about.

 

[deleted162650]

My choice was between pain and critical care. I went with pain for a little better lifestyle and I had issues with keeping dead patients alive by artificial means for their family's comfort.

Anyway here are my thoughts on pain. I love the procedures and getting to actually help people get some relief from their chronic pain, but the types of patients you get in an academic setting and those you get in the "real world" are totally different. In academics you typically get straightforward chronic pain patients and you may actually have the resources to offer them a procedure or treatment plan that will help them. In the real world, most insurance plans suck and make patients jump through hoops for procedures. Also in private practice, if you prescribe you will get over run with drug seekers and problems. The sweet little grandmother will become a raging psycho when you tell her you aren't going to prescribe to her the Oxy 40 QID her PCP had been giving her for her vague pain complaints. You become the dumping ground for other people's problems. The PCP's patient with fibro who insists on getting narcotics....send them to pain. The ortho spine doc who did a 6th revision-fusion on a 45 yo and left the guy in agony...send him to pain. The psychiatrist who has a bipolar former heroin addict/alcoholic with a bad back....send him to pain. If it were up to me my practice would be procedures and med consults only but it's tough to stay alive without prescribing to some people. Some states are even mandating that pain management be involved in all patients who are on chronic narcs. Don't get me wrong, I like what I do but you have to really make sure you can stomach it.

You make a pretty convincing argument for peds.

 

[deleted171991]

Peds is cooking a problem some people might not realize: inflation of providers. There are/will be way too many pedi anesthesiologists compared to the number of truly sick kids who need one. Even including the healthy kids. In translation, be prepared to do at least 50% adult cases in your future, if not much more. I am not sure it's worth the $200-300k loss. It's gonna be like OB, or neuro: nice to have, but not commanding a premium.

I considered pedi myself, because I was visibly enjoying my pedi rotations. I just didn't like doing really sick kids, and I am not sure the fellowship is worth doing for anything else.

 

[IlDestriero]

I think that's true of peds. Many grads won't be able to get into a 100% peds job at one of the big freestanding hospitals. However many of our fellows don't want to commit to only peds anyway or want to be a peds expert in a PP group. In the future if there is an oversupply, I suspect they'll either decrease the number of fellowship spots or people simply won't fill them, particularly at the smaller programs that lack the name recognition and connections needed to get those competitive jobs.
The quote above explains why I changed my mind about pain. I was pain bound until my eyes were opened by a couple former faculty that were out in PP pain land.

 

[pgg]

I think that's true of peds. Many grads won't be able to get into a 100% peds job at one of the big freestanding hospitals. However many of our fellows don't want to commit to only peds anyway or want to be a peds expert in a PP group. In the future if there is an oversupply, I suspect they'll either decrease the number of fellowship spots or people simply won't fill them, particularly at the smaller programs that lack the name recognition and connections needed to get those competitive jobs.
The quote above explains why I changed my mind about pain. I was pain bound until my eyes were opened by a couple former faculty that were out in PP pain land.

Has any medical field in the history of ever made a collective decision to reduce the overall number of grads? Who wants to shrink their program and give up their slave labor pool?

We need an OPEC-like cartel to quit pumping grads out when the market cost declines ... (Now that I'm in and got mine, of course! 😉)

 

[GassmanMD]

"Time to choose a Fellowship." Why is that always the question residents think they must ask themselves? Now that everyone is doing a fellowship, it leaves the door open for the generalists to get the jobs where they do not need a specialist. And if you think about the majority of the cases being performed, there are more jobs out there for generalists. I am starting to believe you have more options in the market by not doing a fellowship.

 

[deleted162650]

"Time to choose a Fellowship." Why is that always the question residents think they must ask themselves? Now that everyone is doing a fellowship, it leaves the door open for the generalists to get the jobs where they do not need a specialist. And if you think about the majority of the cases being performed, there are more jobs out there for generalists. I am starting to believe you have more options in the market by not doing a fellowship.

It's not like you can't take a generalist job after doing a fellowship, you just "wasted" a year that's all. Some groups might even take a fellowship trained guy over someone without a fellowship even if the job doesn't entail that subspecialty.

 

[GassmanMD]

That is a big, expensive waste of a year. I bet it happens often. We are experiencing a fellowship bubble right now, propagated by the institutions that benefit from the cheap labor.

 

[pgg]

"Time to choose a Fellowship." Why is that always the question residents think they must ask themselves? Now that everyone is doing a fellowship, it leaves the door open for the generalists to get the jobs where they do not need a specialist. And if you think about the majority of the cases being performed, there are more jobs out there for generalists. I am starting to believe you have more options in the market by not doing a fellowship.

I agree, anesthesiology residency graduates shouldn't feel obligated to do a fellowship.

But. You say the market favors generalists? I can't imagine how that'd be true, unless the fellowship-trained people hold out for subspecialty jobs only. I don't agree at all that a fellowship is a liability for someone who's willing to take an OR-only job. What group wouldn't want a CCM-trained anesthesiologist doing 100% OR cases? Or someone who did peds or cardiac doing non-peds or non-cardiac cases? Those people bring extra experience, knowledge, and talent to all of the cases they do.

Maybe if the cardiac guy shows up and says "Hey I'm not taking general call, and I'm not doing butt pus, and I'm not doing OB, and I want to be paid more than you mere inferior generalists" ... that's a liability if the group doesn't need a 100% cardiac guy.


The best reason to do a fellowship is if you're happy to trade the opportunity cost of that year for the skills, knowledge, subspecialty board certification, pedigree, and connections you get in return. The opportunity cost is pretty easy to assign a dollar value to. The rest of it is more complicated.

 

[Dawkter]

In regard to pain management, is it realistic to practice 50% pain and 50% OR general anesthesia? Do these jobs exist?

 

[deleted171991]

In regard to pain management, is it realistic to practice 50% pain and 50% OR general anesthesia? Do these jobs exist?

Yes. In ambulatory surgicenters. Not really 50-50, because you make them more money with interventional pain than with anesthesia.

I know a pain doc who used to do pain during the week, and moonlight in the OR in the weekend. Now all he does is anesthesia. Guess why? 🙂

 

[Dawkter]

I hear stories like this far too often which is discouraging when considering the fellowship...

 

[244913]

I hear stories like this far too often which is discouraging when considering the fellowship...

I wouldn't be discouraged about pain just because a few posters on this forum are down on it. FFP is a well known malcontent who left Anesthesia to do critical care...felt he wasn't respected enough in the OR and was being trampled by mid levels, OR nurses, janitors etc. In my residency program the only difference between the surgeon-anesthesia dynamic in the OR vs the ICU was that instead of being told which blocks you could or could not do or how high to raise the table you were being told what antibiotics to prescribe, what stool softener to use by the surgeon and being sniped at by bitchy, entitled ICU nurses (who think they are doctors) and shift work NP's (who hate your guts and think they do a better job). I can't tell you how demoralizing it is to watch the CT surgeon interrupt rounds and blow up the intensivists entire plan over and over again and the ICU doc just stands there and wears it. Maybe this doesn't happen to FFP though...The only ICU's which are truly closed are MRICU's and generally to work in those you need to be Pulm trained.

I chose pain because I felt a lot of the same frustrations FFP did and pain is the only true escape. True, you have to deal with drug seekers and cultivate a referral base but you are actually treated like a Doctor. Nobody refers to their pain doc as "Anesthesia" and no one is going to tell you how to do your job. You can work in an office setting and escape the incredibly toxic OR environment with its egomaniac surgeons, cluster b circulators and super morbid obese catlady scrub nurses.

Anesthesiologists, even good ones, are utterly expendable and this problem will only get worse as production pressure continues to increase and salaries continue to fall. Partner tracks will be a thing of the past and for me 300K a year isn't enough to stomach endless night call, the above mentioned stressors, systemic disrespect from all comers, and supervising 4 people who resent you on a daily basis.

If you are truly interested in pain come on over to the pain forums- most of those guys, even with the SDN bias don't regret their choice, especially those who were anesthesia trained.

- ex 61N

 

[244913]

Yes. In ambulatory surgicenters. Not really 50-50, because you make them more money with interventional pain than with anesthesia.

I know a pain doc who used to do pain during the week, and moonlight in the OR in the weekend. Now all he does is anesthesia. Guess why? 🙂

Because he sucked at Pain? Because he wanted to sit on his ass all day and have crnas or residents do the work?

- ex 61N

 

[deleted171991]

Because he sucked at Pain? Because he wanted to sit on his ass all day and have crnas or residents do the work?

- ex 61N

Actually, he works solo for an AMC. And he was a good pain doc with very good people skills. It was just too much work and stress for too little money, in a bad market.

Why do you think gaswork has so many pain positions, if it's all so rosy?

By the way, wasn't only last June when you were still a resident asking about pain fellowships? And now you are posing as a pain attending? 😉

 

[deleted171991]

Chapeau!

 

[Nivens]

It's hard for me to see past the fact that pain and CCU broaden your skills, while all of the other fellowships narrow your focus. The exception to this is cardiac, assuming advanced TEE becomes limited to fellowship trained folks.

 

[pgg]

It's hard for me to see past the fact that pain and CCU broaden your skills, while all of the other fellowships narrow your focus. The exception to this is cardiac, assuming advanced TEE becomes limited to fellowship trained folks.

For those who completed residency July 1st 2009 or later, eligibility for certification is limited to fellowship trained folks.

 

[GA8314]

"Time to choose a Fellowship." Why is that always the question residents think they must ask themselves? Now that everyone is doing a fellowship, it leaves the door open for the generalists to get the jobs where they do not need a specialist. And if you think about the majority of the cases being performed, there are more jobs out there for generalists. I am starting to believe you have more options in the market by not doing a fellowship.

My own situation was with a group that did not need (would not pay extra for) a fellowship trained doc. What they NEEDED was a good, all around generalist comfortable doing a variety of cases. OUTSIDE of academia and the larger community hospitals, most groups MUST have versatile docs because their practice requires it. Too few partners (or even attendings if employed) to have "teams" the way most of us see in our residency (at large tertiary care centers mind you)......

The other "need" was a partnership track opportunity THEN, but not NOW. So, I took it. And, I'm glad I did.

That being said, I will never say it's "bad" to do a fellowship (even if you don't practice at a larger tertiary care center). It's just not at 100% clear cut as most Residency PD's will lead you to believe. That's all.

 

[GA8314]

I hear stories like this far too often which is discouraging when considering the fellowship...

Remember that SDN Anesthesia is a pretty doom and gloom place. I'm in an ACT model. I supervise 95% of the time. Every situation has it's +/-'s. There is no perfect gig. The variety of practice settings is large and diverse.

Pain will be fine. Work hard, and be good at what you do and you will have a nice life. Whether it be in anesthesia or Pain or doing both.

 

[GassmanMD]

That being said, I will never say it's "bad" to do a fellowship (even if you don't practice at a larger tertiary care center). It's just not at 100% clear cut as most Residency PD's will lead you to believe. That's all.

Agreed. Like you said, there is an incredibly diverse group of practices with equally diverse needs. And those needs constantly change with time. Maybe PD's think they are helping residents by encouraging them to do a fellowship because they see it as "insurance" to deal with all of this uncertainty. Luckily, I did not listen to my PD and it was the best decision I personally could have made.

My situation is similar to yours. My group was not looking for anyone fellowship trained, but were indifferent to whether or not the applicants had done one. They said they were just looking for someone who works hard, gets along well with others, low drama, nice, etc.

Every situation is different though.