Love the work, hate the outcomes

[Levo]

New intern on a MICU rotation here! I started my IM residency with the firm intention of doing pulm/crit as my career. I love respiratory physiology, ventilator management, pressors etc. I also love working with broad differentials and thinking through the diagnostic challenges of the MICU. Safe to say that the subject matter I'm working with right now on MICU is some of the most fascinating in medicine. However, the more time I spend in the MICU, the more I start to get a creeping feeling that we're not actually accomplishing that much. Many of our patients either have advanced cancer or are end-stage liver disease with no transplant on the horizon, being bridged to nowhere. Of the cases that were truly the most medically interesting, none have survived to discharge. The ones that do tend to be young people with DKA from non-compliance, which we have plenty of. So, while I love every minute of my actual work in the MICU, the end results feel unsatisfying. So much so that I'm actually thinking of primarily-outpatient specialties instead (and I never used to like outpatient). Has anyone else had these feelings? Thanks!

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[AdmiralChz]

New intern on a MICU rotation here! I started my IM residency with the firm intention of doing pulm/crit as my career. I love respiratory physiology, ventilator management, pressors etc. I also love working with broad differentials and thinking through the diagnostic challenges of the MICU. Safe to say that the subject matter I'm working with right now on MICU is some of the most fascinating in medicine. However, the more time I spend in the MICU, the more I start to get a creeping feeling that we're not actually accomplishing that much. Many of our patients either have advanced cancer or are end-stage liver disease with no transplant on the horizon, being bridged to nowhere. Of the cases that were truly the most medically interesting, none have survived to discharge. The ones that do tend to be young people with DKA from non-compliance, which we have plenty of. So, while I love every minute of my actual work in the MICU, the end results feel unsatisfying. So much so that I'm actually thinking of primarily-outpatient specialties instead (and I never used to like outpatient). Has anyone else had these feelings? Thanks!

Yes, this is a very common reason that people do NOT like MICU - the futility of care. It can be very frustrating, for sure. My ICU experience is more surgical-based where people typically do better and recover from surgical issues more readily. You may find you are more drawn to CCU (coronary ICU) s/p MIs or even SICUs better, so maybe see if you can do a rotation there. Unfortunately SICUs come with it often very protective and overbearing surgeons limiting your independence in some instances, so there are pros and cons.

 

[Hamhock]

Yes, this is a very common reason that people do NOT like MICU - the futility of care. It can be very frustrating, for sure. My ICU experience is more surgical-based where people typically do better and recover from surgical issues more readily. You may find you are more drawn to CCU (coronary ICU) s/p MIs or even SICUs better, so maybe see if you can do a rotation there. Unfortunately SICUs come with it often very protective and overbearing surgeons limiting your independence in some instances, so there are pros and cons.

Right. I've found a mix of SICU and MICU gets the best of both and just enough time in each unit to forget the problems associated with each.

HH

 

[WheezyBaby]

New intern on a MICU rotation here! I started my IM residency with the firm intention of doing pulm/crit as my career. I love respiratory physiology, ventilator management, pressors etc. I also love working with broad differentials and thinking through the diagnostic challenges of the MICU. Safe to say that the subject matter I'm working with right now on MICU is some of the most fascinating in medicine. However, the more time I spend in the MICU, the more I start to get a creeping feeling that we're not actually accomplishing that much. Many of our patients either have advanced cancer or are end-stage liver disease with no transplant on the horizon, being bridged to nowhere. Of the cases that were truly the most medically interesting, none have survived to discharge. The ones that do tend to be young people with DKA from non-compliance, which we have plenty of. So, while I love every minute of my actual work in the MICU, the end results feel unsatisfying. So much so that I'm actually thinking of primarily-outpatient specialties instead (and I never used to like outpatient). Has anyone else had these feelings? Thanks!

Yes, it's one of the primary reasons I'm interested in PICU over MICU. As above, there are other areas of ICU with better outcomes, but they come at the expense of other things. There are also other aspects of the work to draw fulfillment from - excellent teaching opportunities, interdisciplinary work, helping patients and their loved ones through the end of life process, etc

 

[WheezyBaby]

Tangential but how often are you doing procedures in the PICU? I love working with kids but gen peds is not something I am interested in. I've always seen myself as an intensivist of sorts but have come to realize recently that I love using my hands/ doing procedures. I am not interested in anesthesia (thought about peds anesthesia). I can't see myself working with adults but I really love being both a 'doer' and a 'thinker'. In your experience would you say PICU fits this the best?

Any insight is more than appreciated!

There's a good thread on it in the peds forum

PICU procedures

In general for peds, there's a lower threshold to escalate care and a higher threshold to perform invasive procedures than in the adult world. PICU definitely provides some balance of doer/thinker, but it's going to be heavily slanted to the latter, much more so at community places than large academic centers. That's preferable to me, but it's tough for me to say if it's the right balance for you

 

[SurfingDoctor]

Thanks, doc!

I've seen that thread: thank you for the info! I suppose the thing I fully don't understand is how often one is doing procedures as a PICU doc. Every day? Once a week? Once a month? Or is it too variable to say?

I guess that is what I was trying to get at in my original post but clearly didn't articulate it well (actually at all lol).

Depends on the size of the unit and patient acuity and honestly, random chance. If I had to average, I would say fellows do a couple a week. But, as you mentioned, it is highly variable. As a fellow, I can remember doing about 10 procedures on 1 patient in the span of a week (replacing lines, multiple chest tubes) but I remember dry weeks too.

 

[BigRedBeta]

Thanks, doc!

I've seen that thread: thank you for the info! I suppose the thing I fully don't understand is how often one is doing procedures as a PICU doc. Every day? Once a week? Once a month? Or is it too variable to say?

I guess that is what I was trying to get at in my original post but clearly didn't articulate it well (actually at all lol).

Really is highly variable - depends on the season, how many beds are in your unit, and private vs academic practice (and by extension number/type of trainees) and culture. I work in large (38+ beds and expanding), busy, non-academic unit. We have NP's who can do the procedures and PICC team that is available 6 days/wk to the bedside. But if I want, I can do all my own procedures. During RSV season, probably doing at least one intubation a week, a CVL a little less frequent and art lines less frequently than that as my group feels safe managing with CBG's and the occasional central VBG for most kids. But without trainees and a pretty independent nursing staff, there are definitely a portion of patients who we work hard to NOT intubate that would be tubed at other places. If our PICC team wasn't as active, I would do a lot more CVL's than I do.

As a fellow...lots more procedures than what I do now (except for chest tubes which had been farmed out to IR at my institution). Any kid that was borderline generally got intubated, PICC's required a trip to IR, and my attendings didn't feel that CBG's were sufficient so there were a lot more afternoons spent digging for an arterial line on a lot of patients. A fair amount of that was probably due to educational needs as there was fellow coverage 24 hours a day, and we needed the learning opportunities. Some of it was likely Ivory Tower hubris at work (ABG's are the gold standard, so CBG's are beneath us), and some of it was institutional (eg the lack of a bedside PICC team, better place a CVL).

After fellowship, in an academic setting with lots of fellows...attendings supervise the procedures but rarely perform them. You might be in the room with a new first year fellow, but with a third year fellow in the unit, you may be down the hall (or even asleep) while they're doing everything. But if you were at a place with just residents (and some places put interns into the PICU), there will be more procedures, but likely not as many as I do working on my own, since you can "supervise" the more competent residents.

The truth is though that procedures like LP's, intubation, CVL's, and art lines grow old. They're only part of the job and no longer have quite the draw they used to when I was a student or resident. I still like them, and enjoy the satisfaction when things go well, but it's just not the same.

Compared to anesthesia, it's definitely apples to oranges. You can't compare 2-4 procedures a week to running a room with 20 T&A's that will all be intubated. You'll have to ask the anesthesiologists if procedures are still a draw mid career...I anticipate that most would say "no" - that it's just a fact of daily life.

 

[bashwell]

You'll have to ask the anesthesiologists if procedures are still a draw mid career...I anticipate that most would say "no" - that it's just a fact of daily life.

At least on SDN's anesthesia forum, a lot of the anesthesiologists often say things like anyone can teach a monkey to do procedures, but what separates anesthesiologists from CRNAs is the deeper thinking, decision-making, knowledge base, etc. I love procedures, and so do many other residents (and med students), but my guess is by the time you've done so many over so many years it just becomes routine.

 

[bashwell]

New intern on a MICU rotation here! I started my IM residency with the firm intention of doing pulm/crit as my career. I love respiratory physiology, ventilator management, pressors etc. I also love working with broad differentials and thinking through the diagnostic challenges of the MICU. Safe to say that the subject matter I'm working with right now on MICU is some of the most fascinating in medicine. However, the more time I spend in the MICU, the more I start to get a creeping feeling that we're not actually accomplishing that much. Many of our patients either have advanced cancer or are end-stage liver disease with no transplant on the horizon, being bridged to nowhere. Of the cases that were truly the most medically interesting, none have survived to discharge. The ones that do tend to be young people with DKA from non-compliance, which we have plenty of. So, while I love every minute of my actual work in the MICU, the end results feel unsatisfying. So much so that I'm actually thinking of primarily-outpatient specialties instead (and I never used to like outpatient). Has anyone else had these feelings? Thanks!

Lots of great comments so far.

Maybe another thing to consider is how working in a MICU is different in a major academic center (where I assume you are for residency) vs. a community hospital (assuming you eventually want to work in the community).

Also, if you do pulm/cc, then I've heard that a lot of people as they age tend to do more pulm and less MICU. If you build your future practice to do primarily outpatient pulm, then it could meet your need to do an outpatient specialty.