can EM/CC teach in CC in IM residency?

[ILEMres]

So as you all probably know, ABEM now offers subspecialty certification in CC in all 3 fields (IM, Surg & Anesthesia). Now, per ABEM if you are boarded in one of these, it is still ABEM (not ABIM, ABA) that gives you the subspecialty certification, but it is "co sponsored" by ABIM, ABS, or ABA (i.e., these boards agree that the board certification is equivalent to theirs). So, can ABEM boarded Intensivists teach in a residency program that has IM residents rotating through the ICU? If so, do you have to be ABEM/ABIM-CC certified? Or can you be ABEM/ABA-CC certified? Thanks!

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[CCMhopeful]

So as you all probably know, ABEM now offers subspecialty certification in CC in all 3 fields (IM, Surg & Anesthesia). Now, per ABEM if you are boarded in one of these, it is still ABEM (not ABIM, ABA) that gives you the subspecialty certification, but it is "co sponsored" by ABIM, ABS, or ABA (i.e., these boards agree that the board certification is equivalent to theirs). So, can ABEM boarded Intensivists teach in a residency program that has IM residents rotating through the ICU? If so, do you have to be ABEM/ABIM-CC certified? Or can you be ABEM/ABA-CC certified? Thanks!

I've been told yes, but that there are some quirks. I think there has to be an internal-medicine trained intensivist available, or "supervising" or something like that. Not 100% sure though.

 

[jdh71]

So as you all probably know, ABEM now offers subspecialty certification in CC in all 3 fields (IM, Surg & Anesthesia). Now, per ABEM if you are boarded in one of these, it is still ABEM (not ABIM, ABA) that gives you the subspecialty certification, but it is "co sponsored" by ABIM, ABS, or ABA (i.e., these boards agree that the board certification is equivalent to theirs). So, can ABEM boarded Intensivists teach in a residency program that has IM residents rotating through the ICU? If so, do you have to be ABEM/ABIM-CC certified? Or can you be ABEM/ABA-CC certified? Thanks!

My guess? IM resident will need to have their *primary* (as in MOST of their teaching) don'e by IM folks, but no reason why a boarded intensivist in any of the others can't teach an IM resident or fellow. I had plenty of attendings that were not just straight IM CC people.

 

[EMIM2011]

EM-CC docs cannot be core faculty in IM-CC programs. RRC/ACGME announced that they want to change this last year, but that hasn't happened yet, AFAIK.

 

[ORL10]

My understanding is that EM-CC docs boarded by ABEM co-sponsored by ABIM can supervise and educate IM residents while who are rotating in the MICU. I haven't seen it in writing but received this e-mail over a year ago...:

"Just found out that at the recent RRC meeting, the IM RRC voted to allow ABIM-CC trained ABEM diplomats to supervise residents. Here is the announcement by Wally Carter.

Greetings,
I wanted to give you some late breaking news regarding our conversations in November around ABIM Critical Care Medicine trained ABEM diplomates supervising Internal Medicine trainees in the MICU.
I am pleased to tell you that after a lengthy but collaborative and collegial discussion the Internal Medicine RRC at its meeting in late January announced the following; “ The committee voted to allow these individuals to supervise internal medicine residents in the MICU without restrictions”.

The ACGME is currently developing an FAQ. Since I am unsure of its timing and in case any of your members may be awaiting this decision for employment opportunities I wanted to get it to you as soon as possible.

I am available for any questions you might have."

 

[ILEMres]

Thanks ORL 10. Seems promising for ABEM/IM-CC! What about ABEM/ABA-CC? EM-CC fellowships are very similar in curriculum whether they are ABA or ABIM accredited. Any rumors about what role the ABEM/ABA-CC docs can play in residency programs?

 

[EMIM2011]

My understanding is that EM-CC docs boarded by ABEM co-sponsored by ABIM can supervise and educate IM residents while who are rotating in the MICU. I haven't seen it in writing but received this e-mail over a year ago...:

"Just found out that at the recent RRC meeting, the IM RRC voted to allow ABIM-CC trained ABEM diplomats to supervise residents. Here is the announcement by Wally Carter.

Greetings,
I wanted to give you some late breaking news regarding our conversations in November around ABIM Critical Care Medicine trained ABEM diplomates supervising Internal Medicine trainees in the MICU.
I am pleased to tell you that after a lengthy but collaborative and collegial discussion the Internal Medicine RRC at its meeting in late January announced the following; “ The committee voted to allow these individuals to supervise internal medicine residents in the MICU without restrictions”.

The ACGME is currently developing an FAQ. Since I am unsure of its timing and in case any of your members may be awaiting this decision for employment opportunities I wanted to get it to you as soon as possible.

I am available for any questions you might have."

Yes, I received the same email, but I haven't seen any action on this yet, unfortunately!

 

[inspirationmd]

Yes you can. Came into effect 9 months or so ago. Two faculty at my program are EM-CC and attend in the MICU teaching IM residents and supervising Pulm-CCM fellows. They can't supervise therapeutic Bronchs in the MICU but that's about it from what I have seen. One is about 60-40 and one is 75-25 EM/MICU responsibilities.

 

[ILEMres]

Are they IM-CC or Anesthesia-CC Boarded? Will itmake a difference?

 

[inspirationmd]

IM-CC. And yes it makes a difference at this point. You have to be IM-CC trained to be part of the core faculty to teach IM residents and fellows.

 

[ORL10]

do you know where it is written down? I've looked and couldn't find anything concrete although I've heard LOTS of rumors and similar stories of ABIM boarded EM/CC docs.

 

[ILEMres]

Thanks for the info!

 

[namethatsmell]

On a somewhat related note...do people think that EM folks who do an IM-based fellowship may have more jobs to choose from after fellowship than if they get boarded via the anesthesia or surg routes?

 

[inspirationmd]

do you know where it is written down? I've looked and couldn't find anything concrete although I've heard LOTS of rumors and similar stories of ABIM boarded EM/CC docs.

Not sure where it is written. Sorry. I just heard it was decided at the ABIM January 2014 meeting.

 

[Doctor Bob]

So, can ABEM boarded Intensivists teach in a residency program that has IM residents rotating through the ICU? If so, do you have to be ABEM/ABIM-CC certified? Or can you be ABEM/ABA-CC certified?

As of right now, you have to go through an IM-CC fellowship to be able to be faculty at an academic IM based ICU (eg: MICU). That's per the agreement between ABEM and ABIM.

EM-CC fellowships are very similar in curriculum whether they are ABA or ABIM accredited. Any rumors about what role the ABEM/ABA-CC docs can play in residency programs?

Surgical based ICUs use EM-CC people who've gone through ABA fellowships, but only when the ICU has dedicated intensivists.
As for EM-CC fellowships being similar in curriculum... ABA and ABIM fellowships tend to be different primarily in the percent of time you spend in an ICU type. ABA fellowships tend to be SICU heavy whereas ABIM fellowships tend to be MICU heavy. There are programs that are exclusively one or the other (not a good fit for EM people in my opinion, and with ABA expanding out to 2 years to accomodate EM people sitting for the ABA boards, that exclusivity is going away). There are a few programs where the IM track and the Anesthesiology track are mirrored or combined. So although they are 2 separate departments for financial reasons, the fellows have the same schedule regardless of which track they are in. Those places tend to be much more balanced (Pitt and WashU being the models in my mind). Fellows still sit for the boards of the track they are in (and even if you did an ABA-CC fellowship at a place where the curriculum is the same as the IM-CC, you can't choose which one you sit for).

On a somewhat related note...do people think that EM folks who do an IM-based fellowship may have more jobs to choose from after fellowship than if they get boarded via the anesthesia or surg routes?

Ehhhh... in that the academic IM jobs are open to IM-CC people, maybe. But since the majority of EM-CC people end up in SICUs, because that culture is more friendly to EM people, it probably doesn't make a difference.

 

[Instatewaiter]

EM-CC docs cannot be core faculty in IM-CC programs. RRC/ACGME announced that they want to change this last year, but that hasn't happened yet, AFAIK.

That seems kinda stupid.

 

[deleted171991]

That seems kinda stupid.

The IM RRC is royally stupid for not allowing board-certified academic intensivists, from other specialties, broaden the horizons of their residents. Actually, as (super)acute intensive care goes, the internists are not the best, simply because they don't deal with rapidly crashing patients day in and day out. Most rapidly-crashing patients arrive to the ICU relatively stabilized (either by an EM doc in the ED, or an anesthesiologist in the OR, or a rapid-response team on the floor), and the number of daily life-threatening critical events in an ICU is not that high. Hence you get IM residency graduates who don't know how to properly run a code, bag-mask-ventilate, titrate dangerous cardiovascular drugs, or even put in an IV etc. Things an EM or anesthesia-trained intensivist excels at. Heck, if I were crashing, I would want a badass cardiac or CCM anesthesiologist to be around and personally take care of me, not an IM intensivist, no offense.

By the way, what's next? Having internists teach emergency medicine in the ED for the IM residents, because ED docs are not good enough?

Smart people know that the best training is based on cross-polination. That's what leads to debate and evidence-based medicine (I use it every day when debating surgeons in the OR). Every type of intensivist (EM specialist, internist, surgeon, anesthesiologist) brings certain specialty-based strengths that the others don't posess. The single denominational priest model only leads to dogma.

 

[Hamhock]

Below is copied from the ACGME Review Committee for Internal Medicine FAQ. (2012)
EM-CCM can serve as internal medicine core faculty.
The tragedy is that IM continues to limit IM-CCM fellowship spots available to EM grads to 25% of each program; thereby limiting both the quality and quantity of intensivits.

HH


Can a faculty member who is ABIM-certified in his or her subspecialty area but not in core internal medicine serve as a core faculty member?
[Program Requirement: II.C.3.a)]

Yes, provided that he or she maintains certification in the subspecialty.

 

[Instatewaiter]

The IM RRC is royally stupid for not allowing board-certified academic intensivists, from other specialties, broaden the horizons of their residents. Actually, as (super)acute intensive care goes, the internists are not the best, simply because they don't deal with rapidly crashing patients day in and day out. Most rapidly-crashing patients arrive to the ICU relatively stabilized (either by an EM doc in the ED, or an anesthesiologist in the OR, or a rapid-response team on the floor), and the number of daily life-threatening critical events in an ICU is not that high. Hence you get IM residency graduates who don't know how to properly run a code, bag-mask-ventilate, titrate dangerous cardiovascular drugs, or even put in an IV etc. Things an EM or anesthesia-trained intensivist excels at. Heck, if I were crashing, I would want a badass cardiac or CCM anesthesiologist to be around and personally take care of me, not an IM intensivist, no offense.

By the way, what's next? Having internists teach emergency medicine in the ED for the IM residents, because ED docs are not good enough?

Smart people know that the best training is based on cross-polination. That's what leads to debate and evidence-based medicine (I use it every day when debating surgeons in the OR). Every type of intensivist (EM specialist, internist, surgeon, anesthesiologist) brings certain specialty-based strengths that the others don't posess. The single denominational priest model only leads to dogma.

Agree. Seems kinda stupid. That said there are intricacies to Surgical ICU patients which Pulm/CC doesn't get trained well in and intricacies of MICU patients that Surgical CC don't see. But for the most part, critical care is critical care.

 

[deleted171991]

Agree. Seems kinda stupid. That said there are intricacies to Surgical ICU patients which Pulm/CC doesn't get trained well in and intricacies of MICU patients that Surgical CC don't see. But for the most part, critical care is critical care.

I find the 25% quota pretty decent, as long as it actually happens. That would assure that, while the IM resident/fellow is exposed mainly to an IM faculty, they get decent exposure to other dogmas. The problem is that the percentage does not apply to anesthesiologists and other non-ABIM intensivists, even ones with MICU experience. Basically this is just a land grab making sure that academic MICUs are off-limits for non-internists.

So while it's OK for an anesthesia CCM fellow to be trained in a MICU by an IM intensivist, upon graduation the same fellow could not train IM residents. Just laughable.

 

[Nash]

Heck, if I were crashing, I would want a badass cardiac or CCM anesthesiologist to be around and personally take care of me, not an IM intensivist, no offense.

Why is it that so many anesthesiologists think that critical care is defined by the first 15 minutes of resuscitation? Critical care is so much more than that. The implication that medical intensivists and pulmonologists are incapable of reacting quickly to crashing patients is ridiculous. I'm coming from the pulmonary perspective here, and I often get asked to help out surgeons, EM docs, and other non-IM trained intensivists in our surgical/trauma and burn ICUs. I certainly rely on these people from time to time, as well, but not to help me "resuscitate" a patient, or place a central line, dialysis catheter, chest tube, etc. I've seen plenty of poorly-run codes, screwed up CRRT orders, and bizarre vent management in surgical ICUs. Does that mean that surgeons and anesthesiologists are bad intensivists? Absolutely not. No one is an expert in all things critical care.

I actually agree with your premise that non-IM trained intensivists should be able to supervise IM residents in the ICU, and this will likely occur within the next year or two. As you pointed out, dogma and tradition are difficult to overcome. The best path forward is a multidisciplinary approach to teaching and practicing critical care. The rest of your post is the same crap I hear from anesthesiologists all the time, the vast majority of whom spent no more than 3-4 months in a SICU or TICU as a resident.

 

[G-Man82]

I agree with FFP. At my Anesthesiology/CCM program, we see the pulmonary fellows come through the SICU electively, mostly because they want to learn from one of our badass cardiac/CCM Attendings who makes it his life's work to educate the next generation of fellows. I mean, he's used interactive approaches to teach us about airway resistances and ventilators, and mandates fellow-driven academic sessions twice a week without fail, which the pulmonary fellows often sneak into on their own time. But usually once rounds are complete, the pulmonary fellows basically disappear, if they even turn up for rounds. But that's the only way they're permitted to learn from non-IM intensivists.

On the other hand, my entire CCM education as a resident (all 6 months) was under pulmonologists and surgeons. It was interesting to see things from that perspective and I learned a lot. It's a little sad that although CCM is meant to be multi-disciplinary these days, it seems that it applies only in non-medical ICUs.

 

[CCMhopeful]

I find the 25% quota pretty decent, as long as it actually happens. That would assure that, while the IM resident/fellow is exposed mainly to an IM faculty, they get decent exposure to other dogmas. The problem is that the percentage does not apply to anesthesiologists and other non-ABIM intensivists, even ones with MICU experience. Basically this is just a land grab making sure that academic MICUs are off-limits for non-internists.

So while it's OK for an anesthesia CCM fellow to be trained in a MICU by an IM intensivist, upon graduation the same fellow could not train IM residents. Just laughable.

I think you may be misunderstanding the 25% rule (or maybe I misread your post).

The 25% rule says that only 25% of each programs matriculating fellows can be from EM averaged over a 5 year period. It has nothing to do with attendings (unless you're discussing the downstream affects).

 

[deleted171991]

I think you may be misunderstanding the 25% rule (or maybe I misread your post).

The 25% rule says that only 25% of each programs matriculating fellows can be from EM averaged over a 5 year period. It has nothing to do with attendings (unless you're discussing the downstream affects).

You are right. I did misread it. Mea culpa.

 

[deleted171991]

Why is it that so many anesthesiologists think that critical care is defined by the first 15 minutes of resuscitation? Critical care is so much more than that. The implication that medical intensivists and pulmonologists are incapable of reacting quickly to crashing patients is ridiculous. I'm coming from the pulmonary perspective here, and I often get asked to help out surgeons, EM docs, and other non-IM trained intensivists in our surgical/trauma and burn ICUs. I certainly rely on these people from time to time, as well, but not to help me "resuscitate" a patient, or place a central line, dialysis catheter, chest tube, etc. I've seen plenty of poorly-run codes, screwed up CRRT orders, and bizarre vent management in surgical ICUs. Does that mean that surgeons and anesthesiologists are bad intensivists? Absolutely not. No one is an expert in all things critical care.

Sorry, but I think you are missing the point here. You are almost dead in the water without a nurse to help you, so you depend on her speed, and that becomes your speed of thinking and doing things. Can you draw up, dilute, titrate, and administer your own drugs? And I am not talking about a code situation. I am talking about what happens before, about what one does rapidly to avoid getting there. You cannot compare yourself with somebody who's used to do things solo, if needed, no offense. You might be great in a team, you might be great at putting in a central line (especially when all is needed is a large bore peripheral IV), your long-term and even short-term medical thinking may be outstanding, but you are not the best at hands-on patient care, because you really don't do enough of it. Your speed is your team's speed, and what kind of speed is that when you guys almost never practice as a team? One can't really supervise things one hasn't done solo, and I see it all the time when around ICU "teams".

You are doctors, while we are doctors and nurses and pharmacists and respiratory techs etc. We do whatever we need to do. Patient is bucking, or overbreathing the vent? Fixed in a minute. (And I am not talking about just pushing a stick of rocuronium, but deciding in ten seconds why the patient is doing it and what's the best way to treat it.) Patient is uncomfortable? Fixed in a blink, again. (Your patients are either oversedated and/or in pain, rarely where they should be, according to your own science, because the show is run by your nurses and protocols, not true individualized patient care. How come a lot of ICU patients remember having pain while in the ICU, and nobody feels ashamed about this level of "care"?) Patient is unstable? Fixed. We don't care about bruising egos; we care about saving patients. Your speed is usually not an anesthesiologist's speed, and same goes for some surgeons at bedside. It's always faster to just do stuff, than give orders to nurses and explain. The whole ICU is set up almost like a regular floor; except for a code situation, one cannot get things done without a nurse and an order (do you guys have your own Pyxis access?), or having the pharmacy bless them (while even the first year anesthesia resident has an entire cart at his fingertips), cannot change vent settings without hurting the poor RT's ego, must keep the nurses happy etc. It's all about egos and bureaucracy. It's the difference between snail mail and email.

So, yeah, I'd rather crash in an OR or PACU with some badass (not just any) anesthesiologists around.

 

[Doctor Bob]

Without this turning into a pissing contest (which it seems to be rapidly devolving into), lets keep in mind that there are good and bad people in all fields.
Anecdotally I've seen plenty (lots lots lots) of anesthesiologists who don't live up to the picture painted in the above post. I have also seen some who are phenomenal.

It is not an inherent quality of the specialty, it is the person.

I draw up and titrate my own drugs and I can do it as fast (or faster sometimes) than some of my anesthesia colleagues. But that's a product of the training and practice environment I came from. There are plenty of things I'm terrible at and it's not a reflection on emergency physicians in general.

So let's try to keep this on topic and not change it into which specialty is the best. There isn't an ICU thing in which one specialty is across the board better than all other fields. There will be outliers which never prove the point, and everything else is just opinion and handwaving.

/soapbox

 

[deleted171991]

I don't want a pissing contest either. Every specialty brings something special to the table, which was the entire point of me arguing for cross-polination during ICU training for IM (or other) residents and fellows.

You might have noticed that I did not mention EM physicians. You guys are the kings of emergent care. It's just dumb not to let you teach some of those skills to IM trainees.

 

[nephrondoc]

You are doctors, while we are doctors and nurses and pharmacists and respiratory techs etc. We do whatever we need to do.

The whole ICU is set up almost like a regular floor; except for a code situation, one cannot get things done without a nurse and an order (do you guys have your own Pyxis access?), or having the pharmacy bless them (while even the first year anesthesia resident has an entire cart at his fingertips), cannot change vent settings without hurting the poor RT's ego, must keep the nurses happy etc. It's all about egos and bureaucracy. It's the difference between snail mail and email.

So, yeah, I'd rather crash in an OR or PACU with some badass (not just any) anesthesiologists around.

Generalizing things to a specialty and addressing an individual as you guys ( as if he is the representative of the entire specialty or even for that matter as if you represent the entire anesthesiology community ) doesn't reflect well on a senior member like you.

Also, if you have to act like a doctor,nurse,technician, pharmacist and RT, it just shows how little command or respect you have from your team members. It also reflects very poorly on your leadership qualities. I am guessing if you see a dirty linen in the OR, you probably wash the linen all by yourself as well because the other team members are not as skilled as you.

And, your comment about whole ICU set up like a regular floor speaks volumes about your ignorance. Either you were drunk yesterday or you lost touch with outside world. Next time, when you get sick, please request that you be kept in the OR , where your guys can keep you happily sedated and pain free for the rest of your life.

I can't get over one comment of you specifically. You said that half of patients in ICU remember pain during this stay. In ICU, it's not always comfort that takes priority. There is something called as a safety as well as speedy recovery.

No wonder CRNA's are taking over you guys so fast because i guess the society doesn't deserve the brilliant minds that YOU GUYS are. ( PS: This post is intended only for FFP and not for doctors in general. I have great respect for anesthesiology).

 

[deleted171991]

Generalizing things to a specialty and addressing an individual as you guys ( as if he is the representative of the entire specialty or even for that matter as if you represent the entire anesthesiology community ) doesn't reflect well on a senior member like you.

Also, if you have to act like a doctor,nurse,technician, pharmacist and RT, it just shows how little command or respect you have from your team members. It also reflects very poorly on your leadership qualities. I am guessing if you see a dirty linen in the OR, you probably wash the linen all by yourself as well because the other team members are not as skilled as you.

And, your comment about whole ICU set up like a regular floor speaks volumes about your ignorance. Either you were drunk yesterday or you lost touch with outside world. Next time, when you get sick, please request that you be kept in the OR , where your guys can keep you happily sedated and pain free for the rest of your life.

I can't get over one comment of you specifically. You said that half of patients in ICU remember pain during this stay. In ICU, it's not always comfort that takes priority. There is something called as a safety as well as speedy recovery.

No wonder CRNA's are taking over you guys so fast because i guess the society doesn't deserve the brilliant minds that YOU GUYS are. ( PS: This post is intended only for FFP and not for doctors in general. I have great respect for anesthesiology).

I was talking about (not every, just) badass anesthesiologists vs the average IM-intensivist, in the context of a rapidly deteriorating patient. My example was about what a good anesthesiologist can and will do, if needed. We can direct teams as well, but one cannot properly direct something one does not know how to properly do solo, whatever the Kool Aid one drinks is.

You can take my suggestions, or you can ignore them. That's all. Instead, you took them personally. You have probably almost zero capacity to agree or disagree, for the simple reason that you have not worked in both settings (OR and MICU), with both kinds of specialists. I have. I don't consider myself a badass, so I don't consider myself superior to anybody, but there are people out there who are much better than me. You should seek them out and learn from them, instead of hiding behind personal attacks. I definitely do learn a lot from good nephrologists.

If I see those "dirty linen", I might put them away myself, yes, if that helps the patient, instead of waiting for a nurse to do it much later, if at all. Yes, I would do a lot of what a nurse is supposed to do, if it helps my patient now. I believe that the patient comes first. It might degrade me in your "leader" eyes, but my patients would disagree. The sad thing is that I used to think like you.

I hope you will one day realize that a team is not always better than an individual. Only a synchronized, well-rehearsed, team. Otherwise it's just a group of people, some pulling forward, some backwards, some not at all. Just like a chorus, it can be magnificent, or it can be just noisy, in which case one might just prefer listening to the lonely opera singer.

And those CRNAs you mention... they all were ICU nurses before. They started thinking that they are better than doctors because of the intensivists they had worked with. Just ask them about their intensive care experience, and they will tell you about how they ran the ICU.

 

[Nash]

I was talking about (not every, just) badass anesthesiologists vs the average IM-intensivist, in the context of a rapidly deteriorating patient. My example was about what a good anesthesiologist can and will do, if needed. We can direct teams as well, but one cannot properly direct something one does not know how to properly do solo, whatever the Kool Aid one drinks is.

You can take my suggestions, or you can ignore them. That's all. Instead, you took them personally. You have probably almost zero capacity to agree or disagree, for the simple reason that you have not worked in both settings (OR and MICU), with both kinds of specialists. I have. I don't consider myself a badass, so I don't consider myself superior to anybody, but there are people out there who are much better than me. You should seek them out and learn from them, instead of hiding behind personal attacks. I definitely do learn a lot from good nephrologists.

If I see those "dirty linen", I might put them away myself, yes, if that helps the patient, instead of waiting for a nurse to do it much later, if at all. Yes, I would do a lot of what a nurse is supposed to do, if it helps my patient now. I believe that the patient comes first. It might degrade me in your "leader" eyes, but my patients would disagree. The sad thing is that I used to think like you.

I hope you will one day realize that a team is not always better than an individual. Only a synchronized, well-rehearsed, team. Otherwise it's just a group of people, some pulling forward, some backwards, some not at all. Just like a chorus, it can be magnificent, or it can be just noisy, in which case one might just prefer listening to the lonely opera singer.

And those CRNAs you mention... they all were ICU nurses before. They started thinking that they are better than doctors because of the intensivists they had worked with. Just ask them about their intensive care experience, and they will tell you about how they ran the ICU.

Again, your point about the stupidity of the ABIM preventing non-IM trained intensivists from supervising IM residents & fellows is right on point. Unfortunately, it gets lost with rest of your commentary, which shows a very limited perspective of what critical care is. I can assure you it isn't just the initial resuscitation of a hemodynamically unstable person or performing ICU procedures, as you seem to imply. You make a lot of generalizations about IM-trained intensivists, which is silly. There is a tremendous amount of variability between providers within any discipline, and I think you know that. I certainly don't wait for an RT to make critical vent changes, and I often place peripheral IVs for nurses. I can certainly draw up and administer meds when necessary, but if my patient is coding, he/she is best served by me functioning as the "team leader." Being distracted by doing other individual tasks (placing IVs, drawing up meds, etc.) is potentially detrimental in a code situation.

Your focus on the benefits of mastering a bunch of individual tasks reflects what you do every day. You provide care for a single patient at a time in the OR (or you supervise/direct CRNAs providing anesthesia to mostly healthy patients), and I have an ICU with 20 ventilated patients who often have unique and complex pathology. If I'm lucky, I'll have 2 more sitting in the ED waiting for a bed to open up. Sometimes I wish I could just focus on a single sick patient for 3-4 hours at a time, but I don't have that luxury. You can't be a one man army in the ICU, at least not in the ones I work in. This is becoming a bit redundant. FFP, I've enjoyed many of your posts in the past. I just think you're a bit off base in this instance. Cheers!

 

[deleted171991]

Again, your point about the stupidity of the ABIM preventing non-IM trained intensivists from supervising IM residents & fellows is right on point. Unfortunately, it gets lost with rest of your commentary, which shows a very limited perspective of what critical care is. I can assure you it isn't just the initial resuscitation of a hemodynamically unstable person

But that's the only thing I was comparing, and the only part where I consider a good anesthesiologist to be superior to the many IM intensivists. Sorry if that point got lost in too long posts..

There is a very good reason anesthesiologists have to do a fellowship to be able to practice CCM, so I would never imply that they are better at critical care (or internal medicine) in general. Not even close.

 

[Doctor Bob]

<sigh>
Let it go... let it go... don't quote a post anymore...
(with apologies to Frozen)

if you have to act like a doctor,nurse,technician, pharmacist and RT, it just shows how little command or respect you have from your team members. It also reflects very poorly on your leadership qualities.

Throughout all of my officer and leadership training, the opposite view has been stressed. The leader should know how to do the job of every other person under their command, and should be willing to step in and do it if that's what is needed to complete the mission. So along those lines, I would say, in general, that a doctor should be able and willing to do the job of every other person in the ICU (or OR, or ER, or floor, or office...). Not to say that you need to do it, but you should know how, and be willing to do it when others aren't doing it well, or fast enough. There is no job in a hospital that is beneath us. It just may not be the best utilization of our time. However, if you're standing around with little else to do, and the staff is trying to turn a room quickly so a new patient can come in, then it doesn't diminish your standing in someone's eyes to pitch in and help clean countertops and put new linen on the bed. In my experience the docs that do that garner more respect from the staff because they aren't viewed as aloof and harboring a "better than you" attitude. When there is a better use of your time then it's reasonable to leave these jobs to other people.

 

[EMIM2011]

Throughout all of my officer and leadership training, the opposite view has been stressed. The leader should know how to do the job of every other person under their command, and should be willing to step in and do it if that's what is needed to complete the mission. So along those lines, I would say, in general, that a doctor should be able and willing to do the job of every other person in the ICU (or OR, or ER, or floor, or office...). Not to say that you need to do it, but you should know how, and be willing to do it when others aren't doing it well, or fast enough. There is no job in a hospital that is beneath us. It just may not be the best utilization of our time. However, if you're standing around with little else to do, and the staff is trying to turn a room quickly so a new patient can come in, then it doesn't diminish your standing in someone's eyes to pitch in and help clean countertops and put new linen on the bed. In my experience the docs that do that garner more respect from the staff because they aren't viewed as aloof and harboring a "better than you" attitude. When there is a better use of your time then it's reasonable to leave these jobs to other people.

Couldn't agree more. Every acute care physician (ICU, ED, anesthesiology etc) should be able to run a one-man show. That doesn't mean this is the preferred way of doing things, but ultimately, you need to be able to save a patient by yourself. You never know who will be around to help, how qualified they will be etc. One of the best examples is the ED/ICU doc intubating and then holding the ET tube for 10 mins waiting for RT to tape it! How embarassing.

 

[throckmortonDO]

Now that ABEM/ABIM is co-sponsoring, what happens to folks with EDIC?

There are no boards for AOA/osteopathic graduates from EM programs at the current time, the only thing open to DO's completing AOA residencies would be EDIC, regardless of whether the graduate completed a 2 yr ACGME fellowship at this current time.

of course, things may change now that everything is merging to ACGME?

 

[Instatewaiter]

I was talking about (not every, just) badass anesthesiologists vs the average IM-intensivist, in the context of a rapidly deteriorating patient. My example was about what a good anesthesiologist can and will do, if needed. We can direct teams as well, but one cannot properly direct something one does not know how to properly do solo, whatever the Kool Aid one drinks is.

You can take my suggestions, or you can ignore them. That's all. Instead, you took them personally. You have probably almost zero capacity to agree or disagree, for the simple reason that you have not worked in both settings (OR and MICU), with both kinds of specialists. I have. I don't consider myself a badass, so I don't consider myself superior to anybody, but there are people out there who are much better than me. You should seek them out and learn from them, instead of hiding behind personal attacks. I definitely do learn a lot from good nephrologists.

If I see those "dirty linen", I might put them away myself, yes, if that helps the patient, instead of waiting for a nurse to do it much later, if at all. Yes, I would do a lot of what a nurse is supposed to do, if it helps my patient now. I believe that the patient comes first. It might degrade me in your "leader" eyes, but my patients would disagree. The sad thing is that I used to think like you.

I hope you will one day realize that a team is not always better than an individual. Only a synchronized, well-rehearsed, team. Otherwise it's just a group of people, some pulling forward, some backwards, some not at all. Just like a chorus, it can be magnificent, or it can be just noisy, in which case one might just prefer listening to the lonely opera singer.

And those CRNAs you mention... they all were ICU nurses before. They started thinking that they are better than doctors because of the intensivists they had worked with. Just ask them about their intensive care experience, and they will tell you about how they ran the ICU.

We can speak in generalities and anecdotes all day long. I have seen cardiac anesthesia make some very questionable decisions for instance i have seen them push phenylephrine in someone with bad cold and wet decompensated heart failure who just came back. We spent the rest of the day trying to keep this guy alive. This year I have seen anesthesia kill 2 of our AI patients with precedex alone. Cardiac anesthesia consults us (cardiology) all the time fo management of complex cardiac patients (in "their" cardiac surgery ICU).

You can pound your chest all day about how good anesthesia is about taking care of a crashing patient but it is more of a skill to prevent a patient from crashing than bringing them back from their crash.

 

[deleted171991]

We can speak in generalities and anecdotes all day long. I have seen cardiac anesthesia make some very questionable decisions for instance i have seen them push phenylephrine in someone with bad cold and wet decompensated heart failure who just came back. We spent the rest of the day trying to keep this guy alive. This year I have seen anesthesia kill 2 of our AI patients with precedex alone. Cardiac anesthesia consults us (cardiology) all the time fo management of complex cardiac patients (in "their" cardiac surgery ICU).

What can I say? Giving precedex to an AI patient (optimally kept at a high HR and low MAP) is risky, because it can induce an atropine-resistant bradycardia. It's rare, but it can happen. Same thing about a decompensated CHF: one doesn't want to increase afterload on that guy with phenylephrine. Let's not speak about what it does to a possible pulmonary hypertension.

In both cases, what matters the most is not what they gave, but how much and how fast. Slowly titrating that precedex, and even the phenylephrine, with an A-line in place, allows for turnaround space if things start going south. Also, many times people are very sensitive to certain drugs, so even that is not enough. Had I been there, I would have asked them why they chose that specific drug and dose.

By the way, where I trained, the interventional cardiology stuff, like most off-floor anesthesia, was reserved for weaker anesthesiologists (except for pedi), for two reasons: 1. it is considered mostly straightforward, beyond induction and emergence; 2. there is a cardiologist there who knows how to fix a cardiac emergency better. The really good anesthesiologists did not spend much time off-floor, so we are probably talking about different levels of professionals.

Of course there are exceptions to all rules but, as a rule, I tend to trust our badasses more in an emergent situation, because you only see the 2-3-5 bad outcomes, but I see the many times when they avoid them. When a patient survives a surgery, especially a sick one, it's usually not because everything went so smoothly that nothing needed to be done, but because the anesthesiologist worked hard behind the curtains to adjust for every little change, to prevent crashes. No offense, but the average doctor, even the average surgeon, has no idea what it takes to take some patients through general anesthesia and real surgery. It's friggin' induced coma. Some of the really sick patients are so fragile they can be killed just with a vial of propofol.

I doubt that the cardiac surgery ICU people will call you in an emergency to save one of their patients. Of course they will consult you for the non-emergent management of their patients; any good intensivist would. A good doc actually knows where her knowledge ends, so it's much more shameful not to ask for help.

You can pound your chest all day about how good anesthesia is about taking care of a crashing patient but it is more of a skill to prevent a patient from crashing than bringing them back from their crash.

I read not 2-3, but many more than 20-30 absolutely dumb preop assessments/year, coming from cardiologists who must have zero idea about what happens in the OR and what the real surgical/anesthetic risk is for a certain procedure, or that certain procedures have an unacceptable chance of turning into general anesthesia.

And if we are generalizing anyway, I still have to meet an interventional cardiologist who induces respect by not being cocky and know-it-all.

 

[Instatewaiter]

And if we are generalizing anyway, I still have to meet an interventional cardiologist who induces respect by not being cocky and know-it-all.

The point you seem to be missing is that generalizing is stupid.

 

[deleted171991]

The point you seem to be missing is that generalizing is stupid.

And you are missing that I was not generalizing. I was comparing the best anesthesiologists with the average medical intensivist, only in a certain situation.

 

[Instatewaiter]

And you are missing that I was not generalizing. I was comparing the best anesthesiologists with the average medical intensivist, only in a certain situation.

That's a pretty stupid comparison, in any situation.

 

[deleted171991]

That's a pretty stupid comparison, in any situation.

I hope you feel better after splitting hairs here. Because the poor ICU guys really needed a noble champion to defend them. There is so little an anesthesiologist can learn from them I actually signed up for a CCM fellowship.

We all have strengths and weaknesses. We should work together, and learn from each other; one person's weakness my be another's strength, hence there is opportunity for learning from a different medical "culture". That also includes teaching trainees.

 

[G-Man82]

I'm in an Anesthesia/CCM fellowship right now, mostly focused in cardiac surgery and general surgery ICUs. But we also run a consult service for hospitalists who admit to the MICU, and we do months in the Neurosciences unit and the academic portion of the medical ICU. As far as jobs go, I've applied to a series of both PP Anesth/CCM jobs and academic ones. The academic ones have me limited mostly to Surgical ICU settings largely as a result of longstanding rules set by the ABIM that prevent Medical Residents (and perhaps even the Fellows) from obtaining a different perspective. But, in the PP setting, where there are no fellows or residents to teach, the majority of my ICU duties would be in MEDICAL ICUs.

My point: I did a CCM fellowship, which stands for Critical Care MEDICINE, which is certainly different from Internal medicine or Perioperative medicine. I'm not really interested in the minutia that most internists chase, because frankly, in the ICU, that's not my top priority. You don't need to be an Anesthesiologist to be a good Intensivist, and you certainly don't need to be a stellar Internist to be a good intensivist, either, but you do have to have a solid blend of skills from both fields. Even here at my fellowship hospital, we (the Anesthesiologists) have a very collegial relationship with our pulmonary colleagues. So honestly, I think we should leave the chest pounding to the CT, Neuro, and other surgeons, as well as other proceduralists who continue to bring disasters to us, because without our efforts, the only pounding they'd hear would be the judge's gavel.

 

[sluggs]

All the pissing actually raises good points. I did an IM residency, so when I did my critical care fellowship I focused on areas in which I had less training: neuro, SICU, cticu, chest tubes and intubations (lots of OR/anesthesia time); the anesthesia ccm folks did a lot of electives in micu to broaden. As above, yu have to know your strengths and weaknesses; improve the latter and play to the former.

 

[mrpankration]

What has been interestingly absent amongst all the discussion about who has access to the pyxis, who can draw up medications the quickest, and who can most effectively manipulate ventilator settings, is a discussion about the importance of communication and palliative care skills in an intensivist's aresenal. You can be the Delta Force of cardiac anesthesiologists, doing 10 different things at once to a crashing patient, but it doesn't make a difference, and in fact is harmful, if the patient didn't want it in the first place. The point of my commentary is not to minimize the importance of, or skills that people have in hyperacute resuscitation scenarios, it's just to point out that these skills need to be supplemented with the longer-term, bigger picture perspective that may often get lost, but that is so important to practicing effective critical care.

 

[omgwhtamidng]

Sorry to bump up an old thread but wanted to see if anyone knew of updates or a better answer to the OP's question.

I'm debating between anesthesia and medicine ccm fellowships. Just wanted to know if with an ABEM-ABA CCM certification I won't be allowed to work in a MICU that has medicine residents working in it. Thanks in advance.

 

[RandomChaos]

Sorry to bump up an old thread but wanted to see if anyone knew of updates or a better answer to the OP's question.

I'm debating between anesthesia and medicine ccm fellowships. Just wanted to know if with an ABEM-ABA CCM certification I won't be allowed to work in a MICU that has medicine residents working in it. Thanks in advance.

I will be starting an Anesthesia CC program come July, I am EM background. While on the interview trail, this was a question I asked fairly often and it does not seem to be a limiting factor. A recent EM grad from the Anesthesia CC program at my place ended up taking a place at an Academic MICU.
On another note, I ended up choosing an Anesthesia program as they seemed more well rounded between all the ICUs compared to the Medical programs. I have equal time in the MICU, SICU, CCU, Neuro ICU, Burn ICU etc... The anesthesia programs also seem to have more emphasis on TTE, TEE, ECMO and procedures when compared to the Medical programs.

 

[CCM-MD]

I will be starting an Anesthesia CC program come July, I am EM background. While on the interview trail, this was a question I asked fairly often and it does not seem to be a limiting factor. A recent EM grad from the Anesthesia CC program at my place ended up taking a place at an Academic MICU.
On another note, I ended up choosing an Anesthesia program as they seemed more well rounded between all the ICUs compared to the Medical programs. I have equal time in the MICU, SICU, CCU, Neuro ICU, Burn ICU etc... The anesthesia programs also seem to have more emphasis on TTE, TEE, ECMO and procedures when compared to the Medical programs.

I wouldn't make this into anesthesia vs medicine based critical care programs, it will degenerate quickly. There's really crappy and really good programs on both sides. Multidisciplinary training is important. But don't get fooled by programs promising well rounded training but you're just hanging out on the side... example: neuro ICU month where there's neuro ICU fellows doing all the fun stuff. It's easier to match into anesthesia programs - there's always some going empty.

It will be hard to get hired as MICU faculty without internal medicine or internal medicine based critical care medicine training but not impossible.

 

[Nephro critical care]

Anesthesia and EM are both more hands on and focus on management and symptom control rather than diagnosis and actually figuring out what’s going. Anesthesia more than EM but I see ED physicians pass to me a critically ill patient who has a lactate of 16 and is on pressers and will be labelled a severe urosepsis with 5-10 WBC in urine. That patients real problem will be dead gut from mesentric ischemia or biliary cholangitis with fulminant hepatic failure. Yes they are a sometimes little faster at the initial management than me but not by much and I have the advantage that I will have the right diagnosis 99% of the time as compared with only 50% for these guys.
Similarly procedurally although EM/Anesthesia were faster initially now because I do so many procedures day in and day out I can do a better and much safer job at CVLs , A-lines , Bronchs, Chest tubes etc.
So yes given the anesthesia/EM training is so much focused on short term acute management rather than the big picture they can’t be supervising docs in MICU.
Although MICU trained I am not a fool and know that my relative inexperience in the CTICU , Neuro , Transplant and Burn ICU puts me at a disadvantage in these units. I am looking to actually do a year of anesthesia ICU fellowship if there was a way to broaden my scope into these parts of critical care.

 

[Crabbygas]

OK I will confess up front that I stopped carefully reading the posts in the middle and yes it's sorta off the original topic. But I will strongly agree with some of the sentiment about certain intensivists. I spent many years working in a place where I spent a lot of time working with the ICU. I didn't work with any EM trained guys so I will not address them. But I worked with many critical care trained surgeons and internists. It was absolutely my experience that they were almost hopeless when it came to hands on care of a crashing patient in the unit. Sure if they needed a chest tube the surgeons could do that plenty quick. But actually drawing up a med and giving it? Adjusting the vent? It was amazing how little they seemed able to do. This isn't meant to be a dig at those guys. I would probably be hopeless at writing CRRT orders. But I would have time to look it up or find someone who could. When time is short somebody who is used to doing it themselves can make a difference. If anything I think this should argue for better training for the internists and the surgeons. It's not that hard to do it yourself. You just need to be trained to and it appears to me that many are not.

 

[Nephro critical care]

OK I will confess up front that I stopped carefully reading the posts in the middle and yes it's sorta off the original topic. But I will strongly agree with some of the sentiment about certain intensivists. I spent many years working in a place where I spent a lot of time working with the ICU. I didn't work with any EM trained guys so I will not address them. But I worked with many critical care trained surgeons and internists. It was absolutely my experience that they were almost hopeless when it came to hands on care of a crashing patient in the unit. Sure if they needed a chest tube the surgeons could do that plenty quick. But actually drawing up a med and giving it? Adjusting the vent? It was amazing how little they seemed able to do. This isn't meant to be a dig at those guys. I would probably be hopeless at writing CRRT orders. But I would have time to look it up or find someone who could. When time is short somebody who is used to doing it themselves can make a difference. If anything I think this should argue for better training for the internists and the surgeons. It's not that hard to do it yourself. You just need to be trained to and it appears to me that many are not.

Being able to draw up a medication and give it is not as cool as some people make it to be. It’s just scutwork. Nurses do it all the time. Similarly RTs work the vent all the time and so can I. I get the big bucks to figure out what’s going on with the patient and how to manage it. I have a nurse in the ICU often 1:1 for my patient to carry out my orders. It’s not my job to give the patient 4 units of blood. It’s my job to put the 9 French catheter and order the blood/FFP/plts. The unit secretary get the blood from the blood bank and the nurse runs it in through the level 1 blood transfuser.

 

[SpacemanSpifff]

Anesthesia and EM are both more hands on and focus on management and symptom control rather than diagnosis and actually figuring out what’s going. Anesthesia more than EM but I see ED physicians pass to me a critically ill patient who has a lactate of 16 and is on pressers and will be labelled a severe urosepsis with 5-10 WBC in urine. That patients real problem will be dead gut from mesentric ischemia or biliary cholangitis with fulminant hepatic failure. Yes they are a sometimes little faster at the initial management than me but not by much and I have the advantage that I will have the right diagnosis 99% of the time as compared with only 50% for these guys.
Similarly procedurally although EM/Anesthesia were faster initially now because I do so many procedures day in and day out I can do a better and much safer job at CVLs , A-lines , Bronchs, Chest tubes etc.
So yes given the anesthesia/EM training is so much focused on short term acute management rather than the big picture they can’t be supervising docs in MICU.
Although MICU trained I am not a fool and know that my relative inexperience in the CTICU , Neuro , Transplant and Burn ICU puts me at a disadvantage in these units. I am looking to actually do a year of anesthesia ICU fellowship if there was a way to broaden my scope into these parts of critical care.

How many of the listed procedures did you complete in residency vs. fellowship?