2 year CC fellowship after IM

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How is the job market for internists who do a 2 year fellowship in CC? Especially if they want the majority of their practice to be ICU shift work type of arrangement.

Originally Posted by igcgnerd

How is the job market for internists who do a 2 year fellowship in CC? Especially if they want the majority of their practice to be ICU shift work type of arrangement.

It's good generally but starting to saturate in certain "desirable" markets. You may end up with more night and weekends in those places starting off.

I don't mean to hijack the forum, but I thought this would be a relevant question: is there an avantage technically in doing a P/CCM over a two year CCM program? It may be premature for me to consider this, but right now it's what am interested in: IM and CCM, I don't want to bother with pulmonary but it seems the most conventional way to go through IM to CCM. I was wondering anyone's thoughts on this, preferably residents, fellows, and attendings.

Originally Posted by ajleyva

I don't mean to hijack the forum, but I thought this would be a relevant question: is there an avantage technically in doing a P/CCM over a two year CCM program? It may be premature for me to consider this, but right now it's what am interested in: IM and CCM, I don't want to bother with pulmonary but it seems the most conventional way to go through IM to CCM. I was wondering anyone's thoughts on this, preferably residents, fellows, and attendings.

Doing a Pulm-CC fellowship makes you more marketable from what I hear which translates into more job opportunities. This is mainly since you can truly be a part of the group and share in all the calls. There are some job openings out there for strictly intensivists but they are a bit more few and far between. Who you know is going to be key.

I am thinking about doing a critical care fellowship after my residency but I am doing very thorough research on practice patterns and demand for my desired areas before I commit. I am aware of a few ID and Nephro fellows who are doing 1 year CC fellowships after their original IM-subspecialty training which will be very marketable for them. Seems to me that if you are not Pulm-CC then you need to have something that will appeal to a Pulm-CC dominant group (private>academia) since you won't be able to do Pulm consults/clinic. If you are strictly IM-CC then maybe something like ECMO, TEE skills, still being able to Bronch, etc would be my guess but I am still looking into it so take it with a grain of salt.

Perhaps JDH or one of the other Pulm-CC experts will comment.

If I am not mistaken the big thing about pulm CC is that once you burn out with ICU you can retreat/fall back on the pulmonary part for a more relaxed lifestyle. Like one of our attendings at my hospital who went to become chief of pulmonary at another hospital and no longer does any ICU.

Having said that if you did CC after IM I guess you could similarly fall back on IM for a relaxed lifestyle.

There may also be a slight advantage to doing pulmonary as it can help with vent mgmt although perhaps the same can be said of doing ID can help with Abx or doing Renal can help with fluid management.

The other issue is I actually thought that shift based work for intensivists is on the rise and demand for nocturnal intensivist also on the rise. I guess that kind of jobs dont leave much room for pulmonary.

Personally I love pulmonary too and so I chose that.

Originally Posted by inspirationmd

Doing a Pulm-CC fellowship makes you more marketable from what I hear which translates into more job opportunities. This is mainly since you can truly be a part of the group and share in all the calls. There are some job openings out there for strictly intensivists but they are a bit more few and far between. Who you know is going to be key.

I am thinking about doing a critical care fellowship after my residency but I am doing very thorough research on practice patterns and demand for my desired areas before I commit. I am aware of a few ID and Nephro fellows who are doing 1 year CC fellowships after their original IM-subspecialty training which will be very marketable for them. Seems to me that if you are not Pulm-CC then you need to have something that will appeal to a Pulm-CC dominant group (private>academia) since you won't be able to do Pulm consults/clinic. If you are strictly IM-CC then maybe something like ECMO, TEE skills, still being able to Bronch, etc would be my guess but I am still looking into it so take it with a grain of salt.

Perhaps JDH or one of the other Pulm-CC experts will comment.

The reason being is that I'm interested in primary care as well, which is what I would hope to do when I'm not in the ICU. As I understand it, few dedicate their entire practice to CCM for burnout reasons. With this being said, instead of falling back doing pulmonary clinic, I would return to my primary care patients. This is the reason I'm adverse to pulmonary; because I'm not interested in practicing it at all outside of the ICU, so I don't see it economically viable to spend the extra time for it.

I suppose I could go a step further and say (without knowing exactly how this works) if a patient of mine is hospitalized, then I can round on them on the general medicine floor and follow them to the ICU if needed. Of course, this depends on many things such as hospital privileges, institutional policies, open vs closes ICUs, etc. But I can dream.

Originally Posted by ajleyva

The reason being is that I'm interested in primary care as well, which is what I would hope to do when I'm not in the ICU. As I understand it, few dedicate their entire practice to CCM for burnout reasons. With this being said, instead of falling back doing pulmonary clinic, I would return to my primary care patients. This is the reason I'm adverse to pulmonary; because I'm not interested in practicing it at all outside of the ICU, so I don't see it economically viable to spend the extra time for it.

I suppose I could go a step further and say (without knowing exactly how this works) if a patient of mine is hospitalized, then I can round on them on the general medicine floor and follow them to the ICU if needed. Of course, this depends on many things such as hospital privileges, institutional policies, open vs closes ICUs, etc. But I can dream.

Originally Posted by Hernandez

Would you care to elaborate? I would love the input.

Originally Posted by ajleyva

Would you care to elaborate? I would love the input.

It's like say IM/EM guys, it's ungodly rare to see someone actually do IM, often time due to the salary discrepancies. After working ICU, the last thing I want to deal with is the bull**** insurance companies and bogus complaints and pain seekers for a pittance. Then the next question is, who is going to cover your primary care office when your in the office? You can't run away from a code to see a sick visit, or push off doing a procedure to do a pap. If you're n the ICU, you need to be in the ICU. Then the next question is, who's going to hire you? There is a massive shortage of CC docs, many don't need a primary care intensivist. Then if you're doing the old school IM, where you have office, in pts, and even cover your ICU pts, good luck with that life style, you're pager will..... never ......stop.........

Originally Posted by Hernandez

It's like say IM/EM guys, it's ungodly rare to see someone actually do IM, often time due to the salary discrepancies. After working ICU, the last thing I want to deal with is the bull**** insurance companies and bogus complaints and pain seekers for a pittance. Then the next question is, who is going to cover your primary care office when your in the office? You can't run away from a code to see a sick visit, or push off doing a procedure to do a pap. If you're n the ICU, you need to be in the ICU. Then the next question is, who's going to hire you? There is a massive shortage of CC docs, many don't need a primary care intensivist. Then if you're doing the old school IM, where you have office, in pts, and even cover your ICU pts, good luck with that life style, you're pager will..... never ......stop.........

I've thought of some of these things before as well, albeit (obviously) not extensively. So it is safer to assume that it would be easier to be a hospitalist working in the ICU, then? I feel like this (being only IM/CCM) would be easier to accomplish in academia versus in private practice (based on what you told me), I suppose unless I joined a hospitalist group?

Could I pick your brain about this, too: I'm also interested in anesthesiology. Do you know how common it is for an anesthesiologist-intensivist to practice in a MICU as well as a SICU (in both academic and private hospitals)? I, personally, would like to practice in both, but I suppose at the end of the day I'm more interested (or rather more motivated) to work in the MICU.

I really appreciate your responses; they're really informative and I feel like they're clearing up a lot of the assumptions I'm making (I am only premed after all). Thank you!

Re anesthisia, you like pay cuts? As you will make less as a gas-icu doc. Than as gas doc. So some work in MICU? Yes. It in theory, it's possible, but I'm theory America can still put a man on the moon.

Originally Posted by Hernandez

Re anesthisia, you like pay cuts? As you will make less as a gas-icu doc. Than as gas doc. So some work in MICU? Yes. It in theory, it's possible, but I'm theory America can still put a man on the moon.

I am aware of the pay cut and I'm certain I wouldn't mind it. I'm not entirely concerned with the money, more with the art. I suppose at the end of the day I won't really know where I want to go until medical school. I do know I want to practice critical care medicine, though. Thank you for your time and replies, good sir.

One of our hospitalists is IM/CC trained and so he sees a combo of regular floor pts as well as ICU pts. The other hospitalists on the group are strictly IM. At least here they're still allowed to manage pts in the ICU but will transfer to the IM/CC guy if they are vented or truly require CC.... procedures, bronch, etc...

That of course will vary on the hospital/ ICU policies and the hospitalist group.

Ultimately I guess he could give up the CC portion and just do IM work, but honestly, between the social work aspect/headaches of a general floor pt, I'm not sure that's much less stressful than his typical ICU duties...

Originally Posted by nlax30

One of our hospitalists is IM/CC trained and so he sees a combo of regular floor pts as well as ICU pts. The other hospitalists on the group are strictly IM. At least here they're still allowed to manage pts in the ICU but will transfer to the IM/CC guy if they are vented or truly require CC.... procedures, bronch, etc...

That of course will vary on the hospital/ ICU policies and the hospitalist group.

Ultimately I guess he could give up the CC portion and just do IM work, but honestly, between the social work aspect/headaches of a general floor pt, I'm not sure that's much less stressful than his typical ICU duties...

That's a really helpful sentiment. Do you have any idea what kind of pts the IM/CC doc manages in the ICU?

On a relative tangent, it's interesting. I was looking at Pitt's CCM fellowships websites and comparing the sample rotations between the IM pathway and anesthesia and it seems that anesthesia's training is geared strictly toward the surgical patient; this makes sense. However conversely, the IM fellows seem to rotate in both the medical and surgical ICUs. Granted, the surgical patients IM manages are primarily transplant pts, but I believe I saw a trauma/SICU rotation on there, too. This seems to echo a lot of what I read on here: IM/CC (and pulmonary) seem to manage both pts populations more than anesthesia (whom focuses primarily on surgical pts). Do I have the right idea here? Someone please correct me if I'm wrong.

Originally Posted by ajleyva

That's a really helpful sentiment. Do you have any idea what kind of pts the IM/CC doc manages in the ICU?

Basically all sorts of unit patients..... post surgical, intubated, intracranial hemorrhages, septic, CHF, etc.... Technically he doesn't do diagnostic bronchs since he's not pulm trained so on occasion may have to bring a Pulm guy on board but in practice operates like one of the other Pulm/CC teaching attendings.

Originally Posted by ajleyva

That's a really helpful sentiment. Do you have any idea what kind of pts the IM/CC doc manages in the ICU?

On a relative tangent, it's interesting. I was looking at Pitt's CCM fellowships websites and comparing the sample rotations between the IM pathway and anesthesia and it seems that anesthesia's training is geared strictly toward the surgical patient; this makes sense. However conversely, the IM fellows seem to rotate in both the medical and surgical ICUs. Granted, the surgical patients IM manages are primarily transplant pts, but I believe I saw a trauma/SICU rotation on there, too. This seems to echo a lot of what I read on here: IM/CC (and pulmonary) seem to manage both pts populations more than anesthesia (whom focuses primarily on surgical pts). Do I have the right idea here? Someone please correct me if I'm wrong.

I don't think I would use Pitt's CCM program or the IM-CCM 'rotation schedule' as a represetative of "typical" of IM-based CCM fellowships...

HH

Originally Posted by Hamhock

I don't think I would use Pitt's CCM program or the IM-CCM 'rotation schedule' as a represetative of "typical" of IM-based CCM fellowships...

HH

I'm under the impression that their bar is set a bit high?

Originally Posted by Hernandez

It's like say IM/EM guys, it's ungodly rare to see someone actually do IM, often time due to the salary discrepancies. After working ICU, the last thing I want to deal with is the bull**** insurance companies and bogus complaints and pain seekers for a pittance. Then the next question is, who is going to cover your primary care office when your in the office? You can't run away from a code to see a sick visit, or push off doing a procedure to do a pap. If you're n the ICU, you need to be in the ICU. Then the next question is, who's going to hire you? There is a massive shortage of CC docs, many don't need a primary care intensivist. Then if you're doing the old school IM, where you have office, in pts, and even cover your ICU pts, good luck with that life style, you're pager will..... never ......stop.........

Perhaps you want to read this. If by ungodly rare you mean 44% practice IM at least part-time then yes it is ungodly rare.

http://onlinelibrary.wiley.com/doi/1...9.00503.x/full

Anecdotally that has not been my experience with a n>20. I only know 2 people who have done any IM post graduation. But anecdote < data.

As an IM/CC fellow looking for jobs, the jobs for PCCM are definitely more available. There are physician groups that only do CCM without pulmonary clinics or practices, the more often than not the group practices are PCCM. That said, a physician group that handles both a pulmonary practice AND critical care coverage for hospitals it is contracted with is a MUCH different job that someone who works in a group that exclusively does CCM. In a pulmonary practice the days you're not in the ICU you are expected to manage your pulmonary practice, that means taking calls at night for outpatient practice and for pulmonary consult, scheduling bronchs, getting to tumor board, and seeing your patients.
A critical care group practice is very similar to a Hospitalist group or an emergency Medici e group where it is designed around shift work. And when you are off, you are off. There are certainly areas in Pulmonary that are very interesting, and if you have a strong desire to make it apart of your career, such as lung cancer, CF, sleep, transplant, chronic ventilator management, or asthma, it's definitely something you should into. But keep in mind that a PCCM physician job will expect more output from you in the days you are not in the ICU.

As an IM/CC fellow looking for jobs, the jobs for PCCM are definitely more available. There are physician groups that only do CCM without pulmonary clinics or practices, the more often than not the group practices are PCCM. That said, a physician group that handles both a pulmonary practice AND critical care coverage for hospitals it is contracted with is a MUCH different job that someone who works in a group that exclusively does CCM. In a pulmonary practice the days you're not in the ICU you are expected to manage your pulmonary practice, that means taking calls at night for outpatient practice and for pulmonary consult, scheduling bronchs, getting to tumor board, and seeing your patients.
A critical care group practice is very similar to a Hospitalist group or an emergency Medici e group where it is designed around shift work. And when you are off, you are off. There are certainly areas in Pulmonary that are very interesting, and if you have a strong desire to make it apart of your career, such as lung cancer, CF, sleep, transplant, chronic ventilator management, or asthma, it's definitely something you should into. But keep in mind that a PCCM physician job will expect more output from you in the days you are not in the ICU.