Is it possible to do CCM fellowship after Neurocritical Care fellowship (neurology trained)?

[Neurocrit]

In medical school I was debating IM-->critical care vs. anesthesia-->critical care, but I rotated on neuro ICU and fell in love with the neuro population specifically and choose the neurology path. I always felt a little out of place in my neurology residency and even did all my elective time in things like MICU and CCU. Now that I'm in fellowship Im much happier than when I was in residency, and I still find that I really love the non neurological critical care issues that come up in our patients and was wondering if there is any pathway by which I could obtain board certification in general critical care and do some work in other ICUs as an attending. I know that an IM or anesthesia trained person could easily do this after neuro ICU, but I think my neurology background may exclude me.

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[psychbender]

I don't know if you can do an approved fellowship, but you may be able to just go work in other units out in the community. One of my colleagues is Neuro-CC trained, and she rotates through all of the units, just like everyone else, but works most closely with our Neuro ICU and developing practice agreements with Neurosurgery and Neuro-IR. I also remember two Neuro-CC trained staff at my fellowship program that were part of the Medicine department, and covered the Medicine CCM team responsible for the Neuro-ICU (and general medical ICU patients).

 

[Katheudontas parateroumen]

In community practice does not seem to matter which unit you can/will cover.

 

[Doctor Bob]

In medical school I was debating IM-->critical care vs. anesthesia-->critical care, but I rotated on neuro ICU and fell in love with the neuro population specifically and choose the neurology path. I always felt a little out of place in my neurology residency and even did all my elective time in things like MICU and CCU. Now that I'm in fellowship Im much happier than when I was in residency, and I still find that I really love the non neurological critical care issues that come up in our patients and was wondering if there is any pathway by which I could obtain board certification in general critical care and do some work in other ICUs as an attending. I know that an IM or anesthesia trained person could easily do this after neuro ICU, but I think my neurology background may exclude me.

Unfortunately neurology is not a specialty that can go through IM, anesthesia, or surgical critical care fellowships.

 

[Hamhock]

Unfortunately neurology is not a specialty that can go through IM, anesthesia, or surgical critical care fellowships.

Unfortunately?

As much as I believe in multi-disciplinary CCM, I would propose Neurology is too focused, even with a prelim year.

Neuro to NCCM, sure. Neuro to general, sure -- after three years.

HH

 

[CCM-MD]

In community practice does not seem to matter which unit you can/will cover.

Neurocritical care credentialed to practice non-neuro critical care is rare. Can one find a place that will allow this? Sure - the most desperate will hire anyone. However, the physician's liability would be high practicing outside his/her area of expertise.

I think OP is smart to consider further training in general CCM but I agree with HH that neurology residency training probably does not provide an adequate base.

 

[Neurocrit]

Appreciate everyone’s responses.

Certainly not proposing that one should be able to do general critical care directly from neurology residency. While I think we do a lot more inpatient than people realize in a neurology residency, I agree that the range of topics is much more narrow. Sure, neurology primary patients have other active or chronic comorbidities we manage in residency but by no means does implementing cardiology recommendations for decompensated HF in a stroke patient mean I have the same knowledge or experience as an IM resident who spent a month or two in the CCU.

Regarding whether I can practice general critical care after a neurocritical care fellowship, it seems like the answer is yes but unofficially and depends on my comfort level and hospital need. I would imagine that I’d be comfortable with bread and butter community MICU pathology (GI bleed, sepsis, etc) after this fellowship but I wouldn’t want to be primarily responsible for hardcore MICU patients like bad right heart failure from pulmonary hypertension or a CVICU ECMO patient. This is why I wondered if I could do a second general critical care fellowship and the answer to that remains unclear.

At the end of the day it is neurocritical care I love the most and I’d be happy to stay in my niche. I just love learning and am a junkie for more knowledge

 

[Doctor Bob]

Unfortunately?

As much as I believe in multi-disciplinary CCM, I would propose Neurology is too focused, even with a prelim year.

Neuro to NCCM, sure. Neuro to general, sure -- after three years.

HH

Unfortunately in that it is a disappointing answer for them.

 

[ProReduction]

When I was interviewing for NCC fellowship at University of Maryland / Shock Trauma, one of the junior attendings there had done a NCC fellowship at Hopkins (if I remember correctly) and then did a Surgical Critical Care fellowship at UMD / Shock Trauma immediately after, and was hired as faculty after. I have no idea if he is boarded in both or just in NCC, but even the other Neurointensivists at the time were attending on the SICU service at Shock Trauma, so it was a very intrainstitutional thing.

So yes, you can do a Surgical Critical Care fellowship after NCC. You would have to contact the boarding organization to see if you would qualify for cert in surgical or not.

Like it or not, all other Intensivists still see Neurointensivists as glorified stroke doctors, likely because for the first 15 years of NCC fellowship training programs, that is what they were. There are still many big-name NCC fellowships with little to no airway training. In some community hospitals Pulm CC would rather have a Hospitalist cover their ICU than a Neurointensivit. At other more progressive groups, CC is a mixed group with all types of Intensivists covering all units.

 

[Neurocrit]

Like it or not, all other Intensivists still see Neurointensivists as glorified stroke doctors, likely because for the first 15 years of NCC fellowship training programs, that is what they were. There are still many big-name NCC fellowships with little to no airway training. In some community hospitals Pulm CC would rather have a Hospitalist cover their ICU than a Neurointensivit. At other more progressive groups, CC is a mixed group with all types of Intensivists covering all units.

Do you think that as NCC has developed and become common in academic training centers it will create a positive feedback loop?

For example, where I did my residency MICU fellows, SICU fellows, anesthesia residents nor EM residents rotated in the neuro ICU. Granted, other places have more cross pollination but not a ton. How much interest does the younger generation of pulm CC trained intensivists have in managing neurological patients if they trained with the availability of a dedicated neuro ICU?

 

[chessknt]

Any place that takes care of head stuff sick enough to need a neurointensivist is going to have CCM trained intensivist covering the icu. You don't need neuro CCM in a community/regional hospital dealing with routine head stuff, the volume isnt there.

 

[Doctor Bob]

When I was interviewing for NCC fellowship at University of Maryland / Shock Trauma, one of the junior attendings there had done a NCC fellowship at Hopkins (if I remember correctly) and then did a Surgical Critical Care fellowship at UMD / Shock Trauma immediately after, and was hired as faculty after. I have no idea if he is boarded in both or just in NCC, but even the other Neurointensivists at the time were attending on the SICU service at Shock Trauma, so it was a very intrainstitutional thing.

So yes, you can do a Surgical Critical Care fellowship after NCC. You would have to contact the boarding organization to see if you would qualify for cert in surgical or not.

I was an intensivist at Shock-Trauma for a while and they would do this from time to time... train someone internally who wouldn't meet board eligibility requirements, and then keep them on staff. They weren't board certified/eligible though and if they wanted to get a job somewhere else that required BC/BE, they wouldn't be able to.

As mentioned, neuro trained docs can't sit for surgical crit-care boards. Whether a program will take you and train you is an entirely different question than whether you would be board eligible after that training.

Surgical Critical Care Certifying Exam | American Board of Surgery (if you're curious about eligibility requirements for the surgical critcare boards)

Do you think that as NCC has developed and become common in academic training centers it will create a positive feedback loop?

For example, where I did my residency MICU fellows, SICU fellows, anesthesia residents nor EM residents rotated in the neuro ICU. Granted, other places have more cross pollination but not a ton. How much interest does the younger generation of pulm CC trained intensivists have in managing neurological patients if they trained with the availability of a dedicated neuro ICU?

It's likely to be more common that it will be desired for the people staffing tertiary referral center neuroICUs to be neurocritcare boarded. There is certainly a benefit to having specialized understanding if you work in a place with high volume, high acuity, and a diverse range of neuropathology.

 

[jonathanlikes]

Why is it that an internist who does Pulm CCM is allowed to attend in general ICUs but an internist who does Neuro ICU fellowship is not?
At my institution, depending on how they use their elective time, the Neuro ICU fellows spend the same amount of weeks in Anesthesia, POCUS, MICU, SICU, CVICU as the Pulm fellows.
When you add up all those rotations that train you to cover general ICU pts, It's about 42-46 weeks for both of them.
On top of that, obviously the Neuro fellows spend much more time than the Pulm fellows taking care of encephalitis, GBS, neurotrauma, and Stroke pts.
So, they actually have much more ICU experience than their Pulm colleagues.

 

[CCM-MD]

Why is it that an internist who does Pulm CCM is allowed to attend in general ICUs but an internist who does Neuro ICU fellowship is not?
At my institution, depending on how they use their elective time, the Neuro ICU fellows spend the same amount of weeks in Anesthesia, POCUS, MICU, SICU, CVICU as the Pulm fellows.
When you add up all those rotations that train you to cover general ICU pts, It's about 42-46 weeks for both of them.
On top of that, obviously the Neuro fellows spend much more time than the Pulm fellows taking care of encephalitis, GBS, neurotrauma, and Stroke pts.
So, they actually have much more ICU experience than their Pulm colleagues.

That may be the case at your specific neuro ICU fellowship but isn’t the case in every neuro ICU fellowship. There is also the question of didactics and other education in the fellowship that I would expect to be neuro focused in a neuro ICU fellowship. In addition, there are institutions where fellows, outside their “home unit” function more as observers rather than the primary fellow in charge. So a MICU rotation as a neuro ICU fellow may not be the same as a MICU rotation as an IM-CCM fellow.

Bottom line is its terrible idea to do IM+NCC without CCM as it will limit employment options significantly. Soon ABIM won’t let an internist take the NCC exam without CCM certification and that will ultimately limit options further.

 

[SpacemanSpifff]

Why is it that an internist who does Pulm CCM is allowed to attend in general ICUs but an internist who does Neuro ICU fellowship is not?
At my institution, depending on how they use their elective time, the Neuro ICU fellows spend the same amount of weeks in Anesthesia, POCUS, MICU, SICU, CVICU as the Pulm fellows.
When you add up all those rotations that train you to cover general ICU pts, It's about 42-46 weeks for both of them.
On top of that, obviously the Neuro fellows spend much more time than the Pulm fellows taking care of encephalitis, GBS, neurotrauma, and Stroke pts.
So, they actually have much more ICU experience than their Pulm colleagues.

Agree with @CCM-MD - really depends on the institution. In the three places I’ve trained, the neuro fellows are receive very specialized training and would be ill equipped to manage a non neuro unit alone. Two of these units routinely admit very simple postop patients at the whim of neurosurgery, none of whom are critically ill.

The neuro fellows at my current shop started doing rotations outside the neuro ICU last year. The first month they are essentially senior residents, and if they return for a second month they will function as fellows. Their understanding of core CCM concepts like shock, simple ventilator management, and hypoxemic respiratory failure is just not up to par with the MICU trainees, including those who worked as hospitalists prior to coming to fellowship.