4th year Med stud debating EM/IM vs IM, and Pulm CC vs CC HELPPP!!

[SpartanStrong]

As a 4th year med student fielding interviews, I'm at a critical fork in the road with regards to career planning, and I don't have many IRL mentors who can help me with these nuanced questions:

I'm applying to IM and IM/EM residencies, and I'm fairly competitive in that I expect to match at one of my top 3 choices. I've gotten interviews to many of the top tier IM programs, and most of the IM/EM programs.

My end game is definitely in critical care. I'm not too excited about pulmonology, and the general theme seems to be that you should have something to "retreat" to when you need a break from the ICU. Can one of you kind souls please help me out, since these are my options below. One issue I'm struggling with is that I've gotten interviews at some really prestigious academic places (i.e. better rep than the combined programs), so I'm wondering how much would the "prestige" of my residency program influence what fellowship offers/interviews I get?

For those who don't know, the EM/IM places I'm talking about are Hennepin county, Henry Ford, UIC, Christiana, VCU, Ohio State (not listed in any particular order)

I'm looking at:

1) IM/Pulm/CC (which I'm not very crazy about the pulm part)
2) IM/EM/CC wherein I could do some 10-12 hour ED shifts as my "break" and eventually retire with outpatient IM clinic
3)IM/ID/CC - ID clinic + ICU shifts

One thing I've heard a bit about while on the interview trail is that many academic places won't take a CC trained doc into their MICU, because they want someone who is also pulm-trained for outpatient clinics and bronchs. Or they'll say something like we need someone who's done 250+ bronchs (which can only happen if you've got formal pulm training).

I'm not 100% on working in an academic ICU, but I definitely want that door to be open for me to decide 5 years down the line. However, from what I understand, MICU shifts are different than SICU and Cardiac ICU shifts. Could someone elaborate a little more on the differences between the 3? And also, if anyone has any opinion on the "requirement" for pulm training to work in an academic MICU, I'd really appreciate it.

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[AdmiralChz]

This is a pretty winding post, although not in CC know a lot about the process being in Anesthesiology and paying attention to the lay of the land. I would caution against laying exact career plans this early - I personally was positive I'd go into CC through Anesthesiology, but I saw the transition from being an MS-4 into a resident in the ICU wasnt very smooth - CC gets some strong MS4 interest because some units with lots of supervision allow med students to get very involved, much more than other specialties. I then did rotations in other things I enjoyed so much more, so I ultimately decided on another subspecialty. So keep an open mind going through residency, especially if you aren't completely sold on CC.

I'm not sure about the decision to do a combined EM/IM to go into CC - the training models for CC out of each are pretty different (medical vs surgical based).

For fellowships, prestige definitely matters but I'd wager that LORs and personality matter much more unless you are looking at fellowship programs in the local areas (e.g. more straightforward to get into a Boston program from the Boston or at least NE area).

I can't speak much about ICU hours (5 days to 1 week on service seems standard), but in general, MICUs are almost exclusively staffed by medical intensivists. There are several CC-only programs through IM I've seen on this forum. SICU/CICU are staffed by surgeons/anesthesiologists, medicine (esp in PP) and I'd wager lastly by EM-CC. The EM CC grads in our program have had some difficulty finding jobs, so staying flexible with geography is warranted. Hope this is helpful.

 

[deleted547339]

This is a pretty winding post, although not in CC know a lot about the process being in Anesthesiology and paying attention to the lay of the land. I would caution against laying exact career plans this early - I personally was positive I'd go into CC through Anesthesiology, but I saw the transition from being an MS-4 into a resident in the ICU wasnt very smooth - CC gets some strong MS4 interest because some units with lots of supervision allow med students to get very involved, much more than other specialties. I then did rotations in other things I enjoyed so much more, so I ultimately decided on another subspecialty. So keep an open mind going through residency, especially if you aren't completely sold on CC.

I'm not sure about the decision to do a combined EM/IM to go into CC - the training models for CC out of each are pretty different (medical vs surgical based).

For fellowships, prestige definitely matters but I'd wager that LORs and personality matter much more unless you are looking at fellowship programs in the local areas (e.g. more straightforward to get into a Boston program from the Boston or at least NE area).

I can't speak much about ICU hours (5 days to 1 week on service seems standard), but in general, MICUs are almost exclusively staffed by medical intensivists. There are several CC-only programs through IM I've seen on this forum. SICU/CICU are staffed by surgeons/anesthesiologists, medicine (esp in PP) and I'd wager lastly by EM-CC. The EM CC grads in our program have had some difficulty finding jobs, so staying flexible with geography is warranted. Hope this is helpful.

I'm EM->CCM. You can do medical or surgical fellowships, depending on your competitiveness, desire and location preferences. Our EM--> CCM grads seem to all find great jobs (at an admittedly name brand program).

 

[aspergilloma]

I'll address the whole "not too excited about pulmonary" thing: That's a common sentiment among medical students (and was the way I felt up until about halfway thru intern year) because it's one of the IM fields where the exposure isn't that great during medical school. You see the boring stuff (burned out COPD, maybe some lung CA, etc) but not as much of the cool pulmonary bugs, ILD, etc etc. It's not like Onc and Cards and GI where you get consistent exposure to the things you'll be consulted for during fellowship and beyond. I wouldn't use your current lack of interest in Pulm as a reason to paint yourself into a corner by foregoing opportunities at prestigious IM programs. A really good IM program will keep essentially every door open for you. A lot of those combined programs you listed might end up closing some doors (especially if pulmonary continues to become more competitive as it has been over the last several years).

TL;DR: Don't cross off pulmonary just yet, especially if doing so means you'll also be less likely to go to big league IM programs that keep all your options open.

I guess the other question I have for you is this: Why are you looking at IM/EM programs if it's sounding like you only want the EM training as a "fall back" if/when you get burned out on CC? Doesn't EM itself have the highest burnout rate according to some of the studies? The benefit of having Pulm in your back pocket is that you can do clinic, consult work, interventional, even Sleep depending on where life(style) takes you.



And yes, "prestige" absolutely matters for PCC applications, especially if you're thinking about going to a non-university residency. Not sure about the EM-CC fellowships.


P.S.: Two of my best friends in medical school went into IM/EM programs and both have said they regret it. Obviously "anecdote =/= data", but make sure you've talked to residents/recent grads about this extensively...

 

[deleted547339]

And yes, "prestige" absolutely matters for PCC applications, especially if you're thinking about going to a non-university residency. Not sure about the EM-CC fellowships.


P.S.: Two of my best friends in medical school went into IM/EM programs and both have said they regret it. Obviously "anecdote =/= data", but make sure you've talked to residents/recent grads about this extensively...

1) EM is applying to the same fellowships (at least those EM folks going into the IM slots - many do go through anesthesia)
2) Yes, you're giving an anecdote, but there are only a handful of EM/IM people in the country, 2 is actually a fair sample size.

 

[engineeredout]

P.S.: Two of my best friends in medical school went into IM/EM programs and both have said they regret it. Obviously "anecdote =/= data", but make sure you've talked to residents/recent grads about this extensively...

N=1 here, love EM/IM. I'd never trade this residency for anything else

 

[deleted547339]

N=1 here, love EM/IM. I'd never trade this residency for anything else

But what are you going to do with it that you couldn't have done with EM or IM alone? Are you going to be a cardiologist who works in the ED, too? Do you really want to round on general medical patients on the floor?

 

[Rekt]

N=1 here, love EM/IM. I'd never trade this residency for anything else

We had 3 different guest IM/EM guest speakers over the past year at my school. They all said they loved the residency, but themselves and everyone they knew that was EM/IM ended up doing one or the other. When asked if they would do it again, they all say it's a waste of time because of that reason.

 

[engineeredout]

But what are you going to do with it that you couldn't have done with EM or IM alone? Are you going to be a cardiologist who works in the ED, too? Do you really want to round on general medical patients on the floor?

We had 3 different guest IM/EM guest speakers over the past year at my school. They all said they loved the residency, but themselves and everyone they knew that was EM/IM ended up doing one or the other. When asked if they would do it again, they all say it's a waste of time because of that reason.

As an EM person with IM training: Vastly expanded knowledge base, knowing what an inpatient (or outpatient for that matter) work up would involve, what can get started in the ED. Far more ICU/CC experience than the straight EM residents (byproduct of our medicine program here being highly critical care weighted). Managing (especially ICU) holds beyond the initial few hours? Increasing prevalence of ED-OBS units? An EM/IM would be able to run that like second nature.

IM person with EM training: Managing critical illnesses, procedural skill, decisive action, multitasking. Not going to be able to give the longest differential for someone's elevated creatinine but instead of pontificating for days we take action and keep people moving. It's very interesting to see an EMIM rounding in the hospital vs an IM trained person. The list tends to clear out very quickly because we don't like to keep people lingering in the hospital. Which model will our administrative overlords appreciate more?


As for what we actually end up practicing? From my program, most do just EM, some do a mix of EM/IM (hospitalist, not outpt). Those that have gone on to fellowship do critical care - actually this year 3/4 of the graduating class are doing crit fellowships. Don't know anyone who just does exclusively medicine.

Of course nobody needs the combined program to do one or the other. And yes it is a long residency which I admit gets tiring at times. We also tend to get worked hard because we can cover every service in the hospital.

It's not for everyone, but I believe we're some of the strongest residents/physicians out there. As a 4/5 right now, I still have no regrets.

 

[Doc Doc Doc Goose]

This is a pretty winding post, although not in CC know a lot about the process being in Anesthesiology and paying attention to the lay of the land. I would caution against laying exact career plans this early - I personally was positive I'd go into CC through Anesthesiology, but I saw the transition from being an MS-4 into a resident in the ICU wasnt very smooth - CC gets some strong MS4 interest because some units with lots of supervision allow med students to get very involved, much more than other specialties. I then did rotations in other things I enjoyed so much more, so I ultimately decided on another subspecialty. So keep an open mind going through residency, especially if you aren't completely sold on CC.

I'm not sure about the decision to do a combined EM/IM to go into CC - the training models for CC out of each are pretty different (medical vs surgical based).

For fellowships, prestige definitely matters but I'd wager that LORs and personality matter much more unless you are looking at fellowship programs in the local areas (e.g. more straightforward to get into a Boston program from the Boston or at least NE area).

I can't speak much about ICU hours (5 days to 1 week on service seems standard), but in general, MICUs are almost exclusively staffed by medical intensivists. There are several CC-only programs through IM I've seen on this forum. SICU/CICU are staffed by surgeons/anesthesiologists, medicine (esp in PP) and I'd wager lastly by EM-CC. The EM CC grads in our program have had some difficulty finding jobs, so staying flexible with geography is warranted. Hope this is helpful.

Any word on the market for EM/CC docs in the Southeast region. I’m a student trying to decide if I should go EM/CC or Pulm/Crit. Know I want to be in the Unit to some degree, don’t particularly love/like IM; love EM; could tolerate pulm if it meant having some sort of break from the Unit.

 

[grt398]

PCCM will give you the most versatility in terms of the job market pretty much anywhere in the country.

 

[deleted547339]

Any word on the market for EM/CC docs in the Southeast region. I’m a student trying to decide if I should go EM/CC or Pulm/Crit. Know I want to be in the Unit to some degree, don’t particularly love/like IM; love EM; could tolerate pulm if it meant having some sort of break from the Unit.

EM market everywhere kind of sucks right now. There are a lot of EM residency programs opening. CCM is pretty wide open.

 

[sylvanthus]

As much as the EM market sucks now, I still think EM/IM/CC is the way to go. Im obviously biased and hate clinic with a burning passion. Id rather do icu and pickup ED shifts than do random pulm clinic.

 

[deleted547339]

As much as the EM market sucks now, I still think EM/IM/CC is the way to go. Im obviously biased and hate clinic with a burning passion. Id rather do icu and pickup ED shifts than do random pulm clinic.

But you don’t need the extra year. Can do it all in 5. Could do EM/CCM + US, research year, CC-subspecialty, sim, pall care or any number of other beneficial things in the same time as EM/IM/CCM.

 

[sylvanthus]

Aye, could save a year going that road, we could go back and forth all day regarding the plus/minus of extra IM training, but naww pass. Some EM//IM programs also guarantee the CC fellowship option, given that more and more EM grads are going fellowship now, that could also make a difference. Id personally recmend applying em/im, and EM 3 year programs and then make the decision come rank time. More options always good.

 

[Katheudontas parateroumen]

Anesthesia CCM... that’s the only way to go! 😂 but really, IM is the most versatile way to go. For any specialty including the sub specialty and CCM. Like mentioned they can do ID or Nephro for 2 years and tack on 1 yr CCM if they don’t like pulm. Same amount of years, lots of options. I don’t know much about EM track but I’ve had one EM/CCM attending cover a community mostly Medical ICU and I thought he was really good. He looked incredibly burned out everyday though even as a new grad. Didn’t seem like EM shifts vs ICU shifts provided him relief lol. But who knows. My hope is that anesthesia ccm gets more opportunities in the coming future after all this covid boom.

 

[Tipsy McStagger]

Well, I can only give you my impression as an EM-CCM person graduating this year who just signed their first contract.

1) I really appreciated my EM training, and I enjoyed training with my IM colleagues. I learned from them, and they learned from me. At the end of two years I'm not sure there's too much of a difference. A few more years out I'm not sure you could even tell who trained in EM or IM.

2) The ED is not the place you want to fall back to when you get burned out in the ICU. It might just be my opinion, but I think the ED is much more stressful than the ICU and if I'm lucky the only time I have to step foot in the ED again is to admit someone. So don't think you'll take the stress off yourself by just picking up some ED shifts. The only surefire way is to work less.

3) You need to think about what your career will look like. Do you want to split your time? If so how much ED vs ICU, or how much clinic vs ICU or whatever. When it comes to ED and ICU this can be difficult because often you have to get 2 different services to agree to hire you under those circumstances. Much easier to just work in one place.

4) As EM/CCM there is still some resistance to ED trained intensivists. Usually because the group is PCCM and they want you to see pulmonary consults, or run a pulm clinic as well. Though this is not as prevalent I believe as it once was.

PCCM will give you by far the most flexibility as far as ramping down your practice as you get older, and I think pulm is interesting. I'd have done it if it was an option for me. But I have no interest in pulmonary clinic or seeing those consults / fielding patient calls. EM CCM is a good option, but don't think that retiring to the ED is going to be a viable option for you. EM will also give you the option of SICU/CVICU/NICU whereas I don't know any IM trained intensivists that work those areas - but perhaps they're out there somewehre (EDIT: See below CCM-MD is doing just that, I stand corrected). Whereas I know several EM trained intensivists that regularly rotate through MICU/SICU/CVICU which is a good way to break up the monotony of one unit.

Best of luck!

 

[CCM-MD]

Well, I can only give you my impression as an EM-CCM person graduating this year who just signed their first contract.

1) I really appreciated my EM training, and I enjoyed training with my IM colleagues. I learned from them, and they learned from me. At the end of two years I'm not sure there's too much of a difference. A few more years out I'm not sure you could even tell who trained in EM or IM.

2) The ED is not the place you want to fall back to when you get burned out in the ICU. It might just be my opinion, but I think the ED is much more stressful than the ICU and if I'm lucky the only time I have to step foot in the ED again is to admit someone. So don't think you'll take the stress off yourself by just picking up some ED shifts. The only surefire way is to work less.

3) You need to think about what your career will look like. Do you want to split your time? If so how much ED vs ICU, or how much clinic vs ICU or whatever. When it comes to ED and ICU this can be difficult because often you have to get 2 different services to agree to hire you under those circumstances. Much easier to just work in one place.

4) As EM/CCM there is still some resistance to ED trained intensivists. Usually because the group is PCCM and they want you to see pulmonary consults, or run a pulm clinic as well. Though this is not as prevalent I believe as it once was.

PCCM will give you by far the most flexibility as far as ramping down your practice as you get older, and I think pulm is interesting. I'd have done it if it was an option for me. But I have no interest in pulmonary clinic or seeing those consults / fielding patient calls. EM CCM is a good option, but don't think that retiring to the ED is going to be a viable option for you. EM will also give you the option of SICU/CVICU/NICU whereas I don't know any IM trained intensivists that work those areas - but perhaps they're out there somewehre. Whereas I know several EM trained intensivists that regularly rotate through MICU/SICU/CVICU which is a good way to break up the monotony of one unit.

Best of luck!

Hey there are many of IM folks that do those 2 year multidisciplinary CCM fellowships too. I’m one of those: IM followed by 2 years of CCM. I work in an group that sees all critical medical, surgical, neuro and CV patients. My cofellows that have graduated work in all sorts of units. I agree: completing a multidisciplinary CCM fellowship will allow one to get a more diverse experience and exposure to various non-medical/surgical patients than a tradition straight medical or surgical fellowship. But I think everyone evens out after a few years in practice. Also agree that pulm-CCM will provide the most employment opportunities and ability to deescalate with age. I guess with IM one could eventually “deescalate” to primary care but for me personally that would probably cause more burnout.

 

[Tipsy McStagger]

Hey there are many of IM folks that do those 2 year multidisciplinary CCM fellowships too. I’m one of those: IM followed by 2 years of CCM. I work in an group that sees all critical medical, surgical, neuro and CV patients. My cofellows that have graduated work in all sorts of units. I agree: completing a multidisciplinary CCM fellowship will allow one to get a more diverse experience and exposure to various non-medical/surgical patients than a tradition straight medical or surgical fellowship. But I think everyone evens out after a few years in practice. Also agree that pulm-CCM will provide the most employment opportunities and ability to deescalate with age. I guess with IM one could eventually “deescalate” to primary care but for me personally that would probably cause more burnout.

Oh, very cool! I suspected there would be some I just never met any. I don't think there's anything special about EM that would make them better in multidisciplinary ICUs (the time spent in trauma/surgical ICUs in residency is not difficult to make up in fellowship / attendinghood). So it would make sense that IM trained folk work there as well.

Oof, I can't imagine primary care being the exit strategy, I'd go nuts.

At this point I have no clear exit strategy aside from some windfall investment (unlikely) or maybe palliative / hospice. But by that time it'll probably be saturated.

 

[grt398]

I think primary care as an exit strategy might depend on how you do it, and what you mean by exit strategy. I've always thought it might be nice to run a very small clinic, direct pay type, where you had a panel of maybe 100-200 patients who were with you because you had shared goals for improving their health. Patients would self-select out if they didn't like your approach since they'd be paying cash to see you. If you only needed to pay your day-to-day living expenses b/c you had already worked 20 years as an intensivist for your retirement needs, you really wouldn't need to earn that much. Or if you liked education you might be able to do something local or even overseas focused. This is from the abstract of a paper out of Mayo I think is very interesting:

"Weekly 45-min case-based tele-education rounds were conducted in the recently established medical intensive care unit (MICU) in Banja Luka, Bosnia and Herzegovina. The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) was used as a platform for structured evaluation of critically ill cases. Two practicing US intensivists fluent in the local language served as preceptors using a secure two-way video communication platform. Intensive care unit structure, processes, and outcomes were evaluated before and after the introduction of the tele-education intervention...The intervention was associated with reduction in ICU (43% vs 27%) and hospital (51% vs 44%) mortality, length of stay (8.3 vs 3.6 days), cost savings ($400,000 over 2 years), and a high level of staff satisfaction and engagement with the tele-education program."

Impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit - PubMed

Weekly, structured case-based tele-education offers an attractive option for knowledge translation and quality improvement in the emerging ICUs in low- and middle-income countries.

pubmed.ncbi.nlm.nih.gov

Maybe I'm being optimistic but I think there's a lot more opportunities than traditional pulm/primary care clinic part time vs full retirement.

 

[Doc Doc Doc Goose]

P.S.: Two of my best friends in medical school went into IM/EM programs and both have said they regret it. Obviously "anecdote =/= data", but make sure you've talked to residents/recent grads about this extensively.

Why do they regret it out of curiosity? Did they end up only practicing in one of the fields? And if that's the case, weren't they warned of that when they were applying/looking into those programs?

 

[Doc Doc Doc Goose]

But what are you going to do with it that you couldn't have done with EM or IM alone? Are you going to be a cardiologist who works in the ED, too? Do you really want to round on general medical patients on the floor?

Some would argue that a single physician good at IM, EM, AND CC would have a synergy of GOODNESS to create a GREATNESS at all THREE.

 

[deleted547339]

Some would argue that a single physician good at IM, EM, AND CC would have a synergy of GOODNESS to create a GREATNESS at all THREE.

You entirely missed my point. Extra knowledge is great, but why stop there? Why don’t you do OB, too? You might have pregnant patients sometimes? Oh, and endocrine would be helpful, too, for dka, you know?
My point is that extra training may help, but it comes at a cost and is unnecessary.

 

[Doc Doc Doc Goose]

You entirely missed my point. Extra knowledge is great, but why stop there? Why don’t you do OB, too? You might have pregnant patients sometimes? Oh, and endocrine would be helpful, too, for dka, you know?
My point is that extra training may help, but it comes at a cost and is unnecessary.

I see what you’re saying Doc. I was being facetious. Those three fields in particular seem to mesh well with significant overlap; and you could train and become boarded in all three after 6-8 years of training.

I guess you could do a combined EM/OB residency (if one existed), or two separate residencies, in the same amount of time, but is the scope of practice or the overlap even remotely as close?

The cost you refer to consists of 1-2 years of your life. Like with every decision, I guess the question for people is, is the juice worth the squeeze??

 

[FunnyDocMan1234]

Why do they regret it out of curiosity? Did they end up only practicing in one of the fields? And if that's the case, weren't they warned of that when they were applying/looking into those programs?

The majority of the few people I know who did EM/IM regretted it. I think mainly it just sucks to be doing resident BS 5 years out of med school while all the interns you started with are living an attending lifestyle or almost done with fellowship (which also is a way better job than residency even in the busier fellowships). You will be up at 4AM having to coordinate a discharge and OSH records for minimal pay while everyone else you know is either doing the same job for 10x the pay (and working less hours) or doing a job that isn't filled with social work.

 

[Doc Doc Doc Goose]

The majority of the few people I know who did EM/IM regretted it. I think mainly it just sucks to be doing resident BS 5 years out of med school while all the interns you started with are living an attending lifestyle or almost done with fellowship (which also is a way better job than residency even in the busier fellowships). You will be up at 4AM having to coordinate a discharge and OSH records for minimal pay while everyone else you know is either doing the same job for 10x the pay (and working less hours) or doing a job that isn't filled with social work.

Yea I get that. And as a student I know I’m ignorant to the woes of residency. But if you’re aware of that going in ..... just seems like you can be prepared for it not to crush your soul.
Maybe it’s just a different mindset. I don’t know.

 

[deleted547339]

Yea I get that. And as a student I know I’m ignorant to the woes of residency. But if you’re aware of that going in ..... just seems like you can be prepared for it not to crush your soul.
Maybe it’s just a different mindset. I don’t know.

Nah dude. Trust me, when you have achieved competence, your threshold to deal with attendings who are FOS approaches zero.

 

[Doc Doc Doc Goose]

Nah dude. Trust me, when you have achieved competence, your threshold to deal with attendings who are FOS approaches zero.

I hear that. It’s all just a matter of perspective though. A person shouldn’t concern themselves so much with what the interns they started with are doing.

On that note, one could take a look at the plastics or CT or ENT surgeons that started residency when I did and think, man they still got a few years to finish residency/fellowship.

All that comparison analysis of other people’s lives, what it may look like over this fence or that fence, just seems like an awful waste of time.

 

[deleted547339]

I hear that. It’s all just a matter of perspective though. A person shouldn’t concern themselves so much with what the interns they started with are doing.

On that note, one could take a look at the plastics or CT or ENT surgeons that started residency when I did and think, man they still got a few years to finish residency/fellowship.

All that comparison analysis of other people’s lives, what it may look like over this fence or that fence, just seems like an awful waste of time.

It says you’re a med student. Respectfully, you have no idea what you’re talking about. When youre making 55k working 80h/week and it’s 3 in the morning and you didn’t get to kiss your wife and kids goodnight and you realize you are getting nothing but superfluous training, you don’t say to yourself “I shouldn’t concern myself with my peers.” And comparing your training pathway with someone who is doing a different specialty is a straw man argument - sure they train longer, but they are training for a different job.

I did EM->CCM. You have no idea how ready I was to be done with training at the end. I was competent several months of training.

 

[InternistDO]

I hear that. It’s all just a matter of perspective though. A person shouldn’t concern themselves so much with what the interns they started with are doing.

On that note, one could take a look at the plastics or CT or ENT surgeons that started residency when I did and think, man they still got a few years to finish residency/fellowship.

All that comparison analysis of other people’s lives, what it may look like over this fence or that fence, just seems like an awful waste of time.

It's very different when you know that every single CT surgeon in the US has done a minimum of 5 years of training. Very very few IM/EM residents do true IM/EM combined practice (hospitalist or primary care + ED). Most do critical care, pure EM, or an IM subspecialty. This means in some sense they "wasted" some years of training getting a board certification they may never actually use. It doesn't take a big leap to see how frustrating it is when you're an IM/EM (5 yrs) now in a crit care fellowship (2 yrs), looking at your friend who did 3 yrs EM + 2 yrs crit care only to get exactly the same job as you and have a better schedule and more flexibility while you're stuck in training for 2 more years.

Don't get me wrong, I enjoy residency and I'm not some burned out SDN stereotype. But you're crazy if you think I'd stay in PGY training for any longer than I had to to get the specialty/subspecialty I need.

Also, as an aside about combined training--you can get boarded in as many things as you want, and I believe that in residency/fellowship, when you're working a zillion hours a week and studying for boards you can retain all that info. But when you're an attending, unless you want to keep up with that level of work (unlikely), you're going to forget stuff. You'll be EM/IM/CC boarded but you won't have set foot on the general floors in 3 years. You aren't going to remember how to work up some weird rheum or endocrine condition that isn't going to land you in the ICU. You aren't going to be comfortable doing primary care. You'll be great at crit care and EM, sure. But then why waste your time doing IM in the first place?

 

[Doc Doc Doc Goose]

It's very different when you know that every single CT surgeon in the US has done a minimum of 5 years of training. Very very few IM/EM residents do true IM/EM combined practice (hospitalist or primary care + ED). Most do critical care, pure EM, or an IM subspecialty. This means in some sense they "wasted" some years of training getting a board certification they may never actually use. It doesn't take a big leap to see how frustrating it is when you're an IM/EM (5 yrs) now in a crit care fellowship (2 yrs), looking at your friend who did 3 yrs EM + 2 yrs crit care only to get exactly the same job as you and have a better schedule and more flexibility while you're stuck in training for 2 more years.

Don't get me wrong, I enjoy residency and I'm not some burned out SDN stereotype. But you're crazy if you think I'd stay in PGY training for any longer than I had to to get the specialty/subspecialty I need.

Also, as an aside about combined training--you can get boarded in as many things as you want, and I believe that in residency/fellowship, when you're working a zillion hours a week and studying for boards you can retain all that info. But when you're an attending, unless you want to keep up with that level of work (unlikely), you're going to forget stuff. You'll be EM/IM/CC boarded but you won't have set foot on the general floors in 3 years. You aren't going to remember how to work up some weird rheum or endocrine condition that isn't going to land you in the ICU. You aren't going to be comfortable doing primary care. You'll be great at crit care and EM, sure. But then why waste your time doing IM in the first place?

Great points. Thank you. I at least have experienced enough to understand the reality of what you mean.

 

[CallMeDoctorLov]

Nah dude. Trust me, when you have achieved competence, your threshold to deal with attendings who are FOS approaches zero.

Yea its pretty painful when you are trying to teach your junior residents and students about updated guidelines while dealing with an attending who hasnt read them or just refuses to change their practice from what they were trained 10 years ago.

Also, just to note for anyone considering EM/IM.... look at the rotation schedule of these programs. You will be on core rotations for like 8-10 months per year, every year.
its much harder than it looks on the surface

 

[sylvanthus]

Wait until your interns become your attending. That was a fun time

 

[Doc Doc Doc Goose]

Yea its pretty painful when you are trying to teach your junior residents and students about updated guidelines while dealing with an attending who hasnt read them or just refuses to change their practice from what they were trained 10 years ago.

Also, just to note for anyone considering EM/IM.... look at the rotation schedule of these programs. You will be on core rotations for like 8-10 months per year, every year.
its much harder than it looks on the surface

what are core rotations? non-elective ones?

 

[chocomorsel]

what are core rotations? non-elective ones?

Yes

 

[Hamhock]

My individual experience probably isn't useful to the OP or anyone else...even my consolidated experience.

That said -- not to the OP -- but the entire community: Could we not all agree that critical care medicine is independent and beyond anesthesiology, internal medicine, and surgery?

Let's work to solve the OP's issue with the most obvious answer: critical care medicine residency. It'll be 4-6 years and it will include EM, IM, surgery, and anesthesiology.

Thanks again for considering what's obvious to me.

HH

 

[Rekt]

My individual experience probably isn't useful to the OP or anyone else...even my consolidated experience.

That said -- not to the OP -- but the entire community: Could we not all agree that critical care medicine is independent and beyond anesthesiology, internal medicine, and surgery?

Let's work to solve the OP's issue with the most obvious answer: critical care medicine residency. It'll be 4-6 years and it will include EM, IM, surgery, and anesthesiology.

Thanks again for considering what's obvious to me.

HH

Every single aspect of medicine is essentially adversarial. Our training, interactions with other specialties, consultants, admins, etc. It's why medicine is at its current state. Too busy fighting micro battles between each other.

 

[grt398]

My individual experience probably isn't useful to the OP or anyone else...even my consolidated experience.

That said -- not to the OP -- but the entire community: Could we not all agree that critical care medicine is independent and beyond anesthesiology, internal medicine, and surgery?

Let's work to solve the OP's issue with the most obvious answer: critical care medicine residency. It'll be 4-6 years and it will include EM, IM, surgery, and anesthesiology.

Thanks again for considering what's obvious to me.

HH

This is what they do over in Australia/New Zealand and it seems to work pretty well for them. I'd love to see a similar pathway in the US. Their coordination (via the ANZICS group) also produces prodigious and impressive research. It's too bad we can't coordinate as well here.

For those interested, here's the general training pathway (6 yrs total):

CICM - ICU training program

www.cicm.org.au

Here's the specifics of the rotations:

https://www.cicm.org.au/CICM_Media/CICMSite/Files/Training/CICM-Training-and-Assessment-Program-following-PGY1-General-Pathway.pdf

 

[Doc Doc Doc Goose]

Yes

Better than being on IM subspecialty rotations like ID and Nephro .... Boooorrringgg

 

[chocomorsel]

Better than being on IM subspecialty rotations like ID and Nephro .... Boooorrringgg

So ID and Nephro are not core rotations in the two years of fellowship?

 

[Doc Doc Doc Goose]

So ID and Nephro are not core rotations in the two years of fellowship?

That poster was referring to EM/IM curriculum, core rotations vs elective/others ..