Ccm?

[APACHE3]

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Sorry, I'm back guys, When you say anethesiology is progressing more to CCM..is that towards more SICU responsibilities? You guys are gunning for MICU and CCU too? I cant imagine the Cardiologist, Pulmonologist, ID will give up their territory that easy. Listen, gas docs are smart, no doubt, but without actually doing an IM residency, I just dont see how it can work. MICU is not SICU. No flaming please, this is a legitmate question, just curious on what the gas definition of CCM is. see ya 🙂

 

[cchoukal]

I think it depends on location. It seems like, for the most part, anesthesiologists tend to stick to SICU, cardiothoracic ICU, and other post-surgical ICUs. At the University of Chicago, there are 1 or 2 anesthesiologists in the MICU, I think at Mayo there are anesthesiologists in the renal and neuro ICUs (I think), and I got the impression that anesthesiologists were in the MICUs at UCSF and Stanford as well. I also recall that being the case at a couple of the smaller community hospitals where I applied for TY programs. It defenitely happens, but I think that if your heart is set on MICU, IM and pulm/CC fellowships are a more certain route.

 

[chicamedica]

Sorry, I'm back guys, When you say anethesiology is progressing more to CCM..is that towards more SICU responsibilities? You guys are gunning for MICU and CCU too? I cant imagine the Cardiologist, Pulmonologist, ID will give up their territory that easy. Listen, gas docs are smart, no doubt, but without actually doing an IM residency, I just dont see how it can work. MICU is not SICU. No flaming please, this is a legitmate question, just curious on what the gas definition of CCM is. see ya 🙂

Actually, at one of my anesthesia rotations, the issue was brought up regarding the downfall of not having anesthesia residents rotate through the MICU at a certain institution. This was because the MICU functioned in a distinct way from how the SICUs did, yet anesthesia still responds to codes and is needed for such things as EGDs, etc there. The unfamiliarity with the MICU led, in one particular instance, to stalling and miscommunication in a situation that would have otherwise been smooth. I personally think it's a hazard to the patient if anesthesia isn't involved on a regular basis in a setting where they can be needed. And the patient IS the priority, after all. . .I wouldn't call it "gunning" 😉 . . .just a better integrated system of patient care.

 

[APACHE3]

I agree that for anesthesia to rotate through MICU would be a benefit for all people involved. But there is much more to managing a medical patient than sedation and intubation. No one will argue that anesthesia are the best at lines and tubing, but what then? Believe me there's some really crazy stuff you see in the MICU and if you did not do an IM residency, you really couldn't formulate the best strategy. I think??Anyway, no problem, there's certainly enough patients to go around for all of us. see ya

 

[militarymd]

That's what a fellowship is for....

 

[VentdependenT]

As an ICU attending you gotta QB a lot of consult services. Sure you have to keep up on all types of medicine but in the end its a bunch of repetition on the sickest of the sick. One may pontificate on all sorts of academia but cmon man, you know whats gotta get done to improve or move someone.

As long as you have a plan and can see that discharge. Wheather its the floor (yeah!), vent center (sux, but glad my beds open now), long term care, or DNR/family time, then you da man. Did I simplify that too much and use poor grammar? Perhaps. Never the less I dig it.

 

[Noyac]

I agree that for anesthesia to rotate through MICU would be a benefit for all people involved. But there is much more to managing a medical patient than sedation and intubation. No one will argue that anesthesia are the best at lines and tubing, but what then? Believe me there's some really crazy stuff you see in the MICU and if you did not do an IM residency, you really couldn't formulate the best strategy. I think??Anyway, no problem, there's certainly enough patients to go around for all of us. see ya

I sort of see where you are coming from APACHE but lines and intubations are the simplest tasks of all. If you have followed this forum much you will remember some of us refering to these as "monkey skills" w/c they are essentially. It is the other skills that are what separates the good from the adequate. Honestly, the "crazy stuff" you refer to isn't all that difficult either. Some pts can prove to be difficult (ie: status asthmaticus pts) but the treatment is pretty straight forward.

Now I still feel that the MICU is mostly for IM fellows and the SICU, Neuro, Trauma, and Burn units are the area of anesthesia and surgery. But does it really matter? All you need is someone with skills and knowledge.

 

[APACHE3]

Hey, its those "monkey skills" that get you all the reimbursement rates! Its why you get paid 50k more than me!!!😀 But, I understand better now, if a gas doc does a CC fellowship, by all means he/she is ready to staff MICU, CCU, etc. I thought there was a push to expand the "role" of the anesthesiologist without going through the normal pathway of CC certification..my bad!! see ya

 

[chicamedica]

I agree that for anesthesia to rotate through MICU would be a benefit for all people involved. But there is much more to managing a medical patient than sedation and intubation. No one will argue that anesthesia are the best at lines and tubing, but what then? Believe me there's some really crazy stuff you see in the MICU and if you did not do an IM residency, you really couldn't formulate the best strategy. I think??Anyway, no problem, there's certainly enough patients to go around for all of us. see ya

There's more to anesthesia than lines, tubing, sedation, and intubation. 😉
Knowing medicine well is a must in anesthesiology. (dont forget we do a medical intern year, preferably (vs. surgical)). And yeah, as militarymd says, that's what fellowship is for. Actually there've been studies that found that patient outcomes are better when anesthesiologists run the ICU. I personally think departments should put their heads together, and so i'd support making units multidisciplinary.

 

[chicamedica]

Hey, its those "monkey skills" that get you all the reimbursement rates! Its why you get paid 50k more than me!!!😀 But, I understand better now, if a gas doc does a CC fellowship, by all means he/she is ready to staff MICU, CCU, etc. I thought there was a push to expand the "role" of the anesthesiologist without going through the normal pathway of CC certification..my bad!! see ya

EXPAND the role of anesthesiologists? U kidding? CCM as a field was founded by anesthesiology. In Europe, the anesthesiologists have always been the intensivists. The medical finance dynamics in the US had unfortunately been discouraging anesthesiologists from going into CCM over the past couple decades. Thus the medicine folks had to take over. This isn't expansion, my friend, this is reclaiming what was originally an anesthesiology specialty.

P.s. if you want to do CCM so bad, I recommend the anesthesia route. I think it's better preparation, personally.

 

[VolatileAgent]

there is a world of difference managing a SICU patient and a MICU patient. there is no poaching going on at all. anesthesia trained CCM folks (along with surgery trained CCM) focus on trauma and the peri-operative arena. you don't want medical folks with their completely different skill set managing these folks. likewise, i personally don't want to manage endstage chf or diabetic comas either.

different disciplines. different units. different training. different expertise.

 

[bullard]

There's more to anesthesia than lines, tubing, sedation, and intubation. 😉
Knowing medicine well is a must in anesthesiology. (dont forget we do a medical intern year, preferably (vs. surgical)). And yeah, as militarymd says, that's what fellowship is for. Actually there've been studies that found that patient outcomes are better when anesthesiologists run the ICU. I personally think departments should put their heads together, and so i'd support making units multidisciplinary.

Could you post some references to these studies?

Incidentally, I did my ICU rotation in a combined MICU/SICU with attendings trained in medicine, trauma/surg crit care, and anesthesia...they told me that their internal data suggested no difference in outcomes between the different specialties in their ICU. I was under the impression that this is generally true elsewhere but that there's no good data (yet).

 

[toughlife]

.

 

[militarymd]

there is a world of difference managing a SICU patient and a MICU patient. there is no poaching going on at all. anesthesia trained CCM folks (along with surgery trained CCM) focus on trauma and the peri-operative arena. you don't want medical folks with their completely different skill set managing these folks. likewise, i personally don't want to manage endstage chf or diabetic comas either.

different disciplines. different units. different training. different expertise.

I disagree, but that's just me....5 years experience attending in a combined MICU/SICU where my partners were medical and surgical trained folks.

 

[chicamedica]

Could you post some references to these studies?

Incidentally, I did my ICU rotation in a combined MICU/SICU with attendings trained in medicine, trauma/surg crit care, and anesthesia...they told me that their internal data suggested no difference in outcomes between the different specialties in their ICU. I was under the impression that this is generally true elsewhere but that there's no good data (yet).

I mean, i dont know if i agree with those studies myself. . .I've heard of em. Haven't really read em myself.

My feeling is that the most optimal outcomes come from multidisciplinary collaboration, though.

 

[chicamedica]

there is a world of difference managing a SICU patient and a MICU patient. there is no poaching going on at all. anesthesia trained CCM folks (along with surgery trained CCM) focus on trauma and the peri-operative arena. you don't want medical folks with their completely different skill set managing these folks. likewise, i personally don't want to manage endstage chf or diabetic comas either.

different disciplines. different units. different training. different expertise.

Are you saying a post-CABG patient can't go into end-stage CHF? Or that a type I diabetic who just had surgery can't go into DKA on you? I gotta agree with militarymd. . .I really dont see the difference, other than in the SICU, in addition to knowing the medical stuff, you also have to be aware of the surgical implications.

 

[VolatileAgent]

i'm saying that the type of patient that generally ends-up in the SICU is different than the type of patient that generally ends up in the MICU. and, everywhere i've been, there is a different philosophy on managing them. yes, you can get a chf patient in the SICU or a post-thoracotomy patient with a chest tube in the MICU. but, we read different journals and our training and approach to the patient is different - not necessarily completely different - as well as our training and expertise level in managing those folks.

as for those who work in MICU/SICU environments, i'm sure you've benefitted from an environment that fosters collegiality and an interdisciplinary approach where your more medical colleagues have benefitted from your greater surgical knowledge, and vice versa. where i train and went to med school, the MICU and SICU were very separate places with separate attendings and separate ideas.

and, i don't necessarily think this is a bad thing.

 

[KGUNNER1]

Regardless of your basic training, if you complete a strong ccm fellowship where you are taking in house call on a regular basis, high volume, strong attendings that love to teach, you can really handle anything.

It is a little tougher for non-IM trained intensivists to "break through" into the MICU. Not because of competency issues, but more because of politics and complicated billing structures.

In small-medium private hospitals, most units are mixed and an intensivist group manages them (if the hospital is lucky). If the group is lucky, they will find a good Anesth-ccm that will want to take the pay cut to round for a week/month.

Once you have your CCM training, all the chest puffing and posturing all goes away about "who is better". That stuff is mostly left for our residents and med-students to fight it out. We all respect each others strengths and weaknesses and learn from them both.

But a little bit of rivalry always makes for fun rounds. 😀
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