Cardiac Critical Care Fellowship

[Vtach00]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

---

Members don't see this ad.

 

[P Diddy]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

I wouldn't go into this fellowship thinking that it will learn you about LVADs; that's what the Advanced Heart Failure and Cardiac Transplantation fellowship does. A Cardiac Critical Care fellowship would be helpful for someone attending in a CCU, but is not a prerequisite (yet) for doing so. You could attend in a CVICU (ie CT surgery), but you'd be competing with the pulmonologists and cardiac anesthesiologists who also want those jobs, and traditionally have taken them.

I find it unfortunate that there's a separate fellowship required for cardiologists (who deal with critical care issues often, including ventilator management) to be boarded in critical care. Ideally, critical care training would be a significant portion of the advanced heart failure fellowship, so one going through that fellowship would have both sets of skills. That's a fellowship I'd love to do (but luckily don't have to).

p diddy

 

[jdh71]

I wouldn't go into this fellowship thinking that it will learn you about LVADs; that's what the Advanced Heart Failure and Cardiac Transplantation fellowship does. A Cardiac Critical Care fellowship would be helpful for someone attending in a CCU, but is not a prerequisite (yet) for doing so. You could attend in a CVICU (ie CT surgery), but you'd be competing with the pulmonologists and cardiac anesthesiologists who also want those jobs, and traditionally have taken them.

I find it unfortunate that there's a separate fellowship required for cardiologists (who deal with critical care issues often, including ventilator management) to be boarded in critical care. Ideally, critical care training would be a significant portion of the advanced heart failure fellowship, so one going through that fellowship would have both sets of skills. That's a fellowship I'd love to do (but luckily don't have to).

p diddy

Everyone doing "critical care" has to do a separate fellowship - surgeons, anesthesiologists, EP's, and medicine people. No one gets to come out of a single training program and call themselves an "intensivist" even if they work often with patients admitted to ICUs and "deal with critical care issues often, including ventilator management".

 

[jdh71]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

The question is: "where do you plan on practicing?". The extra year would probably great for staying in academia, however, private practice in almost any location is not set up with a cardiology critical care model. The IM critical care trained people (usually pulmonary groups, though more and more just critical care trained [two year programs] +/- those who did an extra year of critical care after sub-specialty fellowship) cover the cardiology patients for the cardiologists who normally don't admit into an MICU but serve as consultant. So probably in order for this to be something viable for you in the private practice world, you'd have be to ok with being the general medicine critical care rotation. There currently just aren't the openings to do just straight cardiology critical care in omst places - though there is plenty of work to go around, and you could always try some trailblazing into the private practice world if you're feeling motivated.

 

[Trifling Jester]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

I've never heard of it. But at first glance it seems like a waste of time for a cardiologist to do this.

 

[intcards]

Everyone doing "critical care" has to do a separate fellowship - surgeons, anesthesiologists, EP's, and medicine people. No one gets to come out of a single training program and call themselves an "intensivist" even if they work often with patients admitted to ICUs and "deal with critical care issues often, including ventilator management".

This is not true. I worked in a community hospital as an intensivist without dedicated training. In fact, most CCU directors have had no formal ICU training.

As for the original question, what skills does the program advertise that they will teach that you do not already learn in general fellowship? Bronchoscopy? Chest tube insertion? Because those aside, I felt very confident running a CCU after finishing general fellowship.

 

[jdh71]

This is not true. I worked in a community hospital as an intensivist without dedicated training. In fact, most CCU directors have had no formal ICU training.

As for the original question, what skills does the program advertise that they will teach that you do not already learn in general fellowship? Bronchoscopy? Chest tube insertion? Because those aside, I felt very confident running a CCU after finishing general fellowship.

You clearly misunderstood what I was saying.

The mere fact that you did work as an (quote-unquote) "intensivist" or that you can staff a CCU (which isn't an MICU) doesn't mean you are a critical care physician. I don't know why a CCU director would need critical care training? Why is it even a relevant point?

You want to be a "critical care physician"? Complete the training, sit for the boards.

Just because you may work in and out of the ICU or take care of critically ill patients at times doesn't change that.

Put lipstick on a pig, and it's still a pig.

 

[P Diddy]

Everyone doing "critical care" has to do a separate fellowship - surgeons, anesthesiologists, EP's, and medicine people. No one gets to come out of a single training program and call themselves an "intensivist" even if they work often with patients admitted to ICUs and "deal with critical care issues often, including ventilator management".

You've misunderstood me. I do think everyone who does critical care needs extra training.

It's just that cardiologists do not need an extra year on top of their fellowship, as they already rotate through some of the critical care requirements during fellowship.

In fact, there are people who rotate through 'a single training program and call themselves an "intensivist"': those who complete pulmonary/critical care fellowships, which are only 3 years.

This is coming for cardiology fellowships too. See:

http://www.cardiosource.org/~/media...SeptOct/SepOct12_Cardiomag_Critical_Care.ashx

I believe there is a Boston area cardiology program that is looking to get its fellows critical care eligibility in abbreviated time. I look forward to more of these.

p diddy

 

[KRichards62]

For those interested in cardiac critical care, you should check out the following Scientific Statement published in 2012 which provides a nice discussion on the topic:

Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012 Sep 11;126(11):1408-28. Epub 2012 Aug 14

 

[jdh71]

You've misunderstood me. I do think everyone who does critical care needs extra training.

It's just that cardiologists do not need an extra year on top of their fellowship, as they already rotate through some of the critical care requirements during fellowship.

In fact, there are people who rotate through 'a single training program and call themselves an "intensivist"': those who complete pulmonary/critical care fellowships, which are only 3 years.

This is coming for cardiology fellowships too. See:

http://www.cardiosource.org/~/media...SeptOct/SepOct12_Cardiomag_Critical_Care.ashx

I believe there is a Boston area cardiology program that is looking to get its fellows critical care eligibility in abbreviated time. I look forward to more of these.

p diddy

Pulmonary and critical care is not technically a single training program. It's two fellowships at once. You sign up to do both in the three years - they run concurrently - pulm is the only subspecialty to do this per usual. Pulmonary fellowship? Two years. Where you you think the extra year is coming from? It's the ABIM requirement. You can't sit for CC boards until you pass pulmonary. Those people finishing pulm/crit can call themselves intensivists because they are . . .

A cardiologist would need an extra year of training if they wanted to work in an MICU taking care of regular non-cardiac ICU patients. No one bugs the cardiologists about taking care of their own patients in a CCU. IN FACT, we are very happy to have them do it and not have it pawned off onto MICU. That's a BIG thumbs up. So if OP is asking about taking a critical care year so he can attend both the CCU and MICU, then it might be worth it to him.

 

[P Diddy]

This is not true. I worked in a community hospital as an intensivist without dedicated training. In fact, most CCU directors have had no formal ICU training.

As for the original question, what skills does the program advertise that they will teach that you do not already learn in general fellowship? Bronchoscopy? Chest tube insertion? Because those aside, I felt very confident running a CCU after finishing general fellowship.

What happens is a lot of intensivists get butthurt when other physicians work as intensivists without critical care boarding. It makes them feel that their training was useless/redundant, which in most cases is correct.

The more salient point is whether the boarding is necessary, and that depends on the job. It is not necessary to be critical care boarded to work in an ICU, as I also have done. Even for a CCU director, as I mentioned, the boarding is not yet required. That landscape may well change in the future, which is why this question has even come up now. Hospitals may want their ICUs (and CCUs) overseen by a board certified critical care physician, just as they want board certified physicians now to see patients.

That's why it is important for cardiologists to drive to achieve an accelerated pathway now. We have the influence and the incentive. There is much overlap between a [cardiology fellowship + advanced heart failure/tx fellowship] and a critical care fellowship. With some well placed electives, I can easily see cardiologists fulfilling the critical care requirements over 4 years. As you mention, it wouldn't take too long to learn how to place chest tubes and bronch.CCU intensivists would have added training in managing pVADs, ECMO, and other mechanical circulatory support.

That would be one well trained, desirable physician cohort. Where would they work? Probably in an academic medical center. And they could do some sick moonlighting to supplement their meager heart tx income.

p diddy

 

[jdh71]

For those interested in cardiac critical care, you should check out the following Scientific Statement published in 2012 which provides a nice discussion on the topic:

Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012 Sep 11;126(11):1408-28. Epub 2012 Aug 14

Excellent piece. Couldn't agree more.

Here's a link to free full text

 

[jdh71]

What happens is a lot of intensivists get butthurt when other physicians work as intensivists without critical care boarding. It makes them feel that their training was useless/redundant, which in most cases is correct.

This is ridiculous. There's plenty of work to go around. No one cares outside of your ability to actually do the things that need to be done to take care of the critically ill.

All the critical care trained people are saying is define your practice and minimum training requirements to do the work you say you can do before running around calling yourself an intensivist and working as one. I'm hardy butthurt by anything you call yourself, patients . . . they might get more than "butthurt" if someone is trying to work outside of a generally community accepted and defined scope of practice.

And I can't think of a single case of an intensivist whose training was useless or redundant. You want to take care of the sickest of the sick? Maybe you should have some training doing so? That seems legit.

The only butthurt here seems to be you by anyone suggesting that you may not be as much of an intensivist as you posture. You might have the chops. I don't know. Neither does anyone else. This is why standards should be defined and then met. Looks like cardiology is attempting to do this and this is good thing.

 

[P Diddy]

The only butthurt here seems to be you by anyone suggesting that you may not be as much of an intensivist as you posture.

I hope your intensivist skills do not approximate your grammar.

p diddy

 

[jdh71]

I hope your intensivist skills do not approximate your grammar.

p diddy

When my grammar gets attacked, I know I've won the discussion.

I do gladly accept your defeat and acknowledgment of the superiority of my argument.

And Burnett's Law too! Priceless.

 

[Hernandez]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

How would you plan on practicing after you finish? What type of pt population will this fellowship expose you to (pure cards or mixed medical)? Are they looking to train you in more advanced vent management? Or is this dedicated towards what you mentioned (LVAD, etc)

The majority of ICU work could be handled by a competent internist, but sadly many residencies aren't producing those anymore.

Honestly, If its just a traditional tract for CC to get MICU exposure, I'd ask why? If its for cards stuff, well, y'all crazy cardiologists are getting way to split happy for specialization.

 

[Hernandez]

What happens is a lot of intensivists get butthurt when other physicians work as intensivists without critical care boarding. It makes them feel that their training was useless/redundant, which in most cases is correct.

This is rather funny as there are no where near enough CC guys to cover the demand as it is, unless you're in a popular population center with an excess of docs who wanna protect their turf

. There is much overlap between a [cardiology fellowship + advanced heart failure/tx fellowship] and a critical care fellowship.

May I ask, what's the overlap?

 

[P Diddy]

This is rather funny as there are no where near enough CC guys to cover the demand as it is, unless you're in a popular population center with an excess of docs who wanna protect their turf ?

I must admit I was just trying to get a rise out of jdh and get him off his 'intensivist' high horse; it was too easy to accomplish and pass up.

May I ask, what's the overlap?

Currently (and please correct me if I am wrong), for criitical care you need to do 9 clinical months and 3 elective (which can be research); the clinical months can be split between MICU, CICU(ie CCU), and surgical ICU.

If you look at the current critical care guidelines, they state that "6 months of critical care medicine experience in CVD and critical care medicine training can be applied to admission for both examinations," meaning cardiology boards and critical care boards.

During cardiology fellowship, depending on the fellowship, a fellow might spent 6 months or more in the CCU + CVICU. That would go toward 2/3 of the critical care fellowship. The guidelines do not explicitly state that MICU time is required for a critical care fellowship(again, correct me if I am wrong).

During a 1 year heart failure/transplant fellowship, fellows take care of post-surgical patients (LVADs, transplant) and also may obtain CCU experience. This could serve as the remaining surgical ICU experience required

The procedures not typically covered during cardiology + advanced heart failure include endotracheal intubation, insertion and management of chest tubes, and fiberoptic bronchoscopy, which could be done during those 4 years.

p diddy

 

[Hernandez]

[Program Requirements: IV.A.6.a)-b)]

Does time in the coronary care unit (CCU) or in observation units count toward the months of required experiences in a MICU?

[Program Requirement: IV.A.6.a).(1).(a)]

Only time in the MICU itself can be used meet this requirement. Experiences in the CCU can be used toward the three months of non-MICU medicine, but not toward the months required in the MICU. Experience in observation units cannot be used to fulfill any part of the required six months of prerequisite clinical experiences.​

So they require 6 months of MICU/CICU. but if this is done after another fellowship, itmcan be reduced to only 3 months, however, if the CC fellowship is done after another fellowship, the above guidelines apply, so for the situation you describe for cards, you would have to do 3 months of MICU

 

[Hernandez]

I
During cardiology fellowship, depending on the fellowship, a fellow might spent 6 months or more in the CCU + CVICU. That would go toward 2/3 of the critical care fellowship. The guidelines do not explicitly state that MICU time is required for a critical care fellowship(again, correct me if I am wrong).

Correct....unless you're talking about doing CC after another sub-specialty.

 

[P Diddy]

[Program Requirements: IV.A.6.a)-b)]

Does time in the coronary care unit (CCU) or in observation units count toward the months of required experiences in a MICU?

[Program Requirement: IV.A.6.a).(1).(a)]

Only time in the MICU itself can be used meet this requirement. Experiences in the CCU can be used toward the three months of non-MICU medicine, but not toward the months required in the MICU. Experience in observation units cannot be used to fulfill any part of the required six months of prerequisite clinical experiences.​

So they require 6 months of MICU/CICU. but if this is done after another fellowship, itmcan be reduced to only 3 months, however, if the CC fellowship is done after another fellowship, the above guidelines apply, so for the situation you describe for cards, you would have to do 3 months of MICU

Thanks, that's helpful. The overall point I'm making is that there can be enough ICU experience in cards+advanced transplant for such a fellow to be an intensivist and sit for boards. The idea that there are different criteria depending on when the 'critical care fellowship' is done seems strange to me. There should be an integrated experience for those who want it, a la pulmonary/crit care; those fellows don't do 2 years pulm and then one year of all crit care, they mix it up. I anticipate that in the future, the MICU requirement will fall away for cards fellows and be replaced with equivalent CCU/CTICU time.

p diddy

 

[VentdependenT]

Unless you can get boarded in critical care from this it sounds like they are looking for another warm body to eat calls and do more work to save others from doing the same..

 

[jdh71]

I must admit I was just trying to get a rise out of jdh and get him off his 'intensivist' high horse; it was too easy to accomplish and pass up.

If that was your goal, then you failed. I was never on a high horse, nor did you get a real rise out of me. Though, why someone would want to intentionally be a dick is odd, but probably typical for many of douche personalities that go into cards.

- jdh71

(signed because it's never clear who is posting around here . . . at all)

(if only the website could come up with a way to attached a screen name to every post?)

 

[antoniohg]

It is so nice to see this is becoming a reality. Personally I am applying to cardiology and later to critical care. I understand and know that there is an overlap with advance heart failure, but they aren't the same. First, you don't do medication optimization in the outpatient setting, you don't follow post cardiac transplant once they are discharged from the unit, you don't optimize inotropes in the floor for stable patients.
There is certainly a need of a cardiologist who can be able to wean a patient out of the ventilator appropriately, deal with the hemolysis caused by the VAD, treat VAP, recognize early septic states in an intermacs 1-3 patient. Deffinetly is needed. And I foresee a time where the CCU is run by a CCC.

 

[go lakers]

Hi Guys:
My Cardiology fellowship program is starting a new track in 'Cardiac Critical Care'. Its a one year ACGME accredited fellowship geared towards achieving board certification in 'Critical Care' after cardiology and a chance to train as a cardiac intensivist.

I find the concept quite exciting and tempting and would like to know people's thoughts about pursuing this.
Seems like the demand for cardiac intensivists is likely to rise in the near future with the advent of LVADs/assist devices.

Thoughts?
Future of this field vs pursuing a more traditional route like interventional cardiology?

What fellowship are you at? Anybody know of any other programs like this?

 

[nope80]

Bump!

Anyone know of which formal programs exist like this?

 

[P Diddy]

Bump!

Anyone know of which formal programs exist like this?

Brigham and UNC are at the forefront.

p diddy

 

[gutonc]

Brigham and UNC are at the forefront.

p diddy

But pretty much any place that has both Cards and a CCM alone option can give you the option to do this by adding an extra year of CCM.

 

[P Diddy]

But pretty much any place that has both Cards and a CCM alone option can give you the option to do this by adding an extra year of CCM.

This is true. The question is how easily that critical care time can be integrated with cardiology training, and how that training overall can be fashioned into a career.

p diddy