Academics vs community for pul/crit fellowship?

[FattySlug]

Hi, I am an MS4 who is interested in pul/crit. After reading many threads in this sub-forum, it seems that IM residencies vary greatly in their preparation for critical care which is understandable because not everyone wants to do critical care. I think residents have elective blocks so how much exposure to the unit is also partly up to you.

1) My question is about the procedural training part of critical care. Is it true that you generally get to do more procedures at good community hospital whereas at an academic center there are usually specific people for the job and as an IM residents you won't get to do many of them? But I also heard if you are from an academic IM program, your chance of fellowship is also higher. How to balance this?

2) I read in some other threads that who intubate MICU patients depends on the institution. Many leave it up to anesthesia. I wonder that as a pul/crit guy, do you have to call them or only call when you think the airway is difficult? Is there additional training you can have to raise you to their level of competency?

3) What are the things to look for and what questions to ask while choosing IM programs if you are interested in pul/crit?

Thank you very much.

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[sluggs]

Good questions:

1. Procedural training and experience is extremely variable in residency, and does not necessarily depend on community vs university. In some community programs, private attendings do the majority of procedures; in others the residents are autonomous. When you narrow your application/interview list, you could actually post a mini-thread listing your top choices and inquire about procedural experience and autonomy to the IM crowd. In general, academic programs give you more broad case mix, better "reputation", and theoretically a leg up on fellowship, but there are exceptions on both ends of the spectrum. I lucked out and had a university residency that had great fellows, but was "resident-driven" and we had first crack at almost all procedures.

2. See #1. I did a fair # of supervised intubations in residency, but really learned the skills by doing a lot of anesthesia electives during fellowship. If you are planning on ending up in community hospital, this is a skill you should work to develop.

3. See #1 and #2, BUT go to a place that gives you good general internal medicine training-- there is no substitute for this. A resident who went to a procedures heavy program may have a leg up during the first few months of fellowship, but in the end procedural skills equilibrate and you need to be broad-thinking and know ID, cards, endo and GI to be a cognitively skilled intensivist.

The best residencies combine good teaching with resident autonomy. Almost every program says they have this, but obviously there is variation-- make sure you bring your bulls--t meter to interview day!