Critical Care: Anesth x Internal Medicine

[Galli]

Hi guys!

I am still a med student, and I would like to work in Critical Care. I am not sure if I go into anesthesiology or Internal Medicine for that. I am more to the side of anesthesiology, that I think it's much more interesting. But I would like to hear your opinions on the advantages and disadvatages of each track. Even if it's difficult to get a fellowship position, preferences the hospitals may have on one type of intensivist over the other, and so.
Thanks!!

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[droliver]

Just my bias, but I think anesthesia prob. gives you a better understanding of the physiology for critical care than a IM background. And for that matter, I think the Surgical Critical care physicians are even better than anesthesia for all around ICU patient care because it's something you have a lot more experience with in general.

 

[gas-x]

but i think most of the ICUs are headed by pulm/crit care people. the remaining SICUs are mainly headed by surgery. anesthesia intensivists are probably considered "consultants," where their responsibilities might vary quite a bit. as far as residency, some anesth crit care residents must contact surgery teams before any decision can be made, lines to be changed, etc... basically, the anesth team are just "baby-sitters." at least that is how my rotation went while in the SICU. some other residency programs might be different.

as far as in private practice, i don't know what happens. an anesth attending told me not to go into critical care because the pay is lower than being a "meat and potatoes" kind of general anesthesiologist.

 

[gasdoc]

As far as I know as a CA-1, CC medicine is one of the subspecialty/fellowships of anesthesiology. In decades past, anesthesiologists actually directed and controlled most of the critical care units in this country, as many of the original ICUs were founded by anesthesiologists.

However, anesthesiologists, as you all know, mostly do not take care of ICU patients anymore. There are several reasons for that, but mostly its money. As some of you said, anesthesiology intensivist are more expensive than pulmonologists. An anesthesiologist who practice in general anesthesia makes more money than as a critical care doc, and that's w/o the fellowship training. Most anesthesia residents HATE their minimal required 2 months of ICU rotation. They don't like the longer hours and more rounding, etc. ICUs in academic centers come in two ways, closed or open. A closed ICU means that when a patient is admitted to it, than the primary team "gives up" that patient's care to the ICU team. So, if that anesthesia resident is part of the ICU team, s/he will become very important and do all the decision making/orders for the patient. However, if that ICU is a "open" one, that means the primary team still has the ultimate responsibility for the patient and allt he ICU team does is act in a consulting role. Their "recommendations" could be heeded or not heeded by the primary team. In that case, the anesthesia/critical care resident's position has little "teeth". Personally, I favor a open ICU b/c I really don't care too much about taking care o very complicated ICU patients.

 

[Ratty]

And if you're interested in the numbers, only 6% (!) of all intensivists are anesthesiologists, and only 4% of all anesthesiologists go into critical care. Not a popular option at all.

Source: Hanson et al Anesth 2001:95:781-788

 

[Tenesma]

the original question was internal medicine vs anesthesia prior to critical care fellowship... to be quite honest, those IM people who just do a year of critical care medicine are totally useless. They have no concept of any interventional procedures that would play a big role in the ICU setting, and are generally still trying to figure out how to adjust vent settings. So if you want to do critical care and be good at it, then choose anesthesia...

now, if you do a pulmonary fellowship with critical care, then things even out a lot more (but that is also 1 to 2 years more training).

I have to agree with DrOliver in the SICU setting that surgical intensivists tend to have a deeper grasp of the patients, but anesthesiologists are not very far behind (if you think about it, every day in the OR is like doing some critical care- while the surgeons are mucking around on the other side of the curtain).

The big issue now for critical care is money - there was a recent study (i think it was the "leapfrog" trial) that showed better outcomes in ICUs with dedicated intensivists (duh....); so based on that study every body expected the compensation to improve (which it really didn't). ICU docs generally make between 120 and 160 a year, but work like real dogs... now why would anesthesia people wanna do that for half their normal salary?
the other issue is that medicare won't be reimbursing intensive care time unless it is provided by a primary physician (ie: surgeon or internal medicine and yes even family practice docs - can you imagine???), so consultative intensivists (even in closed units) - and that includes anesthesiologists - only end up getting reimbursed indirectly through the surgery dept or the hospital.

did that answer your question? i still think anesthesia is the way to go, because critical care is what we provide every day...

my 2 cents

 

[Galli]

Thank you, guys, for all your answers!

Yes, you have answered my question. As far as I can see, if the issue is to become a good ICU doctor so the best way would be anesthesia. Tenesma has a very good point in saying that the anesthesiologist provide a critical care every day...
The problem is if it's worth working more for less. It really seems foolish said this way...anyway, maybe it's still too early for me to say...I just think about ICU because I find it very interesting taking care of people who are so sick, and having practically all the physiology in your hand while doing it.
Anyway, thanks for the insights!

 

[rtk]

Galli;

I'm gonna make a plug for the IM route to CC...

First, Tenesma, I'm not sure where you're getting your info, but the vast majority of the 'useless' intensivists out there are IM trained first... Besides, if you choose to go on to CC after an IM residency, it's 2 years, not 1. It's only one year if done after pulm, cards, or nephrology fellowship.

It may boil down to what you enjoy more (anesthesia or medicine) but the time committment to CC training is the same via either route: IM (3yrs) + CC (2 yrs)= 5yrs VS. prelim+anesthesia (4yrs) + CC (1 yr)= 5yrs.

I would argue that training to care for critically ill patients is better through medicine. Granted, anesthesiologists care for pts when they are critical (in the OR, post-op, etc), however, caring for a non-operative critically ill patient is arguably much different. Having additional training in cardiology, nephrology, pulmonary medicine, infectious diseases, rheumatology, GI, endo, heme/onc will prepare you for the multiple medical problems that critically ill pts face.

Tenesma also states: "to be quite honest, those IM people who just do a year of critical care medicine are totally useless. They have no concept of any interventional procedures that would play a big role in the ICU setting, and are generally still trying to figure out how to adjust vent settings"

Obviously, Tenesma hasn't been in the MICU of any large medical center... believe it or not, those medicine trained intensivists actually place central-lines, do bronchoscopies, float swans, place IV pacers, etc... All this after they changed vent settings and interpreted blood gas values... Imagine

 

[Tenesma]

sorry to disagree... after doing internship at a huge hospital complex in baltimore, and now doing residency at a huge hospital complex in boston... i can tell you that the intensivists are mainly pulmonary/critical care people, not IM critical care people - as far as the MICU goes. I would contend that you mainly see IM CC trained folks mainly in smaller centers...

and the contention that non-operative critically ill patients and operative critically ill patients are different is weak... what is different about them? both populations are in need of critical care because of 1) multi-organ system failure 2) sepsis 3) ARDS 4) cardiac 5) neuro (ICH) 6) GI bleed...

i hate to say this, but after my "limited" experience with intensivists i would choose pulm/CC, anesth/CC or surg/CC over IM/CC for any family member of mine... now, this doesn't mean i don't respect IM - in fact, i think it is an unbelievably challenging intellectual field - i just wish their CC training was a notch higher.

 

[rtk]

Tenesma, maybe you misunderstood my point. Understand that as a med student one must decide which route to take to become an intensivist: this can be done through anesthesia, internal medicine, emergency medicine and surgery. I was simply stating that I feel the best route to critical care training is through internal medicine. Obviously any of the medical subspecialties (pulm included) would require IM residency first.

I'm not discounting anesthesia's training, I have many very well trained friends who have done anesthesia and I have great respect for the rigorous training that they underwent (frankly, they are the internists of the OR).

However, although anesthesiologist's must do a pre-lim year (either med or surg), their exposure to the medical subspecialties is more limited than an IM trained intensivist.

Galli, my advice to you or other med students who are considering the best path to become a good intensivist would be to do a residency in internal medicine first. The extensive exposure to the medical subspecialties will be crucial... Critical patients present in many forms: Tenesma may disagree, but (atleast at the training hospitals that I been in) patients in the SICU are different from those in the MICU, the NICU, the CCU or the PACU. What's the one thing they all have in common? When these patients are critical, they all have medically related problems. It may only involve one organ system, perhaps 5, but experience dealing w/ a patient in thyroid storm, or posterior wall MI, or DKA, or gram (-) sepsis all require knowning internal medicine well.

Believe me, you'll get plenty of invasive procedures through IM residency, more than enough to feel confident to manage critical patients. You'll also spend a significant amount of your training in the unit in internal medicine residency particularly if you complete your training in an IM program w/ an open ICU policy. Meaning you'll see and manage critical patients every month you see inpatients. The programs where I trained, the IM residents had more critical care time than the anesthesiology residents.

 

[Galli]

Thank you all again!!

It's very good to see different approaches to that question. I don't know how it was at your med school, but for me and my friends it seems an endless discussion...
Using tenesma and rtk points, I would like to make a hook to add a new question to that thread: what are the best programs in Critical Care in your oppinion? I mean, both in Anesthesiology and IM. Tenesma and rtk, I thank you for your insights again!

 

[womansurg]

In my experiences, the IM folks were just as facile with procedures as the rest of us (well, all of the non-surgeons, including IM, pulm, and anesthesia - in that order, tend to drop a lot more lungs during CVC placement, and also to produce a signficantly higher rate of line infections - true stats from our institution).

For us, the major difference in patient management between surgical intensivists and medical intensivists has to do with fluid management. We believe strongly in the concept of 'resuscitation' - "give 'em fluids, boss!" Medical folks tout the saying "dry lung is good lung!"

Probably both of us err on the side of our own philosophy on occasion, but we see an awful lot of permanent renal insufficiency and failure in the medical ICU patient population. Our tact in the immediate post op (or systemic inflammatory response syndrome of any etiology) period is to maintain mechanical intubation until fluid equilibration is reached. That way, you don't have to worry about fighting elements of pulmonary edema while you are combating pre-renal azotemia and systemic hypotension from third spacing. You just support their pulmonary function until you are out of the woods. I'd rather give someone a higher PEEP or FI02 for a brief period of time then lose their kidneys permanently because I was trying to run their lungs dry. We are also much more liberal about the use of pulmonary artery catheters to guide our fluid management, especially when dealing with known CHF.

Lots of jargon - sorry kids.