Anesthesiology, Critical Care

I'm also an MS4 that has been interested in anesthesiology and possibly CCM. however, i'm not sure that CCM is what i want anymore. I'm doing a CCM rotation right now, and it seems that the CCM service doesn't really have the final say over the treatment of the patient, and all we do is mostly management and making sure what the primary service (i.e. CT surgery, renal, etc) wants to do gets done. Not to mention we don't get to do much in the way of code resuscitation type medicine.

Contrast that with a patient i'd been following over the past week and a half, who DID undergo a 15-20 minute code resuscitation, INTRAOPERATIVELY. Who resuscitated him? anesthesiology, of course!

By the time he got to the ICU he was already stable, and we've just been observing him and tweaking the fluids/pressors/sedation/vent since. And. . .he's gonna be A-OK. . .(neurologically fine!). . .thanks to the anesthesiologists!

What i mean is, i'm really glad he was stabilized and I recognize that what goes on in the ICU is incredibly important, but i'd rather be involved in the resuscitation aspect than in the observation part.

Well, I guess i have 3-4 years to decide about CCM.

chicamedica said:

I'm also an MS4 that has been interested in anesthesiology and possibly CCM. however, i'm not sure that CCM is what i want anymore. I'm doing a CCM rotation right now, and it seems that the CCM service doesn't really have the final say over the treatment of the patient, and all we do is mostly management and making sure what the primary service (i.e. CT surgery, renal, etc) wants to do gets done. Not to mention we don't get to do much in the way of code resuscitation type medicine.

Contrast that with a patient i'd been following over the past week and a half, who DID undergo a 15-20 minute code resuscitation, INTRAOPERATIVELY. Who resuscitated him? anesthesiology, of course!

By the time he got to the ICU he was already stable, and we've just been observing him and tweaking the fluids/pressors/sedation/vent since. And. . .he's gonna be A-OK. . .(neurologically fine!). . .thanks to the anesthesiologists!

What i mean is, i'm really glad he was stabilized and I recognize that what goes on in the ICU is incredibly important, but i'd rather be involved in the resuscitation aspect than in the observation part.

Well, I guess i have 3-4 years to decide about CCM.

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Don't presume that what your hospital's policies are is the norm for most critical care physicians out there. It sounds almost like your ICU service is more of a consult service, which is not a typical situation. Most critical care physicians are the primary physicians in codes, resuscitations, etc. Of course, a code in the OR would obviously be dealt with by the anesthesiologist doing the case.

In the ICUs at the hospitals I'm at, we (ie critical care physicians) have the final say on the management of the vast majority of our patients. We also do all the resuscitation and run all the codes. We also have to resuscitate anyone coming to us from the ED, because once our ED decides that someone's a unit player, they drop them like a hot potato. The only exception to this are the thoracic surgery patients -- thoracics likes to do everything themselves here, but that's okay - they have their own ICU so we rarely deal with them.

You'll have plenty of time to decide about CCM during residency, and you will learn that not everywhere does things the way that you've become used to.

I finished my fellowship in CCM in 1999, and practiced CCM in a closed unit for 5 years in a Navy academic environment where my partners were all pulmonologists. The unit is a combined micu/sicu where the intensivists own all the patients.

The field is fascinating. As a CCM guy, you will make decisions that will affect whether some one lives or dies....the down side is that the reward is not immediate...like in the OR. Outcomes in CCM are measured in 30 day survival, etc.....kind of hard to see on a day to day basis...and you can do all the right things and patients will still die....that is the nature of the beast.

As anesthesiologists in the US....expect to have little involvement in the ICU if you are in private practice.....reimbursements don't justify your time away from the OR...but do expect a lot of respect from your surgical colleagues about your opinions on taking care of patients.

Take a look at the Leapfrog initiative....things may change as anesthesia reimbursements drop, and hospitals realize that the standard of care for critically ill patients in the next century lie with specially trained physicians who spend a fair amount of their time with ICU patients.

Cool post. 2 questions:

1. Even if anesthesia reimbursements don't drop substantially, given the Leapfrog initiative, don't hospitals have an incentive to provide a stipend to anesthesia groups that have CCM guys who can provide some SICU coverage? The anesthesia guys are satisfied, the hospital gets better care, and it would be worth the extra money for the hospital since lengths of stay would be shorter, happier ancillary staff, surgeons free to operate more instead of rounding on sick unit patients, etc. I suppose hospitals have already crunched the numbers and decided it's not worth it, but I'd have thought things would have changed by now.

2. Say I want to do a CCM fellowship after anesthesia. Does it really matter if I train in a place that doesn't have closed units? Does it really matter if the SICU is not run by anesthesia?

militarymd said:

I finished my fellowship in CCM in 1999, and practiced CCM in a closed unit for 5 years in a Navy academic environment where my partners were all pulmonologists. The unit is a combined micu/sicu where the intensivists own all the patients.

The field is fascinating. As a CCM guy, you will make decisions that will affect whether some one lives or dies....the down side is that the reward is not immediate...like in the OR. Outcomes in CCM are measured in 30 day survival, etc.....kind of hard to see on a day to day basis...and you can do all the right things and patients will still die....that is the nature of the beast.

As anesthesiologists in the US....expect to have little involvement in the ICU if you are in private practice.....reimbursements don't justify your time away from the OR...but do expect a lot of respect from your surgical colleagues about your opinions on taking care of patients.

Take a look at the Leapfrog initiative....things may change as anesthesia reimbursements drop, and hospitals realize that the standard of care for critically ill patients in the next century lie with specially trained physicians who spend a fair amount of their time with ICU patients.

Click to expand...

militarymd said:

Take a look at the Leapfrog initiative....things may change as anesthesia reimbursements drop, and hospitals realize that the standard of care for critically ill patients in the next century lie with specially trained physicians who spend a fair amount of their time with ICU patients.

Click to expand...

I have read about the Leapfrog initiative, but have found nothing that would cause anesthesia reimbursement to drop.

asdash said:

Cool post. 2 questions:

1. Even if anesthesia reimbursements don't drop substantially, given the Leapfrog initiative, don't hospitals have an incentive to provide a stipend to anesthesia groups that have CCM guys who can provide some SICU coverage? The anesthesia guys are satisfied, the hospital gets better care, and it would be worth the extra money for the hospital since lengths of stay would be shorter, happier ancillary staff, surgeons free to operate more instead of rounding on sick unit patients, etc. I suppose hospitals have already crunched the numbers and decided it's not worth it, but I'd have thought things would have changed by now.

2. Say I want to do a CCM fellowship after anesthesia. Does it really matter if I train in a place that doesn't have closed units? Does it really matter if the SICU is not run by anesthesia?

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It would be worth the money for hospitals to pay anesthesia CCM guys. We easily pay for our salaries by decreasing costs.....probably 3 to 4 times our salary depending on the level of acuity you have in the ICU.

However, it is money "saved" ie....money that the hospital doesn't have to use.....so it is somewhat nebulous.....The administration has to buy into the idea for them to do it.

One group that I interviewed with in Ohio was recruiting me so that they could take over the ICUs again. They had given up the ICU because of cost, and the hospital noticed that after anesthesia gave up the unit, the ventilator times and VAPs went up, so the hospital asked the group to takeover again.....I'm not sure what the subsidy was going to be.

If you plan on doing a fellowship, pick a place where you have a closed unit...better experience that way.

Etomidate said:

I have read about the Leapfrog initiative, but have found nothing that would cause anesthesia reimbursement to drop.

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The Leapfrog initiative won't make anesthesia reimbursements drop...you dope.

The Leapfrog initiative should raise reimbursements for CCM guys, and if anesthesia reimbursements drop, then more anesthesia guys would do CCM....as opposed to now ...that's what I mean.

militarymd said:

The Leapfrog initiative won't make anesthesia reimbursements drop...you dope.

The Leapfrog initiative should raise reimbursements for CCM guys, and if anesthesia reimbursements drop, then more anesthesia guys would do CCM....as opposed to now ...that's what I mean.

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gotcha.

you called me a dope.

Etomidate said:

gotcha.

you called me a dope.

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It was meant in fun

AJM said:

Don't presume that what your hospital's policies are is the norm for most critical care physicians out there. It sounds almost like your ICU service is more of a consult service, which is not a typical situation. Most critical care physicians are the primary physicians in codes, resuscitations, etc. Of course, a code in the OR would obviously be dealt with by the anesthesiologist doing the case.

In the ICUs at the hospitals I'm at, we (ie critical care physicians) have the final say on the management of the vast majority of our patients. We also do all the resuscitation and run all the codes. We also have to resuscitate anyone coming to us from the ED, because once our ED decides that someone's a unit player, they drop them like a hot potato. The only exception to this are the thoracic surgery patients -- thoracics likes to do everything themselves here, but that's okay - they have their own ICU so we rarely deal with them.

You'll have plenty of time to decide about CCM during residency, and you will learn that not everywhere does things the way that you've become used to.

Click to expand...

Which hospitals are the ones with closed unit ICUs? My attending last month told me there is no such thing. . .which i know is untrue b/c i know for a fact that hopkins' icu is totally run by anes.

where else besides hopkins?

chicamedica said:

Which hospitals are the ones with closed unit ICUs? My attending last month told me there is no such thing. . .which i know is untrue b/c i know for a fact that hopkins' icu is totally run by anes.

where else besides hopkins?

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Anyone?? I also know MGH and BWH do.

Any others??? Please help. . .it would really help me decide which programs to apply to. . .

military and others,
I think about doing a critical care fellowship as well, I just like it. But since most private groups have zero ICU coverage, are there still opportunities to use the training? Are SICU jobs sometime open to part time work? I mean the surgeons do it, so it would mean joining their group on a 1 week or so per month basis, and being considered less than fulltime by the anesthesia group. This would assume that I 1) entered private practice and 2) wanted a significant OR practice.

I would imagine the MICU would be harder to break into as most that I've seen are staffed by a pulmonary group and I wouldn't be to do any pulm or sleep.

Perhaps practicing primarily as an intensivist and doing OR per diem or part time work is easier?

Michigan runs the CT ICU.

chicamedica said:

Anyone?? I also know MGH and BWH do.

Any others??? Please help. . .it would really help me decide which programs to apply to. . .

Click to expand...

if you're interested in anesthesiology, that's certainly a start. programs differ in who runs the unit and whether it is open or closed, so ask around when you interview. regardless of where you end up, you'll get experience in the unit, and you'll find that it centers around vent management and acute illness. there are a lot of jobs out there for intensivists, and i've heard that anesthesia program may soon require up to 6 months of icu training. it's a field that requires a strong knowledge of medicine, especially pulm and cards. i just got of a icu month, and to be honest there is a lot more to know than regular OR anesthesiology. your hours will be tough, but it's very rewarding to get patient who is sick as hell out of the unit and back on the road to recovery. it certainly helps going to a program where anesthesia runs the unit.

2ndyear said:

military and others,
I think about doing a critical care fellowship as well, I just like it. But since most private groups have zero ICU coverage, are there still opportunities to use the training? Are SICU jobs sometime open to part time work? I mean the surgeons do it, so it would mean joining their group on a 1 week or so per month basis, and being considered less than fulltime by the anesthesia group. This would assume that I 1) entered private practice and 2) wanted a significant OR practice.

I would imagine the MICU would be harder to break into as most that I've seen are staffed by a pulmonary group and I wouldn't be to do any pulm or sleep.

Perhaps practicing primarily as an intensivist and doing OR per diem or part time work is easier?

Click to expand...

Most ICUs in private practice are "open" units...meaning anyone can admit patients and write orders...anyone means..OB, FP, peds, IM, surg...anyone. If any of these people who admits will consult you, then you have a practice....you could see the patients before and after your OR cases, and bill for your services.

Most anesthesiologists will feel that it is not worth it...like me...and just squeeze the bag in the OR.

chicamedica said:

Anyone?? I also know MGH and BWH do.

Any others??? Please help. . .it would really help me decide which programs to apply to. . .

Click to expand...

Columbia's SICU is a closed unit run by anesthesiology. I'm not sure about the CT-ICU or neuro-ICU.

militarymd said:

Most ICUs in private practice are "open" units...meaning anyone can admit patients and write orders...anyone means..OB, FP, peds, IM, surg...anyone. If any of these people who admits will consult you, then you have a practice....you could see the patients before and after your OR cases, and bill for your services.

Most anesthesiologists will feel that it is not worth it...like me...and just squeeze the bag in the OR.

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Hey military do you feel that having done your CCU fellowship makes you that much stronger in your daily practice life. I'm seriously considering a fellowship and personally feel that CCU would make me a meatier doc.

Would appreciate your take on it.

VentdependenT said:

Hey military do you feel that having done your CCU fellowship makes you that much stronger in your daily practice life. I'm seriously considering a fellowship and personally feel that CCU would make me a meatier doc.

Would appreciate your take on it.

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I feel that it was worth it. I don't know if it made me a better anesthetist or not, but I feel I am a much better physician.

A lot of the things that non-anesthesiologists (cards/IM/pulm, etc.) put on paper are things which they having training in, and we don't....the fellowship made me "understand" them better.

chicamedica said:

Anyone?? I also know MGH and BWH do.

Any others??? Please help. . .it would really help me decide which programs to apply to. . .

Click to expand...

UCSF anesthesia directs _all_ the critical care services (medical and surgical) at moffit-long. the units are semi-closed at ucsf. most services do not write orders on pts in ucsf icus, however, some highly specialized services, like transplantation surgery, do write orders that are _not_ related to critical care (i.e., they do not write sedation, ventilation, hemodynamic related orders). ucsf residency program is on track to get to 6 months of critical care training. my class will be required to do 4. if you interview there, miller will tell you he thinks it's essential to a good icu experience (from an anesthesia point of view) that anesthesia provide the medical direction in the unit. the dept is highly interested in its critical care endeavors and would be a good place to check out if you're interested in critical care.

xjohns1 said:

UCSF anesthesia directs _all_ the critical care services (medical and surgical) at moffit-long. the units are semi-closed at ucsf. most services do not write orders on pts in ucsf icus, however, some highly specialized services, like transplantation surgery, do write orders that are _not_ related to critical care (i.e., they do not write sedation, ventilation, hemodynamic related orders). ucsf residency program is on track to get to 6 months of critical care training. my class will be required to do 4. if you interview there, miller will tell you he thinks it's essential to a good icu experience (from an anesthesia point of view) that anesthesia provide the medical direction in the unit. the dept is highly interested in its critical care endeavors and would be a good place to check out if you're interested in critical care.

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Are you sure about this? At least as far as the medical ICU is concerned, UCSF is one of the few remaining academic medical centers that still have open units. The medicine teams continue to take care of and write orders on their patients in the MICU. The MICU team is there as primarily a consult service. That was one of my main turnoffs about UCSF when I looked at it for pulmonary/cc fellowship -- the main critical care experience the pulm fellows get there are consultations on vent management, and not much else.
Maybe it's different in the SICUs, I don't know -- but I wasn't too happy with what I saw and heard from the fellows.

My understanding of the system at UCSF is that the units are co-directed by anesthesia and pulmonary. This setup is similar to what Stanford does, and has it's pros and cons. The pluses, for example, are that you learn critical care from lots of attendings of different backgrounds, and the teams of residents are mixed between anesthesia and medicine, which I think complement each other very well. The main con to this system is the potential for disjointed teaching and care -- at least at Stanford, the anesthesia/cc and pulm/cc attendings don't always see eye-to-eye, so if your attending is anesthesia during one week and pulm the next week, the plan of care can change drastically, often for really no good reason other than style differences.

By the way - some other hospitals that I know of that have closed units:
Stanford has a closed MICU and SICU. CT surg has their own ICU that I'm pretty sure anesthesia is not involved with. Neurosurg takes care of their own patients in the ICU, but the MICU team, which is half anesthesia and half medicine/pulm, consults on all the NSG patients (but never writes orders on them).
MGH is closed
BWH definitely has closed MICUs and SICUs. The thoracics ICU is run as a separate deal, as is the Neuro ICU.
BID is a closed MICU and semi-closed SICU. The primary surgical teams are allowed to write orders in the SICU, but those orders are not supposed to pertain to the actual critical care that the SICU is providing (for example, they can write for immunosuppressant meds for the transplant patients, but can't change the vent).
UW I'm pretty sure is completely closed.

Those are the ones I can remember for now. Hope that helps.

AJM said:

Are you sure about this? At least as far as the medical ICU is concerned, UCSF is one of the few remaining academic medical centers that still have open units. The medicine teams continue to take care of and write orders on their patients in the MICU. The MICU team is there as primarily a consult service. That was one of my main turnoffs about UCSF when I looked at it for pulmonary/cc fellowship -- the main critical care experience the pulm fellows get there are consultations on vent management, and not much else.
Maybe it's different in the SICUs, I don't know -- but I wasn't too happy with what I saw and heard from the fellows.

My understanding of the system at UCSF is that the units are co-directed by anesthesia and pulmonary. This setup is similar to what Stanford does, and has it's pros and cons. The pluses, for example, are that you learn critical care from lots of attendings of different backgrounds, and the teams of residents are mixed between anesthesia and medicine, which I think complement each other very well. The main con to this system is the potential for disjointed teaching and care -- at least at Stanford, the anesthesia/cc and pulm/cc attendings don't always see eye-to-eye, so if your attending is anesthesia during one week and pulm the next week, the plan of care can change drastically, often for really no good reason other than style differences.

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unfortunately, i haven't yet done an icu rotation at ucsf, and i know less about the experience from the medicine side of things, so what i relay is what i was told during my interview visit and afterwards in researching the anesthesia program. anesthesia (michael gropper) definitely provides all the medical direction for the icu's--miller is quite proud of this. also, there is no "medical icu" per se at ucsf--it's a combined medical-surgical unit (38 beds). however, you're right that medicine also attends and has trainees in the units (along with surgery and ER residents). the issue of being closed or not was asked about and addressed explicitly several times, and it was always referred to as "semi-open," with certain primary services writing certain specialized non-icu-related orders (e.g., immunosuppression orders in transplant pts was given as an example); i had not heard that primary medicine teams write orders on their icu pts, and that sounds contrary to the way anesthesia described the situation. the benefit to this (again, as it was sold to us) was that we as trainees are exposed to every sort of critical care pt (medical, neuro, transplant, ct, cardiac, other surgical) because the primary services are allowed to take care of things the icu team is not trained to care for. again, my first-hand knowledge is limited, so of course i'm happy to yield to those who know better.