CCM / Anesthesia Lifestyle

[student-of-life]

Hi,

I'm a student interested in the blend of CCM and Anesthesia. I'm hoping some attendings can shed light on:

Scheduling
- My impression is that one will generally do one week in the ICU and then 3 weeks in the OR. However, I'm also under the impression that pure CCM attendings generally have a week off after 7 days in the ICU, so am wondering if it is / why it's not 1 week ICU, 1 week off, 2 weeks OR. I'm also wondering what your rough vacation policy is in terms of weeks off. Overall, I like to play hard and work hard; I appreciate the intensity of these specialties but I also want adequate time to enjoy hobbies, spend time with family, and travel. Ideally, I'm looking to avoid a traditional M-F schedule; I'm hoping to get some good stretches of days off and am happy to work some nights and weekends to make it happen (though I would like to avoid the constant fluctuation of days/nights that seems to be the case in emergency medicine).

Patient continuity in CCM to complement the lack of it in Anesthesia
- In CCM, do you have a reasonable patient load that allows you to build relationships with patient families? Are you able to work with (more or less) this same patient cohort through the week/until they leave the unit and monitor longitudinal changes, or are you more bouncing around doing procedures and consults for midlevel providers and not working with an intimate caseload?

Sustainability
- I'm starting medical school at 31 so am hoping to practice until 65 or so. My impression is that doing a blend of anesthesia and CCM is more sustainable than pure CCM, which unfortunately seems conducive to burnout given the current structuring - would you agree? Is doing a combo of CCM/Anesthesia generally sustainable into your 60s? Are there solid opportunities to scale back ie do less anesthesia without having to work in a boring bread and butter clinic?

Thanks in advance!

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[spacegun]

Hi,

I'm a student interested in the blend of CCM and Anesthesia. I'm hoping some attendings can shed light on:

Scheduling
- My impression is that one will generally do one week in the ICU and then 3 weeks in the OR. However, I'm also under the impression that pure CCM attendings generally have a week off after 7 days in the ICU, so am wondering if it is / why it's not 1 week ICU, 1 week off, 2 weeks OR. I'm also wondering what your rough vacation policy is in terms of weeks off. Overall, I like to play hard and work hard; I appreciate the intensity of these specialties but I also want adequate time to enjoy hobbies, spend time with family, and travel. Ideally, I'm looking to avoid a traditional M-F schedule; I'm hoping to get some good stretches of days off and am happy to work some nights and weekends to make it happen (though I would like to avoid the constant fluctuation of days/nights that seems to be the case in emergency medicine).

Patient continuity in CCM to complement the lack of it in Anesthesia
- In CCM, do you have a reasonable patient load that allows you to build relationships with patient families? Are you able to work with (more or less) this same patient cohort through the week/until they leave the unit and monitor longitudinal changes, or are you more bouncing around doing procedures and consults for midlevel providers and not working with an intimate caseload?

Sustainability
- I'm starting medical school at 31 so am hoping to practice until 65 or so. My impression is that doing a blend of anesthesia and CCM is more sustainable than pure CCM, which unfortunately seems conducive to burnout given the current structuring - would you agree? Is doing a combo of CCM/Anesthesia generally sustainable into your 60s? Are there solid opportunities to scale back ie do less anesthesia without having to work in a boring bread and butter clinic?

Thanks in advance!

How about IM, then Pulmonary & Critical Care? I heard you can back off the ICU and do more pulm if you burn out from the ICU or as you get older.

The older guys seem to say that it's easier to do outpatient clinic (like pulm) with a more predictable schedule than the grind in the OR in anesthesiology, especially if you want or need to continue taking in-house call. Anesthesia seems to have a lot of in-house call, unless you are on a mommy track or you are a senior partner closer to retirement.

Also anesthesia seems like you are more at the mercy of the surgeon and their cases as to when your day will end.

But to be fair I have also seen anesthesiologists in their 60's and even a couple in their 70's and they seem happy.

Some people just hate clinic so clinic might cause them to burn out.

A consideration is what type of ICU you want to end up working in. I read somewhere on here there are more jobs for pulm & crit care in the MICU (if you want to be in the MICU) than for anesthesia & crit care, but there are more jobs for anesthesia & crit care in the SICU and CVICU. That's just what I heard, maybe I am wrong, attendings can give you a better idea.

Edit: You might want to ask your question at the anesthesia forum as they would know more.

 

[Morzh]

It is relatively easy for an anesthesiology-trained intensivist to get a private practice ICU-only job, MICU / SICU / CVICU are all readily attainable. What is NOT easy in private practice is finding a mixed anesthesiology + ICU job. PP anesthesia groups just don't do much ICU (it's not as lucrative compared to being in the OR). Some people have taken a 3/4 FTE job with a traditional anesthesia group and then moonlight in their off time in different ICUs.

If you want to meaningfully practice both then you are most likely going to end up in academics. So before pursuing anesthesiology/CCM you have to ask yourself, practically and realistically, if you're going to be happy pigeon-holed into academics. You get to practice both, but you're always going to be supervising residents and medical students. You're salary will be lower than PP, but you'll get all the perks of academia like admin days and a generally cushier schedule. You'll be expected to contribute academically - typically a clinical education or research track. At my institution the CCM faculty typically work one 7-day stretch per month (on average), and are in the ORs the rest of the time. They don't get a week off after being on, but then again they don't really need much time off because it is extremely rare for them to have to come in overnight because the fellows can generally handle everything by phone until morning.

I was drawn to ICU during medical school and through the first couple years of my anesthesiology residency because I found it interesting, fun to read about, and exciting. I enjoyed interacting with patients and their families. Unfortunately when considering career options, the practical utility of a CCM fellowship just didn't seem like it was for me. I liked the ICU but definitely loved the ORs more, and I wasn't thrilled about 95% of the job options being in academics. I'll miss not doing ICU in my career, but it just wasn't the right choice for me. I wish anesthesiology in the United States more closely mirrored how the specialty is practiced in the rest of the world. But I digress...

 

[student-of-life]

Thanks so much for the responses! @spacegun I don't think the clinic is for me, but I appreciate the suggestion. @Morzh have you been satisfied with the pure anesthesia route? I worry that being the OR week in week out would get monotonous. Also, how's your life/work balance?

 

[psychbender]

The schedules of dual Anesthesiology/Critical Care jobs vary greatly. First off, the overwhelming majority of these jobs are in academics, so if that's not what you want, you're going to have to really look harder to find something (particularly if you are even slightly geographically limited). Every academic place I looked at had a different schedule. Two weeks in the OR (no nights, no weekends), followed by one week in the ICU (either seven nights or days), then one week off, with an extra couple weeks of vacation was a more common one. One of my cofellows went to a place the attendings in the ICU continue to cover at home overnight (residents in house) for their week in the unit. Another place had the attending and fellow (both on call at home) alternate who was first called by the in-house resident, but the attending was still the ultimate backstop. I've also seen settings that were more ICU heavy, like 12 ICU shifts/month with only 4 OR days. Another rapidly flipped attendings from day to night and back again, as they could be in the unit for a week of days, then have a day or two off, then be on for a stretch of four nights, post call plus one day off, then in the OR for a couple of days, then back in the unit again.

In private practice (or, really, nonacademic practice, as some are hospital-employees), there are some of the same models, and other weirder ones, too. A private group I know does the two weeks OR, one week ICU, one week off, with an additional six weeks of vacation. However, they also take OR call during their OR weeks, so they end up working more nights and weekends. Another had 24hr ICU shifts, with the intensivists rotating through the unit for 24hrs (home call), then post call, then back to the OR. Or, I've seen two partners rotate 24hr shifts in the ICU (home call) for a week, then they both go back to the OR the next week.

 

[CCM-MD]

Agree with what everyone has mentioned so far. In my experience, combined anesthesiology & CCM gigs are rare outside of academics - just like CCM combined with EM, nephro, ID... you name it. The only specialty in combination with CCM that continues to have plenty of opportunities is Pulm. Although it does seem like moderate to large community hospitals are more likely nowadays to have employed intensivists. So perhaps if you want to practice CCM in a decent sized hospital with a high enough acuity, it will probably require contributing 100% of your time to practicing CCM in the future.

CCM is a great field but has its notable downsides. It is hard work, involves dealing with the sickest patients in the hospital, lots of emotionally challenging situations, many difficult conversations with families, you will probably have to work some nights in-house or take call depending on the setup, compensation is decent but there are specialties that can pay you the same amount or more for much less work. All of this leads to high burnout in CCM. Anesthesiology is definitely a more "lifestyle" friendly specialty. That being said, I personally know several physicians who are practicing CCM in their 60s - a couple of them I currently work with.

 

[ToKingdomCome]

The schedules of dual Anesthesiology/Critical Care jobs vary greatly. First off, the overwhelming majority of these jobs are in academics, so if that's not what you want, you're going to have to really look harder to find something (particularly if you are even slightly geographically limited). Every academic place I looked at had a different schedule. Two weeks in the OR (no nights, no weekends), followed by one week in the ICU (either seven nights or days), then one week off, with an extra couple weeks of vacation was a more common one. One of my cofellows went to a place the attendings in the ICU continue to cover at home overnight (residents in house) for their week in the unit. Another place had the attending and fellow (both on call at home) alternate who was first called by the in-house resident, but the attending was still the ultimate backstop. I've also seen settings that were more ICU heavy, like 12 ICU shifts/month with only 4 OR days. Another rapidly flipped attendings from day to night and back again, as they could be in the unit for a week of days, then have a day or two off, then be on for a stretch of four nights, post call plus one day off, then in the OR for a couple of days, then back in the unit again.

In private practice (or, really, nonacademic practice, as some are hospital-employees), there are some of the same models, and other weirder ones, too. A private group I know does the two weeks OR, one week ICU, one week off, with an additional six weeks of vacation. However, they also take OR call during their OR weeks, so they end up working more nights and weekends. Another had 24hr ICU shifts, with the intensivists rotating through the unit for 24hrs (home call), then post call, then back to the OR. Or, I've seen two partners rotate 24hr shifts in the ICU (home call) for a week, then they both go back to the OR the next week.

I'm a PGY-1 anesthesia resident. If I end up doing CCM, should I really end up doing academics? Are private practice gigs really that rare for doing 70/30 OR/ICU?

 

[psychbender]

I'm a PGY-1 anesthesia resident. If I end up doing CCM, should I really end up doing academics? Are private practice gigs really that rare for doing 70/30 OR/ICU?

If you really want to do a split of Anesthesiology and CCM, be mentally prepared to remain in the hallowed halls of academia for your career. Again, there are exceptions, and I know of a handful of practices with ads running on Gaswork or in the back of our journals right now, but the majority of the jobs are with the academic medical centers. Some fellowships will list on their websites former fellows, and where they went after graduation. Peruse the names of the places and you'll see where many are practicing.

 

[Dr.CCM]

If you want to split in your career, I’d probably consider Pulm or EM. It is very easy to find PRN positions in the community for EM on your off ICU blocks.

Pulm guys can typically get their week of clinic in in an off block or it can count toward your FTE with a group.

I doubt any IM-CCM guy would go and do IM on the off weeks either as a hospitalist or a small clinic practice. Never seen in but maybe they do.

Outside of academics, I think it would be very hard to do both in anesthesia unless. It doesn’t seem like the prn jobs are as ubiquitous as their others in major cities but I could be wrong. One of my co fellows found a sweet gig with a split in the community of 2 weeks icu and 7-10 days OR with a ton of vacation.

 

[ToKingdomCome]

Ah I see. Thanks so much for your advice. I do an anesthesia-CCM rotation early next year. I'm still super interested in doing CCM but I don't want to be pigeonheld by academics. It seems as a whole that SDN doesn't recommend doing CCM after an anesthesia residency. I'll definitely see how much I like ICU as an anesthesia resident and decide if it's something I want to do on top of OR anesthesia

 

[student-of-life]

@psychbender @ToKingdomCome can you please provide insight into your decision to opt away from academics? Is it simply that you don't enjoy teaching (something I do enjoy) and/or don't want to take the salary hit (not a huge factor for me), or are there other factors at play? ie worse hours, pressure to conduct research as an academic, having to deal with bureaucracy, etc (factors that could be important considerations for me looking forward) Thanks!

 

[ToKingdomCome]

@psychbender @ToKingdomCome can you please provide insight into your decision to opt away from academics? Is it simply that you don't enjoy teaching (something I do enjoy) and/or don't want to take the salary hit (not a huge factor for me), or are there other factors at play? ie worse hours, pressure to conduct research as an academic, having to deal with bureaucracy, etc (factors that could be important considerations for me looking forward) Thanks!

I actually prefer the academic lifestyle. I enjoy teaching, I enjoy publishing papers, I enjoy the collegial aspect of it. For me salary is the concern, not that it should be the end all be all but it's something that I am considering. Since, I'm only a PGY-1, I don't want to lock myself into academica quite yet with a presumed lower salary. Of course things can change, from now until my CA-2 year.

 

[spacegun]

Aren't salaries in academia vs. private practice for anesthesia 2X difference? $250-$300K vs. $500-$600K?

Not sure about critical care academic. But MGMA and AMGA say critical care median is about $400K, I assume that's private.

 

[CCM-MD]

Aren't salaries in academia vs. private practice for anesthesia 2X difference? $250-$300K vs. $500-$600K?

Not sure about critical care academic. But MGMA and AMGA say critical care median is about $400K, I assume that's private.

The MGMA/AMGA medians include all practice settings - including academics. If you purchase the full data, you can dissect it however you want to.

Anesthesiology medians - MGMA: 448k & AMGA 416k.
CCM medians - MGMA 381k & AGMA 400k.
Pulm & CCM medians - MGMA 390k & AMGA 397k
Pulm medians - MGMA 373k & AMGA 372k
(Numbers are medians from the 2017 surveys, which are based on data from 2016)

The difference doesn't look like much when you look at medians alone, but in general anesthesiology pays a decent amount more than CCM. This is part of the reason why you don't see too many anesthesiology trained intensivists outside academics. To most people, it doesn't make sense to work harder and have a ****tier lifestyle just to get paid less... but there's always some "outliers".

 

[psychbender]

@psychbender @ToKingdomCome can you please provide insight into your decision to opt away from academics? Is it simply that you don't enjoy teaching (something I do enjoy) and/or don't want to take the salary hit (not a huge factor for me), or are there other factors at play? ie worse hours, pressure to conduct research as an academic, having to deal with bureaucracy, etc (factors that could be important considerations for me looking forward) Thanks!

For Anes/CC jobs in academia, you have to think about both academic critical care and academic anesthesiology. I like a lot of aspects of academic critical care (several that I find less appealing), but I really don't like academic anesthesiology. For everything that I am about to say, there are places where it is not true. However, the points were true for the majority of places I contacted in my job hunt.

In academics, there is a lot of pigeon-holing into specific roles. Peds cases, regardless of age and acuity, are done by the Peds-trained staff, regional is performed by the dedicated Regional/Acute Pain team, Cardiac and Thoracic procedures are only done by the CT team, which is composed solely of CT fellowship-trained staff, etc. There are good arguments that can be made to do it this way, particularly in a high-acuity setting, to keep the same small pool of people actively involved in focused clinical areas, working with the same people every day. However, working long in such an environment can cause skills to atrophy, as you no longer take care of entire patient populations or use certain anesthetic techniques. I like to be able to do just about any case, so being restricted in that fashion is unpalatable.

Supervision was the rule at all of the academic programs with which I spoke. At several, I was told that if I went there, I would never again do my own cases. At some, it was supervision of one CRNA in one room and one resident in the other. In others, it was supervising 3 or 4 CRNAs, and only working with residents maybe once a week. I enjoy doing my own cases, so anything more than 50% supervision is a deal-breaker. Also, if I am to supervise, I prefer to work with residents, not predominantly supervise CRNAs, only rarely getting to work with residents.

Academic surgeons all think they are amazing, for the simple fact that they are academic surgeons. That is not to say that surgeons in the community do not think that they are gods, but the degree of arrogance I saw among the surgeons in the university hospitals outshone that of their peers in the community setting. Patients that have no business having surgery are regularly taken to the OR at the university, with the expectation of perfect outcomes, simply because they are at The University. No, the demented, bed-bound 90 year old who got cathed for no good reason does not need a re-do CABG. No **** he was delirious in the unit after surgery and died a few days post-op. Maybe the patient with an active URI shouldn't undergo elective intrathoracic surgery. Let's not completely remove the sacrum and majority of the lumbar spine, fusing the rest to his pelvis, and place a large muscle flap in one twenty-two hour surgery on the elderly patient with metastatic prostate cancer, just to "give him a few more months to get his affairs in order" (spoiler, he died). It's like Jeff Goldblum's line from Jurassic Park, "they were so preoccupied with whether they could, they didn't stop to think if they should." Again, stupid **** happens in the community, but less frequently, and I've found surgeons outside of the Meccas to be more receptive to a quick smack upside the head.

Then, there are the little things. Turnovers suck in academics. There is little incentive to move quickly, so closures can take forever, as the intern or M3 learns to sew under the eyes of the PGY2. Once out of the room, the OR nurse drags her butt turning the room over, because she leaves at 3pm, regardless of what case they're on. No one seems particularly interested in helping out, and getting equipment ready so that you can do your job. You're the one (or your resident) that gets to run around trying to find the bronch tower, difficult airway cart, ultrasound, etc while setting up your room. Nurses in the OR, wards, and units are used to the endless rotation of trainee physicians, are taught to treat them without respect, and allow that to carry over to interactions with attendings (particularly if those attendings trained there). The nurse mafia is strong everywhere, but it dominates in the hallowed halls of academia. Money is also an issue. I'd take a greater than $100-150,000 pay cut to go to the academic programs back in my home state. If I only did anesthesiology, the gap is even wider. With benefits, you're looking at over $200,000 difference between the academic programs and the better non-AMC private practices. Vacation is another issue. My current package isn't that much more than a typical academic gig, but private anesthesia groups back home commonly give their staff 10-12 weeks of vacation, while it's 4 (plus one week CME) at a lot of academic places.

I would prefer an academic ICU to my current small community ICU, largely because my current job is lacking in volume and acuity that I had as a fellow. The BS that I mentioned above often spills over into the units, too, but it's a little less noticeable.

 

[AdmiralChz]

I actually prefer the academic lifestyle. I enjoy teaching, I enjoy publishing papers, I enjoy the collegial aspect of it. For me salary is the concern, not that it should be the end all be all but it's something that I am considering. Since, I'm only a PGY-1, I don't want to lock myself into academica quite yet with a presumed lower salary. Of course things can change, from now until my CA-2 year.

These are presumptuous statements for an intern. Not to say there aren’t people who feel this way out there, but a solid 1/3 of our residency class was interested in CCM coming in. I was one of them! That was pretty quickly beat out of them (and me!) during their rotations and talking to academic attendings. Each year there are far more CCM positions available than applicants from anesthesia, which I think is a shame but reflective of the state of the field (maybe).

There are some great combo jobs out there, but one has to be VERY flexible with geography (as in moving several states away). There are a lot of awful, 100+ hour weeks while on the unit jobs as well that pay crap. For me, there aren’t any anesthesia CCM jobs at all within a 3 hour radius of where I wanted to end up and took a PP job.

 

[ToKingdomCome]

These are presumptuous statements for an intern. Not to say there aren’t people who feel this way out there, but a solid 1/3 of our residency class was interested in CCM coming in. I was one of them! That was pretty quickly beat out of them (and me!) during their rotations and talking to academic attendings. Each year there are far more CCM positions available than applicants from anesthesia, which I think is a shame but reflective of the state of the field (maybe).

There are some great combo jobs out there, but one has to be VERY flexible with geography (as in moving several states away). There are a lot of awful, 100+ hour weeks while on the unit jobs as well that pay crap. For me, there aren’t any anesthesia CCM jobs at all within a 3 hour radius of where I wanted to end up and took a PP job.

Thanks for the insight, I definitely appreciate it! It’s definitely presumptuous for sure as an intern. Just trying to get a feel for what I might be interested in so I could best prepare myself for fellowship apps

 

[Dam272]

The schedules of dual Anesthesiology/Critical Care jobs vary greatly. First off, the overwhelming majority of these jobs are in academics, so if that's not what you want, you're going to have to really look harder to find something (particularly if you are even slightly geographically limited). Every academic place I looked at had a different schedule. Two weeks in the OR (no nights, no weekends), followed by one week in the ICU (either seven nights or days), then one week off, with an extra couple weeks of vacation was a more common one. One of my cofellows went to a place the attendings in the ICU continue to cover at home overnight (residents in house) for their week in the unit. Another place had the attending and fellow (both on call at home) alternate who was first called by the in-house resident, but the attending was still the ultimate backstop. I've also seen settings that were more ICU heavy, like 12 ICU shifts/month with only 4 OR days. Another rapidly flipped attendings from day to night and back again, as they could be in the unit for a week of days, then have a day or two off, then be on for a stretch of four nights, post call plus one day off, then in the OR for a couple of days, then back in the unit again.

In private practice (or, really, nonacademic practice, as some are hospital-employees), there are some of the same models, and other weirder ones, too. A private group I know does the two weeks OR, one week ICU, one week off, with an additional six weeks of vacation. However, they also take OR call during their OR weeks, so they end up working more nights and weekends. Another had 24hr ICU shifts, with the intensivists rotating through the unit for 24hrs (home call), then post call, then back to the OR. Or, I've seen two partners rotate 24hr shifts in the ICU (home call) for a week, then they both go back to the OR the next week.

The " Two weeks in the OR (no nights, no weekends), followed by one week in the ICU (either seven nights or days), then one week off, with an extra couple weeks of vacation was a more common one" doesnt sound too bad.

 

[psychbender]

The " Two weeks in the OR (no nights, no weekends), followed by one week in the ICU (either seven nights or days), then one week off, with an extra couple weeks of vacation was a more common one" doesnt sound too bad.

As with everything, the devil is in the details. How are the nights/days distributed? Are they 12-hour shifts, or are you doing 24/7 with home call (resident or NPP in-house)? What kind of unit are you covering, and what is your team composition (all anesthesia residents, smattering of residents from multiple services, NPPs)? For the OR, what kinds of cases? How are the rooms staffed (two resident rooms, one resident and one CRNA room, or three to four CRNA rooms)? When does the day end? Is it a finish your cases, with a fairly assigned marching order of who gets to leave first, or are you working five set 8 or 10 hour shifts? Finally, is this for $250k or $450k?

 

[NunquamDormio]

@psychbender @ToKingdomCome can you please provide insight into your decision to opt away from academics? Is it simply that you don't enjoy teaching (something I do enjoy) and/or don't want to take the salary hit (not a huge factor for me), or are there other factors at play? ie worse hours, pressure to conduct research as an academic, having to deal with bureaucracy, etc (factors that could be important considerations for me looking forward) Thanks!

Academic hospitals are way bigger. With size comes more hierarchy within your department, and more administrators breathing down your neck. You'll get emails about "quality" and "compliance." You'll have mandatory training modules. You'll have to deal with committees that have endless meetings but never get anything done. Bigger hierarchy within your department means departmental politics. Promotion will require building fluff into your CV and earning brownie points with your chair.

In private practice, you matter more to the hospital. This is reflected in your salary, but also in your relationship with the administration. Groups are smaller, so there is less politics and more close relationships with your colleagues. Salary and productivity are typically more closely correlated. You'll have more say over your schedule. And if you become a partner, you get to decide how the groups' money is spent, and can't be fired.

 

[chocomorsel]

Preach on @NunquamDormio

 

[nimbus]

Academic hospitals are way bigger. With size comes more hierarchy within your department, and more administrators breathing down your neck. You'll get emails about "quality" and "compliance." You'll have mandatory training modules. You'll have to deal with committees that have endless meetings but never get anything done. Bigger hierarchy within your department means departmental politics. Promotion will require building fluff into your CV and earning brownie points with your chair.

In private practice, you matter more to the hospital. This is reflected in your salary, but also in your relationship with the administration. Groups are smaller, so there is less politics and more close relationships with your colleagues. Salary and productivity are typically more closely correlated. You'll have more say over your schedule. And if you become a partner, you get to decide how the groups' money is spent, and can't be fired.

All true except the “can’t be fired” part.