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Division Chief, Critical Care Medicine Department of Anesthesiology
University of North Carolina at Chapel Hill
The beauty of anesthesiology is the diversity of what you can pursue once you complete your training. Personally, I loved the operating room, but I was also interested in the management of patients once they left our care. Cardiothoracic patients are a challenge; they are complex, and often have intricate physiology that requires a deep understanding in order to treat them effectively. Completing a cardiothoracic fellowship allows you to understand the intraoperative complexities of these patients. The postoperative course, however, can be very different. The body has a unique way of healing and doing a fellowship in critical care medicine gives you insight into this process. I spend half of my clinical time in the operating room with an emphasis on cardiothoracic cases and the other half in the cardiothoracic intensive care unit, caring for those very same patients. Completing a dual fellowship allows me to be a perioperative physician. Whether I am in the operating room or the intensive care unit, I can use the skills from each experience to enhance the care I provide on a daily basis.
Embarking on a dual fellowship, you are forfeiting two years of potential work experience and the financial implications of this are not minor. Whether you choose to do critical care or cardiothoracic first, each year has new challenges and intense experiences.
The goal of a critical care fellowship is to gain experience working with a variety of critically ill patients. You will spend several months in a cardiothoracic ICU, surgical ICU, medical ICU, and perhaps even a neuro or burn ICU. In a one-year span, you will have taken care of a wide variety of patients with a wide spectrum of critical diagnoses. You will learn how to navigate and lead in a multi-disciplinary model and develop interpersonal relationships with leaders from multiple fields of medicine. Most fellowships also aim to teach point of care ultrasound, which is a skill that can be useful in many clinical settings.
The goal of a cardiothoracic fellowship is to expose fellows to a wide variety of cardiac, vascular, and thoracic pathology. You will take care of very ill and very challenging patients, and ultimately gain a deeper understanding of their complex physiology. The fellowship is often ‘cardiocentric,’ in that the majority of your time will be doing advanced pump cases, mechanical circulatory support, transplant, and innovate valvular surgery.
Transesophageal Echocardiography, both 2D and 3D, is a core component of the curriculum and fellows will obtain advanced perioperative certification at the conclusion.
Both fellowships encourage each fellow to complete a research or clinical project that is to be developed over the year. There is an ongoing emphasis to engage fellows in quality improvement processes that focus on system improvements and/or patient safety. Fellows in both years will be encouraged to attend subspecialty national meetings and present their projects. Scholarly activity and national presence serves a dual purpose in that it introduces trainees to the ongoing advancements in their subspecialty but also allows fellows to interact with others in their subspecialty community. It opens the door of opportunity for both professional growth and career advancement.
There are a number of paths that can be taken after completing a dual fellowship. Some may choose to pursue an academic career in which they split their time evenly between ICU and OR (with an emphasis on cardiothoracic OR). The choice of ICU is wide open; after a critical care fellowship you can functionally operate in a surgical ICU, a cardiothoracic ICU, burn ICU and even a neuro ICU. That decision is generally based on institutional culture and personal preference. Some folks choose to only practice in one area and not practice in both capacities. Other people choose to join private practice groups, doing either a mixture of both or just one discipline. There really are endless options. In my experience, I would say a majority of people who choose to complete a dual fellowship generally take academic jobs with a variety of clinical schedules. The advantage of being both cardiothoracic trained and critical care trained is your flexibility in terms of clinical assignment. It is a huge asset to have people with these skills in either a private or academic setting.
I foresee the dual fellowship track becoming increasingly popular. The market, especially in academics, for anesthesiologists who provide dual services is on the rise. More and more intensive care units across the country are moving into ‘anesthesia run’ entities where anesthesiologists provide the majority of the work force. I would not be surprised if more programs started offering residents a choice of doing the dual fellowship at the same program. Because of rising interest in completing a dual fellowship, I imagine more institutions will be interested in starting fellowships and expanding the options for applicants.
Because a dual fellowship is a two-year commitment, the residents that succeed are those that are motivated. The days are long and the nights seem longer. These two years are rigorous but the training and understanding that fellows gain is unparalleled. Residents who are hardworking, passionate, and enthusiastic about caring for these patients are the ones that succeed. As the fellows progress through each year, they will gain more confidence, and eventually develop into leaders in the care team of these patients and respective units. Both fellowship years offer some level of elective time where fellows can expand their training into learning more about perfusion, point of care ultrasound, advanced heart failure, congenital cardiac anomalies, transfusion medicine, etc. The most successful resident is one who is humbled by these patients and willing to put in the necessary work to gain insight into their pathology.
Both fellowships are part of the match process. Residents typically submit applications in the fall and winter of the previous year. Interviews generally begin after the New Year and can go as late as May. Typically, Match Day is in late May or early June. Both fellowships have exemptions to the match, which can be found on their respective websites. If you are interested in doing a dual fellowship at the same program, that is an exemption, and you can be offered a spot outside of the match. If you are interested in doing each fellowship at a different program, you will apply to each program individually and undergo the match process for both. Whichever fellowship you choose to do first, the application will need to be done during your CA-2 year. The second year of fellowship will require the application to be done during your CA-3 year.
After completion of the cardiothoracic fellowship, fellows will take the National Board of Echocardiography (NBE) Advanced Perioperative TEE examination (PTEeXAM). This allows anesthesiologists to perform intraoperative/perioperative TEE to guide clinical and surgical decision-making. After completion of the critical care fellowship, fellows will take the ABA Critical Care Medicine board examination. The NBE is starting a new examination, the NBE Examination of Special Competence in Critical Care Echocardiography (CCEeXAM) which focuses on point of care transthoracic echocardiography.
Both certifications require recertification every 10 years.
Date of Publication: Summer 2018
