can PCCM work full time in an ICU without pulm clinic?

[BlueAvenue]

I just wanted to know if after completing a pulm/critical care fellowship if one could function in an ICU full time as an intensivist without having to do pulm consults or clinic. thanks in advance for your responses!

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[bigtuna]

yes but most choose not to due to lower compensation and stress

 

[BlueAvenue]

is being a full time intensivist not a feasible option because of the stress?

 

[bigtuna]

Doing critical care full time is feasable and many people do it. Right now there is a huge shortage of critical care physicians and one would have no trouble finding a job. I have several friends who are doing this in private practice right now. I am very familiar with the set up for one person. He makes about 270K per year. He does about 20 twelve hour shifts a month and at least 5 of them are overnight, sometimes more.

Critical care can also be done in an academic setting with generally less pay but a substantially easier schedule. Many academic critical care attendings have a significant research career in addition to their clinical work.

The reasons that many pulmonary/ccm boarded physicians do not do only critical care can be hard to understand for pre-meds/med students/residents. The thrill of the ICU with intubations, lines, crashing patients eventually wears off for everyone...often by the completion of a fellowship. At this point, dealing with some of the downsides of the ICU (upset families, poor patient outcomes, long hours, night work) becomes relatively less attractive. I mentioned earlier that reimbursement can be less for intensivist work. As an ICU attending your billing is limited to the number of ICU beds that you round on. As a pulmonologist doing consults in the office and hospital, the only limit theoretically is your referrals and time. Also, in the majority of private practice settings, the CCM doctor is only a consultant and the interactions with other physicians can be painful. i.e. - having to consult the local pulmonologist for vent managment or a bronch even though you are pulmonary trained due to political reasons.

I hope this answers some of your questions. The bottom line is that after a pulm/ccm fellowship you can pretty much find a practice opportunity anywhere from 100% pulmonary to 100% critical care if you want. Its just that most find doing at least some if not primarily pulmonary more satisfying.

 

[BlueAvenue]

thanks bigtuna for taking the time to explain this to me in a way I understand having no hospital experience myself. it was extremely helpful

 

[howelljolly]

. Also, in the majority of private practice settings, the CCM doctor is only a consultant and the interactions with other physicians can be painful. i.e. - having to consult the local pulmonologist for vent managment or a bronch even though you are pulmonary trained due to political reasons.

.

Really? Is that because they contract to different groups for CCM and Pulm at the same time?

I cant imagine how a consult for vent management would go. Would you have to get verbal orders from an outside pulmonologist, or would you just call for a stat consult and stand there wringing your hands?

 

[bigtuna]

There are a lot of different ICU staffing models out there. The typical scenario in academic medicine (i.e. critical care is the attending of record for everyone in the ICU, makes the final decisions, etc) is relatively uncommon though not non-existant in the private practice world.

Vent managment consults are part of the bread and butter for pulmonologists (appropriately so). If the hospital hires an intensivist who is pulmonary trained, the local pulm guys are not going to be happy if they are no longer consulted for any vent managment just because the ICU guy is completely comfortable running the vent.

If you speak to IM hospitalists, many are dissatisfied because all of the care is directed by the subspecialists and they are reduced to record keepers and order writers. The same situation can happen in critical care. The gi, cards, heme, renal people are "running the show" and youre there for things like lines, tubes, unexpected crumping. That can get old after awhile.

True story...during the first several weeks of a new crit care job an aquaintance of mine (2 years of pulm experience post fellowship) was dressed down in front of the icu staff by a local pulmonologist for extubating one of his patients without his "permission" even though the patient was totally stable and did fine.

 

[CBrack]

I read this post and felt inclined to reply.

The Tuna commented on this thread that folks who work straight CCM will become burned-out and their compensation is less then Pulm/CCM.

I respectfully disagree with both statements.

Regarding the burned out issue:
This is highly variable and probably has more to do with the individual then the job itself. Pick a specialty which you can see yourself doing for the next twenty years. The key is to know what type of job you are signing up for (open vs closed units ect..) Most CCM jobs are moving towards shift-work. That being said, jobs that I interviewed for were ~14-18 shifts per/month including 3-5 night shifts. If you do your research you will find several opportunities filling this description.

**CCM jobs come in all shapes,sizes,colors and flavors.
I was fortunate to train at the best CCM program in the country (forgive my bias). Upon completion fellows are prepared to work in several different types of units..
Neuro, Trauma, Surgical, Transplant, Cardio-thoracic, and Medical ICUs.
The reason I mention this is because "most" pulm/ccm fellowships are MICU heavy and these folks tend to gravitate towards the MICUs. This is a very important point because it lends to variety. Whether your niche is research, clinical, educational, administration, or a hybrid of the aforementioned you will have options.

The salary issue:
Refer to the 2008 MGMA compensation scale.
Straight Pulm $265k
Straight CCM $285k

Reimbursements are increasing for ccm and are stagnate for out-pt pulm.
Over the years the pulm folks have done sleep fellowships which CURRENTLY have excellent reimbursement rates but the government will be cutting these in the very near future (12-18mos0.

Check out UPMC's CCM program.

Best,
CB

 

[bigtuna]

CB,

I agree with your point that the issue of burn out probably does depend more on the individual.

However, I still stand by my point that relatively few pulm/ccm trained individuals do strait CCM and the primary reasons for this are compensation and "job satisfaction".

Your comments on reimbursement are not entirely correct. It appears to me that you are not pulm trained based on your profile and probably not all that familiar with how it is reimbursed in private practice. I can only generalize because there are a lot of different business models but let me give you examples that are the most typical in my opinion.

Doc A: does 100% CCM, receives salary from hospital (probably in the mid 200's) for working set number of shifts. Could probably increase salary a little bit by working extra number of shifts but not a lot. Often, these positions require a bit of "subsidizing" by the hospital because the level of billing doesn't support the salaries of all the intensivists. This is due to issues like number of beds turned over and the fact that nocturnal intensivists cant bill as much if the day guy already billed.

Doc B: typical private practice pulmonologist. salary is based directly on money generated through billing minus overhead. Practice may be approximately split 50/50 between inpatient consults and outpatient clinic. If the person is busy and efficient can see many many more patients in a day than intensivist. Salary often subisidized by things like PFT's, sleep, clinical research, maybe procedures. Upper limit of salary is much higher than the mid 200's.

I was just trying to help the OP understand why most pulm/ccm people dont end up doing 100% CCM. As i mentioned, you certainly can if you want and will make plenty of $$. If it makes you happy, go for it.

 

[CBrack]

CB,

I agree with your point that the issue of burn out probably does depend more on the individual.

However, I still stand by my point that relatively few pulm/ccm trained individuals do strait CCM and the primary reasons for this are compensation and "job satisfaction".

Your comments on reimbursement are not entirely correct. It appears to me that you are not pulm trained based on your profile and probably not all that familiar with how it is reimbursed in private practice. I can only generalize because there are a lot of different business models but let me give you examples that are the most typical in my opinion.

Doc A: does 100% CCM, receives salary from hospital (probably in the mid 200's) for working set number of shifts. Could probably increase salary a little bit by working extra number of shifts but not a lot. Often, these positions require a bit of "subsidizing" by the hospital because the level of billing doesn't support the salaries of all the intensivists. This is due to issues like number of beds turned over and the fact that nocturnal intensivists cant bill as much if the day guy already billed.

Doc B: typical private practice pulmonologist. salary is based directly on money generated through billing minus overhead. Practice may be approximately split 50/50 between inpatient consults and outpatient clinic. If the person is busy and efficient can see many many more patients in a day than intensivist. Salary often subisidized by things like PFT's, sleep, clinical research, maybe procedures. Upper limit of salary is much higher than the mid 200's.

I was just trying to help the OP understand why most pulm/ccm people dont end up doing 100% CCM. As i mentioned, you certainly can if you want and will make plenty of $$. If it makes you happy, go for it.

BT,

Appreciate your insights. You are correct I am not Pulm/CCM trained. I did however interview with several pulm/ccm groups who wanted to transition to a 24hr in-house coverage. They themselves were transitioning towards more ccm billing because of the stagnation of out-pt reimbursements and the future of sleep medicine. My personal reasoning for choosing straight CCM over the combined route was based on two major points (major to me of course).

1) Lifestyle - Shift work appealed to me as a way to balance my family life and medicine. From my personal experience the older pulm/ccm model did not seem attractive. Long hours and trying to manage critical patients from outside the hospital. That being said...currently, there are several different coverage models which have addressed this issue. But this is variable from practice to practice.

2) Salary - Typically, if a CCM trained physician is able to bill for 12 critical pts (not just pts in the unit) you can expect to generate ~$250k. So, as you mentioned the total number of beds dictates your billing. However, there are ways to subsidize your income other then working more shifts. One way is to form a rapid response team (aka code team). You can bill for procedures and critical care time as dictated by pts clinical status. Another option at larger institutions is to do critical care consults (vent management / procedures).

Final comment:
I would never want to discourage anyone from doing pulm/ccm.
But realize that critical care is a rapidly evolving field just in its infancy.
The future is very bright as are the lifestyle and ability to generate a very sustainable lifestyle.
Best of luck in your pursuits...

CB

 

[souljah1]

Just want to point out that this entire discussion is directed at what seems like private practice.

It is important to know that there are many opportunities to solely practice critical care in an academic setting either through an NIH funded career or through a combination of administration/education. The former group attends in the MICU about 2 months per year and the later does anywhere from 3-6 months per year depending on how involved they are in their non-clinical responsibilities.

The pay is less than private practice, but not sure if it will stay that way. With pay-for-performance, not reimbursing iatrogenesis, and not reimbursing treatments or procedures/tests which have no evidence, I wouldn't be surprised if the private sector of medicine gets crunched a bit.

 

[CBrack]

Souljah-
Interesting. There are several different practice models in both the academic, private practice, and hybrid models. I currently work in a tertiary teaching hospital which is the basis for my postings.

My training was at UPMC which has the largest ccm fellowship and department in the country. We are very heavy in research. Currently, the ccm department has ~ 100 faculty members with 20-25 adult ccm fellows per/yr. Please refer to the following:

http://www.ccm.upmc.edu/CCM_Annual_Report_2008.pdf

At UPMC there are no entirely NIH funded positions for administration or education (if they existed I can assure you we would). The NIH funded positions are for both bench and clinical research. Would be very interested in knowing and where these positions are?

The pay structure is typically less in academic centers as you have mentioned. And yes, if our President has his way we could all get crunched.. but this is beyond the scope of my posting.

*KG if you have any input that you would like to add from your experience please do so.

Best,
CB

Just want to point out that this entire discussion is directed at what seems like private practice.

It is important to know that there are many opportunities to solely practice critical care in an academic setting either through an NIH funded career or through a combination of administration/education. The former group attends in the MICU about 2 months per year and the later does anywhere from 3-6 months per year depending on how involved they are in their non-clinical responsibilities.

The pay is less than private practice, but not sure if it will stay that way. With pay-for-performance, not reimbursing iatrogenesis, and not reimbursing treatments or procedures/tests which have no evidence, I wouldn't be surprised if the private sector of medicine gets crunched a bit.

 

[howelljolly]

*KG if you have any input that you would like to add from your experience please do so.

Best,
CB

Id expected him to have jumped in by now. the bat-signal must be malfunctioning.

 

[KGUNNER1]

Id expected him to have jumped in by now. the bat-signal must be malfunctioning.

Okay, okay, sometimes it's just nice to see how this evolves without me running my e-mouth again.

CB did a very nice job at summarizing this. I'll add a little. I currently work in a large Level 1 Trauma center affiliated with a large state university and medical school. I always have and probably always will (but who knows). I've had several, pure intensivist, friends go other routes, and I've actually tested the private practice market too.

There is tremendous heterogeneity in practice models. I swear, every time I look at another medical center, they come up with a local solution towards CC that fits their needs.

With that being said, there are several private practice groups, private hospital affiliations, and academic positions that work shift-work hours. Usually these end up being close to 180 shifts/yr for a full-time-equivalent. In-house night coverage (or e-ICU) is becoming more popular.

I've seen private practice groups that hire 4 or 5 pure intensivisits to cover the ICU solely, while the pulmonologists cut back their own ICU time. These groups usually have some relationship with the hospital, and get some amount of reimbursement by the hospital. They also get a percentage of their collections.

Some are pure hospital employees and are pure salaried positions, maybe with some incentive or bonus based on some quality measure at the end of the year.

The academic models are also varied. Research funding is hard to get in this climate and if you are serious about doing that, you should really pursue a good research mentor and consider taking some grad level courses. NIH funding is rare, but is there if you are really motivated. NIH funding will not pay your full salary, and those researchers that are 100% funded (in critical care) you can count on one hand. So you will have to pull a few shifts/month.

Pay ranges all over the place, but it is going up. I've seen private practice offers as high as $350-400, but usually the avg is in the upper 200's to low 300's. Academic can be much lower, anywhere from the 160's to mid 200's. It really is variable....but it has trended up over the past 5 yrs.

CB was correct in stating that the biggest factor that influences our bottom line is VOLUME of truly critically ill patients. You really do need a unit of 10-12 pts/day of CC billing (EM - 99291). Ideal would be around 15 or so. It gets crazy and out of hand over 20, but many people do that.

Again, I really can't say it any better than CB did. I also agree, if you love pulm/ccm, go for it. I did EM/IM/CC and I still work in the ER, so all options really are open with a critical care practice. Just find a career path that you enjoy and do it.

Hope this helps.....and wasn't too long.

KG

 

[Intensivist]

just wanna to ask you guys, how many of your hospitals ICUs were managed by anesthesia/CCM fellows...
here, in Europe, it is quite common to have the anesthesia cover all of surgical ICUs, any if necessary others as well, including MICU and PICU.
in my hospital they are actually the only intensivists in hospital... and as far as l see it, they do it quite well... and by my logic it makes sense due to my presumption that they are best skilled with emerg stuff, like tubes and lines... not saying that others aren't...
love to hear your insights...

 

[howelljolly]

As I understand it, in Europe, MidEast, and Asia, there are a few other flavors of intensivists or high acuity specialist.... EM/CCM, and commonly Anesth/EM. (thats an odd one)

I suppose it might have something do with with where patients get triaged in these particular locations. Does a sepsis patient go to the ICU? Is sepsis something that fits well with an anesthesia paradigm of management? Do your general medical floor nurses get antsy if they have to run more than 2 drips at once... thereby sending a patient who doesnt have any tubes into the ICU?

Just some ramblings... but I suppose it depends on how clinical decisions are made, and what sorts of patients go to the ICU.

 

[Intensivist]

well, most of sepsis pts are managed in our ICU which is runned by anesth staff, sometimes but rarely by infectious disease spec., but if they progress to any kind of hemodynamic compromise they are reffered to anesth/CC.
well, they mostly avoid ICU admissions that aren't supposed to be ICU pts, such as those recieving multiple drugs therapy, but not require vent. our ICU is a closed one.

 

[draks]

Thank you guys for all the info. It really helps. I am new to this forum, all the info really seems helpful.

I am currently working as a Hospitalist in a big city making decent money with very good work hrs. I matched for PCCM for subsequent year but now am confused. Should I do PCCM or should I go in Prim CAre. The prob with Hospitalist is it is a good start but not much room for subsequent growth.

The way I understand is it is better to do a fellowship or go in prim care. My freinds who r in prim care are making really good living.

I recently found out that the start salary of PCCM in big city- one of the hospital I work in is from 190-200k. In the same hospital- Hospitalist is 170k. Is it worth then to do 3 yrs of PCCM and then come back to almost the same salary bracket or is it better to do prim care.

Most of the prim care people who i know tell me to go in prim care and not to waste time and money. I am really confused.

Any opinions, please help me in decision making, have never been this doubleminded.

 

[howelljolly]

What do you want to DO for a living? If the salaries are roughly equal, that's where the decision lies. You have three options for what you want to do.

a) hospitalist, primary care
b) pulmonary critical care fellowship
c) make money

From they way you wrote, it sounds like you're only decision making factors are: making a good living....salary bracket...wasting time and money.

So it sounds like you chose "C". If thats the case, be an internist. As you said, you can make decent money. Going back for fellowship will be a pay cut for 3 years. So indirectly, go with "A"

Unless you want to do pulmonary critical care. In that case, you would choose "B". You can not do PCCM if you choose "A" or "C"

Its an easy choice if you think about what you want to do.

 

[Apollyon]

Here in town, there's one hospital where the admitting doctors are IM, and they take home call only. The CCM docs are consultants only, but the CCM docs are the ones in-house 24/7 (scheduled - not because they are continually called in).

This is community/non-academic/nearly 100% insured.

 

[draks]

What do you want to DO for a living? If the salaries are roughly equal, that's where the decision lies. You have three options for what you want to do.

a) hospitalist, primary care
b) pulmonary critical care fellowship
c) make money

From they way you wrote, it sounds like you're only decision making factors are: making a good living....salary bracket...wasting time and money.

So it sounds like you chose "C". If thats the case, be an internist. As you said, you can make decent money. Going back for fellowship will be a pay cut for 3 years. So indirectly, go with "A"

Unless you want to do pulmonary critical care. In that case, you would choose "B". You can not do PCCM if you choose "A" or "C"

Its an easy choice if you think about what you want to do.

But after 3 yrs of fellowship in PCCM, is the salary scale a lot diff than traditional prim care? Because if it is diff, then 3 yrs is like an investment for ur career.

Anyone doing PCCM who can shed some light please

 

[Hernandez]

But after 3 yrs of fellowship in PCCM, is the salary scale a lot diff than traditional prim care? Because if it is diff, then 3 yrs is like an investment for ur career.

Anyone doing PCCM who can shed some light please

If you google ACCP jobs, you can see some of the various job pay scale, those that publish the offers range from $220k/year to $500k. In addition there are several survey's that offer regional percentiles of the average pay for different specialties.

 

[howelljolly]

But after 3 yrs of fellowship in PCCM, is the salary scale a lot diff than traditional prim care? Because if it is diff, then 3 yrs is like an investment for ur career.

Anyone doing PCCM who can shed some light please

You don't like my non-PCCM trained input?

How about if the job description is a lot different than traditional prim care, then the 3 years is an investment in your career.

 

[Underdog8921]

So after completing Pulm/CCM fellowship, if one were to choose the 100% critical care route and become a full-time intensivist (shift work, salaried position at a hospital, the whole 9 yards), wouldn't that person lose some of the skills they learned during their fellowship training? Are all of the procedures represented in a private practice pulmonology setting still fully represented in the ICU setting? I guess it would depend on the level of care that the hospital is equipped to handle.

Kind of a weird question, I know. I would appreciate any open-minded responses, lol. Please don't be mean, it's my first time posting.

 

[bigtuna]

actually its kind of the other way around. If you do 100% critical care you will get rusty with outpatient management. Most of the pulmonary procecures are done in the icu (bronchs, intubations, lines, chest tubes, perc trachs, etc) You might get rusty on some of the interventional pulmonary stuff doing 100% critical care - things like endobronchial ultrasound guided biopsies, airway stents, etc.

 

[Underdog8921]

actually its kind of the other way around. If you do 100% critical care you will get rusty with outpatient management. Most of the pulmonary procecures are done in the icu (bronchs, intubations, lines, chest tubes, perc trachs, etc) You might get rusty on some of the interventional pulmonary stuff doing 100% critical care - things like endobronchial ultrasound guided biopsies, airway stents, etc.

Hey BigTuna,

Thanks for the response, very helpful. It's kind of odd because many of the job postings out there are requiring the "triple board" candidate (IM/Pulm/CC) for full time intensivist positions. I'm not sure I understand why this is the case since the option of doing a 2 year critical care fellowship exists.

Anyhow, I'll keep doing some research on the job postings and see what the trend is. I'll post any updated information for anyone that might be interested.

 

[drdev]

Hi Guys, I am new to this forum. I am currently working as a Hospitalist for almost 2 years now. Now planning to go to either Primary care- traditional versus Pulmonary and Critical Care. I am really confused between the two. Hospitalist is great but there is no room for growth after a point. Can someone help me decide between Primary care and PCCM. I know specialist codes have been gone but I believe that if I DONT do it now I will never bbe able to do it. I would appreciate any input from any attendings, fellows or Pulmonologits. Thank you.

Dev