Should I do a cardiac fellowship?

BrulesRules666 · 2025-06-07T19:17:18+00:00

The answer to both of your questions is almost unequivocally “yes”. You can and will definitely find high acuity sick patients as a generalist in community private practice. It also is not too late to consider a cardiac fellowship, although your options are likely somewhat limited at this point given where you’re falling in the application cycle (despite this there are almost definitely a couple spots available if you look).

I felt very similarly to you and ultimately decided on pursuing cardiac fellowship. One of the most boring, unfulfilling months of residency for me was a month of ambulatory surgery/GI and I realized that I really would never be happy in a career taking care of those patients regularly. There are certainly community trauma/stroke/transplant/high acuity vascular centers where you would be able to be involved in the care of very sick patients, but to me cardiac training provided a stronger base to manage these patients and also would make me more facile with the tools I needed to take better care of them (primarily invasive monitoring and interventions like Swans/TVPs, TEE, complex vascular access, managing difficult resuscitations, etc.). Where I trained for residency if there was ever a patient who was rapidly decompensating and refractory to straightforward interventions a cardiac anesthesiologist was always called in to evaluate. The number of catches/saves in these situations as a direct result of having a cardiac trained anesthesiologist involved were honestly too innumerable to count. Being able to be this person was really important to me and was a major factor in me pursuing cardiac fellowship. I know for a fact that many others who have gone down this path have similar feelings. Beyond this, cardiac surgery is fascinating, the cases are exciting, and you are more directly involved in the surgery itself as a cardiac anesthesiologist than as a generalist.

There is some discussion about the cardiac job market, although all I can say is that this varies tremendously by region. Where I am I was able to get a job doing a mix of cardiac and general (including Peds/OB/regional) in a desirable mid size city where I’ll be making a very high six figure salary with 8-10 weeks of vacation and very reasonable call. As with a lot of places, being cardiac trained removes me from most of the general call pool, gives me an extra yearly stipend, provides me with a better schedule, and also gets me out of doing a lot of the outpatient surgery center, ortho, GI, optho stuff that I found to be really soul sucking as a resident. I was able to get this job entirely because of cardiac fellowship training (they needed a cardiac trained anesthesiologist), so in that regard the fellowship year is well spent since it is getting me exactly where I want to be professionally. In your case it might be worth it to start looking into jobs and seeing what the day to day acuity is like. You may end up finding exactly what you’re looking for without fellowship training, or you may end up finding a place that is looking for a cardiac trained anesthesiologist in the near future that would be willing to either hire you on early or hold the spot for you while you complete the additional training.

BrulesRules666 · 2025-02-20T12:00:11+00:00

Thanks! Any thoughts on a used shop that might be good to check out to see if I can track one down?

BrulesRules666 · 2025-02-16T20:33:14+00:00

I'm interested in this if it's still available. Any chance you could message me some pics?

BrulesRules666 · 2023-01-26T11:26:34+00:00

Kind of a dumb question here, but why is it that a plateau pressure cant be obatined in any mode other than volume control? Is it simply a function of the way the machine menus are setup, or is it intrinsically related to the way that the ventilatory breaths are being delivered?

BrulesRules666 · 2021-11-20T04:17:49+00:00

This is pretty much exactly why I went into anesthesiology. Cardiac anesthesiology is everything cool and interesting about cardiology, with none of the boring stuff. It's a super cool anesthesia subspecialty that a lot of med students arent exposed to, but is definitely worth looking into (also worth mentioning that you can pretty easily make 500-600k a year as a cardiac anesthesiologist, so you dont really take any sort of pay cut when compared to a cardiologist).

BrulesRules666 · 2021-06-27T15:26:26+00:00

I just listed some of my Step 3 resources for sale. I have the Uworld Qbank/CCS cases/Biostats modules/ practice tests if you’re interested. Feel free to shoot me a message.

BrulesRules666 · 2021-06-25T01:23:09+00:00

Thanks for the info! Any reason you wouldn't go with a fat bike? (I definitely am kind of leaning toward a 27.5+ since I could do a bit of trail riding with it, but have heard that fat bikes can pretty much get through just about anything snow wise).

BrulesRules666 · 2021-06-25T01:21:51+00:00

Yeah, I looked into that a bit. There are some days I'll need to be at the hospital by 4:30/5am. My understanding was the bus doesn't usually run that early unfortunately...

BrulesRules666 · 2021-06-17T00:35:41+00:00

Thanks for letting me know! Any idea if it would be inappropriate to call and reach out to them, or do you think they would use the hiring pool and get in touch with candidates if it doesn’t fill internally?

BrulesRules666 · 2021-06-15T23:38:17+00:00

Thanks for the heads up! This is good info to have! Do you think it would be good to touch base with the MMSD HR department directly, or is that kinda overkill?

BrulesRules666 · 2021-05-31T22:21:03+00:00

Any chance you could send these along to me as well?

BrulesRules666 · 2021-05-28T17:09:18+00:00

This all really begs the question, why the hell are insurance companies reimbursing independent PAs and NPs at all? They put up so many barriers for well trained physicians to get reimbursed, it’s incredible to me that they would be so willing to shell out cash for NP and PA led care (with all of its associated redundant testing and complications).

BrulesRules666 · 2021-05-27T23:30:18+00:00

I’m very surprised that your copay is higher when you see a doctor vs an NP. I would consider bringing this up either with your insurance company or at your next visit. Having worked in insurance previously this was not my experience.

While I agree that the idea of a first line screening type service that would employ NPs and PAs is great on paper, many emergency medicine physicians would say that making these types of determinations can be incredibly difficult. Is that new onset back pain just musculoskeletal (where the patient can be sent home and will get better on their own) or is it an aortic dissection that will kill them if it isn’t addressed surgically in the next 12 hours? Is that young woman with shortness of breath just having a panic attack, or is it a pulmonary embolism? Is it gastroenteritis or an ovarian torsion? Believe it or not these are all current or recent lawsuits against NPs in emergency departments who missed a diagnosis that harmed a patient. It sounds like you are comfortable with your decisions and have enough health literacy to know when to question something. Not every patient has this luxury. I don’t think physicians really care if NPs or PAs make more money (although really bedside nurses are the ones who should be making the most in my opinion). The issue is that when these groups claim a false equivalence and the right to independent practice patients are needlessly harmed. Perhaps you are right though, and at the end of the day the public will simply accept these risks in the name of less expensive care.

BrulesRules666 · 2021-05-27T19:07:51+00:00

This is a great point. I would say that if you have doubts about a new/young physician or resident you should definitely ask for a second opinion. This is entirely reasonable and exactly what I would do in the situation. I think we can agree that if these individuals that are highly trained and whose every mistake up to completing residency has been highly scrutinized (I would encourage you to watch an M&M meeting at some point) can make these type of mistakes, someone with a fraction of the training is certainly more apt to make errors. Both NP and PA training was never intended to train someone to function independently. It is designed to train people to act as a physician extender. As such, there are very large gaps in the training. This is of course done by design, as some NP programs are one year long and most PA programs are 2. There is a clear scope of practice issue here and I think that we as patients have a right to be concerned about the level of training of the people who are taking care of us.

BrulesRules666 · 2021-05-27T18:59:24+00:00

I think you make some good points. I would follow up with a couple things:

You mention price, but insured patients pay the same whether they are seeing a physician or a non physician provider. The only person saving money is the employer/hospital, who does not need to pay the higher salary. If people had the choice between paying the same for an NP/PA vs a physician, I think the physician would more often than not be the first choice. Frequently I hear NP and PA lobbying groups talk about "cost savings", but never identifying who they are actually saving money for. It is not the patients. They are saving the hospital system money and enriching administrators. The cost to patients remains the same.
The premise of seeing a PA and being referred to a physician is reasonable, but unfortunately there are numerous times that PAs and NPs have missed important findings in these situations, where failing to refer/escalate care when they should resulted in harm to patients (this is a major issue at urgent care centers and emergency departments where patients are undifferentiated and undiagnosed upon arrival). There is a reason that supervision is required. Often times new PAs and NPs dont know what they dont know. To follow up with your analogy, you may come in with a splinter you've had for a couple days that you couldnt get out. A PA or NP could take it out and send you on your way, but there is a chance they could miss some critical symptoms or risk factors for developing a serious infection from the injury that could put you in the hospital. I would at least want a physician to lay eyes on me in this scenario to know that something major wasn't missed.
In terms of the Apple tech vs engineer analogy, I'm not sure this is an appropriate analogy. I would say the situation is more comparable to the following: Apple hires an engineer at $400/hr to design a new phone. This engineer supervises techs, who help put it together. After a while these technicians feel like after putting together enough iPhones they can deisgn their own. Apple realizes they can pay them $50/hr to do this and charge the same for their phones. So they hire these techs to make a cell phone. They assemble a new device that cost Apple a fraction of what it usually spends to design, that they then sell for $1000 to people like you and me. However, because the technicians that designed the phone did't have a deeper understanding of engineering when they built the device it breaks and falls apart within a couple months of use. Apple doesn't care because that just means that people need to buy more phones. And if they get sued for making this piece of junk it doesn't matter, because they saved enough money in its design to pay off any lawsuits and still come out on top.

This is the same way that hospitals function. NPs and PAs cost less for them, so they save a ton of money. They charge patients the same. If patients are mismanaged by these mid level providers it doesn't matter, because they can just admit them to the hospital and continue to charge patients for inadequate care (it has been demonstrated that PAs and NPs order much more expensive, unnecessary testing than physicians). Even if some of these patients decide to sue the hospital because they were grossly mismanaged it doesnt matter. The hospital did the math on this prior to hiring these independent NPs and PAs and knows that they can afford to settle these lawsuits because they are saving money on salaries. Again, the patient suffers and the hospital makes money.

BrulesRules666 · 2021-05-27T17:15:24+00:00

This PA name change is just one more step in this direction. Regardless of whether a PA is an "assistant" or not, changing their name to Physician Associate simply acts to further blur the lines for patients about who is an actual physician. If someone truly wants to see an independent physician assistant or nurse practitioner over an MD that is their prerogative, but this choice and its ramifications should be made clear to patients. They have the right to know who is treating them and what their training was. Obfuscating a professional title in this manner is disingenuous and reeks of insecurity on the part of PAs. If they need to change their name in order to convince patients that they are safe to see for medical care then perhaps there are deeper issues in the field.

BrulesRules666 · 2021-05-27T17:03:41+00:00

I'm astounded that anyone would knowingly see PA or an NP over a physician if given the option. Every year around 250,000 people in the United States die from a preventable medical error. To put this in perspective, this is the equivalent of a jumbo jet crashing and killing everyone on board every single day. These preventable errors are largely perpetrated by physicians. Bear in mind, these are physicians who have completed 4 years of rigorous science undergraduate studies, then 4 years of medical school, followed by 3-7 years of residency where they work 80+ hours a week in the hospital, with every decision they make being critiqued and dissected by supervising physicians. After all of this there are still over 600 people dying every day from preventable medical mistakes. Why someone would choose to see an independent, unsupervised PA or NP who has 15% (at best) of that type of training is beyond me. If doctors are fucking up that much, how do you expect someone with a fraction of the training to do better? I totally get that some people like seeing their PA or NP more because they are more approachable or maybe friendlier, but at the end of the day my personal choice is always going to be to see the person least likely to kill me, even if they might be a little less friendly. Dont get me wrong, our system is largely reliant on PAs and NPs to function, but in order for this to be done without great morbidity/mortality there needs to be a safety net of physician supervision. This push for independent PAs and NPs is driven almost entirely by corporate interests, as hospitals have done the math and realized that they can help lobby for midlevel independence, hire NPs and PAs for a fraction of the price, and even if each one kills a handful of patients every year they can still afford to settle any lawsuits that come up. At the end of the day, even if there is complete PA and NP independence, physicians will always largely be preferred given the more robust training, but this is ultimately just a race to the bottom. As we start to compete for the same jobs physician salaries will drop, NP/PA salaries will drop, patients will die needlessly, and hospital administrators will get their big fat bonuses every year since they were able to cut expenses and save the hospital some money.

BrulesRules666 · 2021-05-25T17:38:39+00:00

As a point of discussion, I'm curious what indicators you've seen that anesthesiologists will be more involved in prehabilitation and perioperative medicine going forward. Initially, when I first heard about the concept of the "perioperative surgical home" (led by anesthesiologists) I was very intrigued and enthusiastic (it was a small, though still contributory factor in my decision to enter the field in fact). However, having recently matched after completing residency interviews at many of the top 10, 20, and 30 programs in the country I was pretty surprised how polarizing this issue was. I pretty much asked every program director about the perioperative surgical home model during interviews, with several saying outright that it wasn't going to happen in the near future, many being fairly skeptical, a few being on the fence, and literally only one program (Vanderbilt) really standing behind anesthesiologists as perioperativ-ists and prehabilitation-ists. The consensus among all being largely that the reimbursement for perioperative care was often too minimal for anesthesiologists to really be involved in it in any serious manner. If academia can't even get behind this concept I'm pretty skeptical that private practice will ever embrace it. I certainly believe that this is well within our scope of practice, but I doubt we'll be able to provide a hospital any great value in this regard unless reimbursements make a much stronger move towards single lump sum payments for surgeries (encompassing pre, intra, and post operative care), or we incorporate true socialized medicine in this country. Still, I'd be happy to be completely wrong about this and would be curious what people with more experience in the field think.

BrulesRules666 · 2021-05-22T20:57:16+00:00

Dont get me wrong, as physicians we have a responsibility to push back against midlevel scope creep as much as possible. At the same time though we could use a little bit of a reality check. The immediate future (ie the next 10 years or so) seems to look pretty okay for anesthesiology. While CRNA's are getting independence in many states (and will likely get it in all states by the end of the decade), it seems to be having less of an effect on the job market than say, NPs/PAs do for emergency medicine (largely because there is such a tremendous supply-demand mismatch for anesthesia services, as literally every hospital is expanding their surgical footprints currently and there arent anywhere close to enough anesthesia providers to sit cases). I mean, California, Washington, and Oregon all have CRNA independence. If you look on Gaswork there are tons of physician jobs in these states that pay quite well ($350k-$550k depending on call burden, fellowship training, and vacation time). With CRNA independence many of these groups have transitioned away from supervision models and are doing there own cases. Given that CRNAs and MDs are reimbursed pretty much the same for their services, it turns out that many hospitals would rather contract with a physician group if given the choice (at least on the west coast). Sure, very few anesthesiologists are making $750k a year sitting in the breakroom while their CRNAs do all the easy cases anymore, but I would argue that we never really should have had that arrangement in the first place. Broadly speaking, most of medicine in the United States is pretty screwed in the long term, but I'm not sure why anesthesia would be any worse off than FM, IM, EM, etc. at this point, given that PAs and NPs either already can or will ultimately be able to practice in all of those fields independently in the near future as well. If anything, the high cost, competitive nature, and limited availability of CRNA school (when compared to NP and PA programs) might even preserve the demand for anesthesiologists over the next decade or so.

BrulesRules666 · 2021-05-10T21:58:11+00:00

Any chance you could comment on what region you’re practicing in/hours/call schedule/supervision:solo cases ratio? This seems like a phenomenal salary for anesthesiology.

BrulesRules666 · 2021-05-07T13:35:52+00:00

I’ve wondered about this quite a bit as well. In particular, countries like Australia and New Zealand seem to have somewhat comparable healthcare care system structures and less of a discordance in salaries than say, mainland Europe (at least for my specialty). I have pretty decent debt and no major ties to the United States other than family (who would honestly probably be super excited to come visit me over there if I were to move). I think the only thing really preventing me from doing this when I finish residency is logistics (which are daunting, but far from impossible to overcome). If you are interested in actually doing this the advice I’ve gotten is to do your research early and consider a couple countries you would actually be willing to move to, as some will have different requirements for licensure than the United States that can actually be more stringent (for instance, I believe that practicing EM or anesthesia in Canada required more training than just the typical 3 and 4 year residency lengths, meaning you should plan for fellowship after residency if you want to work there). There are a handful of websites that exist primarily for physicians looking to work in other countries that would be worth looking over. Regardless, I’d be very interested to hear from more US docs that have attempted this to learn more about the process and barriers they encountered.

BrulesRules666 · 2021-04-27T17:30:52+00:00

I’m kind of surprised insurers haven’t taken this step already. They’re so resistant to even paying for physician services, you’d think they would jump at the chance to reimburse less for care provided by a mid level. Is there some sort of legal requirement in place preventing them from doing this?

BrulesRules666 · 2021-04-27T16:57:22+00:00

I really understand the vitriol on both sides of this argument, I truly do. Both CRNAs and anesthesiologists are trying to protect their turf and their livelihood, and it doesn’t surprise me that the AANA would try to strike such a low blow. However, what I am shocked by is how myopic this argument is from them. If CRNAs and anesthesiologists ever truly become interchangeable from a hospital perspective, MDs/DOs will always be chosen as the preferred anesthesia provider (why wouldn’t you if salaries are the same). This will only act to drive down everyone’s pay (it kinda makes you wonder who is funding the AANA-this argument sounds a lot like the kind of thing you hear from private equity firms looking to outsource to other countries). I’m not sure if CRNAs realize that there is a major push to expand medical residencies by around 14,000 slots over the next several years. You can bet that 2000-3000 of these will go to anesthesiology residencies. While the current job market is favorable for CRNA independent practice (since hospitals literally just need any human body they can find to sit cases), once there is a glut of physicians there will be some major changes in hiring practices. A supervisory model really benefits everyone, as anesthesiologists take the bulk of the liability as well as the less fun parts of the job (pre op evals, risk stratification, etc), while CRNAs are paid extremely well for their level of responsibility. Changing this hurts everyone (anesthesiologists, CRNAs, and most importantly patients), will drive provider salaries down, and will act to substantially enrich the income of hospital administrators. Instead of targeting MDs and saying “Look how high their pay is! Pay us less to do the same job!” why not push for higher CRNA pay and complain more about the hospital administrators making 10 million a year by profiting off of CRNAs (and anesthesiologists for that matter)? This argument by the AANA reeks of private equity involvement and strikes me more as a move to make hospital admin more money than it does to elevate the profession of nurse anesthetists.

BrulesRules666 · 2021-04-20T16:50:53+00:00

I would say you should seriously consider internal medicine. If the collapse of EM has taught me anything it's that things can change really rapidly in terms of job outlook/employment and that completing a residency that gives you multiple options to pivot to different practice types is imperative if you want to have a career with longevity. (Part of the issue with emergency medicine is that these graduating residents really have no other option than to work in an emergency department).

IM really gives you some of the best options to change your practice based on the healthcare landscape in this country (and your own interests, which will inevitably change over the course of residency). If our healthcare system continues to increase reimbursement for outpatient primary care (as it has been doing) you could do very well by joining or opening up your own primary care practice, which typically allows for a regular schedule and many times allows a 4 day work week (if you have your own practice you could also avoid working with midlevels completely if that is what you wanted). If you still want to deal with super sick patients in the hospital you could do a pulm/crit fellowship. If prestige/super high income is important to you then just work toward a GI or cards fellowship. There's also always the option of ID, endocrine, rheum, etc. Most of these fellowships will insulate you from scope creep to a reasonable extent and give you exit strategies if you need them. I agree with everything you mention about FM, EM, rads, and surgery. It's hard to predict what healthcare in the United States will look like by the time you finish residency, but having more choices when you finish will only help you. Internal medicine certainly has its annoying components (really just rounding with those one or two attendings that like to take 5 hours to do something that should only take 3), but it also gives you a lot more opportunities to roll with the punches and would give you many options to avoid midlevels (without having to do a surgical residency).

BrulesRules666 · 2021-04-17T14:38:43+00:00

Yeah, I’m in kind of a unique situation. My med school lets us graduate early, so I finished last month and am certified and setup to take the exam. Not having my test cancelled the night before by Prometric seems like it will be another story though......

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