Critical Care Medicine Versus Pulmonary Critical Care

[JasonLChertoff]

Hello,

I am new to this website and had a few questions regarding fellowship training in critical care. I am an IM resident and definitely want to pursue a critical care fellowship, but am not sure that I would like to pursue the pulmonary portion of the fellowship. I know that typically residents apply for pulmonary/critical care. Why is that? Is it that people are typically interested in both?

I'm interested in rheumatology and critical care and would rather be double boarded in rheum/ccm, instead of pulm/ccm. Is this a bad idea?

One last question: Is it a bad idea to pursue the 2 year ccm fellowship instead of the 3 year pulm/critical care fellowship? What are the advantages of doing the third year and getting the double board certification in pulm and cc?

Sorry for all of the questions at once. Thank you for your help.

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[Hernandez]

Rheum-CCM? I don't see the utility.

I went into pulm-cc thinking I'd do pure cc, I'm only doing CC work as a consultant and almost all my time doing pulm work. Cc has a pretty big burn out rate, I love it but I get cranky after a few weeks of Micu. I would recommend a double board to have as a back up when you get sick of watching gomers dying.

 

[JasonLChertoff]

Thanks for the reply. So, you don't think it would be possible to do part-time in the ICU as an intensivist and part-time as a rheumatologist? Why is the other half so frequently pulmonary?

 

[Hernandez]

Thanks for the reply. So, you don't think it would be possible to do part-time in the ICU as an intensivist and part-time as a rheumatologist? Why is the other half so frequently pulmonary?

Possible sure......practical, no.... And Dunno.......

 

[dotcb]

I'm in EM, but these combos seem cool paired w/ CCM - renal, ID, palliative care, or cards....

 

[Hernandez]

palliative care,

You'll spend 2 years doing palliative care.....the extra certificate seems superfluous........

Although...I would not want my Trauma Doc to be duel boarded in palliative care.......

 

[JasonLChertoff]

So have you heard of physicians doing CCM with any specialties other than pulmonary? If so, why not rheum or heme/onc?

 

[Dwindlin]

So have you heard of physicians doing CCM with any specialties other than pulmonary? If so, why not rheum or heme/onc?

My buddy actually did ID/CCM. Seems to enjoy it.

 

[KLPM]

I have always found respiratory physicians running ICU interesting because in my country the renal folks run most of the ICUs. But I think that's mainly traditions since when the ICUs were first established here it was by a group of renal physicians. That's for adult ICUs though. PICUs and NICUs seem to be captained by general paediatricians and paediatric surgeons.

Some places have specialised ICUs that require specific physician specialties. For instance I have been to an ICU that had a section that took care of only bone marrow transplant patients which had many haematologists on staff. Another section was devoted to cardiothoracic + transplant (heart, lungs) so there was multiple cardiologists, resp phys and CT surgeons on call.

However, I think general ICUs still mostly compose of resp physicians, renal physicians and anaesthetists here.

 

[jdh71]

I see no reason why NOT to do rheum critical care. I've seen ID/CC, Renal/CC, and Cards/CC.

And why did pulm get stuck with the combo? Uh. The vent. Duhr.

 

[Hernandez]

I see no reason why NOT to do rheum critical care. I've seen ID/CC, Renal/CC, and Cards/CC.

And why did pulm get stuck with the combo? Uh. The vent. Duhr.

Rheum has very little utility in a MICU. I've not seen rheum be much help even on the rare times I wonder if someone is having a rheum emergency.

And I can't imagine many. Jobs looking for part time CC and part time rheum

 

[jdh71]

Rheum has very little utility in a MICU. I've not seen rheum be much help even on the rare times I wonder if someone is having a rheum emergency.

And I can't imagine many. Jobs looking for part time CC and part time rheum

Who cares if there is any utility cross-over? I fail to see how it's even relevant.

And there are plenty of places looking for both rheum and critical care (though not necessarily at the same time). You just work our your contract: a week covering the unit, and two weeks in rheum clinic, a week off, etc. Plenty of hospital systems could work with that kind of set-up.

 

[JasonLChertoff]

jdh71, your responses are very useful. Thank you for your help. I thought that it would be possible to work it out in the contract, and I'm glad to hear that you agree.

 

[JasonLChertoff]

The crossover isn't what I'm concerned about, because I'm confident that I'll have enough training from the CCM fellowship to feel confident in the unit. My concern was whether anyone could get hired being rheum/ccm boarded.

 

[jdh71]

The crossover isn't what I'm concerned about, because I'm confident that I'll have enough training from the CCM fellowship to feel confident in the unit. My concern was whether anyone could get hired being rheum/ccm boarded.

A private practice group probably wouldn't know that to do with you but that practice model is going the way of the dinosaurs. Finding a hospital to hire you to do both, cover the unit and then see out patient rheum consults in their clinics as an employee of their system is something very doable.

 

[mrpankration]

The only potential problem I could see with that set up though is that the funding for your salary would likely have to come from 2 different departments that probably have different budgets.

 

[GalenVesalius]

.

 

[thierryhenry]

Can anyone comment if there are solely ID/CC fellowships that are 3 years at a single place? I was trying to figure this out and I couldn't. Thanks

 

[bigtuna]

This question seems to come up over and over.

I hesitate to post this because I have the suspicion that I will get multiple arguments from residents and fellows in various stages of training but here's the truth:

Doing critical care without pulmonary will absolutely hurt your chances of finding a desirable job - especially in the non-academic setting.

You will have a hard time finding a situation where you practice critical care and a non-pulmonary IM subspecialty simultaneously - especially in the non-academic setting.

There is currently a shortage of critical care physicians - I'm not saying you won't be able to find a job. I'm saying you wont find a job in a nice hospital in a desirable city with good pay. Someone will hire you to work night coverage in their ICU - definitely. That's not what you want for your full time gig.

If you do pulmonary with the CCM you probably have 10X the options that you would have without it.

I know many people who have done CCM and an IM subspecialty and one of my co-fellows did rheum/ccm. None of these people are currently doing any CCM.



I

 

[2win]

That's absolutely dumb. rheum ccm???? Why ????

 

[2win]

I see no reason why NOT to do rheum critical care. I've seen ID/CC, Renal/CC, and Cards/CC.

And why did pulm get stuck with the combo? Uh. The vent. Duhr.

Do it - my group will never hire u.

 

[jdh71]

Do it - my group will never hire u.

They hired someone would types out responses like a 14 year old girl though.

So I don't know what that says about YOUR group (or should I say, "ur" group).

It's all moving to shift work. If a hospital system needs bodies in both the rheum clinic and MICU, you'll simply do some rheum clinic and some ICU days based on a contracted number of shifts per month, with a shift being a day in clinic or a day (or night) in the unit. Might not be a fit for all groups at the moment, but could work very well with the new hospital employee shift model going forward.

Times are changing.

 

[KLPM]

They hired someone would types out responses like a 14 year old girl though.

So I don't know what that says about YOUR group (or should I say, "ur" group).

No 14 year old types that well.

 

[bigtuna]

I would be wary of this line of thinking.
In general, being a hospital employee sucks.
The hospital will have no loyalty to you.
They will replace you if you become too expensive.
They will bully you into doing a ton of administrative work for no compensation.
They will hire crappy docs to work with you without your input.

You guys in training see these jobs because those are the ones that are advertised and readily available.
Look at people who are in long term critical care jobs and are happy.
These are often not hospital employed positions.

I've seen this over and over....

 

[jdh71]

I would be wary of this line of thinking.
In general, being a hospital employee sucks.
The hospital will have no loyalty to you.
They will replace you if you become too expensive.
They will bully you into doing a ton of administrative work for no compensation.
They will hire crappy docs to work with you without your input.

You guys in training see these jobs because those are the ones that are advertised and readily available.
Look at people who are in long term critical care jobs and are happy.
These are often not hospital employed positions.

I've seen this over and over....

I know plenty of perfectly happy employed pulmonary and critical care docs who have been employed for years. You know what these guys tell me? They no longer work like dogs like they did in a private practice group, and with plenty of time off, they have time to spend with their families and doing activities they like. They also don't miss having to find and pay someone to do the billing, transcription, run the front desk, or room the patients. I even had one guy tell me, with production bonuses, he's making much more now as an employee than he ever did in private practice.

I don't know whose anecdote gets to win.

Different set-ups are going to work for different people and different situations. You paint a worst case scenario picture. And maybe a community hospital in San Diego has no reason to be loyal, but a mountain town in Wyoming sure does. People definitely need to pay attention to the culture of the institution where they are thinking about working, but not every (and probably not even most) employed gig(s) is(are) going to exploit a physician.

 

[Laryngophed]

I'm still a student going into anesthesia with my sights set on cardiac/ccm fellowships (you can go ahead and quit reading now, if you'd like) and after talking about my plans with a few CCM attendings at our big house, I know that the the critical care half of my plans could easily be fulfilled. It's one group, and we're talking 6 years down the road, but he says that the group never has quite enough people to have the work balanced out as they'd like (this is the MICU, not the SICU or NeuroICU) and are always looking to hire good folks. He thinks if I do cardiac/ccm, that finding a job shouldn't be difficult. After all, patients with bad hearts are living longer and having more operations later into life, leading to need for more cardiac anesthesiologists. (I foresee a time when the cardiac anesthesiologists expertise is carried out of the heart room and into the general room or other rooms where the patients with sick hearts are having other operations) And second, the increasingly aging population isn't going to stop filling ICUs.

Just my $0.02 and know you can go back to your regularly scheduled programming.

 

[Kal EI]

I'm still a student going into anesthesia with my sights set on cardiac/ccm fellowships (you can go ahead and quit reading now, if you'd like) and after talking about my plans with a few CCM attendings at our big house, I know that the the critical care half of my plans could easily be fulfilled. It's one group, and we're talking 6 years down the road, but he says that the group never has quite enough people to have the work balanced out as they'd like (this is the MICU, not the SICU or NeuroICU) and are always looking to hire good folks. He thinks if I do cardiac/ccm, that finding a job shouldn't be difficult. After all, patients with bad hearts are living longer and having more operations later into life, leading to need for more cardiac anesthesiologists. (I foresee a time when the cardiac anesthesiologists expertise is carried out of the heart room and into the general room or other rooms where the patients with sick hearts are having other operations) And second, the increasingly aging population isn't going to stop filling ICUs.

Just my $0.02 and know you can go back to your regularly scheduled programming.

All the talk about specialties usually has little to do with demand, and much more to do with reimbursement/lifestyle. Saying there will be plenty need for whatever is a pretty typical answer. E.g. it can be said for FM or palliative care too.

 

[Taels]

Isn't cardio/CCM a good idea?

 

[AlmostAnMD]

Isn't cardio/CCM a good idea?

I was curious about that actually...what is day-to-day life like for cardio/CCM boarded guy? Not sure how you would use both of those other than doing a lot of bouncing around.

 

[POW16]

I'm still a student going into anesthesia with my sights set on cardiac/ccm fellowships (you can go ahead and quit reading now, if you'd like) and after talking about my plans with a few CCM attendings at our big house, I know that the the critical care half of my plans could easily be fulfilled. It's one group, and we're talking 6 years down the road, but he says that the group never has quite enough people to have the work balanced out as they'd like (this is the MICU, not the SICU or NeuroICU) and are always looking to hire good folks. He thinks if I do cardiac/ccm, that finding a job shouldn't be difficult. After all, patients with bad hearts are living longer and having more operations later into life, leading to need for more cardiac anesthesiologists. (I foresee a time when the cardiac anesthesiologists expertise is carried out of the heart room and into the general room or other rooms where the patients with sick hearts are having other operations) And second, the increasingly aging population isn't going to stop filling ICUs.

Just my $0.02 and know you can go back to your regularly scheduled programming.

Quick question since I am going into anesthesiology with views on CCM down the road. Are you talking about two anesthesia fellowships (CC and CT) or a combined ? I have never heard of the latter.

 

[Laryngophed]

Quick question since I am going into anesthesiology with views on CCM down the road. Are you talking about two anesthesia fellowships (CC and CT) or a combined ? I have never heard of the latter.

Two separate fellowships, but some places are intertwining them and making life more agreeable for those who are interested in the two fellowships.

 

[netrunner]

Hello,

I am new to this website and had a few questions regarding fellowship training in critical care. I am an IM resident and definitely want to pursue a critical care fellowship, but am not sure that I would like to pursue the pulmonary portion of the fellowship. I know that typically residents apply for pulmonary/critical care. Why is that? Is it that people are typically interested in both?

I'm interested in rheumatology and critical care and would rather be double boarded in rheum/ccm, instead of pulm/ccm. Is this a bad idea?

One last question: Is it a bad idea to pursue the 2 year ccm fellowship instead of the 3 year pulm/critical care fellowship? What are the advantages of doing the third year and getting the double board certification in pulm and cc?

Sorry for all of the questions at once. Thank you for your help.

I was once told by a much wiser man: "Make sure you have a day job."

Basically, like others have already posted, CC has a high burnout rate--at the very least, you will have a hard time doing it for more than 2-3 weeks a month. Therefore, you have to ask yourself where you will refresh yourself--a subspecialty (I practice anesthesiology) or the medicine wards? If your answer is the latter then hats off to you--you have my respect. Most would not view working as a hospitalist a "break" from the ICU.

Rheum-ICU doesn't seem like a bad idea but you will get very few cross-over skills there to help you.

hope that helps

 

[Bostonredsox]

I was once told by a much wiser man: "Make sure you have a day job."

Basically, like others have already posted, CC has a high burnout rate--at the very least, you will have a hard time doing it for more than 2-3 weeks a month. Therefore, you have to ask yourself where you will refresh yourself--a subspecialty (I practice anesthesiology) or the medicine wards? If your answer is the latter then hats off to you--you have my respect. Most would not view working as a hospitalist a "break" from the ICU.

Rheum-ICU doesn't seem like a bad idea but you will get very few cross-over skills there to help you.

hope that helps

You don't need to have a day job for most med-CC careers. The CC is week on week off. And the pay for that is higher than the base hospitalist pay for 7 on 7 off. No need to work the other two weeks a month.

 

[VentJockey]

On a somewhat related note....how competitive are the Critical Care only programs? After a lot of reflection I think this is the way to go for me. I'm just curious if I'm going to be fighting an uphill battle where very few who apply ultimately land positions, or if a good IM resident who talks a good story in the interview will land a place somewhere?

 

[jdh71]

On a somewhat related note....how competitive are the Critical Care only programs? After a lot of reflection I think this is the way to go for me. I'm just curious if I'm going to be fighting an uphill battle where very few who apply ultimately land positions, or if a good IM resident who talks a good story in the interview will land a place somewhere?

From what I can tell, if you have an interest you should be able to land a spot somewhere.

 

[cbrons]

How is CC/nephro in the US? Just curious because for the longest time ive been interested in CC and havent thought as much about anything else thus far save for nephrology.(which as a side note I additionally loved most in pathology and phys as well).


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[jdh71]

How is CC/nephro in the US? Just curious because for the longest time ive been interested in CC and havent thought as much about anything else thus far save for nephrology.(which as a side note I additionally loved most in pathology and phys as well).


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It's probably the second most common subspecialty pairing with CC that I've seen. You probably won't have too much trouble fitting into the MICU schedule somewhere when you are done. It would be a good way to supplement your income if you're going to do renal.

 

[inspirationmd]

It's probably the second most common subspecialty pairing with CC that I've seen. You probably won't have too much trouble fitting into the MICU schedule somewhere when you are done. It would be a good way to supplement your income if you're going to do renal.

How wrecked do you think you would be with a 1 week on 1 week off (12 hour shifts) Intensivist schedule? Would work with PAs and Critical Care fellows during that time. Do you think there would be energy to cover 2-3 12 hour shift primarily (some overlapping PA coverage) in a low-moderate acuity ED during the off weeks? This would likely be in 1 health system at 2 separate hospitals (1 community and 1 community-university affiliated hospital). Total of about 18-20 days a month. Would average $170 an hour for all shifts. Unsure about RVUs - sounded like flat rate. May be able to negotiate some loan repayment but would probably drop the Intensivist hourly wage. Starting to negotiate with a hospital system for a few years out and before the next meeting I want to get an idea how I should be thinking about this. I'll be EM/IM/CCM.

 

[jdh71]

How wrecked do you think you would be with a 1 week on 1 week off (12 hour shifts) Intensivist schedule? Would work with PAs and Critical Care fellows during that time. Do you think there would be energy to cover 2-3 12 hour shift primarily (some overlapping PA coverage) in a low-moderate acuity ED during the off weeks? This would likely be in 1 health system at 2 separate hospitals (1 community and 1 community-university affiliated hospital). Total of about 18-20 days a month. Would average $170 an hour for all shifts. Unsure about RVUs - sounded like flat rate. May be able to negotiate some loan repayment but would probably drop the Intensivist hourly wage. Starting to negotiate with a hospital system for a few years out and before the next meeting I want to get an idea how I should be thinking about this. I'll be EM/IM/CCM.

Hm. It sounds like a lot of work to me. Any overnight call expected or all shift work and days?

 

[Idiopathic]

just 12's it shouldnt be that bad i know people that do 7 12's and then work in the OR the following week

 

[inspirationmd]

Hm. It sounds like a lot of work to me. Any overnight call expected or all shift work and days?

Days and nights interspersed in a shift work setup. No conventional call.

Working harder when I first come out to recoup some of the cash lost from training so long.

Definitely don't want to set myself up to burnout though so just trying to get a sense for what is reasonable.

 

[jdh71]

Days and nights interspersed in a shift work setup. No conventional call.

Working harder when I first come out to recoup some of the cash lost from training so long.

Definitely don't want to set myself up to burnout though so just trying to get a sense for what is reasonable.

So they'd be picking you to cover the unit but you'd be picking up ED shifts as you wanted or are you thinking of contracting X amount of ED shifts per month too?

 

[inspirationmd]

ED shifts as I want, won't be part of the contract.

So they'd be picking you to cover the unit but you'd be picking up ED shifts as you wanted or are you thinking of contracting X amount of ED shifts per month too?

l

 

[jdh71]

ED shifts as I want, won't be part of the contract.

I think seems reasonable. As long as you can schedule those extra shifts. Otherwise you might be running into some burnout. Sure that ICU doesn't sound too bad with PA's and house staff. But 12 hours is still 12 hours.

 

[Hernandez]

Days and nights interspersed in a shift work setup. No conventional call..

The alternating days/nights is what will get ya if it isn't done in a reasonable fashion. Otherwise, for a few years that won't be bad.

 

[tartesos]

ED shifts as I want, won't be part of the contract.


l

Good luck!and please let us know how that works out in the future burn out wise.
I would like in my future a batched shift setting( 7 on 7 off and some stuff in the week off).

 

[inspirationmd]

I think seems reasonable. As long as you can schedule those extra shifts. Otherwise you might be running into some burnout. Sure that ICU doesn't sound too bad with PA's and house staff. But 12 hours is still 12 hours.

Thanks a lot.

 

[inspirationmd]

The alternating days/nights is what will get ya if it isn't done in a reasonable fashion. Otherwise, for a few years that won't be bad.

Cool. I will definitely watch this.

 

[deleted481566]

For the pulm/CCM folks (jdh, Hern, others),

What kind of schedules are you guys seeing out in the private practice world? I, and I'm sure many other still in training, only see the academic model of splitting pulmonary clinic/consults and unit. Any differences based on location/size of town? The only private pulm/CCM doc I know still works on the older consult only model of ICU care, but I know things are changing.

 

[Hernandez]

It's still pretty varied on what's available. Many places are looking for pure pulm for mostly out patient coverage and many are looking for pure CCM, and there any many looking for the old school cover everything model. I didn't find many places outside of the coasts who had the split set up. Granted I limited myself to fly over states, I was very interested in the Montana/Wyoming area but I'll be honest, the prospects of being the ONLY pulm doc covering a large system wasnt appealing to me since I have a family