Who can do CCM?

[ariwax]

I guess it's a pretty straightforward question... is it just anesthesiologists, or can surgeons or primary care people get in on the action, too?

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[southerndoc]

Anesthesiology, internal medicine, and surgery all have subspecialty certifications available in critical care.

Emergency medicine trained individuals can enter into critical care, but cannot get subspecialty certified in the US (they can take a European certification exam). It is unlikely that emergency medicine trained individuals can become subspecialty certified in critical care in the near future. It's questionable if they can in the distant future. The hanging point seems to be when the specialty was granted board/specialty status, they agreed to not provide inpatient care. This is why emergency medicine has no critical care subspecialty board. On another note, the Leapfrog group recognizes emergency medicine individuals trained in critical care as intensivists. You can secure a job even if you are not subspecialty certified.

I have heard of neurologists and cardiologists who have done critical care fellowships.

 

[militarymd]

And in private practice.....ANYONE can do critical care...no fellowship or certification required.

 

[JackBauERfan]

And in private practice.....ANYONE can do critical care...no fellowship or certification required.

anyone can do critical care, but I think there are only selected specialties that can get board certified in it. I know its Internal medicine, surgery (from trauma part, and just general), anesthesiology, and for some reason I remember seeing Ob/gyn can. EM as a bunch of fellowships, but you can't get certified is my understanding. There was a nice paper in the EM annals...can't find it now though.

 

[proman]

To be considered an intensivist for Leapfrog purposes you can be:

BC + subspecialty certified in CCM (anesthesiology, IM, OB, peds, surgery)
BC in EM + completion of CCM fellowship
BC in IM, anesthesiology, peds, surgery prior to subspecialty certification being available (1986) AND have done a minimum of 6 weeks CCM a year since 1987.

Like MMD said, anyone in private practice open model can take care of patients in the ICU, but they are not intensivists. I've seen FP do it, and I've known internists who were the medical directors of their ICU (town of 15,000). Note that this does not meet Leapfrog requirements.

 

[waterski232002]

What exactly is the "Leapfrog Group"?

To be considered an intensivist for Leapfrog purposes you can be:

BC + subspecialty certified in CCM (anesthesiology, IM, OB, peds, surgery)
BC in EM + completion of CCM fellowship
BC in IM, anesthesiology, peds, surgery prior to subspecialty certification being available (1986) AND have done a minimum of 6 weeks CCM a year since 1987.

Like MMD said, anyone in private practice open model can take care of patients in the ICU, but they are not intensivists. I've seen FP do it, and I've known internists who were the medical directors of their ICU (town of 15,000). Note that this does not meet Leapfrog requirements.

 

[proman]

http://leapfroggroup.org/

It's a consortium of organizations that buy health care (mostly large corporations). The mission is to improve outcomes, safety and efficiency at lower cost. The purpose is to use group purchasing power to shape US healthcare to be more evidence and "best practice" based. It's voluntary, but hospitals that are in compliance get their business at the expense of those not in compliance. It was founded after the 1999 IOM medical error study. For main measures: 1) computer physician order entry 2) evidence-based hospital referral 3) ICU physician staffing 4) Safe Practice Score. They've funded a lot of the research that shows the reduced M&M and cost associated with staffing of ICUs with fellowship-trained intensivists. Their website has a lot more info.

 

[Adcadet]

In my neck of the woods the nephrologists used to be the main providers of critical care services. I guess there was a large group practice and they covered the MICUs until it became more profitable to run dialysis centers. Todays it's pulm/cc people doing most of the MICU work, at least in the closed units.

 

[Firebird]

Is board certification necessary to be a competent intensivist? Can one train in an IM residency to be capable of attending an ICU? If so, is board certification mainly helpful in getting jobs where the hospitals require board certificaiton?

 

[Firebird]

Bump

 

[proman]

I think hospitals consider the following in order:

1) BC/BE
2) fellowship trained but not boarded
3) residency trained/BC but not fellowship trained
4) residency trained but not boarded (red flag)

Can you be competent without the fellowship? Depends on you. But, do you think that the 2-4 months of CCM that most residencies offer is sufficient training vs the 1 year + previous training? I don't. BTW the EM guys don't have a subboard so they take the European boards to show proficiency.

 

[Firebird]

No I would agree that the fellowship would offer much more of an opportunity to learn Critical Care. However, here are a couple questions.

1. Don't the Pulmonary/Critical care fellowships only require like 6 mo. of critical care management training?
2. If you were doing an IM residency, couldn't you choose to do your electives in critical care settings? That would provide quite a bit more time in the ICU.

 

[waterski232002]

That's like saying a medical student could just do a couple 4th year electives on the general medical wards/ambulatory clinics and they would be qualified to practice as an internist.

If you want to practice and be competent in critical care, do a fellowship. As an internist you get little-to-no experience in any of the life saving procedures crucial to the ICU (central line placement, acute airway management, RSI, cricothyroidotomy, pericardiocentesis, tube thoracostomy).

 

[Firebird]

That's like saying a medical student could just do a couple 4th year electives on the general medical wards/ambulatory clinics and they would be qualified to practice as an internist.

If you want to practice and be competent in critical care, do a fellowship. As an internist you get little-to-no experience in any of the life saving procedures crucial to the ICU (central line placement, acute airway management, RSI, cricothyroidotomy, pericardiocentesis, tube thoracostomy).

Well, as a 4th year your responsibilities are very limited, but as a resident, you have quite a bit more that is required of you. So I wouldn't say that your analogy is dead on...but I'll buy the rest of what you said.

 

[proman]

The evidence is clear: residency trained physicians who take care of ICU patients are less cost efficient and have worse outcomes. In addition, the 24 hour direct supervision by fellowship trained intensivists is even better. Why do you fight this?

 

[Eidolon6]

No I would agree that the fellowship would offer much more of an opportunity to learn Critical Care. However, here are a couple questions.

1. Don't the Pulmonary/Critical care fellowships only require like 6 mo. of critical care management training?
2. If you were doing an IM residency, couldn't you choose to do your electives in critical care settings? That would provide quite a bit more time in the ICU.

Waterski's comments are little off the mark as most internists are required to have some dedicated critical care training (just like EM, Surgery, anesthesia) though it is agreed that it is not adequate to be routinely taking care of critically ill patients...this argument could be extended to anesthesiology and surgery (esp surgical subspecialists) who do not have dedicated critical care training.

Most IM residencies offer 6 months or so out of 3 years of ICU time and options for electives. Many community programs don't have dedicated closed ICU's so critical care is applied is an open ICU model....which is not ideal. Some surgical residencies are like this as well with a lot of ICU care performed in the open ICU model with some dedicated closed ICU time. As for Pulmonary/CCM, the rule is a minimum of 6 months of dedicated critical care and given staffing shortages, most fellowships have more...for example we cover the ICU in my fellowship >12 months of 36 total training months, including call. For example, in my first year I was on 6 months of dedicated ICU time, taking ICU call on weeknights and weekends, alternating with other fellows for the entire 12 months....plenty of critical care experience and I still have 6 months of dedicated ICU staffing to go.

Currently, Pulmonary/CCM is the largest subspecialty practicing "critical care" with ~80% of BC/BE physicians being IM/CCM or IM/Pulm/CCM trained, trend which is likely to continue as the population ages and the need for non-surgical critical (and some surgical) critical care grows.

As for procedures, it is true that there has been a decline in IM procedures...we use more PICCs, US guided "centeses", and we are becoming more judicious about central lines and many hospitals are employing airway crews/anesthesia for intubations. That being said, all the opportunities to do these procedures and become facile with them exist in IM residency and beyond....just may require a little extra effort seeking them out. The other side note here is to beware of spending too much time in the ICU and not doing other things (inpt renal, some critical subspecialties) as one can insulate himself too much in the ICU and forget how systems based medicine is performed outside of it.

Now to look at the pool in IM wanting to do critical care full time, its fairly small. In a somewhat recent study in Critical Care Medicine, despite 41% of 150 IM residents marking an interest in Pulm/CCM medicine, only 2% actually persued the specialty. IM is a feeder specialty for medical subspecialties...larger than any other in medicine and many of those specialties do not focus solely on critical care...therefore to offer too much critical care time would subtract from other practical experiences. This also leads to a broad range of personalities in a given program charged with providing critical care...and frankly some people are not as suited to it as others. Its not an ideal model and talk, given the recent work hours changes, has been leveled about increasing IM training time to four years and providing fastracking options for specialty bound residents. This may favor the subspecialties but would likely hurt the general IM workforce given additional length of training.

 

[Firebird]

The evidence is clear: residency trained physicians who take care of ICU patients are less cost efficient and have worse outcomes. In addition, the 24 hour direct supervision by fellowship trained intensivists is even better. Why do you fight this?

Note that I said I would buy the rest of what he said, just not his analogy. So I'm not fighting what he said, at all.