Why you should do a fellowship!

Are you an anesthesia resident who's debating whether or not to spend an extra year doing a fellowship? 

I'm gonna present four reasons why you should do a fellowship, and why I think doing a fellowship is going to maximize your professional success.

Let's get started.

Reason #1: Marketability

Let’s be honest. Why did you go through all those years of college, medical school, internship, and residency? That’s right, to GET A JOB! (and start making that real money). So you’re thinking, do I really want to spend another year of training and delay that real paycheck by yet another year? Is it really worth it?

Well, a fellowship makes you more marketable, and there are several ways this happens. One, a fellowship immediately turns you into a more appealing applicant to the private practice group or the academic group that you're applying to. How so? You’ve demonstrated to the group that you spent a year, sacrificing real money, to further hone your craft and become a specialist in a specific area. That shows the group you’re someone who’s serious about perfecting their craft, and who doesn't like that?

In addition, almost all groups need subspecialty providers. Why? Due to technology, and the general current of the medical profession as a whole, subspecialization is more prevalent than ever before. In many groups, CRNAs staff the bread-and-butter general anesthesia cases, while fellowship-trained anesthesiologists staff the more complex cases.

A fellowship also makes you more marketable by the simple fact that you’re a “two-for-one”: you’re great at general anesthesia cases, but you’re also competent to perform cases in your subspecialty. That flexibility is very welcome in most groups, since staffing needs and case types vary from day to day.

Reason #2: Technology

Now, you might be asking yourself, technology? What does that have to do with medical practice? Well, let me explain. Over the past 10 to 15 years, I have personally witnessed a sea change in the influence of technology on anesthesia practice and I'm gonna give you three examples. The first example is one that you're very familiar with, it's called the videolaryngoscope. Many of you know this as the Glidescope, although there are other brands as well. Back in 2008, when I first used the Glidescope to perform an intubation, I remember saying to my attending, "This thing is a job killer". He looked at me and chuckled, unsure of how to respond. Well, it turns out I was right.

I started in private practice in 2009 at a medium-size community hospital with a very busy ED. We would get overhead paged about once a month to respond to an urgent airway in the ED. Of course, someone in the group would grab a Mac 3 and Bougie, and take care of business in the ED. Then, in 2010, the ED purchased a Glidescope. You know what happened? The ED never called us again. They didn't have to. The Glidescope had made laryngoscopy and intubation so much easier that they didn't need our airway expertise. It had an immediate and permanent impact on our practice.

The next example is ultrasound. Of course, ultrasound technology has been around for decades. But only recently has the imaging resolution, portability, and price point of ultrasound machines improved to the point where ultrasound imaging is now widely used. During my residency (2005-2008) I learned how to do nerve blocks using nerve stimulators, and I learned central line placements with the landmark technique. Now, with ultrasound, nerve blocks and line placements can be performed by anyone with adequate vision and decent hand-eye coordination -- this includes CRNAs and other mid-level providers.

The final example in this section is YouTube. YouTube is now the go-to reference for learning how to perform ultrasound-guided nerve blocks. This is just another example of the rapid dissemination of easily accessible information. Platforms like YouTube have taken down the barriers to obtaining information and have allowed anyone with an internet connection to learn how to do just about anything. The implication is clear: YouTube has made it easier than ever for our competitors (read: CRNAs) to learn and perform core anesthesia procedures, procedures which historically were performed only by physician anesthesiologists.

So, to put all this together, technology is impacting our profession in real ways that make it easier for our competitors to perform the core procedures we perform. And, because technology only gets better, this situation's only going to get worse.

Reason #3: CRNAs

It's no secret folks...the CRNAs are coming for your job. Over the past few decades, they have lobbied relentlessly at the state and federal level, trying to increase their scope of practice. They even used the Covid-19 pandemic to push their mandate--and scored tangible gains. After President Trump declared a state of emergency in March 2020, the Centers for Medicare and Medicaid Services (CMS) immediately and unilaterally waived the requirement that a CRNA be under the supervision of a physician, stating that this change "will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration". Soon thereafter, the Department of Veterans Affairs instituted the same measure.

In October 2021, the AANA (formerly known as the American Association of Nurse Anesthetists) took perhaps their most aggressive step yet when they changed their association's self-identified moniker to "Nurse Anesthesiology".

Hospitals around the country are testing the waters of using CRNAs as their primary anesthesia providers and finding that significant cost savings can be realized with little increased liability. It's time that physician anesthesiologists be brutally honest about anesthesia practice today: for bread-and-butter general anesthesia cases, most well-trained and competent CRNAs can perform nearly all of what a physician anesthesiologist does.

Given the perfect storm of healthcare cost inflation, pressure on hospitals to lower overhead and maximize profit, and technological advances, it's imperative that tomorrow's physician anesthesiologists distinguish themselves and perform value-added services that are difficult for CRNAs to replicate.

Reason #4: Future-proofing yourself

Unexpected life events occur with little or no warning. A fellowship provides one with an extra set of options when confronted with an unplanned job change or geographic move. The attendings you work with during your fellowship are another set of contacts that can complement the contacts you made during your residency.

Fellowship-trained anesthesiologists are also best positioned to take advantage of advances in technology. To give one example, the number of adult ECMO runs and LVAD placements have both increased 3- to 5- fold over the past 10-15 years. Advances in motors, processors, and surface materials combined to make ECMO machines and LVADs smaller, easier to implant, and easier to manage. The result? A big increase in the need for intensivists, particularly anesthesia-trained dual-trained cardiac and ICU physicians.

Finally, I would be remiss if I didn't mention Covid. During the worst surges of the pandemic, anesthesiologists the world over were redeployed to the ICU where their knowledge of critical care medicine made them a natural fit in caring for critically ill Covid patients. The Covid-19 pandemic demonstrated the true value of physician anesthesiologists and showed that we have a lot of value to add outside the operating room.

Summary: Just do it!

Fellowship training offers myriad benefits that will endure for the remainder of your career.