To cardiac fellow or not

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AdmiralChz said:
Or better, “consider spinal”
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Ortho likes that one too:

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kidthor said:
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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You will get zero arguments from me about Medicare/Medicaid. In a vacuum I agree with that totally, but we can’t deny that almost all of us are subsidized on top of that. Overall if you’re a poorly paid anesthesiologist, it’s by choice or a rare set of circumstances that makes you unemployable.
 
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.
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Agreed for the most part. Except for the CVC. I see surgeons put in slick Sublaclavians. Maybe not IJs. MICU intubations are the worst though.

The ones who do them regularly and typically work in the trauma centers that is.
 
chocomorsel said:
Agreed for the most part. Except for the CVC. I see surgeons put in slick Sublaclavians. Maybe not IJs. MICU intubations are the worst though.

The ones who do them regularly and typically work in the trauma centers that is.
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You just haven't seen the slick anesthesiologists do subclavian from the head of the bed.

I haven't either until I started this job... You know what they say, there is always someone better than you...
 
dchz said:
You just haven't seen the slick anesthesiologists do subclavian from the head of the bed.

I haven't either until I started this job... You know what they say, there is always someone better than you...
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Can’t picture the angle of entry......
 
chocomorsel said:
Agreed for the most part. Except for the CVC. I see surgeons put in slick Sublaclavians. Maybe not IJs. MICU intubations are the worst though.

The ones who do them regularly and typically work in the trauma centers that is.
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Subclavians are easy to make slick. Just slide it right in under the bone and hub it.
 
For what it’s worth, I am a year out of residency now. I applied for CT anesthesia, interviewed at several programs and ultimately withdrew my app prior to the match list deadline. Having trained at an excellent residency I felt confident with my TEE and cardiac exposure and skills to do most CT cases out of residency, so a fellowship would have been a waste aside from the ability to do high level academic, complex CT cases and obtain advanced TEE certification. I never wanted to do these cases post residency.

Additionally, I want to live in a smaller town, which meant less competition and better pay for a good job vs a large city. I also interviewed at a couple practices that would let me do cardiac without a fellowship (but with basic TEE certification). Also, along the interview trail I started to feel that many candidates were doing the fellowship to gain more exposure and experience as they came from lesser residencies, or they were doing it to get a job in a large city. Unfortunately, our specialty has allowed the infiltration of fellowship trained anesthesiologists to prevail when I felt 100 percent confident doing just about any case coming out of residency, so now many well trained doctors are in the situation of a forced fellowship to have access to cases even though they trained to do them in residency very well and had lots of exposure to a huge variety.

I also called several small private practices out west and they ubiquitously told me that if I had a cardiac fellowship they wouldn’t even interview me since the market is flooded with them and they didn’t want to have to guarantee me cases, or give the already employed anesthesiologists fewer CT cases.

Given all that information I was confident to withdraw my CT app and never regret it. I’m in private practice doing a all types of cases (everything except cardiac). I will Get my TEE basic cert soon, but because I love echo and have the numbers. Hope that helps!
 
raztes said:
For what it’s worth, I am a year out of residency now. I applied for CT anesthesia, interviewed at several programs and ultimately withdrew my app prior to the match list deadline. Having trained at an excellent residency I felt confident with my TEE and cardiac exposure and skills to do most CT cases out of residency, so a fellowship would have been a waste aside from the ability to do high level academic, complex CT cases and obtain advanced TEE certification. I never wanted to do these cases post residency.

Additionally, I want to live in a smaller town, which meant less competition and better pay for a good job vs a large city. I also interviewed at a couple practices that would let me do cardiac without a fellowship (but with basic TEE certification). Also, along the interview trail I started to feel that many candidates were doing the fellowship to gain more exposure and experience as they came from lesser residencies, or they were doing it to get a job in a large city. Unfortunately, our specialty has allowed the infiltration of fellowship trained anesthesiologists to prevail when I felt 100 percent confident doing just about any case coming out of residency, so now many well trained doctors are in the situation of a forced fellowship to have access to cases even though they trained to do them in residency very well and had lots of exposure to a huge variety.

I also called several small private practices out west and they ubiquitously told me that if I had a cardiac fellowship they wouldn’t even interview me since the market is flooded with them and they didn’t want to have to guarantee me cases, or give the already employed anesthesiologists fewer CT cases.

Given all that information I was confident to withdraw my CT app and never regret it. I’m in private practice doing a all types of cases (everything except cardiac). I will Get my TEE basic cert soon, but because I love echo and have the numbers. Hope that helps!
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Wait, what? You wanted to do cardiac fellowship, but withdrew your app because you thought you were well trained enough in residency to do most cardiac. But then you ended up getting job where you’re doing all types of cases except cardiac. And now you’re getting basic TEE cert even though you’re not doing cardiac at your current job? What?
 
This is the most depressing thread I have read on here in a long time for so many reasons.
This forum is so prickly now. You talk about Norm and start pissing over him. Dissing each other about how “abused” anesthesiologists are, etc. Our job really isn’t that bad, and yes, you can make it better.

Choco, I generally like your perspective, but you need to take a break.
 
raztes said:
For what it’s worth, I am a year out of residency now. I applied for CT anesthesia, interviewed at several programs and ultimately withdrew my app prior to the match list deadline. Having trained at an excellent residency I felt confident with my TEE and cardiac exposure and skills to do most CT cases out of residency, so a fellowship would have been a waste aside from the ability to do high level academic, complex CT cases and obtain advanced TEE certification. I never wanted to do these cases post residency.

Additionally, I want to live in a smaller town, which meant less competition and better pay for a good job vs a large city. I also interviewed at a couple practices that would let me do cardiac without a fellowship (but with basic TEE certification). Also, along the interview trail I started to feel that many candidates were doing the fellowship to gain more exposure and experience as they came from lesser residencies, or they were doing it to get a job in a large city. Unfortunately, our specialty has allowed the infiltration of fellowship trained anesthesiologists to prevail when I felt 100 percent confident doing just about any case coming out of residency, so now many well trained doctors are in the situation of a forced fellowship to have access to cases even though they trained to do them in residency very well and had lots of exposure to a huge variety.

I also called several small private practices out west and they ubiquitously told me that if I had a cardiac fellowship they wouldn’t even interview me since the market is flooded with them and they didn’t want to have to guarantee me cases, or give the already employed anesthesiologists fewer CT cases.

Given all that information I was confident to withdraw my CT app and never regret it. I’m in private practice doing a all types of cases (everything except cardiac). I will Get my TEE basic cert soon, but because I love echo and have the numbers. Hope that helps!
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Well, you have to give credit where it is due you certainly don't lack self confidence! Well done...
 
kidthor said:
"It's just demand ischemia" for $500, anyone?
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What are you going to do with that patient? Cath them? Then a stent gets put in and the surgeon is pissed that the case is delayed for 6 months. All this for a troponin that should have never been checked in the first place.

Preop assessment is 100% medicolegal. There's not much we can do for perioperative risk reduction except characterize risk. Starting new meds probably doesn't do anything (Poise, POISE II), revascularization doesn't reduce risk (CARP, CASS). Replacing valves routinely is not feasible just for surgery. The point of preop risk assessment is to cover everyone's asses in case something goes south perioperatively.
 
The entropy of SDN threads remains undefeated.

OP: The only good reason to do a cardiac fellowship is a desire to become a true expert in CT anesthesiology. If you don't love it enough to be excited about immersing yourself in it for a year, it's unlikely you'll derive enough benefit to justify the lost financial opportunity. You're better off pursuing a different fellowship in a field that you really love, or getting a job and moving on with your life.

Best of luck.
 
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.
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Bumping an old thread because it seems like the cardiologists have become very keen on making interventional echo a distinct training pathway (of which I'm sure many of these super fellowships, for better or worse, will only be open to cards).

Meanwhile, it sounds like CMS, at least according to Burkhard Mackensen, is *not* reimbursing anesthesiologists for simultaneous medical direction + 93355 CPT (transcatheter intracardiac TEE).

 
vector2 said:
Bumping an old thread because it seems like the cardiologists have become very keen on making interventional echo a distinct training pathway (of which I'm sure many of these super fellowships, for better or worse, will only be open to cards).

Meanwhile, it sounds like CMS, at least according to Burkhard Mackensen, is *not* reimbursing anesthesiologists for simultaneous medical direction + 93355 CPT (transcatheter intracardiac TEE).

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If anyone thinks a cardiologist is qualified to an intraop tee they must be demented...

They wont even try drive the probe for mitraclips, their own procedure.
 
PpfSuxTube said:
If anyone thinks a cardiologist is qualified to an intraop tee they must be demented...

They wont even try drive the probe for mitraclips, their own procedure.
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Cardiac anesthesiologists are, on average, a million times more adept at procedural TEE than even most level III certified cardiologists. Dynamically following catheters and using multiplane/3d comes naturally to those who have done a ton of intraop TEE, but not so much for cardiologists whose TEEs are typically for evaluating if an LAA has clot or looking at a single valve lesion.

So it actually makes sense that ASE wants to make even level III echo trained cardiologists do further training in structural/interventional. The problem is that anesthesiologists are getting hit in the crossfire. I think most TEE boarded cardiac anesthesiologists who have never done structural could go over the literature, do a handful of watchmans and mitraclips with the rep, and then comfortably be at the skill level that the new ASE paper outlines.
 
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If you’re going into PP I would try very hard to be able to put structural heart image guidance on your resume. These are high RVU cases, and your ability to offer the imaging may make or break your access to these rooms.

At my hospital the interventional cardiologists crank these cases and it’s always the most lucrative room on the schedule by a several fold factor
 
T-burglar said:
If you’re going into PP I would try very hard to be able to put structural heart image guidance on your resume. These are high RVU cases, and your ability to offer the imaging may make or break your access to these rooms.

At my hospital the interventional cardiologists crank these cases and it’s always the most lucrative room on the schedule by a several fold factor
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What good is the skill if cardiologists wont let those go to anesthesiologists?

Ive been trying to be involved in structural heart echo at my shop, but cardiologists will not let them go, and we have no buy-in from the proceduralists.
 
JiPo said:
What good is the skill if cardiologists wont let those go to anesthesiologists?

Ive been trying to be involved in structural heart echo at my shop, but cardiologists will not let them go, and we have no buy-in from the proceduralists.
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They do give up the imaging in some places. For your earning potential and if you’re planing to move for a job after training , it would be a good idea to get the experience (if possible)
 
Doesn’t BI have an echo super fellowship specifically designed to cater to this “sub-specialty” that’s only available to anesthesiologists?
 
Cardiologists are doing intraop tee for structural heart in adults? Ive never heard of that
 
PpfSuxTube said:
Cardiologists are doing intraop tee for structural heart in adults? Ive never heard of that
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You and I live in a different world. Most, if not all, jobs I interviewed in the east coast is done by cardiologists, not anesthesiologists.
 
PpfSuxTube said:
Cardiologists are doing intraop tee for structural heart in adults? Ive never heard of that
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Just got back from echo week and probably 10% of people were doing the echo for structural heart procedures while 90%, the cardiologists do it.
 
I’ve done these before, but we now have a dedicated imaging cardiologist for these cases.

While driving the echo for structural cases is easy, it’s even easier to kick back at a safe distance from the II while the cardiologist with the probe in his hands gets irradiated.

I guess there is some compensation for the echo, but I get the sense that for some people this is more about ego.
 
DesiredMemberName? said:
I guess there is some compensation for the echo, but I get the sense that for some people this is more about ego.
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There is definitely some truth to this. I enjoy being more actively involved in patient care with decision making, and working as a true consultant. Sometimes I wonder if I picked the wrong specialty 🤷. But it is just a job at the end of the day.
 
JiPo said:
There is definitely some truth to this. I enjoy being more actively involved in patient care with decision making, and working as a true consultant. Sometimes I wonder if I picked the wrong specialty 🤷. But it is just a job at the end of the day.
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You picked the wrong job. Plenty of places (mine included) where you’re respected as an anesthesiologist, and surgeons value your input and guidance for intraop decisions.
 
anaesthetic said:
You picked the wrong job. Plenty of places (mine included) where you’re respected as an anesthesiologist, and surgeons value your input and guidance for intraop decisions.
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This isn’t an either/or situation. You can be respected by and provide valued guidance for surgeons in the heart room without being the one holding the probe in the cath lab.

Thankfully, I don’t do routine intubations in the ED or ICU either. It doesn’t mean I feel like they don’t respect my intubating skills.
 
I agree with both points. I get along very well with other surgeons and feel well respected by all surgeons except for cardiac surgeons. You can all guess which cases quickly became my least favorite.

I should look for a different job…
 
DesiredMemberName? said:
I’ve done these before, but we now have a dedicated imaging cardiologist for these cases.

While driving the echo for structural cases is easy, it’s even easier to kick back at a safe distance from the II while the cardiologist with the probe in his hands gets irradiated.

I guess there is some compensation for the echo, but I get the sense that for some people this is more about ego.
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Anesthesia generally has that problem which ED/Rads also has, i.e. we're seen as a costly but necessary service which drags on the profit to be made by the proceduralist/hospital.

I think separate from the reimbursement for interventional echo (which is low enough that imaging cards is saying the hospital and proceduralists should be giving them a cut of their structural fees), or the ego thing, it behooves us as a specialty - especially in this current market of our salaries being subsidized in many places to hit that $275 - 375/hr figure - to stay maximally involved in cutting edge, lucrative procedures which bring in a lot of money to the hospital.
 
vector2 said:
Anesthesia generally has that problem which ED/Rads also has, i.e. we're seen as a costly but necessary service which drags on the profit to be made by the proceduralist/hospital.

I think separate from the reimbursement for interventional echo (which is low enough that imaging cards is saying the hospital and proceduralists should be giving them a cut of their structural fees), or the ego thing, it behooves us as a specialty - especially in this current market of our salaries being subsidized in many places to hit that $275 - 375/hr figure - to stay maximally involved in cutting edge, lucrative procedures which bring in a lot of money to the hospital.
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I don’t really disagree with this.

As cardiac anesthesiologists, we should be able to grab the probe and guide the procedure if needed, but it seems a little silly and futile to get into a turf war with the cardiologists over who “gets” to do the echo for these procedures.
 
DesiredMemberName? said:
I don’t really disagree with this.

As cardiac anesthesiologists, we should be able to grab the probe and guide the procedure if needed, but it seems a little silly and futile to get into a turf war with the cardiologists over who “gets” to do the echo for these procedures.
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Futile....probably. The non-invasive cardiologist refers to the structural cardiologist who consults the imaging cardiologist to do the intra-procedure TEE. If they don't want us to do the exam, it probably ain't gonna happen.

But silly? I don't think it's silly for us to be an integral part of procedures (whether it's structural heart, open heart, spine, etc) that have total costs of $50-100k+ a pop.
 
Agreed, I wonder how many of you are in PP where the cardiologists stack days with these procedures and and blow through them. Clips are base 15 units before any lines.

This is the future growth area right Now in medicine.
 
vector2 said:
Futile....probably. The non-invasive cardiologist refers to the structural cardiologist who consults the imaging cardiologist to do the intra-procedure TEE. If they don't want us to do the exam, it probably ain't gonna happen.

But silly? I don't think it's silly for us to be an integral part of procedures (whether it's structural heart, open heart, spine, etc) that have total costs of $50-100k+ a pop.
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It’s not silly to do the echo. It’s silly to try to fight the cardiologists for the echo (political costs > benefit, especially when considering futility). The calculus may be different for those in academics, though.
 
DesiredMemberName? said:
It’s not silly to do the echo. It’s silly to try to fight the cardiologists for the echo (political costs > benefit, especially when considering futility). The calculus may be different for those in academics, though.
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I disagree, and I don't think it matters what your practice setting is. Obviously the discussion is best had diplomatically, but I find it rather shortsighted to just completely defer without at least broaching the topic of who is doing interventional echo with the structural directors and other folks who run the cathlab.
 
vector2 said:
I disagree, and I don't think it matters what your practice setting is. Obviously the discussion is best had diplomatically, but I find it rather shortsighted to just completely defer without at least broaching the topic of who is doing interventional echo with the structural directors and other folks who run the cathlab.
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I agree that a diplomatic discussion in which a topic is broached is not silly. Fighting the cardiologists for the echo is silly.
 
DesiredMemberName? said:
I agree that a diplomatic discussion in which a topic is broached is not silly. Fighting the cardiologists for the echo is silly.
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Yeah, just like how many CT surgeons thought vying for transcatheter procedures / making it part of their training was silly.





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vector2 said:
Yeah, just like how many CT surgeons thought vying for transcatheter procedures / making it part of their training was silly.
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Why are you like this?

I already said we should be capable of doing it, so that’s not anything like saying it shouldn’t be part of our training, not that it is challenging for anyone well-trained in TEE.

You said we should be an integral part of the case, and I agreed with that (although I don’t think that requires having the probe in your hands).

You said we should try to be diplomatic when discussing echo coverage with the interventionalists, and I agreed with that.

I just don’t think this is a hill worth dying on if the cardiologists really want to do it. Maybe we’ll have to agree to disagree on that point.
 
DesiredMemberName? said:
Why are you like this?

I already said we should be capable of doing it, so that’s not anything like saying it shouldn’t be part of our training, not that it is challenging for anyone well-trained in TEE.

You said we should be an integral part of the case, and I agreed with that (although I don’t think that requires having the probe in your hands).

You said we should try to be diplomatic when discussing echo coverage with the interventionalists, and I agreed with that.

I just don’t think this is a hill worth dying on if the cardiologists really want to do it. Maybe we’ll have to agree to disagree on that point.
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I could ask you the same question.

All your responses, despite any superficial agreements, have ultimately ended with you trivializing the question of who will be performing interventional TEE going forward. And I don't necessarily think the matter is all that trivial for folks who are interested in cardiac anesthesia. This is evidenced by the fact that 1. New TEE CPT codes have being created and imagers are pushing for enhanced reimbursement well above what intraop TEE usually pays, 2. The ASE thinks interventional echo is important enough to warrant a further year of training for people who are already echo boarded, and 3. Interventional procedures are [relatively] quick, high volume, and extremely lucrative to proceduralists and the hospital.

I think it's strange that it doesn't give you pause that cardiologists couldn't care less about intraop TEE during cardiac surgery, but yet they're climbing over themselves to be at the helm of interventional/structural TEE...
 
At my shop, the cardiologists have stepped back from all intraop imaging with the exception of mitraclips. Even there, they've given some indication that the one guy that does the imaging would be willing to step back, as he could be more productive spending the day in clinic, rather than "wasting" a full day being available to help the structural guy do three mitraclips (very slow here). The one imaging guy that used to do all Watchmen already ceded them all to us. However, I asked our billers, and we're not getting anything extra for doing the imaging ourselves, as they say that it's bundled into the procedure itself. Maybe if these new codes materialize, it'll become profitable. Until then, it's at least fun and rewarding doing the guidance for Watchmen, TAVRs (when not done under sedation), and TMVRs.
 
We are are performing the echos for TAVRs, PFO/ASD repairs, PVL plugs, tendyne and mitral clips currently. If a CTS is involved they prefer cardiac anesthesiologist to image.
 
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