-

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
EM, anesthesia and CCM are all tied to the hospital, have problems with mid level encroachment and growth of corporate staffing groups. These are bad things. If you can tolerate clinic, pulmonary gives you another avenue to practice that is disconnected from the hospital and a “way out” in the event of burnout. For these reasons I think pulm/CCM is the best option unless you absolutely hate clinic. Residency is only 3 years, rest of your career is much longer, so I wouldn’t make a decision based on that. Academic MICU will have a preference for IM trained.

At the end of the day, you can become a good intensivist from any of the paths as long as you put the effort in.
 
EM (not CCM) perspective. I chose EM. Went to a heavy EM/CCM program for residency. Started filling out applications for critical care fellowships, but ultimately backed out before submitting. Still not sure if I regret it or or not years later.

I don’t believe much in medicine. I still like it in its truest sense, but don’t think it involves helping people that are living their healthiest lives or offers the benefit that we all would like to think it does. I also like life outside of medicine a lot. Mountains, trails, whiskey, dogs, experiences, simple things, etc. If medicine isn’t the end all be all, then EM is the answer as it gives more breadth and realer to people’s every day experiences. If the medicine is all you want (and sometimes I think it is, but know in my own heart for me it isn’t), then I’d do IM->CCM/Pulm. It will give you the most opportunities and prepare you well. You become more quickly better at procedures and rapid resuscitation in EM. That’s not what CCM is. You want broad inpatient training. That’s what IM is. That’s what separates you from the pretenders. 3-4 years is short. Your career is long. Unless of course you pick EM, FIRE in 10-15 and end up looking at the sunset contemplating your life choices while not working over a glass of whiskey. Good luck!

P.S. Hope not offending any of you CCM folks EM trained or otherwise. Your opinions matter more. Just offering my two cents from a different path.
 
Last edited:
I the community, hospital- employed or management company employed practices, CCM is CCM, regardless of the initial specialty. You're a body to fill a hole in the schedule. Academics tends to have more siloing, with anesthesia or EM- trained having a greater tendency to be in the various surgical ICUs (SICU/Trauma, Neuro, Cardiac), while Pulm and IM tend to cover MICU. This is not universal, however, particularly at universities with an integrated Critical Care department (as opposed to a critical care division under the Department of Medicine, a critical care division under the Department of Surgery, and a critical care division under the Department of Anesthesiology).

A lot of medical students think they want the ICU, then change their minds during training. Pick a primary specialty that you would enjoy doing in its own, both in case you decide that you don't want to do CCM, and to do on non-ICU days (or when you get burned out).
 
I am Anesthesia CCM. I also struggled with what primary residency to do before icu. I was always gung-ho about doing 100% icu until completing my fellowship feeling super burnt out. It it definitely wise to think about what you could fall back on to take that weight off from your ICU days/weeks. Anesthesia allows me that reprieve from a unit full of complex patients and complex social issues and complex everything. It is necessary. The pulm people at my work covet their pulm days as it is much less stress and work that icu. Idk about you, but I’ve always found EM to be the most stressful job. There is literally no filter to the patients you see. But everyone is different and you just have to hedge on what you think would be best for you.

If you want full “control” you could think about surgery -> sicu. Depends if you’re a surgical vs medical type of person. But yes in general, IM gives you that “control” you’re looking for. I didn’t understand that concept until I became a resident. It’s an important one.

I’m very fortunate that as an anesthesia icu trained person that I found an academic place that welcomes a multidisciplinary team for their micu. Overall though, I’ve found in the community the need for anyone is quite high and your primary residency means much less.
 
A lot of good info above. First, you can become an excellent intensivist whichever pathway you go down. I’m EMCCM. I always felt I would end up in the ICU, and did EM because I thought if I changed my mind I would prefer to be in the ED than the OR or a hospitalist. While I love what I do, I would encourage you to look into the IM and anesthesia pathways. I think the med student experience of EM does not usually reflect the reality of every day practice, so many come in with unrealistic expectations after having a month where they felt more significantly more involved than their other rotations.

I agree with @CCM-MD: the IM pathway offers the most varied and durable opportunities. While general intensivist positions are on the rise, many regions are still dominated by pulmCCM. Having just gone through the job search, only a small fraction of those groups were willing to hire an EM trainee, although I expect that fraction will continue to grow. While many of my pulmonary colleagues came to the pathway for CCM, most tend to end up loving the pulmonary side even more. Further, if you change your mind in IM residency, the CCM pathway remains open even if you do cardiology, nephrology, infectious disease, etc.

Anesthesia critical care also tends to be the primary pathway staffing academic cardiac ICU's in my experience. In this setting you would still be expected to collaborate with the surgeon, but the pathology is quite different (better in my opinion). This would also open up the world of mechanical circulatory support (i.e. ECMO, LVAD's, etc.), which is often housed in the CICU. On the whole the anesthesia folks seem to work more than I do, but YMMV.

EM/IM - I wouldn't recommend it if you’re planning on CCM. I don't think the extra training adds much.
 
GotToGetThatGPAUp said:
M3 trying to choose between several pathways to CCM.

I, as of right now, want to go into academic crit care, and frankly would want as much autonomy over my unit as possible. What I love about crit care is the breadth of knowledge, it being multi-system, the procedures, the intensity and mixture of fast-paced responses as well as deep thinking, and the range of pathology you can see.

I was interested in the anesthesia pathway because I really enjoyed my anesthesia rotation, I love the physio and the ability to do procedures early and get truly good at them but I hear when they go through CC they're typically relegated to the SICU only which sounds dreadful. Don't get me wrong, I love the SICU, but when it comes to autonomy it's hard to go around the surgeon's plan given it was their procedure and their outcomes, and it some places they're the primary.

I was also interested in EM or EM/IM because I really, really enjoy working in the ED. I think this is something I would continue enjoy doing in balance with the ICU. I felt my personality really meshed with the EM folks

Then there's IM only. I actually really enjoyed my IM rotation. I like being able to have training in complete management of a patient, and it's also quite flexible with the plethora of other subspecialties one could enter. I'd do this over EM/IM if I wanted to pursue PulmCC just to lessen the overall training time from 7 to 6 years (EM/IM/PulmCC vs IM/PulmCC that is).

Despite believing I'd enjoy the EM and anesthesia residency over IM (not subject wise perse, just could see the IM dispo stuff becoming exhausting), I feel like you typically see more opportunities, especially for academics, in PulmCC though I've seen an emergence of EM/IM/CC docs popping up.



Any suggestions, pros and cons of each pathway, thanks!
Click to expand...

Do IM or GS first. The two specialties that really get to know the hospital and unit well (and cover the wide breadth of medicine that you have to know for CC) are Internal Medicine and General Surgery. Let's be honest.

How we let so many others into the mix of CC is beyond me. (of course, everyone wants to get in on CC for the money)

Anes? Stay in the PACU and OR please, we need you there (especially to babysit now the plethora of CRNAs). Your work there is 'critical' enough. Don't need you managing vents and complex DKA in the same patient for 5 days.

EM? Same, need you in the ER. Acute stabilization is 'critical'.

Neurologists? Sweet jesus. Don't need you for anything.
 
DrMetal said:
Do IM or GS first. The two specialties that really get to know the hospital and unit well (and cover the wide breadth of medicine that you have to know for CC) are Internal Medicine and General Surgery. Let's be honest.

How we let so many others into the mix of CC is beyond me. (of course, everyone wants to get in on CC for the money)

Anes? Stay in the PACU and OR please, we need you there (especially to babysit now the plethora of CRNAs). Your work there is 'critical' enough. Don't need you managing vents and complex DKA in the same patient for 5 days.

EM? Same, need you in the ER. Acute stabilization is 'critical'.

Neurologists? Sweet jesus. Don't need you for anything.
Click to expand...
My goodness, you’re a toxic person aren’t you.
 
RemyMcswain said:
My goodness, you’re a toxic person aren’t you.
Click to expand...

Said a crazy x-girlfriend to me once too, as I also pointed out many truths to her about her way of life. Amen for restraining orders.
 
Pulmonary is a nice out if you're ok with clinic and internal medicine. From the financial perspective, anesthesia/CCM or if you're willing to go a longer route, IM/Cards/CCM are better options.

FWIW, I trained in a mixed med/surg ICU staffed by intensivists with IM, anesthesia, and pulm backgrounds and they all did fine. The anesthesia people were more adept in the procedural aspects and tended to practice more protocolized/algorithmic critical care while the pulm people were likely to delve into esotera and rounds tended to be a bit longer.

If you're planning to practice in an academic setting, you can usually count on good subspecialty consultant support for harder cases, may be a bit more challenging if you're doing MICU in a community place with less reliable consultant availability.
 
DrMetal said:
Said a crazy x-girlfriend to me once too, as I also pointed out many truths to her about her way of life. Amen for restraining orders.
Click to expand...
You mean your ex-gf has a restraining order against you? because that's the only way your post makes sense.
 
depends on what you like. In my group there are 2 EM/CC docs. No anesthesia CCM. But if you want to have options like clinic in the future, should consider Pulm/CC
 
You must log in or register to reply here.
Top Bottom