CCM

[CAILARTEN Doc]

Applying for CCM Fellowship as I am only interested in practicing under ICU setting. However I have been reading, that job opportunities and salary may be lower compared to PCCM Peers. Can someone shed some light on this ?. Any experiences ?

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[CCM-MD]

Full time CC is 22-26 weeks of ICU per year. PCC is a mix of clinic/consults and ICU. 2023 MGMA averages are ~$450k for CC and ~500k for PCC. You can make much more (or much less) depending on where you want to live and how much you want to work. Biggest pro for PCC over CC alone is not the $ (in fact CC usually pays more than pulm), but the ability to transition out of the ICU to the clinic as one ages or in the event midlevels take over.

I'm CC "only" but I tell all my residents to do PCC, unless they truly hate clinic. Both are in high demand so you will find a job just fine and make very similar money regardless of whether you do CC or PCC. PCC will give your career more longevity.

 

[CAILARTEN Doc]

Thanks for the info.
Clinic isn’t much of an issue; just don’t like pulmonary and least interested. That being said, the longevity aspect does worry me with the physician burnout rate, mid level creep, hospital administration hassles etc.

 

[SurfingDoctor]

Thanks for the info.
Clinic isn’t much of an issue; just don’t like pulmonary and least interested. That being said, the longevity aspect does worry me with the physician burnout rate, mid level creep, hospital administration hassles etc.

After +10 years… everyone wants a parachute.

 

[tartesos]

Thanks for the info.
Clinic isn’t much of an issue; just don’t like pulmonary and least interested. That being said, the longevity aspect does worry me with the physician burnout rate, mid level creep, hospital administration hassles etc.

Join the FIRE movement. Live like a resident and save/invest a lot and you might be able to retire before burn out( maybe )

If you don’t like Pulm, don’t do it, save a year. You will be fine with Ccm alone.

 

[chessknt]

Thanks for the info.
Clinic isn’t much of an issue; just don’t like pulmonary and least interested. That being said, the longevity aspect does worry me with the physician burnout rate, mid level creep, hospital administration hassles etc.

Pulmonary is actually kind of fun once you get past mount stupid--broad field that really likes to throw curve balls, get to help with cancer diagnosis, palliative care etc. I thought the same but I do like it now.

That being said you can do any 2 year primary clinical specialty (nephro, rheum, Endo etc) followed by 1 of ccm if you wanted to give yourself an outpatient option but the 1 year ccm for IM grads might be hard to find. I agree with the other that if you don't want to do pulm straight ccm is your best option.

 

[CAILARTEN Doc]

Thanks everyone. Lots to think about. Guess it all comes down to prioritizing interest over longevity.

 

[Tipsy McStagger]

I’m EMCCM, but if I could do it over I’d do PCCM. it’s only one more year, and it will not only open doors for you, one of those doors leads out of the unit 20 years from now when you’re just done with it all.

I cannot stress how much I would encourage you to do pulm. Years from now you will look back and regret it if you don’t I suspect.

Best of luck regardless!

 

[sylvanthus]

I’m EMCCM, but if I could do it over I’d do PCCM. it’s only one more year, and it will not only open doors for you, one of those doors leads out of the unit 20 years from now when you’re just done with it all.

I cannot stress how much I would encourage you to do pulm. Years from now you will look back and regret it if you don’t I suspect.

Best of luck regardless!

Agreed, Im EM/IM/CC and prob shoulda just dont pulm crit.

 

[The kitchen sink]

Agreed, Im EM/IM/CC and prob shoulda just dont pulm crit.

Why?

 

[chessknt]

Why?

Because going from the ICU to the ER isn't scaling back and doing FT ICU long enough will leave you useless if you decide to become a PCP. Doing a specialty let's you usually alternate some time in it so you don't become an ancient useless dinosaur.

You can't really do a week of PCP every 2 months.

 

[sylvanthus]

Why?

ER is a terrible place to work now, and I have no real cush fallback plan now. Maybe hospitalist in a tiny ass hospital down the road? But thatd be a huuugee paycut. So reslly nothing to transition to save for cutting back.

 

[CCM-MD]

12 weeks of ICU a year is $250k+ in my area, thats my plan to deescalate.

Pulm is still better to have for just 1 extra year and I recommend it to almost everyone. Unless you’re like me and clinic sucks the soul out of your life.

 

[chessknt]

12 weeks of ICU a year is $250k+ in my area, thats my plan to deescalate.

Pulm is still better to have for just 1 extra year and I recommend it to almost everyone. Unless you’re like me and clinic sucks the soul out of your life.

3k/shift is nice...

 

[psychbender]

12 weeks of ICU a year is $250k+ in my area, thats my plan to deescalate.

Pulm is still better to have for just 1 extra year and I recommend it to almost everyone. Unless you’re like me and clinic sucks the soul out of your life.

A one on-three off model can offset a lot of bull****.

 

[The kitchen sink]

A one on-three off model can offset a lot of bull****.

it is

Some priv prac pccm models are 1 week CC (usually day shifts with home call if in consultant intensivist open icu model)

2 weeks pulm outpt (you choose how many clinic days depending on how much you want to make so can be 2-5 days a week)

1 week pulm inpatient consults

From what my colleagues report, it can be pretty sustainable

if they burn out from CC aspect they move into Pulm only models, either inpatient + outpatient or pure outpatient

Other models have groups of 5-6 pulmonologist

3 do purely outpatient

3 do combo inpt outpt , no CC

No one is complaining about compensation

 

[CCM-MD]

it is

Some priv prac pccm models are 1 week CC (usually day shifts with home call if in consultant intensivist open icu model)

2 weeks pulm outpt (you choose how many clinic days depending on how much you want to make so can be 2-5 days a week)

1 week pulm inpatient consults

From what my colleagues report, it can be pretty sustainable

if they burn out from CC aspect they move into Pulm only models, either inpatient + outpatient or pure outpatient

Other models have groups of 5-6 pulmonologist

3 do purely outpatient

3 do combo inpt outpt , no CC

No one is complaining about compensation

We're talking 1 week on 3 weeks off. Not 1 week on and go work a totally different job for 3 weeks. What you are describing is too much work for 1.0 FTE, every ICU week should come with a week off. I'd rather work an extra week in the unit and take 2 weeks off rather than work all 4 weeks.

This "private practice pulmonologist rounding in an open ICU at the local hospital" model, is becoming historical outside of small towns. I wouldn't go into the fellowship hoping for a job like this.

 

[psychbender]

Yeah, I was meaning three fully off, not just out of the unit. I do a week in the unit, often a week of OR, one off, two to three more OR before my next unit week now, and it sucks (close to 2400 hours a year). Next year is structured better to mostly be a week ICU, week off, 2-3 weeks OR with call, but it's still a lot of hours (should be less than 2300, though).

I'm thinking of dropping OR call, and going to fixed hourly for 1840 total (10 weeks ICU, 25wks OR) for a better lifestyle soon.

 

[The kitchen sink]

We're talking 1 week on 3 weeks off. Not 1 week on and go work a totally different job for 3 weeks. What you are describing is too much work for 1.0 FTE, every ICU week should come with a week off. I'd rather work an extra week in the unit and take 2 weeks off rather than work all 4 weeks.

This "private practice pulmonologist rounding in an open ICU at the local hospital" model, is becoming historical outside of small towns. I wouldn't go into the fellowship hoping for a job like this.

Are there enough fellowship trained intensivist in the burbs to staff your closed ICUs or is it hospitalist run? Or midlevels?

I was just describing some actual models that I see , probably scheduled like that to generate more revenue for the practice

 

[The kitchen sink]

Yeah, I was meaning three fully off, not just out of the unit. I do a week in the unit, often a week of OR, one off, two to three more OR before my next unit week now, and it sucks (close to 2400 hours a year). Next year is structured better to mostly be a week ICU, week off, 2-3 weeks OR with call, but it's still a lot of hours (should be less than 2300, though).

I'm thinking of dropping OR call, and going to fixed hourly for 1840 total (10 weeks ICU, 25wks OR) for a better lifestyle soon.

How many weekends off are you getting per year on that schedule?

 

[CCM-MD]

Are there enough fellowship trained intensivist in the burbs to staff your closed ICUs or is it hospitalist run? Or midlevels?

I was just describing some actual models that I see , probably scheduled like that to generate more revenue for the practice

My city is all hospital employed or corporate groups like Sound. This is what most major metros are looking like. The city lost 2 private large pulmonary groups in 2023 alone, due to unsustainable rise in overhead. Same story with private endocrine and ID groups. Rising overhead combined with CMS cuts makes it a tough environment for private groups. Employed positions are offering better pay for less work.

 

[The kitchen sink]

My city is all hospital employed or corporate groups like Sound. This is what most major metros are looking like. The city lost 2 private large pulmonary groups in 2023 alone, due to unsustainable rise in overhead. Same story with private endocrine and ID groups. Rising overhead combined with CMS cuts makes it a tough environment for private groups. Employed positions are offering better pay for less work.

The loss of private groups is a loss for physician autonomy in the grand scheme of medicine

 

[gulmohr]

Happy to be corrected, but it seems to me that administrators are trying to close the gap between intensivist and hospitalist compensation - this is specially true in NE metro areas which I'm familiar with.
Compounded by the fact that when you think about it, a lot of hospitalists round and leave early afternoon (while still getting paid for the entire 12 hour shift) whereas most ICU jobs require you to be physically in the unit for the entirety of the 12 hour shift.

 

[CCM-MD]

Happy to be corrected, but it seems to me that administrators are trying to close the gap between intensivist and hospitalist compensation - this is specially true in NE metro areas which I'm familiar with.
Compounded by the fact that when you think about it, a lot of hospitalists round and leave early afternoon (while still getting paid for the entire 12 hour shift) whereas most ICU jobs require you to be physically in the unit for the entirety of the 12 hour shift.

Not true in the west or midwest. ~$100/h+ or ~200k/yr difference. Hospitalists are a dime a dozen, while intensivists are still hard to recruit. Admin has no interest in “closing the gap”, they want to spend less on anything they can and it’s much easier to squeeze the folks that are easier to replace.

The leaving early stuff is honestly bull**** because it leads to reflex ICU consults from a distance for floor patients. Don’t worry, people are catching on. My group cut the hospitalist rounding shift duration from 12 to 8, and are giving us an extra ICU midlevel from the savings. I’m sure this trend will continue as admin catches on, “leaving early” is short term gain for long term pain.

 

[The kitchen sink]

Not true in the west or midwest. ~$100/h+ or ~200k/yr difference. Hospitalists are a dime a dozen, while intensivists are still hard to recruit. Admin has no interest in “closing the gap”, they want to spend less on anything they can and it’s much easier to squeeze the folks that are easier to replace.

The leaving early stuff is honestly bull**** because it leads to reflex ICU consults from a distance for floor patients. Don’t worry, people are catching on. My group cut the hospitalist rounding shift duration from 12 to 8, and are giving us an extra ICU midlevel from the savings. I’m sure this trend will continue as admin catches on, “leaving early” is short term gain for long term pain.

There are ICU consults from near and from a distance

Hospitalist asks ER to consult ICU prior to admission… a note with a plan is written prior to floor admission

Hospitalist is at home after rounds, nurse calls for something… hospitalist tells floor midlevel to consult ICU…. Pt rejected….

Floor nurses keep paging hospitalist …. Hospitalist tells RN to call rapid

ICU gets tired of constant calls for pt with ‘fever’ and upgrades to stepdown or ICU

That’s what happened in my academic house in different iterations

Same with the PACU & ER…. hammer page ICU for anything that remotely needs more monitoring than q8 vital signs….

So basically the floors are nursing home and the ICU is the floors + ICU

We have fought back and created hospitalist run step down units so now they have to take care of their own messes and only if its something serious it gets an upgrade but it’s annoying

 

[psychbender]

How many weekends off are you getting per year on that schedule?

My anesthesia-only partners generally work 8-11 weekends, depending on how much vacation they take. Since I work 10 weeks in the ICU, including their weekends, I do not have to work weekends in the OR.

 

[chessknt]

Not true in the west or midwest. ~$100/h+ or ~200k/yr difference. Hospitalists are a dime a dozen, while intensivists are still hard to recruit. Admin has no interest in “closing the gap”, they want to spend less on anything they can and it’s much easier to squeeze the folks that are easier to replace.

The leaving early stuff is honestly bull**** because it leads to reflex ICU consults from a distance for floor patients. Don’t worry, people are catching on. My group cut the hospitalist rounding shift duration from 12 to 8, and are giving us an extra ICU midlevel from the savings. I’m sure this trend will continue as admin catches on, “leaving early” is short term gain for long term pain.

Yea makes no sense at all to pay for 12 hours of work when they're dipping out after 6. This is low hanging fruit for them--either double their census to give them something to do or pay them for the hours they are actually in house providing a service. They could pay a mid-level to x-cover who will happily stay in house for way less than the x hospitists that are all gone after 2 pm.