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Stanford University Department of Anesthesiology
VA Palo Alto, Palo Alto, California
One of the key questions that all residents face during their training is whether to pursue a fellowship. Fellowship training offers many advantages and opportunities, but the appeal of being finished with training is also very strong. In this article, we’ll look at some of the arguments in favor of fellowship training.
Fellowship-trained anesthesiologists offer value-added skills which allow practice groups to demonstrate their value to surgeons and hospitals. Having a fellowship can also be a way to "get a foot in the door" in a competitive job market, and serves as a springboard for those seeking an academic career. The value of a fellowship extends beyond simply performing cases or procedures; fellowship-trained anesthesiologists can use their expertise to provide consultation or start programs at hospitals and surgery centers. For example, a regional-trained anesthesiologist could set up a nerve block catheter service for a surgery center’s outpatient total joint program, or a pediatric-trained anesthesiologist could advise on anesthesia staffing and hiring for a hospital that is starting a pediatric surgery program.
The American Association of Nurse Anesthetists (AANA) continue to lobby aggressively for increased autonomy and scope of practice. They have made tangible gains in recent years. In one example, the Department of Veterans Affairs (VA) proposed granting CRNAs “full practice authority” in 2016, but the VA decided against this only after a fierce lobbying campaign organized by the ASA. It should be noted that the VA’s decision was not based on a judgment of CRNA qualification, but rather, veteran access to care.1 The VA also voiced its willingness to reconsider granting full practice authority for CRNAs should access to care become an issue in the future.
The line between a CRNA and a general anesthesiologist is becoming increasingly blurred; in many institutions, CRNAs now perform nerve blocks, central lines, labor epidurals, and cardiac cases, with variable levels of supervision. As healthcare costs continue to climb, hospitals are increasingly using mid-level providers to fill patient care roles. Mid-level providers are growing in number and are becoming increasingly accepted as the primary caregiver in the physician-patient interaction,2 a role historically filled only by physicians. The increasing visibility and autonomy of mid-level providers adds legitimacy to the AANA’s efforts to increase CRNA scope of practice.
A worker is best protected from competition, and can demand a higher compensation, when he/she possesses a skill set that is difficult to learn and perform. Recent advances in technology such as the video laryngoscope, YouTube, and high-quality ultrasound make learning and performing core anesthetic techniques easier than ever. Fellowships provide the opportunity to gain a skill set which cannot be easily learned or imitated. Thus, fellowship-trained anesthesiologists often perform cases that other anesthesia providers shy away from, making them invaluable resources to anesthesia groups and hospitals. While accurate compensation data are hard to come by, there is ample anecdotal evidence that the long-term financial gain from fellowship training outweighs the short-term loss. Increased compensation can come in the form of increased pay, a subspecialty call stipend, or simply, the ability to be hired into a more prestigious group practice.
On the other hand, unforeseen changes can benefit fellowship-trained physicians. To give one example, the total number of adult Ventricular Assist Device (VAD) implantations went from 2,156 in the period 2006-2010 to 10,174 in the period 2014-2017, a 5- fold increase in seven years.3 Advances in technology have allowed VAD devices to become significantly smaller, easier to use, and more widely adopted. As a result, there is now an increased demand for ICU physicians and cardiac anesthesiologists with VAD experience. Fellowship-trained physicians are better positioned to adapt and apply new advances in medical technology.
Fellowship training confers many career benefits to an anesthesiologist, with little downside. Residents should strongly consider pursuing a fellowship in order to maximize their long-term professional and financial success.
1. https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-29950.pdf. Page 5.
2. Bodenheimer T, Bauer L. Rethinking the Primary Care Workforce—An Expanded Role for Nurses. N Engl J Med 2016; 375:1015-1017
3. http://www.uab.edu/medicine/intermacs/images/ Federal_Quarterly_Report/ Federal_Partners_Report_2017_Q3.pdf. Page 9
Date of Publication: Summer 2018
