CCM only compared to PCCM, what am I missing?

[lostarkenthusiast]

I am another IM guy that likes critical care but is not excited about pulmonology in particular. I am leaning towards CCM only, my question is. How much more independent does the combine fellowship in pulmonary critical care makes you compared to CCM only trained physician. Specifically, historically CCM and pulmonary have been linked nicely together through vented patient and what not. However nowadays that is not an issue. However, how often does a CCM doctor has to consult pulmonary in the ICU? I guess my question is, what I cannot managed in an ICU patient as a CCM only physician that a PCCM physician could manage.
If i need a bedside BAL, for example, can a CCM do that without the help of pulmonary, are they trained on that? Obviously more complex procedures like EBUS are outside of CCM scope and not something that you would do in a ICU patient.

I would appreciate more insight

Thanks

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[CCM-MD]

I do BAL, I’m not pulmonary trained. I have gotten input from my pulmonary colleagues regarding interstitial pneumonias and other rare diseases but it’s not a frequent thing, and often times they don’t have a significant amount to add. We mainly have antibiotics and steroids to treat lung diseases in the unit, not many other magical treatment modalities. Will I be consulting pulmonary more than someone trained in pulmonary? Yes. Will both of us be be consulting ID more than an ID trained intensivist? Probably yes also. One of the locum guys I just worked with is ID, Pulm, CCM, and Sleep trained, I guess he’s going to consult the least.

How frequently you’re going to be consulting pulm isn’t the factor you need to be considering but rather is pulmonary going to give you a hedge when it comes to dependency on CCM to earn a living. There’s potential for increasing midlevel encroachment, more corporate groups and increased number of critical care training pathways and positions. This is where having pulmonary boards is an advantage - as amazing as things are in CCM right now, if they go bad in the future you have the ability to do something totally different as a pulmonologist.

My advice is: if you can tolerate pulmonary then do the extra year. It will give you a lot of flexibility. If you’re the type of person who is confidently disinterested in chronic lung disease and cannot tolerate clinic at all (like me) then skip it and save the $450k in opportunity cost for the extra year of training. You will be just fine in the ICU when it comes to managing 95% of respiratory critical illness.

 

[grt398]

As someone who had similar thoughts, really disliked clinic, and went the CCM only route, I still recommend everyone do combined PCCM. As CCM-MD above pointed out, pulm gives you significant flexibility and there are a lot of jobs that want you to do ICU/inpatient pulm consults (no clinic required), especially in slightly more rural areas and out west. The job flexibility it gives you is difficult to appreciate before you start your job hunt...I would go so far as to say if you're not one of the prior fellowship people (aka you did nephro/ID/cards/whatever), it's very difficult to recommend you don't do PCCM. Basically, if you do PCCM, you can do ICU only, ICU/inpatient consults only, outpatient only, or any combination of those. And you can flex b/w them at various points in your career based on your interests and lifestyle needs. That's an incredibly valuable option 15-20 years down the road.

But yes I do BAL's/bronch's etc.

 

[Siggy]

I am another IM guy that likes critical care but is not excited about pulmonology in particular. I am leaning towards CCM only, my question is. How much more independent does the combine fellowship in pulmonary critical care makes you compared to CCM only trained physician. Specifically, historically CCM and pulmonary have been linked nicely together through vented patient and what not. However nowadays that is not an issue. However, how often does a CCM doctor has to consult pulmonary in the ICU? I guess my question is, what I cannot managed in an ICU patient as a CCM only physician that a PCCM physician could manage.
If i need a bedside BAL, for example, can a CCM do that without the help of pulmonary, are they trained on that? Obviously more complex procedures like EBUS are outside of CCM scope and not something that you would do in a ICU patient.

I would appreciate more insight

Thanks

I'm CCM only. I do my own BALs and had a ton of bronchs during fellowship. I have seen Reddit people claim that only pulm should manage "complex" vent settings like APRV... and you know what... I manage APRV the handful of times I've needed it just fine.

 

[Nephro critical care]

I am neph/CC now only doing CC and I would advise anyone interested in CC to do pulm/CC. As a resident I really liked CC but hated pulm just because of all the COPD pts. So I ended up doing Neph and then CC. That was a big mistake. There are no Neph /CC jobs and I ended up doing just critical care. With CC too my job market is more limited there are a lot of pulm /cc jobs that I am not eligible for. CC job market varies ; during COVID it was quite good but now you have to look around.

 

[CCM-MD]

Just had a patient with a total right lung atelectasis that needed a relatively urgent bronch. My resident asked if I was going to consult pulmonary… yeah the patient might be dead by the time one of our pulm docs comes to see them after their clinic. Bronchoscopy is a core competency for intensivists for a reason, and its not that difficult for our indications. Some places have NPs credentialed for bronchs, which is a bit crazy.

 

[CCM-MD]

I'm CCM only. I do my own BALs and had a ton of bronchs during fellowship. I have seen Reddit people claim that only pulm should manage "complex" vent settings like APRV... and you know what... I manage APRV the handful of times I've needed it just fine.

That’s silly. The EMCrit folks are some of the biggest proponents of APRV and they aren’t pulmonologists.

 

[chessknt]

I have to say I have seen CCM only people bronch and the ones I have observed totally suck compared to pulm people. They dont know any of the anatomy, don't know how to clear their optics, use way too much saline to clear plugs, run in to the bronchial walls etc etc. They get by because CC bronchs are usually stupid nonsense that isn't necessary anyways but sometimes in that rare case where you have a critical airway bleed and know where the problem is those hundreds of extra bronchs you did and the muscle memory (from having to regurgitate the anatomy to every attending you bronch with) can help you if you cant see where you are going. I assume the anesthesia folks think the same thing when I intubate or the CT surgeons when I put a chest tube in. Just dont have the same numbers.

Not worth doing an extra fellowship just for that though--should do GI instead for sure way more useful for CCM although I doubt you would do CC if you did GI. Pulm med is in huge demand and can be quite academically fulfilling but doesnt pay well. That might matter in the future but right now CCM is where it is at.

 

[NewYorkDoctors]

If you see yourself doing office/private practice/clinic, doing PFTs, maybe doing CPETS, doing outpatient bronchs (without necessarily intubation or advanced airway in place) to work up cancer/infection/ILD, doing inpatient non ICU consults, then just do the Pulmonary with CCM.

If you never see yourself doing anything outpatient, go straight CCM. Even if you hate clinic now, you have to ask yourself if you can see yourself in the ICU at age 60. Your fallback as CCM only is do general medical admissions or primary care clinic.

Like others have said, you value flexibility, do both.

 

[Benzo4every1]

it will give you options if you want to cut back in the future and do just clinic and inpt pulm. no overnight calls when you do just pulm
if you want to do the ccm route, even our APP now do bronchs and chest tubes... so...
If you do CCM only, then you will be just doing Inpt work for a while. or I am sure there is option for telemedicine for CCM as well

 

[spacegun]

Or what about pulm only +/- sleep med for $$$ and lifestyle!

 

[CCM-MD]

Or what about pulm only +/- sleep med for $$$ and lifestyle!

Or

CCM and Sleep 🤯

 

[lafamilia]

Or

CCM and Sleep 🤯

I understand that this can be done, but is this combination commonly seen in practice? I’ve only seen job ads where “sleep is optional”, but none that allow for a CCM-Sleep combo with “Pulmonary optional.”

 

[CCM-MD]

I understand that this can be done, but is this combination commonly seen in practice? I’ve only seen job ads where “sleep is optional”, but none that allow for a CCM-Sleep combo with “Pulmonary optional.”

Uncommon. But I have seen it.