FP Critical Care

[betamale]

Anyone know a CCM fellowship program that is willing to accept an FP doc? A bunch of us have been doing ER/Hospitalist for >1-2 years and the workflow requires us to cover ICU patients. We have hospitalist-fellowships but the ICU rotations are limited. It would be great to have FPs with intensive care training to cover our rural/critical access hospitals that need a provider with OB/ER/Hospital medicine/Peds skills.

Any disparaging remarks...not welcome...only real leads, thanks.

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[CCM-MD]

Anyone know a CCM fellowship program that is willing to accept an FP doc? A bunch of us have been doing ER/Hospitalist for >1-2 years and the workflow requires us to cover ICU patients. We have hospitalist-fellowships but the ICU rotations are limited. It would be great to have FPs with intensive care training to cover our rural/critical access hospitals that need a provider with OB/ER/Hospital medicine/Peds skills.

Any disparaging remarks...not welcome...only real leads, thanks.

Consider FCCS: SCCM | FCCS Sixth Edition

No ACGME CCM fellowship will take an FM doc.

 

[ParkerLocker]

Anyone know a CCM fellowship program that is willing to accept an FP doc? A bunch of us have been doing ER/Hospitalist for >1-2 years and the workflow requires us to cover ICU patients. We have hospitalist-fellowships but the ICU rotations are limited. It would be great to have FPs with intensive care training to cover our rural/critical access hospitals that need a provider with OB/ER/Hospital medicine/Peds skills.

Any disparaging remarks...not welcome...only real leads, thanks.

Shock Trauma Surgical CC program has accepted a FM physician in the past. I trained alongside her.

 

[CCM-MD]

Shock Trauma Surgical CC program has accepted a FM physician in the past. I trained alongside her.

I know of her. Exceptional person. Unlikely to happen again. There isn't enough inpatient or ICU exposure in standardized FM residency training to produce quality intensivists.

 

[chocomorsel]

I know of her. Exceptional person. Unlikely to happen again. There isn't enough inpatient or ICU exposure in standardized FM residency training to produce quality intensivists.

What if the FM person had a keen interest in it and did a few electives in it? Enough to equal the IMs? Of course, most won’t, but there will be a few. Just like there are a small percentage of us from anesthesia.
Quite frankly, I would look at the San Fran March and see what anesthesia programs didn’t fill and reach out. There are always free spots. Always. They may want a body and work it out w ACGME. I train alongside NPs. Why the hell can’t an MD or DO be given a position?

 

[CCM-MD]

There is always outliers. Anyone can do anything. Standardized training and board certification provide a level of generalizable quality. FCCS is adequate training for FM/IM docs in rural/critical access hospitals. Followed by transfer to a higher level of care if necessary. This is what FCCS was designed for.

 

[betamale]

Thanks. Canada has a CCM residency that accept FM docs that have enough ICU rotation for acceptance into the program; we'll look into those.The training pathway should probably evolve soon and accept FM docs into the training programs.

In any case, not all FM residencies are same just as IM resident experiences vary. Some of us trained in Level II trauma where we are the only residents and have to cover 2-3 specialty/general ICUs, get all the lines/intubations...

Tisherman SA, Spevetz A, et al. A Case for Change in Adult Critical Care Training for Physicians in the United States: A White Paper Developed by the Critical Care as a Specialty Task Force of the Society of Critical Care Medicine. Crit Care Med. June 2018.

 

[CCM-MD]

Thanks. Canada has a CCM residency that accept FM docs that have enough ICU rotation for acceptance into the program; we'll look into those.The training pathway should probably evolve soon and accept FM docs into the training programs.

In any case, not all FM residencies are same just as IM resident experiences vary. Some of us trained in Level II trauma where we are the only residents and have to cover 2-3 specialty/general ICUs, get all the lines/intubations...

Tisherman SA, Spevetz A, et al. A Case for Change in Adult Critical Care Training for Physicians in the United States: A White Paper Developed by the Critical Care as a Specialty Task Force of the Society of Critical Care Medicine. Crit Care Med. June 2018.

You’re mistaken about Canada. I know their training system well as I did part of my training there. Family medicine training is accredited by CFPC and all other “specialty” training is accredited by the Royal College. Critical care medicine training is accredited by the Royal College. There is no pathway to "accredited" critical care medicine training after completion of a family medicine residency. There is probably non-accredited fellowships that anyone can do... but theres those in the US also.

 

[CCM-MD]

That is an excellent paper by the way . I am all for unified multidisciplinary training and certification for CCM. Maybe there will be a ABCCM in my life time.

Link to paper: A Case for Change in Adult Critical Care Training for Physicians in the United States: A White Paper Developed by the Critical Care as a Specialty Task Force of the Society of Critical Care Medicine

 

[Lexdiamondz]

What if the FM person had a keen interest in it and did a few electives in it? Enough to equal the IMs? Of course, most won’t, but there will be a few. Just like there are a small percentage of us from anesthesia.

The difference though is that anaesthesiologists have a considerable amount of critical care training built into their residency experience, and caring for the critically ill and managing haemodynamically unstable patients is a fundamental part of anaesthesiology (and IM, Surgery and EM) in a way that it simply isn't in FM. Of course, there are exceptions to the rule, but when you're talking about FM as a whole which typically spend 6 mos or less on inpatient medicine rotations, it's hard to argue that they should be taking a leadership role in the ICU as a fellow supervising PGY-3 IM residents who in many cases have more experience managing unstable patients.

 

[jdh71]

My preference wouldn't be for more critical care training for rural/access FP docs but sending those sick patients asap to a bigger facility that has all the main services available and trained guys who see these patients all day every day.

I mean any smart and motivated medical professional can learn anything given enough time and mentorship. This isn't me suggesting FP guys are idiots. Nor is it me trying to "get rich" hogging all the critically ill patients. It's just a reflexes thing and availability of services thing. The same reason I can't just walk into an OR and pretend to be an anesthesiologist just because there is some superficial surface overlap in drugs and vents or why you don't want me managing your outpatient HTN, CKD, and DM2 even though I knew how once and wasn't too bad at it.

OP. I wish you luck. I mean that. Very often critical care fellowships don't fill. I think I'd simply ask around after the match and see if you get any bites. You'll never be able to sit for any kind of boards but if that doesn't matter to you or your employer/group then . . .

 

[chocomorsel]

The difference though is that anaesthesiologists have a considerable amount of critical care training built into their residency experience, and caring for the critically ill and managing haemodynamically unstable patients is a fundamental part of anaesthesiology (and IM, Surgery and EM) in a way that it simply isn't in FM. Of course, there are exceptions to the rule, but when you're talking about FM as a whole which typically spend 6 mos or less on inpatient medicine rotations, it's hard to argue that they should be taking a leadership role in the ICU as a fellow supervising PGY-3 IM residents who in many cases have more experience managing unstable patients.

This is true as far as anesthesia residency.

However those family medicine residencies that train in unopposed hospitals get a vastly different, more in depth experience than family residents training in a hospital with a bunch of other residencies. But I don’t know how much inpatient versus outpatient they do.

 

[VA Hopeful Dr]

The difference though is that anaesthesiologists have a considerable amount of critical care training built into their residency experience, and caring for the critically ill and managing haemodynamically unstable patients is a fundamental part of anaesthesiology (and IM, Surgery and EM) in a way that it simply isn't in FM. Of course, there are exceptions to the rule, but when you're talking about FM as a whole which typically spend 6 mos or less on inpatient medicine rotations, it's hard to argue that they should be taking a leadership role in the ICU as a fellow supervising PGY-3 IM residents who in many cases have more experience managing unstable patients.

I don't really have a dog in this fight, but just to clear up a misconception. In My Family Medicine Residency I did 10 months of adult inpatient.

I can't speak for the entire country, but there is no program in my state that lets you get away with as little as six.

 

[deleted171991]

I find it sad that FM docs are trying to do non family-related fellowships. Why not a fellowship in OB, or surgery, or EM (if any of these exist), or something actually useful to a FAMILY practitioner? I subscribe to @jdh71's opinion.

This coming from somebody who actually likes patient-doctor relationships, and would have gone even into FM, had it not been for the midlevel takeover and the surgical side.

 

[Hernandez]

In My Family Medicine Residency I did 10 months of adult inpatient.

I’m trying to think how many non- inpatient months I had in IM training. I think 2. Allergy and endocrine.......

 

[deleted171991]

I’m trying to think how many non- inpatient months I had in IM training. I think 2. Allergy and endocrine.......

No clinic months/days?

 

[jdh71]

I’m trying to think how many non- inpatient months I had in IM training. I think 2. Allergy and endocrine.......

I think I was about the same. But during those months I still had to cover two Saturday weekend 24 hour supervisor calls.

 

[Hernandez]

No clinic months/days?

2 1/2 days a week every week.

 

[betamale]

According to the Royal College website...would I not qualify based on number "2" if I meet those rotations (which I do)?

ELIGIBILITY REQUIREMENTS
There are two routes of entry into adult Critical Care Medicine.

1. Royal College Certification in Anesthesiology, Cardiac Surgery, Emergency Medicine, General Surgery, or Internal Medicine, or enrolment in a Royal College approved training program in one of these areas (see requirements for these qualifications). Three (3) years of one of these primary specialties must be completed prior to the entry into the Critical Care Medicine program.
   OR
2. Entrance from other specialties may occur but must follow completion of the primary specialty training which must have included a minimum of:
   1. Three (3) months in a general medical/surgical intensive care unit (ICU)
   2. Fifteen (15) months of clinical rotations in Internal Medicine and / or General Surgery

You’re mistaken about Canada. I know their training system well as I did part of my training there. Family medicine training is accredited by CFPC and all other “specialty” training is accredited by the Royal College. Critical care medicine training is accredited by the Royal College. There is no pathway to "accredited" critical care medicine training after completion of a family medicine residency. There is probably non-accredited fellowships that anyone can do... but theres those in the US also.

 

[CCM-MD]

According to the Royal College website...would I not qualify based on number "2" if I meet those rotations (which I do)?

ELIGIBILITY REQUIREMENTS
There are two routes of entry into adult Critical Care Medicine.

1. Royal College Certification in Anesthesiology, Cardiac Surgery, Emergency Medicine, General Surgery, or Internal Medicine, or enrolment in a Royal College approved training program in one of these areas (see requirements for these qualifications). Three (3) years of one of these primary specialties must be completed prior to the entry into the Critical Care Medicine program.
   OR
2. Entrance from other specialties may occur but must follow completion of the primary specialty training which must have included a minimum of:
   1. Three (3) months in a general medical/surgical intensive care unit (ICU)
   2. Fifteen (15) months of clinical rotations in Internal Medicine and / or General Surgery

No. This is referring to other Royal College accredited specialties only - like neurology etc.

In addition, to pursue graduate medical training in Canada, you would have to pass Canadian licensing examinations - MCCQE 1 & 2, and would have to be a Canadian Citizen or permanent resident. Also keep in mind that CCM is a very competitive fellowship to obtain - theres only ~40 spots nationally for the entire country.

 

[Lexdiamondz]

I don't really have a dog in this fight, but just to clear up a misconception. In My Family Medicine Residency I did 10 months of adult inpatient.

I can't speak for the entire country, but there is no program in my state that lets you get away with as little as six.

It's still somewhat awkward when you consider that an IM PGY-1 at a mid-tier programme often gets 8-10 months of inpatient experience. Again, I'm not saying that FM trained intensivists are inherently worse, just that it's hard to justify putting a fellow with less than a year of total inpatient experience in charge of IM PGY-3s with more than double that (or in the case of SCC, anaesthesiologists or surgeons who have a longer total residency, period along with far more experience dealing with surgical patients and their particular post-op needs and complications)

 

[betamale]

It's still somewhat awkward when you consider that an IM PGY-1 at a mid-tier programme often gets 8-10 months of inpatient experience. Again, I'm not saying that FM trained intensivists are inherently worse, just that it's hard to justify putting a fellow with less than a year of total inpatient experience in charge of IM PGY-3s with more than double that (or in the case of SCC, anaesthesiologists or surgeons who have a longer total residency, period along with far more experience dealing with surgical patients and their particular post-op needs and complications)

fair point. i happen to have done an internal medicine year, radiology year, and emergency medicine year...6 years of GME. shouldn't entry be competency based? i can tell you that my hospital medicine experience in family medicine was more rigorous than any of my county-hospital and university-based, level I trauma center IM inpatient rotations since we were on call DAILY (daily census of 25-30 on a 3 resident rotation with new admits throughout the day) in family medicine and not q3 or q4 like we had in IM.

what if an FP has completed a hospitalist fellowship on top of FP residency or have taken additional hospital medicine/ICU rotations...would that not be enough?

 

[chocomorsel]

fair point. i happen to have done an internal medicine year, radiology year, and emergency medicine year...6 years of GME. shouldn't entry be competency based? i can tell you that my hospital medicine experience in family medicine was more rigorous than any of my county-hospital and university-based, level I trauma center IM inpatient rotations since we were on call DAILY (daily census of 25-30 on a 3 resident rotation with new admits throughout the day) in family medicine and not q3 or q4 like we had in IM.

what if an FP has completed a hospitalist fellowship on top of FP residency or have taken additional hospital medicine/ICU rotations...would that not be enough?

Geez, that’s a schmorgeshborg of years you did there.
I for one, don’t see the problem considering that so many anesthesia CCM Spots go unfilled. If there are physicians out there who want them they should be given a fair shot. However there would need to be an understanding as far as supervisory roles and such. It would be a fellowship the FMs would be more like senior residents the first year and then fellow next year.

 

[CCM-MD]

Op I feel for you. I don’t know why you took such a convoluted training path. Maybe you can find an IM program that will give you credit for ~2 years of training and let you graduate after a year - pursue CCM training after that.

Unless we are going to open up every IM subspecialty to family docs with “lots of IM exposure” or “hospital medicine” fellowships, a pathway to CCM from family med makes no sense. Something like endocrine or rheum even makes more sense than CCM.

 

[VA Hopeful Dr]

I find it sad that FM docs are trying to do non family-related fellowships. Why not a fellowship in OB, or surgery, or EM (if any of these exist), or something actually useful to a FAMILY practitioner? I subscribe to @jdh71's opinion.

This coming from somebody who actually likes patient-doctor relationships, and would have gone even into FM, had it not been for the midlevel takeover and the surgical side.

My understanding is that most FPs agree with you. We go into the field because we want to be generalists.

 

[VA Hopeful Dr]

I’m trying to think how many non- inpatient months I had in IM training. I think 2. Allergy and endocrine.......

Not trying to compare, just pointing out an inaccuracy.

My wife is an internist and I'm well aware that my inpatient training was not near what hers was.

 

[betamale]

I can make an argument that CCM is a "generalist". When have u ever seen a CCM doc do cardiac catheterization, colonoscopy, or major surgery...they consult as much as the hospitalists do. What I would like to gain from a CCM fellowship that we may not get in hospitalist fellowship is experience with real critical patients like crashing ARDS, alveolar hemorrhage, mucous plug, angioedema, status asmaticus, ICH, status epilepticus...that may show up in our ER or happen while in our ICU so we can stabilize them while awaiting a specialist consult which sometimes may not happen especially in rural areas or transport to tertiary facilities which many times is hampered by lack of transport/bad weather/ED/ICU diversion.

I love being a generalist but I want to be able to competently do it as much as I can...again...I have much more training than most FP which is why I like rural but there are so many things out there that really scare me but I probably can manage if I do a CCM fellowship (would like experience with bronchoscopy, SLED, surgical airway, endoscopy... which I have performed on cadavers, manikins but not in alive persons). I have plenty experience with most CC procedures including fiberoptic intubation, thoras, paras, dialysis caths, central lines, chest tubes, vent mgmt so that's not what I'm trying to learn...I've even placed ecmo catheters, IVC filter under my attending's supervision, place PICC lines, use fluoroscopy for procedures, use Vigileos but I haven't had the chance to learn how to place a transvenous pacemaker...(one of the things I'd like to learn)

I've read the FCCS book twice...fyi

Anyways, this is hard to understand for people who have not worked in rural hospitals or have only worked in academic facilities.

Australia have fellowships too...I'll look there.

I find it sad that FM docs are trying to do non family-related fellowships. Why not a fellowship in OB, or surgery, or EM (if any of these exist), or something actually useful to a FAMILY practitioner? I subscribe to @jdh71's opinion.

This coming from somebody who actually likes patient-doctor relationships, and would have gone even into FM, had it not been for the midlevel takeover and the surgical side.

 

[SDN]

This thread has been pruned and moved. Individuals that engaged in inappropriate behavior received a warning or had their membership revoked.

Moving forward, please stay professional and respectful. It's okay to have different opinions, it's not okay to disrespect fellow members.

 

[leviathan]

There are always opportunities for people to do training in anything. The only catch is you will not find an opportunity to do an accredited fellowship program or something that would make you certified as an intensivist.

If all you're looking for is more training to be a better doc for your patients, I 100% support that and think you should be able to find some sort of unofficial program out there that would take you under their wing. Canada does not have anything accredited, but if I had a family doc approach me and ask to work with me in the unit for a period of time it's something I might be receptive to doing, as long as medicolegally we and the hospital were all covered and approved for it.