Critical Care and practicing primary specialty

[Downbytheicu]

I've heard recently that some, if not many, Critical Care docs practice in the ICU and also in their primary specialty. I'm assuming that this is primarily talking about Pulmonologists who also do Critical Care. But does anyone know of anyone ICU docs who also do general internal medicine, either in patient or outpatient? I have this thing--I'm sure many do--where the idea of only outpatient care drives me nuts, and the idea of only doing high intensity ICU care doesn't sound ideal either. If I had my perfect practice, I would do two shifts a week of ICU and two weeks of outpatient preventative care in a group practice. Does anyone know of anybody who practices like this?

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[G-Man82]

I'm a prelim in medicine right now doing one of my MICU months at our private affiliate hospital in an open-style MICU with private PCCM attendings. The way it seems to work in the private sector is that they are primarily pulmonologists, who take ICU consults from the PMD of whoever needs to go to MICU, either a floor transfer or from the ER. Once consulted, they pop in once a day, plus when they are called, to see the patient in the ICU and then go back to their general practice. Sometimes though, one PCCM attending from their group will cover the group's patients in the ICU while the others are in the pulmonology clinic or doing scheduled procedures elsewhere in the hospital. That's the impression I got from the Medicine side. Back at the University, I've seen Trauma surgeons who are also intensivists do both. Primarily trauma surgery, but they'll take general surgery call and those patients are theirs throughout their hospital stay. The anesthesiologists work more of a 1 week on/1 week off schedule in the ICU. When not in the ICU they are in the OR doing cases. To us, the OR and ICU are similar environments.

I don't know about this "2 shifts a week" thing. Though that would imply a closed unit and I guess it's possible that there could be a different attending every day. I also don't know how many PCCM attendings also do general medicine. To me the 2 are completely different. Headaches and low-back pain one day to septic shock with multi-organ dysfunction the next. The reason I say that is while the outpatient stuff can be handled on a daily basis, I think the unit requires more than a day's commitment.

 

[Downbytheicu]

Thanks for the insight. I'm a third year, and we don't get to rotate through the ICU until 4th year. I haven't had any experience in it, but I like the in-depth phys, variety, codes, and managing an airway that seems to come with it. What prompted the question was reading Iserson's Getting into Residency and he made a comment about many ICU docs still practicing in their primary specialty. I guess I hoped this could extend to a general medicine also. If I only wanted to do critical care and give up the diagnostics, then I'd go anesthesia. But since I love diagnostic work, on top of procedures, codes, etc., I think I may want to have my cake and eat it too.

 

[G-Man82]

Thanks for the insight. I'm a third year, and we don't get to rotate through the ICU until 4th year. I haven't had any experience in it, but I like the in-depth phys, variety, codes, and managing an airway that seems to come with it. What prompted the question was reading Iserson's Getting into Residency and he made a comment about many ICU docs still practicing in their primary specialty. I guess I hoped this could extend to a general medicine also. If I only wanted to do critical care and give up the diagnostics, then I'd go anesthesia. But since I love diagnostic work, on top of procedures, codes, etc., I think I may want to have my cake and eat it too.

Well, it depends what you mean by "diagnostics." If you're in the ICU, regardless of primary specialty, you'll still be doing a lot of diagnostic workups on patients as you get them. General anesthesiologists still do that too, only more acutely in the perioperative time period. You still diagnose and treat the underlying cause for electrolyte disturbances, pH imbalances, GI upset, pain, etc especially in the PACU, and some of that even intraoperatively while the patient is open in the OR. Anesthesiologists who are Cardiothoracic or CCM boarded also do echos (if certified) and bronchs when necessary in the ICU/OR. With anesthesiology, everything is acute or an acute manifestation of a chronic disease, rather than chronic. It's also the full spectrum of patients: OB, peds, adult etc. If by diagnostics, you want to work-up and manage chronic pulmonary disease (COPD, asthma, lung cancers) in the outpatient setting, then Internal Medicine to PCCM would benefit you. If you want a long-lasting relationship with your patients, then Medicine is for you.

You've still got some time. I too was attracted to the ICU after some experience with it very early in 4th year, and I made my decision to go the Anesthesiology route instead of Medicine primarily because I liked the acuity of anesthesia vs the chronicity of internal medicine, the full-spectrum of patients etc. Remember, though that CCM is a fellowship. Don't go into a residency with your endpoint being a specific fellowship because it can and most likely will change. Compare the 2 residencies you are applying to and see if you would be happy in either of them in the event fellowship does not work out or you change your mind.

 

[Downbytheicu]

That's good advice. I appreciate it. I'm not too gung-ho on a particular fellowship as I am also considering cardio, GI, critical care, and general, in either medicine or peds. Haven't decided on that front either. I guess anesthesia should be in the cards too though I'm not quite sure what I think the future holds for anesthesia. Of course, no one knows for sure, but I at least want to be settled in my own mind before I head into something. And I guess what I mean by diagnostics is a complex problem to sit down and try to figure out. Maybe that exists in Anesthesia too as you watch the monitors, trying to figure out what's happening as someone's crashing. Since I'm in Psych right now, I'll try to get in with some anesthesiologists over the next few weeks and see what it's like. Thanks.

 

[Intensivist]

If you like taking care of codes, and especially difficult a/ws then you should consider anaesthesia. I also was thinking about doing Medicine comb with CCM without pulm stuff, but the proficiency of anaesthesia training and l dare to say superiority in CCM above other two option drove me in that direction. I train in Europe where where my postgrad training last up to 7 yrs, and includes all aspects of anaesthesia, CCM and pain, as well as considerable time spent in Medicine, therefore it kind of satisfied my appetite. l can always play dr. House in ICU though

 

[proman]

One thing to consider, if you want to do OP preventive care as your other practice, you'll never get that through anesthesiology. IM + CCM (5 years) would be the path. I don't think you'll find many jobs that offer that combination though.

 

[Downbytheicu]

Thanks for all the insight and advice. I'm still in the process of trying to find balance: wanting to run codes and do critical work, but have some healthy, non-life-threatened patients also. I don't feel the need to spend lots of time with all my patients (anesthesia), but I'd like to be able to spend plenty of time with some. Personally, I feel that finding this balance will be what is satisfying in my career.
Anyway, thanks again for the insight.

 

[ariwax]

Another option would be neurocritical care. It would be more than possible to do shiftwork in the NSCU half the month, and the remainder spent seeing either general neurology patients or followups on NSCU "graduates" in the clinic. That necessitates 1) a neurology residency, 2) a neurocritcare fellowship, and 3) an interest in pursuing nos. 1 and 2. Me, I want no part of an outpatient practice, but it takes all kinds.

 

[Hernandez]

f I had my perfect practice, I would do two shifts a week of ICU

then why do ccm at all?