Discrimination against Anesthesia CCM docs

[chocomorsel]

Hey y'all,
Just want to know for any of y'all regular posters who have a part to do with hiring. I have sent out lots of feeler emails for jobs that are advertised for CCM only, not Pulmonary consult or outpatient consults. Only of course to get back "Sorry, we are looking for Pulmonary/CCM or people with an IM background".

I just want to get an idea of what you guys/gals think about anesthesiologist in the unit. Clearly many of you think we aren't up to par and/or want to hold on to your territory or there's something else. Ignorance of hospitals and recruiter I believe plays a role. Are there some disease processes/pathology that I am not as familiar with as an IM person? Yes, like some of the immunology/oncology diseases that immediately come to mind. But I can read and familiarize myself with stuff since I didn't get exposed to as much of that as the MICU intensivists.

I guess I am butt hurt for being discriminated against. Our anesthesia department ran the community hospital ICU with the usual bread and butter community admissions which is what is prevalent in the community and the type of jobs I have applied to. It also ran the Neuro ICU. But yet I am told by some of these hospitals that they are looking for someone with IM background AND a Neuro-CCM fellowship. Do these hospitals have any idea how many people, outside of neurology are actually doing a NeuroCCM fellowship?

I have had a few job offers but have gotten more rejections than offers simply because I don't have an IM background. It's quite annoying.

Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.

---

Members don't see this ad.

 

[tartesos]

Haven’t experienced anything like this.
We would hire you if you come to our group with no issues.

 

[DrMetal]

I just want to get an idea of what you guys/gals think about anesthesiologist in the unit.

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

 

[chocomorsel]

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

In what kind of setting have you met these intensivists? In academics or the community?

 

[DrMetal]

In what kind of setting have you met these intensivists? In academics or the community?

Academic and military....admittedly a small crappy ICU. I'm sure there's great anes CC folks out there: I suppose if you had the right fellowship, then strictly practiced CC, you could become great at it. But if you're toggling between the OR (and complex cases) and the ICU, I thinks that's a lot to ask from any one individual. [By contrast, it's easier to ask a general surgeon to do that, because she's probably managing the patient in the SICU for the next 4 days anyway!]

So the people doing the hiring/firing may have the same bias I do. Anyway, at least anes knows how to manage complex airways, sometimes that's half the fight in the ICU.

Neuro-CC, that's a real weird one. I met a neuro-CC fellow who had to go buy a stethoscope, he hadn't used one in 6 years.

 

[chocomorsel]

We had CHF patients who needed intubation, DKA was everyday all day, we had AKI needing dialysis, cirrhotic patients( admittedly not as much as MICU) waiting on livers or OD on Tylenol, all kind of sepsis, COPD/Pneumonia etc. This was an anesthesia run ICU.

I am looking to take care of bread and butter community ICU patients. Not the complex oncology patients with weird syndromes, and those Zebra autoimmune patients besides who end up usually in the big academic ICUs. I did see weird crap in the MICU that I had to go learn about like the cancer stuff. Saw weird stuff in the neuro unit as well.

Anyway, hopefully it changes.

 

[Dr.CCM]

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

I’d say EM is fine in the unit ( I am one). My residency did more ICU months than IM/Surgery/Gas in a 3 year program and my fellowship required a minimum of 18 months exclusively in the ICU (all different types). That’s more than what IM/Pulm/Surgery/Gas requires of their residents who go in into those fellowships pursuing CCM. Honestly I think Anesthesia docs are the best in the unit when the patients are acutely ill. Most detailed oriented in my experience and best at most of the bedside procedures we do in the unit.

 

[deleted697535]

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

Omfg, what did you just say?
Thats probably the most insulting thing ive read this year. Who the f do you think you are.

And im sorry but i wouldnt let an internist like you resuscitate my cat. You guys dont have a bloody clue what you're doing. Cant even put in a peripheral IV. Jesus wept, That is too funny...

Where do you actually work? A barn or something? The breaddddddddth of medicine = DKA and CHF. Wtf? Lololol.

 

[Modanq]

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

This is the most garbage statement I have heard on SDN in a very long time.

Critical care is best practiced by those who have critical care fellowship training. Anesthesia, Neuro, IM, gen surg, EM and then attending experience.
Care is based on a bell curve. There are good doctors and so-so doctors.
Hell this is the exact reason APRNs are infiltrating ICU care. Physician hating on each other. ICU training is one of the areas in medicine that many subspecialties can train in and I think that's excellent for CCM. We all contribute.
If we place arbitrary barriers or assumptions then all the Physicians get cannibalized by bigger issues such as midlevels, reimbursement, insurance companies or CMGs.

In my opinion: examples include-
Rad Onc should be able to do Med Onc fellowships
Med Onc should be able to do Rad Onc fellowships
CT surgery should be able to do interventional cards Fellowships
EM / Anesthesia should be able to match IM fellowships
Just like IM should be able to do Pain or regional or toxicology or ultrasound fellowships
Obviously this should be hashed out by ACGME but we should not shoot ourselves in the foot by cross bickering and limiting training.
There is a bigger threat out there = midlevels, reimbursement, and CMGs.

Anesthesia is not coming for CCM jobs
Midlevels are.

 

[Modanq]

Omfg, what did you just say?
Thats probably the most insulting thing ive read this year. Who the f do you think you are.

And im sorry but i wouldnt let an internist like you resuscitate my cat. You guys dont have a bloody clue what you're doing. Cant even put in a peripheral IV. Jesus wept, That is too funny...

Where do you actually work? A barn or something? The breaddddddddth of medicine = DKA and CHF. Wtf? Lololol.

Agree. What the holy -ish was that statement. Is this person living under a rock to insult anesthesia CCM or even any physician training pathway to CCM.

The question was about seeking jobs...
I think anesthesia CCM is a small cohort and primarily academic. Very closely linked to CT and CCU.
In europe most CCM is initially trained Anesthesiologist.

 

[deleted547339]

Omfg, what did you just say?
Thats probably the most insulting thing ive read this year. Who the f do you think you are.

And im sorry but i wouldnt let an internist like you resuscitate my cat. You guys dont have a bloody clue what you're doing. Cant even put in a peripheral IV. Jesus wept, That is too funny...

Where do you actually work? A barn or something? The breaddddddddth of medicine = DKA and CHF. Wtf? Lololol.

Triggered much?

 

[Kryptonite11]

I totally agree with OPs statement but I think it’s the general culture across bigger hospitals. From what I’ve seen is any IM related CC physicians (Pulm, Nephro, ID) or EM-CC; usually end up in the MICU. If the hospital has a separate SICU than usually the attendings there are surgery CC or AnesthesiaCC or sometimes EM-CC there as well.

I think if you don’t mind working with surgeons than try applying to hospitals with surgical ICUs, I’m sure no one will hesitate to get u onboard. This obviously should not discourage you from applying to any CC job but just my two cents.

Also, one of the smartest attendings I’ve come across during my fellowship was in the SICU, she was AnesthesiaCC trained from northwestern.

 

[jdh71]

Triggered much?

Looked more like rustled jimmies from where I was sitting.

 

[jdh71]

Hey y'all,
Just want to know for any of y'all regular posters who have a part to do with hiring. I have sent out lots of feeler emails for jobs that are advertised for CCM only, not Pulmonary consult or outpatient consults. Only of course to get back "Sorry, we are looking for Pulmonary/CCM or people with an IM background".

I just want to get an idea of what you guys/gals think about anesthesiologist in the unit. Clearly many of you think we aren't up to par and/or want to hold on to your territory or there's something else. Ignorance of hospitals and recruiter I believe plays a role. Are there some disease processes/pathology that I am not as familiar with as an IM person? Yes, like some of the immunology/oncology diseases that immediately come to mind. But I can read and familiarize myself with stuff since I didn't get exposed to as much of that as the MICU intensivists.

I guess I am butt hurt for being discriminated against. Our anesthesia department ran the community hospital ICU with the usual bread and butter community admissions which is what is prevalent in the community and the type of jobs I have applied to. It also ran the Neuro ICU. But yet I am told by some of these hospitals that they are looking for someone with IM background AND a Neuro-CCM fellowship. Do these hospitals have any idea how many people, outside of neurology are actually doing a NeuroCCM fellowship?

I have had a few job offers but have gotten more rejections than offers simply because I don't have an IM background. It's quite annoying.

Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.

Critical care and ICUs after being staffed largely by plum/cc for the last three to four decades is obviously evolving but I assume there may be some perceptions and biases that have not yet kept up with the newer landscape. There isn’t much we can do about that currently and I’m sorry you got told not interested by a few places. It is what it currently is.

The neuro cc certification stuff is becoming a much bigger deal. I do a lot of it myself as well but not enough to grandfather based on practice pattern and I’m definitely not going back to fellowship. There will be a day coming soon where if you want the tip top hospital rating in stroke you will need to have a neuro cc *certified* neuro Intensivist. More of that evolution.

 

[chocomorsel]

@Newtwo and @Modanq, yes that response was insulting. I was trying to stay civil and not get too miffed. However I did laugh at the "breadth of medicine like ….bad DKA and CHF". Like couldn't you come with better, more complicated examples?
Like I say they things they see that we don't tend to see in the surgical units are the weird oncology/immunology stuff and we see plenty of solid organ CAs because those get resected. I think a lot of the weird zebras that can't be improved/figured out get shipped out to the Ivory towers or larger hospitals anyways.

But because I was trying to be a little more diplomatic and less defensive to keep the conversation going, I didn't react.
Yes, it is insulting to imply that we don't know how to treat CHF and DKA. But maybe the guy/gal has run across some seriously bad doctors out there.

I am not looking to work in hospitals with >400 beds and mostly looking at your regular bread and butter community ICU which is what we ran where I trained for fellowship. And we also ran the neuro ICUs as well.

Anwyay, keep it coming.

 

[jdh71]

Can anesthesia critical care even take care of septic shock?????

 

[kjamess]

Can anesthesia critical care even take care of septic shock?????

propofol should do the trick

 

[psychbender]

In Dr Metal's defence, military medicine is a really small world, and I think there are only about six anesthesia-trained intensivists in the entire DoD. It could be that the one that he encountered just isn't that great, likely as a result of years of skill atrophy. The loss of VA referrals killed my old hospital's acuity, as they mostly ended up just taking care of active duty younger retirees. It may be that this person just hadn't seen anything other than a routine post-op heart, Whipple, SBO, etc in years.

 

[spacegun]

Hey y'all,
Just want to know for any of y'all regular posters who have a part to do with hiring. I have sent out lots of feeler emails for jobs that are advertised for CCM only, not Pulmonary consult or outpatient consults. Only of course to get back "Sorry, we are looking for Pulmonary/CCM or people with an IM background".

I just want to get an idea of what you guys/gals think about anesthesiologist in the unit. Clearly many of you think we aren't up to par and/or want to hold on to your territory or there's something else. Ignorance of hospitals and recruiter I believe plays a role. Are there some disease processes/pathology that I am not as familiar with as an IM person? Yes, like some of the immunology/oncology diseases that immediately come to mind. But I can read and familiarize myself with stuff since I didn't get exposed to as much of that as the MICU intensivists.

I guess I am butt hurt for being discriminated against. Our anesthesia department ran the community hospital ICU with the usual bread and butter community admissions which is what is prevalent in the community and the type of jobs I have applied to. It also ran the Neuro ICU. But yet I am told by some of these hospitals that they are looking for someone with IM background AND a Neuro-CCM fellowship. Do these hospitals have any idea how many people, outside of neurology are actually doing a NeuroCCM fellowship?

I have had a few job offers but have gotten more rejections than offers simply because I don't have an IM background. It's quite annoying.

Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.

@Newtwo and @Modanq, yes that response was insulting. I was trying to stay civil and not get too miffed. However I did laugh at the "breadth of medicine like ….bad DKA and CHF". Like couldn't you come with better, more complicated examples?
Like I say they things they see that we don't tend to see in the surgical units are the weird oncology/immunology stuff and we see plenty of solid organ CAs because those get resected. I think a lot of the weird zebras that can't be improved/figured out get shipped out to the Ivory towers or larger hospitals anyways.

But because I was trying to be a little more diplomatic and less defensive to keep the conversation going, I didn't react.
Yes, it is insulting to imply that we don't know how to treat CHF and DKA. But maybe the guy/gal has run across some seriously bad doctors out there.

I am not looking to work in hospitals with >400 beds and mostly looking at your regular bread and butter community ICU which is what we ran where I trained for fellowship. And we also ran the neuro ICUs as well.

Anwyay, keep it coming.

I don’t agree with what @DrMetal said, but to be fair you did ask people: “Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.” We don’t have to agree with @DrMetal, but he or she did give their “honest responses” about “bad experiences” they had. Nothing wrong with that. They have a right to their opinion, which you asked for, even though it turned out to be a disagreeable or debatable opinion.

 

[Siggy]

I’d say EM is fine in the unit ( I am one). My residency did more ICU months than IM/Surgery/Gas in a 3 year program and my fellowship required a minimum of 18 months exclusively in the ICU (all different types). That’s more than what IM/Pulm/Surgery/Gas requires of their residents who go in into those fellowships pursuing CCM. Honestly I think Anesthesia docs are the best in the unit when the patients are acutely ill. Most detailed oriented in my experience and best at most of the bedside procedures we do in the unit.

Strange. I did 3 months of CCM during residency, during my IM months I always had at least a few critical care patients that I worked directly with the intensivist to manage, and my fellowship is 24 straight months of CCM.

So... tell me again how much better your preperation is when the EM residency associated with my IM residency (different hospital, same consortium) couldn't even do theraputic hypothermia and the ED physicians at my fellowship hospital don't remember how to float transvenous pacemakers.

 

[Dr.CCM]

Strange. I did 3 months of CCM during residency, during my IM months I always had at least a few critical care patients that I worked directly with the intensivist to manage, and my fellowship is 24 straight months of CCM.

So... tell me again how much better your preperation is when the EM residency associated with my IM residency (different hospital, same consortium) couldn't even do theraputic hypothermia and the ED physicians at my fellowship hospital don't remember how to float transvenous pacemakers.

Didn’t say it was better. I’m saying EM/CC docs are definitely capable in the unit. The poster in question said only surgeons and internists should be in the unit. I’m saying based on the ACGME requirements IM/CC only has to have 12 months CC. Surgery 9 months and Anesthesia 9 months. I think if you do Pulm/CC it only has to be 9 months minimum right? If you do EM and go through Anesthesia you have to do a minimum of 18 months in the unit in fellowship alone and most EM programs do at least 5-6 months in the unit now, minimum is 4 I think. I’m sure most of fellows in the above pathways do more (surgery and anesthesia can’t really do more than 12 during their fellowship). Also there’s a difference between “working with the the Intensivist on a few patients” than being in the unit while on service responsible for 20+ patients, I’m sure you’d agree.

 

[chocomorsel]

I don’t agree with what @DrMetal said, but to be fair you did ask people: “Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.” We don’t have to agree with @DrMetal, but he or she did give their “honest responses” about “bad experiences” they had. Nothing wrong with that. They have a right to their opinion, which you asked for, even though it turned out to be a disagreeable or debatable opinion.

Exactly. And that is why I didn’t get defensive like I already stated. I want honest opinions and am keeping it diplomatic.

 

[chocomorsel]

I certainly hope Pulm CCM does more than just 9 months minimum in the unit. I mean it is a total of 36. Would hope it would be evenly divided between the two subspecilaties with maybe a couple of months of research.
Amyway, I have never floated a pacemaker myself. Let me you tube that. Is it like floating a Swan?

 

[Siggy]

I certainly hope Pulm CCM does more than just 9 months minimum in the unit. I mean it is a total of 36. Would hope it would be evenly divided between the two subspecilaties with maybe a couple of months of research.
Amyway, I have never floated a pacemaker myself. Let me you tube that. Is it like floating a Swan?

Basically. Place introducer, go in about 15 cm, set pacer to VVI, desired rate, 15-20mA, inflate balloon, advance until capture, deflate balloon, titrate down mAmps.

 

[grt398]

I certainly hope Pulm CCM does more than just 9 months minimum in the unit. I mean it is a total of 36. Would hope it would be evenly divided between the two subspecilaties with maybe a couple of months of research.
Amyway, I have never floated a pacemaker myself. Let me you tube that. Is it like floating a Swan?

Many PCCM programs (particularly at bigger name places) are actually 18 months mandatory research/18 months clinical time. The clinical time split b/w pulm rotations and CCM rotations (mostly MICU) can vary quite a bit by program. If interested you'll see some discussion here b/c people with clinical interests have to be careful about which programs they choose:

Academic programs with strong clinical training??

I'm applying to pulm/ccm and, as of now, I have minimal interest in joining the grant-application rat race of a research career and mainly want to be a good clinician. However, I am learning that many ‘top’ pccm programs seem to have poor clinical training. While getting strong clinical...

forums.studentdoctor.net

 

[Dr.CCM]

I certainly hope Pulm CCM does more than just 9 months minimum in the unit. I mean it is a total of 36. Would hope it would be evenly divided between the two subspecilaties with maybe a couple of months of research.
Amyway, I have never floated a pacemaker myself. Let me you tube that. Is it like floating a Swan?

If you can float a swan, you can float a pacer I bet pretty easily even if you haven’t done one just YouTube it. The skill set is very transferable for you. I did them in the ER in residency and did them in fellowship. In the private world, at least in my CC group, we now would just call interventional cards at least that’s what my partners say they do. I’d still do one in a pinch though and feel comfortable with it but I’m out recently if I didn’t do one for like 5 years I’d prob let cards do it unless they are unavailable. It isn’t one of the more common things we do. Anyone have ways they like to remain competent in the more rare procedures like this? Stuff like crics also comes to mind.

 

[DrMetal]

I don’t agree with what @DrMetal said, but to be fair you did ask people: “Would love to hear some HONEST responses please.

I was just being honest. Truthfully, I don't know that I even agree all that much with what I said, but I was just trying to point out the bias that exists.

And judging by some of the reactions above, that bias (for more medicine and surgical trained CC) does indeed exist and has been felt by others. The OP encountered it. At heart, I think it is a stupid bias, any physician well trained in CC should be allowed to do it, and I'd much prefer a EM- Anes- whatever have you- CC physician than a mid-level.

I do worry though that we may be allowing "too many chefs in the kitchen" when it comes to critical care.

but i wouldnt let an internist like you resuscitate my cat.

That's just as well, I wouldn't try very hard. I'm more of a dog person.

 

[DrGasPasser]

It’s probably a little more complicated than that at many programs. The research time is often not completely protected. Follows still have pulm clinic during research months as well as occasional night float ICU responsibilities.

However, your larger point is very valid. EM trained intensivists arrive at their fellowship very well prepared to succeed and leave in a great position to be leaders in the field if they apply themselves - just like any other fellow.
Z

Many PCCM programs (particularly at bigger name places) are actually 18 months mandatory research/18 months clinical time. The clinical time split b/w pulm rotations and CCM rotations (mostly MICU) can vary quite a bit by program. If interested you'll see some discussion here b/c people with clinical interests have to be careful about which programs they choose:

Academic programs with strong clinical training??

I'm applying to pulm/ccm and, as of now, I have minimal interest in joining the grant-application rat race of a research career and mainly want to be a good clinician. However, I am learning that many ‘top’ pccm programs seem to have poor clinical training. While getting strong clinical...

forums.studentdoctor.net

 

[chocomorsel]

@DrMetal, which chefs should be in the kitchen?

 

[jdh71]

I certainly hope Pulm CCM does more than just 9 months minimum in the unit. I mean it is a total of 36. Would hope it would be evenly divided between the two subspecilaties with maybe a couple of months of research.
Amyway, I have never floated a pacemaker myself. Let me you tube that. Is it like floating a Swan?

I had a research heavy fellowship. 18 months giving knock out mice bacterial pneumonia (if I get much more specific than that you will probably be able to easily find me out with some basic search terms in the pubmed). We only had “9 months” as the main ICU fellow. I don’t suck too bad, I don’t think. We did still have pretty aggressive home call schedules throughout the entire fellowship, an in-house moonlighting at one location (get paid to be the admitting and rounding fellow), and plenty of VA ED moonlighting in a busy VA ED. Two year fellowships might be overkill to be honest. More is better to a point in training it seems from my perspective; after that you seem to level out.

 

[jdh71]

I was just being honest. Truthfully, I don't know that I even agree all that much with what I said, but I was just trying to point out the bias that exists.

And judging by some of the reactions above, that bias (for more medicine and surgical trained CC) does indeed exist and has been felt by others. The OP encountered it. At heart, I think it is a stupid bias, any physician well trained in CC should be allowed to do it, and I'd much prefer a EM- Anes- whatever have you- CC physician than a mid-level.

I do worry though that we may be allowing "too many chefs in the kitchen" when it comes to critical care.



That's just as well, I wouldn't try very hard. I'm more of a dog person.

 

[chocomorsel]

I had a research heavy fellowship. 18 months giving knock out mice bacterial pneumonia (if I get much more specific than that you will probably be able to easily find me out with some basic search terms in the pubmed). We only had “9 months” as the main ICU fellow. I don’t suck too bad, I don’t think. We did still have pretty aggressive home call schedules throughout the entire fellowship, an in-house moonlighting at one location (get paid to be the admitting and rounding fellow), and plenty of VA ED moonlighting in a busy VA ED. Two year fellowships might be overkill to be honest. More is better to a point in training it seems from my perspective; after that you seem to level out.

Is that the norm? Is that what you guys prefer? Are most pulm CCM docs doing research after fellowship? Maybe you are right. It may be too long a fellowship.

 

[jdh71]

Is that the norm? Is that what you guys prefer? Are most pulm CCM docs doing research after fellowship? Maybe you are right. It may be too long a fellowship.

It’s the norm at any “big name” academic PCCM program (or those that try to fancy themselves that way - heh).

Preferences are personal. And based around what you want or think you want to do. I wanted to be a physician scientist until I realized it was a snake pit complete with Machiavellian style politics in the pool of assistant and associate professors trying to carve out space and time and money and advancement.

Where I did residency the PCCM fellows had the minimum amount of research time and just spent their time rotating between locations in pulmonary and icu until they were done.

I’d say the vast majority of places I interviewed were somewhere in between. Probably 9 months of protected research time second year and IF productive or you were very interested with a suitable project they could find you more time for research in your third year, maybe 3 to 6 more months.

First year everywhere is usually pretty brutal. Lots of ICU, in patient pulmonary consults, and call every other night and every other full weekend for the ICU. Probably not too much different than most critical care only fellowships.

 

[gulmohr]

I had a research heavy fellowship. 18 months giving knock out mice bacterial pneumonia (if I get much more specific than that you will probably be able to easily find me out with some basic search terms in the pubmed). We only had “9 months” as the main ICU fellow. I don’t suck too bad, I don’t think. We did still have pretty aggressive home call schedules throughout the entire fellowship, an in-house moonlighting at one location (get paid to be the admitting and rounding fellow), and plenty of VA ED moonlighting in a busy VA ED. Two year fellowships might be overkill to be honest. More is better to a point in training it seems from my perspective; after that you seem to level out.

In terms of clinical exposure, how important would you say is experience with transplant and ECMO during fellowship? How many airways and vascular procedures should one be looking to have done at the end of one's training?

 

[jdh71]

In terms of clinical exposure, how important would you say is experience with transplant and ECMO during fellowship? How many airways and vascular procedures should one be looking to have done at the end of one's training?

ECMO is getting more widely used and is pretty simple and straightforward with the VV set ups. VA can be a bit of a different beast. But I think ECMO exposure is important.

Transplant exposure is relatively important. You likely won’t see a huge amount of these patients in the community but some familiarity with their medications and possible infectious or neoplastic issues can only help your reflexes.

I think do as many supervised airways as you possibly can during training. You need to see complicated ones abs how those better than you handled them. Thankfully most airways are relatively straightforward (though I still get a little nervous with every single one). It’s not the easy ones you are training for. I don’t know how to put a number on that to be honest. I mean a bare minimum starting number might be like 30?

Same basic point with vascular access to a point as it’s not quite as critical/life and death and I think after you’ve done 100-150 you have all you really need to think your way around complicated vascular cases.

 

[deleted547339]

I felt comfortable with airways around 100. Around 300 I felt like that if I can’t get it, it’s unlikely someone else can.

Ecmo isn’t hard. They bleed and clot. They chatter and they get infected.

CCM is tough. I did 2 years of basically full time CCM in fellowship (I’m EM). I felt like 12 months was definitely not enough time to learn Critical Care. I felt like 2 years was too much. I think i was ready for independent practice around the 18 month mark.

I did worry about my surgical and anesthesia colleagues after only a year. It’s hard to learn the vent and crrt circuit and feeding and antibiotics and fungal infections and palliative care and family dynamics and neuro and ecmo and....you get the point in 12 months, 9 of them in the icu.

 

[Siggy]

I'm going to go off on a tangent, but what I find interesting in this discussion is how little it seems most critical care fellows are actually in the ICU. At my program we spend all 24 months in the ICU. No research months. No elective months. The only month not in the ICU at our hospital... is the month doing trauma at one of the local level 1 trauma centers.

Are there really a significant number of stand alone critical care programs where critical care fellows are only getting 12 months of ICU?

 

[grt398]

FWIW, here's the curriculum from UW's 2 year critical care fellowship:

Critical Care Fellowship | Division of Pulmonary, Critical Care, & Sleep Medicine

pulmccsm.uw.edu

They pulled out of the process this year but their split is 13 months mandatory ICU time/9 months elective time + presumably some vacation. Another common split seems to be 15-18 months ICU time/3-6 months elective + vacation time. I didn't come across many programs that were 24 months ICU only.

 

[Dr.CCM]

I felt comfortable with airways around 100. Around 300 I felt like that if I can’t get it, it’s unlikely someone else can.

Ecmo isn’t hard. They bleed and clot. They chatter and they get infected.

CCM is tough. I did 2 years of basically full time CCM in fellowship (I’m EM). I felt like 12 months was definitely not enough time to learn Critical Care. I felt like 2 years was too much. I think i was ready for independent practice around the 18 month mark.

I did worry about my surgical and anesthesia colleagues after only a year. It’s hard to learn the vent and crrt circuit and feeding and antibiotics and fungal infections and palliative care and family dynamics and neuro and ecmo and....you get the point in 12 months, 9 of them in the icu.

I agree with you but maybe us EM people need a little more marinating than the rest of
the specialities...

 

[deleted547339]

I'm going to go off on a tangent, but what I find interesting in this discussion is how little it seems most critical care fellows are actually in the ICU. At my program we spend all 24 months in the ICU. No research months. No elective months. The only month not in the ICU at our hospital... is the month doing trauma at one of the local level 1 trauma centers.

Are there really a significant number of stand alone critical care programs where critical care fellows are only getting 12 months of ICU?

I went to a similar program (maybe the same one?). It was rough, but I feel competent.

 

[Hamhock]

I am EM-CCM now working part-time at a community hospital with a mixed ICU (although most would call it a MICU 80/20).

A qualified cardiac-CCM anesthesiologist was interested in joining our group. The anesthesiology group was really recruiting him; mostly because he would support the cardiac program perfectly. However, the CCM director immediately dismissed the candidate when I presented the idea.

I am not sure why, TBH. This is a community ICU where all sick transplant, oncology (all acute leukemias, for example), and even complex poly-trauma (mostly due to pelvic fractures) are transferred out. I suspect the cardiac-CCM anesthesiologist would be able to become an equal, but the director was certain this would not work.

I find it particularly interesting since I was hired as an EM-CCM grad (granted from a big name fellowship and with lots of MICU experience backed by IM/Pulm-CCM docs) very early in the natural history of EM-CCM and I joined a very traditional PulmCCM-dominated group. So, the director is not completely closed-minded.

There is something there. I just don't know what it is.

The discrimination exists. Unfortunately, I can not offer any clarifying insight. Just my experience/example.

That said, in my experience, the CCM-anesthesiologists I have worked with have been very SICU-oriented. They are acute resuscitationists (almost a blend between a CCM-surgeon and CCM-EM doc), but they do seem to loose interest in such things as hyperglycemia, appropriate anti-microbial use, and most IM topics that are't acute. Of couse, this was a concern with accepting EM-CCM folks into the world of IM and the MICU.

I get it. I just can't explain it. I guess this post is just a free-flow of my thoughts; most likely to be helpful to me...but maybe it will help someone else or generate new perspectives.

Would anesthesiologists benefit from participating in multi-disciplinary CCM training programs? [obviously yes; like all of us]

Should anesthesiology-CCM programs become 1+ years? [I hear TimesNewRoman: 24 month are excessive but 9 are inadequate}

Would we not all benefit form the transition to multi-disciplinary CCM training? There is no reason that CCM should be so tightly associated with Pulmonolgy (yes, I know the history). All anesthesiology, EM, IM, and surgery grads should be competing for the same CCM spots. The fellowship should be fully multi-disciplinary. We should all do the same number of ICU months in fellowship. We all have lots of deficiencies based on our backgrounds.

HH

 

[chocomorsel]

@Hamhock agree with your thoughts, especially your last paragraph wholeheartedly. Where I trained we ran the SICU, MICU and smaller hospital mixed unit. We did an elective in the MICU at the large hospital. I found it very interesting. Lots of zebras.

The pulmonologists though Never left the MICU for any other unit. But someone like them gets preference over someone like me. I mean people were doing two week stints in Neuro if they got a job covering the NICU and no one ever did SICU but yet, they get preference.

Yes, I am a little whiny about it, but I do have a job thankfully.

Just interesting to see all those places that turned me down, in not the best locations still looking when they turned me down. I think people honestly look down on us and we are mainly associated with being “resus” docs. But plenty of us are interested in more than just SICU medicine.

Did your director give you a reason why he rejected the candidate?

 

[Gastrapathy]

Any place with an IM residency will need IM-trained CC MDs to supervise the residents.

We understand and trust the process we went through.

 

[psychbender]

We understand and trust the process we went through.

I think this is a big part of the bias. Simply due to sheer numbers, most directors are Pulm/CC, so understand the pathway and assume a general level of knowledge and competence for other Pulm/CC. While there are programs where the Pulm/CC folk never leave the MICU, and may never see a post-surgical patient, I'd wager most have more broad based training, and those in the position to hire figure that if one can handle the MICU, one can handle the other units. The reverse is not always the case, and there are plenty of anesthesiology-CC programs that have no MICU rotations, and only see post-surgicals of one form or another. In their own training, maybe the CVICU and SICU were almost entirely surgeon-driven, with the intensivist just managing the vent, and they think that's all the anesthesiologists were doing. Or, some of the rejections may be coming from a secretary doing the screening that didn't realize that there are other training pathways, and is just flat out rejecting anyone without an IM background. I had a voicemail from one community hospital rejecting my application because they "are only interested in applicants with critical care training." I called them back to let them know that I actually am fellowship-trained and board certified, but they never called back.

 

[chocomorsel]

Any place with an IM residency will need IM-trained CC MDs to supervise the residents.

We understand and trust the process we went through.

I am not looking for or at those places specifically for that reason. Because I know how you all are about your training and who the ABIM or whoever are about training residents.
Whatever the case the place I will be working will have some IM residents at times. Wasn’t what I was looking for but what I found. And my boyfriend is teaching IM residents. He must be doing a shoddy job.
Like I said, bread and butter community ICU.

 

[Gastrapathy]

There’s lots that those residents can learn from you. To be clear, I wasn’t saying it makes sense and I promise I hate the ABIM 1000x more than you do

 

[chocomorsel]

There’s lots that those residents can learn from you. To be clear, I wasn’t saying it makes sense and I promise I hate the ABIM 1000x more than you do

Sorry if I did get defensive. But I know how the ABIM is and stay away from any known community places with IM residents. EM and FM residencies don't seem to care who's the attending though. I also avoid contacting places that specify that they need someone who does pulmonary floor consults or outpatient work. Although most of the ads say "Pulmonary/CCM" when you read the description of the job you can tell who needs pulmonologists and who doesn't. But even then, I often get, "Sorry, we are only looking for pulmonary/CCM" and when I ask specifically why I never get a response when I explain that I can do Intensive Care just like a Pulm/CCM does intensive care, I get told "We are looking for Pulm/CCM and aren't changing that anytime soon". For real.

Oh well, I have a pretty good job lined up with good pay, so I guess I should just let it go. I find it that most ignorant recruiters are not open to learning about anesthesia CCM although I have found a couple that were receptive. Didn't lead anywhere, but at least they gave me a chance to explain. Many times, they immediately want to push me off to the anesthesia department even when I tell them that I am not looking for OR work.

Ehh...

 

[Vermicious Knid]

I find this thread hilariously inaccurate, although that is probably because I am practicing in a country where intensivists are primarily from an anesthesia background (although those from medicine/EM background are increasing in numbers_
Most places in Europe have intensivists from an anesthesia background, and they are not practicing at a 'lower level' than those in the USA. Training structure and the ICU set up appears to be different too. In the UK for example there arent typically separate MICUs and SICUS (rather a combined medical/surgical ICU) so perhaps all intensive care trainees are necessarily exposed to a wide variety of medical AND surgical pathology. Training time is much longer as well in the UK (with at least a mandatory year in medicine if coming from a non internal medicine background) as intensive care is a 4-5 year fellowship after core training. Perhaps things are much different in the USA...

 

[aafisahar]

I find this thread hilariously inaccurate, although that is probably because I am practicing in a country where intensivists are primarily from an anesthesia background (although those from medicine/EM background are increasing in numbers_
Most places in Europe have intensivists from an anesthesia background, and they are not practicing at a 'lower level' than those in the USA. Training structure and the ICU set up appears to be different too. In the UK for example there arent typically separate MICUs and SICUS (rather a combined medical/surgical ICU) so perhaps all intensive care trainees are necessarily exposed to a wide variety of medical AND surgical pathology. Training time is much longer as well in the UK (with at least a mandatory year in medicine if coming from a non internal medicine background) as intensive care is a 4-5 year fellowship after core training. Perhaps things are much different in the USA...

The unit is a different beast in Europe. They aren't giving 80 year olds 7+3 for AML like we do in America. They are tubing, traching, and pegging 90 year old gomers. They aren't admitting moribound patients to hang out on the vent and CRRT for 5 days while the family prays to Jesus hoping for a miracle.

 

[chocomorsel]

I find this thread hilariously inaccurate, although that is probably because I am practicing in a country where intensivists are primarily from an anesthesia background (although those from medicine/EM background are increasing in numbers_
Most places in Europe have intensivists from an anesthesia background, and they are not practicing at a 'lower level' than those in the USA. Training structure and the ICU set up appears to be different too. In the UK for example there arent typically separate MICUs and SICUS (rather a combined medical/surgical ICU) so perhaps all intensive care trainees are necessarily exposed to a wide variety of medical AND surgical pathology. Training time is much longer as well in the UK (with at least a mandatory year in medicine if coming from a non internal medicine background) as intensive care is a 4-5 year fellowship after core training. Perhaps things are much different in the USA...

Yes they are. We are the USA. We are always striving to be different. Not necessarily better IMO. But we gotta be different.
So this is “hilariously innacurate” for you precisely because you are in Europe. Not here. Fellowship here for straight CCM is 2 years max.