how to get into a critical care fellowship

[im2b]

I'm a 3rd year med student interested in critical care. What is the application process for a critical care fellowship? What type of qualifications do you need to get in? Are pulm / critical care fellowships very competitive?

Thanks!

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[Eidolon6]

There are multiple avenues.

90% of critical care physicians go through internal medicine (3 years), followed by fellowship in pulmonary and critical care (3 years). The lionshare of critical care docs in practice outside of major medical/academic centers are PCCM. Generally, pulmonary/CCM is less competitive than GI or Cards, however prestigious programs are very competitive.

You may also gain CCM training without pulmonary, which is typically 2 years after IM residency or 1 year of training after an IM subspecialty fellowship (cardiology, nephrology, etc.)

Surgical critical care, usually tied with trauma surgery, is 1-2 years following a 5-7 year general surgery residency.

Anesthesiology critical care is usually 1-2 years following a 4 year anesthesiology residency.

Neurology critical care does exist, usually tied in with a fellowship in stroke.


Pediatric critical care is a 2 year fellowship following 3 years of pediatric residency.

As of yet, emergency medicine has been trying to get a certified critical care specialization...but this has not happened yet. A handful of fellowships will train EM docs in critical care.

Some "fast track" opportunities are available, but these generally involve trading a year of say IM training to be a PCCM or CCM fellow for and extra year.

Which route to go depends on personal preferences. If you want the cerebral aspect of IM and broad number of diagnoses/conundrums then PCCM is the way to go. As a pulm CCM guy, I find the variety of problems in the MICU the most interesting and challenging.

If you like trauma (and trauma patients), the OR, post op patients/issues and management peppered with internal medicine issues, surgery/anesthesia is better bet.

As for jobs...not going to be a problem. PCCM jobs are abundant as are trauma/CCM jobs.

 

[Toohotinvegas33]

Correct me if I'm wrong, but I also thought there is a route thru EM is this true? Or is it thru EM/IM/CCM?

 

[Eidolon6]

EM/IM/CCM at Pittsburgh is one....still, for board certification you have to have the IM currently....may change with time.

 

[KGUNNER1]

Nice summary Eidolon. Just a few additions.

Now all of Peds fellowships are 3 years after the 3 years of pediatrics.

Most of the variation in training is related to an optional year of research that some fellows take. Strictly speaking, the only pathways that aren't one year fellowships are Peds and IM/CC (2 yrs).

EM is variable. There are a couple EM/IM/CC 6 yr programs - Henry Ford in Detroit and Pittsburgh. You are boarded through IM though.

EM can sit for European boards and may be helpful for certain hospitals (Univ of Pittsburgh requires that all of their attendings are "board certified". They recognize the European - EDIC - "board")

kg

 

[Lucid Dreaming]

So can a general surgeon who did a CCM fellowship be the intensivist for a MICU or PICU? Likewise, can an IM who did PCCM be the attending for a SICU?

Sounds like that's the way to go if someone wanted to learn surgery but didn't want the lifestyle of a surgeon.

 

[Pilot Doc]

So can a general surgeon who did a CCM fellowship be the intensivist for a MICU or PICU? Likewise, can an IM who did PCCM be the attending for a SICU?

No one has the power to set rules for who can be a CCM attending. All you need is a license. You could have only completed 18 months of an OB residency and still be a MICU, PICU or SICU attending.

On a practical level, it varies substantially by institution. If I had to generalize, adult intensivists are fairly mobile across MICU/SICU/etc. I don't think people go back and forth from adult to peds, though.

 

[somedude98317]

EM/IM/CCM at Pittsburgh is one....still, for board certification you have to have the IM currently....may change with time.

While on the interview trail for EM, I interviewed at a few Prelim Medicine places since I applied to several 2,3,4 programs. At one of those Prelim Med programs, I mentioned that I was interested in Critical Care following my EM residency. The doctor that was interviewing me is a dinosaur and prominent figure in the Pulm/CC world. His response to my statement was quite discouraging. While laughing he said, ER docs and CC docs only have 2 things in common:

1) They work shifts

2) They "see" really sick patients, then went on to say that ER docs literally only "see" the sick but haven't a clue when it comes to properly managing them.

That gave me the sense that the dinosaurs won't be letting any of the EM trained folks to sit for the boards anytime soon.

Safe to say I won't be ranking that prelim med program....

 

[KGUNNER1]

While on the interview trail for EM, I interviewed at a few Prelim Medicine places since I applied to several 2,3,4 programs. At one of those Prelim Med programs, I mentioned that I was interested in Critical Care following my EM residency. The doctor that was interviewing me is a dinosaur and prominent figure in the Pulm/CC world. His response to my statement was quite discouraging. While laughing he said, ER docs and CC docs only have 2 things in common:

1) They work shifts

2) They "see" really sick patients, then went on to say that ER docs literally only "see" the sick but haven't a clue when it comes to properly managing them.

That gave me the sense that the dinosaurs won't be letting any of the EM trained folks to sit for the boards anytime soon.

Safe to say I won't be ranking that prelim med program....

One guarantee about dinosaurs, they all eventually become extinct.

These types are out there, I know some personally. However, there are not nearly as many as there were 10 or 15 years ago. Many of the freshly minted intensivists have trained in a contemporary model and understand that a multidisciplinary approach to CC is what is needed if we are going to staff as many ICUs with properly trained intensivists in the future.

Your approach is wise. I just smile when I hear these folks, you will NEVER change their mind for them, no matter what rationale you use. They either slowly come around or they will just fade away over the next 5-10 years.

Remember, you'll be around practicing medicine long after they're gone, and what the field looks like in 10 years will be different than what it is today.

kg

 

[Dr. Dukes]

Doesn't the SCC program at Shock Trauma take EM grads?

 

[Eidolon6]

While on the interview trail for EM, I interviewed at a few Prelim Medicine places since I applied to several 2,3,4 programs. At one of those Prelim Med programs, I mentioned that I was interested in Critical Care following my EM residency. The doctor that was interviewing me is a dinosaur and prominent figure in the Pulm/CC world. His response to my statement was quite discouraging. While laughing he said, ER docs and CC docs only have 2 things in common:

1) They work shifts

2) They "see" really sick patients, then went on to say that ER docs literally only "see" the sick but haven't a clue when it comes to properly managing them.

That gave me the sense that the dinosaurs won't be letting any of the EM trained folks to sit for the boards anytime soon.

Safe to say I won't be ranking that prelim med program....

This is an area of frustration we face in light of increasing numbers of ICU beds (and LTAC beds) without a significant increase in manpower. EM folks represent a possible resource for providing critical care services which some of the old guard may not fully embrace, despite the growing gap between increasing number of ICU beds without a substantial increase in providers.

Agreeing with KGUNN here, critical care is not a domain ruled by one group or another... Multidisciplinary critical care is the wave of the future, where there is consistency among training programs from different specialty backbones and where guidelines composed of expert opinions from the different disciplines can be employed with some consistency.

As I have said before, the backbone the EM provides would be entirely adequate to support a *complete* training program for delivery of critical care beyond the ER. I can't predict that this potential worker pool will make a dramatic dent in the forthcoming shortages in CCM but perhaps may be at least a finger in the crack within the dam.

Now I can say all these things and it sounds nice, but to get the Sharks and the Jets to agree on combining critical care training programs nationally and establishing a multidisciplinary training model is a daunting if not impossible task....and hence we have just a handful of such programs where the "Division" of critical care exists.

If ER is your passion then follow it...but be careful if you decide critical care is your grand amour as the road for acceptance for ER/CCM may still be bumpy as the old guard changes, although the movement needs its leaders. At this time, there are more expeditious, guaranteed ways to reach that goal.

One final statement/opinion/rant ---> ICU care is not necessarily "shift work" and we should be more aware of how we think of critical care delivery. 12 hour shift models exist but at current, most ICUs employ physicians that cover daytime work hours for at least a week or > 1 week periods with call or *shifts* being shared, much as it is with other inpatient practices. "Shift work" implies washing one's hands of the care of critically ill patients at the end of the day when the reality is if the the patient is fortunate to be alive in the morning, they are still your responsibility and the longer term knowledge of their condition is generally more enriched than a covering call physician. The ICU stay of a critically ill patient may range from 3 hours to 3 months and provision of continuous care does have an impact on our success in the ICU and this should be reflected in the future goal of 24 hour MD ICU coverage. Additionally, many of these patient's care following their ICU stay and/or hospitalization will be continued by the ICU physician (as occurs with, for example, the pulmonary/CCM, trauma/CCM models). This may be distinctly different than the shift model of staffing found in emergency departments.

 

[dbiddy808]

I think that as long as Emergency Medicine guys do a MINIMUM of two years fellowship (if not three) there is nothing wrong with having them become intensivists. From my experience in internal medicine (I did an internal medicine residency prior to going into anesthesiology) the ED guys had a limited depth of knowledge regarding managing complex medical problems. Its not neccessarily their fault, just a reflection of their role. I do think that they have good knowledge as far as treating acute, life-threatening problems though....which is also very important.

 

[southerndoc]

I think that as long as Emergency Medicine guys do a MINIMUM of two years fellowship (if not three) there is nothing wrong with having them become intensivists. From my experience in internal medicine (I did an internal medicine residency prior to going into anesthesiology) the ED guys had a limited depth of knowledge regarding managing complex medical problems. Its not neccessarily their fault, just a reflection of their role. I do think that they have good knowledge as far as treating acute, life-threatening problems though....which is also very important.

I'm not sure where you are, but most quality EM programs teach residents in-depth knowledge of complex medical problems, particularly with management.

 

[NDESTRUKT]

From what I see, Pulm/CC aren't too competitive to get into unless you wanna go to top of the line programs...

Is what I'm saying correct? I know some residents I worked with who didn't know what to do afterwards and so they never got a chance to do research in pulm/CC and got fellowships...

Again, am I right or just speculation?

 

[Eidolon6]

Pulm/CCM is less competitive overall than cardiology and GI. Top programs are very competitive however. Anesthesia CCM and surgical CCM generally are less competitive out of their respective base training.