Thoughts on Pulmonary/Critical Care

Not too sure about the overall outlook for Pulmonary and/or Critical Care. As long as there are smokers, there will be business/bronchoscopies/biopsies/etc. to be done.

One thing that I have heard tossed around a lot has to do with the increasing utilization of intensivists as more hospitals (particularly private hospitals) go towards "closed" ICU's. There is potential for 'shift-work', similar to ER physicians.

I was recently talking with a pulmonary/critical doctor about this. I think that there is going to be a continued decrease in the number of smokers and amount that smokers smoke in this country (tob companies are focusing advertisements on other markets besides the US), and that means that there will probably be fewer out-patient procedures that need to be done and fewer out-patient consults that will be needed. Inpatient-wise, I think that pulmonary will get more consults to rule out things like TB (growing prevalence in third world countries and their immigrants), to bronch atypical pneumonias in the growing number of HIV patients, and to bronch and manage patients with new viruses like SARS. So my thought is that pulmonary will become more and more in-patient focused. This pulmonary doctor told me that critical care is expected to have a huge increase in demand with the aging population and the current attitude that everyone who dies should die in a critical care setting. There aren't nearly enough critical care doctors being trained to handle that type of capacity. Lifestyle is as previously the previous user stated, more emphasis on shift-work. Some states only require that a board certified or eligible critical care physician be present in the ICU 8 hrs per day, which means that regular internists are sometimes called upon to manage the floor work during the odd/nighttime hours. Anyways, this is all just speculation by myself and the pulmonary doctor that I was talking to. It's tough to predict future demand on any one specialty, and historically, the experts have usually been wrong.

It's hard to predict what the job outlook will be in any specialty in the next few years, since the market fluctuates so much. It seems that pulmonary/cc job opportunities are much better than they were several years ago, especially with the growing trend to have board certified critical care physicians staffing ICUs. For pulmonologists who do an extra certification in sleep medicine (only 1 additional year tagged onto the 3-year pulmonary/cc fellowship), the outlook is excellent. Everyone and their mother is looking to hire pulmonologists who are sleep-certified to staff the growing numbers of sleep centers around the country. Sleep medicine in particular is quite lucrative with a great lifestyle (no emergencies, the techs do the sleep studies at night, and you read the studies the next day during business hours, as well as see lots of outpatients in clinic).

The lifestyle of pulmonary is highly variable depending on how you shape the scope of your practice. You can do primarily ICU, or do inpatient consults, or outpatient clinics, or sleep. There are also several subspecialties within pulmonary that you can focus in. Or you can mix and match between your pick of the above to a ratio of your liking. The ability to change the mix and acuity of your practice I think is one of the big pro's to the specialty.

I can't comment on Pulmonary, however Critical Care faces a huge shortage and there are several strategic planning groups working on addressing this issue. ATS, SCCM and ACCP are all working together on this.

You can check out the recent issue of CHEST. There are 3 articles addressing it. The classic one is the COMPACCS study published in JAMA by Angus et al.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15078767


http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15078768

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15078766

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=11105183

Gunner, thanks for the info.

What is your take on pulm critical care vs. anesthesia critical care? My ICU attending say that your get better cc training in anesthesia programs-the pulm docs are too busy doing bronchs, etc.

Annette,
I don't think it really matters between IM and Anesth so-to-speak. I feel that a true multidisciplinary training program is the best. This includes exposure and rotations in Surgical ICUs (preferably Cardiac Surgery, Neurosurgery, Gen Surgery/Trauma), and Medical ICU's.

Most ICU jobs (not academic) are in a combined med/surg unit and you'll need to be comfortable with both medical and surgical types. The hottest unit now to cover is the Cardiac Surgery units.

Any new intensivist needs to have a broad exposure to all of these. Make sure you ask the programs you are interested in if they are structured like this. If they are not, ask them if they are flexible enough for you to take electives in the other units. This is key.

The classic and arguably "gold standard" for multidisciplinary critical care is the University of Pittsburgh. I can tell you from personal experience, it was a great fellowship. You can check out the program at www.ccm.upmc.edu.

Good Luck,
KG

Annette,
BTW I know your group of intensivists very WELL! They are all excellent (and mostly Pitt grads). The newest member of the group is a close friend of mine. I would trust what they have to tell you.

KG

KGunner,
Any insight into the top programs in the country? In Chicago? On the East coast? I am mulling it over and a lot depends on my soon to be wife's career but I am trying to decide which direction I want to head in. Any input would be greatly appreciated.

Countless threads on SDN are about the "best program". Unfortunately it's not that easy. Every applicant wants something different.

I knew I was going to Pitt, so I didn't look too hard. I've met intensivists over the years and have friends at differnent places. I really don't know too much about fellowship programs other than Pitt, SLU, Henry Ford and a smattering of others.

With that being said, some places where I know someone and they are proud of their programs are in no particular order:

NYC - Monte Fiore - Vlad Kvetan is the Chair and is top notch. (don't know any other NY places

Jersey - Cooper - Joe Parrillo, Phil Derringer, Steve Hollenberg and Steve Trzeciak are all recent additions from Rush in Chicago. They are a very good group and have recharged the critical care program at Cooper.

Hopkins - Several good docs, Peter Provonost and Pam Lipsett are also very good.

Baltimore -Shock Trauma - Only if you want Trauma

Richmond - VCU/MCV - Curt Sessler, Berry Fowler, Rao Ivatury are some great guys at an up and comming program

Jacksonville Fl - Anesth based program is excellent.

These are only a few of the programs that I know of. I don't really know anyone in Chicago anymore. There are several other great programs that aren't included, including my old stompin grounds at Pitt.

Good luck,
KG

I've just finished up my interview trail for Pulmonary/Critical Care. There seems to be a lot of variability amongst programs and some do seem more pulmonary heavy than others. The schedules also vary quite a bit, but from what I have seen, which is quite a bit, when a fellow is dedicated to the ICU, they are generally in the ICU. Currently, for pulmonary critical care, on is required to do 6 months of clinical critical care and about 12 months of clinical pulmonary. Remember too that many pulmonary consults activities take place in SICUs. The remaining 18 months generally are dedicated to research, however some clinical programs have 24 months of clinical training.

Most of the programs I interviewed with have multidisciplinary ICU exposure, which is generally a good thing but one of the downsides of this in surgical ICUs is that the pulm fellow gets relegated to managing the vent, cleaning up medication errors and managing coexisting chronic medical problems.

One program in particulary had a separate critical care fellowship that was run by anesthesiology. A running theme(and one that thankfully steered me from doing a CCM only fellowship) is that both private practice and academic positions for strictly CCM trained folks are much more scarce. The other snafu is that a lot of places will not give you privileges for bronchoscopy and other billing procedures in the ICU without the pulmonary training. Something to think about when you look at the bottom line.

I would encourage most IM folk interested in critical care to explore the pulmonary side simply because is actually grows on you. In a lot of ways it has the breadth of internal medicine with the benefits of a specialty. The other advantage is that a large percentage of MICU admissions are secondary to primary pulmonary processes. Other specialties meld quite well with CCM including ER, nephrology.

As for best programs, all I can say from my interview experience, is that you have to interview around...there is a lot of variability and frankly a lot of opinions about critical care simply because the data is not there to support a lot of what we do. The good thing is that there are a lot of good programs out there, the job market is excellent and the research opportunities in both pulmonary and critical care are ripe.

What do you guys think about neuro critical care?
Most of neurocritical care is combined with Vascular neurology and is under neurology/neurosurgery. But does it have any overlap with Pulm/critical care or anesthesia/critical care?

I know one neuro CCM doc. She is overworked by the equally overworked neurosurgery department. It certainly has a role though, but a lot of work is done to transition patients to chronic care facilities. She tends to rely upon the pulmonary/CCM service for procedures like chest tubes, but otherwise handles most CCM problems. The scope of problems is interesting though.

Thanks for your reply Eidolon6.
I was going through the latest fellowship core curriculum for neuro critical care proposed by the section of American acad of neurology. A new neurocritical care society was also formed in 2002. The curriculum now also includes arterial lines, central venous/pulm art catheters, ventilator management and endotracheal intubation and all aspects of critical care medicine as relevant to neuro, apart from things specific to neuro ( as raised ICP, hydrocephalus,status epilep, acute ischemia, etc,etc). Do you think that with inclusion of these aspects will make it a completely independent subspeciality ?

IMGforNEURO,
Neuro critical care is a fairly new idea and gaining a lot of underground attention lately. There have been a few good clinicians doing this for some time, and now there has been some estabilished fellowship programs cropping up. Tom Bleck at UVA is probably the most well know Neurointensivist. He is a very nice guy and would welcome any interest you have.

About Eidolon6's comments about straight CCM. It is true that there are more pulm/ccm jobs out there. But I would NOT recommend doing pulm/ccm if you don't like office work. I could not stand PFT's, lung ca workups, COPD etc... Office based medicine was not in my bag. I was not going to waste 2.5 yrs to get only 6 months of ICU training. That's just my 2 cents.

Don't worry about straight IM/CCM. You can get privilages to perform bronchoscopies. There may be a few isolated programs that limit you due to billing, politics, etc... but they are few and far between and you and your chairman can work through the red tape easily. At Pitt, I performed more ICU bronchoscopies than any of the pulm fellows.

As far as jobs, there is no shortage. CCM is a well connected speciality and you'll be recruited out of the top programs before you even start your second year.

Do what you feel interested in. In my fellowship class I had 1 nephrologist, 1 ID, 1 cardiologist, 1 pulmonologist, 5 IM only, 1 ER, 1 ER/IM, 1 Anesth, and 2 surgeons. Everyone got jobs easily.

Follow your interests. Don't settle, you don't have to. Remember, you'll be doing this for your entire career. If you want Neph/CCM or any other combination, then do it.

KG

KGUNNER1 said:

IMGforNEURO,
About Eidolon6's comments about straight CCM. It is true that there are more pulm/ccm jobs out there. But I would NOT recommend doing pulm/ccm if you don't like office work. I could not stand PFT's, lung ca workups, COPD etc... Office based medicine was not in my bag. I was not going to waste 2.5 yrs to get only 6 months of ICU training. That's just my 2 cents.
KG

Click to expand...

As said before, part of pulmonary fellowship is spent on inpatient consults in addition to ICU duties. Most fellowships only require 1 to 2 half days of clinic per week for their fellows. The combination of pulmonary and critical care allows some flexibility and with the current job market, it is likely that one could find a shoe that fits so to speak. But hey, I suppose a little clinic is as unbearable for some as working the ER is for others. It also may add a little to help some avoid the "treat 'em and street 'em" mentality which, like the ER, plagues some ICUs. A goodly number of former ICU patients become pulmonary or chronic medicine patients.

As for academic job opportunities, the market is much better for specialty trained CCM folks in that they have a wider range of skills, more in depth research training, and can fill more roles. These jobs still are not the easiest to come by. Not to say that pulmonary is for everyone, or the only route. Nephro, Cards, ID, and even GI can fit well with CCM training. Not to say that regional differences do not exist, but more often than not, CCM training, through IM, is tied to Pulmonary.

As for Neurocritical care, UCSF for example has a very good fellowship program that is combined with stroke training. I suspect a number of straight CCM fellowships may also accept neurology trained folks as well.

Bottom line for CCM training is that everyone...surgeons, anaesthesiologists, IM/CCM and Pulm/CCM take the same boards for accreditation/certification and the curriculum taught in these fellowships probably reflect this...so for good training, depending on your background, you have choices, all of which have a market now and will have in the future.

Eidolon6, we agree on more things than not. If you want to work in a traditional MICU pulm/ccm department then you are absolutely correct, a pulm/ccm path is more familiar to you future employer and you'll find jobs easier.

Along the same line, if you like the surgical patient, it is rare (not unheard of) to have a pulmonologist rounding in a SICU. It is quite common to have a multidisciplinary trained IM/CCM rounding in a SICU right along side the Anesth/CCM and Surgeon/CCM. Personally I like this patient population. The surgical patients that get sick have a fascinating inflammatory response and it is fun balancing their chronic disease state with their acute surgical process. They usually get better and go home rather quickly (neurosurg excluded)

The MICU seems to have more chronic lung disease. You will find more zebras that are buried deep in Harrison and your IM skills and pulmonary training will really be utilized.

As far as the test. Each specialty has their own. Anesth. and Surg. are both CAQ (certificate of added qualification). These are not "boards" and are not regulated by ABMS. They are regulated by ABA and ABS. The questions are probably very similar.

The internal medicine test is now considered a "board". This is new. It is now regulated by ABMS.

If you are trained in OB/Gyn and do a CCM fellowship, you can sit for either the Anesth or Surg CAQ, depending on what specialty sponsored the fellowship.

If you are trained in Neurology, EM, or any specialty other than IM, Surg, Anesth, or Peds you currently can't take U.S. CC board or CAQ exams. Europe will allow you to through the ESICM. This is recognized by almost all 3rd party payers. Most places still don't require you to be CC trained to bill for CC time.

KG

I think that even though many people certified in CCM have had a diverse training experience (ie experience in both MICU and SICU), there are still large differences in competence based on their prior backgrounds. As Kgunner said, the pulm/CC physicians are better suited to managing MICU patients, while the anesth/CC and surg/CC are much better at working in the SICU. We have a combined MSICU at one of our hospitals that's co-run by anesthesia and pulmonary, so I have worked with several anesthesia/CCM physicians. They are outstanding at managing our surgical patients, especially the CT surgery patients, however when we have an anesthesia/CC attending on service, I get very frightened about the management of the medical patients in the ICU. They are great at hemodynamics, airway, and sedation, etc, but I feel that they are very much lacking in knowledge and experience in the underlying problems of the medical patients (such as end stage liver disease, COPD, and cardiomyopathy.). This just points to their original training background -- people who go into anesthesia don't want to deal with medical pathology -- they'd rather spend more time on physiology and recussitation. So they will be much more comfortable when they take care of healthier patients who have a very acute disease (ie surgery or sepsis in an otherwise healthy patient), rather than an acute on chronic process.

That said, most people who do pulm/CC would rather deal primarily with the MICU patients. Again, this goes back to why people choose their original residency. People who choose IM tend to like dealing with complex pathology, multi-organ disease, and various manifestations of chronic disease. You see much more of that in the MICU than in the SICU. As far as the amount of SICU training in pulmonary fellowships, it's highly variable. I just finished interviewing for pulmonary as well, and I've noticed that some programs only have a month of SICU time, while others have a majority of the ICU time in the surgical specialties... it seems like there is an option for everyone based on their preference of mix of patients.

As far as pulm/CC vs IM/CCM, most people trained in IM who want to do critical care will opt to do pulm/CC rather than straight CCM. I think this has to do a lot with marketability. IM/CCM has fewer options as far as scope and arenas of practice. Maybe it's true that it's easier for them to find positions in SICUs as Kgunner has said, but most of the IM/CCM fellows I know are wanting to work in MICUs rather than SICUs. Several of the IM/CCM fellows I know who are finishing up this year have been having a very difficult time finding positions in MICUs, while their pulmonary counterparts have had several offers by now.

To comment on whether you have to like outpatient medicine to do pulmonary/CCM, I really don't think you have to, because you can really tailor the scope of practice of pulmonary to a mix of your choice. I'm going into pulmonary/CC, and I personally really dislike outpatient medicine. (I think I would go crazy if I did more than 1 day of clinic a week.). My current plan is to primarily do ICU and inpatient pulmonary (with a possibility of specializing in interventional pulmonary), and to try to minimize the amount of outpatient clinic time. The beauty of the specialty is that if I decide later on that I might want to do more outpatient time than I thought, it would be easy to change my scope of practice to one that suits my style.

KGUNNER1 said:

Along the same line, if you like the surgical patient, it is rare (not unheard of) to have a pulmonologist rounding in a SICU. It is quite common to have a multidisciplinary trained IM/CCM rounding in a SICU right along side the Anesth/CCM and Surgeon/CCM. Personally I like this patient population. The surgical patients that get sick have a fascinating inflammatory response and it is fun balancing their chronic disease state with their acute surgical process. They usually get better and go home rather quickly (neurosurg excluded)

KG

Click to expand...

I think there are a fair amount of regional differences concerning both the scope of CCM training, especially that which is combined with pulmonary. Pitt is unique (and impressive) in a lot of ways because it espouses such multidisciplinary training and has such a large CCM physical plant and faculty. I think at most other academic places, CCM, through IM, is more closely tied to pulmonary and the embracing of CCM training can vary quite widely from place to place.

I certainly don't dispute what you are saying KGunn and apologize if it seems that way. I would agree that for most of the places I explored, the MICU training was a focus, but multidisciplinary training was also stressed. I have personally chosen a CCM heavy program because I prefer complicated patients with complex physiology....I come from an institution that has generally Pulm/CCM folks that are routinely consulted to manage both surgical and medical patients in their Shock Trauma Unit. This occurs in our private hospital. At our public hospital, the lines are more divided to surgical and medical sides, with Pulm/CCM running the MICU and consulting in the SICU for pulmonary, vent mgmt or complex medical problems. The fact that they face such diversity in patients certainly broadens the pulm/CCM fellows experience here to handle all different patient types. We do not have a separate anaesthesia run CCM program or trauma/CCM fellowship for our surgeons.

I think the more worrisome thing is that 70-80% of ICUs are currently run without a CCM trained or certified MD and recent data in NEJM and JAMA suggests cost and morbidity/mortality are reduced in closed ICUs with intensivist coverage. That in itself speaks volumes about the market available for all types of folks with advanced CCM training.

I think the more worrisome thing is that 70-80% of ICUs are currently run without a CCM trained or certified MD and recent data in NEJM and JAMA suggests cost and morbidity/mortality are reduced in closed ICUs with intensivist coverage. That in itself speaks volumes about the market available for all types of folks with advanced CCM training.

Click to expand...

I couldn't agree with you more!! Another worrisome revelation. While knowing about the intensivist shortage and subsequent staffing crisis we are facing, the ABIM has recently closed its doors for all of those who were trained in another base specialty and now want formal CC training. Before, up to 25% of any IM based specialty could have non-IM based fellows in their fellowship. They weren't board eligible, but they could at least get the training.

Now those ER and Neuro grads need to find surgery and anesth programs to apply to. We, as a specialty, should be opening doors and not closing them! Especially now!

I certainly don't dispute what you are saying KGunn and apologize if it seems that way.

Click to expand...

No need to. Not taken out of context at all. I just wanted to emphasize that the future needs intensivists comfortable with ALL types of critically ill patients. Most traditional pulmonologists I know are a little uncomfortable with the complex surgical pt. You know there's more to it than being a "Vent Jockey". That paradigm would fit nicely in the SICU 10 yrs ago, but there have been some big changes in the last 10 yrs. and us nonsurgeons need to be more involved in patient care than what was done in the past.

KG

Consult MICU for vent management!

Just send'em on over.

I just found this old thread, and wanted to resuscitate it.
How do youall like Pulmonology? Im really interested in it. I really dig this less common things like ILD, pulm-renal syndromes, and pulmonary HTN. Will a pulmonologist be able to wrestle a pulmonary HTN patient away from the cardiology service every once in a while?

howelljolly said:

I just found this old thread, and wanted to resuscitate it.
How do youall like Pulmonology? Im really interested in it. I really dig this less common things like ILD, pulm-renal syndromes, and pulmonary HTN. Will a pulmonologist be able to wrestle a pulmonary HTN patient away from the cardiology service every once in a while?

Click to expand...

In many places the pulmonary section primarily manages all pulmonary hypertension including initial diagnosis (except the echo of course) with right heart catherization (it's just a PA catheter after all, a staple of critical care), drug management, and follow-up. So if you know you're really interested in pulmonary HTN (not just theoretically but have had prolonged exposure to that patient population) you could certainly find training programs that manage their own pulmonary hypertension population.

What's your idea about Pulmonary without critical care ?
In terms of job market, does someone get limited without being CC board certified ?

gutonc said:

It will be difficult if not impossible to get a fellowship that is Pulm only. Ditto for a job, at least coming straight out of fellowship. After a few years (like 10 or 20), you will probably be able to shift your focus to outpatient/consult Pulm, without having to pull ICU coverage as well.

Click to expand...

Dont many academic programs have a 2 year-only Pulm fellowship (e.g. UColorado)? Of course, it is in your best interest to do the 3 year, because otherwise you would also have to do a 2 year CC fellowship later.

I did a medicine in internal medicine and have finished a neurocritical care fellowship. During my fellowship i had a heavy trauam exposure, got comforatable with all types of lines, chest tubes, intubations, along with management of ARDS, Sepsis, Pneumonia, Dialysis. What are your thought about doing a pulmonary fellowship afterward or a general critical care fellowship afterwards. Would one be better than the other. Any input would be appreciated. Thanks