Competitiveness for pulm CC spot?

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Jay Sree

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How competitive has critical care fellowships become? I used to read that they were not as hard but then recently there has been an uptick. Furthermore I'm finding conflicting information including that NRMP data showed a drop in applicants year over year recently though I'm not sure how true this is.

What do you guys think? What can someone who really wants it but is not very competitive do? I am currently about to start third year IM residency. I had my difficulties including some health diagnosis that were only now discovered which would explain my academic/board struggles.

What can someone like myself do to become more competitive or get in?

Should I consider applying at all? Or should I apply and also attempt to work as a hospitalist near or where I want to get a fellowship and then reapply (assuming that the staff get a chance to see me working as a physician there)

Critical care medicine is an amazing field and is really my passion so I'm really hoping to fight for this job

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I think there are 2 big questions that would go a ways towards answering this - probably the most important is your status as US MD grad vs other grad. If you are a US MD grad, then for a large majority of fellowships, there will be spots available if you want them, despite what you state is a weaker application for various reasons. The other related factor is location - if you are willing to travel and work in some of the less "ideal" regions of the country, this will also boost your chances of a successful match


How competitive has critical care fellowships become? I used to read that they were not as hard but then recently there has been an uptick. Furthermore I'm finding conflicting information including that NRMP data showed a drop in applicants year over year recently though I'm not sure how true this is.

What do you guys think? What can someone who really wants it but is not very competitive do? I am currently about to start third year IM residency. I had my difficulties including some health diagnosis that were only now discovered which would explain my academic/board struggles.

What can someone like myself do to become more competitive or get in?

Should I consider applying at all? Or should I apply and also attempt to work as a hospitalist near or where I want to get a fellowship and then reapply (assuming that the staff get a chance to see me working as a physician there)

Critical care medicine is an amazing field and is really my passion so I'm really hoping to fight for this job
 
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OP might get more replies if he shares more about him/herself. Are you a US grad? Does "board struggles" mean you have multiple attempts or that you passed the first time but with low scores? Have you done well in residency so far? Any research done? How strong is your home residency program?

Giving more info could give the more experienced posters a better idea on how to advise you. Not trying to get on your case either, btw. As someone who's also a little weaker on paper and about to start internship in a week I'm curious what people have to say.
 
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OP might get more replies if he shares more about him/herself. Are you a US grad? Does "board struggles" mean you have multiple attempts or that you passed the first time but with low scores? Have you done well in residency so far? Any research done? How strong is your home residency program?

Giving more info could give the more experienced posters a better idea on how to advise you. Not trying to get on your case either, btw. As someone who's also a little weaker on paper and about to start internship in a week I'm curious what people have to say.

Well, for one thing My boards are not the best- multiple attempts for step 1 and 3, I had a health disease that was only discovered now and fully treated for which I am rcovering and I truly believe-in fact I'm confident- that had I been treated before med school I'd be doing really well. I'm at a community hospital. No research that is published. I have done average in my residency. We historically have had some trouble filling spots.
 
Well, for one thing My boards are not the best- multiple attempts for step 1 and 3, I had a health disease that was only discovered now and fully treated for which I am rcovering and I truly believe-in fact I'm confident- that had I been treated before med school I'd be doing really well. I'm at a community hospital. No research that is published. I have done average in my residency. We historically have had some trouble filling spots.
Are you a US citizen? Do you have any visa issues or concerns? That might make a big difference in your case.
 
^ bumpsies. And is research required?

I hate research :(
 
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How important is residency program "prestige" for pulm/ccm? I'm only an M2 at a US MD school (above average rank but not super high tier) but think I might be most interested in IM specialties. Is it much easier to get in from a better known program?
 
Here is NRMP's fellowship match data (2017):

Pulmonary and Critical Care
-U.S. Grads 289/323 (89.5%)
-Total 524/742 (70.6%)

Obviously it doesn't tell us what each applicant did (e.g., which IM programs they graduated from, how much research they have, what kind of research), but the percentages seem promising if you're a "U.S. Grad."
 
CC is still not competitive but I forsee it will get more competitive over the next year. ABIM hasn't protected the field as much as it should and anesthesia/EM are now encroaching big time. If not in fellowships at least in jobs I as a straight IM/CC have had to compete with EM/CC.
EM and anesthesia have some strengths. Their strengths are in acute management/procedures. Their reflexes will be faster than IM doctors. But when you have to do a chart biopsy on a patient here for 25 days or running the show with 5 consultants on board or having a goal of care discussion with a difficult family our strengths will show up.
 
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After a few years though I think pulm/CC will become separate specialities. Pulm will do output clinic and complex interventional procedures but move out / be pushed out of CC. There is no way a pulm/cc guy who does CC once every 6 weeks will keep the knowledge that a CC doctor who does CC day in and day out will keep. CC as a field is exploding from a knowledge perspective and with all the different subspecialities of CC i.e trauma/CC, cardiology /CC, neuro /CC and MICU it's gonna become too much for a pulm/CC guy doing ICU every 6 weeks to handle.
 
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CC is still not competitive but I forsee it will get more competitive over the next year. ABIM hasn't protected the field as much as it should and anesthesia/EM are now encroaching big time. If not in fellowships at least in jobs I as a straight IM/CC have had to compete with EM/CC.
EM and anesthesia have some strengths. Their strengths are in acute management/procedures. Their reflexes will be faster than IM doctors. But when you have to do a chart biopsy on a patient here for 25 days or running the show with 5 consultants on board or having a goal of care discussion with a difficult family our strengths will show up.

Lol. Yea, us pitiful EM docs just can't remember why the patient we've been rounding on for 4 weeks is here. And yep, were incompetent to manage any complaint without a consultant. And God forbid anyone allow us to talk to families!!!!

Stop it. You sound idiotic.

And EM/CCM "encroaching" on your field is ridiculous. If an EM grad takes the spot in an IM fellowship, that isn't encroaching, that is being better than you at your own game. Im sorry you think your board needs to "protected the field" from us....
 
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After a few years though I think pulm/CC will become separate specialities. Pulm will do output clinic and complex interventional procedures but move out / be pushed out of CC. There is no way a pulm/cc guy who does CC once every 6 weeks will keep the knowledge that a CC doctor who does CC day in and day out will keep. CC as a field is exploding from a knowledge perspective and with all the different subspecialities of CC i.e trauma/CC, cardiology /CC, neuro /CC and MICU it's gonna become too much for a pulm/CC guy doing ICU every 6 weeks to handle.

And FYI , I did 14 months of ICU in my fellowship( which is more ICU than your 1 yr total), most pulmonary fellowships are ICU heavy since hospitals need bodies to run their ICUs.
Hospitals prefer people who are double-triple boarded. But whatever rocks your boat
 
I did a 2 year critical care fellowship. Lots of CTICU/ neuro ICU. Your program has a pretty good ICU exposure but lots of pulm / cc programs are top heavy with ICU primarily in 1st year while 2nd , 3rd year is spent doing clinic , outpt bronchs and reading PFTs. Our ICU is staffed by both CCs and pulm /CCs and after a while you can tell that the pulm/ CC guy doing ICU and call every 6 weeks is not as solid in ICU as the CC guy doing it day in and day out. Nor do pulm /cc want to be in the ICU.
ED guys by definition have an attention span of 2 hrs with a patient and that point they either want to discharge the patient or transfer to someone else. But of course everyone sees a quick buck in CC and want to gatecrash the party. Do a 3 yr IM residency.
 
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I did a 2 year critical care fellowship. Lots of CTICU/ neuro ICU. Your program has a pretty good ICU exposure but lots of pulm / cc programs are top heavy with ICU primarily in 1st year while 2nd , 3rd year is spent doing clinic , outpt bronchs and reading PFTs. Our ICU is staffed by both CCs and pulm /CCs and after a while you can tell that the pulm/ CC guy doing ICU and call every 6 weeks is not as solid in ICU as the CC guy doing it day in and day out. Nor do pulm /cc want to be in the ICU.
ED guys by definition have an attention span of 2 hrs with a patient and that point they either want to discharge the patient or transfer to someone else. But of course everyone sees a quick buck in CC and want to gatecrash the party. Do a 3 yr IM residency.

You are insanely poorly informed. How many actual EM trained intensivist do you currently work with? My guess is damned near zero. There are only about 200 EM/CCM trained docs in the country, so unless you are at one of about 10 hospitals in the country, you've at most worked with 1-2 EM trained intensivists (and probably not even that). You are either extrapolating what you imagine ED docs would do if they worked in an ICU, you work with one or two and are extrapolating that small sample size widely, or you work at a Pitt, Michigan, WashU, New Mexico, Shock Trauma or a handful of other top tier crit care programs where you probably have exceptional EM/CCM folks.

CC is the furthest thing from an easy buck. It's an extra 2 years of fellowship to make less money than working in the ED.

Just stop. You have no idea what you're talking about.
 
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I honestly don't know why there is so much concern over the CC turf. As a person who went through IM training, I believe IM and EM training are both competent to go in CC. They have their weakness and strengths. The average EM resident will excel in procedures especially with access (this potentially is more important in community practices where lines are expected from attendings, but not as much in academic centers where attendings typically do minimal procedures.) On the other hand IM residents will typically have far greater exposure in pathophysiology in management of diseases beyond pressors/abx/ventilation. Ie, most EM residents have no exposure taking care of liver patients, onc patients, or cards pts. That said, having pulm background will add more value given the ability to bronch which is something that EM can't do.
 
I honestly don't know why there is so much concern over the CC turf. As a person who went through IM training, I believe IM and EM training are both competent to go in CC. They have their weakness and strengths. The average EM resident will excel in procedures especially with access (this potentially is more important in community practices where lines are expected from attendings, but not as much in academic centers where attendings typically do minimal procedures.) On the other hand IM residents will typically have far greater exposure in pathophysiology in management of diseases beyond pressors/abx/ventilation. Ie, most EM residents have no exposure taking care of liver patients, onc patients, or cards pts. That said, having pulm background will add more value given the ability to bronch which is something that EM can't do.

EM does bronch. Mind you, I'm not doing EBUS or anything like that, but your basic 1) verify tube 2) BAL 3) therapeutic aspiration and 4) low level intervention to achieve hemostasis should be within the purview of all intensivists - besides, this consitutes 99% of ICU bronchs. Sure, you may be getting biopsies if you have a lung transplant patient, but I imagine your pulm transplant guys are going to want to do their own bronchs on those patients anyway.

Saying EM has no exposure to cirrhotics or onc or cards is also untrue. Yes, we do not longitudinally manage these patients, but all the neutropenic fevers or decompensated cirrhotics or chf exacerbations come through the ED.

No, we do not manage patients long term in residency, but that's what the fellowship is for. I agree that all specialties have their own strengths and weaknesses coming into fellowship, but if they go through a good training program, they should all come out of the other side on relatively even footing.
 
EM does bronch. Mind you, I'm not doing EBUS or anything like that, but your basic 1) verify tube 2) BAL 3) therapeutic aspiration and 4) low level intervention to achieve hemostasis should be within the purview of all intensivists - besides, this consitutes 99% of ICU bronchs. Sure, you may be getting biopsies if you have a lung transplant patient, but I imagine your pulm transplant guys are going to want to do their own bronchs on those patients anyway.

Saying EM has no exposure to cirrhotics or onc or cards is also untrue. Yes, we do not longitudinally manage these patients, but all the neutropenic fevers or decompensated cirrhotics or chf exacerbations come through the ED.

No, we do not manage patients long term in residency, but that's what the fellowship is for. I agree that all specialties have their own strengths and weaknesses coming into fellowship, but if they go through a good training program, they should all come out of the other side on relatively even footing.

Stand corrected, did not know CC trains people to do bronchs outside of pulm/cc fellowship.

As for management of onc/liver/cardiac disease, I hope you realized i specifically did not mention "neutropenic fevers", "cirrhotics", or "CHF", because those are only 1 large categories of disease within each of those organ systems. I'm sorry, but vast majority of EM residencies do not provide training in those areas unlike in many IM programs where you will spend 4+ months on cards/CCU, 2+ months on Liver, and 2-4 months on oncology services during IM residency.

Also, please realize the context of what I was saying. I am talking about the differences between residencies in the differences of EM vs IM GOING INTO CC fellowship, not the end result of after CC fellowship. Hence my conclusions are similar to yours, after CC I'm sure either EM or IM trained people will be competent in CC. THat goes for anesthesia as well who IMO is even more different type of training than EM and IM.
 
Stand corrected, did not know CC trains people to do bronchs outside of pulm/cc fellowship.

As for management of onc/liver/cardiac disease, I hope you realized i specifically did not mention "neutropenic fevers", "cirrhotics", or "CHF", because those are only 1 large categories of disease within each of those organ systems. I'm sorry, but vast majority of EM residencies do not provide training in those areas unlike in many IM programs where you will spend 4+ months on cards/CCU, 2+ months on Liver, and 2-4 months on oncology services during IM residency.

Also, please realize the context of what I was saying. I am talking about the differences between residencies in the differences of EM vs IM GOING INTO CC fellowship, not the end result of after CC fellowship. Hence my conclusions are similar to yours, after CC I'm sure either EM or IM trained people will be competent in CC. THat goes for anesthesia as well who IMO is even more different type of training than EM and IM.

Fair points.
 
Fair points.
Everyone will protect his own turf, just naturally. I am sure if tomorrow the ABEM allowed a 1 year fellowship open to all IM/FM doctors to get board certified in EM, EM docs would be up in arms.
But anyway come to the point of CC certification, I feel many of the pulm/CC programs are rich in MICU training but not CTICU,CCU,neuro ICU, fresh post transplant or trauma as in big multi-traumas. So some stuff we don't know I think we should know TEEs or difficult airway as in anesthesia level difficult airway=fiberoptic, intubating LMA intubations. That may not happen in the 1 yr CC training or a 3 year pulm/CC program but should happen in 2 year CC training. We rotated through the CT , neuro ICU but were not primary , getting the nursing calls or managing pts at night. Our ECMO , LVAD trading was not that great.
Unfortunately Anesthesia runs the CTICU, Neuro ICUs in bigger centers and pulm / CCs .If IM/CC acquires those skills it will make us marketable if you want to go to a bigger ICU.
 
You are insanely poorly informed. How many actual EM trained intensivist do you currently work with? My guess is damned near zero. There are only about 200 EM/CCM trained docs in the country, so unless you are at one of about 10 hospitals in the country, you've at most worked with 1-2 EM trained intensivists (and probably not even that). You are either extrapolating what you imagine ED docs would do if they worked in an ICU, you work with one or two and are extrapolating that small sample size widely, or you work at a Pitt, Michigan, WashU, New Mexico, Shock Trauma or a handful of other top tier crit care programs where you probably have exceptional EM/CCM folks.

CC is the furthest thing from an easy buck. It's an extra 2 years of fellowship to make less money than working in the ED.

Just stop. You have no idea what you're talking about.

I agree with everything you said except for the part about compensation. EM salaries are exaggerated on SDN.

CCM 2016 - MGMA: 398k; AMGA: 399k
EM 2016 - MGMA: 311k; AMGA: 355k
 
I agree with everything you said except for the part about compensation. EM salaries are exaggerated on SDN.

CCM 2016 - MGMA: 398k; AMGA: 399k
EM 2016 - MGMA: 311k; AMGA: 355k

That's a bit surprising. The EM jobs that I've looked at were more lucrative than the CCM jobs. That being said, my n is relatively small and confined to a small part of the country.

Also, how much did it cost you to buy that data? And how detailed is it? I'm debating whether or not I should get that before I negotiate my contract (I'm a second year CCM fellow currently). Do you think it's worth buying?
 
That's a bit surprising. The EM jobs that I've looked at were more lucrative than the CCM jobs. That being said, my n is relatively small and confined to a small part of the country.

Also, how much did it cost you to buy that data? And how detailed is it? I'm debating whether or not I should get that before I negotiate my contract (I'm a second year CCM fellow currently). Do you think it's worth buying?

I didn't purchase the data myself but I did look into it - its quite expensive. I have access to very limited versions of both MGMA and AMGA. The medians give a good idea of how much you're actually worth which can be helpful when looking for a job. There is a lot of misinformation about compensation.
 
How difficult is it for DOs?
Do able . I was the first pulm cc fellow taken in a program that never took outsiders. Several friends who matched pulm cc as DO in allopathic programs too. Helps to be at IM program with pulm/cc fellowship thought as I see our program often consistently fill from within. If your at least average across the board in board scores, research, residency letters you have a chance but its face time that usually get you better known to a program and much more likely to be picked against someone of similar ranking that isn't known.
 
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