can we do critical care fellowship after family medicine?

[smiles312]

I know that pretty much the door is closed after doing family medicine for any fellowship opportunities.
I am PGY3 in family medicine and during my residency I got really interested in critical care and rheumatology but after searching around have pretty much found that there is no way of getting into any of these if you are a family medicine doc.
Does anyone know of a way around this? Any sound advice/suggestions would b greatly appreciated.

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[Winged Scapula]

Moving to FM forum

 

[VA Hopeful Dr]

I know that pretty much the door is closed after doing family medicine for any fellowship opportunities.
I am PGY3 in family medicine and during my residency I got really interested in critical care and rheumatology but after searching around have pretty much found that there is no way of getting into any of these if you are a family medicine doc.
Does anyone know of a way around this? Any sound advice/suggestions would b greatly appreciated.

We don't have fellowships in those, no. For critical care, you can always find a hospital with FM hospitalists and an open ICU... that'll get you some critical care.

 

[George85]

You can't do any meaningful fellowship from FM - as for working as a hospitalist with an "open" ICU very little chance - easy enough for FM to work as a hospitalist but if there's an ICU then there will be a critical care or pulm doc - no facility is going to take the liability risk of letting an untrained doc loose in the ICU. My advise - look for an IM residency that will give you credit for the intern year, do the 2 years of IM, then the 3 years of pulm/critical care.

 

[deleted87716]

You can't do any meaningful fellowship from FM

News flash, dude...family medicine is a PRIMARY CARE specialty.

 

[EdibleEgg]

You can't do any meaningful fellowship from FM - as for working as a hospitalist with an "open" ICU very little chance - easy enough for FM to work as a hospitalist but if there's an ICU then there will be a critical care or pulm doc - no facility is going to take the liability risk of letting an untrained doc loose in the ICU. My advise - look for an IM residency that will give you credit for the intern year, do the 2 years of IM, then the 3 years of pulm/critical care.

This isn't really true. If you work in an ivory tower there will be a closed ICU, but in the real world, many ICU's are still open. I don't know exact numbers, but significant percentage of ICU patients are managed by internist/FM docs. If you are planning on doing this, I suggest you spend much more than the required one month during training.

 

[George85]

Not from what I have seen. Where I work the night shift ER docs cover the ICU but if there's no critical care doc available or on call then the hospitalist won't admit ICU patients. And it's the hospitalists that technically manage the ICU patients but when they need a line then they call surgery or the ER, same for transvenous pacer and most other procedures. Lets face it - most docs can't even place an IV. And most IM docs struggle with vent management and critically ill patients. A personal injury lawyer would clean up on a poor outcome if the patient had not been transferred to a facility with the appropriate level of care.

 

[MedicineDoc]

There are alot of small hospitals where the hospitalist is it for the icu and alot of medium to large where is comanagement. Alot of times if it's going bad in a very small hospital there will be a icu to icu transfer to a larger hospital. In some patients where it's deemed they need icu but not an intensivist they aren't consulted. Typically patients not on the vent. Sometimes it's hospitalist sees and pulmonologist or intensivist sees the next day. Of course there are all kinds of variations. Preliminary vent settings are pretty standard and not hard to write for. There's probably a protocol available at the specific hospital in question just as there is probably one for each pressor and weaning of pressors. Weaning off vent also usually standardized at each institution. Example the rule of 100s gor weaning, spontaneoes breathing trial, maintaining a MAP of 65 for weaning pressors, 5 to 10 ml per kg for tidal volume,imv of 4 on simv start to think might be able to try a SBT ect. In my FM residency we saw our own icu patients and we generally consulted the pulmonologist for vent management but not always and they would see the patient the next day as long as the patient was there at the hour they rounded. I currently work at a hospital as a hospitalist with intensivist comanagement but not on every cAse. They are consulted on all the vents. There are also supposed midlevel "intensivists" there that cover for intensivists at times. I'm not typically impressed with them although I haven't seen any huge mistakes as of yet.

 

[VA Hopeful Dr]

You can't do any meaningful fellowship from FM - as for working as a hospitalist with an "open" ICU very little chance - easy enough for FM to work as a hospitalist but if there's an ICU then there will be a critical care or pulm doc - no facility is going to take the liability risk of letting an untrained doc loose in the ICU. My advise - look for an IM residency that will give you credit for the intern year, do the 2 years of IM, then the 3 years of pulm/critical care.

There are 5 hospitals within 30 minutes of my house including one university one and 2 with FM programs.... they all have open ICUs and they all have FM hospitalists. The only rule, and this at the university, is that if someone is on the vent for more than 48h then pulm/cc must be consulted - and that is for IM hospitalists as well.

 

[deleted19731]

I just think its rediculious that family medicine isn't allowed to complete critical care fellowships.

Why is it offered to every other primary care speciality except FM? Doesn't make sense. Hell I don't even think I'd do it but its just stupid that Peds, IM, ER, Ob/Gyn, and Gen Surg can do the fellowship and we cant...

 

[VA Hopeful Dr]

I just think its rediculious that family medicine isn't allowed to complete critical care fellowships.

Why is it offered to every other primary care speciality except FM? Doesn't make sense. Hell I don't even think I'd do it but its just stupid that Peds, IM, ER, Ob/Gyn, and Gen Surg can do the fellowship and we cant...

Ob can do critical care? Since when?

 

[George85]

VA Hopeful Dr - Hospitalists can usually manage basic ICU patients but struggle with anyone that is critically ill - they generally can't manage a vent and have a couple of general settings that they use - can often (but not always) place a central line and intubate - I doubt the 48 hr rule is the only rule - what happens when a patient's sats are in the toilet despite being on the vent at 100% ? What happens if the patient needs a bronch ? If you don't consult pulm/cc or move to a higher level facility and there's a bad outcome then you're toast.

 

[deleted19731]

Ob can do critical care? Since when?

Since surgical critical care has existed... I think its rare but it's an officially listed route.

 

[VA Hopeful Dr]

Since surgical critical care has existed... I think its rare but it's an officially listed route.

Even for OBs.... huh, learn something new every day

 

[VA Hopeful Dr]

VA Hopeful Dr - Hospitalists can usually manage basic ICU patients but struggle with anyone that is critically ill - they generally can't manage a vent and have a couple of general settings that they use - can often (but not always) place a central line and intubate - I doubt the 48 hr rule is the only rule - what happens when a patient's sats are in the toilet despite being on the vent at 100% ? What happens if the patient needs a bronch ? If you don't consult pulm/cc or move to a higher level facility and there's a bad outcome then you're toast.

1. If your patient on the floor needs a bronch, you consult pulm. Why would that be different in the ICU?

2. All of our hospitalists can/do put in central lines/intubate. If you're at a hospital with an open ICU, you should expect to be able to do that.

3. Just because a patient is tanking doesn't mean you MUST consult anyone... but its always a good idea. I mean, if a patient gets hypotensive from a GI bleed... is pulm really your first call?

 

[EdibleEgg]

Not from what I have seen. Where I work the night shift ER docs cover the ICU but if there's no critical care doc available or on call then the hospitalist won't admit ICU patients. And it's the hospitalists that technically manage the ICU patients but when they need a line then they call surgery or the ER, same for transvenous pacer and most other procedures. Lets face it - most docs can't even place an IV. And most IM docs struggle with vent management and critically ill patients. A personal injury lawyer would clean up on a poor outcome if the patient had not been transferred to a facility with the appropriate level of care.

VA Hopeful Dr - Hospitalists can usually manage basic ICU patients but struggle with anyone that is critically ill - they generally can't manage a vent and have a couple of general settings that they use - can often (but not always) place a central line and intubate - I doubt the 48 hr rule is the only rule - what happens when a patient's sats are in the toilet despite being on the vent at 100% ? What happens if the patient needs a bronch ? If you don't consult pulm/cc or move to a higher level facility and there's a bad outcome then you're toast.

The lawyers won't clean up when an ICU patient crashes and the EM doc is managing patients he's probably never seen?

Just because you are uncomfortable with lines, intubation, vent management, it doesn't mean everyone is. Don't put your own inadequacies on everyone else. I do all of those things often.

I'm happy to talk to you about methods of improving oxygenation, but that is a very broad topic.

I consult and tranfer all the time. I still take care of critical patients.

 

[Lesassier]

Late to the party on this one...

There are rare programs that have critical care fellowships for family medicine, however I am not aware of any that are ACGME accredited, and it is likely that if you did not train @ those programs you might be at a disadvantage in securing a spot. That being said, if the programs have made them financially sustainable it is definitely worth a shot and they would likely consider outside players if no one from their own institution was considering filling the spot.

While family medicine is a primary care specialty, family medicine encompasses more than primary care depending on the area of the country you are in. There are many places that would be excited to know that you want to do hospitalist work, and yes, would feel comfortable managing your patients in their open ICU, vent management and all. Granted this would not be in most of your urban centers. And your luck is best found west of the mississippi.

Family medicine residencies run the gamut of having 0 ICU exposure (in spite of the RRC requirement to follow 10 patients) to spending 3 months of dedicated block time in a closed ICU (the latter being much less common).

As far as family docs that have done ICU care without a fellowship, I am aware of some that have done this; but normally after a period of preceptorship and with appropriate backup-- whether it be pulm, anesthesia, etc.

If looking for that, it might be best to find a more remote/rural hospital with an ICU understaffed by intensivists desperately looking for someone to take the burden of some call off their shoulders. This might mean you get precepted for months, where you run every admission by them, and then gradually only call them when you need support. You would be more attractive to a group like this if you already had reasonable hospitalist training and felt comfortable with arterial lines, central lines, and intubations.

 

[MedicineDoc]

In my FM residency we went where our patients went after we sent them there including the ICU. We did consult pulm for vent management but not all the time and when they did see them it was just the next day if the patient was there in the icu at 9 am. Icu work is not magically hard in my opinion. Most the time they are going to live and only a huge blunder will change that, they are going to die and doesn't matter who is doing what or they are going to hang on and on with no quality of life while getting common sense care and consults until the family says uncle and pulls the plug.