Anesthesia v IM CC

[hector10]

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EM resident
Subpar CV

looking to do critical care. I would like to end up mostly doing micu / cicu.
With current climate of EM I suspect that CC will become more competitive.

I know there are some multidisciplinary anesthesia programs who offer IM board or anesthesia board for their EM fellows. These programs use the SF match.
Stanford
WashU
UF I think

does anyone know any more of these programs ?

which anesthesia programs are micu heavy ? I really don’t

Also, how easy would it be for me to land a job in a micu with anesthesia board if I did a lot of my elective time in the micu ?

 

[CCM-MD]

I think this is the 3rd time you’ve made this post. Anesthesiologists will tell you to do anesthesia/CCM and internists like myself will tell you to do IM/CCM. You will probably be fine in the community setting with either path. If you like MICU more then do IM/CCM is probably the better choice. You will see everything in the community with medical patients being the majority.

I think the bigger question EM residents like yourself looking at CCM as an “escape” need to answer is whether you want to invest an extra 2 years of training to enter a subspecialty that has the same challenges faced by EM.

 

[hector10]

I think this is the 3rd time you’ve made this post. Anesthesiologists will tell you to do anesthesia/CCM and internists like myself will tell you to do IM/CCM. You will probably be fine in the community setting with either path. If you like MICU more then do IM/CCM is probably the better choice. You will see everything in the community with medical patients being the majority.

I think the bigger question EM residents like yourself looking at CCM as an “escape” need to answer is whether you want to invest an extra 2 years of training to enter a subspecialty that has the same challenges faced by EM.

I know but not getting a whole lot.

It does have the same challenges but if our wages drop, hell id like a more regular hour job, with 12 patients the whole day and not to deal with pain seekers, homeless without real complaints, actually seeing critically ill people get better, building some relationship with patients and families, an actual lunch break, actually teaching students and residents, more respected in the medical community.

Unless there's another fellowship out there that doesn't have the " same " problems as EM then im stuck doing the lesser of the two evils. thought long and hard about pain, but it would be too difficult for me, and the patient pop is garbo.

I even considered, applying to FM after residency...

Im stuck. trying swim.

 

[CCM-MD]

I wish I saw 12 in a day, maybe that’s the case in ivory tower academia. I saw 28 one day this week as covid surges in my area. I can understand where you are coming from, just know that you’re investing 2 years and 700-800k of opportunity cost to end up in a similar situation as your base specialty. Wish you the best.

 

[hector10]

I wish I saw 12 in a day, maybe that’s the case in ivory tower academia. I saw 28 one day this week as covid surges in my area. I can understand where you are coming from, just know that you’re investing 2 years and 700-800k of opportunity cost to end up in a similar situation as your base specialty. Wish you the best.

Im not sure by the time I get out, 400K per year is even a thing.

 

[Siggy]

I wish I saw 12 in a day, maybe that’s the case in ivory tower academia. I saw 28 one day this week as covid surges in my area. I can understand where you are coming from, just know that you’re investing 2 years and 700-800k of opportunity cost to end up in a similar situation as your base specialty. Wish you the best.

I wish I only saw 28 patients my last day shift... I was at 48 because people love their freedum and libturdy.

 

[CCM-MD]

Im not sure by the time I get out, 400K per year is even a thing.

With midlevels encroachment, corporate groups and growth in fellowship spots, it’s not really clear what critical care is going to look like in 5-10 years also.

 

[CCM-MD]

I wish I only saw 28 patients my last day shift... I was at 48 because people love their freedum and libturdy.

Thats insane.

 

[Doc Doc Doc Goose]

Yea but …… you can work EM AND in the ICU. So The Negatives x The Negatives cancel out and all you get is POSITIVES. Duh. Everybody knows that. Simple math.

 

[dartmed]

In the same spot, quite honestly. I don't think it's just EM. It's CCM, Anesthesia, GI, heck Interventional Cards has NP IC fellowships these days. Medicine as a whole is changing. No one is immune.

CCM might be harder to convince family that a NP or a physician "associate" is managing your nana or papa.

 

[CCM-MD]

In the same spot, quite honestly. I don't think it's just EM. It's CCM, Anesthesia, GI, heck Interventional Cards has NP IC fellowships these days. Medicine as a whole is changing. No one is immune.

CCM might be harder to convince family that a NP or a physician "associate" is managing your nana or papa.

It will technically be a doctor managing… doctor of nursing practice. Plus heart of a nurse!

 

[dartmed]

It will technically be a doctor managing… doctor of nursing practice. Plus heart of a nurse!

The tide of anti-intellectualism is strong in America. It's worrisome

 

[Tipsy McStagger]

The tide of anti-intellectualism is strong in America. It's worrisome

You may find this book interesting: The Death of Expertise: The Campaign against Established Knowledge and Why it Matters|Paperback

EM resident
Subpar CV

looking to do critical care. I would like to end up mostly doing micu / cicu.
With current climate of EM I suspect that CC will become more competitive.

I know there are some multidisciplinary anesthesia programs who offer IM board or anesthesia board for their EM fellows. These programs use the SF match.
Stanford
WashU
UF I think

does anyone know any more of these programs ?

which anesthesia programs are micu heavy ? I really don’t

Also, how easy would it be for me to land a job in a micu with anesthesia board if I did a lot of my elective time in the micu ?

If you're looking to work MICU then do an IM-CCM fellowship and you can still work CICU.

How easy would it be to land a job in MICU with anesthesia? Oof, hard to say. In the community it's maybe possible. Isn't anesthesia CCM only one year? You're going to be competing with people from 2 (and 3 if you include pulm) year fellowships with vastly more MICU experience. The job market isn't as wide open as it seems. I think you're shooting yourself in the foot to shave off a year. Are you just trying to bail out of EM and looking for the quickest way? If so CCM isn't a shortcut out of the field. If you really enjoy CCM and want to work MICU, then drop anesthesia and do IM-CCM.

If you're still a med student and haven't applied / matched yet. Then drop EM and go into anesthesia or IM (depending on which you like more).

Those are my recs anyway.

 

[subnaucticmed]

I'm an EM physician that trained in Anesthesia CCM. I had a great clinical experience, but if I had to do it again, I'd do IM-CCM at a place with solid MICU exposure, with options to rotate in the SICU and CTICU. I currently work as a medical intensivist and I enjoy the job. Multidisciplinary CCM groups will be interested in you, but those are relatively rare. I think you'll have an easier time looking for a job if you go the IM-CCM track (because most ICUs in general are composed of medical patients, with complex surgical patients relegated to relatively few hospitals).

I chose anesthesia CCM because I wanted a clinically heavy fellowship, because I thought I'd be interested in CTICU, and because I thought it would be very challenging to get an academic job in a MICU. So I hedged my bets thinking I could do academic EM and round in a surgical unit. I learned a few things about myself and about anesthesia CCM as a fellow:

1. I enjoy SICU and CTICU, but, my fulfillment in the surgical units was hampered by how much power the surgeons gave their intensivists. While the physiology and patients are great, in the "closed" CTICU I trained in, in about 50-75% of cases you couldn't do anything without running it by a surgeon every time (mostly due to a lack of trust among the intensivists). Our SICU was more closed but there was plenty of management of surgeons as well as the patients. This is more the rule than the exception - many places I interviewed at while looking for jobs were explicit in stating their CT and surgical units were open and you would be relegated to vent management, procedures, etc. It was personally irritating to me because I did CCM to be able to primarily manage or at best co-manage patients with surgeons - many of these surgeons treat you as a glorified NP. This isn't the case at all places, but my EM practice involved arguing with consultants because they were frequently wrong - the subservient relationship some surgical units breed was something that deeply irritated me.

2. Disadvantages of an EM/Anesthesia CCM trained physician - you'll be trained for jobs in high level surgical/trauma/cardiac surgical units, which for the most part are relegated to academic centers. if CTICU is your passion, figuring out a way to get TEE certified (whether by the TEE Basic or whatever) is going to be important because it'll be a significant advantage to walk away with this skill. For CTICU, you'll still be at a disadvantage while looking for jobs compared to an anesthesiologist (1. because you aren't a cardiac anesthesiologist, 2. because you can't fit into the typical OR/CCM split, and because you can't do OR you're not going to be bringing in as much money). This is still probably easier than if you were looking for an academic MICU job. If this is a path you find yourself potentially interested in, doing an anesthesia residency + 1y CCM fellowship may be a good option. This sounds insane but I know a number of people that have done anesthesia after EM because of the bull**** of EM and were happy. wasn't a good option for me.

3. MICU time as an anesthesia-CCM fellow - the amount of time you'll get will realistically be limited, because there are pulm/CCM fellows that need to get the experience. unless there are required MICU rotations already built into the schedule, your MICU elective experience may involve you just shadowing.

4. A note on combining EM/CCM - I am not really sure what is going to happen with this pathway in the future. I made the decision early on in fellowship to do 100% CCM because I liked the work more. Splitting time between two departments where the relationship doesn't already isn't already well established (trauma/CCM or anesthesia/CCM) is still relatively novel and juggling the schedules/faculty meetings/etc will be a challenge.

TLDR - IM-CCM with rotations in surgical units will give you broader training and will prepare you better for most jobs. by the end of it if you really feel like you need more surgical experience, you can do a 1y anesthesia CCM fellowship or an ECMO fellowship that'll let you rotate in those units. PM me if you have specific questions.

 

[chocomorsel]

You may find this book interesting: The Death of Expertise: The Campaign against Established Knowledge and Why it Matters|Paperback


If you're looking to work MICU then do an IM-CCM fellowship and you can still work CICU.

How easy would it be to land a job in MICU with anesthesia? Oof, hard to say. In the community it's maybe possible. Isn't anesthesia CCM only one year? You're going to be competing with people from 2 (and 3 if you include pulm) year fellowships with vastly more MICU experience. The job market isn't as wide open as it seems. I think you're shooting yourself in the foot to shave off a year. Are you just trying to bail out of EM and looking for the quickest way? If so CCM isn't a shortcut out of the field. If you really enjoy CCM and want to work MICU, then drop anesthesia and do IM-CCM.

If you're still a med student and haven't applied / matched yet. Then drop EM and go into anesthesia or IM (depending on which you like more).

Those are my recs anyway.

IM CCM and Anesthesia CCM are both five years.
And I am Anesthesia CCM working in a 500 bed hospital in their 28 bed ICU with a bunch of Pulmonologists and Internists and couple of ER dudes. And I am the only dudette.

 

[Tipsy McStagger]

IM CCM and Anesthesia CCM are both five years.
And I am Anesthesia CCM working in a 500 bed hospital in their 28 bed ICU with a bunch of Pulmonologists and Internists and couple of ER dudes. And I am the only dudette.

Anesthesia is 4 years though. How many years for the fellowship? Is it 2 - just asking. Or is it 1 year for anesthesia trained folks and 2 years if you're EM or IM?

Also, there's always exceptions. I'm EM-CCM and work in MICU, CVICU and NICU. But it's advantageous to train for the job you want. If we choose based off exceptions we're liable to be disappointed when looking for jobs in a market that is growing more competitive. So while you do work in a MICU, I'm pretty firm on my recommendation that if MICU is what you really want, IM-CCM is the best way to go about it. If you want to work SICU, anesthesia or surgery is best (though obviously there are IM-CCM people in those roles as well).

That's just where I come down on things. I'm open to disagreement.

 

[chocomorsel]

@Tipsy McStagger
While I may agree with some of what you are saying, we are now in the midst of Covid and discrimination against anesthesiologists and ER docs is going down. People don’t care as much anymore as long as one is fellowship trained and boarded.
The doors are opening wide my friend. I say do whatever base specialty you can see yourself enjoying.
And fellowship is one year.

 

[subnaucticmed]

@chocomorsel

I agree with you and hope we will be morphing toward more departments of multidisiciplinary critical care. there are a few caveats I'd add to the EM/CCM side of things though:

1. Certain things are definitely easier if you do IM or Anesthesia CCM compared to EM/CCM. With regards to training, I think acquiring an CCM fellowship in general is probably more competitive if you're coming out of EM/CCM (re IM: some very good programs prioritize EM fellows, most don't give a ****; same with anesthesia. The other issue you have to deal with anesthesia is going through the hassle to see if they even fund the second year of training).

2. There are some shenanigans with some of the EM/CCM training tracks from the anesthesia side - anesthesia-CCM programs are 1 year in length, but it is two years for EM/CCM fellows. Some programs "fund" the second year by having you Ed shifts. Even BWH's IM-CCM program does this, but in general it'll be more rare on the IM side of things as most of those programs are funded for two years.

3. There is no credit towards a CCM fellowship if you end up doing a 4-year EM residency. So the 4th year, while being a good year to hone up your skills and lose $200k in earnings, is essentially a waste unless you're going to continue practicing EM.

4. EM and CCM - as I mentioned above, integrating the two fields is harder than I expected or was sold to me. Getting a split FTE where you aren't overburdened with nights and holidays is logistically tricky because both your departments probably won't speak to one another and they will prioritize their 1.0 FTE players. Many people I know just do CCM and work some extra EM shifts here and there. What I've heard that in general it's the rare person that practices both specialties after 5 years due to the above issues. I've seen this happen in the vast majority of cases with most of the attendings I worked with as a trainee.

5. Skill Overlap - I think there is less overlap between the two fields than I thought. A small fraction of EM involves the care of the critically ill. You aren't going to be doing orthopedic reductions, taking care of children, doing complex laceration repairs, etc. as an intensivist. It's not to say the broad skillset isn't useful to have going into CCM, but going back to EM after you've been an intensivist and being able to wield those skills at a high level is a very difficult thing (unless you're an attending and can punt all of this to residents or if you don't need to see kids, for instance).

A question for the anesthesia/EM intensivists here - do any of you guys split your time or do you work 100% CCM?

 

[chocomorsel]

100% CCM this year so far. Last year was split as I was locums. But I then took on a full time job that pays extremely well although it’s a W2.
Trying to find shifts in the other city I live in ( I split time) is silly because they want to pay $180-200 an hour since that is the “going” rate in the big city.
So no thanks. I am all about the money right now. And CCM money is good even in the big city.

 

[ToKingdomCome]

Is having a full time gas gig and then locum CCM reasonable ?

 

[psychbender]

Is having a full time gas gig and then locum CCM reasonable ?

Not really, but I guess it depends on the amount of vacation. When I was a fellow, I thought that working full-time with a group that offers twelve weeks of vacation, then turning around and working in the unit for eight of those weeks was an OK idea, because I would still have four weeks off each year, which was more than I had throughout training. Turns out, that much vacation may be necessary to decompress from the job, spend time with family, and not have a breakdown. If you average 50-60 hours per week in the OR, then work 84-86 hours per week in the ICU, and only take 4 weeks off, you are effectively working about 56 hours per week every single week of the year. Your colleagues just working in the OR, and actually taking the time off are averaging just over 40 hours per week every week of the year. Do you yearly want to be working nearly 50% more?

Now, if you join a group that allows partners to take up to 26 weeks off, and you want to work 10-12 in the unit, then you probably still have plenty of time to enjoy yourself and be with family.

If you want a hybrid practice, it would probably be better to find those rare places (more prevalent in academics, but do exist in the community) that allow both, and take your unit time out of your OR time, rather than vacation time. This year, I'm doing 33 weeks in the OR, 10 weeks in the unit. If I want to change the ratio around a bit for future years, my group and our deal with the hospital are somewhat flexible.

 

[step213]

Stanford grad here - there is no locums needed to fund your extra year. Loved my program but im biased since i also did residency (IM/Anesthesia) and my first fellowship (CT Anesthesia) there. Lots of micu time if thats you're thing even if youre in the anesthesia track.

 

[chessknt]

For reference my w2 pay is probably north of 270/hr for a Ccm only job with about 1/3 nights. It bothers me when people keep taking about vague numbers and how well they are paid but don’t cite a number. Only people who benefit from that are the admin parasites.

 

[bingbongbink]

For reference my w2 pay is probably north of 270/hr for a Ccm only job with about 1/3 nights. It bothers me when people keep taking about vague numbers and how well they are paid but don’t cite a number. Only people who benefit from that are the admin parasites.

What is that range on a yearly salary?

 

[chessknt]

What is that range on a yearly salary?

Mid 500s + standard benefits no retirement though

 

[bingbongbink]

Mid 500s + standard benefits no retirement though

Cool. Geographic region?

 

[chocomorsel]

Mid 600k here. And four weeks vacation.

 

[CCM-MD]

Mid 600k here. And four weeks vacation.

Damn!

 

[chocomorsel]

Damn!

Took almost a decade, locuming for four years, and developing a reputation and then meeting the right friend who was starting a group to get here. And unlike other people I never made $500K+ in anesthesia.

Thankfully now with Covid, salaries has gone up and locums can be $300+ an hour.
My COO cousin in California says he’s paying ICU RNs $200 an hour. Think about that.

The W2 job I almost signed up for in 2019 after fellowship was at $200 an hour for Envision and no vacation. I believe that is still their going rate and people are still signing those contracts.

 

[CCM-MD]

Took almost a decade, locuming for four years, and developing a reputation and then meeting the right friend who was starting a group to get here. And unlike other people I never made $500K+ in anesthesia.

Thankfully now with Covid, salaries has gone up and locums can be $300+ an hour.
My COO cousin in California says he’s paying ICU RNs $200 an hour. Think about that.

The W2 job I almost signed up for in 2019 after fellowship was at $200 an hour for Envision and no vacation. I believe that is still their going rate and people are still signing those contracts.

I see lots of >350/h locums but haven’t seen very many permanent gigs paying 600k+ to work 22 weeks. That’s awesome.

 

[chocomorsel]

I see lots of >350/h locums but haven’t seen very many permanent gigs paying 600k+ to work 22 weeks. That’s awesome.

Word of mouth. Right place and right time and met my close friend who heard good things about me who then recruited me. Wasn’t advertised. Jobs like that don’t tend to be.
And thank you. I do have to commute every other week on a plane though and wish I could in the small town permanently but I have family here that can’t move.

 

[bingbongbink]

Took almost a decade, locuming for four years, and developing a reputation and then meeting the right friend who was starting a group to get here. And unlike other people I never made $500K+ in anesthesia.

Thankfully now with Covid, salaries has gone up and locums can be $300+ an hour.
My COO cousin in California says he’s paying ICU RNs $200 an hour. Think about that.

The W2 job I almost signed up for in 2019 after fellowship was at $200 an hour for Envision and no vacation. I believe that is still their going rate and people are still signing those contracts.

Is this a pure CCM gig?

 

[grt398]

Took almost a decade, locuming for four years, and developing a reputation and then meeting the right friend who was starting a group to get here. And unlike other people I never made $500K+ in anesthesia.

Thankfully now with Covid, salaries has gone up and locums can be $300+ an hour.
My COO cousin in California says he’s paying ICU RNs $200 an hour. Think about that.

The W2 job I almost signed up for in 2019 after fellowship was at $200 an hour for Envision and no vacation. I believe that is still their going rate and people are still signing those contracts.

Can confirm Envision in many places is still paying ~$200/hour w/no vacation fwiw.

 

[chocomorsel]

Is this a pure CCM gig?

Yes.

 

[Prometheus2772]

In my anesthesia group, one can easily make $275/hr doing OB anesthesia (epidurals, etc) at a busy hospital. You will be working the majority of the 12 hour shift, but it pays well.

I have a feeling locum tenens rates are about to be turned on their heads, as are CCM rates.

Woman I know did a CCM fellowship after anesthesia residency. Going rates here in Las Vegas in 2019 were like $200/hr. Travel nurses are getting $130/hr all over the country now. Special Covid RN jobs are getting more than that. Physicians might get left behind, but I doubt it. There will be a trickle down effect. What RN is going to drop $250,000 on CRNA school to make $110/hr when they can already do that as a regular RN? That will lead to a shortage of CRNAs.

Covid is going to change things so much. If my group doesn't see significant changes in our various contracts, I might leave and do locums. I am seeing many jobs paying $300/hr with an overtime bonus after 8 hours. I did LT from 2002 to 2005 and I was getting around $180/hr for the first 8 hours. Sometimes $200/hr.

Private practice income hasn't really changed at all. Group I was with in 2001, partners made around $475,000. Now, not much different. Maybe $515,000. That isn't much of a raise in 20 years.

I say that Locum Tenens is the "Great Equalizer."

 

[The kitchen sink]

In my anesthesia group, one can easily make $275/hr doing OB anesthesia (epidurals, etc) at a busy hospital. You will be working the majority of the 12 hour shift, but it pays well.

I have a feeling locum tenens rates are about to be turned on their heads, as are CCM rates.

Woman I know did a CCM fellowship after anesthesia residency. Going rates here in Las Vegas in 2019 were like $200/hr. Travel nurses are getting $130/hr all over the country now. Special Covid RN jobs are getting more than that. Physicians might get left behind, but I doubt it. There will be a trickle down effect. What RN is going to drop $250,000 on CRNA school to make $110/hr when they can already do that as a regular RN? That will lead to a shortage of CRNAs.

Covid is going to change things so much. If my group doesn't see significant changes in our various contracts, I might leave and do locums. I am seeing many jobs paying $300/hr with an overtime bonus after 8 hours. I did LT from 2002 to 2005 and I was getting around $180/hr for the first 8 hours. Sometimes $200/hr.

Private practice income hasn't really changed at all. Group I was with in 2001, partners made around $475,000. Now, not much different. Maybe $515,000. That isn't much of a raise in 20 years.

I say that Locum Tenens is the "Great Equalizer."

It’s so tempting to transition into Locums to become a hired gun/mercenary or firefighter. Those are the rates we need to be getting on the regular.

 

[deleted87051]

heck Interventional Cards has NP IC fellowships these days.

From what I’ve seen, the NPs in IC do all the scut so the cardiologists can spend all day in the lab. They’re like surgical NPs. They’re not actually doing any TAVRs, watchman’s or mitraclips.

 

[deleted87051]

@chocomorsel

I agree with you and hope we will be morphing toward more departments of multidisiciplinary critical care. there are a few caveats I'd add to the EM/CCM side of things though:

1. Certain things are definitely easier if you do IM or Anesthesia CCM compared to EM/CCM. With regards to training, I think acquiring an CCM fellowship in general is probably more competitive if you're coming out of EM/CCM (re IM: some very good programs prioritize EM fellows, most don't give a ****; same with anesthesia. The other issue you have to deal with anesthesia is going through the hassle to see if they even fund the second year of training).

2. There are some shenanigans with some of the EM/CCM training tracks from the anesthesia side - anesthesia-CCM programs are 1 year in length, but it is two years for EM/CCM fellows. Some programs "fund" the second year by having you Ed shifts. Even BWH's IM-CCM program does this, but in general it'll be more rare on the IM side of things as most of those programs are funded for two years.

3. There is no credit towards a CCM fellowship if you end up doing a 4-year EM residency. So the 4th year, while being a good year to hone up your skills and lose $200k in earnings, is essentially a waste unless you're going to continue practicing EM.

4. EM and CCM - as I mentioned above, integrating the two fields is harder than I expected or was sold to me. Getting a split FTE where you aren't overburdened with nights and holidays is logistically tricky because both your departments probably won't speak to one another and they will prioritize their 1.0 FTE players. Many people I know just do CCM and work some extra EM shifts here and there. What I've heard that in general it's the rare person that practices both specialties after 5 years due to the above issues. I've seen this happen in the vast majority of cases with most of the attendings I worked with as a trainee.

5. Skill Overlap - I think there is less overlap between the two fields than I thought. A small fraction of EM involves the care of the critically ill. You aren't going to be doing orthopedic reductions, taking care of children, doing complex laceration repairs, etc. as an intensivist. It's not to say the broad skillset isn't useful to have going into CCM, but going back to EM after you've been an intensivist and being able to wield those skills at a high level is a very difficult thing (unless you're an attending and can punt all of this to residents or if you don't need to see kids, for instance).

A question for the anesthesia/EM intensivists here - do any of you guys split your time or do you work 100% CCM?

Probably close to 10% of my larger 250+ member anesthesia group is CCM trained and boarded but they do 100% anesthesia. CCM is dominated by IM/pulm/CC in my city.

 

[chocomorsel]

Probably close to 10% of my 250+ member anesthesia group is CCM trained and boarded but they do 100% anesthesia. CCM is dominated by IM/pulm/CC in my city.

Not just your city. All throughout the US.

 

[lunaire]

Where are you folks finding locum jobs? recruiters?

 

[The kitchen sink]

Where are you folks finding locum jobs? recruiters?

Yep, or online posting , word of mouth etc