dual applying, Anesthesia/IM dual residency

[NicMouse64]

Hello all. I am currently applying to residency and all I really know is I really enjoy the ICU. I did back-to-back ICU rotations (Medical, then surgical) for 8 weeks and loved both of my rotations. I am dual applying anesthesia and IM and have equal numbers of interviews in each specialty, but I also have been lucky to receive an invite to IM/Anesthesia combined program. There are aspects to each specialty that I like/dislike. I would like to think that IM/Anesthesia->Anesthesia/ccm fellowship will end up in the most well-rounded training but would like to hear what others have to say. COPD/Pulm consults seem somewhat boring but I can see it being a good escape later in my career. With IM training I suppose having a primary care or post-hospitalization clinic would be an option that only Anesthesia wouldn't allow to escape the ICU.

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[jdh71]

Boring?! Knowing you have a diagnosis and a plan before walking into the room?! I'll take a FULL day of COPD. Don't let them stop.

You're probably getting ahead of yourself though. Even if you did medicine you wouldn't need to do any Pulmonary to do a CCM fellowship and work CCM in the future.

 

[NicMouse64]

Boring?! Knowing you have a diagnosis and a plan before walking into the room?! I'll take a FULL day of COPD. Don't let them stop.

You're probably getting ahead of yourself though. Even if you did medicine you wouldn't need to do any Pulmonary to do a CCM fellowship and work CCM in the future.

The main thing that worries about me with the IM path is the increasing competitiveness of the fellowship. If I went IM only, I would certainly do the pulm/cc route. I also really enjoy procedures, and have seen that the Medical ICU attendings aren't quite as comfortable with intubating as the anesthesia CCM attendings.

 

[jdh71]

The main thing that worries about me with the IM path is the increasing competitiveness of the fellowship. If I went IM only, I would certainly do the pulm/cc route. I also really enjoy procedures, and have seen that the Medical ICU attendings aren't quite as comfortable with intubating as the anesthesia CCM attendings.

A lot of that has to do with the ivory tower. Of course anesthesia will probably always be more comfortable with intubation as that's way inside their wheelhouse on any given day in training and practice it's lots of tubes, usually in the context of the OR but still. I remember being in training and watching the 3rd year anesthesia residents come for all of the in hospital intubations and at some places the EM residents would come up and do the intubations. I remember the MICU academics largely being uncomfortable with intubations. So I do understand your calculus. But critical care is NOT "doing things to people" so I might humbly suggest when it comes time worry about the path that will get you best training, you feel, will lead you to having the best management of critically ill people getting them from admit to transfer or discharge. Critical care is the art of the MANAGEMENT of the critically ill, often within the context of their multiple chronic medical conditions and medications all playing and interacting. Intubations you can learn and get better at regardless of pathway. Leaving yourself some open options like a double residency is very interesting. I wouldn't overthink it too much. You'll turn out fine either way.

 

[Tipsy McStagger]

Anesthesia gets more airway experience in their residency than anybody else. This is why they're more comfortable, but that doesn't equate to incompetence in the MICU attendings. You could say the inverse about bronchoscopy, where PCCM is generally superior. The truth is that no matter the route, all critical care physicians are going to be competent managers of airways (unless you stay in academics where the fellows/residents do everything).

I think what you should think of is (if the ICU is where you want to be) what population of patients are you most interested in? If medical, then do PCCM. If surgical, then you either do surgery or anesthesia and CC from there. Now it is true that in the community you can work in multidisciplinary ICUs, but I still think it's prudent to train for the ICU that you are most likely going to spend time in. If you don't want to do only ICU work then I suppose the next step would be to consider what job you could envision doing? Like the OR - anesthesia. Hate the OR - medicine / EM (I don't recommend EM).

I'm EM/CCM trained. To do it all over again I think I'd do IM/PCCM. Procedural competency you will achieve anywhere, then it's just a matter of where to apply your skillset.

 

[NicMouse64]

A lot of that has to do with the ivory tower. Of course anesthesia will probably always be more comfortable with intubation as that's way inside their wheelhouse on any given day in training and practice it's lots of tubes, usually in the context of the OR but still. I remember being in training and watching the 3rd year anesthesia residents come for all of the in hospital intubations and at some places the EM residents would come up and do the intubations. I remember the MICU academics largely being uncomfortable with intubations. So I do understand your calculus. But critical care is NOT "doing things to people" so I might humbly suggest when it comes time worry about the path that will get you best training, you feel, will lead you to having the best management of critically ill people getting them from admit to transfer or discharge. Critical care is the art of the MANAGEMENT of the critically ill, often within the context of their multiple chronic medical conditions and medications all playing and interacting. Intubations you can learn and get better at regardless of pathway. Leaving yourself some open options like a double residency is very interesting. I wouldn't overthink it too much. You'll turn out fine either way.

I definitely agree with you in regards to the experience being skewed by the academics side of things. It's good to hear that procedural competency can be learned in PCCM path as well. I guess I just think it would be cool to be dual trained and do ICU training after that, but ultimately probably a waste of 2 years of my life.

 

[jdh71]

I definitely agree with you in regards to the experience being skewed by the academics side of things. It's good to hear that procedural competency can be learned in PCCM path as well. I guess I just think it would be cool to be dual trained and do ICU training after that, but ultimately probably a waste of 2 years of my life.

Opportunity costs to consider as well for sure.

 

[Colorado outliers]

Hello all. I am currently applying to residency and all I really know is I really enjoy the ICU. I did back-to-back ICU rotations (Medical, then surgical) for 8 weeks and loved both of my rotations. I am dual applying anesthesia and IM and have equal numbers of interviews in each specialty, but I also have been lucky to receive an invite to IM/Anesthesia combined program. There are aspects to each specialty that I like/dislike. I would like to think that IM/Anesthesia->Anesthesia/ccm fellowship will end up in the most well-rounded training but would like to hear what others have to say. COPD/Pulm consults seem somewhat boring but I can see it being a good escape later in my career. With IM training I suppose having a primary care or post-hospitalization clinic would be an option that only Anesthesia wouldn't allow to escape the ICU.

A lot of residents and medical student 'love' the ICU and find clinic boring, but this can change when you're a fellow or attending and you have a more sophisticated understanding of medicine. Some of the most fascinating cases I see these days are pulm consults or outpatients. Also see some boring ones but honestly that's nice sometimes.

I work at a large academic center - our pulm-CCM and IM-CCM fellows easily get 200 tubes a year. But they'll never be as good as anesthesiologists at intubating. Pulm-CCM trained fellows here are just as good at central lines, chest tubes (surgical and seldinger) as other fellows. Pulm-CCM fellows will always be better with a bronch. Interventional pulm/ICU is a popular combo for those who like procedures and ICU. Pulm-CCM docs are rather adept at vents and have a better understanding of respiratory physiology, IMO although you can certainly learn this on your own.

What I would ask yourself is, do you want to be 50 yrs old and working mostly ICU shifts? For me the answer was definitely no.

 

[CCM-MD]

IMO. The way things are currently, Pulm-CCM is the best pathway to become an intensivist in the United States. And this is coming from someone who is not pulmonary trained (I am IM/CCM, no pulm). Pulm CCM will give you the most employment opportunities and a good way to bow out of the unit as you age. Obviously if you don’t like pulmonary medicine, like myself, you can opt to do CCM by itself after IM also.

All pathways will allow you to become competent in common ICU procedures like lines and tubes. I wouldn’t worry about that. Less common procedures like trachs, PEGs, cannulating for ECMO will vary from institution to institution. As IM/CCM I do my own perc trachs and I’ve cannulated for VV ECMO.

I suggest against dual residency training in IM and anesthesia. Pick one and save the years.

 

[Katheudontas parateroumen]

I would also say that if one is even suggesting they'd be interested in medicine, forego the anesthesia training if you're interested in ICU. Save yourself the years. Pulm/CC works in both med and surg settings. As an anesthesia CCM fellow now, the things I need to catch up on are all medical/diagnostic management related which in my opinion takes much more time to learn than procedural skill. Of course, I still bring a lot of comfort with sedation, pressors, vents, airway, echo, pushing my own meds, setting up my own pumps, making my own drips, etc than the majority of attendings who aren't anesthesia trained (that's what drew me into anesthesia as a med student). Each pathway you take brings its strengths/weaknesses so our biases are strong. However, as an anesthesia fellow now, I can see ICU is a team sport and you really can't do that alone for all 10+ pts you're seeing. And apart from the initial stabilization/resuscitation; that's the crux of good ICU medicine is.

 

[chessknt]

To echo the above the procedural part should not be a concern. IM->CCM offers the most widely accepted route right now but things are changing and all CCM boarded people are being considered whereas in the past it was only pulm/ccm. Some CTICU centers will only want anesthesia/CCM people but that is an easy pass because CT surgeons are the most difficult group of doctors to work with in all of medicine.

 

[step213]

I did the dual residency at Stanford - fell in love with cardiac, did a cardiac anesthesia fellowship followed by a CCM fellowship (only 2 years total). i have the sweetest gig a PP in the bay area doing CV anesthesia and CVICU. The micu here said they'd love to get me involved but with all the ECMO from covid i've been pretty busy in the CVICU. I would do it again - it made my CCM fellowship experience "easier" (probably the wrong term to describe it but CCM was a breeze) but it is opportunity cost (1 extra year) that you need to decide if its worth it. Jobs are super plentiful with great pay and i live in what is considered a very "competitive market" area.

 

[chocomorsel]

I did the dual residency at Stanford - fell in love with cardiac, did a cardiac anesthesia fellowship followed by a CCM fellowship (only 2 years total). i have the sweetest gig a PP in the bay area doing CV anesthesia and CVICU. The micu here said they'd love to get me involved but with all the ECMO from covid i've been pretty busy in the CVICU. I would do it again - it made my CCM fellowship experience "easier" (probably the wrong term to describe it but CCM was a breeze) but it is opportunity cost (1 extra year) that you need to decide if its worth it. Jobs are super plentiful with great pay and i live in what is considered a very "competitive market" area.

How long is dual training in IM anesthesia?

 

[NicMouse64]

How long is dual training in IM anesthesia?

5 years

 

[chocomorsel]

5 years

So this person trained for seven years? I hope he is is banking some serious money.