Anesthesia trained to 100% ICU gig

[hikikomori]

I was wondering if it would be possible to do ICU 100% after anesthesia residency.
I have 2+ more years of residency to go and I don't find being in the OR that exciting or personally gratifying. I do, however, love studying for anesthesia and the nooks and crannies of physiology and pharmacology. I am just having a difficulty deciding if I really want to do them after residency.
I don't like Pain, so that option is out of the window. The only option that I know of being out of the OR is ICU and I do like medicine. Is it possible to do pure ICU as an attending or should I be looking for a new residency in EM or IM, instead of an ICU fellowship? What are the career options of a BE/BC anesthesiologist but no OR?

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[Ezekiel2517]

Yes, I know several that do. That's the whole point, you can practice independent of the OR. But I don't think you have the exposure yet at this point to find the OR not "exciting" enough. If you're managing a sick pt or doing a big case in the OR, what's the difference? You don't have to be in the unit to practice critical care.

 

[gtb]

Why not bail from anesthesiology and pick up an internal medicine residency followed by a fellowship in critical care or pulmonology? Are you a CA1? If you've already completed an intern year, the IM residency should only be another two years, just like you've got remaining in anesthesiology.

 

[urge]

I have 2+ more years of residency to go and I don't find being in the OR that exciting or personally gratifying.

Did you not know that going in?

 

[deleted171991]

S/he's probably having the CA-1 blues. Going from an IM internship to an anesthesia residency is like going from the Hilton to prison. Sometimes it made me wonder whether surgical people (including anesthesiologists) had ever heard of the words professional courtesy.

hikikomori, wait till you start the subspecialty rotations. You'll change your opinion.

 

[Ipassgas]

There's no shame in not liking OR anesthesia. Maybe you'll like the subspecialties, maybe you won't.

If you like the unit and can finish your residency, go do a one year CC fellowship. Total time out - 5 years.

Or you can quit and get to the same place on the medicine path 3+3, plus the year (?) you've been in anesthesia - 7 years. 2 years you can't get back. It's up to you.

 

[Femtochemistry]

Of course. I personally know a person who after we completed a ccm fellowship ended up only doing ccm. They found a gig at a major hospital that only wanted ccm. They did it for personal reasons and did not want to do any more OR work. Nothing wrong with that.

 

[Mman]

I was wondering if it would be possible to do ICU 100% after anesthesia residency.

For the most part, no it is not possible after just anesthesia residency. But you can do an ICU fellowship for a year and then it's perfectly possible, although that'd be more likely to be within an academic department. ICU doesn't generate much revenue so private groups tend to be loathe to get that involved with it.

 

[Femtochemistry]

I don't think it is possible to do ICU work without a fellowship if you are an anesthesiologist...that's pretty reckless if you ask me. However, some of the old guys who are anesthesia trained but have been doing ICU work since the stone-age are "grand-fathered" in; which it doesn't sound you are :/

tl;dr
you need an ICU fellowship to do any ICU work if you are an anesthesiologist these days.

 

[Mman]

I don't think it is possible to do ICU work without a fellowship if you are an anesthesiologist...that's pretty reckless if you ask me. However, some of the old guys who are anesthesia trained but have been doing ICU work since the stone-age are "grand-fathered" in; which it doesn't sound you are :/

tl;dr
you need an ICU fellowship to do any ICU work if you are an anesthesiologist these days.

I've seen a psychiatrist covering an "ICU" in a small hospital. You'd be amazed at what goes on in non major medical centers.

 

[msbbc833]

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[Mman]

Please elaborate. As a prelim IM PGY-1 hoping to get a CA-1 spot for next year this scares me.

Because you find out anesthesia is physically hard work and you work a lot of hours. I'd go home and fall asleep on the couch at 6 PM some days. And this is despite not being on call or post call or post post call. Getting up before dawn and setting up your room and busting your butt for 10 or 12 hours is not easy. As a medicine intern you basically wander around and write orders and H/Ps and discharge summaries. But you can also go to the bathroom whenever you need to and take a lunch break and do things like round where you just wander around at a slow pace. In anesthesia, you are physically humping it to turn your room over fast case after case.

As you progress through your residency you become more efficient at doing things and have less wasted time and motion and it gets easier. But the first year is tough. Far tougher than being an intern.

 

[Ronin786]

Because you find out anesthesia is physically hard work and you work a lot of hours. I'd go home and fall asleep on the couch at 6 PM some days. And this is despite not being on call or post call or post post call. Getting up before dawn and setting up your room and busting your butt for 10 or 12 hours is not easy. As a medicine intern you basically wander around and write orders and H/Ps and discharge summaries. But you can also go to the bathroom whenever you need to and take a lunch break and do things like round where you just wander around at a slow pace. In anesthesia, you are physically humping it to turn your room over fast case after case.

As you progress through your residency you become more efficient at doing things and have less wasted time and motion and it gets easier. But the first year is tough. Far tougher than being an intern.

That probably depends heavily on how laid back your intern/transitional year is. Speaking for myself as an intern, and after comparing hours with the CA-1s, hours are better as a CA-1.

 

[Mman]

That probably depends heavily on how laid back your intern/transitional year is. Speaking for myself as an intern, and after comparing hours with the CA-1s, hours are better as a CA-1.

No. I'm not talking hours. I'm talking physical labor. I did way more hours as an intern, sometimes 100/week in surgical ICU (rounded down to 80 average). The actual labor of being a CA1 is physically harder than anything an intern does. It is physically exhausting at times. Being an intern was an emotional drain and getting scut worked dumped on you day after day is annoying as hell, but it isn't a physical challenge. Being a CA1 made me physically tired.

 

[deleted171991]

Please elaborate. As a prelim IM PGY-1 hoping to get a CA-1 spot for next year this scares me.

In IM the culture is that, even if you are an intern, you are a doctor. By the end of the intern year, you get respect and your attendings treat you pretty nicely (as long as you do your job).

In anesthesia you are just a resident, a glorified slave who can't do **** without her attending (at least in the eyes of non-anesthesia people). You may be disrespected by OR personnel and made fun of by surgeons. It's a culture where some surgeons are still kings, and the long-term OR staff are the royal court, and the anesthesia resident is about as important as the court jester. Your attendings won't really take your side; you are swimming with sharks every day, and God forbid you talk back to surgical attendings or OR "mamas". Respect is not given, it's earned, the hard way. Also, because anesthesia is a hyperacute specialty, there is no time for niceties in (imminent) crisis situations, so expect your attending to literally push you out of the way if she needs to take over stat; that has also hurt some feelings over the years.

The relationship with your attendings is not as tight as on the medical floors because you have a different one every day, and they barely get to know you. There is a lot of gossip; they (mis)judge you based on their own and other attendings' first impressions. It doesn't matter how much you really know; what matters is that you are low-maintenance, that you don't need much help, even if you otherwise suck as a physician (knowledge-wise). There is a reason CRNAs can function at least at the level of a CA-1; you are just a glorified stool-sitter and room setup tech. Some attendings will teach you way more if they like you, and quasi-ignore you if they don't; because teaching is done on an individual basis (there are no rounds in the OR), you might get pretty crappy teaching while popular people will have a great experience. It's all a vicious circle that's not easy to break. If you get labeled in any way, you're done. It's a surgical specialty; you cannot learn it from books, you learn the most by doing, and you need more supervision than in IM (because you can do much more harm).

This is all OK and survivable if you are in love with the specialty. The hours are shorter than in IM internship (and longer than for IM residents), but way more exhausting. Also the learning experience is more intense and fruitful. Compared to what you get to do on a daily basis in medicine, occasionally IM will seem like a joke; you will be able to run circles around most medical/surgical residents regarding the acute care of really sick patients or crisis situations. They will beat you at chronic care.

As long as you don't expect to be treated like a PGY-2, but more like a PGY-0.25, you'll be fine. And the more time passes during residency, the more beautiful the specialty will seem. What you get to know and to do on a daily basis can be simply breathtaking. It's just not for people who can't leave their ego at the door or who want to be the center of their Universe.

For truly intelligent people who have trouble hiding it, the OR can be a really unhappy place. It doesn't take a genius to cut and sew, or to administer anesthesia to most people. Unfortunately, that's becoming something to consider in most specialties nowadays.

 

[kazuma]

In IM the culture is that, even if you are an intern, you are a doctor. By the end of the intern year, you get respect and your attendings treat you pretty nicely (as long as you do your job).

In anesthesia you are just a resident, a glorified slave who can't do **** without her attending (at least in the eyes of non-anesthesia people). You may be disrespected by OR personnel and made fun of by surgeons. It's a culture where some surgeons are still kings, and the long-term OR staff are the royal court, and the anesthesia resident is about as important as the court jester. Your attendings won't really take your side; you are swimming with sharks every day, and God forbid you talk back to surgical attendings or OR "mamas". Respect is not given, it's earned, the hard way.Also, because anesthesia is a hyperacute specialty, there is no time for niceties in (imminent) crisis situations, so expect your attending to literally push you out of the way if she needs to take over stat; that has also hurt some feelings over the years (not mine, but I have seen CA-1 mimosas report it).

The relationship with your attendings is not as tight as on the medical floors because you have a different one every day, and they barely get to know you. There is a lot of gossip; they (mis)judge you based on their own and other attendings' first impressions. It doesn't matter how much you really know; what matters is that you are low-maintenance, that you don't need much help, even if you otherwise suck as a physician (knowledge-wise). There is a reason CRNAs can function at least at the level of a CA-1; you are just a glorified stool-sitter and room setup tech. Some attendings will teach you way more if they like you, and cvasi-ignore you if they don't; because teaching is done on an individual basis (there are no rounds in the OR), you might get pretty crappy teaching while popular people will have a great experience. It's all a vicious circle that's not easy to break. If you get labeled in any way, you're done. It's a surgical specialty; you cannot learn it from books, you learn the most by doing, and you need more supervision than in IM (because you can do much more harm).

This is all OK and survivable if you are in love with the specialty. The hours are shorter than in IM internship (and longer than for IM residents), but way more exhausting. Also the learning experience is more intense and fruitful. Compared to what you get to do on a daily basis, occasionally IM will seem like a joke; you will be able to run circles around most medical/surgical residents regarding the acute care of really sick patients or crisis situations. They will beat you at chronic care.

As long as you don't expect to be treated like a PGY-2, but more like a PGY-0.25, you'll be fine. And the more time passes during residency, the more beautiful the specialty will seem. What you get to know and to do on a daily basis can be simply breathtaking. It's just not for people who can't leave their ego at the door or who want to be the center of their Universe.

For truly intelligent people who have trouble hiding it, the OR can be a really unhappy place. It doesn't take a genius to cut and sew, or to administer anesthesia in most people. Unfortunately, that's becoming something to consider in most specialties nowadays.

You nailed it FFP. The first 6 months of CA1 year were fairly miserable if I worked with one of the the attendings you described. Funny thing is, it seemed like overnight around March everything changed and even some of the most critical attendings started treating me like a colleague. I think this is one area where doing well on the ITE helps because it gives attendings some sort of objective benchmark to judge your knowledge base instead of things like cloth tape vs plastic tape for taping the ETT.