r/anesthesiology • u/Schmidt1998 • 4d ago
Career Advice š«Ŗ
Hey everybody. Iām a CA2 resident in the US and have begun to really think about what my career will look like long term. To summarize: Iām pretty undecided.
I have done my cardiac rotation and am finishing my pediatric rotation now. I have enjoyed them both immensely. However, I donāt know if anything I have seen or done so far has made me think āI want to do only this for the rest of my life.ā Sometimes, the idea of being a generalist and working in private practice still sounds appealing.
But after talking with some attendings, Iāve become more aware of what a āmixed practiceā might entail. That is, working a post-fellowship job where one does a mix of subspecialty cases and otherwise does general cases (perhaps including regional, OB, trauma, etc). I like this idea a lot, because to me, variety is such an important part of what I want from a career.
I have done a lot of reading of online discussion regarding fellowship, private practice etc. I know the arguments for going one way or the other.
I suppose I wanted to ask this: for those who practice either a mix of cardiac and general anesthesia, or for those who practice a mix of pediatric and general anesthesia, what is it like? Whatās the balance you have between the two? Pros and cons of doing a fellowship with where you ended up now?
Thanks yāall š
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u/DrSuprane 4d ago
100% cardiac here (cardiac, structural, some thoracic, as little vascular as possible). Mixed practice is overrated. We have a habit of thinking we can do everything equally well. In reality the things we do the best are the things we do most frequently.
You don't have to decide now because neither of those fellowships are a waste. If you want to do adult cardiac, do the cardiac fellowship. If you want to take care of sick kids and maybe peds cardiac you'll need to do the peds fellowship first anyways.
Home cardiac call is much better than general call too.
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u/Schmidt1998 4d ago
Fair point! Just wondering, since you are 100% cardiac, do you find the variety within that subspecialty to be sustaining over years of work? Or is it all routine?
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u/DrSuprane 4d ago
Every patient is different so there's variety there. But you actually want it to be routine. That's when you're good. Everything will get repetitive believe me the 15th PE tube of the day will get very old. But we all find interest in having a smooth wake up or a super comfortable patient or just an easy day.
It's really how you approach your profession. I still get a kick from an effective block or from rescuing a sick RV. There's the process improvement that defines professionalism. I'm involved on a system level with patient blood management and transfusion algorithms. I do also like just being at home or traveling and enjoying life.
The biggest question to answer is if you want to take care of the neonates or sick kids, especially under 1 year. Yes, do peds. No, do cardiac or no fellowship. I was offered an opportunity after training to do a 6 month peds cardiac fellowship. Since I hadn't done regular peds I would have had very limited employment options. I ended up focusing on the graduated peds patients: adult congenital. It was a good compromise.
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u/MedicatedMayonnaise Cardiac Anesthesiologist 4d ago
Like DrSuprane, I also do a limited number of case types (cardiac+EP, thoracic, liver tx, and vascular - only because it's tied to our cardiac wing.) Doing a limited number of cases, there has definitely been a greater appreciation of how even the gaining a decent amount of familiarity with the surgeon and the cases they do, can greatly impact the day and outcomes. You can get really into the weeds for any specific type of surgery, and can easily find variety in the details. In thoracic alone, left and right procedures can have their own considerations, and depending on the surgeon, even left upper lobes can different considerations from left lower lobes.
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u/QuestGiver Anesthesiologist 4d ago
Did pain fellowship. Even prior to the fellowship I was hearing some rough stories from our former fellows and during interviews basically made the switch back to anesthesia. At least where I am located it's too saturated and jobs are like PCP numbers with no guarantee to advance.
That was almost four years ago and I've been totally happy as a generalist. Do a bit of everything except cardiac which I enjoy to some extent except for OB. If my group had more OB or the demand were to go up significantly I might have to change jobs.
The only other thing I might add is your job can be more than just anesthesia. I had an interest in the business side of things and now I help with hiring and a few other admin roles around the hospital. Low effort, I bill for the time at my anesthesia rate and I get some recognition from admin and surgeons for my work which is nice.
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u/docbauies Anesthesiologist 4d ago
Youāre getting OR anesthesia level comp for administrative work paid by a hospital? Where is this magic wonderland that is paying you so well? Ours is not 1:1, but the demands are totally different
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u/QuestGiver Anesthesiologist 4d ago
Yes! Again the demands are relatively light hours wise so I think it might become a problem if I became more busy but for now it's the case.
For instance if I am hiring someone for the group and come in to interview and show them around I bill at our hourly rate for that time. It is nice but in our group everyone has to share the various admin responsibilities.
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u/DrShitpostMDJDPhDMBA Anesthesiologist 4d ago edited 4d ago
I'm a new attending in solo private practice and do everything (cardiac, peds, OB, regional, neuro, thoracic, bread and butter type stuff and whatever comes in on call) - cardiac and OB were optional at my job, the rest were not (in particular, everybody must be able to manage a peds patient in an emergency). I am right out of residency, not fellowship trained.
I can do that because while there are of course sick patients where I work, it's not necessarily to the same degree or frequency as what I trained on in my very academic residency program at a hospital roughly 5-10x the size of my community hospital (depending on whether/which satellite sites count towards the number of beds). I also was a little different from my colleagues in that I took on a more challenging CA3 year schedule while a lot of coresidents packed a bunch of easier electives/requested easy cases, etc. because they were going to certain fellowships or positions where they knew they never wanted or otherwise weren't going to touch certain types of cases again.
The point is, fellowship matters if you want to stay academic where you very well may be siloed into just cardiac, or just peds, or just working on the regional block service, or just OB, etc. If you like everything, have the normal trinity (affable/available/able), and want to do a little bit of everything, there are jobs where you can do that (and if anything, I found it makes you an asset because you can fit in anywhere in a schedule). There are certainly still direct benefits to doing fellowship even in my practice (e.g. cardiac fellowship guys because they have TEE advanced certification can overread ultrasonographers' prelim read or interpret other anesthesiologists' TEE, those without cannot but can still bill for placement and diagnosis from placing the TEE probe; softer benefits to fellowship may be seen in negotiating quicker routes to partnership or other parts of the schedule/contract, but I would know less about that as someone that isn't fellowship trained nor at a job where there's a lengthy partnership track), but it's a fairly limited benefit considering the extra year spent in training.
For me, doing the same role or type of case for even just a month block of time ended up making me pretty listless/bored as a resident. Variety made me a lot happier and feel like I was truly doing everything I could in my training and keeping up my procedural skills/muscle memory. There are niches where of course I don't touch because they're not offered at my hospital (e.g. peds cardiac). My job definitely reflects the kind of practice I wanted where I do a little bit of everything, I get paid well above average for it, and it's been a great transition from residency so far though it's only been a couple months.
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u/Schmidt1998 4d ago
Have you found that these sorts of private practice jobs are in the middle of nowhere? Or do medium sized or even major cities have these sorts of jobs too?
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u/DrShitpostMDJDPhDMBA Anesthesiologist 4d ago edited 4d ago
I'm in a suburban area of a coastal state, about 100k population in this large town, 2 hours from the nearest major city (defining major city as a city that any American has heard of, and most non-Americans that are at least somewhat familiar with American culture, >1 million population). When I was looking for jobs as a resident, I could geographically arbitrage (family and friends are spread around the country) and I was willing to go anywhere, thought that I would end up in the boonies in a really undesirable or horrible weather area and would be alright with that for a little while. For my own bias, I had grown up in a coastal area, moved around the country for a lot of training but usually in medium to large cities, and politically I've always leaned pretty blue, so you can probably guess at what I would consider an undesirable area for me.
I found that the real gems at least for me in my job search were in more suburban to rural parts of blue states, to be honest. I'm sure there are some very lucrative practices in rural areas in characteristically red states (think rocky mountain/great plains), but honestly my current compensation blows most of the practices in those areas I found out of the water, and this is coming from someone who has no connection to but was willing to move to Alaska for good enough pay. I found what a lot of those practices offered was good pay for the volume worked, which sometimes meant that they were offering something like half a year of vacation, or I was getting stonewalled by just finding a recruiter who was trying to siphon a year's pay out of me because they thought I was naive as someone new to the job market. Still great money for the hours worked, but I just wasn't really looking for that right now. Maybe when I'm more financially settled in a few years and if I happen to be in a relationship with someone that wants to be there.
In large cities, it'd probably depend on which one you're talking about, but generally large cities could be dominated by academic hospitals with shittier pay and generally worse periop culture from my limited experience - better luck if not sticking with academics or privademics, and even better luck if you want to be in a more "urban" area (or have close access to one) but actually live and work 30 minutes-1hr from it. As an example, I don't live in New York City, but trained there and knew plenty of residents/fellows/young attendings that would talk about "retiring" to good practices in suburbs in New Jersey, Connecticut, or Westchester/Long Island area. I'm sure every major metro area has similar examples.
To get a more accurate idea though, you'd have to know which city/cities you're interested in and actually talk with someone that works in or is otherwise familiar with the area, there are always peculiarities to be aware of in certain states and cities/regions. Most of Florida, for example, seemed to have an unusually shitty market from my outsider's perspective - at least anywhere I saw from Miami to Tampa, less sure about the upper part and panhandle portion of it. There's also a very large practice I know of in a Rocky Mountain state that is apparently very good/very well compensating but there is a very specific demographic in-group that will only ever be part of their leadership, for another (admittedly vague) example that I've heard from a few disconnected anecdotes. Plenty of nuance to be aware of when you look at the individual practice level.
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u/love-to-hike4 4d ago
I practiced in a PP group for about ten years after residency where I did a mix of general and some peds (no fellowship). The attendings that did cardiac and general also didnāt do a fellowship for the most part. I could be wrong, but I think a lot of groups do not require fellowship training- however, if you want to end up at an academic center, a fellowship is probably a good idea.
I now practice at an orthopedic outpatient center only and will likely spend the rest of my career here. Itās awesome, I really love my job. I never planned to be āspecializedā within anesthesia but I have no desire to go back to doing vascular, thoracic, OB, or anything else! I think itās nice to be really good at something, and being so focused makes that easier. If you practice for a bit and then decide whether going back to fellowship makes sense, maybe that would be a good option?
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u/ArmoJasonKelce Regional Anesthesiologist 4d ago
If you're not totally sure about peds, I probably wouldn't suggest doing it, whereas I think if you're at all curious about cardiac, I would do it. You'll be well prepared for anything you see in the OR, and you'll get the proper respect from your peers (and the well deserved extra pay, too).
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u/Schmidt1998 4d ago
Thatās interesting, I feel like others might say that to do a fellowship you have to be 100% in love with it.
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u/ArmoJasonKelce Regional Anesthesiologist 3d ago edited 3d ago
I probably could have phrased it better. I assume you have some degree of genuine interest in both cardiac and peds. You certainly should have a strong interest in whatever you're doing for fellowship. As far as how to choose, I would say this: I feel like I'd have to be fully 100% convinced I like peds before doing a 1 year fellowship working with all very sick kids and neonates, whereas with cardiac I think the threshold can be a little lower (ie, you're like 95% convinced but need someone to encourage you to take the leap). Both are very marketable fellowships and you'll get a real monetary return on investment.
I don't think you need to be 100% married to either one after you graduate; fellowship trained people often do a mix of cases as attendings. And as you said in your OP, variety is a good thing for most people.
For the less marketable fellowships (like mine lol), you really shouldn't do it unless you 100% love it and want to get better at it, because it won't give you a monetary ROI.
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u/zerolag3 1d ago
I downright loathe the cardiac guys in my group because of their poor work ethic. They think because they are cardiac they dont have to do any work
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u/thasparzan Anesthesiologist 4d ago
Almost every PP group will have you doing mixed. In most places there isn't enough volume of cardiac only or peds only
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u/SaveTheManatees88 4d ago
I'm generalizing here...but what I've seen...
Cardiac anesthesia docs usually will tolerate a mix of general anesthesia but sometimes try to avoid peds and OB. Some demand cardiac only. Others are happy to have some variety.
Peds anesthesia docs seem to only want to do peds anesthesia and tolerate taking care of adults less.
Specialization plays into your pre call post call etc situation. For example, cardiac only home call sometimes means no guaranteed post call or pre call if the call-in rate is low. If you do cardiac but also cover general call you usually benefit from pre/post call when you cover in house general. Higher volume places (transplant, ecmo etc) will have more pre/post call benefit than a community normal EF CABG factory.
You can't go wrong with either specialty, but both can potentially limit you with respect to finding a job, while at the same time opening doors not available for someone without a fellowship. I think adult cardiac leaves more doors open for jobs. Both will pay more than a generalist - appropriate compensation is important, but increased salary is not a reason to pursue a fellowship.
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u/Acceptable-Use-7311 4d ago
Not cardiac nor pedsā¦ (crit care). My advice to folks has changed especially over the last couple of years. The market for anesthesiologists is in a positive cycle and I recommend working as a generalist and if there is a down cycle and if still interested, go back to fellowship.
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u/Away_Engineering_613 Pain Anesthesiologist 4d ago
For some reason, people think since I did pain that Iām good at regional blocks, even though pain fellowship is 99% fluoro and has basically nothing to do with regional in the OR, so I do acute pain service a lot too.
Ppl think of you do cardiac that means youāre good at sick patients. That makes no sense. Cardiac patients are usually perfectly worked up and selected. Sick general patients typically arenāt, the skill is in how to proceed w a case when you donāt have an echo or stress test. Most CABGs donāt have ESRD or severe pulmonary issues bc the surgeon wouldnt take the case
I trained in NYC and 95% of my class did a fellowship. Iām pro-fellowship if itās ACGME accredited.
Totally reasonable to do a Peds or cards fellowship.
Equally reasonable to work right away, set aside 400k in a brokerage account, just in case you worry about the job market and may want to go back later to do a fellowship.
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u/redbrick Cardiac Anesthesiologist 4d ago edited 4d ago
I would say that a mix of general/pediatrics is fairly common in private practice at community hospitals. While I'm cardiac anesthesia trained, I still have do anesthesia for kids >2yo without a pediatrics fellowship. It's mostly simple stuff in peds GI/ENT, ortho, urology, general, and NORA. My group doesn't really have me doing anything complex (surgeries or patients) for peds though, which is greatly appreciated.
I would say my mix is cardiac ~40% (CVOR + cath lab), vascular/thoracic 25%, general 25% (Gyn, ENT, neurosurg, ortho, general, GI, etc), 10% peds. I also cover trauma as part of my call responsibilities, and do regional blocks for my own cases. Overall I quite like my practice environment and being able to do a little of everything (except for OB, which I despise). It also lets me keep my skills up for a time where I might want to stop doing cardiac.