To cardiac fellow or not

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Hey all,

So as I browse job offers on the internet there's a huge demand for cardiac trained anesthesiologist. This demand seems to only grow as time passes due to hospital admin shift to wanting fellowship trained physicians doing intra-op TEE. I am currently in the process of deciding on a fellowship or not.

I am not crazy about doing heart, Id do them if they come up in my practice and they don't require fellow trained physicians, but my question is how did you guys decide on doing a fellowship in cardiac or going out and practicing. From what I am understanding is the pay is not significant. My biggest push to do it is job security.

Any productive insight would be greatly appreciated.
 
Plenty of threads on this.

the main cons i see...
Cardiac is fine but the fellowship is rough enough. Long, long hours and sometimes dingus surgeons and colleagues. Concentrated pool of people so if you get bad egg's/god complex colleagues its not so easy. Plus the money isnt much better. Really depends on what you do, how fast your surgeons are etc... Its another exam, albeit not as hard.

Pros
people look to you as a dude to sort things out... In hindsight i realise that most of what i learned was how to give a shed load of blood, epi, norepi, vaso, dob but anyone can really do that. The fellowship gave me confidence more than anything else. In a crashing generalist case, the answer is very rarely found in the complex minutae of a year of tee. Its just basic shock...
Job security - maybe - depends on where you work.
Were all only a number at the end of the day. Easily replaced.

A lot of countries require fellowship trained cardiac people to do hearts so its hard to fathom non fellowship trained anesthesia doing cardiac.
Sewing on a few grafts is one thing, anyone can do that, but double valve's trido sternotomy, infective endocarditis, pte, circ arrest, congenital stuff, mitral clips etc etc
 
Interventional echo.
Thats the future.
No amount of surgery can replace the volume of tavr, mitral clip, appendage closure we will see in the next 10 years.
Need CV anesthesia for echo in those rooms. Cardiologists can't make it from the clinic.
Most hospitals would rather have one person doing echocardiographer plus anesthesia versus seperate anesthesia plus cardiologist and echo tech.
 
Modanq said:
Interventional echo.
Thats the future.
No amount of surgery can replace the volume of tavr, mitral clip, appendage closure we will see in the next 10 years.
Need CV anesthesia for echo in those rooms. Cardiologists can't make it from the clinic.
Most hospitals would rather have one person doing echocardiographer plus anesthesia versus seperate anesthesia plus cardiologist and echo tech.
Click to expand...
At my shop there seem to be plenty of cardiologists available for this. All they need is for is the ETT....
 
dannyboy1 said:
At my shop there seem to be plenty of cardiologists available for this. All they need is for is the ETT....
Click to expand...
the change is not going to be from academics but rather from the midsize shops and the secondary tier hospitals that are cost conscious and don't have accessive staff available. These lean places need the cardiologist to see the patients in clinic and work the patients up and don't have time to spare throughout the day to do a 4 hour long mitral clip continuous echo. It will go the same way as the cardiac OR did 20 years ago.

Necessity is the mother of invention or in this case innovation. The one Caveat is that currently the reimbursement rate for these echoes are extremely low and therefore not advantageous for the cardiologist to do it unless in the academic setting however in the horizon if interventional echo gets different billing coding and reimbursement then all bets are off. That's why I think we should as anesthesiologist continue to push in this space
 
Newtwo said:
that most of what i learned was how to give a shed load of blood, epi, norepi, vaso, dob but anyone can really do that.
Click to expand...
True, but that’s like a Tour de France rider saying that anyone can ride a bike.
 
kidthor said:
They’ll make it if TEE reimbursement goes up from pathetic to fair. And by making it I mean they’ll steal it from you.
Click to expand...

At my institution cards does the echo for clips, amplatzers, PFO closures etc. The interventional guys are slow AF so the echo guy has to waste 2-4 hrs of his day for one case. The quick ones can read and report over like 50-100 TTEs in the time it takes to finish just one of these procedures sometimes. It's hard to imagine how interventional echo reimbursement could ever get to the point where it makes it more viable than sitting in the reading room unless these procedures start taking only 15-30 min.
 
IMGASMD said:
It’s ALL about the Benjamins.
Click to expand...

At two different institutions that i've experienced with very good volume of interventional structural hearts, the cardiologists do not care about TEE for watchman or TAVR. But they seem to be VERY protective of the Mitraclip. As a fellow, i tried to go to the training for Mitraclip by talking to a rep, the amount of backlash that request caused made me realize how much we have to learn about protecting our turf from the cardiologists, and how hard it is to get our hands on this if they don't want us to have it.

OP, do what you love. Wasting 1 year for perceived job security is a fool's errand.

vector2 said:
At my institution cards does the echo for clips, amplatzers, PFO closures etc. The interventional guys are slow AF so the echo guy has to waste 2-4 hrs of his day for one case. The quick ones can read and report over like 50-100 TTEs in the time it takes to finish just one of these procedures sometimes. It's hard to imagine how interventional echo reimbursement could ever get to the point where it makes it more viable than sitting in the reading room unless these procedures start taking only 15-30 min.
Click to expand...

dude, believe me. there are interventional guys out there there are FAST AF, like a day with them makes it hard to chart.... the money will make sense once people are good at it.

0kazak1 said:
True, but that’s like a Tour de France rider saying that anyone can ride a bike.
Click to expand...

Oh no, I have to cut off one testicle and then dope blood to do CT Anes?
 
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dchz said:
At two different institutions that i've experienced with very good volume of interventional structural hearts, the cardiologists do not care about TEE for watchman or TAVR. But they seem to be VERY protective of the Mitraclip. As a fellow, i tried to go to the training for Mitraclip by talking to a rep, the amount of backlash that request caused made me realize how much we have to learn about protecting our turf from the cardiologists, and how hard it is to get our hands on this if they don't want us to have it.

OP, do what you love. Wasting 1 year for perceived job security is a fool's errand.



dude, believe me. there are interventional guys out there there are FAST AF, like a day with them makes it hard to chart.... the money will make sense once people are good at it.



Oh no, I have to cut off one testicle and then dope blood to do CT Anes?
Click to expand...

So are you saying not only do I have “no patients” now I have “no procedures”? (Heavy dose of sarcasm here)

I am not cardiac, but isn’t it kinda sad even cardiac anesthesiologists, who are expert in cardiac physiology in the operating room is getting pushed around?

It IS all about the Benjamins. Twenty years ago, they were making banks for putting in stents. Reimbursement drops, then they started putting stents in asymptomatic patients. Then studies shows no real benefits, now they’ve move onto watchman and TVAR. I understand newer technology and advances in medicine is moving forward, but that isn’t the case for us.

Anesthesia has no turf to protect, we weren’t first anywhere.... maybe IF we start doing PAT seriously, and clear all ASA 2+ patients. You can have cardiac anesthesiologists clear cardiac cripples. But there is no money there either, so no anesthesia services will really pick that up. How many of us take PAT seriously? We are using other fields scoring systems or criteria to make recommendations.

I digress and I have no real point. It’s Friday night.
 
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IMGASMD said:
So are you saying not only do I have “no patients” now I have “no procedures”? (Heavy dose of sarcasm here)

I am not cardiac, but isn’t it kinda sad even cardiac anesthesiologists, who are expert in cardiac physiology in the operating room is getting pushed around?

It IS all about the Benjamins. Twenty years ago, they were making banks for putting in stents. Reimbursement drops, then they started putting stents in asymptomatic patients. Then studies shows no real benefits, now they’ve move onto watchman and TVAR. I understand newer technology and advances in medicine is moving forward, but that isn’t the case for us.

Anesthesia has no turf to protect, we were anywhere first.... maybe IF we start doing PAT seriously, and clear all ASA 2+ patients. You can have cardiac anesthesiologists clear cardiac cripples. But there is no money there either, so no anesthesia services will really pick that up. How many of us take PAT seriously? We are using other fields scoring systems or criteria to make recommendations.

I digress and I have no real point. It’s Friday night.
Click to expand...

There was money and turf to protect...

Saving patients from death and getting them through through anesthesia and all - seems like a good thing to protect (especially the way it used to pay). So much turf too that could be (re)couped. But some of the old timers decided to exploit each other and then exploit midlevels, then sell out to private equity. Many of those MD solo guys were making near 7 figures in today's money (and some in yesterday's money).

And now we are left with shambles and crumbs.
 
kidthor said:
There was money and turf to protect...

Saving patients from death and getting them through through anesthesia and all - seems like a good thing to protect (especially the way it used to pay). So much turf too that could be (re)couped. But some of the old timers decided to exploit each other and then exploit midlevels, then sell out to private equity. Many of those MD solo guys were making near 7 figures in today's money (and some in yesterday's money).

And now we are left with shambles and crumbs.
Click to expand...

“AMCs are too big, their market share is all over.” “CRNAs are lobbying the shiiit out of everyone.” Even the ASA are in bed with all these bad and nasty people. There are at least two state societies presidents who work for AMCs.

All I ever wanted to do was to save my patients from death, not mud fights. But you’re absolutely right, our fights shouldn’t be with other speciality physicians, just need to regain own turf.

Edit: I am sorry op, will turn it back to regular programming.
 
dchz said:
At two different institutions that i've experienced with very good volume of interventional structural hearts, the cardiologists do not care about TEE for watchman or TAVR. But they seem to be VERY protective of the Mitraclip.
Click to expand...

This was my experience on the interview trail. The vast majority of fellowships can’t give their fellows much, if any, access to learn mitra-clip echo because cards owns it and won’t give it up. I think I only interviewed at 2 places where anesthesia was routinely doing these echos.
 
We do the echo for all structural heart. I wish I could say it’s the next frontier, but I remain unconvinced. While we do our best to make it seem complicated, it boils down to bicaval -> me4 -> bicaval -> en face -> midcomm biplane. Any extra english we put on it seems to just annoy the cardiologists.
 
chocomorsel said:
Dude, he had cancer. Yeah, he was a total cheater.
But since when is having Cancer something to make fun of?
Click to expand...

DCC9FDFB-1895-484E-A0C0-039D7E36E36D.jpeg
 
Nivens said:
We do the echo for all structural heart. I wish I could say it’s the next frontier, but I remain unconvinced. While we do our best to make it seem complicated, it boils down to bicaval -> me4 -> bicaval -> en face -> midcomm biplane. Any extra english we put on it seems to just annoy the cardiologists.
Click to expand...

Difficulty is not the point. Cardiologists are excellent at breaking down the nuances of each procedure and then billing separately and coding separately for each aspect. That's why they have created a new codr called interventional echo versus intra operative echo. we on the other hand are now helping intraop with cannulation and guiding wires and coronary sinus catheters, Adult congenital and just still bill for the same exact thing.

You can look at my previous posts on sdn. In my opinion there are 2 ways for Anesthesiologists to succeed. one is to protect their own current turf and the 2nd has to expand their scope of practice. Cardiologists have no problems going into imaging and now reading MR & CT scans, doing procedures, peripheral vascular, etc. We should adapt...The chair of Anesthesiology at Cleveland clinic at Echo week even suggested that we should even be placing our own impellas and that at one point it was considered crazy for us to even do our own swans.

At many shops On the cardiac side We are doing our own VV and VA ECMOs. Thats new scope of practice.

Much to hear from your all thoughts.... but in my mind we are doctors and can expand whichever way we want in our scope of practice.
 
chocomorsel said:
You are a child.
Wasn't there a physician here who actually died of CA and you write this s hit? Are we grown PHYSICIANS here or children?
I am sorry to kill your buzz.
Click to expand...

Yeesh. I mean, I feel like there's not much of a difference sometimes really... 😉

Anyways, agreed with most of the above, OP. If you love cardiac, do cardiac. You'll have a year of working with some really, really sick patients, be able to put almost anyone to sleep and wake them up, become comfortable with bypass/ECMO, and be extremely facile with echocardiography. If that sounds like a fun way to spend a year, come join us, brother (or sister).
 
chocomorsel said:
You are a child.
Wasn't there a physician here who actually died of CA and you write this s hit? Are we grown PHYSICIANS here or children?
I am sorry to kill your buzz.
Click to expand...

UTSW. His real name was Norm. He was a brilliant contributor to this board. I still think of him not infrequently. He was taken far, far too soon.

If you want to honor the man, at least try to remember his name.
 
SaltyDog said:
UTSW. His real name was Norm. He was a brilliant contributor to this board. I still think of him not infrequently. He was taken far, far too soon.

If you want to honor the man, at least try to remember his name.
Click to expand...

You wanna hear something full circle?

I was gonna pursue the job in San Diego until I found his blog. Read every single post of it. I'm in his old group now 🙂 The partnership track wasn't my best offer so I treated it as a long term play, but I knew the group was legit from reading his posts on the archives of this forum.

According to the OR staff that knew him back in the day, he was as a nice guy as any. Many of the people here at the ORs still remember him fondly. From reading all his blog posts and the way he carried himself through his last 2 years of his life. I'm 100% sure he would have found every post by me and @SaltyDog in this thread, or in general, to be HILARIOUS.

It's amazing how he still makes positive contributions to people on this board even today. I go through extraordinary lengths to avoid getting zapped by the c arm during cases because of his story. Furthermore, I would have never taken the plunge for my current job if it wasn't for him talking about how awesome his group was.... I never knew him, but I'm gonna honor his memory by carrying myself like he carried himself: not too seriously. We are also the same race so there's that comparison too.

For anyone not familiar with his story: here is the sticky:

forums.studentdoctor.net

Dearest UT Southwestern, a.k.a. NORM

Dear UT, I'll preface this post with the fact that I love to write, and hope to publish a novel someday. My writing coach and mentor, an accomplished screenwriter, doctor712, has told me incessantly to write unfiltered. With that said, I'll take his advice during this post...and write...
forums.studentdoctor.net forums.studentdoctor.net

Perspective is important in life. Here, have some perspective:

www.CrushMyCancer.Blogspot.com
 
Last edited:
SaltyDog said:
UTSW. His real name was Norm. He was a brilliant contributor to this board. I still think of him not infrequently. He was taken far, far too soon.

If you want to honor the man, at least try to remember his name.
Click to expand...
I know exactly what his name is. I am from Dallas. He’s no longer linked to this board so therefore I didn’t type his username. Thank you.
I am sure he would be going right along with you on this one and your buzzkill.
 
Modanq said:
Difficulty is not the point. Cardiologists are excellent at breaking down the nuances of each procedure and then billing separately and coding separately for each aspect. That's why they have created a new codr called interventional echo versus intra operative echo. we on the other hand are now helping intraop with cannulation and guiding wires and coronary sinus catheters, Adult congenital and just still bill for the same exact thing.

You can look at my previous posts on sdn. In my opinion there are 2 ways for Anesthesiologists to succeed. one is to protect their own current turf and the 2nd has to expand their scope of practice. Cardiologists have no problems going into imaging and now reading MR & CT scans, doing procedures, peripheral vascular, etc. We should adapt...The chair of Anesthesiology at Cleveland clinic at Echo week even suggested that we should even be placing our own impellas and that at one point it was considered crazy for us to even do our own swans.

At many shops On the cardiac side We are doing our own VV and VA ECMOs. Thats new scope of practice.

Much to hear from your all thoughts.... but in my mind we are doctors and can expand whichever way we want in our scope of practice.
Click to expand...

What shops are doing their own VV/VA ECMOs?
 
dchz said:
Plenty of people in the mid atlantic region. Also some people at Mayo if i remember correctly.
Click to expand...

anesthesiology.pubs.asahq.org

Evolving Role of Anesthesiology Intensivists in Cardiothoracic Critical Care

The role of cardiothoracic anesthesiology intensivists has expanded over the past few decades. Cardiothoracic anesthesiology intensivists are taking on larger roles in cardiac critical care specializing in cardiogenic shock and extracorporeal membrane oxygenation.
anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
 
kidthor said:
There was money and turf to protect...

Saving patients from death and getting them through through anesthesia and all - seems like a good thing to protect (especially the way it used to pay). So much turf too that could be (re)couped. But some of the old timers decided to exploit each other and then exploit midlevels, then sell out to private equity. Many of those MD solo guys were making near 7 figures in today's money (and some in yesterday's money).

And now we are left with shambles and crumbs.
Click to expand...

Agree 100%

Before running around and trying to encroach on and protect turf that other physicians can lay claim to, let’s start with the turf battle against a group with 1000x less experience yet 10000x more vitriol. If we can’t even win a turf war against a group of nurses, why even bother engaging with other physicians.

I don’t know about y’all, but I’m investing heavily in KY to secure my future.
 
Urzuz said:
Agree 100%

Before running around and trying to encroach on and protect turf that other physicians can lay claim to, let’s start with the turf battle against a group with 1000x less experience yet 10000x more vitriol. If we can’t even win a turf war against a group of nurses, why even bother engaging with other physicians.

I don’t know about y’all, but I’m investing heavily in KY to secure my future.
Click to expand...
KY?
 
Ew Anesthesia driven ECMO service? So you can get called at all times of night for insertions, and get sued when your young healthy patient strokes from a clot in the circuit? No thanks.

A lot of talk about intervention, structural echo. At my shop cardiology will likely be taking over echo guidance soon and discussions are ongoing (of course, we are left out of the discussion). I can’t complain much as TEE reimbursement sucks anyways and out interventionalists aren’t much to write home about. Expect more places to follow suit especially if somehow they get more reimbursement for advanced TEE stuff. Those cardiologists sitting reading echoes and EKGs will come out of the woodwork. Who will do rounds - oh their NP of course! And they will co-sign the unhelpful consult. But I’ve been saying this for a long time and feel like old man River typing this stuff.

I agree with just about all others - do it if you are interested. Fellowship gave the me the skill set and, more importantly, confidence to be the “gadget” or “fix it” guy within the group. A nice position to have if there are storm clouds coming...
 
Modanq said:
Difficulty is not the point. Cardiologists are excellent at breaking down the nuances of each procedure and then billing separately and coding separately for each aspect. That's why they have created a new codr called interventional echo versus intra operative echo. we on the other hand are now helping intraop with cannulation and guiding wires and coronary sinus catheters, Adult congenital and just still bill for the same exact thing.

You can look at my previous posts on sdn. In my opinion there are 2 ways for Anesthesiologists to succeed. one is to protect their own current turf and the 2nd has to expand their scope of practice. Cardiologists have no problems going into imaging and now reading MR & CT scans, doing procedures, peripheral vascular, etc. We should adapt...The chair of Anesthesiology at Cleveland clinic at Echo week even suggested that we should even be placing our own impellas and that at one point it was considered crazy for us to even do our own swans.

At many shops On the cardiac side We are doing our own VV and VA ECMOs. Thats new scope of practice.

Much to hear from your all thoughts.... but in my mind we are doctors and can expand whichever way we want in our scope of practice.
Click to expand...

I agree. We have older surgeons learning the DaVinci essentially on the job. TAVRs, and all the other structural heart stuff? On the job for most of those docs.

We have been so fuc.ing stupid in anesthesia where we limit ourselves so much. Yet look at all of the other specialties and how they just do it when new technologies come into the market. Meantime we bicker about who should be doing the healthy 4 yo for a humerus fracture and whether they should be Ped's fellowed. It's got to stop.
 
AdmiralChz said:
Ew Anesthesia driven ECMO service? So you can get called at all times of night for insertions, and get sued when your young healthy patient strokes from a clot in the circuit? No thanks.

A lot of talk about intervention, structural echo. At my shop cardiology will likely be taking over echo guidance soon and discussions are ongoing (of course, we are left out of the discussion). I can’t complain much as TEE reimbursement sucks anyways and out interventionalists aren’t much to write home about. Expect more places to follow suit especially if somehow they get more reimbursement for advanced TEE stuff. Those cardiologists sitting reading echoes and EKGs will come out of the woodwork. Who will do rounds - oh their NP of course! And they will co-sign the unhelpful consult. But I’ve been saying this for a long time and feel like old man River typing this stuff.

I agree with just about all others - do it if you are interested. Fellowship gave the me the skill set and, more importantly, confidence to be the “gadget” or “fix it” guy within the group. A nice position to have if there are storm clouds coming...
Click to expand...

Agree but I think we might be missing the forest for the trees. ECMO was just one example. Maybe that's not your cup of tea but another area might be. As I said before on SDN for the neuro inclined perhaps we should bill for our own neuromonitoring. At least we should train for that subarea. Same with sleep studies or lung function testing. Do our own trachs perhaps like in Miami. Do our own outpt workup maybe. For the pain people there should be no doubt that we should place all the catheters and stimulators, etc and not be limited by what we consider is "Traditional Anesthesiology".

Instead what Anesthesiologists do for example is we have these bogus regional courses where everyone can sign up and we train everyone how to do things. You can argue that its "monkey skills" but its how medicine is precived that gets coding and reimbursement. And now we have nurse anesthesia having a go at regional.

For example for the longest time I was always wondering what a "right heart cath and a shunt run" done by the cardiologists was. Yup load of crock... same ole swan we do in the OR everyday. But you know what the cardiologists do. They hype it up and itemize each element. Access, bling, fluro, bling, sat checks bling, pressure waveform analysis, bling, wedge, bling, Calculations qp:qs pvr, bling.

We do one cervical spine case managing complex pain, prone positioning, high BMI, inline intubation and neuromormitoring and bill basically by the minutes. We are a group of suckers. We should bill by complexity. Thats the point. We don't stand up for each other...and I do tend to agree with most of what you say Ad.

Basically my point is. Embrace the new and push the boundaries.
 
Modanq said:
We do one cervical spine case managing complex pain, prone positioning, high BMI, inline intubation and neuromormitoring and bill basically by the minutes. We are a group of suckers. We should bill by complexity. Thats the point. We don't stand up for each other...and I do tend to agree with most of what you say Ad.
Click to expand...

Yep.
 
Beeftenderloin said:
Moderate risk for moderate risk surgery. Avoid hypotension and tachycardia.

...absolutely brilliant
Click to expand...
lol rcri=1. avoid hypotension and excess fluid. ok to proceed with careful ga.

says the mofo that cant even place an peripheral iv and has never drawn up a drug is his/her life. mortality would be 100% if these guys tried to put a 20yo to sleep for a lap appy

its beyond funny
 
Nivens said:
We do the echo for all structural heart. I wish I could say it’s the next frontier, but I remain unconvinced. While we do our best to make it seem complicated, it boils down to bicaval -> me4 -> bicaval -> en face -> midcomm biplane. Any extra english we put on it seems to just annoy the cardiologists.
Click to expand...
It's simple to us ...

I hate watching cardiologists do TEE. They suck at it. Most of the time they need a tech standing there next to them to push buttons, and even so they struggle to get good views.

It probably annoys them to see us do TEE because we're better at it than they are.
 
pgg said:
It's simple to us ...

I hate watching cardiologists do TEE. They suck at it. Most of the time they need a tech standing there next to them to push buttons, and even so they struggle to get good views.

It probably annoys them to see us do TEE because we're better at it than they are.
Click to expand...

haha well there is an explanation I hadn’t considered. They do suck, don’t they?
 
pgg said:
I hate watching cardiologists do TEE. They suck at it. Most of the time they need a tech standing there next to them to push buttons, and even so they struggle to get good views.
Click to expand...

I hate watching any non-anesthesiologist doing one of our core procedures. Ever see a Micu doc do an intubation, a surgeon do a Cvc, or an ED doc do procedur sedation? It’s always an amateur production across the board.

Granted if I did something rarely I’d ideally want lots of help and all - but our speciality is held perhaps to the highest standard of procedural slickness and speed. Only to be shat upon.
Funny how we let putting someone into a medically induced coma, controlling every part of their physiology, then saving them from disease or proceduralist induced death into a “hey anesthesia hurry up” poorly paid pestilence.
 
kidthor said:
I hate watching any non-anesthesiologist doing one of our core procedures. Ever see a Micu doc do an intubation, a surgeon do a Cvc, or an ED doc do procedur sedation? It’s always an amateur production across the board.

Granted if I did something rarely I’d ideally want lots of help and all - but our speciality is held perhaps to the highest standard of procedural slickness and speed. Only to be shat upon.
Funny how we let putting someone into a medically induced coma, controlling every part of their physiology, then saving them from disease or proceduralist induced death into a “hey anesthesia hurry up” poorly paid pestilence.
Click to expand...
Poorly paid?
 
Man o War said:
Poorly paid?
Click to expand...

For the stakes involved, yes. Literally life or death.

ok paid from private insurers, awfully paid from medicare/Medicaid.

Is the lap apply part harder or the anesthesia part? Maybe equal? And yet Medicare pays the anesthesia part about the same as a Camry tuneup. Poorly paid.
 
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