I should clarify, I was not trying to dump on PCCM. I was just mentioning that although, intensive care medicine has the benefit of shift work, it's not as easy a gig as joseph1 or whatever his/her name is makes it out to be. In a medium to big size hospital, it can be tiring work, the shifts rotate (i.e. not every intensivist will work nights or days only), and the recovery can be hard on your week or days off. Second, hospitalists are valued who have more ICU medicine experience. That is they are valued by hospital adminstrators that hire them or make money from them. In some places (usually the more rural you get), hospitalists can be the sole intensivists. From an economic/business perspective, it will make sense from the bean counters to pay hospitalists in the future a little bit more and intensivists a little bit less to manage the ICU to improve their bottom line, so from that perspective and the fact that CCM fellowship is 1 year in some places, if intensive care medicine actually becomes more profitable and a better quality of life per hour, intensivists are going to be encroached upon by a whole host of people.
Regarding my thoughts of PCCM. I enjoy the ICU portion more, but that's just me. From what I've seen in the different avenues I've worked, it's easier to be PCCM in an academic setting and transition more to pulmonology. In the private setting, it's not so easy to do both, unless you are part of a PCCM group because you are having to balance your rotating ICU schedule with consults. I guess if you got a group of PCCM together who can plan this type of schedule then it's feasible, but you have to negotiate with the hospital. ICU docs work on a schedule. Pulm docs work on referral - big difference.
Regarding, scope: ICU is ICU: septic shock, GIB, pulmonary syndromes (i.e. severe pneumonias/ARDS) rule the day. You will also have to manage co-manage with cardiology (sometimes they take care of their patients themselves), neurology, and depending on hospital and your surgical colleagues, you may have to manage or co-manage their patients.
Pulm: if you are in a small hospital and you are the only Pulm doc, most likely you are dealing primarily with ICU. Where I worked in a small rural region, I only had the pulmonologist half the time because he split time with the other intensivist (who was an ID doc - see what I mean about encroachment). So half the time, I had no Pulmonologist to help me. Entities like AIP, it was basically me and the radiologist. I ended up having to transfer cases that were above my experience to the university. The need was far and few between and was a great learning experience for me but a disservice to patients. In a bigger hospital, pulm docs are consulted by the ER on just about every SOB that walks through the door. I mean EVERY patient. I come in the morning often to see pulmonology consulted for a patient with asthma / COPD excerbation or Pneumonia. I would have been blasted for these consults in residency. It's basically redundant work, so in that aspect, I think pulm part is boring (and why I feel sometimes I am babysitting patients for all of these subspecialists). Pulm docs don't do that many bronchs, or rather, it is not as common a need as say GI endoscopy. They don't put in lines. That work is done by CRNAs or the hospitalist themselves. Thoracentesis is done by ICU docs in ICU. As for the floor, it's basically the preference of the hospitalist. In the small hospital, I worked in, CTS was readily wanting to do thoracentesis if I didn't want to do it. In the ICU, CCM docs do most procedures (venous/art line, intubations, chest tubes, thoracentesis, paracentesis) as they can bill for it and are usually in control of deciding who does what.
From the pulmonogists that I see in the hospital I work at now (capacity ~400 beds), most are not doing any ICU work anymore. Some are doing some LTACH work because they don't have to physically be there 24/7, though if the *&^$ hits the fan, guess who handles it?
Again, this is just my experience from seeing them. It is thus narrow, and I think the best bet would be to get the opinion of pulm/icu docs at your hospital and on these forums. I think all medicine subspecialities are interesting, but the private world has many business intricacies you have to learn to make your decision. I decided to apply for cardiology. I can always go back and get 1 year of CCM training, but it's much difficult to do the other way. Sure there is opportunity cost, but you can't put a price on doing what you like to do, and feeling content in your work.
