To do a fellowship or not.... that is the question

[Dominator39]

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I'm a freshly minted CA-3 with a bit of a dilemma. I was recently offered a cardiac fellowship spot, but now I'm having second thoughts about taking it. I liked my cardiac rotation as a CA-2, but I'm having a hard time deciding if it's worth doing the fellowship. Part of the problem is that I don't think I want to do cardiac cases exclusively for my career. At the same time, it would be nice to improve my skills and feel more comfortable taking care of heart patients in case I do end up in a job with a good amount of cardiac. I don't do my CA-3 cardiac rotation for another couple months, so I can't really say if I really would love doing those cases on a consistent basis. But I am probably going to have to reply to the offer before that. With all the uncertainty with the future of anesthesia because of the CRNA issue and healthcare reform, I feel pressured to just do the fellowship now so I don't end up regretting it later. I feel like doing the fellowship would give me marketability and job security for the future. But is that a good enough reason to do it? I was also thinking about working in the real world for a couple years and maybe applying for fellowship later, but it seems like it's becoming more competitive. Is anyone else in a similar situation? Any advice would be appreciated.

 

[Arch Guillotti]

Hardly anybody ever goes back to do a fellowship. Once you get a real paycheck its hard to turn back. I met a guy one time who went back to do pain in his 40's but he was the exception not the rule. Just because you do a CT fellowship doesn't mean you will be doing only hearts the rest of your life.

Sure you lose a year of income but my perosnal opinion is that it will only help you in the long run. You will be more attractive to employers and your TEE cert will be a great calling card.

 

[Jeff05]

I feel like doing the fellowship would give me marketability and job security for the future. But is that a good enough reason to do it?

is 11 months (1 month vacation) worth greatly increasing your marketability and job security - the things you've been working for the last decade?

i don't see a better reason to do a fellowship.

unless you think it's a "passion." but, you're a ca3, so you must have befriended realism by now.

 

[CrazyJake]

Dominator - if you absolutely hate and despise hearts, then I wouldn't do it...but if you applied for the fellowship, one is left to assume that you probably enjoyed your CA-2 rotation.

It's 1 year, it's huge marketability and protection from the CRNA world, plus you'll get the TEE cert. I would not work for a few years and go back, won't happen. Don't know you from Adam, but you're not going back once you see the cash.

Take the year, invest in your future, create a niche. And last, as for 'only' doing hearts that's up to you...the guys I worked with as a student would do hearts 2 days a week and then general cases on the other days. They didn't want to do sole hearts everyday forever, so they just played it off as to stressful and intense to do daily and give 2-3 patients daily the care they deserved...the hospital was good with that. Plus, I believe that in the near future we're going to have to have that fellowship cartification and TEE signoff to man the Cardiac OR's...it's the way hospitals and insurance coverage is heading. The older guys will hopefully get grandfathered in, but if you're just coming out you're going to have to have a formal fellowship, IMHO.

Goodluck

 

[Trisomy13]

had been struggling with this as well, and have essentially written off CCM because I like the OR too much, and for other reasons...

still kicking around the idea of Peds because I enjoyed all 3 of my months, and the job security issue.

what do people think about Neuro fellowships? Useless, purely for academia advancement, or worthwhile? i think i've only seen two or three jobs in the past few months that require a neuro fellowship or experience.

 

[BLADEMDA]

had been struggling with this as well, and have essentially written off CCM because I like the OR too much, and for other reasons...

still kicking around the idea of Peds because I enjoyed all 3 of my months, and the job security issue.

what do people think about Neuro fellowships? Useless, purely for academia advancement, or worthwhile? i think i've only seen two or three jobs in the past few months that require a neuro fellowship or experience.

Neuro can lead to big $$$




http://www.neurosurgery-online.com/...WLJtV97lvvBZ9S!-1465501618!-949856144!8091!-1

 

[ultm8frisbee]

Blade,
How does that relate to bigger $$$ for anesthesiologists?

 

[2ndyear]

So neuro, like interpreting SSEP, MEP, and EEG in the OR? Not just doing cranies all day and thinking about CBF and CMRO2?

 

[Pilot Doc]

what do people think about Neuro fellowships?

I've seen recent ads from the groups in Charlotte, NC and Asheville, NC - both very desirable places to live in the SE - looking for neuro trained guys. My guess is that neuro would give you a niche in a big group.

The other nice thing about neuro fellowships is that, since they are not accredited, they often combine the fellowship with some amount of attending work and you make a real salary.

 

[Haole]

Some have argued against going into PP for a few years before beginning a fellowship...saying you will never go back because the cash is too good. Well, if the cash is that good, your marketability as a residency trained anesthesiologist was sufficient.

If you do find out that the CRNA thing becomes such an issue that you can't get a good job, there won't be the enticement of "cash" keeping you from going back.

It seems the reason most people never do go back to do a fellowship is because they haven't had too. They have a good job and are making good money.

If the CRNA thing never does pose enough of a threat to the residency trained anesthesiologist...you'll be a full year ahead in salary.

You can always go back if you need to...and if fellowships become more competitive maybe your years of experience in PP will be a plus on your CV.

 

[RussianJoo]

how do pd's look at working in pp for a few years and being away from academics without research or anything and then applying for a fellowship? if i had to guess it wouldn't be a plus just cause you didn't look committed to the sub-specialty and are just doing it to make more money... especiallly if fellowships become more competitive one would think that a PD would much rather take someone straight out of residency then out of 5 or more years of pp.

 

[Jeff05]

Some have argued against going into PP for a few years before beginning a fellowship...saying you will never go back because the cash is too good. Well, if the cash is that good, your marketability as a residency trained anesthesiologist was sufficient.
the cash is good for now...

If you do find out that the CRNA thing becomes such an issue that you can't get a good job, there won't be the enticement of "cash" keeping you from going back.
ok, so now you're making crappy money AND you have to go back to fellowship (to make even crappier money) for a year and then start all over (since you're a new grad as far as the fellowship acquired specialty is concerned)

It seems the reason most people never do go back to do a fellowship is because they haven't had too. They have a good job and are making good money.
most people don't go back to fellowship because they don't want to be a b1tch again. also, no matter how little your job pays now, again, the fellowship is going to pay 3 times less.
you said it "because the haven't had to." that's now and in the past. we're talking about the future. when you MAY have to. so it's much better to get it out of the way now.

If the CRNA thing never does pose enough of a threat to the residency trained anesthesiologist...you'll be a full year ahead in salary.
that money will be long gone...

You can always go back if you need to...and if fellowships become more competitive maybe your years of experience in PP will be a plus on your CV.

if you are going back after private practice to fellowship, overall conditions must be so bad that MANY OTHER PEOPLE will also want to go back. there is a very limited number of fellowship spots and competitiveness has already greatly increased. time in PP land will not necessarily be a + on the CV. In fact, if i was a PD i would want a young new Ca4 who has never been an attending that I can really teach, instead of some middle aged person who already is set in his/her way of practice. i think most attendings would find it really awkward to tell someone of their age and experience what to do.

 

[Haole]

if you are going back after private practice to fellowship, overall conditions must be so bad that MANY OTHER PEOPLE will also want to go back. there is a very limited number of fellowship spots and competitiveness has already greatly increased. time in PP land will not necessarily be a + on the CV. In fact, if i was a PD i would want a young new Ca4 who has never been an attending that I can really teach, instead of some middle aged person who already is set in his/her way of practice. i think most attendings would find it really awkward to tell someone of their age and experience what to do.

You make good points. I see what you are saying and appreciate the input.

As an intern I have no idea what the real world of anesthesiology is like outside of residency, let alone what its really like as a CA1-3. I just always hear the "cash is too good" argument and wonder how then is it so bad. I wasn't trying to give any advice, just trying to get a bit more information on why sub-specialty training is the way to go...kinda thinking out loud.

The time I spent in this forum as a med student was limited...and maybe as others have said the threads weren't so politically minded b-in-the-d...so I didn't fully realize the weight of the challenges facing this specialty. It's kind of worrisome. I don't know of too many fields of medicine where mid-levels aren't seeking more privileges through changing legislation rather than seeking more training to actually deserve such. I am committed to doing what I need to protect myself and work toward the preservation/improvement of the specialty overall.

Sounds like it's best to do the fellowship.

 

[BLADEMDA]

So neuro, like interpreting SSEP, MEP, and EEG in the OR? Not just doing cranies all day and thinking about CBF and CMRO2?

Exactly. There are Neuro Anesthesiologists making well in excess of $1 mil a year running their own monitoring companies. A busy Group which does a lot of backs/necks would consider "in house" monitoring a make a bundle. NeuroAnesthesia Monitoring is big $$$

 

[anesthesiadoc]

For the moment lets set aside the argument that the economics of a private practice job are difficult to walk away from. Unless you plan on working at a practice with an anesthesia residency, your ties to academic anesthesia will never be as strong as they are now. The further away you get from your training, the less likely you'll have the same support from your residency institution to help get you into fellowship (program directors are more likely to fight for their current residents to get into fellowship). Also, while some programs may value the experience you gain out in private practice, fellowship directors may be wary of people who have long since left the trainee mindset.

I'm a freshly minted CA-3 with a bit of a dilemma. I was recently offered a cardiac fellowship spot, but now I'm having second thoughts about taking it. I liked my cardiac rotation as a CA-2, but I'm having a hard time deciding if it's worth doing the fellowship. Part of the problem is that I don't think I want to do cardiac cases exclusively for my career. At the same time, it would be nice to improve my skills and feel more comfortable taking care of heart patients in case I do end up in a job with a good amount of cardiac. I don't do my CA-3 cardiac rotation for another couple months, so I can't really say if I really would love doing those cases on a consistent basis. But I am probably going to have to reply to the offer before that. With all the uncertainty with the future of anesthesia because of the CRNA issue and healthcare reform, I feel pressured to just do the fellowship now so I don't end up regretting it later. I feel like doing the fellowship would give me marketability and job security for the future. But is that a good enough reason to do it? I was also thinking about working in the real world for a couple years and maybe applying for fellowship later, but it seems like it's becoming more competitive. Is anyone else in a similar situation? Any advice would be appreciated.

 

[Jeff05]

Yeah whatever. I've seen fellowships transpire out of thin air. There will always be departments eager to add more fellowships for cheap labor. I feel it will never be hard to secure a fellowship. Of course, if your dead set on a specific fellowship, that might be a different story.

1. you can't just open up shop and "add a fellowship" there are many strict requirements which must be met - and it takes time to get a program off the ground. so rapidly expanding the number of spots is not an option. most programs already have the max number of fellows - the issue is that you have to have the case load for each fellow, etc.

2. it is already NOT easy to secure a fellowship. for example, there are ONLY 80ish peds spots in the country. the solid programs are very competitive. same with pain - lots of competition for the top programs.

and it's not just about the quality of the program, it's about location. so if you're living with your family and doing private practice and wish to go back and do a fellowship - are you really going to relocate to some bumblef7ck town for that? because fellowship in and around major metropolitan areas ARE very competitive.

3. the fellowships that "transpire out of thin air" are not the ones you want to do if you're actually going back to improve your skills and marketability, you want a solid reputable clinical setting.

 

[Jeff05]

Exactly. There are Neuro Anesthesiologists making well in excess of $1 mil a year running their own monitoring companies. A busy Group which does a lot of backs/necks would consider "in house" monitoring a make a bundle. NeuroAnesthesia Monitoring is big $$$

what is the extra training required? because the neuro-anes fellows that i know are not being trained to manage neurophysiologic monitors.

 

[BLADEMDA]

👍

1. you can't just open up shop and "add a fellowship" there are many strict requirements which must be met - and it takes time to get a program off the ground. so rapidly expanding the number of spots is not an option. most programs already have the max number of fellows - the issue is that you have to have the case load for each fellow, etc.

2. it is already NOT easy to secure a fellowship. for example, there are ONLY 80ish peds spots in the country. the solid programs are very competitive. same with pain - lots of competition for the top programs.

and it's not just about the quality of the program, it's about location. so if you're living with your family and doing private practice and wish to go back and do a fellowship - are you really going to relocate to some bumblef7ck town for that? because fellowship in and around major metropolitan areas ARE very competitive.

3. the fellowships that "transpire out of thin air" are not the ones you want to do if you're actually going back to improve your skills and marketability, you want a solid reputable clinical setting.

👍👍👍

Agree 100%. Do a fellowship and guarantee your future.

Blade

 

[BLADEMDA]

Dominator - if you absolutely hate and despise hearts, then I wouldn't do it...but if you applied for the fellowship, one is left to assume that you probably enjoyed your CA-2 rotation.

It's 1 year, it's huge marketability and protection from the CRNA world, plus you'll get the TEE cert. I would not work for a few years and go back, won't happen. Don't know you from Adam, but you're not going back once you see the cash.

Take the year, invest in your future, create a niche. And last, as for 'only' doing hearts that's up to you...the guys I worked with as a student would do hearts 2 days a week and then general cases on the other days. They didn't want to do sole hearts everyday forever, so they just played it off as to stressful and intense to do daily and give 2-3 patients daily the care they deserved...the hospital was good with that. Plus, I believe that in the near future we're going to have to have that fellowship cartification and TEE signoff to man the Cardiac OR's...it's the way hospitals and insurance coverage is heading. The older guys will hopefully get grandfathered in, but if you're just coming out you're going to have to have a formal fellowship, IMHO.

Goodluck

Damn. You guys are really smart.

 

[BLADEMDA]

what is the extra training required? because the neuro-anes fellows that i know are not being trained to manage neurophysiologic monitors.

Well, someone is training these guys because they earn in excess of $1-1.5 mil per year doing "neuro monitoring." It may be as easy as a Neurofellowship plus a two week course in monitoring. I bet the companies that make this equipment sponsor detailed courses all the time.

In my area Neuro monitoring is routine and if Obamacare fails these guys will continue to make in excess of $1 mil per year.

 

[periopdoc]

Creating an ACGME fellowship position is onerous and takes time.

A non-ACGME fellowship can be created at the whim of the chairman. In our program, two non-ACGME fellowship positions were conceptualized, developed, and filled in less than two months (probably within a month).

One of them is the "Thoracic and Vascular" fellowship position. The only differences between that position and mine.

1 - I am ACGME.
2 - I get first dibs on cases.
3 - My title is "Cardiac Anesthesia Fellow", hers is "Senior Fellow in Thoracic and Vascular Anesthesia".
4 - She gets paid twice what I get paid.
5 - If she doesn't meet the ACGME established minimum case numbers, she still finishes in 12 months. I have to stay on until I meet my case numbers or forfeit the fellowship (highly unlikely, but still).
6 - She has to/ gets to attend in the general OR and is not REQUIRED to have a supervising attending in the cardio-thoracic rooms.
7 - She is not required to spend a month in the ICU.

We both get a month in the cardiology echo lab.

Will anyone care that I was ACGME and she was not since the caseload is identical and we will both be TEE certified???

I don't particularly care, but it just goes to show how easily a reasonably valuable fellowship can be created. Look at it from the chairman's perspective...

I get a cheap attending to make money for the department. I get to trumpet about how many fellows I have. What do I have to lose?

- pod

 

[BLADEMDA]

Creating an ACGME fellowship position is onerous and takes time.

A non-ACGME fellowship can be created at the whim of the chairman. In our program, two non-ACGME fellowship positions were conceptualized, developed, and filled in less than two months (probably within a month).

One of them is the "Thoracic and Vascular" fellowship position. The only differences between that position and mine.

1 - I am ACGME.
2 - I get first dibs on cases.
3 - My title is "Cardiac Anesthesia Fellow", hers is "Senior Fellow in Thoracic and Vascular Anesthesia".
4 - She gets paid twice what I get paid.
5 - If she doesn't meet the ACGME established minimum case numbers, she still finishes in 12 months. I have to stay on until I meet my case numbers or forfeit the fellowship (highly unlikely, but still).
6 - She has to/ gets to attend in the general OR and is not REQUIRED to have a supervising attending in the cardio-thoracic rooms.
7 - She is not required to spend a month in the ICU.

We both get a month in the cardiology echo lab.

Will anyone care that I was ACGME and she was not since the caseload is identical and we will both be TEE certified???

I don't particularly care, but it just goes to show how easily a reasonably valuable fellowship can be created. Look at it from the chairman's perspective...

I get a cheap attending to make money for the department. I get to trumpet about how many fellows I have. What do I have to lose?

- pod

Correct me if I am wrong (long time out in PP) but don't you have to be ACGME now or soon to sit for the TEE exam? In other words, next year will non ACGME "fellows" be allowed to sit for the TEE exam?

Blade

 

[periopdoc]

Well, someone is training these guys because they earn in excess of $1-1.5 mil per year doing "neuro monitoring." It may be as easy as a Neurofellowship plus a two week course in monitoring. I bet the companies that make this equipment sponsor detailed courses all the time.

In my area Neuro monitoring is routine and if Obamacare fails these guys will continue to make in excess of $1 mil per year.

If that's the case, I should seriously look into this. I did all of my neuro with Art Lam and company and essentially did a neuro fellowship in residency. Neuro monitoring is fairly straightforward. I wonder what the liability is like though.

- pod

 

[periopdoc]

Incidentally, I am fairly certain that the docs doing the neuromonitoring are neurologists and not anesthesiologists, but that could be a local phenomenon.

- pod

 

[Bertelman]

Correct me if I am wrong (long time out in PP) but don't you have to be ACGME now or soon to sit for the TEE exam? In other words, next year will non ACGME "fellows" be allowed to sit for the TEE exam?

Blade

I have not heard of such a thing. Only that you have to have completed a fellowship to become certified.

 

[periopdoc]

Correct me if I am wrong (long time out in PP) but don't you have to be ACGME now or soon to sit for the TEE exam? In other words, next year will non ACGME "fellows" be allowed to sit for the TEE exam?

Blade

You are not wrong. This year's class (completed residency in 2009) is the last that can be TEE certified without doing an ACGME fellowship.

Everyone will still be able to obtain Testamur status.

Realistically I do not see a significant difference in Certification vs Testamur, especially since the vast majority of TEE experts and TEE practitioners are not certified at this time and we won't be churning out a significant enough number of certified individuals to make a claim the certification should be mandatory.

- pod

 

[drmuni]

To the Admin, the cut and paste is not appropriate, please delete and put up a link to the Blog.
[/QUOTE]

 

[Arch Guillotti]

Agree with above, the website that is the source of the information that Blade quoted is visible in the post above. Cutting and pasting someone else's work without their permission or crediting them is bad form.

 

[ProRealDoc]

The issue that may become a problem re: TEE is billing. It may well be that in the near future only those who are board certified in TEE will be able to bill for it. If that becomes the case, those folks who are now doing TEE and not board certified will become obsolete.

I actually spoke with a dude who is a partner in one of the big groups in denver who especifically stated they were looking for cardiac trained folks because they are anticipating this billing issue to come up soon.

 

[periopdoc]

Well I wish I was so certain. I don't want to rehash an old argument, but with only 125 +/- ACGME Cardiac Anesthesia slots per year if they do start requiring certification for payment then I am going to be sitting pretty. It will be challenging to fill the need for certified echocardiographers even with the practice experience pathway.

I don't believe that certification will become mandatory for billing in the near future, but there are plenty of people who are smarter than I am that do feel that way.

Being certified certainly won't hurt (other than the cost of an additional year of training). We will have to wait to see how much it helps.

- pod

 

[BLADEMDA]

Agree with above, the website that is the source of the information that Blade quoted is visible in the post above. Cutting and pasting someone else's work without their permission or crediting them is bad form.

Sorry,

Deleted per request. I just assume all info. on the web is readily avail.

 

[Pilot Doc]

The issue that may become a problem re: TEE is billing. It may well be that in the near future only those who are board certified in TEE will be able to bill for it.

I don't know where this billing myth keeps popping up. Certainly for medicare, you don't need anything other than a medical license to bill for TEE. A psychiatry group could set up a TEE shop on the side. Private insurers might have hoops to jump through, but those are so unpredictable I can't see teh goal in chasing them.

 

[mike hammer]

yes you should, for all of the reasons listed prior