Choosing between EM/IM/CCM

Transmogrifier · Jan 28, 2012

I'm looking for thoughts on EM vs hospitalist vs intensivist. I'm a third year and I've done neuro, psych, IM, surgery, and FM. I'll be doing EM next month followed by OB and peds.

As a pre-med and through the first two years of med school I was sure I wanted to do EM. I like undifferentiated complaints, fast pace, the adrenaline rushses, always something new, lots of breadth, along with the lifestyle/hours/pay of EM.

Going through third year and being on the receiving end of patients admitted through the ED, I've realized how little follow up there really is in EM. Patients get admitted because they're sick and often without a definitive diagnosis. You don't get to do much of a workup or have the satisfaction of arriving at a diagnosis and helping a patient get better. I've enjoyed that side of IM (and even surgery) quite a bit. I've loved getting to see new consults for our service or having to go see patients in the ED. Part of me would love to be House and sit around and come up with crazy differentials.

I don't have much experience with the ICU, but it's something I'd consider if I were to do IM. I like the idea of managing the sickest, most complicated patients. But I don't really feel a need to make a decision about CCM just yet. I know there are some opportunities from EM to do CCM, but that there is no board certification as of yet.

I don't mind procedures, but I definitely don't need them in whatever I end up doing.

Obviously doing my EM rotation next month with help a whole lot in sorting this out. I'm also going to talk to an EM faculty member who actually did EM/IM and CCM. But I'd like to hear from anyone who was in a similar situation.

If you were considering similar specialties, what pushed you to choose one over the other?

How similar/different are the lifestyle/hours/pay of an EP vs hospitalist? My understanding is that in EM you probably get paid a bit more and work a bit less, but this would be dependent on location and physician choice as well.

Anything else I should consider or do as I try to make up my mind?

horhay1241 · Jan 29, 2012

I was in the same position last year- but throw anesthesia into the mix and thats where I was at. After a ton of debate, I chose IM because it gives you the most options. You can do fellowships in basically whatever you want, or do the hospitalist gig which does sound appealing or primary care. There are just tons of doors open. When I did my EM rotation, i loved the action and trauma and really sick pts and making the initial diagnosis. But the other 95% of the time I wasn't enjoying it. I also enjoyed some continuity with patients- even just a few days like a hospitalist would have. Another thing was one of the EM docs told me that its a great job in your 30s and early 40s, but after that it really gets to wear on you and it takes a lot longer to bounce back from those overnights. Finally, there are some comm hospitals that still have IM guys in the ED although thats becoming increasingly more difficult to find as I understand. You'll figure it out after your rotation.

alphaholic06 · Jan 29, 2012

Sounds like medicine is the path for you.

Transmogrifier · Jan 29, 2012

horhay1241 said:
I was in the same position last year- but throw anesthesia into the mix and thats where I was at. After a ton of debate, I chose IM because it gives you the most options. You can do fellowships in basically whatever you want, or do the hospitalist gig which does sound appealing or primary care. There are just tons of doors open. When I did my EM rotation, i loved the action and trauma and really sick pts and making the initial diagnosis. But the other 95% of the time I wasn't enjoying it. I also enjoyed some continuity with patients- even just a few days like a hospitalist would have. Another thing was one of the EM docs told me that its a great job in your 30s and early 40s, but after that it really gets to wear on you and it takes a lot longer to bounce back from those overnights. Finally, there are some comm hospitals that still have IM guys in the ED although thats becoming increasingly more difficult to find as I understand. You'll figure it out after your rotation.

Anesthesia was in the mix for me to but I think I've ruled it out. I really like physiology and pharmacology so that part of gas was appealing, but I want to see and evaluate patients and workup their complaints. Sure I could do critical care through gas, but I'd rather not go into something only because of a fellowship that I (might) want to do.

I did two weeks of pulm consults while on IM and my fellow had recently taken a year off and worked as a hospitalist. She was an FMG, so she went with IM instead of EM to play it safe. She seems perfectly happy in IM, but says she would have done EM were she more competitive.

I feel like I could enjoy doing both but it seems that most people who do combined residencies end up sticking with just one thing. I suppose this month in the ED will really help me sort things out.

EAC · Feb 1, 2012

I was deciding between EM & IM until October. I had a blast during my EM rotations, but ultimately decided on IM because I love following up on differentials and figuring out what the patient actually has. I actually really enjoy sit-down rounds where we talk about pathophys for an hour, which doesn't happen in EM. Also wasn't super excited about babysitting the drunk-homeless-and-mentally-ill patients in the ED. Plus I couldn't see myself working nights & overnights for the rest of my life. Hard to imagine being 40 with small kids and still working those 11-7 or 3-11 shifts.

My understanding is that hospitalists and EM docs have comparable pay and hours (both hospital-based shift workers), but I'm no expert on this by any means. Regarding CCM from EM, I'd check out the EM forum. EM-trained physicians just became eligible for CC board certification, I believe.

jdh71 · Feb 1, 2012

EAC said:
I was deciding between EM & IM until October. I had a blast during my EM rotations, but ultimately decided on IM because I love following up on differentials and figuring out what the patient actually has. I actually really enjoy sit-down rounds where we talk about pathophys for an hour, which doesn't happen in EM. Also wasn't super excited about babysitting the drunk-homeless-and-mentally-ill patients in the ED. Plus I couldn't see myself working nights & overnights for the rest of my life. Hard to imagine being 40 with small kids and still working those 11-7 or 3-11 shifts.

My understanding is that hospitalists and EM docs have comparable pay and hours (both hospital-based shift workers), but I'm no expert on this by any means. Regarding CCM from EM, I'd check out the EM forum. EM-trained physicians just became eligible for CC board certification, I believe.

That is only after doing 2 years of critical care fellowship through an ABIM program

codeb1ue · Feb 5, 2012

I too was choosing between IM/EM/CCM/Anesthesia. Chose IM with the goal of pursuing PCCM. Currently a PGY-2 and enjoying it overall. However there are many aspects of medicine I DON'T enjoy which include, and not limited to, the multitude of social admissions involved, being the hospital dump ground for every pt other specialties don't want to deal with, having patients on your service that never want to leave, the endless amounts of H&Ps and discharge summaries that consume half your day, 3am pages for bowel regimens, potassium of 3.6, etc. This was tolerable for the first year but is really getting tiring now.

Having said that, I have chosen to switch specialties to Anesthesiology and am now set to start my CA-1 year this fall. In anesthesia, I still get to enjoy the mental masturbation that I love, though maybe not to the extent of IM. I love the physiological aspect of analyzing why someone's BP suddenly drops, why someone suddenly goes hypoxic, and the opportunity to push meds myself and seeing the effects immediately. I also love the procedural aspect of the field. Will likely still pursue CCM in the end.

Anyways just thought I'd share my journey with fellow comrades who appear to share similar joys of medicine as myself.

Transmogrifier · Feb 5, 2012

EAC said:
I was deciding between EM & IM until October. I had a blast during my EM rotations, but ultimately decided on IM because I love following up on differentials and figuring out what the patient actually has. I actually really enjoy sit-down rounds where we talk about pathophys for an hour, which doesn't happen in EM. Also wasn't super excited about babysitting the drunk-homeless-and-mentally-ill patients in the ED. Plus I couldn't see myself working nights & overnights for the rest of my life. Hard to imagine being 40 with small kids and still working those 11-7 or 3-11 shifts.

My understanding is that hospitalists and EM docs have comparable pay and hours (both hospital-based shift workers), but I'm no expert on this by any means. Regarding CCM from EM, I'd check out the EM forum. EM-trained physicians just became eligible for CC board certification, I believe.

I had seen this as a drawback to EM, but since I can't see myself doing anything in IM besides being a hospitalist or doing CCM it looks like I'm stuck with shift work for the rest of my life, for better or for worse!

codeb1ue said:
I too was choosing between IM/EM/CCM/Anesthesia. Chose IM with the goal of pursuing PCCM. Currently a PGY-2 and enjoying it overall. However there are many aspects of medicine I DON'T enjoy which include, and not limited to, the multitude of social admissions involved, being the hospital dump ground for every pt other specialties don't want to deal with, having patients on your service that never want to leave, the endless amounts of H&Ps and discharge summaries that consume half your day, 3am pages for bowel regimens, potassium of 3.6, etc. This was tolerable for the first year but is really getting tiring now.

Having said that, I have chosen to switch specialties to Anesthesiology and am now set to start my CA-1 year this fall. In anesthesia, I still get to enjoy the mental masturbation that I love, though maybe not to the extent of IM. I love the physiological aspect of analyzing why someone's BP suddenly drops, why someone suddenly goes hypoxic, and the opportunity to push meds myself and seeing the effects immediately. I also love the procedural aspect of the field. Will likely still pursue CCM in the end.

Anyways just thought I'd share my journey with fellow comrades who appear to share similar joys of medicine as myself.

Thanks for mentioning that. I've been trying to think what the downsides to being a hospitalist would be. Having only been a medical student and not a resident, I have seen, but not really dealt as directly with most of that stuff.

I've now done 3 shifts in the ED and it has helped recenter me in considering the two specialties. I had some confirmation bias going on in thinking "the ED doesn't actually figure out what's wrong, they just shotgun and admit." It's been a lot of fun seeing new patients and doing workups, even if we don't get it all sorted out.

I can still tell that I like continuity, but I also remember being on IM and being bored to death with patients that I wasn't doing anything for but weren't ready to go home. If I do EM and decide I'm dying for continuity, CCM is always an option.

I looked into EM/IM combined programs, but it seems like a hell of a lot of effort just to have my cake and eat it too.

Hamhock · Feb 6, 2012

Transmogrifier said:
I looked into EM/IM combined programs, but it seems like a hell of a lot of effort just to have my cake and eat it too.

It's also a lot of work, but you should at least look at EM/IM/CCM (6 years, I think) programs.

I know at least Henry Ford has such a program.

HH

Apollyon · Feb 6, 2012

Transmogrifier said:
I had some confirmation bias going on in thinking "the ED doesn't actually figure out what's wrong, they just shotgun and admit." It's been a lot of fun seeing new patients and doing workups, even if we don't get it all sorted out.

You will hear that from any and every place where IM is the power-holder. Frankly, that is just not true. For me to throw my hands up and call the admitting doc and say "I don't have any idea what it is" means I have gone through an exhaustive workup to try and find out the source of the problem.

Think of it this way: The EM doc tees off. S/he may occasionally go into the rough, but tries to stay on the fairway. S/he will hit a few more times, and get on the green, then calls in someone to putt. Recall that 1 to 2 putts are expected over 20 yards, but that leaves 1 to 4 strokes over 300-500 yards.

Now, on occasion, the EM doc will hole out. However, not always. In my experience, the surgeons and their ilk are the sharpshooter 1 putters. IM, by the very nature of such a wide differential that may still have yet to evolve, will be the 5-putters.

When I was a resident, at a place with a top 10 IM residency, the chair and the PD of the IM program asked our chief and PD to have us do not such thorough workups. As the chair said, "You're leaving my residents to write a note and look up a journal article".

I am the first person to tell my hospitalist that I am conservative, and not a cowboy, and my reasons for not wanting to D/C a patient. However, at the same time, I make all the calls - to cards, GI, ENT, GSx, neuro, ID - and I collate all the specialists. I even inserviced a hospitalist at 10pm on a Saturday night on insertion of a Rapid Rhino (up on the floor).

So, to say that we in EM are just shotgunning and admitting is giving us the short shrift. At the same time, remember micro from first year? How there were so many bacteria and parasites and a mind-boggling amount of information? And how, despite that, all roads led to the same thing - Augmentin, Cipro, albendazole. Still, despite the treatment being the same in a vast majority of cases, each individual case is still investigated, and the scientific method (such as it is in this case) is followed. What you think is shotgunning, just ask - and, if the ordering doc can't give you a reason, then it is being shotgunned. For one, that ain't me.

Transmogrifier · Feb 6, 2012

Hamhock said:
It's also a lot of work, but you should at least look at EM/IM/CCM (6 years, I think) programs.

I know at least Henry Ford has such a program.

HH

I sat down with an EM faculty member today who did EM/IM and then Pulm/CCM (and a masters!) today. He splits his time about 75/25 between the ED and MICU.

He's very happy with the training he has gotten and would do it over again, though he said if CCM were more of an option for EM like it is now he would have given it some serious thought. However, he also said he hadn't made up his mind on CCM as a third/fourth year med student.

He encouraged me to do a general medicine sub-i at the beginning of my fourth year if I'm still undecided. He was very adamant about not doing EM/IM just out of indecision and only if it's what will really make me happy and give me the opportunities I want.

A majority of EM/IM grads end up doing mostly EM, but there is a mix of everything out there.

He also recommended applying to and ranking straight EM or IM programs should I decide to go the EM/IM combined route as there are only about a dozen programs with 3-6 spots per class.

Transmogrifier · Feb 6, 2012

Apollyon said:
You will hear that from any and every place where IM is the power-holder. Frankly, that is just not true. For me to throw my hands up and call the admitting doc and say "I don't have any idea what it is" means I have gone through an exhaustive workup to try and find out the source of the problem.

Think of it this way: The EM doc tees off. S/he may occasionally go into the rough, but tries to stay on the fairway. S/he will hit a few more times, and get on the green, then calls in someone to putt. Recall that 1 to 2 putts are expected over 20 yards, but that leaves 1 to 4 strokes over 300-500 yards.

Now, on occasion, the EM doc will hole out. However, not always. In my experience, the surgeons and their ilk are the sharpshooter 1 putters. IM, by the very nature of such a wide differential that may still have yet to evolve, will be the 5-putters.

When I was a resident, at a place with a top 10 IM residency, the chair and the PD of the IM program asked our chief and PD to have us do not such thorough workups. As the chair said, "You're leaving my residents to write a note and look up a journal article".

I am the first person to tell my hospitalist that I am conservative, and not a cowboy, and my reasons for not wanting to D/C a patient. However, at the same time, I make all the calls - to cards, GI, ENT, GSx, neuro, ID - and I collate all the specialists. I even inserviced a hospitalist at 10pm on a Saturday night on insertion of a Rapid Rhino (up on the floor).

So, to say that we in EM are just shotgunning and admitting is giving us the short shrift. At the same time, remember micro from first year? How there were so many bacteria and parasites and a mind-boggling amount of information? And how, despite that, all roads led to the same thing - Augmentin, Cipro, albendazole. Still, despite the treatment being the same in a vast majority of cases, each individual case is still investigated, and the scientific method (such as it is in this case) is followed. What you think is shotgunning, just ask - and, if the ordering doc can't give you a reason, then it is being shotgunned. For one, that ain't me.

Thanks for the perspective.

I've done a lot of thinking about my gut feelings about both specialties. I realized I had become somewhat disenchanted with EM after doing a short shadowing shift earlier this year and pretty well ****ing up some of my patient presentations. I think I had taken some of that personally and was projecting some of my ill feelings back on to EM.

Apollyon · Feb 7, 2012

Transmogrifier said:
Thanks for the perspective.

I've done a lot of thinking about my gut feelings about both specialties. I realized I had become somewhat disenchanted with EM after doing a short shadowing shift earlier this year and pretty well ****ing up some of my patient presentations. I think I had taken some of that personally and was projecting some of my ill feelings back on to EM.

Well, you get major props for insight. The typical "should I do it?" post that is not in the EM forum is on the lines of "I like ER, but I want to diagnose people and not just shotgun workups and how do you deal with not having the respect of anyone else?" Hell, I could probably enter that sentence into search, and find a bunch of threads.

However, don't throw the baby out with the bathwater - if you screwed up a presentation, you get 10 more chances each shift. As such, you either get better, or you don't.

Hamhock · Feb 7, 2012

Transmogrifier said:
I sat down with an EM faculty member today who did EM/IM and then Pulm/CCM (and a masters!) today. He splits his time about 75/25 between the ED and MICU.

He's very happy with the training he has gotten and would do it over again, though he said if CCM were more of an option for EM like it is now he would have given it some serious thought. However, he also said he hadn't made up his mind on CCM as a third/fourth year med student.

He encouraged me to do a general medicine sub-i at the beginning of my fourth year if I'm still undecided. He was very adamant about not doing EM/IM just out of indecision and only if it's what will really make me happy and give me the opportunities I want.

A majority of EM/IM grads end up doing mostly EM, but there is a mix of everything out there.

He also recommended applying to and ranking straight EM or IM programs should I decide to go the EM/IM combined route as there are only about a dozen programs with 3-6 spots per class.

I think that is pretty good advice.

The EM/IM folks publish a fairly descriptive career track of nearly every EM/IM grad. This comes out every few years. It may be worth a quick review.

As I remember, most do EM.

HH

tartesos · Feb 11, 2012

Transmogrifier said:
I had seen this as a drawback to EM, but since I can't see myself doing anything in IM besides being a hospitalist or doing CCM it looks like I'm stuck with shift work for the rest of my life, for better or for worse!

Thanks for mentioning that. I've been trying to think what the downsides to being a hospitalist would be. Having only been a medical student and not a resident, I have seen, but not really dealt as directly with most of that stuff.

I've now done 3 shifts in the ED and it has helped recenter me in considering the two specialties. I had some confirmation bias going on in thinking "the ED doesn't actually figure out what's wrong, they just shotgun and admit." It's been a lot of fun seeing new patients and doing workups, even if we don't get it all sorted out.

I can still tell that I like continuity, but I also remember being on IM and being bored to death with patients that I wasn't doing anything for but weren't ready to go home. If I do EM and decide I'm dying for continuity, CCM is always an option.

I looked into EM/IM combined programs, but it seems like a hell of a lot of effort just to have my cake and eat it too.

continuity in CCM? hmmm that does not sound quite right.
Hospitalist?( I`m doing some of it moon lightning during my fellowship) as a prior poster said, depends on the place, but it gets pretty old very quick, calls about pain, constipation, insomnia, i think he has chest pain, or this is my first time with this patient and he doesn't look so good( and the patient has been doing the same jerking for the month + hes been in there) at all times of day get old pretty fast.
as For EM, it is complex and i have a lot of respect for most em docs, except the ones that hold on to the cases all day until is time to sign off and admit everything( or worse, send to the floor without telling anyone, you know who you are!!! lol), in general, all ER docs i`ve dealt with are cool and have very good interpersonal skills, because they have to mingle and handle all the specialties and deal with all egoes of some prima donnas lol.
Good luck on your search, but choose wisely, this could mean your long term happiness or hell. Go with what makes you the most happy, see one of your attendings and see if you'd be happy with his schedule, life and the kind of work he does, thats a good start.

K31 · Feb 11, 2012

Transmogrifier said:
I sat down with an EM faculty member today who did EM/IM and then Pulm/CCM (and a masters!) today. He splits his time about 75/25 between the ED and MICU.

He's very happy with the training he has gotten and would do it over again, though he said if CCM were more of an option for EM like it is now he would have given it some serious thought. However, he also said he hadn't made up his mind on CCM as a third/fourth year med student.

He encouraged me to do a general medicine sub-i at the beginning of my fourth year if I'm still undecided. He was very adamant about not doing EM/IM just out of indecision and only if it's what will really make me happy and give me the opportunities I want.

A majority of EM/IM grads end up doing mostly EM, but there is a mix of everything out there.

He also recommended applying to and ranking straight EM or IM programs should I decide to go the EM/IM combined route as there are only about a dozen programs with 3-6 spots per class.

Yeah, this is about where I am right now. I came into med school wanting to do pulm/CCM but decided that CCM is all I'm really interested in in IM and that EM is really a better fit for me. I'm planning on applying to mostly EM programs plus all the EM/IM/CCM programs.

tartesos said:
continuity in CCM? hmmm that does not sound quite right.

"Continuity" is relative. When someone considering EM talks about continuity, it usually refers to seeing the same patient more than one day in a row. Most people interested I'm EM have no interest in a multi-year relationship with a patient, just following them beyond their initial presentation.

inspirationmd · Feb 12, 2012

codeb1ue said:
I too was choosing between IM/EM/CCM/Anesthesia. Chose IM with the goal of pursuing PCCM. Currently a PGY-2 and enjoying it overall. However there are many aspects of medicine I DON'T enjoy which include, and not limited to, the multitude of social admissions involved, being the hospital dump ground for every pt other specialties don't want to deal with, having patients on your service that never want to leave, the endless amounts of H&Ps and discharge summaries that consume half your day, 3am pages for bowel regimens, potassium of 3.6, etc. This was tolerable for the first year but is really getting tiring now.

Having said that, I have chosen to switch specialties to Anesthesiology and am now set to start my CA-1 year this fall. In anesthesia, I still get to enjoy the mental masturbation that I love, though maybe not to the extent of IM. I love the physiological aspect of analyzing why someone's BP suddenly drops, why someone suddenly goes hypoxic, and the opportunity to push meds myself and seeing the effects immediately. I also love the procedural aspect of the field. Will likely still pursue CCM in the end.

Anyways just thought I'd share my journey with fellow comrades who appear to share similar joys of medicine as myself.

Yeah I can completely understand this. I am more EM minded than IM minded so all the social/dispo issues for the various rocks on the service drives me up the wall. The chronicity also kind of sucks. Not only that but I dislike clinic far more than I anticipated as well.

IM has its redeeming qualities though that make it a great baseline training. Extensive pathophysiology knowledge is a great thing to foster in this setting and I personally believe that it is a great place to get solid research done since it can be very flexible training with light rotations and requesting of built in research months you can get residency credit for. Having solid training in all the major medical disciplines also comes in handy for whatever you do (ie. Anesthesia, Critical Care, etc).

I am planning on using my EM/IM training to do critical care particularly in Trauma/SICU or CICU. I want to work in the ED as well as the unit. My advice to everyone is to try to gain exposure to the different types of ICUs because all of them are not created equal. I have realized MICU patients drive me nuts since once you get past the acute issue that brings them there, weaning them off the vent and balancing all chronic issues is NOT fun. I would much rather have a relatively healthy and younger patient (on average) where visible improvement is seen more often and then they go on to the next stage in their recovery. Plus I think I vibe more with Surgeons than Pulm/CC docs.

To the OP, I think that a great EM doc will rule out the acute issues as well as start the beginning of the work-up for the floor admission. When I am in the ED I order things like HbA1c, Iron Studies, etc that my EM attendings do not care about but my colleagues upstairs appreciate. Sometimes I take heat for it but that is one of the benefits of being a Medicine resident downstairs since you know what will help you when they come up. Of course, I do not slow the department down with this but if I have time I am a team player. You have to decide if you want to tee-off as mentioned above or if you want to play full blown detective and chase every lead.

Lastly, check this article out. Being an Intensivist as an EM doc is definitely doable.

http://www.ncbi.nlm.nih.gov/pubmed/20370766

Transmogrifier · Feb 12, 2012

K31 said:
"Continuity" is relative. When someone considering EM talks about continuity, it usually refers to seeing the same patient more than one day in a row. Most people interested I'm EM have no interest in a multi-year relationship with a patient, just following them beyond their initial presentation.

Yeah my definition of continuity would be about a week tops. Mostly I just want to know what the diagnosis is. I would possibly give up medicine if I had to do outpatient clinic.

NotAProgDirector · Feb 16, 2012

I wanted to point out that you can now do CCM fellowships directly after completing an EM residency. Thus, you don't need to do an EM/IM/CCM combined program if you don't want to. You simply complete EM training, apply for a Critical Care Medicine fellowship, and that's it.

turkeyjerky · Feb 17, 2012

aProgDirector said:
I wanted to point out that you can now do CCM fellowships directly after completing an EM residency. Thus, you don't need to do an EM/IM/CCM combined program if you don't want to. You simply complete EM training, apply for a Critical Care Medicine fellowship, and that's it.

How's this look from the IM/CCM side of things? I mean, it's been pretty limited in the past, do you think more programs are going to start accepting EM grads into their fellowships, or will it be limited to the 10 or so programs who've been doing it for years?

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