Hospitalists & 1 yr CC fellowship

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Wodahs

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Hey guys, I'm PGY1 in IM right now and interested in CC. I am less than thrilled about doing a 3 yr fellowship with my 200K in loans racking up almost 8% per yr. I've heard people talk about a 1 year CC fellowship if you have already completed a 3 years of hospitalist medicine. I can't seem to find any clear details on if this is possible. If it is, what programs offer it and how marketable are you to work as an intensivist in a group and/or private hospital?

Thanks! :thumbup:

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Hey guys, I'm PGY1 in IM right now and interested in CC. I am less than thrilled about doing a 3 yr fellowship with my 200K in loans racking up almost 8% per yr. I've heard people talk about a 1 year CC fellowship if you have already completed a 3 years of hospitalist medicine. I can't seem to find any clear details on if this is possible. If it is, what programs offer it and how marketable are you to work as an intensivist in a group and/or private hospital?

Thanks! :thumbup:
So this is a propaosal at this point: http://onlinelibrary.wiley.com/doi/10.1002/jhm.1942/pdf

It was NOT well received by leadership heavily involved with American Thoracic Society and thus far no programs have adopted this which isn't surprising since it is a pretty new idea. At this point you can do ICU work as a hospitalist in most community hospitals and it is just the big tertiary care hospitals (ie. academic) where the units are more likely to be closed.
http://ajcc.aacnjournals.org/content/early/2012/06/20/ajcc2012825.full.pdf

It may change by the time we finish but I think if you have academic aspirations you have to either do Pulm-CC or 2- year critical care path. Otherwise expect to look for a ICU Hospitalist job and possibly gradually have more limitations if the intensivist workforce ever increases.
 
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I don't know, guys. At least one program has a one year CC fellowship:



http://www.maimonidesmed.org/medicaleducation/CriticalCareFellowship.aspx


You WILL NOT be board eligible via 1 year fellowship after internal medicine residency.


Diplomates may apply for admission to the critical care medicine examination under one of the three pathways.

Pathway A*

Two years of accredited fellowship training in a subspecialty of internal medicine (three years for cardiovascular disease and gastroenterology), including the care of patients in critical care units
Certification by ABIM in the subspecialty
One year of accredited clinical fellowship training in critical care medicine within the Department of Medicine.
*ABIM Diplomates who are also certified in neurology by the American Board of Psychiatry and Neurology may apply through Pathway A provided neurology training included the care of patients in critical care units and the additional year of accredited critical care medicine fellowship training is sponsored by a department of internal medicine.

Pathway B

Two years of accredited fellowship training in critical care medicine (including twelve months of full-time clinical training) within the Department of Medicine.
Pathway C

Two years of fellowship training in advanced general internal medicine that includes at least six months of critical care medicine
One year of accredited fellowship training in critical care medicine within the Department of Medicine
If you take the Critical Care Medicine Examination after completing two years of training in critical care medicine and before certifying in a subspecialty, you will be required to take two additional years of fellowship training in the subspecialty (three years for cardiovascular disease and gastroenterology) to take the subspecialty examination. No credit will be granted toward certification for training that is not accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada, or the Professional Corporation of Physicians of Quebec.
 
You WILL NOT be board eligible via 1 year fellowship after internal medicine residency.


Diplomates may apply for admission to the critical care medicine examination under one of the three pathways.

Pathway A*

Two years of accredited fellowship training in a subspecialty of internal medicine (three years for cardiovascular disease and gastroenterology), including the care of patients in critical care units
Certification by ABIM in the subspecialty
One year of accredited clinical fellowship training in critical care medicine within the Department of Medicine.
*ABIM Diplomates who are also certified in neurology by the American Board of Psychiatry and Neurology may apply through Pathway A provided neurology training included the care of patients in critical care units and the additional year of accredited critical care medicine fellowship training is sponsored by a department of internal medicine.

Pathway B

Two years of accredited fellowship training in critical care medicine (including twelve months of full-time clinical training) within the Department of Medicine.
Pathway C

Two years of fellowship training in advanced general internal medicine that includes at least six months of critical care medicine
One year of accredited fellowship training in critical care medicine within the Department of Medicine
If you take the Critical Care Medicine Examination after completing two years of training in critical care medicine and before certifying in a subspecialty, you will be required to take two additional years of fellowship training in the subspecialty (three years for cardiovascular disease and gastroenterology) to take the subspecialty examination. No credit will be granted toward certification for training that is not accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada, or the Professional Corporation of Physicians of Quebec.

Interesting. Thank you.

I guess that Pathway C means 2 years of IM fellowship plus 1 year of CC, correct?

I've seen some Nephrology/CC fellowships but I was not aware of arriving at CC via other fellowships. Do 1 year programs exist for people that did a fellowship but want to pursue CC? (A PGY-6 CC after, let's say, a nephrology fellowship).
 
I looked into this extensively before I signed my attending contract. Spoke with several PDs. The only one year fellowship option for IM based CC, is following a fellowship in something else. IE 3 years cardio followed by one year CC with dual boarding. This is crazy to me. You can do a 2 year ID fellowship with absolutely no CC training and then do a 1 year CC fellowship and take the boards, but I can practice as a CC hospitalist running a 20 bed MICU for 2 years and not have the same option of a 1 year fellowship. Sooo, at this point, unless you do a 2 year straight CC fellowship, you cannot be boarded, ACGME or AOA (I am a DO), in CCM. That said , I think it will change. eventually. The intensivist shortage is just too great. There is a teritary care center back home that is actively recruiting CC-hospitalists to join their team, with the hopes of eventually becoming board eligible after 5 or so years experience. This is my next stop after I finish my two years at my current community shop. Hopefully by then they will allow you to sit for the boards after the years of service or atleast allow a 1 year fellowship. After my 3 years of IM, which by the time I am done will have 8 months of total CC, and 4-5 years running a MICU as a CC-hospitalist, you can't tell me that I have less training then the gas guys who do 4 + 1. It would be fantastic if we could get a one year slot after that path. Obviously this is CC only, no pulm boarding. But I see changes coming with the rise in CC hospitalists and the massive shortage of intensivists.

Additionally, the only reason to do this is to work in a tertiary center, which I would like to do. If you are a CC-hospitalist running a community ICU and are happy doing so, keep on doing it. It is highly unlikely the intensivist numbers will increase and cause you to have to move back to general hospitalist medicine. But if community ICU is not enough, you need the fellowship, atleast as of now.
 
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I looked into this extensively before I signed my attending contract. Spoke with several PDs. The only one year fellowship option for IM based CC, is following a fellowship in something else. IE 3 years cardio followed by one year CC with dual boarding. This is crazy to me. You can do a 2 year ID fellowship with absolutely no CC training and then do a 1 year CC fellowship and take the boards, but I can practice as a CC hospitalist running a 20 bed MICU for 2 years and not have the same option of a 1 year fellowship. Sooo, at this point, unless you do a 2 year straight CC fellowship, you cannot be boarded, ACGME or AOA (I am a DO), in CCM. That said , I think it will change. eventually. The intensivist shortage is just too great. There is a teritary care center back home that is actively recruiting CC-hospitalists to join their team, with the hopes of eventually becoming board eligible after 5 or so years experience. This is my next stop after I finish my two years at my current community shop. Hopefully by then they will allow you to sit for the boards after the years of service or atleast allow a 1 year fellowship. After my 3 years of IM, which by the time I am done will have 8 months of total CC, and 4-5 years running a MICU as a CC-hospitalist, you can't tell me that I have less training then the gas guys who do 4 + 1. It would be fantastic if we could get a one year slot after that path. Obviously this is CC only, no pulm boarding. But I see changes coming with the rise in CC hospitalists and the massive shortage of intensivists.

Additionally, the only reason to do this is to work in a tertiary center, which I would like to do. If you are a CC-hospitalist running a community ICU and are happy doing so, keep on doing it. It is highly unlikely the intensivist numbers will increase and cause you to have to move back to general hospitalist medicine. But if community ICU is not enough, you need the fellowship, atleast as of now.

CCM fellowships for all should be 2 years...except for surgeons who commit to only trauma and post-surgical critical care.

Of course, I think CCM fellowships should be standardized across base specialties...I CCM training should be standardized, independent of base specialty.

HH
 
It seems to me that various people in the hiring process, even the (ugh) recruiters, want to know if you're Board Eligible and is in the final stage of your training or Board Certified, in which case they want to know where to send the bottle of wine and if you need your car detailed this week. Unless you're really looking to be procedure-based and need to fill out every procedure section of your hospital privileges questionnaire, stick with the IM-Hospitalist route and you can manage most patients in most ICUs appropriately.
 
The fellowship is not for the procedures it's for the knowledge in managing critically ill patients, advanced mechanical ventilation techniques, etc., beyond what you learned in residency.
I am 60% through an IM residency and I am credentialed in:
Central lines (all approaches w/wo US)
Airways
Aline's
Chest tubes
Paracentesis
Thoracentesis
Emergent trans-venous pacer placements
Swans
IABP, though a cardio guy is already there with pt on table before I would ever be placing one

Doing IM residency at a community shop has allowed me to perform more procedures Already than several of my cc fellow friends did in academia up to an including what they have done so far in fellowship. But in no way does that mean I have anywhere near the level of CC knowledge as them. That's where the fellowship comes in to play.
 
The fellowship is not for the procedures it's for the knowledge in managing critically ill patients, advanced mechanical ventilation techniques, etc., beyond what you learned in residency.
I am 60% through an IM residency and I am credentialed in:
Central lines (all approaches w/wo US)
Airways
Aline's
Chest tubes
Paracentesis
Thoracentesis
Emergent trans-venous pacer placements
Swans
IABP, though a cardio guy is already there with pt on table before I would ever be placing one

Doing IM residency at a community shop has allowed me to perform more procedures Already than several of my cc fellow friends did in academia up to an including what they have done so far in fellowship. But in no way does that mean I have anywhere near the level of CC knowledge as them. That's where the fellowship comes in to play.
There is a huge difference between "credentialed" and "proficient"... It always scares me when I hear my IM (sometimes even FM) colleagues saying that they "can intubate".... Same is true for many of my fellow EM folks (take a look at the actual ED airway statistics...) - it's interesting to see that those people that actually ARE proficient tend to be very careful and humble when they talk about their skills.

But, anyways, I agree that a CC fellowship is really not about procedures, but about knowledge.
 
There is a huge difference between "credentialed" and "proficient"... It always scares me when I hear my IM (sometimes even FM) colleagues saying that they "can intubate".... Same is true for many of my fellow EM folks (take a look at the actual ED airway statistics...) - it's interesting to see that those people that actually ARE proficient tend to be very careful and humble when they talk about their skills.

But, anyways, I agree that a CC fellowship is really not about procedures, but about knowledge.
As was mentioned, you do learn about many of the procedures in the list in IM residency and proficiency means being able to reproduce what you were tought without supervision. Residency is about just that. I'm not arguing against doing a fellowship if you and your family can take the extra stress for those years, but you really have to be sure you need that extra training. I rarely see High-frequency Vents used anywhere and hospitals may have an anesthesiologist do a non-emergent intubation, but you need to know how to do the latter by the time you finish residency and sitting down with a respiratory tech for a few hours can help you manage the former. That buzzing sound for HFV is awesome for the first few minutes, but becomes very distracting when you're trying to quickly write a note. You're rarely going to be asked to start ECMO and can help manage it if you work in partnership with a good neonatologist. I could go on, but you get the point.

I'll take being BE/BC in IM/Hospitalist medicine and get my proficiency in advanced procedures and management by my first hospital out of residency and carry it through to the next one once the credentialling office and the med-mal people see that everything checks out.

Just my n=1.
 
I agree proficient does not equal credentialed. However my lines are in the 100s, airways in the 50s/60s, difficult airway course certified, etc. so I consider myself credentialed and more than proficient. But i agree with you, you can do most cc without a fellowship. At this point with my fa,ily size and debt load I cannot afford a fellowship. I will be a 'critical care hospitalist' at my shop when I am done with residency. Which is fine and dandy. I still wish I could do the fellowship as I only see it as a means to make me a better critical care attending.
 
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I agree proficient does not equal credentialed. However my lines are in the 100s, airways in the 50s/60s, difficult airway course certified, etc. so I consider myself credentialed and more than proficient. But i agree with you, you can do most cc without a fellowship. At this point with my fa,ily size and debt load I cannot afford a fellowship. I will be a 'critical care hospitalist' at my shop when I am done with residency. Which is fine and dandy. I still wish I could do the fellowship as I only see it as a means to make me a better critical care attending.

So you completed an IM residency and then started working as an hospitalist in the ICU? Is that what you mean by ICU hospitalist? Is this setup seen frequently? Sounds awesome :thumbup: I m just a 4th year student but I ve done 2 months of hardcore ICU SubIs and I love it. At first I was really intimidated by the ICU and vents and drips..etc but after a few weeks its pretty amazing what you can do in a well run ICU. My first rotation was at a "not well run" ICU at a county hospital but next rotation was at what I considered a well run ICU at a county hospital-university program. For the most part I can see how a well trained IM doc could take care of most ICU pts (heck most ICUs are open at most community centers and private hospitals)..

How many months of ICU did you do before you felt comfortable in the ICU?
 
I am an anesthesiologist at a 250 bed community hospital in a medium sized city. Our setup is an open ICU with intensivist coverage during the day (~7am-5pm) with internist/hospitalists covering overnight. Our intensivists (2 IM/CC and 1 anes/CC) our great and I have no qualms about sending sick patients up to them.

However, I am consistently blown away by how terrible the hospitalists at our institution are at managing critically ill patients. First of all, they call us up for every airway, line placement, etc, because they don't feel comfortable with these procedures. I don't mean they call us infrequently for difficult line placement or airways; I mean that we perform every procedure for them when the intensivists aren't there. And I have learned to put blinders on and stay out of the management picture, because they are constantly doing things like running pressors through a peripheral IV without an art line and checking a cuff pressure every 15 minutes while titrating pressors. Or calling to ask me to put some super sick old cardiac cripple to sleep so "interventional radiology can do an LP" (because as far as they know, that's the only way to get an LP). Or "ordering a line placement" from me (like he's ordering a medication or a diet), having a nurse call me up there, and when I have questions about anything, the dude is sleeping in his call room while his patient's crapping out. Or calling to have a patient intubated for "airway swelling" but not considering that this is anaphylaxis and having no treatment considered/ordered/started (I gave the guy 20 mcg epi, watched the swelling/stridor go away, and went back to bed).

Anyway, enough venting (bad pun?). I am not a CC guy, but I did do 8 months of CC in residency (PICU, NICU, MICU, SICU, neuro-ICU, CCU, mixed med/surg ICU, etc) and having supervised IM residents and watched them "lead" the code teams as PGY-3's, I feel that the training just isn't there in most instances. In my residency, ICU seniors were either IM/CC fellows, pulm/CC fellows, trauma/CC fellows, anes/CC fellows, or anesthesia CA-2/3 residents. New IM/CC or pulm/CC fellows were definitely behind the curve with respect to procedures and ICU management. They caught up (with training), but were pretty rough fresh out of IM residency. I know training programs are different, and some IM programs might have excellent CC curricula, but in my experience (both as a resident and in PP), IM folks probably need some more training before they're manning ICU's with no additional help/resources. Just my $0.02.
 
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Early on in my IM residency I knew I wanted to do CCM, so I did A LOT of ICU (probably more than is really legit) by trading with other residents who hated ICU. At the end, I knew a lot of critical care medicine, and "felt comfortable" managing "anything" in the ICU. I had a pretty fat procedure log too.
When I started my CCM fellowship, I realized how much more there was to know, and how "Proficiency" in procedures is a relative term. Both my knowledge and my skills expanded after my first year of CCM fellowship. Then I really knew what I was doing. That is until I started picking up on some of the finer points in my second year of fellowship.
Now that I graduated and started practicing I really know everything that I need to.... yeah, right! Any clinician worth his or her salt, who pays attention, knows that you can never have enough training or spend enough time learning.
At each new level you either improve, or you backslide and fall into bad habits or fail to grow with the discipline.
Anyone who thinks they are proficient or well-trained has essentially given up. There are nuances and new ideas every few months. Clinical judgment should be ever-expanding.
My point is that two years is better than one, if you are paying attention and open to keep learning!
 
The fellowship is not for the procedures it's for the knowledge in managing critically ill patients, advanced mechanical ventilation techniques, etc., beyond what you learned in residency.
I am 60% through an IM residency and I am credentialed in:
Central lines (all approaches w/wo US)
Airways
Aline's
Chest tubes
Paracentesis
Thoracentesis
Emergent trans-venous pacer placements
Swans
IABP, though a cardio guy is already there with pt on table before I would ever be placing one

Doing IM residency at a community shop has allowed me to perform more procedures Already than several of my cc fellow friends did in academia up to an including what they have done so far in fellowship. But in no way does that mean I have anywhere near the level of CC knowledge as them. That's where the fellowship comes in to play.

You're credentialed in balloon pumps as a medicine resident? Who supervises you for those? A cardiologist?
 
The fellowship is not for the procedures it's for the knowledge in managing critically ill patients, advanced mechanical ventilation techniques, etc., beyond what you learned in residency.
I am 60% through an IM residency and I am credentialed in:
Central lines (all approaches w/wo US)
Airways
Aline's
Chest tubes
Paracentesis
Thoracentesis
Emergent trans-venous pacer placements
Swans
IABP, though a cardio guy is already there with pt on table before I would ever be placing one

Doing IM residency at a community shop has allowed me to perform more procedures Already than several of my cc fellow friends did in academia up to an including what they have done so far in fellowship. But in no way does that mean I have anywhere near the level of CC knowledge as them. That's where the fellowship comes in to play.

I'm going to call some shenanigans here, I'm damn near done with fellowship and have literally logged over 1400 procedures in 5.5 years, and am not "credentialed" as a sr pulm-CC fellow to do balloon pumps, or trans venous pacers without an attending in the room. Nor have I done that many and we spend a ton of time in our CCU as consultant CC guys. And this is a hospital that does cardiac transplant and lots of cardiac surgery, it's just not that common of a procedure. Nor have there been much if a need for me to do many swans in the ICU setting, although I am credentialed.
 
You're credentialed in balloon pumps as a medicine resident? Who supervises you for those? A cardiologist?

Yes or the CT surgeons who I voluntarily did 2 months with. Again, not a practical procedure for me in the MICU as they are put in in the cath lab or OR during STEMIs/surgery but I figured getting experience putting them in will make me more competent in managing them in the MICU as an attending. Plus I like procedures :D
 
I'm going to call some shenanigans here, I'm damn near done with fellowship and have literally logged over 1400 procedures in 5.5 years, and am not "credentialed" as a sr pulm-CC fellow to do balloon pumps, or trans venous pacers without an attending in the room. Nor have I done that many and we spend a ton of time in our CCU as consultant CC guys. And this is a hospital that does cardiac transplant and lots of cardiac surgery, it's just not that common of a procedure. Nor have there been much if a need for me to do many swans in the ICU setting, although I am credentialed.

You can call whatever you want. the procedures are there if you look for them. I went to the CT surg guys and anesthesia folk and asked if I could start their cases putting in the swans and Alines early int he morning before going to start my neurology rotation or whatever stupid month I happened to be on at that time. They were all delighted to have a medicine resident so enthusiastic to do procedures. I can't say any of my fellow residents did this nor are any of them capable of doing more than 1/2 of those procedures but then again I am the only one going into CC. And temporary trans venous pacers only need 5 to be signed off by the cardio attending. Similar to swans, its a jugular line which we have done hundreds of, then float a wire, tape in place. I actually got to do 2-3 temp pacers as a med student with my buddy in the ED. Again, this is all based on being a hands on guy at a community shop where most people are not interested in procedures. So when one of my fellow residents is on cardio and they are planning to do outpt Primary care, I come down and do the caths with the cardio attending whenever possible as the other resident has no interest in doing them. They love extra sets of hands and after a few months they just started letting me do everything and just stand there and guide me to make sure I dont F up. Has really worked out well for me.
 
QUOTE=Hernandez;13705850]I'm going to call some shenanigans here, I'm damn near done with fellowship and have literally logged over 1400 procedures in 5.5 years, and am not "credentialed" as a sr pulm-CC fellow to do balloon pumps, or trans venous pacers without an attending in the room. Nor have I done that many and we spend a ton of time in our CCU as consultant CC guys. And this is a hospital that does cardiac transplant and lots of cardiac surgery, it's just not that common of a procedure. Nor have there been much if a need for me to do many swans in the ICU setting, although I am credentialed.[/QUOTE]

This, is why I voluntarily did the CT surg months. After 14 months of residency I only had 2. Just not enough in general MICU practice here, but I wanted to be capable of them should th etime come a pt needed one. So I did CTs and put 1 in every morning for like 8 weeks.
 
So you completed an IM residency and then started working as an hospitalist in the ICU? Is that what you mean by ICU hospitalist? Is this setup seen frequently? Sounds awesome :thumbup: I m just a 4th year student but I ve done 2 months of hardcore ICU SubIs and I love it. At first I was really intimidated by the ICU and vents and drips..etc but after a few weeks its pretty amazing what you can do in a well run ICU. My first rotation was at a "not well run" ICU at a county hospital but next rotation was at what I considered a well run ICU at a county hospital-university program. For the most part I can see how a well trained IM doc could take care of most ICU pts (heck most ICUs are open at most community centers and private hospitals)..

How many months of ICU did you do before you felt comfortable in the ICU?

Yes to everything except I have not finished residency yet. I have taken a job here at this hospital which will start once I complete residency and I will be one of the two CC hospitalists with back up from our 2 pulm-cc docs. I hope, after 2-3 years, my wife will come around so I can do a MICU fellowship. If not, I pray I will continue to have an opportunity to run the MICU at a mid size community shop. at the end of the day I just want to take care of ICU patients. And in med school I did a total of 3 MICU sub Is, 2 trauma surg months and 3 EM months. As a Med resident I have done 4 blocks of ICU and 2 blocks of ICU nights and I have 3 to go before graduation +/- an away at a tertiary center if I can get it worked out. Ideally neuro ICU. we have none here so I have virtually no neuro ICU experience which scares me. :(

and sorry for the 4 posts I do not know how to respond to 4 different peoples posts in one reply.
 
I am an anesthesiologist at a 250 bed community hospital in a medium sized city. Our setup is an open ICU with intensivist coverage during the day (~7am-5pm) with internist/hospitalists covering overnight. Our intensivists (2 IM/CC and 1 anes/CC) our great and I have no qualms about sending sick patients up to them.

However, I am consistently blown away by how terrible the hospitalists at our institution are at managing critically ill patients. First of all, they call us up for every airway, line placement, etc, because they don't feel comfortable with these procedures. I don't mean they call us infrequently for difficult line placement or airways; I mean that we perform every procedure for them when the intensivists aren't there. And I have learned to put blinders on and stay out of the management picture, because they are constantly doing things like running pressors through a peripheral IV without an art line and checking a cuff pressure every 15 minutes while titrating pressors. Or calling to ask me to put some super sick old cardiac cripple to sleep so "interventional radiology can do an LP" (because as far as they know, that's the only way to get an LP). Or "ordering a line placement" from me (like he's ordering a medication or a diet), having a nurse call me up there, and when I have questions about anything, the dude is sleeping in his call room while his patient's crapping out. Or calling to have a patient intubated for "airway swelling" but not considering that this is anaphylaxis and having no treatment considered/ordered/started (I gave the guy 20 mcg epi, watched the swelling/stridor go away, and went back to bed).

Anyway, enough venting (bad pun?). I am not a CC guy, but I did do 8 months of CC in residency (PICU, NICU, MICU, SICU, neuro-ICU, CCU, mixed med/surg ICU, etc) and having supervised IM residents and watched them "lead" the code teams as PGY-3's, I feel that the training just isn't there in most instances. In my residency, ICU seniors were either IM/CC fellows, pulm/CC fellows, trauma/CC fellows, anes/CC fellows, or anesthesia CA-2/3 residents. New IM/CC or pulm/CC fellows were definitely behind the curve with respect to procedures and ICU management. They caught up (with training), but were pretty rough fresh out of IM residency. I know training programs are different, and some IM programs might have excellent CC curricula, but in my experience (both as a resident and in PP), IM folks probably need some more training before they're manning ICU's with no additional help/resources. Just my $0.02.

This is a direct coorelation to what they were exposed to/allowed to do as a resident. At major academic institutions, IM residents are often in line behind endless lists of MICU fellows, SICU fellows, EM , gas, and gen surg residents for procedures. At a community shop, I do all of those myself as I am, shall we say, the only hungry mouth at the table. In my mind however, this is irrelevant. I can teach a monkey to drop in an IJ and float a swan. Teaching the MEDICINE that critical care entails takes years. And I think medicine residents who spend an ample amount of time on CC rotations (8+) are more than capable at the start of fellowship, knowledge wise that is. Far easier to learn the procedures during fellowship than develop the medical knowledge basis you should have already formed.
 
This is a direct coorelation to what they were exposed to/allowed to do as a resident. At major academic institutions, IM residents are often in line behind endless lists of MICU fellows, SICU fellows, EM , gas, and gen surg residents for procedures. At a community shop, I do all of those myself as I am, shall we say, the only hungry mouth at the table. In my mind however, this is irrelevant. I can teach a monkey to drop in an IJ and float a swan. Teaching the MEDICINE that critical care entails takes years. And I think medicine residents who spend an ample amount of time on CC rotations (8+) are more than capable at the start of fellowship, knowledge wise that is. Far easier to learn the procedures during fellowship than develop the medical knowledge basis you should have already formed.

I'm not asserting that IM trained folks aren't qualified or capable of starting a CC fellowship, but rather that they are not ideally suited to run an ICU without having done a fellowship. As you say, CC medicine (as well as procedures) take time and patient numbers learn and develop. Surgeons and anesthesiologists spend a significant amount of their residency taking care of ICU patients (both during and outside of dedicated ICU rotations), with IM residents doing this to a lesser degree. The CC boards recognize this, ergo surgeons and anesthesiologists can do 1 year CC fellowships while IM folks must do 2-3 years (excepting fellowship trained folks like ID, neph, cards). I think having hospitalists with no training outside of IM residency staffing an ICU without some sort of critical care-trained support is not ideal and does a disservice to patients. No matter how many procedures one racks up as a resident, I feel there is no substitute for formal fellowship training to provide the background necessary to properly care for the sickest folks in the ICU. There is a reason one can't sit for CC boards right out of (any) residency.
 
I'm not asserting that IM trained folks aren't qualified or capable of starting a CC fellowship, but rather that they are not ideally suited to run an ICU without having done a fellowship. As you say, CC medicine (as well as procedures) take time and patient numbers learn and develop. Surgeons and anesthesiologists spend a significant amount of their residency taking care of ICU patients (both during and outside of dedicated ICU rotations), with IM residents doing this to a lesser degree. The CC boards recognize this, ergo surgeons and anesthesiologists can do 1 year CC fellowships while IM folks must do 2-3 years (excepting fellowship trained folks like ID, neph, cards). I think having hospitalists with no training outside of IM residency staffing an ICU without some sort of critical care-trained support is not ideal and does a disservice to patients. No matter how many procedures one racks up as a resident, I feel there is no substitute for formal fellowship training to provide the background necessary to properly care for the sickest folks in the ICU. There is a reason one can't sit for CC boards right out of (any) residency.


Agreed. However, less than 1/4 ICU patients are currently seen by an intensivist. There is simply not enough. Too many residents go into cards, GI, nephro, H/O. pulm/cc has long been underserved. And the % of surgeons and anesthetists doing SICU vs staying in the OR or doing some other fellowship is not a high %. Hospitalists have been forced more and more to provide extensive ICU care to patients. This is just the world we live in. This is why many will practice as a critical care hospitalist for years without ever having the boards.
 
Extremely interesting Bostonredsox. I was skeptical initially but I can see how you got all those procedures. You have to go get them.
 
I am not sure I want to get too far into this discussion...especially a discussion with one clearly EXCEPTIONAL internal medicine resident...BUT:

Boston: are you honestly saying that you have put in HUNDREDS of introducer catheters into the IJ during less than 3 years of IM residency?

That's at least one IJ every other day for 1-2 years.

I trained in a 4-year EM residency...we were clearly the most well-respected residency in the hospital (which, for this discussion, means that we put so many lines just in case they would be needed within the next 12-24h) and actually called to assist in resuscitations through-out the hospital; including the OR!

However, despite my many early mornings in the OR before I reported for my afternoon EM shift -- despite my three extra ICU months (on top of the required 5 ICU months) -- despite an extra "junior fellow" month -- despite my extra year of training as an IM resident before I started EM residency -- I still can not honestly say I have put in HUNDREDS of large-bore catheters into the IJ. In fact, I am certain that I am not >100.

The only folks who can claim something like this are the anesthesiologists (maybe surgeons) who have a strong CT-focus (or CCM; or old school). [and, as other frequent readers of the EM and anesthesiology forums will attest, I rarely give ground to anesthesiologists!).

Please be a bit more transparent,
HH
 
Boston: are you honestly saying that you have put in HUNDREDS of introducer catheters into the IJ during less than 3 years of IM residency?
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I trained in a 4-year EM
HH

An IJ central line and an IJ central line.

Our 2 central lines are a 7french 3 lumen and a 10 French 5 lumen. Our introducers are 8.5french. We also put a lot if 12 French dialysis catheters in.

I'm sure what he's saying is that like at my joint, the introducer isn't considered its own special procedure.
 
I am not sure I want to get too far into this discussion...especially a discussion with one clearly EXCEPTIONAL internal medicine resident...BUT:

Boston: are you honestly saying that you have put in HUNDREDS of introducer catheters into the IJ during less than 3 years of IM residency?

That's at least one IJ every other day for 1-2 years.

I trained in a 4-year EM residency...we were clearly the most well-respected residency in the hospital (which, for this discussion, means that we put so many lines just in case they would be needed within the next 12-24h) and actually called to assist in resuscitations through-out the hospital; including the OR!

However, despite my many early mornings in the OR before I reported for my afternoon EM shift -- despite my three extra ICU months (on top of the required 5 ICU months) -- despite an extra "junior fellow" month -- despite my extra year of training as an IM resident before I started EM residency -- I still can not honestly say I have put in HUNDREDS of large-bore catheters into the IJ. In fact, I am certain that I am not >100.

The only folks who can claim something like this are the anesthesiologists (maybe surgeons) who have a strong CT-focus (or CCM; or old school). [and, as other frequent readers of the EM and anesthesiology forums will attest, I rarely give ground to anesthesiologists!).

Please be a bit more transparent,
HH

"blushing"

I didn't say hundred(s), but I am over 100. You can have my new innovations logs if you want. It is fairly easy when nearly every line came to me for awhile. General patients with no access despite 20 tries from 3 nurses on special care, hospitalist calls me "will you put a line in them for me?" Numbers added very fast intern year. Had the same from the ED docs. Now, our ED docs are not real ED docs and just try to see as many patients as they can, have no idea what EGDT except for one who is actually EM trained and just want to get all the Chest pain Obs patients admitted as I think they get a bonus based on admit rate (for profit hospital). So I was puttign quite a few lines in in the ed for them last year when they were 'busy with all of these other patients'.

Anyway I myself am wondering how we got here. Wasnt supposed to be a discussion about my procedural prowess, which I am sure means my medical knowledge is lacking as I spend so much time doing these whenever possible I spent n time on H/O, neuro or rheum actually learning that fields medicine, its hard, I just hate them so much lol :( Was supposed to be a discussion about what you gain from doing a fellowship. And despite all of those procedures I strongly agree for the need for the MICU fellowship. Seeing as my family situation is currently preventing it, my hope is after 5-6 years as CC hospitalist maybe they will grant me a one year fellowship exemption. Wife can suffer through one year of lost salary.
 
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An IJ central line and an IJ central line.

Our 2 central lines are a 7french 3 lumen and a 10 French 5 lumen. Our introducers are 8.5french. We also put a lot if 12 French dialysis catheters in.

I'm sure what he's saying is that like at my joint, the introducer isn't considered its own special procedure.

correct. My triple lumens in the IJ are Arrow 7 french 3 lumen. I have also put many dialysis catheters in the IJ I believe those are the 10 french 15cm Marukhars. I think I have only used the 12 french for femoral HD caths if i remember correctly would have to double check. Dont do those frequently, I try to stick to IJ so the IR guys can change them over a wire to a permcath. And my introducer sheaths/Cordis's for swans and pacers are also 8.5 french.
 
The fellowship is not for the procedures it's for the knowledge in managing critically ill patients, advanced mechanical ventilation techniques, etc., beyond what you learned in residency.
I am 60% through an IM residency and I am credentialed in:
Central lines (all approaches w/wo US)
Airways
Aline's
Chest tubes
Paracentesis
Thoracentesis
Emergent trans-venous pacer placements
Swans
IABP, though a cardio guy is already there with pt on table before I would ever be placing one

Doing IM residency at a community shop has allowed me to perform more procedures Already than several of my cc fellow friends did in academia up to an including what they have done so far in fellowship. But in no way does that mean I have anywhere near the level of CC knowledge as them. That's where the fellowship comes in to play.

So.... by 60% of the way, I take it you are a PGY-2. You may be "credentialed" in airways, chest tubes, TV pacers, PACs and IABP, but that is in a residency training license i.e. under the supervision of an attending. You might *THINK* you can do these - and I don't doubt you can for straight-forward ones - but for a PGY-2 to give the impression that he/she is capable of doing these independently including managing their complications and knowing how to do the ATYPICAL ones, well, that's just laughable.

The worst unknowns are the unknown unknowns.
 
So.... by 60% of the way, I take it you are a PGY-2. You may be "credentialed" in airways, chest tubes, TV pacers, PACs and IABP, but that is in a residency training license i.e. under the supervision of an attending. You might *THINK* you can do these - and I don't doubt you can for straight-forward ones - but for a PGY-2 to give the impression that he/she is capable of doing these independently including managing their complications and knowing how to do the ATYPICAL ones, well, that's just laughable.

The worst unknowns are the unknown unknowns.

Incorrect. I have been supervised for maybe 5-6 of > 100 lines. For maybe 5-6 of 40+ airways. For the first 5-6 chest tubes. For the first 4-5 LPs. Yes I still in general am supervised for pacers and the rarer more difficult things, but YOU are the misinformed one if you think because I have a resident training license and because my procedure note has "attending X" listed as being present and supervising, that any of them in fact are. I have put in more lines then every one of our 15 hospitalists, probably more than most of them combined. If you look at my note, they supervised it, so it can be billed for. I havent seen an attending in the room in over a year, maybe 80-90 lines ago. By the time they show up to the airway I am long done with it. And with good reason, as studies show procedure complication rate is a direct function of the number performed. If I have put in 50-60 more than my supervisor, they are not of much use are they?? Do I come across more difficult procedures that require me to call the surgeon who I know has more experience, sure. Do I call the CRNA/anesthestiologist on call when I forsee a difficult airway to peak over my shoulder and back me up, of course I do. This isnt a pride issue. It is a skill issue. And to assume because I am a PGY-2 I do not possess skill to do these is wrong in my mind. Being a fellow or even an attending does not make you more qualified to do a procedure. Attending X who has floated 15 swans during their residency and attending years is not more profficient than a current resident who has floated 30. Procedures are not like general medical knowledge. There success rate/complicatin rate is not related to the number of years you have been practicing, they are related to the number performed and experience of the operator. I am not trying to say I run around throwin in pacers and swans or anything like that. But If I have a pt that is suddenly in 3rd degree block in my MICU and symptomatic not responding to atropine I will, and have done, had the nurse page cardio,or text them quick myself, and tell them to get here stat while I get access in the neck and start getting ready to float. If I am done before they get there, great. In the past they have showed up midway through and guided me through the rest. Would I have done anything different had they not shown up? no. When I first dropped a lung putting in a subclav, the only one I have ever had, I called surgeon and said Hey man i dropped a lung can you come help me put in a chest tube I am not credentialed yet. He said sure. If it happened at this point or more likely, if the intern I am watching dropped a lung, i would just put in a chest tube.

And as for the license thing and so forth, when I go to a new hospital as an attending, my first 2 years will be here, i will just show my logs, which are signed by attendings, for privledges. Beautiful thing new innovations. Heres my 200 lines signed off by attendnigs I have completed over the years. privledge granted.

And I guess I should furthur clarify, In every case, if I have a patient that needs, a CVC, Aline, Airway, LP, Thora, Para, I do them immediately with a text to the attending, " I am doing X". There response is, "let an intern do it and supervise them", to help enhance others skills, if one is available and it isnt emergent, or "ok let me know if you have any problems". I have had notes left for me when I was on nights by a daytime hospitalist, " hey i admitted so and so with ascites and severe abdominal pain at 6pm, too late for IR to tap them today, can you tap them tonight for me if you get a sec, I already wrote all the orders for the fluid". For pacers that are urgent, I treat them like a cric and do what is best for the patient so they dont code. If they are responding to atropine or pads I will wait for cardio as they usually say bring them to the lab so we can do it under fluoro from the groin, and they supervise me there. For swans, which are never urgent, there is usually someone there, but again, because it isnt urgent and the attending is usually around anyway. The others I did preop for CTS and the attending was there prepping the chest and legs and such while I was doing it. IABP are obviously in the presence of cardiologist, as I previously mentioned.

My general point was for any of the above procedures, I have done enough and feel comfrotable enough that if a patient needed one emergently, I would have no hesitation in doing it regardless of who was present. And I have yet to meet an attending who was upset with me for doing it.

Yes the worst unknowns are the unknown unknowns, but those of us who dont train in academia with a huge heirarchy of experienced people, we learn by doing. and we learn complications when they arise and do our best to figure out why they happened and how to prevent them from happening in the future and better manage them if they do.
 
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Bostonredsox, let me just start off by saying the intent of my question is not to assess or question the validity of your claims so I hope you don't take offense.

My point of view is from a medicine PGY-3 at a busy county hospital who also has an interest in critical care. My question is in this era of restricted work hours, how do you ever find the time to do all of these procedures, including going to the cath lab, while at the same time tending to all of your other patient care responsibilities? When you're the code team in the ICU what happens if someone codes on the floor and your scrubbed in putting in a pacer in the cath lab? When you're on call doesn't the steady influx of admissions prohibit you from having the time to do these more advanced procedures?
 
Bostonredsox, let me just start off by saying the intent of my question is not to assess or question the validity of your claims so I hope you don't take offense.

My point of view is from a medicine PGY-3 at a busy county hospital who also has an interest in critical care. My question is in this era of restricted work hours, how do you ever find the time to do all of these procedures, including going to the cath lab, while at the same time tending to all of your other patient care responsibilities? When you're the code team in the ICU what happens if someone codes on the floor and your scrubbed in putting in a pacer in the cath lab? When you're on call doesn't the steady influx of admissions prohibit you from having the time to do these more advanced procedures?

No the hours actually have never been a problem. Our admissions are spread out over 4 teams during the day, 3 hours each team. And when I was an intern, the MICU was still open. So my 4 blocks of medicine intern year had 20+ patients on a team for 2-3 interns, 6-8 of them were in the MICU, which intern do you think took the ICU patients... Then second year we finally closed the MICU, and I took 2 night and 2 day blocks of ICU. The entire MICU team (4-5 residents) responds to codes. In addition, 4 hospitalists and every other resident in the building responds to that code. There are usually near 20 physicians that show up. While we have a 'code team' we do not have a 'if your not on the code team you are not obligated to atleast show up to make sure everything is going ok' rule. So everyone shows up. If I am in a procedure, someone else runs the codes. Now at night, I have had to run 2 simultaneously. Tubed one gave epi down ETT, gave orders, ran down the hall (thank God both were on the same floor) tubed that one, it had an 18 in the wrist, gave orders, ran back to first, through in femoral, and so on for almost a full 10 minutes before the night team, who was in a third code in psych of all places, on the other side of the hospital, showed up to help me. Nights for the last year and a half were very understaffed and I did 5 blocks, so I gained lots of procedures then. As for many of the others, I have a standing relationship with the specialists. When I was on Neuro, 'hey man do you care if I jet of the the cath lab to throw in a swan when they get one, they are going to call me when they pop up as they are infrequent?" "sure no problem" And we have a separate night call team which is 3 interns and a senior and then the ICU senior. I am usually the latter. My intern year, we did not have the ICU senior ( we were a newe program, not enough bodies), so i functioned as the procedure man most of that year too. My path has been far from the norm but thats one of the large reasons I stayed here when I got a really good ACGME IM program offer 4 months into intern year. I knew I would never get to do another procedure before I graduated. Also factor in I have a lot of fellow seniors who are women wanting to go into ID and Endocrine, stuff like that, not that I am trying to be sexist just the way it is here. They dont like Coding patients and procedures, so they call me quite frequently when one is needed and they happily will go do a COPD admit and leave the crashing pt to me. VERY unique situation, but one that has served me well.

And you will find that at community AOA shops, it is quite easy to skirt around the hours restrictions if you are clever. Not that I have needed to do that with any frequence.

Lastly, influx of patients admits at night does not slow down procedures. If ED calls for 4 admits at once, they have called me for 8 at once before, yeah they batch alot here which sucks, and one of them is severely septic, they will get al lof their procedures. I will make them hold the chest pain rule out and the COPD flare until the sick patient is tucked in if their isnt someone else to pick up them. Now with a dedicated ICU senior at night, the hospitalist and his senior + interns will handle the 20+ general admits that come every night, leaving me free to take care of the 17 in the MICU and all MICU admissions without having to worry about the general stuff. Only prob now is a sicky in the ED when a weak ED doc is on and I have to come to the ED to start care whilst there are 3 upstairs circling the drain.
 
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May I add that doing a procedure ie central line or intubation, is quite different in residency than it is in the real world. Although a resident may be the one performing the procedure, the attending is still within reasonable response time should something go wrong. It is quite different doing a difficult intubation when I know I could have back up at the bedside in less than 5 min's, than when I am the only doctor in the hospital.Knowing that if I don't get this, the patient is dead. Quite a reality check and the great humbler.

While I understand having confidence in your clinical ability as a resident is important to function. When this is taken to the extreme like I am getting from some of the above posts, the risk being taken isn't hurting the provider... it puts patients in danger. Rarely is anyone raked through the coals because they had a difficult patient that had a bad outcome. People get screwed because they assumed an unnecessary risk for their patients by performing something they were not proficient enough at and should not have been performing.

:eyebrow:
 
May I add that doing a procedure ie central line or intubation, is quite different in residency than it is in the real world. Although a resident may be the one performing the procedure, the attending is still within reasonable response time should something go wrong. It is quite different doing a difficult intubation when I know I could have back up at the bedside in less than 5 min's, than when I am the only doctor in the hospital.Knowing that if I don't get this, the patient is dead. Quite a reality check and the great humbler.

While I understand having confidence in your clinical ability as a resident is important to function. When this is taken to the extreme like I am getting from some of the above posts, the risk being taken isn't hurting the provider... it puts patients in danger. Rarely is anyone raked through the coals because they had a difficult patient that had a bad outcome. People get screwed because they assumed an unnecessary risk for their patients by performing something they were not proficient enough at and should not have been performing.

:eyebrow:

This is the last I am going to say about it as this was never ,eamt to be a discussion about one residents procedure capabilities and I am getting tired of posting in it. I agree with your entire second paragraph. It is dangerous for a resident to needlessly do procedures without backup that may hurt the patients. I disagree with your entire first paragraph. I have, on MANY many nights already at this point in my training, been the most capable physician in the hospital including ALL attendings in the building, at performing a particular procedure. So the 'feel of being the attending performing the procedure where if you dont get that airway, that patient may die", been there done that. I realise coming from a resident to you as an attending this sounds crazy, maybe blasphemous, but it is truth. In my shop the ED docs NEVER EVER leave the ed. it is an outside entity and they do not have hospital privledges ouside the ED. Thus a code in the cath lab 60 feet down the hall, they do not respond to. They will venture as far as xray/ct, which is technically attached to the ED. They are of no help at night. none. There is one hospitalist and one CRNA in the building at night apart from the residents. That hospitalist may have put in 3 lines in their entire career. More often than not, they have never seen the inside of an airway. never. they stand at the foot of the bed and run the code. That leaves the CRNA who is generally good airway backup. But there are some who are not the best shall we say. And they are not anesthesiologists, as good as some of them are. And thats all they can help with, the airway. In small community shops like mine there is very little help. And your backup, as I mentioned above, is often not really backup. Its an attending who put in 8 lines and tubed 10 people during their residency 5 years ago. If you want to do what is best for the patient you have to work hard to attain the skills to handle the difficult procedures yourself, knowing that unless it is noon on a wednesday when the OR is in full swing and all the surgeons and anesthesiologists and the ED director, one of the only true EM docs here, are in house working, your backup is essentially nil.

And the death feeling sucks. I had a CRNA call me 4-5 months ago that they could not intubate a patient after 3 tries the pt had aspirated twice, 'will you come try". I got about 15 sec up the stairway when they called a code on him. I got the bougie in and a 7.0 after a few min but it was too little too late. And had I been the initial person intubating that huge behemoth of a man I cannot say it would have gone differently at all. He probably would have coded on me too, although after 2 aspirations I would have cric'd him. But you can be damn sure the hospitalist on that night wasnt making an attempt at that airway, having intubated 3 people in her life. She looked like a deer in the headlights at the foot of the bed. This is why I took difficult airway as a second year IM. I do not want to have to rely on the attending as backup at a place where I know they are not really backup. Being an attending doesnt make a damn bit of difference if you dont have the training. And you dont get good unless you do every possible procedure you can get your hands on. This is why I have done what I have done and why I continue to do things they way that I do. Believe me, is is FOR patient saftey that I do them this way.

On a more sorrowful note, they may finally be getting another Pulm/CC doc at my shop, though rumor has it he just wants to do office and sleep lab, and there is another hospitalist coming in very critical care oriented. My chance of running the MICU 7 on 7 off is turning into 7 on 7 off followed by next 2 rounds of 7 on 7 off as a general hospitalist then back to CCU on week 8. FML. The prospect of having to do hospitalist work with no ICU patients may end up driving me to the ED. Atleast I will get some steady diet of CC patients even if its only 8-10%. Modern general ward work makes me want to put kittens in microwaves.

Anyway, enough said on this. lets get back to critical care discussions.
 
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