Emergency Medicine

The ED Ultrasound Fellowship

huang

What a beaut.
What a beaut.

The use of bedside ED ultrasound is a critical skill to the EM physician in the rapid diagnosis and treatment of a multitude of life and limb-threatening injuries.  As the quality of portable machines and variety of its applications have expanded, so has the need for focused quality research and advanced training in the modality.    In response to this need, a number of fellowships in ED Ultrasound exist across the country that are available to EM-trained physicians looking to specialize.

We’ve asked UNMC EM Residency alumnus, former chief resident, and current faculty and ultrasound fellow at Orlando Health, Dr Robert Huang MD for a few words of advice for those interested in pursuing an US fellowship:

So you say you want to do an Ultrasound Fellowship…

…well, then first off, let me tell you that you’re not alone. The field of Emergency Ultrasound has exploded in the past decade, with fellowship spots popping up around the country and swarm of emergency medicine residents graduating residency with significant ultrasound exposure. While the rush on academic ultrasound director positions has slowed, the community needs are nowhere near satiated, and an ultrasound fellowship can certainly help give you a specific set of skills that makes you more marketable.

But before we get into the nitty-gritty details, I want to ask you the question that every fellowship director will ask you on the interview trail: Why do you want to do a fellowship?

If your answer is “to get better at ultrasound,” you might want to stop here. Nothing drives the ultrasound community crazy quite like the idea that doing a fellowship is just to obtain physical skills. Do people do EMS fellowships in order to meet more paramedics and see more ambulances? Do toxicologists do fellowships so they can hang out at the poison center?

While ultrasound may be the current hot subspecialty in emergency medicine, if you’re going to do a fellowship, it should be because, first and foremost, you find the field interesting. While life in fellowship is much better than residency, the pay is not. And while there are plenty of opportunities to play attending in the emergency room, you’re still not your own boss, or making your own decisions. Before doing a fellowship, I’d recommend you ask yourself one question: are you willing to essentially forgo a year of income/lifestyle in order to functionally spend another year in residency?

If that thought drives you crazy, then you’re done. If not, great! But, as I mentioned before, doing an ultrasound fellowship is much more complicated than just learning ultrasound—though of course, that happens. The goal of a fellowship is to get you the skills you need to be an ultrasound director of an emergency department. While part of that is pure ultrasound skill, the majority involves administrative endeavors (billing codes, battles with radiology, Q+A, oh my!), academic pursuits (research), and teaching (students/residents/nurses/paramedics/midlevels/etc.). If that sounds off-putting, because you “just want to get better at ultrasound,” move on.

Those of you still with me are the people we of the emergency ultrasound community are looking for. But now comes the hard part…how do you apply and what should you look out for?

It all starts with the Emergency Ultrasound (EUS) Fellowship website (http://www.eusfellowships.com). This site provides a list of all active fellowships, as well as detailed information about each one, from your general number of positions and years active down to the small details like the types of US equipment used at the hospital.

It’s a great website, and also non-optional, as it is also the website you will use to apply. The actual application process is poorly explained and mostly free form in nature. Each candidate must submit a CV, 2-3 references, and a letter of intent explaining why he or she wants to do an ultrasound fellowship. While there is no deadline for submission, a good recommendation would be late summer/early fall, as all decisions for the following year will be made in November, and you have to allow ample time for interviews.

I’m not sure what number of interviews you need to “assure” a position. This is because the process is highly variable from year to year. For example, last year over 100 spots went unfilled due to a drastic downtick in applications. The year before was much more competitive and many applicants were unable to find spots. For those of you (such as at the University of Nebraska) who do not have a home fellowship, you are at a distinct disadvantage, because many fellowships will go with the known, homegrown commodity to fill spots, if one (or two) are available. When I applied a couple of programs contacted me and said that they already had interested in house residents and were not taking external applications. So even if you are the best applicant ever, you’ll have to be open-minded when it comes time to deciding on where to interview.

In the past, many fellowships did their interviewing at ACEP, and attending the conference was a good way to knock out multiple interviews. Most (but certainly not all) programs are moving away from this. I see this as an overall benefit. I had two interviews at ACEP, and got no feel for the hospital system or the residents. I only got a feel for the fellowship director, who remains a small part of your overall experience. Many directors will not accept fellows who have not seen the site and “know what they are getting into,” and many applicants are hesitant to accept a position in a hospital they’ve never seen. So while going to ACEP remains a good way to network (many directors are part of the ACEP Emergency Ultrasound Branch, and the annual meeting is a great place to put your face in their minds), it isn’t a must.

The actual process of taking a fellowship has evolved in the past few years. As recently as three application cycles ago, the process was a free-for-all. Applicants were often offered positions on the spot in a take-it-or-leave-it scenario, and often ended up in their non-first choice location simply because of fear of what might happen if they did not. Two years ago, the community decided to set the date of November 1st as the deadline, in order to give applicants more a chance to explore their options. However, this was interpreted liberally, with some places giving early offers, while others began calling at the stroke of midnight on November 1st asking for an immediate answer. This has (hopefully) been relegated to the past with the setting of a “No Offer” policy before 10 am EST on November 14th, as well as giving applicants at least a few hours to field offers and decide what they want to do.

Whew, that was longer than I expected. I will leave this with only two other things. The first is the fact that not all ultrasound fellowships were created equally. Ultrasound is not (yet) an ACGME-certified specialty, which means that, unlike emergency medicine residency, emergency ultrasound fellowships have variable quality and curriculum. While I often say to residency applicants that they will get “good training anywhere they go,” the same is definitely NOT true of ultrasound fellowships. Some of these you will be able to find out about from their EUS profile. Places that take six fellows but have one ultrasound machine are typically not of the highest repute. However, you often won’t know until you have a see for yourself on the interview…and even then you might not know until you meet other fellows and find out what you have been missing out on. That brings me to my second point: get help from the community. Many people can try to steer you towards the programs that consistently produce excellent fellows. I am happy to be one of those people. I’m certainly not all knowing, but I’m connected enough to be able to offer help (and ask colleagues if I’m not sure). Please feel free to contact me at my email: bobdavidh@gmail.com.

I hope to see you all at future ultrasound events! While that may sound bizarre, they happen. And they’re awesome. But until you’re in the club, I can’t talk about them.

Rob Huang

EM Residency University of Nebraska Medical Center Class of 2013

Emergency Ultrasound Fellow Orlando Regional Medical Center 2013-2014

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