Paths to CCM: IM vs EM vs Gas vs Surg ???

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Transmogrifier

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I'm just a first year trying to get educated about possibilities. I've read the FAQs in the various forums about critical care and I was wondering if anyone could provide some comparison and contrast for me.

I'm currently interested in EM, IM, and Anesthesiology and I've recently discovered CCM. I like physiology, I like to think, I like complicated problems, and I like adrenaline. I'm not terribly hands on, I'd never do surgery, but procedures are fun.

It seems like the length of training comes out to be the same whichever route you take (except surgery).

What differences are there in the practice of critical care depending on your background? Obviously EM might still do ED work, pulm still does pulm, etc. What focus does each usually have? Practice setting? Types of cases? Role in the ICU? Could they all be working side by side or do they have their own niches?
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EM is new thing, still some resistance to it's place in ICU, don't want to go into details why, IM well established way to go, Gas started CCM to begin with, Surgery as far as l have seen are mostly capable of performing surgical ICU, of course not all of them. with every one of them u can do both icu and primary thing. if your interested in physiology you might consider anesthesia as primary spec.
 
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IM mostly will work in Medical ICUs, Surgeons and Anesthesiologists will mostly work in Surgical ICUs. not sure where EM fits in and it's kind of weird for me to see EM trained ICU docs. However, all are intensivisits and are CCM board certified and thus can work in any ICU setting they want, it will only matter who's willing to hire them and what type of patients they want to manage or are comfortable managing.
 
RussianJoo said:
IM mostly will work in Medical ICUs, Surgeons and Anesthesiologists will mostly work in Surgical ICUs. not sure where EM fits in and it's kind of weird for me to see EM trained ICU docs. However, all are intensivisits and are CCM board certified and thus can work in any ICU setting they want, it will only matter who's willing to hire them and what type of patients they want to manage or are comfortable managing.
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Not true. While EM docs can do a CCM fellowship, until very recently were unable to sit for boards, and therefore are not "board certified". IM has recently, as in this last fall, decided to allow EM docs to sit for their CCM board but only after taking IM's 2 year CCM fellowship. Which means that there will not be a CCM board certified EM doc until 2012.
 
Transmogrifier said:
I'm just a first year trying to get educated about possibilities. I've read the FAQs in the various forums about critical care and I was wondering if anyone could provide some comparison and contrast for me.

I'm currently interested in EM, IM, and Anesthesiology and I've recently discovered CCM. I like physiology, I like to think, I like complicated problems, and I like adrenaline. I'm not terribly hands on, I'd never do surgery, but procedures are fun.

It seems like the length of training comes out to be the same whichever route you take (except surgery).

What differences are there in the practice of critical care depending on your background? Obviously EM might still do ED work, pulm still does pulm, etc. What focus does each usually have? Practice setting? Types of cases? Role in the ICU? Could they all be working side by side or do they have their own niches?
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Ok, so no surgery for you.

And FYI, you can get into critical care out of neurology as well, but that's a little more specific type of training, obviously mostly above the neck kind of critical care.

From IM you can do a pure CCM fellowship, however, in my opinion the more Pulm you learn the more awesome it becomes, so the chance to be double boarded is an opportunity too good to pass up for me. Plus Pulm is where more of the funded basic science research is being done right now

From EM you'll get plenty of airway experience and trauma, but the learning curve will be steeper stepping from the ED into the ICU

From Gas you'll obviously have the best airway exposure, and you'll have a lot of SICU experience as well.

Personally, I think if you're simply looking to do intensivist medicine only, then I kind of like the Gas route. You can even find a few combined programs like Oregon's which is amazing. Also, look for places where a multidisciplinary approach is applied, like Pitt, which is the tits for CCM training - of note IMHO would also be Baylor, Stanford, and SLU.

Generally, critical care trained people of all kinds should be able to all do roughly the same things in all the same places, especially if they get that important multidisciplinary training I was talking about it. Some places will restrict gas to SICU and pulm/cc to MICU. Basically, what you will be able to do will be a product of what you learn during training, so the only limitation you should have are whatever you place on yourself. Which is one of the cool things about this field.
 
jdh71 said:
Personally, I think if you're simply looking to do intensivist medicine only, then I kind of like the Gas route. You can even find a few combined programs like Oregon's which is amazing. Also, look for places where a multidisciplinary approach is applied, like Pitt, which is the tits for CCM training - of note IMHO would also be Baylor, Stanford, and SLU.
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What about Gas do you think makes it best for doing intensivist only work?

For now, I think I'd like to do a combination of either EM/CCM or Gas/CCM but I can't rule out doing CCM only or doing Pulm/CCM.
 
Transmogrifier said:
What about Gas do you think makes it best for doing intensivist only work?

For now, I think I'd like to do a combination of either EM/CCM or Gas/CCM but I can't rule out doing CCM only or doing Pulm/CCM.
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The ONLY way to get to Pulm/CC is via IM

And I think gas is better route for CCM only mostly because of their airway experience and their ICU experience during residency prior to starting fellowship. I think the curve isn't quite as steep for gas as it is for IM (which unfortunately is moving more and more into the out-patient setting) and EM (which stabilizes and triages, but has little experience with long term hospital management). Meh. Everyone is up to snuff by the end of training. So do what you like.
 
jdh71 said:
Not true. While EM docs can do a CCM fellowship, until very recently were unable to sit for boards, and therefore are not "board certified"....Which means that there will not be a CCM board certified EM doc until 2012......From EM you'll get plenty of airway experience and trauma, but the learning curve will be steeper stepping from the ED into the ICU...Also, look for places where a multidisciplinary approach is applied, like Pitt, which is the tits for CCM training...
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Actually, US EM docs have been able to sit for the EDIC for some time now, so there are a number of board-certified CC docs with EM-training. Pitt in fact has been one of the places actively recruiting EM physicians for their CC training program for quite some time. Of note they put the following their website:

Will emergency medicine training prepare me well enough to be a strong critical care fellow?

 Yes. While other specialties bring their strengths into fellowship programs, your familiarity with handling critically ill patients at their initial presentation, experience with juggling multiple patients at once, and training in “sniffing out” the potential disasters from a sea of undifferentiated complaints will serve you well during fellowship. If you look at the core curriculums of emergency medicine and critical care, you will find that to a large degree our areas of knowledge overlap, particularly in the areas of resuscitation, technical skills needed for “crashing” patients (i.e., intubation, central lines, chest tubes), and exposure to both surgical and medical emergencies. Remember that nobody comes to a fellowship with nothing to learn.
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RxnMan said:
Actually, US EM docs have been able to sit for the EDIC for some time now, so there are a number of board-certified CC docs with EM-training. Pitt in fact has been one of the places
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I know this, but it's NOT american boards. This is usually a problem at many hospitals. Being european boarded is NOT the same thing as saying "board certified" per the context that most people mean when they say "board certified". And as such, there are still not actual board certified EM CCM docs in this country at present.

EDIT: Unless, of course, you are IM/EM residency trained. I'm sure there are more than a few of those guys who went through combined residencies . . . but going from straight EM to CC has been problematic as far as board certification goes and unnecessarily so. I'm glad IM decided to let EM sit for their boards if they do an IM CCM fellowship. Seems like the right ting to do, and I have no clue as to why the gas and surgery boards would be so obstinate about it
 
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Good information guys. I was kind of discounting EM because it seemed like it didn't really fit for CCM or would put me at a disadvantage compared to IM or Gas. It's good to know all options are open.
 
Transmogrifier said:
Good information guys. I was kind of discounting EM because it seemed like it didn't really fit for CCM or would put me at a disadvantage compared to IM or Gas. It's good to know all options are open.
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I would urge you to think of this in terms of not what is the "best" prep for critical care, but what is the best primary residency for your out-of-icu life? IM, Surg, EM, Gas.... vastly different residencies. And if you don't do well in whichever one you choose, I think you will struggle to maintain interest in your long term goal of critical care (to say nothing of the potential difficulty in securing a fellowship spot).

I did EM. I liked emergency medicine more than medicine clinic, and more than either side of the curtain in the OR. Now, I work in a setting where our unit has EM-, anesthesia- and surgical- trained intensivists, and I trained shoulder to shoulder with many IM-trained intensivists. Any differences between their ability is more down to the individual than the stream of training they swam in before going into critical care. I firmly believe this.

I will say that my options seemed somewhat limited compared to my board-certified colleagues when it came to getting a job, at least in academics. In the community, it didn't seem to matter. I got lots of job offers in units in the community. In the end, I took an academic job. I remember thinking that I feared that any EM-trained intensivists coming after me would have a problem getting an ICU job in academics; However, now that they can also get board certified, I think it is clear that they (EM-trained) should have good opportunities, even in academics. For me, well, I just got lucky I think.

Do what you love. The rest takes care of itself. Keep in mind that anyone who says to you that EM-trained intensivists seem "weird" is just because there aren't a lot of them out there. Or, perhaps the ones they know are weak not because of their training, but because of their work ethic. Or, they're frankly exhibiting professional arrogance but hey, that trait is common to all of our specialties in some people (shrug).

Best of luck.
 
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Don't forget another route to critical care is through IM and another IM subspecialty (other than pulm) - for example, critical care + ID, critical care + cardiology, even critical care + nephrology. The critical care fellowship is 1 year in addition to the full time of the other fellowship, and can be done before or afterwards.

I've seen more and more people doing this in the past few years, and in fact this is my plan as well - critical care and ID. Never found pulmonary to be too interesting, and find ID issues to be more prevalent and interesting in the ICU.
 
I don't pretend to know what the best way to critical care is. I know medicine and anesthesia are the more traditional ways. However, some of the four year EM residencies do allow for a fair number of off service rotations. I admit its not the same as the medicine of IM or the critical care physiology of anesthesiology but this is what we do in my EM residency for some of our off service rotations in addition to our emergency medicine months:

1 month anesthesia
1 month medicine wards
1 month surgery wards
1 month MICU
1 month PICU
1 month SICU
1 month cardiology
1 month ortho
1 month OB/gyn
1 month trauma surgery
http://webweekly.hms.harvard.edu/archive/2005/6_13/images/IMG_5171_ww.jpg
 
I must concede - opinions are like rectal orifices: everyone has one & you do not necessarily want to listen to mine...or anyone else's!

In my personal opinion, anesthesia residency grads are head & shoulders more well prepared than are the other board-able docs with surgery following in a fairly close second, IM third and pulm a distant 4th. Yeah, I know you want to know why & my thoughts go beyond simple personal bias - obviously I am biased as I chose anesth/CC.

Minimum Quantity of Training
Pulm/CC: min of 2mos in the IM residency, usually get 3mos. Then, they are only required to spend 6mos out of a 3-year pulm/CC fellowship actually in the ICU - TOTAL MINIMUM ICU TIME IN TRAINING = 8 months, but usually see 9 months.

IM/CC: again, min of 2mos in the IM residency, usually get 3mos. During the IM/CC fellowship, they are required 12mos out of the 24 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 14mos, usually 15 months.

Surg/CC: in the course of a 5yr residency, usually 3 or more months, frequently 4. Their fellowship requires 9mos in the ICU out of a 12 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 15 months.

Anesthesia/CC: minimum of 4 months in the ICU during residency. BUT, nearly all of your OR cases in your CA2 & CA3 years are sick, broken folks undergoing major surgical whacks - for all practical intents & purposes, you are running your own single-patient ICU all day long almost every day. In the OR, WE PRACTICE RESUSCITATIVE MEDICINE DAILY. During our fellowship, also required to do 9mos out of the 12 month total. TOTAL MINIMUM ICU TIME IN TRAINING = 16 months not counting the 24 months of "ICU time" running your CA2/CA3 cases.

Furthermore, EM residents will manage a few airways in the course of a residency - usually somewhere in the neighborhood of 200~300 intubations total - and place a few central/arterial lines. Surgical residents will probably place more lines than an EM resident, but place far fewer ETTs. IM residents do not get too many of either. Pulm/CC fellows will understandably place more of both during their fellowship. None of them will ever come remotely close to the massive volume of intubations, central & art line placements (under controlled and emergent situations) that an anesthesia resident undergoes...and then you add in the additional volume of all of these during our CC fellowship. There is no comparison on how facile anesthesia/CC is with emergent procedures vs. the other disciplines.

A typical anesthesia resident will perform >3000 intubations & > 200 each of central & art lines for comparison. Furthermore, anesthesia is REAL TIME pharmacology & physiology! No other physician training will get you the quantity or depth in managing acutely decompensating patients with fluids (crystalloids & colloids), inotropes, pressors and so on.
 
It's also worth mentioning that the practice of Critical Care Medicine was first established by Anesthesiologists to begin with. I believe it was in the care of polio patients back in mid 1900s. Unfortunately, according to one of the Anes/CCM attendings at my med school, you don't see nearly as many Anesthesiologists practicing CCM nowadays because the compensation, in PP at least, differs greatly from OR Anesthesiology. But I agree. I think in the end regardless of the pathway you take to CCM, you come out well-prepared to practice, but with just residency alone, I think Anesthesiology prepares one for CCM moreso than the other specialties because a lot of CCM is just an extension of what Anesthesiologists do in the OR.


Edited to add: There is a nice journal article that explores this link. I had to login through my medical school to get access, so I don't think I can link it here. But the citation is such:

"Anesthesiology: Traditional linkages to Critical Care Medicine." Anesthesiology Clinics of North America, Volume 15, Issue 4, 1 December 1997, Pages 725-730
 
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Old Man Dave:

Do you think this applies mostly to working in the SICU? Would you argue Gas training is superior for the MICU as well?

Also, does it just take longer for CCM docs from other specialties to be comfortable after fellowship, or do you argue that there is a big gap that doesn't ever close?
 
Transmogrifier said:
Do you think this applies mostly to working in the SICU? Would you argue Gas training is superior for the MICU as well?
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Critical care is critical care; it comes down to the management of airway, breathing and circulaton. As someone who has rotated through a SICU and CTICU, consulted on patients in a MICU and functioned as an attending in all of the above, I can tell you that there are not things done in a SICU that aren't done in a MICU and vice versa. The differences lie in the underlying medical problems, but those are just tinkering adjustments (usually made by consultants). The real nuts and bolts of critical care (especially in private practice) are ensuring the patient oxygenates, ventilates and perfuses. That, in a nutshell, is an anesthesiologist's residency, so I (a surgical trainee) would agree that anesthesia is probably just as good in the MICU as the SICU.
 
OldManDave said:
I must concede - opinions are like rectal orifices: everyone has one & you do not necessarily want to listen to mine...or anyone else's!

In my personal opinion, anesthesia residency grads are head & shoulders more well prepared than are the other board-able docs with surgery following in a fairly close second, IM third and pulm a distant 4th. Yeah, I know you want to know why & my thoughts go beyond simple personal bias - obviously I am biased as I chose anesth/CC.

Minimum Quantity of Training
Pulm/CC: min of 2mos in the IM residency, usually get 3mos. Then, they are only required to spend 6mos out of a 3-year pulm/CC fellowship actually in the ICU - TOTAL MINIMUM ICU TIME IN TRAINING = 8 months, but usually see 9 months.

IM/CC: again, min of 2mos in the IM residency, usually get 3mos. During the IM/CC fellowship, they are required 12mos out of the 24 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 14mos, usually 15 months.

Surg/CC: in the course of a 5yr residency, usually 3 or more months, frequently 4. Their fellowship requires 9mos in the ICU out of a 12 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 15 months.

Anesthesia/CC: minimum of 4 months in the ICU during residency. BUT, nearly all of your OR cases in your CA2 & CA3 years are sick, broken folks undergoing major surgical whacks - for all practical intents & purposes, you are running your own single-patient ICU all day long almost every day. In the OR, WE PRACTICE RESUSCITATIVE MEDICINE DAILY. During our fellowship, also required to do 9mos out of the 12 month total. TOTAL MINIMUM ICU TIME IN TRAINING = 16 months not counting the 24 months of "ICU time" running your CA2/CA3 cases.

Furthermore, EM residents will manage a few airways in the course of a residency - usually somewhere in the neighborhood of 200~300 intubations total - and place a few central/arterial lines. Surgical residents will probably place more lines than an EM resident, but place far fewer ETTs. IM residents do not get too many of either. Pulm/CC fellows will understandably place more of both during their fellowship. None of them will ever come remotely close to the massive volume of intubations, central & art line placements (under controlled and emergent situations) that an anesthesia resident undergoes...and then you add in the additional volume of all of these during our CC fellowship. There is no comparison on how facile anesthesia/CC is with emergent procedures vs. the other disciplines.

A typical anesthesia resident will perform >3000 intubations & > 200 each of central & art lines for comparison. Furthermore, anesthesia is REAL TIME pharmacology & physiology! No other physician training will get you the quantity or depth in managing acutely decompensating patients with fluids (crystalloids & colloids), inotropes, pressors and so on.
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Wow. 3000 intubations and 200 central lines and arterial lines... you must really know how to manage a critical care unit!

Chest tubes? Paracentesis? Thoracentesis? ICP manipulation while managing an EVD? Temporary cardiac pacer? Complex, multi-factorial sepsis and antibiotic/source control strategies? Septic arthritis necessitating arthrocentesis? Traumatic brain injury? Stroke management?

Nice illustration of professional arrogance. It always amazes me how many specialists think their training is superior to others based almost exclusively on their perception of others training and backgrounds.
 
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bulgethetwine said:
Wow. 3000 intubations and 200 central lines and arterial lines... you must really know how to manage a critical care unit!

Chest tubes? Paracentesis? Thoracentesis? ICP manipulation while managing an EVD? Temporary cardiac pacer? Complex, multi-factorial sepsis and antibiotic/source control strategies? Septic arthritis necessitating arthrocentesis? Traumatic brain injury? Stroke management?

Nice illustration of professional arrogance. It always amazes me how many specialists think their training is superior to others based almost exclusively on their perception of others training and backgrounds.
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Paracentesis - that's really hard...
Thoracentesis - see the Paracentesis...
Temporary cardiac pacer - don't tell me that you have more experience than anesthesia. It will be a LIE.
Artrhocentesis - don't forget tha WE do pain medicine.
Traumatic brain injury - who's anesthesia for neuro cases???
Stroke management - you guys call the neuro for a consult - otherwise you follow the protocol. You know - the one printed on that small card...
So anesthesia ROCKS!
I know your struggle to get a spot for CC.
No reason though to be angry. A lot of spots.
 
bulgethetwine said:
Wow. 3000 intubations and 200 central lines and arterial lines... you must really know how to manage a critical care unit!

Chest tubes? Paracentesis? Thoracentesis? ICP manipulation while managing an EVD? Temporary cardiac pacer? Complex, multi-factorial sepsis and antibiotic/source control strategies? Septic arthritis necessitating arthrocentesis? Traumatic brain injury? Stroke management?

Nice illustration of professional arrogance. It always amazes me how many specialists think their training is superior to others based almost exclusively on their perception of others training and backgrounds.
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All those critical care patients are potential surgical patients, and in the OR, there are no cardiologists, pulmonologists, neurologists, hepatologists, etc. All the medical management for those patients is done by the Anesthesiologists. This specialty (anesthesiology) is critical care; they don't do office-based work outside of pain management and preoperative clinics, and they usually don't see patients unless they are sick (or require surgery, which IMO = really sick). I agree with you in that Anesthesiologists are NOT the experts of those respective specialties (e.g. cards, neuro, etc), but they need to know the critical care aspects of them so that they can manage them in the OR, or in this case the ICU. Their knowledge is specialized (anesthetics) but, like FP and EM, general in that they have to have a strong general medical knowledge.

You will become a good critical care physician regardless of which path you take; they are just arguing that its not as difficult a transition coming out of the Anesthesiology residency. Most CCM specialists today in the USA are PCCM, but realize in the current or most recent climate, surgeons/anesthesiologists made more in PP in the OR than in the unit, and that is a major force in an individual's decision to tailor his/her practice. Look across the pond, and you will find that most Intensivists are Anesthesiologists.
 
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Why must physicians continue to try to one up other specialties? Every specialty has its unique characteristics that are benefits to critical care training.

If one specialty was the only specialty to obtain CCM certification, then that would be the only specialty recognized in hospitals to provide intensivist work.

We all need to grow up and get along with each other. Rather than fighting among ourselves, we need to focus our efforts on warding off encroachment of the medical community by other professions.
 
southerndoc said:
Why must physicians continue to try to one up other specialties? Every specialty has its unique characteristics that are benefits to critical care training.

If one specialty was the only specialty to obtain CCM certification, then that would be the only specialty recognized in hospitals to provide intensivist work.

We all need to grow up and get along with each other. Rather than fighting among ourselves, we need to focus our efforts on warding off encroachment of the medical community by other professions.
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I agree. EM docs are the closest one to anesthesia...
I don't fight against them - I appreciate their unique skills.
They are welcome to do CCM.
I was just kicking back :laugh:.
The need for CCM is huge unless Mobama ....
 
While I agree there is no real need to "mother****" our colleagues; however, I do find it hard to argue with the fact that gas gives you more critical care in residency, followed by surgery. With IM moving its emphasis more and more to the out-pt setting and primary care, you just don't normally get as much time in the unit during residency anymore. And EM is very institution dependent how much critical care they will get in their ERs. So, if the question is: "Which is a better residency for critical care?" then I still think gas is going to be the better route.

The only exception I take to oldmandave's post would be the number of unit months seen by Pulm/CC during fellowship training. Every place I interviewed had at least 12 months in the unit over the three years, most more . . . I can appreciate that perhaps at some high power academic places, fellows get less unit time for the sake of research, but I didn't interview at any place where that was the case. So MOST IM docs coming out of Pulm/CC fellowship will have at least 12 months and likely more in the ICU.
 
Just an MS3 here!

I don't know much about this, but it does look like you may get more unit time as a gas intern. However, they also do months of ob...how many epidurals are you going to start in the ICU? They do months of pediatric surg...you are mostly going to be working with adults in the ICU, right?

Also, in my experience in working in the ICU, I saw a lot of infections...wound infections, pneumonia, osteo, connective tissue, etc. Do gas residents deal with a lot of that? Know what abx to throw at the infxn or would an IM resident know more/have more experience?
I also saw a lot of AKI, severe cirrhosis, meningitis, RMSF, etc. Wouldn't an IM resident who has done neprho, GI, ID, etc. be a little more well prepared in those aspects?

Or was this conversation more about procedures? Then gas/surg residents have probably intubated, bronched, started lines more often than IM residents.

Just throwing my opinions in there. Any comments? Thanks.
 
docscience said:
Just an MS3 here!

I don't know much about this, but it does look like you may get more unit time as a gas intern. However, they also do months of ob...how many epidurals are you going to start in the ICU? They do months of pediatric surg...you are mostly going to be working with adults in the ICU, right?

Also, in my experience in working in the ICU, I saw a lot of infections...wound infections, pneumonia, osteo, connective tissue, etc. Do gas residents deal with a lot of that? Know what abx to throw at the infxn or would an IM resident know more/have more experience?
I also saw a lot of AKI, severe cirrhosis, meningitis, RMSF, etc. Wouldn't an IM resident who has done neprho, GI, ID, etc. be a little more well prepared in those aspects?

Or was this conversation more about procedures? Then gas/surg residents have probably intubated, bronched, started lines more often than IM residents.

Just throwing my opinions in there. Any comments? Thanks.
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Well, for one thing, the months of OB you are talking about are more than just epidurals and spinals. They are there for the surgical and pain concerns of the OB patient. Aside from the epidurals for normal labor pain relief, if a patient has a bleeding disorder, or comes in in DIC or is eclamptic, or has an abruption, basically needing emergency surgery, an anesthesiologist must be there to see to the physiologic needs of the patient while the OB tries to control the situation. Also, Anesthesiologists in their training can see the full age-range of patients, so the peds rotations are just that: training in the anesthetic needs of the pediatric patient. But both of those are separate discussions.

In an ICU, yes, you will see those other issues you mentioned: wound infections, pneumonias, etc. Stuff like that is routine in any unit, and the anesthesiologists will know how to care for it. Stuff like this occurs in PACUs, too. If not, then ID or other specialists can be consulted. But, my MICU attending during my sub-I told me that the only reason to consult is for stuff you cannot do yourself. A critical care trained physician, regardless of main specialty, can handle AKI, ARDS, hemodynamic instability, cirrhosis (who do you think handles this patient in the OR?), and infections. Realize that in an ICU, you're basically making sure the patient is oxygenating, ventilating, and is hemodynamically stable. A connective tissue disorder could be their primary problem, but they are in the unit because their life is in danger, so they are to be stabilized. After my month in the unit, this is the main difference I saw between the floors (where Anesthesiologists rarely work) and the unit (where they can often be found): In the unit, diagnosis and treatment of the primary problem (say cancer) takes a backseat to making sure they are hemodynamically stable and perfusing - ABCs first. Once they are stabilized, they can return to their oncologist for treatment of their cancer. There are exceptions of course, like meningitis which will also be treated fully in the unit because it's so contagious. But the unit is not the floor, and when it comes to airway management and hemodynamic resuscitation, the bread and butter of the unit, anesthesiologists are very good.
 
jdh71 said:
no one :laugh: . . . surgeons don't take that kind of patient to the OR
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Well, I was indirectly referring to a liver transplant patient and all the issues they may have if they become a surgical candidate. I've never actually seen a liver transplant yet, so my first will be in residency, but I've seen the room set-ups and I know the cases go on for hours, so my guess is that it is a very very involved case involving coagulopathies and even cardiac issues (my attending always had a TEE set up).

I'm not yet a Resident (start as medicine intern in July), but I just wanted to illustrate that Anesthesiologists are more than just line starters or epidural people. :cool:
 
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G-Man82 said:
Well, I was indirectly referring to a liver transplant patient and all the issues they may have if they become a surgical candidate. I've never actually seen a liver transplant yet, so my first will be in residency, but I've seen the room set-ups and I know the cases go on for hours, so my guess is that it is a very very involved case involving coagulopathies and even cardiac issues (my attending always had a TEE set up).

I'm not yet a Resident (start as medicine intern in July), but I just wanted to illustrate that Anesthesiologists are more than just line starters or epidural people. :cool:
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It's all good. As I understand it, liver cases will be some of the most hairy to work, but there's not a surgeon in the world that will take a patient with all the constellations you mentioned before surgery. If you're waiting for your liver and you get hemodynamically unstable prior to surgery and develop ARDS, secondary to sepsis, for instance . . . hope your affairs are in order because . . . no bueno homes

Good luck.
 
To extend this conversation out a little bit...I wanted to share an experience (excuse the naive use of technical words..still an MS3):

I am on my surgery rotation and went in for weekend rounds on patients/call weekend.
While hanging with the resident in the lounge, the ICU called us to come put a chest tube in a guy with a pretty severe pneumonia (biggest empyema I have seen!). We cut the thoracotomy hole and drained/suctioned the empyema after it spurted everywhere(looked like he was giving birth out of his chest..so much crap came out...lol), put the chest tube in, sutured him up, and we were out of there.

So my question is...who gets to do these chest tubes? Could an ICU doc do it? Why did they consult surgery? I really liked that procedure (vs. 2 hrs with a complex fistula in the OR which was also cool though) and would want to do it if I did an ICU fellowship.
What procedures do ICU docs do? Bronchs? Lines?

Thanks.
 
docscience said:
To extend this conversation out a little bit...I wanted to share an experience (excuse the naive use of technical words..still an MS3):

I am on my surgery rotation and went in for weekend rounds on patients/call weekend.
While hanging with the resident in the lounge, the ICU called us to come put a chest tube in a guy with a pretty severe pneumonia (biggest empyema I have seen!). We cut the thoracotomy hole and drained/suctioned the empyema after it spurted everywhere(looked like he was giving birth out of his chest..so much crap came out...lol), put the chest tube in, sutured him up, and we were out of there.

So my question is...who gets to do these chest tubes? Could an ICU doc do it? Why did they consult surgery? I really liked that procedure (vs. 2 hrs with a complex fistula in the OR which was also cool though) and would want to do it if I did an ICU fellowship.
What procedures do ICU docs do? Bronchs? Lines?

Thanks.
Click to expand...

You can do anything you are trained to do and feel comfortable doing.
 
Talked to a surgery attending about this today. He said, it depends on what you want to do. He said, why would you want to go through 5 years of grueling surgery when you just want to do critical care.

He worked at a large institution in Philly where they were specifically looking to hire a surgeon who had critical care training to staff their closed ICU and also do some surgeries/take trauma call.

So basically it might be a waste to do surgery for years just to do ICU medicine.
Just opinions...
 
Transmogrifier said:
Good information guys. I was kind of discounting EM because it seemed like it didn't really fit for CCM or would put me at a disadvantage compared to IM or Gas. It's good to know all options are open.
Click to expand...

A friend of mine who was EM trained did a CC/Trauma fellowship at The University of Maryland shock trauma center. He is currently working in an ICU and loving every minute of it. Just something to look into if you think of going the EM route.
 
As I sat through my monring continuity clinic trying at the same time to 1) not slit my wrists, and 2) not punch obnoxious patients in the face . . . I thought of this thread. If all you are interested in is Critical Care, then go anesthesia, just do it

:mad:
 
2win said:
Paracentesis - that's really hard...
Thoracentesis - see the Paracentesis...
Temporary cardiac pacer - don't tell me that you have more experience than anesthesia. It will be a LIE.
Artrhocentesis - don't forget tha WE do pain medicine.
Traumatic brain injury - who's anesthesia for neuro cases???
Stroke management - you guys call the neuro for a consult - otherwise you follow the protocol. You know - the one printed on that small card...
So anesthesia ROCKS!
I know your struggle to get a spot for CC.
No reason though to be angry. A lot of spots.
Click to expand...


Only thing I'll add is that procedure's are probably the easiest part of critical care medicine.

I imagine in the grand scheme of things Anasthesia and Surgery are probably about the same for SICU patients and Pulm/CC and IM/CC are probably about the same for MICU patients.

I would take a pulm/cc guy over a anaesthesioloist or surgeon any day of the week to manage a MICU, and vice-versa for SICU.

Not really sure where EM/CC fits in; probably mroe skewed toward the MICU since if they want to be US board certified it will be through IM/CC fellowships and the ABIM.
 
southerndoc said:
Why must physicians continue to try to one up other specialties? Every specialty has its unique characteristics that are benefits to critical care training.

If one specialty was the only specialty to obtain CCM certification, then that would be the only specialty recognized in hospitals to provide intensivist work.

We all need to grow up and get along with each other. Rather than fighting among ourselves, we need to focus our efforts on warding off encroachment of the medical community by other professions.
Click to expand...



plus 1.

For example -- and maybe i'm small minded here -- but I think its absurd that CRNA's are making more than a lot of MD's.

kumbaya everybody.
 
OldManDave said:
I must concede - opinions are like rectal orifices: everyone has one & you do not necessarily want to listen to mine...or anyone else's!

In my personal opinion, anesthesia residency grads are head & shoulders more well prepared than are the other board-able docs with surgery following in a fairly close second, IM third and pulm a distant 4th. Yeah, I know you want to know why & my thoughts go beyond simple personal bias - obviously I am biased as I chose anesth/CC.

Minimum Quantity of Training
Pulm/CC: min of 2mos in the IM residency, usually get 3mos. Then, they are only required to spend 6mos out of a 3-year pulm/CC fellowship actually in the ICU - TOTAL MINIMUM ICU TIME IN TRAINING = 8 months, but usually see 9 months.

IM/CC: again, min of 2mos in the IM residency, usually get 3mos. During the IM/CC fellowship, they are required 12mos out of the 24 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 14mos, usually 15 months.

Surg/CC: in the course of a 5yr residency, usually 3 or more months, frequently 4. Their fellowship requires 9mos in the ICU out of a 12 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 15 months.

Anesthesia/CC: minimum of 4 months in the ICU during residency. BUT, nearly all of your OR cases in your CA2 & CA3 years are sick, broken folks undergoing major surgical whacks - for all practical intents & purposes, you are running your own single-patient ICU all day long almost every day. In the OR, WE PRACTICE RESUSCITATIVE MEDICINE DAILY. During our fellowship, also required to do 9mos out of the 12 month total. TOTAL MINIMUM ICU TIME IN TRAINING = 16 months not counting the 24 months of "ICU time" running your CA2/CA3 cases.

Furthermore, EM residents will manage a few airways in the course of a residency - usually somewhere in the neighborhood of 200~300 intubations total - and place a few central/arterial lines. Surgical residents will probably place more lines than an EM resident, but place far fewer ETTs. IM residents do not get too many of either. Pulm/CC fellows will understandably place more of both during their fellowship. None of them will ever come remotely close to the massive volume of intubations, central & art line placements (under controlled and emergent situations) that an anesthesia resident undergoes...and then you add in the additional volume of all of these during our CC fellowship. There is no comparison on how facile anesthesia/CC is with emergent procedures vs. the other disciplines.

A typical anesthesia resident will perform >3000 intubations & > 200 each of central & art lines for comparison. Furthermore, anesthesia is REAL TIME pharmacology & physiology! No other physician training will get you the quantity or depth in managing acutely decompensating patients with fluids (crystalloids & colloids), inotropes, pressors and so on.
Click to expand...

Wow OldManDave. Way to respresent Ansethesia!! Thanks for the great post.
 
OldManDave said:
I must concede - opinions are like rectal orifices: everyone has one & you do not necessarily want to listen to mine...or anyone else's!

In my personal opinion, anesthesia residency grads are head & shoulders more well prepared than are the other board-able docs with surgery following in a fairly close second, IM third and pulm a distant 4th. Yeah, I know you want to know why & my thoughts go beyond simple personal bias - obviously I am biased as I chose anesth/CC.

Minimum Quantity of Training
Pulm/CC: min of 2mos in the IM residency, usually get 3mos. Then, they are only required to spend 6mos out of a 3-year pulm/CC fellowship actually in the ICU - TOTAL MINIMUM ICU TIME IN TRAINING = 8 months, but usually see 9 months.

IM/CC: again, min of 2mos in the IM residency, usually get 3mos. During the IM/CC fellowship, they are required 12mos out of the 24 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 14mos, usually 15 months.

Surg/CC: in the course of a 5yr residency, usually 3 or more months, frequently 4. Their fellowship requires 9mos in the ICU out of a 12 month fellowship. TOTAL MINIMUM ICU TIME IN TRAINING = 15 months.

Anesthesia/CC: minimum of 4 months in the ICU during residency. BUT, nearly all of your OR cases in your CA2 & CA3 years are sick, broken folks undergoing major surgical whacks - for all practical intents & purposes, you are running your own single-patient ICU all day long almost every day. In the OR, WE PRACTICE RESUSCITATIVE MEDICINE DAILY. During our fellowship, also required to do 9mos out of the 12 month total. TOTAL MINIMUM ICU TIME IN TRAINING = 16 months not counting the 24 months of "ICU time" running your CA2/CA3 cases.

Furthermore, EM residents will manage a few airways in the course of a residency - usually somewhere in the neighborhood of 200~300 intubations total - and place a few central/arterial lines. Surgical residents will probably place more lines than an EM resident, but place far fewer ETTs. IM residents do not get too many of either. Pulm/CC fellows will understandably place more of both during their fellowship. None of them will ever come remotely close to the massive volume of intubations, central & art line placements (under controlled and emergent situations) that an anesthesia resident undergoes...and then you add in the additional volume of all of these during our CC fellowship. There is no comparison on how facile anesthesia/CC is with emergent procedures vs. the other disciplines.

A typical anesthesia resident will perform >3000 intubations & > 200 each of central & art lines for comparison. Furthermore, anesthesia is REAL TIME pharmacology & physiology! No other physician training will get you the quantity or depth in managing acutely decompensating patients with fluids (crystalloids & colloids), inotropes, pressors and so on.
Click to expand...

Your numbers are way off for the pulm/cc route - at least where I trained. I just looked back at my schedules.

2 months each year in ICU as IM resident (1 micu, 1 ccu) = 6 mos
Fellowship year 1: 6 mos MICU
Fellowship year 2: 1.5 mos MICU, 1 mos SICU, 1 mos CTICU, 2 weeks neuroICU, 1 mos CCU = 5 mos
Fellowship year 3: 1 mos MICU, 2 weeks CTICU, 2 weeks neuro ICU = 2mos

Total time = 19 mos. Does not count rotations like pulm HTN and lung transplant with significant amount of ICU experience or interventional pulmonary with significant amount of procedural experience.

I'm not trying to get in a pi$$ing contest, just pointing out that experiences can be different.
 
I don't think anyone is really trying to get into a pi$$ing contest. I think what he was stating was the perceived averages. At my medical school, the PCCM fellows only do MICU. They don't really enter the SICU other than for vent consults (and that too rarely because Anesthesia is usually around). They also don't go to the CTICU other than for a pulmonary issue because that unit is run by Anesthesiology. I've noticed that a lot of the medicine fellowships split their time half-half with research and clinicals. At my school, the clinical half is about 6 months in the MICU/CCU and 12 months Pulm, with the other half research. This is a safety-net hospital and major state trauma center. I think the exposure to CCM you get during fellowship differs with where you complete your fellowship. I've visited the websites of other places, like Pitt, and their CCM fellows are not segregated, and so function in all the units. So, this really shouldn't turn into a contest. I'm about to start my internship (prelim in the Dept of Medicine) before moving on to Anesthesiology but I'm still very interested in CCM. While I still think Anesthesiology residents are more accustomed to the critical care environment (e.g. all the resuscitation that happens in the units, the OR, and occasionally the floors), after completing a decent fellowship, I think the other specialties catch up. Besides, isn't it more a compensation issue today that we don't see as many surgeons/anesthesiologists in community ICUs? Time in the OR pays more for surgeons/anesthesiologists than time in the ICU, despite the fact that both specialties are suited to the unit.
 
bigtuna said:
Your numbers are way off for the pulm/cc route - at least where I trained. I just looked back at my schedules.

2 months each year in ICU as IM resident (1 micu, 1 ccu) = 6 mos
Fellowship year 1: 6 mos MICU
Fellowship year 2: 1.5 mos MICU, 1 mos SICU, 1 mos CTICU, 2 weeks neuroICU, 1 mos CCU = 5 mos
Fellowship year 3: 1 mos MICU, 2 weeks CTICU, 2 weeks neuro ICU = 2mos

Total time = 19 mos. Does not count rotations like pulm HTN and lung transplant with significant amount of ICU experience or interventional pulmonary with significant amount of procedural experience.

I'm not trying to get in a pi$$ing contest, just pointing out that experiences can be different.
Click to expand...

I wish that you gonna make the bucks for all your training!
2win
PS : unlikely though.
 
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Sorry for resurrecting this old thread, but I'm interested if there are any insights for my specific situation. I'm an MD-PhD student who plans to do as much bench research as possible, plus time in the ICU as an intensivist as my only clinical responsibilities. Since I don't plan on doing OR anesthesia, pulm clinic, ED shifts, or trauma surgery, I really need to pick between anesthesia, IM, EM, and general surgery based on 1) how prepared I will be to be a competent intensivist, 2) how long the training lasts, and 3) how easy it will be to find jobs that are 80+% basic research. This seems to narrow it to IM + CC (without pulm) and anesthesia, rather than EM or general surgery. Is that a correct assessment? Any thoughts 0n IM vs anesthesia based on this?

Another consideration is that I'd like to serve in the reserves (Navy or Army). I would think that would make anesthesia pretty valuable, but from what I've read, anesthesiologists mostly end up in ICUs if deployed since the actual anesthesia is given by CRNAs in military field hospitals. Thus, I don't think that helps me narrow down between IM and anesthesia. Maybe EM becomes more valuable in that context? But I'd think EM departments are less conducive to jobs with 80% basic research (in my case, structural biophysics).
 
friedtomato said:
Sorry for resurrecting this old thread, but I'm interested if there are any insights for my specific situation. I'm an MD-PhD student who plans to do as much bench research as possible, plus time in the ICU as an intensivist as my only clinical responsibilities. Since I don't plan on doing OR anesthesia, pulm clinic, ED shifts, or trauma surgery, I really need to pick between anesthesia, IM, EM, and general surgery based on 1) how prepared I will be to be a competent intensivist, 2) how long the training lasts, and 3) how easy it will be to find jobs that are 80+% basic research. This seems to narrow it to IM + CC (without pulm) and anesthesia, rather than EM or general surgery. Is that a correct assessment? Any thoughts 0n IM vs anesthesia based on this?

Another consideration is that I'd like to serve in the reserves (Navy or Army). I would think that would make anesthesia pretty valuable, but from what I've read, anesthesiologists mostly end up in ICUs if deployed since the actual anesthesia is given by CRNAs in military field hospitals. Thus, I don't think that helps me narrow down between IM and anesthesia. Maybe EM becomes more valuable in that context? But I'd think EM departments are less conducive to jobs with 80% basic research (in my case, structural biophysics).
Click to expand...

Where are you in med school now? If you haven't done clinical rotations yet then you'll likely have your answer after that. General surgery, internal medicine, anesthesia, and emergency medicine are extremely different residencies to go through. On top of that, you'd have to consider what type of ICU you want to work in. If your goal is to do lots of research then you're going to be at a large academic medical center working in a very specific ICU setting (medical, surgical, neuro) based on what residency and fellowship you did.

Whatever you choose, you can be a pure intensivist regardless of which route you took to get there. For example, if you do EM then critical care then you don't need to work any shifts at all in an ED and can work exclusively in an ICU setting, though many do split their time by personal preference.
 
So far I've done my general surgery, internal medicine, emergency medicine, and anesthesia rotations. I front-loaded those because I knew I'll be picking between them. By a huge margin I enjoyed general surgery the most, but I'm resigned to the fact that it isn't compatible with the 80% basic science career that I want.
 
I could care less what your background is as long as you are good. My ideal group would be a group that is composed of an equal share of surgeons, anesthesiologist, EM physicians, and pulmonologist who all also spend time in their respective specialties….talk about a powerhouse group within a hospital system…you would have your hand in so many essential moving parts of a hospital. I am an anesthesiologist by trade but was fortunate that my fellowship gave me experience alongside pulmonologist, neurologist, and surgeons. I without question learned from all of them. With that said I do feel the transition into the unit is easiest for those with an anesthesia background from what I have seen. An anesthesiologist job in the operating room is essentially a hyperacute ICU but at the end of your training it does not matter if you are good.
 
I came to CCM straight from IM. 3 years of IM + 2 years CCM. I had rotations in MICU, Neuro ICU, CTICU and mixed community ICUs, in addition to a lot of MICU/CCU in residency (8+ months, which is more than GME allows, normally, but I made trades with people who wanted to avoid ICU.
I would say this: no question that Anesthesia has more airway experience; that is why I did extra anesthesia rotations as a fellow. All other procedures, including chest tubes, are plentiful through any route (provided that you hustle for them, learn how to do them, and do them as much as possible-- initially supervised, then independently). Anesthesia also has TEE experience, which I do not. Anesthesia has, of necessity, more exposure to surgical patients, no matter how much Neurosurg and CTICU I have done. I would say that I have more exposure to medical esoterica (rheum, renal, endocrine) than most non-IM folks. These conditions do come in to play in all ICUs and having a background in them helps.
It is essential that all of us from different training backgrounds get experience and read about our weak spots, and know when to consult.
Pick the route that interests you the most, and focus your electives on the field that is not your primary.
Just my 2cents
 
friedtomato said:
Sorry for resurrecting this old thread, but I'm interested if there are any insights for my specific situation. I'm an MD-PhD student who plans to do as much bench research as possible, plus time in the ICU as an intensivist as my only clinical responsibilities. Since I don't plan on doing OR anesthesia, pulm clinic, ED shifts, or trauma surgery, I really need to pick between anesthesia, IM, EM, and general surgery based on 1) how prepared I will be to be a competent intensivist, 2) how long the training lasts, and 3) how easy it will be to find jobs that are 80+% basic research. This seems to narrow it to IM + CC (without pulm) and anesthesia, rather than EM or general surgery. Is that a correct assessment? Any thoughts 0n IM vs anesthesia based on this?

Another consideration is that I'd like to serve in the reserves (Navy or Army). I would think that would make anesthesia pretty valuable, but from what I've read, anesthesiologists mostly end up in ICUs if deployed since the actual anesthesia is given by CRNAs in military field hospitals. Thus, I don't think that helps me narrow down between IM and anesthesia. Maybe EM becomes more valuable in that context? But I'd think EM departments are less conducive to jobs with 80% basic research (in my case, structural biophysics).
Click to expand...

There are a lot of moving pieces here, but the situation that will allow the best chance of getting what you are looking for will be the surgical or the medicine route (do you want to operate should be a question you need to ask yourself?). Plus what do you want to when deployed? Medical ICU or trauma?
 
Also, who is doing the research you want to do currently? Finding that out will help tremendously, if you don't already know. As an MD/PhD guy, you kind of need to be thinking about this, if you haven't.
 
Thank you very much for all your helpful responses; this discussion has been very useful so far.

I'd like to do very basic research; X-ray crystallography, NMR, and molecular dynamics simulations of RNA complexes involved in epigenetic regulation. My PhD work is very disease agnostic, and can be taken in the direction of neuroscience, immunology, cancer, infectious disease, etc. I have an engineering background, and find the physiology in the ICU appealing (as well as the diverse organ systems). All of the physician scientists I know in this field are internists doing at least 80% research. I know a few anesthesiologists doing work at a comparably basic level, but with a different focus. I don't know of a single surgeon or EM physician who is doing that sort of work, which is why I've assumed that those routes aren't feasible.

However, if I weren't going to be a scientist, my ideal career would be a trauma/CC surgeon splitting time between the OR and ICU (which would also be my ideal role on a deployment with the reserves). Since I know surgery doesn't work with my basic science interests, my ideal "compromise" would be to find another clinical specialty that at least lets me work in the ICU (MICU may actually be more appealing than SICU if not a surgeon), while having a civilian job with 80% research.

As for the reserves: if I'm not a surgeon, I'll be happy to take on whatever role in which I can to contribute the most, whether critical care or anesthesia (if I go that route).
 
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