cbrons

Ratatoskr! *Roar*
10+ Year Member
Jul 29, 2007
6,567
3,639
DEFEND MIDDLE LANE!
Status
Non-Student
vs. IM/CCM/Pulm (or other variations) if you only want to work in ICU.

I figure that financially most places would probably want you in the OR though but I could be wrong.
 

Laryngophed

Supratentorial problems
10+ Year Member
Sep 4, 2007
2,692
892
TDC
Status
Fellow [Any Field]
6 years of trainee salary versus 5 ought to count for something. But most importantly, do you want to be an anesthesiologist or an internist? Do you like clinic? Would you want to have a pulm practice?
 
OP
cbrons

cbrons

Ratatoskr! *Roar*
10+ Year Member
Jul 29, 2007
6,567
3,639
DEFEND MIDDLE LANE!
Status
Non-Student
do you want to be an anesthesiologist or an internist?
I'm not really sure. Both seem to get dumped on pretty hard.

Do you like clinic?
No not really honestly.
Would you want to have a pulm practice?
I don't think I really would like it at all, but they say that you will go crazy being in the hospital and particularly the ICU all the time and need the outpatient pulmonology to keep your sanity.
 

DrOwnage

7+ Year Member
Oct 12, 2011
178
151
Los Angeles
Status
Resident [Any Field]
A pulm practice takes a decent amount of money to start up since you will most likely have to have a PFT machine along with a respiratory therapist and a good amount of staff (depending on patient volume). Just finished my pulm rotation and I actually really liked the clinic setting; most of the patients are very straightforward. However, I'm set on anesthesia, still not sure about pain medicine vs. critical care (since I do like having patients). You would probably have to take a lot more call being a pulm CC rather than an anesthesia CC also.
 

DrOwnage

7+ Year Member
Oct 12, 2011
178
151
Los Angeles
Status
Resident [Any Field]
I might be biased from my location and experiences; but I assumed that a pulmonologist CC with a practice (in a contract with a hospital) that includes less than 3-4 physicians would take a lot more call than an anesthesiologist who is hired by the hospital itself.
 

Guillemot

7+ Year Member
Dec 24, 2010
333
128
Status
Resident [Any Field]
Consider that with an IM residency the majority of your time will be spent dealing with non-compliance, somatization disorders, paper work. Its a hoop you gotta jump through in order to get to fellowship where you get to spend a significantly higher fraction of your time practicing medicine. Personally Id rather cut my balls off. That said, from my limited experience the pulm/cc physicians seem to know the most medicine.
 

G-Man82

10+ Year Member
May 16, 2005
401
188
The Southeast
Status
Attending Physician
I've met anesthesiologists who do solely CCM. It's a little unusual but definitely not unheard of. This would be in both pp and academic settings. As far as the medicine goes, it comes back is what I've been told multiple times. Critical care is medicine, but internal medicine is definitely NOT critical care, if that makes sense.

As other posters have alluded to, don't choose a sub-specialty without realizing the implications of the specialty it's housed under. There are 3 (actually now 4) ways to get to CCM. Pedi isn't counted here because I'm assuming you don't want to do PICU. So, you're choosing between IM, Surgery, Anesthesiology, and now EM. So you need to analyze those specialties first and choose one you actually see yourself practicing in the event that something changes in the future and you no longer are able to do fellowship.

CCM is great and I love anesthesiology, too. To me, being in a pulmonary clinic dealing with COPDers was not appealing at all. Plus, I hear from my pulmonary colleagues that their fellowships tend to emphasize pulm way more than CCM. So IM was out for me and I definitely cannot ever see myself as a surgeon. EM wasn't an option for CCM when I was in medical school.

Anesthesiology was a no brainer for me, and I went into it knowing I'd apply for CCM.

A good question to ask on here of the CCM Anesthesiologists is if we had to choose one or the other (black or white, no in between or "it depends") which would it be. It's a little early for me since I'm just starting off as an Attending and have my first ICU week coming up, but as of the end of fellowship, I'd choose CCM. I know, crazy right? Most general anesthesiologists think I'm weird that way, but I have a suspicion a lot of the CCM ones would choose along the same lines as I. Residency in the ICU is NOT a great look into the practice of CCM, at least not where I trained. Scut work abounds, and unfortunately that will jade a resident's experience and desire to actually pursue Critical Care.
 
Last edited:
  • Like
Reactions: FFP and cbrons

CriTICAL

10+ Year Member
Feb 27, 2008
19
15
Status
Attending Physician
If you already know you ONLY want to do ICU than would probably go Anesth route since I feel Anesth residency is more critical training, more enjoyable if you like ICU stuff, better at procedures and airway mgmt

Imed/CCM: Better at medicine initially and managing MICU pts, play catchup with procedures and airway mgmt
Anesth/CCM: Better at Procedures/airway, hemodynamics intially and managing SICU pts, play catchup with medicine ie; ID
But either way in the end both routes will provide adequate training for any environment to practice, CCM is a multidisciplinary field

Or if u really enjoy IMed you dont have to do pulm can do just CCM fellowship which is 2yrs vs 3yrs so same total time IM/CCM (5yrs) as Anesth/CCM (5yrs) route

However that being said, the overwhelming majority of ICU jobs in private practice want Pulm since thats the setup with splitting time between ICU and covering Pulm. Anesth/CCM you will be mainly limited to Academia however there are jobs out there in Private Practice if your willing to move. I myself cover both MICU and SICU pts in private practice so its possible just harder to find

But in the end I think comes down to where would you rather be when not in the ICU --> OR or Clinic
Can always do 100% ICU but personally I think its good to change things up otherwise ICU burnout can happen pretty fast
 
  • Like
Reactions: cbrons
OP
cbrons

cbrons

Ratatoskr! *Roar*
10+ Year Member
Jul 29, 2007
6,567
3,639
DEFEND MIDDLE LANE!
Status
Non-Student
If you already know you ONLY want to do ICU than would probably go Anesth route since I feel Anesth residency is more critical training, more enjoyable if you like ICU stuff, better at procedures and airway mgmt

Imed/CCM: Better at medicine initially and managing MICU pts, play catchup with procedures and airway mgmt
Anesth/CCM: Better at Procedures/airway, hemodynamics intially and managing SICU pts, play catchup with medicine ie; ID
But either way in the end both routes will provide adequate training for any environment to practice, CCM is a multidisciplinary field

Or if u really enjoy IMed you dont have to do pulm can do just CCM fellowship which is 2yrs vs 3yrs so same total time IM/CCM (5yrs) as Anesth/CCM (5yrs) route

However that being said, the overwhelming majority of ICU jobs in private practice want Pulm since thats the setup with splitting time between ICU and covering Pulm. Anesth/CCM you will be mainly limited to Academia however there are jobs out there in Private Practice if your willing to move. I myself cover both MICU and SICU pts in private practice so its possible just harder to find

But in the end I think comes down to where would you rather be when not in the ICU --> OR or Clinic
Can always do 100% ICU but personally I think its good to change things up otherwise ICU burnout can happen pretty fast
So would you say then that private practice/community jobs for anesthesia/ccm are hard to find?
 

CriTICAL

10+ Year Member
Feb 27, 2008
19
15
Status
Attending Physician
So would you say then that private practice/community jobs for anesthesia/ccm are hard to find?
yup i think so although may change in future
one way to do it is what i am currently doing is find a gig that is 100% ICU 1week on/off model and then can do anesth per diem/locums during your off days or possibly vice versa
 
  • Like
Reactions: cbrons

Carbocation1

5+ Year Member
Nov 23, 2012
688
310
Status
Medical Student
yup i think so although may change in future
one way to do it is what i am currently doing is find a gig that is 100% ICU 1week on/off model and then can do anesth per diem/locums during your off days or possibly vice versa
That actually sounds really flexible and appealing. Life is short.
 

G-Man82

10+ Year Member
May 16, 2005
401
188
The Southeast
Status
Attending Physician
The 100% ICU with locums Anesthesiology is a pretty valid path and I thought about it myself too. However I ended up staying in academics. That being said, it's not that I have a fellow and residents in each unit I attend. I also have Midlevels of varying ability. Take that to mean that I still get to do some procedures.

My primary unit is a CVICU - mostly cardiac, thoracic, and vascular patients. But usually about 20-30% is also purely medical: floor codes, ED Admits, florid sepsis and ARDS. My other unit is mixed med-Surg.

There's a reason we do a CCM fellowship; by the end of it, the playing field is theoretically leveled between the various specialties. Antibiotics in CCM can be pretty routine. Once it's past routine, even the med guys call ID.

And PP jobs exist. The problem is that the ones I found were part of AMCs. I think they see a certain value to CCM, but I didn't want to be a part of it.
 
OP
cbrons

cbrons

Ratatoskr! *Roar*
10+ Year Member
Jul 29, 2007
6,567
3,639
DEFEND MIDDLE LANE!
Status
Non-Student
And PP jobs exist. The problem is that the ones I found were part of AMCs. I think they see a certain value to CCM, but I didn't want to be a part of it.
Sorry, what is an AMC?

Have you heard of anesthesia/CCM trained intensivist working in MICU? How common is this?
 

secants

about:blank
10+ Year Member
Aug 23, 2006
859
17
NYC
Status
Resident [Any Field]
^ I've posted that question around here before and yes, there are people who work in the MICU however it's at community hospitals who usually only have a mixed Med-surg unit. I don't think you can really do MICU in academics since Pul/CCM owns that. Also, I've been told there still is a small learning curve when coming out of anesthesia ccm fellowship and doing only MICU afterwards. That's why if you plan on doing anesthesia ccm make sure your fellowship has adequate elective time for MICU blocks.
 
  • Like
Reactions: cbrons

partydoc

10+ Year Member
Nov 20, 2008
523
199
west of the mid
Status
Resident [Any Field]
the ABIM changed their rules a couple of years ago where you must be an internist to train IM residents or something like that, so only the pulm/cc guys attend in the MICU in academic centers
 
  • Like
Reactions: cbrons

amyl

ASA Member
10+ Year Member
Aug 19, 2006
1,753
127
between scylla and charybdis
Status
Attending Physician
Amc is anesthesia management company.... Also known as shaking hands w the devil according to some here... I have no first hand knowledge or experience
 
  • Like
Reactions: cbrons

Hamhock

10+ Year Member
May 6, 2009
1,214
493
Status
Attending Physician
the ABIM changed their rules a couple of years ago where you must be an internist to train IM residents or something like that, so only the pulm/cc guys attend in the MICU in academic centers
This is not accurate. (anymore)

ABIM has clearly stated that IM residents can be trained by intensivists trained in ACGME-approved IM-CCM fellowships regardless of base speciality. If the CCM fellowship that the intensivist trained in was ABIM supported, that intensivist can train IM residents, as long as it is in the unit.
 
  • Like
Reactions: cbrons

seinfeld

ASA Member
10+ Year Member
7+ Year Member
Apr 12, 2007
596
171
Status
Attending Physician
Residency in the ICU is NOT a great look into the practice of CCM, at least not where I trained. Scut work abounds, and unfortunately that will jade a resident's experience and desire to actually pursue Critical Care.
A common scenario which keeps people from pursuing CCM. Complete accurate statement which needs to be addressed if Anesthesia wishes to produce more CCM docs.

Honestly think Pulm is the worst way to get into CCM. They are internets and are taught to focus on the minutia of care, not the skills to resuscitate. Anesthesiologists are rare physician in that we are very accustomed to pushing our own meds, giving our own fluids/blood. We don't wait for IV therapy, we don't ask "anesthesia" for intubation, we don't get so focused on a patients hx (i.e. CHF) that we fail to make act. We are thinkers who act on our thoughts immediately not persevere while the patient succumbs.
 
OP
cbrons

cbrons

Ratatoskr! *Roar*
10+ Year Member
Jul 29, 2007
6,567
3,639
DEFEND MIDDLE LANE!
Status
Non-Student
A common scenario which keeps people from pursuing CCM. Complete accurate statement which needs to be addressed if Anesthesia wishes to produce more CCM docs.

Honestly think Pulm is the worst way to get into CCM. They are internets and are taught to focus on the minutia of care, not the skills to resuscitate. Anesthesiologists are rare physician in that we are very accustomed to pushing our own meds, giving our own fluids/blood. We don't wait for IV therapy, we don't ask "anesthesia" for intubation, we don't get so focused on a patients hx (i.e. CHF) that we fail to make act. We are thinkers who act on our thoughts immediately not persevere while the patient succumbs.
In general are anesthesiologists limited to SICU or CTICU? I know you are not, but in general, is it hard to find jobs at community/private hospitals covering both SICU/MICU or combined units?
 
Last edited:

seinfeld

ASA Member
10+ Year Member
7+ Year Member
Apr 12, 2007
596
171
Status
Attending Physician
Last weekend I ran into a nephrologist whom I have worked with in the ICU for 6+ years. During our conversation he said " You are you an anesthesiologist? I guess I never knew that."

Yes we can work anywhere, anytime, and with great skill and expertise. It more about how bad do you want to be a well rounded physician in your medical knowledge base. I know surgeons and internal medicine trained CCM docs who are more quick to consult for the most minor of things. I usually only consult when i need something i can't do, i.e. dialysis, cardiac cath, VADs, figure out autoimmune diseases etc
 

dozitgetchahi

10+ Year Member
Oct 21, 2008
1,583
611
Status
Fellow [Any Field]
Last weekend I ran into a nephrologist whom I have worked with in the ICU for 6+ years. During our conversation he said " You are you an anesthesiologist? I guess I never knew that."

Yes we can work anywhere, anytime, and with great skill and expertise. It more about how bad do you want to be a well rounded physician in your medical knowledge base. I know surgeons and internal medicine trained CCM docs who are more quick to consult for the most minor of things. I usually only consult when i need something i can't do, i.e. dialysis, cardiac cath, VADs, figure out autoimmune diseases etc
And there's plenty that don't, so don't lump them all together.
 

seinfeld

ASA Member
10+ Year Member
7+ Year Member
Apr 12, 2007
596
171
Status
Attending Physician
merely pointing out that everyone has a different level of comfort and consultations with specialists is a personal decision not one born out based upon your training background
 

jdh71

Grim Optimist.
10+ Year Member
Dec 14, 2006
68,154
48,092
Last House on the Block, USA
Status
Attending Physician
merely pointing out that everyone has a different level of comfort and consultations with specialists is a personal decision not one born out based upon your training background
There's actually not a whole lot that needs a consult in the ICU from an intensivist perspective. If you think the patient needs a knife but other than that . . . Not too much. Dialysis. But intensivists can run our own crrt so even then not until intermittent time.

Everyone has their experiencial bias I suppose but sweeping generalizations about whole swaths of certain specialities seems unnecessary. YMMV.
 
  • Like
Reactions: Nash

seinfeld

ASA Member
10+ Year Member
7+ Year Member
Apr 12, 2007
596
171
Status
Attending Physician
This is the Anesthesia forum. Take the bias for what it is.
 

jdh71

Grim Optimist.
10+ Year Member
Dec 14, 2006
68,154
48,092
Last House on the Block, USA
Status
Attending Physician
This is the Anesthesia forum. Take the bias for what it is.
Don't worry I do superstar. Read you loud and clear. Though I don't think it's really a great excuse for boorish behavior. Glad I don't have to work with your type. YMMV!! :)
 

seinfeld

ASA Member
10+ Year Member
7+ Year Member
Apr 12, 2007
596
171
Status
Attending Physician
i don't even know what your talking about , how did me suggesting that an anesthesia trained CC doc can work in a MICU and do it very well become an excuse to start trashing someone on a forum?

The intent of all my posts was to suggest that no matter your background, not knowing all the answers and get a consultant for an ICU patient is not unheard of, whether your medicine trained, anesthesia trained or surgical trained.
 

Doctor4Life1769

**tr0llin, ridin dirty**
10+ Year Member
Apr 28, 2008
34,255
902
Where the grass is always greener
Status
Resident [Any Field]
Totally with Seinfeld on this one. He explains everything well and some folks are just looking for drama where it ain't none. JDH, Relax. No insults were thrown at anyone.
horrible timing with the double negative.
 

Doctor4Life1769

**tr0llin, ridin dirty**
10+ Year Member
Apr 28, 2008
34,255
902
Where the grass is always greener
Status
Resident [Any Field]

FFP

Wiseguy
Gold Donor
10+ Year Member
Oct 17, 2007
7,325
7,452
Status
Attending Physician
Critical care is for docs who want to move beyond the procedure jock level. It definitely makes one's cortex thicker and more convoluted, especially in an academic place.

Now some anesthesiologists treat CCM as just another algorithmic procedural field, like anesthesia; they are the ones who can be replaced by midlevels.
 
Last edited: