CCM: anesthesia vs. surgery

[FirstAid]

Hey, everybody. I posted a similar thread in the anesthesia forum, but also wanted to get a surgeon's perspective on surgical-based (without trauma) CCM fellowships vs. anesthesia-based CCM fellowships in terms of overall training. Since most large academic hospitals have both the surgery and anesthesia departments running the SICU and/or CT-ICU, you'd think that the training is basically identical despite the different backgrounds in residency. Just wondering. Thanks in advance!

FA

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[surgical06]

ms IV here.

i think the surgical training in critical care (SCC) is second to none. who better to take care of a patient than a doc who is trained to medically and surgically address a patients problem. i thought most hospitals , especially academic centers had "closed units" which means the surgical crititcal care docs take care of the patients in that unit, not critical care IM or anesthesia. whatever the case, the training is not identical at all.

 

[Winged Scapula]

It is not true that most SICUs are closed units; many are run jointly by Surgery and usually, Anesthesia., with the primary service variably being involved (ie, Urology hardly at all, Trauma or general surgery usually running the show). My residency hospital tried to get a closed unit, but there was too much dissent from primary services who wanted to be directly involved in their patient's care while in the unit.

I do not have a strong feeling about the differences, if any, in CC training. The residency training which precedes the fellowship in both Surgical CC and Medical CC is what differs, although a SCC fellowship may have additional training in procedures like trachs, PEGs, etc.

The vast majority of what goes wrong with patients in a SICU are critical care issues which can be handled well by either pathway: renal failure, ventilatory management, nutritional needs, etc. and does not need a surgeon to manage. Surgeons are better at managing wound and drain care, but in most cases, this can be done by the primary service.

I have had nothing but positive experience with Anesthesiologists on the unit and as long as the surgical issues are being managed by the surgeon, do not have a problem with a medically trained intensivist taking care of CC issues.

 

[cchoukal]

Both Surgery and Anesthesiology residencies offer comprehensive exposure to critical care medicine and allow board certification after a 1 year fellowship. In many places, the surgical CC fellowship is the same as the anesthesiology fellowship. As an anesthesiology resident, I can tell you that our entire residency is based on the _mechanics_ of critical care (airway, pulmonary complications, vent mgmt, weaning, fluid mgmt, resuscitation, sedation, lines, drips, and the dx and tx of rhythm disturbances). That said, I don't know jack about wound care, and, as a rule, anesthesiologists are probably not as adept at dx and tx of surgical complications or underlying medical disease.

An important difference btwn the two fields is that, generally speaking, surgeons stick to surgical critical care, whereas anesthesiologists are found in medical, pediatric, surgical, burn, and cardiac/CVsurg ICUs. I can't speak for the field of surgical critical care, but right now anesthesiology CC fellowships are wide open and not particularly popular, I suspect due to the relatively low reimbursement in the field of CCM relative to that of operative anesthesia. This may change in the future, however, as the ASA encourages more graduates to pursue fellowship training.

 

[FirstAid]

Thanks for the responses, everyone!

On another note, does anyone happen to know why the burnout rate is sooo high for CCM docs? Is the lifestyle really that bad? I heard that most places are basically shift work, which doesn't sound too bad. I'm especially interested in hearing from anybody who knows any anesthesia or surgery trained CCM docs that do critical care full time without O.R. included in their practice.

As you can tell, CCM is very appealling to me. Although I'm not too concerned with the lower reimbursement rate of the field (most surveys state around $200,000 for the average, which is totally fine for me), I am concerned about the high burnout rate and overall lifestyle.

Also, would anyone happen to know if SICU is more intense than MICU or vice-versa? Thanks in advance.

FA

 

[Winged Scapula]

I don't know any surgeons who only do CCM without operating but while it *can* be shift work, there is an incredible amount of stress dealing with the critically ill, their families and the pervasiveness of death. A friend of mine who does Trauma/CC has a MUCH more difficult time with the emotional issues surrounding the field than the hours or surgical work.

I frankly find SICU better than MICU if only because the patients *tend* to be younger (especially when you have a trauma center) and generally, have better hearts and lungs. Then again, the MICU is always a strange place for the surgeon - they do things differently there. But the work is intense in both; I don't know there is any significant difference.

Reimbursement for CC is actually pretty good - you bill for the time you spend; much more fair than in othe fields, IMHO.

 

[2ndyear]

The best SICU attending I ever had was a surgeon who no longer operated. He was involved in an accident and ended up with finger and hand numbness, so he (at at least 40 years old) went back and did a CCM fellowship and on to full time SICU director.

 

[cardsurgguy]

Anesthesia is basically critical care right? Except in the OR instead of an ICU. Like cchoukal said, anesthesia is critical care stuff.

That training wouldn't give anesthesia trained CCM docs a better underlying knowledge base for CCM? I don't know, I'm definitely not telling this, I'm asking.

CCM is so physiology oriented, that doesn't favor anesthesia, who nitpick about the nitty gritty physiology of everything...(or so it has always seemed to me)
Again, not telling, I'm asking...

I don't know any surgeons who only do CCM without operating but while it *can* be shift work, there is an incredible amount of stress dealing with the critically ill, their families and the pervasiveness of death. A friend of mine who does Trauma/CC has a MUCH more difficult time with the emotional issues surrounding the field than the hours or surgical work.

What about all of the other types of healthcare workers who work in ICU's and only ICU's?

I remember some nurses who have been ICU nurses for 25 years straight. They don't have another job that they can do mixed in with being an ICU nurse (ie a couple weeks a month in a non-ICU floor and couple weeks a month in an ICU analogous to a CCM-surgeon who does general surgery 2 weeks and ICU 2 weeks).

Bad outcomes suck for everybody. There's gotta be some other factor to the burnout issue.

Or are the emotional issues of bad outcomes not equal for everybody and worse for docs?

I could see this being the case. When a patient died on the ICU's I worked on before med school, it sucked, but I didn't feel responsible since I was a tech, so obviously didn't have any treatment decision authority.

However, if I was a doctor and therefore the one coming up with the treatment to make the person better, I suppose I'd feel responsible for the death and have a feeling like I failed.

Is this maybe the reason why the emotional issue would be different for docs and the various other jobs on an ICU?

 

[Winged Scapula]

Anesthesia is basically critical care right? Except in the OR instead of an ICU. Like cchoukal said, anesthesia is critical care stuff.

That training wouldn't give anesthesia trained CCM docs a better underlying knowledge base for CCM? I don't know, I'm definitely not telling this, I'm asking.

CCM is so physiology oriented, that doesn't favor anesthesia, who nitpick about the nitty gritty physiology of everything...(or so it has always seemed to me)
Again, not telling, I'm asking...

Perhaps...then again, lots of surgery residents get lots of CC in their training as well. I think its probably 6 of one, half dozen of the other who is better prepared.

What about all of the other types of healthcare workers who work in ICU's and only ICU's?

I remember some nurses who have been ICU nurses for 25 years straight. They don't have another job that they can do mixed in with being an ICU nurse (ie a couple weeks a month in a non-ICU floor and couple weeks a month in an ICU analogous to a CCM-surgeon who does general surgery 2 weeks and ICU 2 weeks).

Bad outcomes suck for everybody. There's gotta be some other factor to the burnout issue.

Or are the emotional issues of bad outcomes not equal for everybody and worse for docs?

I could see this being the case. When a patient died on the ICU's I worked on before med school, it sucked, but I didn't feel responsible since I was a tech, so obviously didn't have any treatment decision authority.

However, if I was a doctor and therefore the one coming up with the treatment to make the person better, I suppose I'd feel responsible for the death and have a feeling like I failed.

Is this maybe the reason why the emotional issue would be different for docs and the various other jobs on an ICU?

Your point is well taken, but I think you are preaching a position that I never argued against. I was simply pointing out that one of the reasons for CCM physician burnout is the emotional stress.

Never meant that to be interpreted that physicians were the only ones who experienced the stressors, but as you rightly note, when YOU are the responsible party, your stress level is much greater. ICU nurses do a wonderful job, but they leave when their shift is over, and when a patient does poorly the blame is often placed on the physician team, not on nursing staff. This is true for ANY area of medicine...the position of being the "name on the chart" contributes to a lot of stress. The buck stops with you, you are the one who is potentially being sued, you are the one who is responsible in the public's eye for the patient's outcome.

Most ICU nursing staff have a policy of rotating the patients they take care of - that is, the same nurse will not take care of the same critically ill patient day after day. When I inquired as to why this was, I was told that it was to prevent burn-out, as well as mistakes that can happen when you become too comfortable with a patient and to increase the skill set you learn when you take care of a new patient. Physicians don't have that luxury - you take care of who you admit, or who's on your service, etc.

I don't pretend to know all of the answers and each individual, rather than a job title, will experience the field differently. There are certainly CC physicians who will work until they die, never experiencing "burn out", just as there are ICU nurses who retire early.

 

[cardsurgguy]

True. All very good points as usual. I'm thinking of surgery CCM, so I'm definitely not bashing it in favor of anesthesia CCM, just for the record in case anybody else thought that...