Thank you for the answer man.
I just find the fact that going critical care after anesthesia/IM/surgery is interesting as (we previously have seen) many seem to warn about the future of anesthesiologists, even with fellowships. So at this point I'm a bit confused - how are CRNAs and a lower salary in the future a threat for an anesthesiologist if he/she did a fellowship within critical care and covers the SICU? Apparently even surgery with a fellowship can end covering SICU, and I never hear CRNAs threat surgery. The thing here is that going anesthesiology was the plan, and if things go bad, a critical care fellowship would be the rescue (as I end with people who did IM/surgery etc. and thus it is as if the anesthesia residency and its ominous future with CRNAs/lower salary etc. never happened).
Also, regarding critical care, is it considered "bad" in terms of lifestyle just because of the shift work? That's how EM docs have it, isn't that so? And EM docs do have a nice lifestyle, even with the shift work being a part of the job.
How are the pulmonologists having it? Seems like they recently have gotten a big rise in salary compared to the other specialities (+11 %). Looks like a promising one, but I have no idea how the work hours are.
The reason I mentioned pulmo- and oncology and critical care is because of their income which seems to be in the 300k+/year category. And based off your text, critical care seems less workload-heavy than oncology. Unless pulmonology is even less workload-heavy than critical care, I might go anesthesia combined with critical care fellowship.
1) I agree with what PlutoBoy said.
2) From what the attending anesthesiologists on the anesthesia forum say, anesthesiology with a critical care fellowship is mixed. It could be good or bad. It depends who you ask. Personally, I think anesthesia with critical care is a good choice, but I'm not 100% focused on having a good lifestyle.
3) If you want lifestyle more than anything else, then critical care after anesthesia is not necessarily a good choice. That's because critical care tends to be a worse lifestyle than anesthesia -- or at best equal. I'm sure there are exceptions like if you are working at a lower acuity unit, but I'm speaking in general. All I'm saying is lifestyle isn't what usually comes to mind when people think of critical care.
4) Also, I keep hearing from anesthesiology attendings that it's very difficult to find a private practice job that allows you to do
both anesthesiology and critical care at the same time (e.g., one week of critical care, the rest of the month anesthesia). There are some exceptions here and there (e.g., Seinfeld has such a job), but they seem few and far between.
5) However, one big exception is academics. You could work both anesthesia and CCM at an academic/university. But academics in general tends to pay a lot less than private practice. And academic lifestyle isn't necessarily any better than private practice either, but it depends on your specific institution. A lot of places do have a better lifestyle in terms of call burden for example than a lot of private practice groups, but again it depends. A lot of private practices have a good lifestyle too. But again just speaking in general, if you don't mind significantly less pay than private practice, +/- good lifestyle, then academics is an option. There are also some perks to working in academics, but again it depends on the specific institution we're talking about.
6) In addition, if you ask the attendings on the anesthesia forum, critical care through anesthesia in general covers the SICU or CCU, and usually not the MICU. Again, there are always exceptions, but I'm speaking in general. If you are covering the SICU, then you won't likely be the attending of record. Instead, that will be the surgeon. So you'll be a consultant to the surgeon. Some people don't mind this, but other people don't like having to "take orders from surgeons" as I heard someone once say. If you always want to be "the boss" and in charge of your patients in the ICU in a closed unit, then critical care via anesthesia might not be the best route for you. You should probably go the IM to pulm/cc route. You're more likely to have to work in the MICU though. But keep in mind that's a different patient population than the SICU.
7) Yes, pulm/cc jobs are currently in huge demand. But ICU physicians in general are in demand. Especially as more ICUs become closed rather than open, there will be only increased demand for ICU physicians. So if you want to do 100% ICU and 0% anesthesia, then you could do anesthesia, then CCM (try to do your CCM at someplace that allows you to get a good mix of different ICU environments including the MICU, so that way you can have experience working in all different types of ICUs), and you should have no problem finding a 100% ICU job even in a MICU (which has traditionally been pulm/cc), at least that's my understanding.
8) Anesthesia does face its problems and challenges. So do many other specialties. But like PlutoBoy said, anesthesia will always be around. Most likely you will have to supervise CRNAs as the care team model is only expanding and as it is financially better to use the model for a lot of anesthesia groups. I think it's already ~50% of all anesthesia groups that use the anesthesia care team model, and only growing. I believe I read Richard Novak at Stanford University citing that number somewhere on his website.
For example, you may likely have to supervise anywhere from 2-4 CRNAs or maybe more in the future (who knows). So, worst case scenario, if you are okay with supervising CRNAs, then you will be fine. But keep in mind a lot of the attending anesthesiologists on the anesthesia forum say they would much rather sit their own cases and not have to supervise CRNAs.
9) CRNAs and other midlevels don't threaten surgeons, because no one else can cut the way surgeons do. There are PAs and other midlevels, but they don't do what surgeons do.
10) In terms of lifestyle, yes, I would say critical care is probably most comparable to EM. Both work tons of nights, weekends, holidays. Both can work long shifts, though from what I've seen, critical care tends to work longer single shifts than EM.
11) But personally, though I'm sure others may disagree, I would say critical care is a bit better than EM in terms of lifestyle in some ways. The pace isn't always as intense as in the ED. You still round on patients, going from one patient to the next, and don't have to juggle a bunch of patients in your head at the same time, not in the same way as in the ED anyway. You're not multitasking as much as in the ED. You're not in the "fish bowl" as in the ED where everyone else in the hospital is judging you. You don't have to call attendings or fellows and convince or sometimes fight with them to admit a patient, or see a patient or at least not as much as in the ED. You're considered a specialist rather than a generalist (though of course I believe EM physicians are specialists but a lot of people in the hospital unfortunately don't treat them that way). I'm sure there are lots of other things.
12) That being said, I would not say critical care is necessarily a good lifestyle, not compared to other specialties or subspecialties. It's still hard work. You still see a lot of deaths. You have to talk to families about why care is futile and you should pull the plug on their family member. You still see a lot of s*** that you probably won't see if you're an outpatient based specialty. Do you want to be doing chest compressions on a crashing patient in the ICU when you're 50 or 60 years old? And that's not even all that bad compared to other worse things you have to do.
13) But anyway, my point is, we all love the excitement of the ICU, especially when we're still young and single, but the problem is that a lot of older ICU physicians, once they get married and have a family, tell me that they would prefer to have a more stable life. Work during more regular hours. Work on less sick patients. Be able to see their families more and spend more time with their families when their families are awake. Obviously most people are awake during the day and asleep at night, unlike working shift work jobs where you're constantly rotating between night and day. The constant rotating or change between night and day and day and night could mess up your Circadian rhythm too. It is easy to recuperate when we're young, although it doesn't always feel that way!, but talk to older ICU physicians and some of them have told me that it gets tougher to recover as you age. I've even heard of marriages being destroyed because the ICU physician couldn't make it to many of their spouse's or children's events but had to be at work. Maybe they can switch to a lower acuity unit or work less shifts if they don't need the money. I'm not sure as I'm not an attending let alone an ICU attending. So in general, the ICU is fun, but it does seem very hard. I still like the ICU a lot though. But sometimes I do worry about working in the ICU as an older physician someday. Maybe you can reach out to older ICU physicians in the US and see what they have to say about the lifestyle of working in the ICU?
14) But that's why I think if you like anesthesia, then general anesthesia might be a better choice in terms of lifestyle than working in the ICU. There are lots of anesthesia jobs out there where you can do mommy track, locums, work for an outpatient surgicenter, and so on, where you can have a good lifestyle and work predictable hours and be home with your family. There are downsides to these jobs too, but if you don't care about money, and you don't care about some possible skills deterioration (though you could pick it up again maybe), then that could be a good choice. You might have to manage CRNAs still though, but if you don't mind CRNAs, then you should be fine.
15) I agree pulm/ccm is a solid choice if you like it. They do work very hard though. But what's good about pulm/cc is that you can transition from doing less CCM and more pulm as you get older. Just focus more on outpatient pulm. You can have a good lifestyle if you do pulm only. So during your younger years, you could do lots of time in the unit since it's fun and exciting, but as you get older, see more pulm patients. You can have a great lifestyle seeing only pulm patients. It's mostly the ICU that is considered bad in terms of lifestyle. Inpatient pulm is bad in terms of lifestyle to some extent too, but not as bad as the ICU at least in my opinion.
16) I don't think oncology is necessarily worse in terms of lifestyle than pulm/cc. Actually, I think oncology is usually better, at least if we are talking about private practice. Maybe a better way to put it is to say that oncology in private practice is mostly outpatient, so it's similar-ish to doing mostly outpatient pulm. Basically, if you want lifestyle, focus more on seeing outpatients. That's true for any specialty though. Hospital-based specialties tend to have worse lifestyles than outpatient based ones, but again I'm just speaking in general, and there are exceptions. Again, as has been said, if you want lifestyle in an IM subspecialty, then allergy/immuno, endo, and rheum are your best bets. They're all mostly outpatient, few emergencies so you don't have much call, and on the rare occasion you do, you'll most likely be taking the call from home in the comfort of your own bed!
Contrast this to many anesthesia jobs where you are in-house, sleeping overnight in the hospital, not at home. Or even if you do home call, then you will often have to come into the hospital in the middle of the night for a case or place an epidural or something. But to be fair, there are anesthesia jobs where you don't have to do things like trauma or OB and so can have a better lifestyle overall.
17) If $300k is your goal, you could do that in many specialties, though again you might have to give up something like location or lifestyle. You can maybe even do that in general IM, or get pretty close, after a few years as a partner in a group. I know a couple of general IM physicians (partners) who make $300k+ in a relatively nice part of the nation. They have a good lifestyle too. So I guess they win in all the three major categories of money, lifestyle, and location. But most of their patients have good private insurance so that's probably why. Not sure if they are the exception though.
18) Actually, if you want lifestyle, and high pay, you could go for radiology (if you like the work). Do teleradiology or emergency radiology.
