What would you do differently?

[intmed2014]

Congratulations to those who matched this cycle. I pose a question to those who are graduating pulm/cc fellowship this year and/or junior attendings in the workforce. Would you approach your training any differently (and if so, why?) There appears to be more emphasis on the workforce on ECMO, certified in "x procedure", administrative responsibilities etc. All fellowships appear a bit different in the clinical exposure they provide.

Appreciate your input.

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[deleted547339]

Congratulations to those who matched this cycle. I pose a question to those who are graduating pulm/cc fellowship this year and/or junior attendings in the workforce. Would you approach your training any differently (and if so, why?) There appears to be more emphasis on the workforce on ECMO, certified in "x procedure", administrative responsibilities etc. All fellowships appear a bit different in the clinical exposure they provide.

Appreciate your input.

Go somewhere that is multidisciplinary and where you have significant responsibility.

 

[jdh71]

Congratulations to those who matched this cycle. I pose a question to those who are graduating pulm/cc fellowship this year and/or junior attendings in the workforce. Would you approach your training any differently (and if so, why?) There appears to be more emphasis on the workforce on ECMO, certified in "x procedure", administrative responsibilities etc. All fellowships appear a bit different in the clinical exposure they provide.

Appreciate your input.

Less time with transplant.

More time with EBUS, ILD, pulmonary hypertension, neuromuscular resp disease, cards (heart failure), surgical ICU, and neuro ICU.

In the community you want to be able to hit the ground running on your basic bronchs and EBUS. In the community you will end up doing a lot of the cardiac, general surgery, and neuro critical care.

If you have the luxury of sending patients to super specialists for ILD, PHTN, or neuromuscular resp failure great but there is a good chance the patients being referred to you will expect you to deal with these things and you're going to want to be comfortable stated an ILD working up, rxing long prednisone treatments, and rxing and monitoring methotrexate, cellcept, and azathioprine. Familiarity of the use of rituxab will be helpful. You will want to feel comfortable working up and initiating and monitoring oral therapy for PHTN.

The neuromuscular stuff really threw me for a loop. I had like basically zero exposure. These folks are often scared and desperate and looking for someone to be the adult in the room because neurology probably isn't stepping up.

 

[Bobblehead]

Don't focus on ECMO or transplant or anything super-specialized unless you plan and know you'll be at a center that will do those things. We send ECMO across town from our large tertiary care center because the infrastructure investment for it is just too high. Same for transplant.

Realize that IP sounds cool but before you go down that rabbit hole make sure you talk to actual IP practitioners and understand how they're making their salaries.

Pay attention when your attendings are doing the billing but realize that many academic attendings are probably doing it wrong because of the multiple layers between them and the money those codes represent.

If you think you've seen enough ILD you have not. You probably won't realize that until you're in practice and you have the rheumatologist, cardiologist and the patient asking for your expert opinion and you realize you need to step up because a lot of things will subsequently occur based on what you write in your note. You may decide to send out patients with pulmonary hypertension by the time they need flolan (and probably should because that takes dedicated infrastructure) but before you get there you should be able to manage them.

 

[cavitarynodule]

Don't focus on ECMO or transplant or anything super-specialized unless you plan and know you'll be at a center that will do those things. We send ECMO across town from our large tertiary care center because the infrastructure investment for it is just too high. Same for transplant.

Realize that IP sounds cool but before you go down that rabbit hole make sure you talk to actual IP practitioners and understand how they're making their salaries.

Pay attention when your attendings are doing the billing but realize that many academic attendings are probably doing it wrong because of the multiple layers between them and the money those codes represent.

If you think you've seen enough ILD you have not. You probably won't realize that until you're in practice and you have the rheumatologist, cardiologist and the patient asking for your expert opinion and you realize you need to step up because a lot of things will subsequently occur based on what you write in your note. You may decide to send out patients with pulmonary hypertension by the time they need flolan (and probably should because that takes dedicated infrastructure) but before you get there you should be able to manage them.

There are plenty of fellowship programs that don't give you any exposure to pHTN (Cards is primary). How do graduates of these programs deal with this once they graduate or are they pidgeon-holed into where they trained?

 

[chessknt]

You guys doing your own rhc then while managing all these pH patients? Do you trial nitric oxide or the other iv agents for response during your cath?

 

[jdh71]

There are plenty of fellowship programs that don't give you any exposure to pHTN (Cards is primary). How do graduates of these programs deal with this once they graduate or are they pidgeon-holed into where they trained?

you learn

 

[jdh71]

You guys doing your own rhc then while managing all these pH patients? Do you trial nitric oxide or the other iv agents for response during your cath?

Where I work cards still wants to do the RHCs, and get them done when I want them. I'd do my own if I got a bunch of crap. I'm ambivalent on trials of nitric or IV flolan. I won't be using calcium channel blockers. Period.

 

[IMreshopeful]

Where I work cards still wants to do the RHCs, and get them done when I want them. I'd do my own if I got a bunch of crap. I'm ambivalent on trials of nitric or IV flown. I won't be using calcium channel blockers. Period.

Honestly, as a cardiologist and someone who has trained at a PH program, the RHCs are my least favorite procedure (hard to find them exciting after placing MCS and doing PCI) ... but by far the easiest. A simple one takes five to ten minutes from stick to catheter out. I’m not sure how lucrative they are to do from a billing/RVU standpoint (probably not a lot). From that perspective it would not bother me if the pulm guys wanted to do them, although the ones I have seen do them don’t always have the catheter skill or training to do tough ones, which is a function of training.

But yeah generally when our MICU wants a RHC done we just do them unless there’s some obvious contraindication/it truly has more risk than benefit.