EM->Critical care fellowship vs IM->CC/PCCM

[okudasai]

Hello all,

This is an extremely common story, but I am a M3 going into M4 who was, until the ACEP jobs report, very much set on EM. I am also interested in critical care as an alternative to EM. With regards to things I like about the ED, I think I would miss the workup of the undifferentiated patient, patient conversations and reassuring patients/families, and the initial stabilization that you are able to do in the ED, but am hoping that some of those aspects are present in critical care as well. Would love to hear from folks what similarities and differences there are in general between EM and CC. Here are some other questions I had:

1 - I was wondering what the competitiveness of critical care fellowships were for EM grads; my current understanding is that they are more competitive since there are less CC only fellowships, but not impossible to get into.

2 - In addition, what does the job market look like for EM/CC people? Is it reasonable to expect to be able to work in a metropolitan area without being PCCM certified?

3 - Finally, I was considering doing IM and then a PCCM or CC fellowship afterwards. However, I would very much like to avoid working in an outpatient setting, and was wondering if I did do PCCM, if I could work soley in the ICU and avoid pulm clinic. I also heard that if you are PCCM and are on a 1 week on 1 week off schedule, then you would have to spend your week off from the ICU doing clinic, which I would not enjoy very much; would like to get clarification on this if possible.

Thanks in advance for any and all advice!

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[NITRAS]

You can find ICU jobs that are without clinic.

I’m “just” a biased Hospitalist, but I feel that IM does a better job of making ICU docs because of the more well rounded training. Also the PCCM will give you more jobs prospects (please don’t construe that as EM/CC or IM/CC docs aren’t good or can’t find jobs. But there is big subset of ICU jobs that want pulmonologists.

Also the one EM/CC doc work doesn’t know her limitations.

EDIT: And i think the IM residency will mess with your sleep way less. . . .

 

[okudasai]

You can find ICU jobs that are without clinic.

I’m “just” a biased Hospitalist, but I feel that IM does a better job of making ICU docs because of the more well rounded training. Also the PCCM will give you more jobs prospects (please don’t construe that as EM/CC or IM/CC docs aren’t good or can’t find jobs. But there is big subset of ICU jobs that want pulmonologists.

Also the one EM/CC doc work doesn’t know her limitations.

If you are PCCM, do most jobs than expect you to cover pulm consults/clinic as well as manage ICU?

 

[NITRAS]

You can find both of those jobs. I wouldn’t say never on clinic. You might think differently when you get out of training. At least having a clinic option is nice.

If you are PCCM, do most jobs than expect you to cover pulm consults/clinic as well as manage ICU?

 

[The kitchen sink]

If you are PCCM, do most jobs than expect you to cover pulm consults/clinic as well as manage ICU?

It really varies from job to job. Generally in academics I've seen it split, so for example you may have something like 1 week of ICU, followed by 1 week off (or admin time/research time etc) followed by 1 week of a couple of half day clinics with some days 'off' for which you can either catch up on work or schedule a few bronchoscopies, followed by 1 week of inpatient pulmonary consults. Now this schedule may be spread apart with more time off if you have a sizable amount of other physicians you are splitting the schedule with and depends on if you take in house night call or home call etc.

In private practice, it tends to be busier, however income potential rises concurrently, and you may have a very similar set up but it may be something to the effect of having 1 week of ICU (while covering in house pulmonary consults), if it is really busy with high volume you may have a dedicated person for ICU and another dedicated person doing the pulm consults, followed by 1 week of clinic mixed in with your bronch days.

Also, if you don't like clinic, you can take a 100% intensivist gig, which can pay quite well in some areas, which would typically be the shift work, 7 on/7 off model. No clinic or outpatient or procedure/bronch responsibilities (save for bronching your ICU pts).

If you don't like ICU, you can be a 100% outpatient pulm, which can be a 4, 4.5 or 5 day work week of pure clinic, or you can do inpatient + outpatient pulm or you can do an additional year of sleep and do mixed pulm/sleep, or if you love doing procedures like bronchoscopies with advanced therapeutics (EBUS, Nav bronch, Stenting/Debulking etc), percuatenous tracheostomies, pleurX catheters, pleuroscopies, you can do an additional 'super' fellowship in Interventional Pulmonary after you complete your 3 years of pulmonary/CC. I am not sure though however, if you can do a 2 year pulmonary only fellowship and go into interventional Pulm.

Hope that helps. Feel free to PM with questions! Good luck!

 

[RandomChaos]

I am EM/CC/Pain here. I was recently on the interview trail for CC and I can say that many community jobs are much more interested in CC as opposed to Pulm. With pandemic, most hospitals have expanded their ICU capacity and therefore are looking for intensivists to staff them. They want people that will commit full time to ICU as opposed to split between pulmonary and ICU.

1 - I was wondering what the competitiveness of critical care fellowships were for EM grads; my current understanding is that they are more competitive since there are less CC only fellowships, but not impossible to get into.
I think that EM is very competitive for CC, I interviewed all over the US at all the big name programs for CC. I think one thing that helps is knowing that you want to do CC before residency and ranking all the programs that have a strong CC emphasis highly. This can help with letters and publications.

2 - In addition, what does the job market look like for EM/CC people? Is it reasonable to expect to be able to work in a metropolitan area without being PCCM certified?
I can not speak for all metro areas, but Chicago, Detroit and Milwaukee are looking for strictly critical care docs, see above.

3 - Finally, I was considering doing IM and then a PCCM or CC fellowship afterwards. However, I would very much like to avoid working in an outpatient setting, and was wondering if I did do PCCM, if I could work soley in the ICU and avoid pulm clinic. I also heard that if you are PCCM and are on a 1 week on 1 week off schedule, then you would have to spend your week off from the ICU doing clinic, which I would not enjoy very much; would like to get clarification on this if possible.
Having spoken with my Pulm/CC co-fellows, they usually split the FTE between pulmonary or CC if they want to split. Fulltime CC is usually 2 weeks a month, I have not heard of any of them looking at jobs where they are greater than 1.0 FTE. So, they would do 1 week a month in the ICU and the other time in clinic.

In general, I think that starting as EM you have more opportunities for CC. You can apply to Medical, Surgical, Anesthesia or Neuro CC programs, where as Internal Med can only apply to PCCM or CCM programs. The benefit of having the range is that you can then also cover any of these ICUs. Many(not all) strictly Pulm/CC programs keep their fellows primarily in the MICU with some small elective time in the others. Whereas the majority of programs with an EM curriculum try to give you equal time in MICU, SICU, CVICU, NeuroICU etc., this makes you a bit more marketable in the end.

I do agree that Pulm/CC is be much better with the nuances of many of the lung diseases and certain complex bronchoscopies. But, most of the ICU care of these patients is not all that complex after you've completed a fellowship and have a good understanding of ventilator management and ARDS. I think the one thing that EM has over most IM is our initial resuscitation skills, airway management and procedures. If you are unable to master the initial ABCs then the smaller nuances do not matter because the patient doesn't make it very far.

In the end, all of the CC specialties (IM, Surgery, Anesthesia, EM, Neuro) have their strengths and weakness, but they are all fellowship trained and can manage critically ill patients with some minor differences.

 

[okudasai]

I am EM/CC/Pain here. I was recently on the interview trail for CC and I can say that many community jobs are much more interested in CC as opposed to Pulm. With pandemic, most hospitals have expanded their ICU capacity and therefore are looking for intensivists to staff them. They want people that will commit full time to ICU as opposed to split between pulmonary and ICU.

1 - I was wondering what the competitiveness of critical care fellowships were for EM grads; my current understanding is that they are more competitive since there are less CC only fellowships, but not impossible to get into.
I think that EM is very competitive for CC, I interviewed all over the US at all the big name programs for CC. I think one thing that helps is knowing that you want to do CC before residency and ranking all the programs that have a strong CC emphasis highly. This can help with letters and publications.

2 - In addition, what does the job market look like for EM/CC people? Is it reasonable to expect to be able to work in a metropolitan area without being PCCM certified?
I can not speak for all metro areas, but Chicago, Detroit and Milwaukee are looking for strictly critical care docs, see above.

3 - Finally, I was considering doing IM and then a PCCM or CC fellowship afterwards. However, I would very much like to avoid working in an outpatient setting, and was wondering if I did do PCCM, if I could work soley in the ICU and avoid pulm clinic. I also heard that if you are PCCM and are on a 1 week on 1 week off schedule, then you would have to spend your week off from the ICU doing clinic, which I would not enjoy very much; would like to get clarification on this if possible.
Having spoken with my Pulm/CC co-fellows, they usually split the FTE between pulmonary or CC if they want to split. Fulltime CC is usually 2 weeks a month, I have not heard of any of them looking at jobs where they are greater than 1.0 FTE. So, they would do 1 week a month in the ICU and the other time in clinic.

In general, I think that starting as EM you have more opportunities for CC. You can apply to Medical, Surgical, Anesthesia or Neuro CC programs, where as Internal Med can only apply to PCCM or CCM programs. The benefit of having the range is that you can then also cover any of these ICUs. Many(not all) strictly Pulm/CC programs keep their fellows primarily in the MICU with some small elective time in the others. Whereas the majority of programs with an EM curriculum try to give you equal time in MICU, SICU, CVICU, NeuroICU etc., this makes you a bit more marketable in the end.

I do agree that Pulm/CC is be much better with the nuances of many of the lung diseases and certain complex bronchoscopies. But, most of the ICU care of these patients is not all that complex after you've completed a fellowship and have a good understanding of ventilator management and ARDS. I think the one thing that EM has over most IM is our initial resuscitation skills, airway management and procedures. If you are unable to master the initial ABCs then the smaller nuances do not matter because the patient doesn't make it very far.

In the end, all of the CC specialties (IM, Surgery, Anesthesia, EM, Neuro) have their strengths and weakness, but they are all fellowship trained and can manage critically ill patients with some minor differences.

If you do a CC only fellowship after IM, are you able to still work in a variety of ICUs, or does that largely depend on the program you do your fellowship at?

 

[RandomChaos]

If you do a CC only fellowship after IM, are you able to still work in a variety of ICUs, or does that largely depend on the program you do your fellowship at?

I think you may be limited to a medical ICU. However, I imagine it would also greatly depend on the program. If you are at a program that provided equal training in Medical, Surgical, Cardiac and Neuro ICU then that would be a different story. This training does seem to be a bit harder to find in programs that are strictly medicine based though. Again, in my experience that kind of mix was much more common with EM curriculums.

 

[okudasai]

I think you may be limited to a medical ICU. However, I imagine it would also greatly depend on the program. If you are at a program that provided equal training in Medical, Surgical, Cardiac and Neuro ICU then that would be a different story. This training does seem to be a bit harder to find in programs that are strictly medicine based though. Again, in my experience that kind of mix was much more common with EM curriculums.

When you say EM curriculums, are you referring to CC only fellowships that take EM grads, or are you referring to the EM residency in general?

 

[CCM-MD]

Doing CCM in an effort to get away from the problems of EM is like jumping from one sinking ship to another. CCM has many of the same issues as EM: hospital administrators trying to cut costs, proliferation of corporate groups, and midlevel encroachment.

I’m trained in CCM and IM. I disliked clinic and did not pursue pulmonary for that reason. Right now things in CCM are great, regardless of one’s training pathway: the job market is great, the $ is great and going up every year. You can get a job basically anywhere. Whether things will remain great is a question because of what has been stated above, similarities with EM etc.

My advice to you would be to do Pulm/CCM if you are sure you actually want to be an intensivist. This path has advantages over all of the others: having a specialty that is not associated with the hospital, ability to deescalate to something totally outpatient in the event of burnout, and the highest employability as most intensivists in this country are Pulm-CCM.

IMO, the next best is CCM via IM, especially if your goal is to practice in the community as majority of the patients will be critically ill medical patients. All “standalone” IM based CCM fellowship programs I interviewed at provided broad training, you weren’t just plugged into the MICU for the whole 2 years. This being “plugged into a unit” is more common in surgical fellowships where one might spend their entire training in the SICU. Regardless, I am sure most will agree that the sickest patients in the hospital are in the MICU and CVICU.

It is also common for some jobs to specifically advertise for IM trained CCM physicians - and the bias is obviously understandable because most intensivists influencing recruitment decisions are Pulm/IM trained and prefer someone with similar training. Perhaps this bias is changing but it still remains for now, even in my community group. Being non-IM trained is going to be more of a disadvantage than an advantage.

I think you may be limited to a medical ICU. However, I imagine it would also greatly depend on the program. If you are at a program that provided equal training in Medical, Surgical, Cardiac and Neuro ICU then that would be a different story. This training does seem to be a bit harder to find in programs that are strictly medicine based though. Again, in my experience that kind of mix was much more common with EM curriculums.

This is not true. I know so many Pulm/ IM/CCM folks that work in all types of settings. Might require some “on the job” learning but once you are an intensivist, you are an intensivist. Now in academia this might be challenging and it’s gonna come down to institutional politics. For example: it is going to be hard to get a job in an academic neuro ICU run by neurologists if you are a neuroCCM doc that’s not trained in neurology, and same thing goes for academic MICUs if you are not IM trained. Can it been done? Sure, but there are forces at work that are going to be against you.

Bottom line: do pulm if you can tolerate it. Otherwise IM/CCM might provide a slight advantage over the others in my personal opinion.

 

[okudasai]

Doing CCM in an effort to get away from the problems of EM is like jumping from one sinking ship to another. CCM has many of the same issues as EM: hospital administrators trying to cut costs, proliferation of corporate groups, and midlevel encroachment.

I’m trained in CCM and IM. I disliked clinic and did not pursue pulmonary for that reason. Right now things in CCM are great, regardless of one’s training pathway: the job market is great, the $ is great and going up every year. You can get a job basically anywhere. Whether things will remain great is a question because of what has been stated above, similarities with EM etc.

My advice to you would be to do Pulm/CCM if you are sure you actually want to be an intensivist. This path has advantages over all of the others: having a specialty that is not associated with the hospital, ability to deescalate to something totally outpatient in the event of burnout, and the highest employability as most intensivists in this country are Pulm-CCM.

IMO, the next best is CCM via IM, especially if your goal is to practice in the community as majority of the patients will be critically ill medical patients. All “standalone” IM based CCM fellowship programs I interviewed at provided broad training, you weren’t just plugged into the MICU for the whole 2 years. This being “plugged into a unit” is more common in surgical fellowships where one might spend their entire training in the SICU. Regardless, I am sure most will agree that the sickest patients in the hospital are in the MICU and CVICU.

It is also common for some jobs to specifically advertise for IM trained CCM physicians - and the bias is obviously understandable because most intensivists influencing recruitment decisions are Pulm/IM trained and prefer someone with similar training. Perhaps this bias is changing but it still remains for now, even in my community group. Being non-IM trained is going to be more of a disadvantage than an advantage.



This is not true. I know so many Pulm/ IM/CCM folks that work in all types of settings. Might require some “on the job” learning but once you are an intensivist, you are an intensivist. Now in academia this might be challenging and it’s gonna come down to institutional politics. For example: it is going to be hard to get a job in an academic neuro ICU run by neurologists if you are a neuroCCM doc that’s not trained in neurology, and same thing goes for academic MICUs if you are not IM trained. Can it been done? Sure, but there are forces at work that are going to be against you.

Bottom line: do pulm if you can tolerate it. Otherwise IM/CCM might provide a slight advantage over the others in my personal opinion.

Thank you for the detailed reply! As I am not interesed in academics, it seems like as you said, the IM pathway will offer me the most versatility in terms of where I want to work and the kind of patient care that interests me the most. Its certainly possible that CCM will start going the way of EM, in which case it might be good to have a pulm background to fall back on.

 

[Doc Doc Doc Goose]

I am a student in a similar boat. Applying to EM/IM and EM (with possibly CCM in mind in the future). I tried to convince myself I could do the Pulm/CCM route.

feel free to direct message if you’d like to talk out some stuff.

how much fo you like/love clinic and outpatient medicine.

I have a low tolerance for clinic. I like it for a few hours tops; the patient Interaction, conversing, but the long-term management of chronic illness in a clinic setting just does not appeal to me. And I have resolved to no longer think that I could “learn” to like/love working in an outpatient clinic.

Maybe you’re different.

EM/CCM docs (and EM/IM) I’ve spoken with both academic and private tell me that if you are flexible, like willing to set up part-time contracts at separate hospitals, it can definitely be done. Finding a single hospital that will hire you in both departments, so you can practice both, is unlikely; since both departments have to be looking for/in need of a part-time employee. Docs on here will say it’s not feasibly or highly unlikely to make it work. Well, I’ve heard different. It’s not common, no. But it’s done.

 

[Doc Doc Doc Goose]

I am a student in a similar boat. Applying to EM/IM and EM (with possibly CCM in mind in the future). I tried to convince myself I could do the Pulm/CCM route.

feel free to direct message if you’d like to talk out some stuff.

how much fo you like/love clinic and outpatient medicine.

I have a low tolerance for clinic. I like it for a few hours tops; the patient Interaction, conversing, but the long-term management of chronic illness in a clinic setting just does not appeal to me. And I have resolved to no longer think that I could “learn” to like/love working in an outpatient clinic.

Maybe you’re different.

EM/CCM docs (and EM/IM) I’ve spoken with both academic and private tell me that if you are flexible, like willing to set up part-time contracts at separate hospitals, it can definitely be done. Finding a single hospital that will hire you in both departments, so you can practice both, is unlikely; since both departments have to be looking for/in need of a part-time employee. Docs on here will say it’s not feasibly or highly unlikely to make it work. Well, I’ve heard different. It’s not common, no. But it’s done.

And part of my deciding against the IM route was when I looked at the curriculum of my home program, with 8-10 months spent on consult services across the 3 years of training. Multiple months of Endo, ID, Nephro…….. no thank you.

 

[NITRAS]

And part of my deciding against the IM route was when I looked at the curriculum of my home program, with 8-10 months spent on consult services across the 3 years of training. Multiple months of Endo, ID, Nephro…….. no thank you.

I would argue that those months on those services is actually quite helpful. Managing complex medical patients involves lots of Endocrine, ID, and nephrology.

Shoot, I hate clinics and ID clinic was the most fun I ever had in a clinic.

 

[CCM-MD]

And part of my deciding against the IM route was when I looked at the curriculum of my home program, with 8-10 months spent on consult services across the 3 years of training. Multiple months of Endo, ID, Nephro…….. no thank you.

Critical care has a ton of ID, nephro and endo. You’re going to have to know that as an intensivist to provide good quality care. I guess you could just have a low threshold to consult these services but in today’s world where every consult service is basically run by an army of midlevels and consultants don’t take any sort of ownership of the patient, you’re probably going to have preventable bad outcomes. And at that point what’s the difference between having an intensivist or having a ICU midlevel?

I am obviously biased being IM trained, but this is why I think IM gives one a leg up. Sure everyone brings something to the table but I feel that ongoing management in an effort to make someone better is the hard part, not the procedures or ultrasound or whatever else. Basically every procedure I do is being done by a midlevel somewhere else, and can be done arguably better by another specialist. Having that pulm certification adds “organ system expertise” which can also be nice.

 

[Doc Doc Doc Goose]

Critical care has a ton of ID, nephro and endo. You’re going to have to know that as an intensivist to provide good quality care. I guess you could just have a low threshold to consult these services but in today’s world where every consult service is basically run by an army of midlevels and consultants don’t take any sort of ownership of the patient, you’re probably going to have preventable bad outcomes. And at that point what’s the difference between having an intensivist or having a ICU midlevel?

I am obviously biased being IM trained, but this is why I think IM gives one a leg up. Sure everyone brings something to the table but I feel that ongoing management in an effort to make someone better is the hard part, not the procedures or ultrasound or whatever else. Basically every procedure I do is being done by a midlevel somewhere else, and can be done arguably better by another specialist. Having that pulm certification adds “organ system expertise” which can also be nice.

Completely understand that.

And I understand why an IM background is probably best for an ICU doc. While the pathophysiology is fascinating to me, those rotations I’m referring to have not been.

But I see why those months/seeing those patients prepare one for the ICU, as all the bodily systems are in play, ALWAYS.

Hopefully I match EM/IM, save myself those some of those months of consult services, and if I still have the ICU “bug and desire,” then I can go from there.

But I hear ya, Doc.

 

[CCM-MD]

Completely understand that.

And I understand why an IM background is probably best for an ICU doc. While the pathophysiology is fascinating to me, those rotations I’m referring to have not been.

But I see why those months/seeing those patients prepare one for the ICU, as all the bodily systems are in play, ALWAYS.

Hopefully I match EM/IM, save myself those some of those months of consult services, and if I still have the ICU “bug and desire,” then I can go from there.

But I hear ya, Doc.

You have a great attitude and I am sure you will do well. And like I said, I am biased being IM trained and everyone is biased in their own way. I've met some excellent anesthesia intensivists and have trained alongside EM fellows that were awesome. I think being an outstanding physician in general has more to do with the person than the training path chosen to get there.

 

[RandomChaos]

When you say EM curriculums, are you referring to CC only fellowships that take EM grads, or are you referring to the EM residency in general?

I am referring to CC programs with an EM track. EM can apply to Medicine, Anesthesia, Surgical and Neuro, the last three of these are traditionally 1 year fellowships, meaning they have an extra year for EM. This usually leads to a much more diverse curriculum.

 

[RandomChaos]

I was also torn at one point of which path to choose for ICU. I ended up interviewing at Medical, Anesthesia and Surgical CC programs. Granted this was about 2-3 years ago, but at that time the majority of medical CC programs I interviewed at had primarily MICU rotations with elective in other ICUs, where you were not fully integrated into the call pool and such. The main exceptions I recall were Cooper, UPMC, Stanford, IU off the top of my head, all of these also having taken many EM applicants in the past.

I think whatever route you choose, making sure that the fellowship fully integrates their fellows into all of the ICUs is important. I saw this more commonly in programs with a strong EM presence.

Again I would say that during my recent interviews in Chicago, Detroit and Milwaukee that many places are looking for straight critical care and wanting to get away from the Pulm/CC split, with the exception of the larger academic centers. They want people that can cover the ICU 24/7 and not worry about covering clinic.

I also very much agree that EM and CC face many of the similar problems as the previous poster had mentioned.

 

[CCM-MD]

I am referring to CC programs with an EM track. EM can apply to Medicine, Anesthesia, Surgical and Neuro, the last three of these are traditionally 1 year fellowships, meaning they have an extra year for EM. This usually leads to a much more diverse curriculum.

For starters in surgical CC, the first year of the 2 years for EM is a surgical intern year, which is a laughable unless you consider a whole year of surgical scut work "diverse training". NeuroCC is 2 year fellowship for everyone including neurologists, unless one has already completed another CCM fellowship. What you are saying maybe holds true for a minority of medicine/anesthesia programs that have a totally separate curriculum set up for EM.

 

[RandomChaos]

For starters in surgical CC, the first year of the 2 years for EM is a surgical intern year, which is a laughable unless you consider a whole year of surgical scut work "diverse training". NeuroCC is 2 year fellowship for everyone including neurologists, unless one has already completed another CCM fellowship. What you are saying maybe holds true for a minority of medicine/anesthesia programs that have a totally separate curriculum set up for EM.

The idea that the first year of surgical CC for EM is solely a surgical intern year is just not true. Many of these programs spend that first year learning how to do trachs, PEGS, EGDs, debridement, fasciotomies, complex suturing, wound/burn management and such. All of which I have done bedside on ICU patients. I’m not surgical CC, but the idea that the first year is nothing more than doing scut work is a misconception.

Critical Care Fellowships

This is a link of the surgical CC programs that have taken EM, the curriculums are on the websites. Obviously they all vary a bit, but from my experience interviewing with many of them for fellowship, the first year is not solely scut work.

Yes, you are correct, I misspoke of neuro CC. They offer 1 year with prior fellowship training and 2 year path directly out of residency. Thanks for catching that.

Obviously we are both very biased as to the best path to get to CC. Ultimately, I think our system would benefit from a strictly CC residency. Forever ending the debate of IM vs Anesthesia vs Surgery vs EM.

 

[CCM-MD]

The idea that the first year of surgical CC for EM is solely a surgical intern year is just not true. Many of these programs spend that first year learning how to do trachs, PEGS, EGDs, debridement, fasciotomies, complex suturing, wound/burn management and such. All of which I have done bedside on ICU patients. I’m not surgical CC, but the idea that the first year is nothing more than doing scut work is a misconception.

Even if that is the case, thats far from EM curriculum providing another year of diverse training ("MICU, SICU, CVICU, NeuroICU etc."). And some of the things you mentioned sound like things surgery residents would consider scut. Hey EM guy, lets get you to do some debridement and wound care since you want to do surgical CC, that seems like a great use of your time.

Obviously we are both very biased as to the best path to get to CC. Ultimately, I think our system would benefit from a strictly CC residency. Forever ending the debate of IM vs Anesthesia vs Surgery vs EM.

Agree with all of this including having a CC residency, that would be really nice. We are both biased but hopefully our exchange on this thread and different perspectives can help future applicants.

 

[Doctor Bob]

If you want to be an intensivist, a pure CCM program is going to train you better than a PCCM program, just by virtue of focus and time. You spend more time in the ICU in a CCM program than a PCCM program. Getting the pulm part so you have a retirement/fallback option is... ok... but if you work pure CCM for years and then try to go to clinic there'll be a lot of knowledge atrophy. And if you spend your whole career splitting your time you won't be as good in either as someone who dedicates their entire time to that field.

The best intensivists aren't defined by the specialty they come from (EM, or IM, or anesthesia, or surgery or whatever)... the best intensivists are the ones who do it full time.

 

[Doctor Bob]

Critical Care Fellowships

I wish they would update this information. It's 3+ years old. There are newer programs that aren't on that list, and some that should be removed.

 

[The kitchen sink]

If you want to be an intensivist, a pure CCM program is going to train you better than a PCCM program, just by virtue of focus and time. You spend more time in the ICU in a CCM program than a PCCM program. Getting the pulm part so you have a retirement/fallback option is... ok... but if you work pure CCM for years and then try to go to clinic there'll be a lot of knowledge atrophy. And if you spend your whole career splitting your time you won't be as good in either as someone who dedicates their entire time to that field.

The best intensivists aren't defined by the specialty they come from (EM, or IM, or anesthesia, or surgery or whatever)... the best intensivists are the ones who do it full time.

I generally agree with you.

I would just add that, after speaking to a number of Pulm/CC folks, that rotating out of the unit into the clinic or consults is a nice change of pace and allows them time to be more refreshed and energized going back into the unit. They usually cite burn out and time for recovery as there reasoning behind this.

 

[grt398]

My advice to you would be to do Pulm/CCM if you are sure you actually want to be an intensivist. This path has advantages over all of the others: having a specialty that is not associated with the hospital, ability to deescalate to something totally outpatient in the event of burnout, and the highest employability as most intensivists in this country are Pulm-CCM.

As an IM-CCM fellow looking at the job market right now, I will say this is by far the best advice if you want the broadest range of options (aka do PCCM). Yes you can get strict CCM jobs in any city, but to me that's not the whole story and something I wish people had discussed with me. The question is also what type of practice do you want, aka do you want to work for HCA/Envision/TeamHealth (who staff many of the big hospitals in the big metro areas), or would you prefer to join a physician owned practice? Because the latter are much more likely to want PCCM people from what I've seen so you can cover inpatient pulm consults/bronchs if nothing else. Additionally, if you think you might have even the slightest inclination to work in a more rural area at any future point in your career, they want PCCM people who can cover pulmonary consults/clinic. Even some large health systems in areas I very much want to live (and are not rural at all) are requesting PCCM to cover 4 days/clinic per month in exchange for some off ICU time. I did IM-CCM because I did not enjoy clinic and wasn't willing to do 2 weeks/month of clinic, which is what everyone in residency told me to expect in private practice...but 4 days/month to live in exactly the location I want? I'd make that trade in a heartbeat.

And I would also argue that the best options for a good quality of life in medicine going forward are specialties that can operate fully outside the hospital system if desired, which you could do with pulmonary.

 

[okudasai]

As an IM-CCM fellow looking at the job market right now, I will say this is by far the best advice if you want the broadest range of options (aka do PCCM). Yes you can get strict CCM jobs in any city, but to me that's not the whole story and something I wish people had discussed with me. The question is also what type of practice do you want, aka do you want to work for HCA/Envision/TeamHealth (who staff many of the big hospitals in the big metro areas), or would you prefer to join a physician owned practice? Because the latter are much more likely to want PCCM people from what I've seen so you can cover inpatient pulm consults/bronchs if nothing else. Additionally, if you think you might have even the slightest inclination to work in a more rural area at any future point in your career, they want PCCM people who can cover pulmonary consults/clinic. Even some large health systems in areas I very much want to live (and are not rural at all) are requesting PCCM to cover 4 days/clinic per month in exchange for some off ICU time. I did IM-CCM because I did not enjoy clinic and wasn't willing to do 2 weeks/month of clinic, which is what everyone in residency told me to expect in private practice...but 4 days/month to live in exactly the location I want? I'd make that trade in a heartbeat.

And I would also argue that the best options for a good quality of life in medicine going forward are specialties that can operate fully outside the hospital system if desired, which you could do with pulmonary.

It seems that both CCM and PCCM will allow you to generally live in the area you want, but since PCCM can cover consults/clinic, you will be able to work for a larger variety of employers, whereas with CCM you will be "stuck" in a sense with corporations that cover the big hospitals. Are there significant advantages to working for a physician owned practice over a HCA, i.e. superior locations, etc.?

The other question I had was regarding the competitiveness of CC fellowships. Since EM folks are able to apply to anesthesia, IM, and surgical CC fellowships, is it easier to get in a CC only fellowship as an EM grad vs IM grad, since IM grads can only apply to IM-CC fellowships? Or is it generally just more difficult across the board for EM grads to get into CC fellowships compared to IM grads?

EDIT: In essence, my end goal is to work in an ICU in a big city kind of area. My absolute ideal job would technically be splitting time between the ED and the ICU, but my understanding is that this is extremely rare so I am definitely not holding my breath for that. Will going through the EM/CC pathway significantly impact my ability to live where I generally want or to work where I want?

My main reason for wanting to do IM/PCCM was to maximize my ability to pick location, but if a CC only fellowship will still generally allow me (without too many issues) to work in a big city ICU, than I think the EM/CC pathway might what I end up in, if only to hold out for the faint hope of somehow finding a place a will let me work in both the ED and ICU.

If I am extremely off base with my logic here, please let me know!

 

[CCM-MD]

It seems that both CCM and PCCM will allow you to generally live in the area you want, but since PCCM can cover consults/clinic, you will be able to work for a larger variety of employers, whereas with CCM you will be "stuck" in a sense with corporations that cover the big hospitals. Are there significant advantages to working for a physician owned practice over a HCA, i.e. superior locations, etc.?

The other question I had was regarding the competitiveness of CC fellowships. Since EM folks are able to apply to anesthesia, IM, and surgical CC fellowships, is it easier to get in a CC only fellowship as an EM grad vs IM grad, since IM grads can only apply to IM-CC fellowships? Or is it generally just more difficult across the board for EM grads to get into CC fellowships compaerd to IM grads?

Hospital employed is probably the most common for intensivists but there is an increasing presence of “corporate” groups and staffing companies especially in popular cities. This is not a good thing.

Pulm/CCM and IM CCM are competitive but anesthesia CCM usually has empty spots every year, so if you just want any CCM program, might be easier as EM. Though keep in mind, not all anesthesia CCM programs are approved to train EM.

If you are a US MD with no red flags, you should have no problem getting into at least a mid tier IM program and no problem getting into pulm/CCM.

 

[RandomChaos]

Even if that is the case, thats far from EM curriculum providing another year of diverse training ("MICU, SICU, CVICU, NeuroICU etc."). And some of the things you mentioned sound like things surgery residents would consider scut. Hey EM guy, lets get you to do some debridement and wound care since you want to do surgical CC, that seems like a great use of your time.



Agree with all of this including having a CC residency, that would be really nice. We are both biased but hopefully our exchange on this thread and different perspectives can help future applicants.

I think there’s no arguing the benefit of being able to do your own bedside trach/PEGs/complex suturing, all of which will be more heavily emphasized in a typical surgical CC fellowship in comparison to a Med CC.

In regards to wound care management and debridement, this is a daily occurrence in a Burn ICU and with dealing with necrotizing fasciitis, and obviously this is not for everyone, but if you happened to be cross covering then it may be good to have a more in depth understanding of this.

You could always rely more heavily on the surgical consultants for much of this, but the major benefit of keeping these procedures within the department is being able to bring money to your department as opposed to another.

Again, I’m not Surg-CC, but there are strengths and weaknesses in each respective CC sub specialty. I think the most important thing whether you do Med vs Surg vs Anesthesia vs EM is being at a well rounded program for fellowship. One that has a stand alone critical care department and looks at all fellows as just CC fellows regardless of background.

 

[CCM-MD]

I think there’s no arguing the benefit of being able to do your own bedside trach/PEGs/complex suturing, all of which will be more heavily emphasized in a typical surgical CC fellowship in comparison to a Med CC.

In regards to wound care management and debridement, this is a daily occurrence in a Burn ICU and with dealing with necrotizing fasciitis, and obviously this is not for everyone, but if you happened to be cross covering then it may be good to have a more in depth understanding of this.

You could always rely more heavily on the surgical consultants for much of this, but the major benefit of keeping these procedures within the department is being able to bring money to your department as opposed to another.

Again, I’m not Surg-CC, but there are strengths and weaknesses in each respective CC sub specialty. I think the most important thing whether you do Med vs Surg vs Anesthesia vs EM is being at a well rounded program for fellowship. One that has a stand alone critical care department and looks at all fellows as just CC fellows regardless of background.

Nobody is arguing against the bolded. My disagreement is with your claim that EM has better access to diverse training programs. You stated that because some fellowships are 1 year and EM has to do 2, they are more likely to have “broad training” unlike IM-CCM who according to you “may be limited to working in the MICU”.

You’ve taken back what you said about neuroCC and I think the same holds true for surgical CC. The usefulness of debridement or wound care for an intensivist is a separate debate but a whole year of non-ICU surgical training in a surgical CC fellowship is the opposite of a well rounded training program with MICU, SICU, CVICU, NeuroICU exposure that you claim EM has better access to.

Regarding procedural training, sure surgical CC has a leg up but procedures isn't what critical care is about. Perc trachs are a part of most IM CCM programs. PEGs not so much. And at the end of the day, these are not big revenue generating procedures: 5 wRVU for a trach and 3.5 for PEG. Compare that to 4.5 for the first 30 minutes of critical care time and 2 for a level 3 follow up.

 

[RandomChaos]

Nobody is arguing against the bolded. My disagreement is with your claim that EM has better access to diverse training programs. You stated that because some fellowships are 1 year and EM has to do 2, they are more likely to have “broad training” unlike IM-CCM who according to you “may be limited to working in the MICU”.

You’ve taken back what you said about neuroCC and I think the same holds true for surgical CC. The usefulness of debridement or wound care for an intensivist is a separate debate but a whole year of non-ICU surgical training in a surgical CC fellowship is the opposite of a well rounded training program with MICU, SICU, CVICU, NeuroICU exposure that you claim EM has better access to.

Regarding procedural training, sure surgical CC has a leg up but procedures isn't what critical care is about. Perc trachs are a part of most IM CCM programs. PEGs not so much. And at the end of the day, these are not big revenue generating procedures: 5 wRVU for a trach and 3.5 for PEG. Compare that to 4.5 for the first 30 minutes of critical care time and 2 for a level 3 follow up.

Through EM you have the opportunity to train in any one of the sub specialties of CC, you’re unable to do that with any of the other specialities. This means you have a much larger number of programs to choose from when it comes to fellowships. So where as there may be a handful of truly multi-disciplinary IM-CC programs, there will be just as many multi-disciplinary Anesthesia and Surg CC programs to choose from. All of which EM has access to.

You say that learning about emergency general surgery, vascular surgery, transplant surgery, thoracic etc. is not useful for critical care, yet rotations like ID, nephrology, endo etc are important. This seems to be one of the common biases I have seen with my internal medicine trained colleagues. Very quick to downplay the knowledge of the surgical intensivist. All of the core critical care topics of these medicine based specialties, which are just as important of the surgical based topics, can be learned during any critical fellowship. These are not concepts that can only be learned after IM residency. If one ends up working in a mixed med-surg unit then it would be just as helpful to know anatomy, surgical technique and complications as it would to know ID, nephro, endo.


I agree a handful of internal med programs do their own perc trachs, but they are going to be far less common in internal med programs than anesthesia/surgical programs. And 5/3.5 wRVU is not bad for a procedure that takes 10-15 minutes. That’s still money that is being given to other departments when it could stay within your own.

 

[CCM-MD]

Through EM you have the opportunity to train in any one of the sub specialties of CC, you’re unable to do that with any of the other specialities. This means you have a much larger number of programs to choose from when it comes to fellowships. So where as there may be a handful of truly multi-disciplinary IM-CC programs, there will be just as many multi-disciplinary Anesthesia and Surg CC programs to choose from. All of which EM has access to.

You say that learning about emergency general surgery, vascular surgery, transplant surgery, thoracic etc. is not useful for critical care, yet rotations like ID, nephrology, endo etc are important. This seems to be one of the common biases I have seen with my internal medicine trained colleagues. Very quick to downplay the knowledge of the surgical intensivist. All of the core critical care topics of these medicine based specialties, which are just as important of the surgical based topics, can be learned during any critical fellowship. These are not concepts that can only be learned after IM residency. If one ends up working in a mixed med-surg unit then it would be just as helpful to know anatomy, surgical technique and complications as it would to know ID, nephro, endo.


I agree a handful of internal med programs do their own perc trachs, but they are going to be far less common in internal med programs than anesthesia/surgical programs. And 5/3.5 wRVU is not bad for a procedure that takes 10-15 minutes. That’s still money that is being given to other departments when it could stay within your own.

Again you keep defending the usefulness of that surgical training for an intensivist - I probably disagree with you on that but that’s not really what we are talking about. Sure nephro, ID and endo are important in residency. No IM-CCM programs spends significant time on non-ICU medicine subspecialty services, that would be a huge detriment to CCM training. Time is much better spent in the unit, taking care of sick patients.

You say access to “multidisciplinary” surgical CC programs but by definition surgical CC is not “multidisciplinary” if one spends half of their CCM fellowship not even in the ICU but outside the unit on surgical service. These are heavily surgical focused programs not “diverse” program by any means. Do you also realize that there are anesthesia and IM CCM programs not approved/won’t train EM? This greater access is where we disagree.

Where did you come up with a handful? You think there are only 5 IM-CCM programs that provide diverse training and exposure to non medical critically ill patients? You think only 5 provide training with perc trachs? On top of this, you are claiming it takes 10 min to do a bedside trach from set up to finish? These are not correct beliefs, you are mistaken. Perc trach training is common enough that it has made it into the IM-CCM ACGME common program requirements as a core competency.

 

[CCM-MD]

I am referring to CC programs with an EM track. EM can apply to Medicine, Anesthesia, Surgical and Neuro, the last three of these are traditionally 1 year fellowships, meaning they have an extra year for EM. This usually leads to a much more diverse curriculum.

Whereas the majority of programs with an EM curriculum try to give you equal time in MICU, SICU, CVICU, NeuroICU etc., this makes you a bit more marketable in the end.

Coming back to these statements, which is where our discussion began and my disagreement lies. NeuroCC you took back and we have determined that EM-surgical CC by definition of its curriculum is heavily surgical focused and does not provide the “diverse” curriculum you claim.

Are you now essentially agreeing with below?

What you are saying maybe holds true for a minority of medicine/anesthesia programs that have a totally separate curriculum set up for EM.

 

[RandomChaos]

Again you keep defending the usefulness of that surgical training for an intensivist - I probably disagree with you on that but that’s not really what we are talking about. Sure nephro, ID and endo are important in residency. No IM-CCM programs spends significant time on non-ICU medicine subspecialty services, that would be a huge detriment to CCM training. Time is much better spent in the unit, taking care of sick patients.

I absolutely agree that a CC fellowship should be spent in the ICU. Per the ACGME "A minimum of 12 months must be devoted to clinical experiences. At least six months must be devoted to the care of critically ill medical patients (i.e., MICU/CICU or equivalent)." This is per their requirements of a Medical Critical Care Fellowship. This is a 24 month critical care fellowship, with the only 6 months of required ICU time. Again per the ACGME. This is their direct quote of the other 12 months. "Twelve additional months must be devoted to appropriate elective experiences or scholarly activity." So, your statement is just absolutely not true.

To sum up, per the ACGME Medical Critical Care fellowship is only required to have a minimum of 12 months of clinic experience with 6 months being in the ICU, much less than half of the fellowship. This is the majority of CC programs that I have seen, with the top tier programs not adhering as much to this. But, usually they are very front loaded with the ICU experience to have more relaxed "research/elective" months later on. This is due to the ACGME requirements of a Medical CC fellowship.

You say access to “multidisciplinary” surgical CC programs but by definition surgical CC is not “multidisciplinary” if one spends half of their CCM fellowship not even in the ICU but outside the unit on surgical service. These are heavily surgical focused programs not “diverse” program by any means. Do you also realize that there are anesthesia and IM CCM programs not approved/won’t train EM? This greater access is where we disagree.

I do realize that there are IM/Anesthesia/Surg programs that are still working on funding the second year required for EM fellowship. However, this number is only getting smaller. Since EM has entered the CC workforce the majority of programs have begun to expand and find ways for funding the 2 year program for EM.

Where did you come up with a handful? You think there are only 5 IM-CCM programs that provide diverse training and exposure to non medical critically ill patients? You think only 5 provide training with perc trachs? On top of this, you are claiming it takes 10 min to do a bedside trach from set up to finish? These are not correct beliefs, you are mistaken. Perc trach training is common enough that it has made it into the IM-CCM ACGME common program requirements as a core competency.

I think you are misinterpreting the ACGME requirements. Per their requirements under the section of procedures it is stated, "Fellows must be able to perform all medical, diagnostic, and surgical procedures considered essential for the area of practice." Some of these procedures include fiberoptic bronchoscopy, paracentesis, thoracentesis, lumbar puncture, endotracheal intubation, intravascular access..." This does not include percutaneous tracheostomy. This is under the section of "Medical Knowledge". Which states "Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care." Included in this is pericardiocentesis and percutaneous tracheostomy. It does not say anything about the actual performance of these procedures being a core requirement beyond knowledge of them. So, yes for this reason the vast majority of Medical CC programs do not emphasize hands on tracheostomy training, as it is not a requirement from the ACGME. Again, I would say the top tier programs are likely the exception.

And absolutely, with an efficient ancillary team that is well trained in tracheostomy open or percutaneous, then a straight forward tracheostomy does not take an experienced proceduralist much more than 15 minutes to perform. I would defer the more complex ones to be done in the OR or by ENT at bedside, so with the proper patient selection, they should be straight forward. Most of the set up/scut work can be done prior to the provider even entering the room. Most EM/surgical airway specialists can perform emergent cricothyroidotomies in literally a tenth of the time, granted in very different situations.

So, obviously not all programs will follow the ACGME requirements exactly, but they set the standard which means that the majority will follow this. I am not sure if you were looking at older requirements but, these are the most recent ones from 2020.

 

[RandomChaos]

Coming back to these statements, which is where our discussion began and my disagreement lies. NeuroCC you took back and we have determined that EM-surgical CC by definition of its curriculum is heavily surgical focused and does not provide the “diverse” curriculum you claim.

Are you now essentially agreeing with below?

I would say that any program that has a specific EM curriculum does what they can in order to make sure that you get exposure in a wide variety of ICUs. I agree that this is not the case for ALL 2 year programs. Just like their is variability with PCCM or straight IM programs. But, I think that the ones that attract EM tend to be the top tier programs due to their diversity in curriculum.

I think this is where all programs should be headed, an intensivist should just be an intensivist and they should be able to seamlessly transition from ICU to ICU. I think this mind set also tends to be more common with EM and hopefully with some of the younger, newer intensivists. This may possibly be due to EM being the newer kid on the block. But, we seem much more open to influence by IM, Anesthesia and Surgical intensivists equally. Maybe because we do not have a true home yet or clear EM-CC programs.

Ultimately, I think the more we can do to blur the lines of IM vs Anesthesia vs Surg vs EM the better it will be for our specialty.

Cheers!

 

[CCM-MD]

So, your statement is just absolutely not true.

To sum up, per the ACGME Medical Critical Care fellowship is only required to have a minimum of 12 months of clinic experience with 6 months being in the ICU, much less than half of the

You are not correctly quoting the requirements.

You forgot the time required managing critically ill non-medical patients. Again, these are minimums and the broad/diverse/multidis nature of IM-CCM training is built into it even by minimum requirements.

Interpret the requirements however you like, but believe it that most IM-CCM programs offer perc trach training in today’s world.

 

[RandomChaos]

You are not correctly quoting the requirements.
View attachment 339075
You forgot the time required managing critically ill non-medical patients. Again, these are minimums and the broad/diverse/multidis nature of IM-CCM training is built into it even by minimum requirements.

View attachment 339076Interpret the requirements however you like, but believe it that most IM-CCM programs offer perc trach training in today’s world.

You just further strengthen my point that less than half of the time in a 24 month fellowship is spent in the ICU. So, internal medicine CC has the same flaw that you argue about with surgical CC. 3 months leaves you with a month in a Neuro, surgical CV, and Surgical ICU or even burn ICU, depending on your set up. That still is not very much time in these rotations.

There’s no misinterpretation of the trach statement, it is clearly stated under medical knowledge, not has a core procedure. That is a fact.

 

[CCM-MD]

You just further strengthen my point that less than half of the time in a 24 month fellowship is spent in the ICU. So, internal medicine CC has the same flaw that you argue about with surgical CC. 3 months leaves you with a month in a Neuro, surgical CV, and Surgical ICU or even burn ICU, depending on your set up. That still is not very much time in these rotations.

There’s no misinterpretation of the trach statement, it is clearly stated under medical knowledge, not has a core procedure. That is a fact.

Key word is minimum. I'm not going to repeat myself about trachs.

You're out here arguing IM-CCM fellows spend 6 months out of their 2 year fellowship in the ICU. And somehow a whole year on the surgical service in the EM-SCC curriculum spent doing debridement, wound care and complex suturing make these programs multidisciplinary. Enough said.

 

[CCM-MD]

Below is from the Surgical CC program requirements: no more than 2 months in non-SICU rotations after a whole year on surgical service as an advanced preliminary resident doing debridement etc. Keyword: maximum. Doesn't seem very "multidisciplinary" or "diverse" to me.

 

[RandomChaos]

Key word is minimum. I'm not going to repeat myself about trachs.

You're out here arguing IM-CCM fellows spend 6 months out of their 2 year fellowship in the ICU. And somehow a whole year on the surgical service in the EM-SCC curriculum spent doing debridement, wound care and complex suturing make these programs multidisciplinary. Enough said.

As you shouldn’t. We all know there is a big difference between talking about doing a trach and then having actual hands on experience doing them. The ACGME even recognizes that it’s not a procedural requirement for internal medicine to perform them.

Also, I literally just added the extra 3 months, 9 months out of 24 months in an ICU is still no more than the requirement in Surgical. So, again by your argument that the majority of time in a CC fellowship should be in an ICU, makes internal medicine no better than surgical CC.

You keep focusing just on these procedures, but seem to exclude the stronger emphasis on other bedside ICU procedures like trach/PEG. Beyond that the focus on the complexities of surgical emergencies throughout all of the surgical subspecialties. What you call scut, most surgeons would call necessary. Just like your argument of needing the basics of internal medicine prior to being in an ICU.

Again, I think this discussion clearly shows that there is no perfect program or that one is greater than the other, but that each has its own strength and weaknesses.

I think we both agree that the majority of time should be in an ICU, but regardless does not seem to be the case. So, the higher ups seem to disagree with us.

 

[CCM-MD]

Interpret the requirements however you like, but believe it that most IM-CCM programs offer perc trach training in today’s world.

I was trained to do trachs in an IM-CCM program. My IM-CCM trained attendings who trained at various different programs were my supervisors. And my colleagues who were IM-CCM trained in the 3 places I have worked in as an attending did perc trachs also. So Idk what else to tell you. We aren't trained in debridement and wound care though, so if you're looking for that you're going to have to go to a surgical CC program.

 

[RandomChaos]

I was trained to do trachs in an IM-CCM program. My IM-CCM trained attendings who trained at various different programs were my supervisors. And my colleagues who were IM-CCM trained in the 3 places I have worked in as an attending did perc trachs also. So Idk what else to tell you. We aren't trained in debridement and wound care though, so if you're looking for that you're going to have to go to a surgical CC program.

I never said that there are no IM programs that do trachs. You implied that the ACGME requires trachs as part of the procedural training of IM-CC. Which is not the case. I already stated that yes the top tier programs are the exception, but not the standard. The ACGME sets the standard across the majority of programs.

 

[CCM-MD]

I never said that there are no IM programs that do trachs. You implied that the ACGME requires trachs as part of the procedural training of IM-CC. Which is not the case. I already stated that yes the top tier programs are the exception, but not the standard. The ACGME sets the standard across the majority of programs.

I do not believe I trained at a "top tier" program. Not all of my IM-CCM attendings trained at "top tier" programs and the IM-CCM trained colleagues I worked at in the last 3 places did not all train at "top tier" programs. We all do perc trachs and weren't handed hospital privileges for just "talking about doing them" in our respective training programs.

 

[RandomChaos]

I do not believe I trained at a "top tier" program. Not all of my IM-CCM attendings trained at "top tier" programs and the IM-CCM trained colleagues I worked at in the last 3 places did not all train at "top tier" programs. We all do perc trachs and weren't handed hospital privileges for just "talking about doing them" in our respective training programs.

That’s fine. I was merely trying to be complementary. I think that we are getting far off topic for the original thread. I think if you’d like to continue this discussion would should do it via PM, as to not take over this thread with it. Your account is restricted and I’m unable to message you, but feel free to message me. I would love to continue chatting.

 

[CCM-MD]

That’s fine. I was merely trying to be complementary. I think that we are getting far off topic for the original thread. I think if you’d like to continue this discussion would should do it via PM, as to not take over this thread with it. Your account is restricted and I’m unable to message you, but feel free to message me. I would love to continue chatting.

Agreed.

 

[Dave1980]

Hello all,

This is an extremely common story, but I am a M3 going into M4 who was, until the ACEP jobs report, very much set on EM. I am also interested in critical care as an alternative to EM. With regards to things I like about the ED, I think I would miss the workup of the undifferentiated patient, patient conversations and reassuring patients/families, and the initial stabilization that you are able to do in the ED, but am hoping that some of those aspects are present in critical care as well. Would love to hear from folks what similarities and differences there are in general between EM and CC. Here are some other questions I had:

1 - I was wondering what the competitiveness of critical care fellowships were for EM grads; my current understanding is that they are more competitive since there are less CC only fellowships, but not impossible to get into.

2 - In addition, what does the job market look like for EM/CC people? Is it reasonable to expect to be able to work in a metropolitan area without being PCCM certified?

3 - Finally, I was considering doing IM and then a PCCM or CC fellowship afterwards. However, I would very much like to avoid working in an outpatient setting, and was wondering if I did do PCCM, if I could work soley in the ICU and avoid pulm clinic. I also heard that if you are PCCM and are on a 1 week on 1 week off schedule, then you would have to spend your week off from the ICU doing clinic, which I would not enjoy very much; would like to get clarification on this if possible.

Thanks in advance for any and all advice!

I've always though it was weird that EM docs can do a 2 year fellowship to be an ICU doc. In med school one of the EM docs would be like 1 week of ICU a month and I was on the team during that week. They didn't seem as sure of themself as the dedicated ICU docs.

 

[sylvanthus]

Well if NPs can do it, why not? May as well let docs lateral into other specialties with shortened training timeframes at this point.

 

[Rekt]

Well if NPs can do it, why not? May as well let docs lateral into other specialties with shortened training timeframes at this point.

Careful. They're called APPs in this forum. They'll never take ICU jobs.

 

[Doc Doc Doc Goose]

EDIT: In essence, my end goal is to work in an ICU in a big city kind of area. My absolute ideal job would technically be splitting time between the ED and the ICU, but my understanding is that this is extremely rare so I am definitely not holding my breath for that. Will going through the EM/CC pathway significantly impact my ability to live where I generally want or to work where I want?

EM/CCM (or IM/EM) docs I’ve spoken with say this isn’t as rare as people (like the ppl on here who aren’t even trained in or looking to practice both) might lead you to believe. What is rare, is you expecting you’ll find a SINGLE hospital, and thus an EM department and CCM department, to hire you and set you up with a perfect 50:50 split.

What is more likely, is you’ll be able to set up part-time positions in both, at different hospitals, but quite possibly in the same city.

Or you find a “75%” position and work PRN, ir full time in one and PRN , or some weird PRN and PRN…… you get the idea ….. you allow yourself to be flexible, and it can work.

 

[sylvanthus]

Yaaa it is pretty damn hard to find a split position. Best ive done is 1/2 or fulltime IcU with working in the ED as a gun for hire. Honestly the best,imo, plan is to work fulltime IcU in a W-2 position at a nonprofit (for PSLF purposes), form an LLC, work ED shifts as an independent contractor for the solok, and other tax writeoffs.

Problem is now, finding ED shifts is difficult.