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KGUNNER1

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The increased work force demands for critical care physicians along with the Leap Frog recommendations that hospitals should strive to have 24/7 intensivist coverage are really pushing the issue of critical care fellowship recruitment.

ACEP and SCCM-EM section have always championed the idea that an EM based trained fellow is just as prepared as an Anes, Surg, or IM fellow to practice critical care.

We may be making some headway, after coming back from this years SCCM meeting in Orlando. There is also a new sepsis initiative "Surviving Sepsis" - check it out at www.survivingsepsis.com - which includes EM substantially in its recommendations. ACEP was officially recognized as a member of this primarily critical care based initiative.

My question, how many of you would be interested in doing a critical care fellowship (probably for 2 years) after your ER training? The reason we would probably push for 2 years is that when we are able to take boards, this is what the other 3 yr approved specialties (the 2-3-4 programs may be able to petition for 1 yr) are doing and we also want to be able to allow grads to practice CC in the units if they want.

Please let me know your thoughts.

*** Remember, you don't need to wait for anything to do a CC fellowship now. You still can. If you want to take boards you can easily take them in Europe and the vast majority of hospitals and insurance companies accept those - since there are none recognized in the states.

Check out Pitt's program as an example anf for FAQs. http://www.ccm.upmc.edu/education/adult/fellowship_emc.html

Thanks,
Kyle
 

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I looked into this a few years back, as I was/am somewhat interested. Somewhere on my HD is a list of fellowships that accept EM docs. I think the number was ~40% of all CC fellowships in the US. The list is a PDF on either AAEM or SAEM's website...
 

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I'm interested but IMHO there just aren't enough fellowships available since I have to convince my wife to live wherever I have to go. Definitely considering it though.

C
 
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I am definitely interested. My only hesitancy in the past was the questionable board-certification and what that would mean in practice for an EM/CC trained physician, i.e. could I practice and bill as the same working in an ICU as my colleague who was IM/CC trained. If European boards are adequate and recognized for billing purposes, then sign me up!

Also, for others interested, the CCM section of ACEP has a great section showing all hospitals with CCM fellowships and which accept EM training. Quite a few if you include IM, Surg, and anesth.

Here is the link to ACEP's CCM section:
http://www.acep.org/1,4252,0.html
 

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GCS is correct. David Huang, some very enthusiastic residents and myself conducted a survey of CC fellowships willing to accept ED physicians, the number is closer to 33%. It is up on the ACEP critical care section's website.

I'd like to make it known this is not a recruiting effort for Pitt, I am actually in Virginia now, but rather an informal "show of hands" for those interested in doing a CC fellowship after your EM training.

Thanks,
Kyle
 

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Coleman, did you realize, looking back at the Medicare database for 2002, who billed the most critical care time (E&M code 99291)? It was straight IM, pulm was second, followed by cardiology, family practice and surgery. Critical Care specialists were 6th, behind FP and IM (with no additional training)!!!

As far as credentialling is concerned, all you need is your respective chair who hires you, sign off that you are qualified to practice CCM. The third party payors will probably need a letter letting them know you sat for the European boards because the US won't let you. It hasn't been a problem for those who are practicing now.

Some horror stories are out there I suspect, but CC is in such a work crisis now, I believe these hurdles will be removed within a few years.

Kyle
 

Coleman

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looking back at the Medicare database for 2002, who billed the most critical care time (E&M code 99291)? It was straight IM, pulm was second, followed by cardiology, family practice and surgery. Critical Care specialists were 6th, behind FP and IM (with no additional training)!!!

Where does EM fit in this? Did they even qualify? How does is work that CC specialists billed behind FP? Is this because of the increased amount of FPs working in ICUs across America?
 

KGUNNER1

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For those of you that are interested, please feel free to subscribe to our critical care e-list.

The Coalition of Critical Care Medicine in the ED (C3MED)

David Huang is the list master, just email him and he'll add you to our list .

[email protected]


Kyle
 

KGUNNER1

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Coleman,
Actually, EM should be in place of Surgery, just above CCM, at about 8%. CCM is about 6%.

You hit the nail on the head. There is no special requirements to who bills for critical care time. Anyone can, as long as they can justify the need and time in the chart.

Of course hospital politics play a major role, but if you don't have any intensivists at your shop, you'll take what you can. The same as in the ER. ER and CCM are brothers in this whole game. Everybody thinks they can do our job just as good without the training.

Kyle
 

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You may not recognize this handle but we've talked before. I'm seriously considering doing a CCM fellowship after graduation. I'd consider it even more strongly if they had American boards.

I'd push for one year after EM training. Heck, I will finish residency with at least six months critical care rotations under my belt. You'd certainly get a lot more EM docs doing the fellowship if it were one year not two.

I'm seriously considering Shock Trauma's Trama/CC fellowship, but again I'd be more serious if I knew I could get boarded.
 
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KGUNNER1

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The problem with a 1 year fellowship is a complicated one. All the U.S. based CAQs (certificate of added qualification - they really aren't boards) in critical care are at least 2 years for the base specialites that are 3 years (peds and IM). Peds is actually 3 years.

Europe requires 2 years as well.

One could make an argument for the 2-3-4 programs that 1 year is enough.

If you are going to just practice in the ED, then a 6mo - 1yr fellowship, to hone and polish skills, is fine and probably overkill as many EM programs train the ED doc just fine in basic critical care skills.

However, if you plan on rounding in the ICU, my bias is that you'll need 2 yrs to gain the fine details of critical care, it's just not resuscitation skills. There may be exceptions, but that 2nd yr is helpful.

But most importantly, I highly doubt we could swing a CAQ for only 1 yr. If we are going to compare ourselves with the other intensivists, we need to complete similar training.

Kyle
 

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Hey KGunner, thanks for this thread, I didn't realize that many medicine and surg CC fellowships were open to EM too. If you happen to know, how often are EM residents really taken at these programs? Is it often enough that they are a real possibility or just lip service.

Also, if you want to secure a CC fellowship, do you have to do a significant amount of CC research during residency?

Thanks

the "C"
 

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EM residents make STRONG fellows. All fellowship directors know this. Also, they know you really want to do this, why else would take such a pay cut to work your guts out in a unit for a year.

Research is always a bonus, but not a requirement. I don't think your application would be turned down because you didn't do a bunch of research.

Kyle
 

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I entered into EM/IM for the potential to do critical care.
I personally don't feel that the EM trained physicians get a strong enough background in basic medicine to properly care for the ICU patients long term.
I do agree they would be procedurally strong, and well motivated but their background knowledge might be slim, especially for the potential 1 year fellowship.
I would be interested to see where this goes in a few years.
As of now, my goal is to combine EM shifts with some ICU time.
I am not a clinic doc and I feel comfortable in the ICU's.
I find a lot of EM docs feel comfortable with the stabilization but once they are stabilized they want them out of the ED. Unfortunately, the trend is for longer waits in the ED prior to getting an ICU and continuous/long term care skills are needed.
 

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Jashanley do you feel that surgery or anes residents get enough medicine background to round in the ICU? Being board certified in all 3 (IM/EM and CCM) I think that a solid EM grad will bring great strengths to a CCM fellowship, and in 2 years will be well prepared. On the other hand, I've seen many IM grads struggle with patients that acutely decompensate, especially post operative patients, and they are actually are harder to train.

I'd be interested to know what year you are in and what programs you are intersted in. (on or off list)

My 2 cents.

Kyle
 

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Agree 100% with Kgunner. IMHO EM docs are probably the best prepared for CCM, better than IM and certainly better than surgery/anesthesia/family.

Most CCM trained docs I know are anesthesiologists, who have had much less training in diagnosing and treating illness than EM docs. IM docs diagnose/treat, but have little experience with acute stabilization of critical patients.

Anesthesia/Surgery only do 1 year for CCM. Why does EM need to do 2? Just because we have 3 year programs? We don't do any less critical care rotations, and we do more critical care medicine.

Our ED and many others have a critical care area, which is basically an ICU holding area while the patient is waiting for a bed. We take care of those patients for days on end until an ICU bed pops up, doing serious investigative tests and treatments. So we're not just stabilize-and-admit anymore.
 

KGUNNER1

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The 1 yr 2 yr fellowship thing is a lot more of a political monster than anyone on this list understands. I've been dealing with this for at least 4 yrs now and as the SCCM EM section chair, I can tell you, if you want to really piss off everyone at ABMS/ABIM/ABP etc... it will be by sticking our chests out as a profession and stating things like "I do critical care everyday, I only need 1 year of training".

They won't even give us the time of day now. We won't pursuade anyone to let us in the door with this type of position. So if we don't want to continue taking someone else's boards (Europe - which by the way is also 2 yrs) then I highly suggest we compromise. I guarantee we will be the winners.

Kyle
 

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You're the one on the front lines. If you can get us boarded with a 2 year fellowship, than you'll be a hero. If you can get it in one, you'll be a superhero!!

It's just hard to take such an incredible pay cut in order to do CCM. 2 years of fellowship + less money at the outset. I'll probably end up doing it anyway...:)

How about 1 year CCM + 1 year deep-sea diving in the tropics? 6 months beach-combing? With electives in bikini removal and pickup lines 101.

I'd take a pay cut for that.
 

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Anyone with a remote interest in CCM needs to listen to Kyle. I have recently become aware of the history of this problem, and it is amazing the idea is still around today. There are people who pride themselves on keeping EM out of the ICU.

My personal experience in the MICU/CCU/SICU through medical school showed me how different the thinking was beyond the ED. While I do not disagree that as Emergency Physicians we are the best at acute decompensations, procedures, and overall great attitudes, the thinking of a patient on day #28 on the vent is not within our training. Weaning parameters, prognosis, 28-d mortalities, etc, etc, these are not our speciality. I think we should be grateful we have this opportunity and there are fellowships who will accept us.

The idea of a 1 year fellowship may sound adequate, but due to several other factors and the history and politics behind this debate, I'd vote for us all to back the 2 year deal and someday get board certified in our own country.
 
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Kyle I got my first C3MED digest today and they mentioned something about Medicine CC fellowships being closed to EM now. Does this mean that EM residents will no longer be accepted at IM based CC programs that previously would take them?

Casey
 

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"IMHO EM docs are probably the best prepared for CCM, better than IM and certainly better than surgery/anesthesia/family"

what? i definitely agree with family practice - they shouldn't be allowed in the ICU unless they are visiting a loved one...
but to say that EM docs are better than IM docs in critical care???? when i did my medicine internship, the medicine inters/residents would go down to the ED to evaluate patients that the ED wanted to put into the ICU... they had no freakin' clue most of the time... they just wanted to manage the airway, put in lines and then cart the patient upstairs out of their ED - so much for all that critical care exposure during residency...
then to say that they are "certainly better" than surgery/anesthesia???? You gotta be kiddin' me...

both in surgery and in anesthesia, there is way more critical care exposure than you can imagine - you don't know how many times i get consulted to the coronary care unit (cardiology), medical ICU, neuro ICU with pleas to transfer the patient to the surgical ICU for care.

Now granted, an IM/EM graduate i think will make a fantastic critical care clinician... but to think that one year of critical fellowship will suffice... it makes me laugh... as does your comment that EM is better prepared for CC than surgery or anesthesia...
 

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no... MGH... the home of ARDSnet, PIOPED II, etc... who cares what clinical trials are ongoing, and what does that have to do with EM?
 

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There is nothing useful to come out of this by sticking out each others chests about who is better at what and where. Especially with such seasoned intensivists that frequent this site. Tread lightly on anecdotal blanket statements. I can tell you one fact. In the last 5 years at the University of Pittsburgh, where there are anywhere from 19-26 fellows in critical care, 3 of those years
"fellow of the year" was an EM grad. The other 2 years didn't have EM grads and one year we had two. The EM grad that didn't get "fellow of the year" received an NIH training grant instead. 2 of those years also had EM grads as chief fellows. So be very careful in your blanket assumptions and your vast experiences.

Casey, you are correct. IM appears to have shut their doors. It has far more implications than just for EM grads especially in light of the intensivist workforce shortage.

We knew about this a couple of months ago and are ready to address this on a national level. Keep your eyes open. You heard it here first (sort of)

Kyle
 

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Originally posted by Apollyon
Where is this at? Surely not at Duke (home of PIOPED).

]Originally posted by Tenesma
no... MGH... the home of ARDSnet, PIOPED II, etc...

Duke was not the home for PIOPED nor is MGH the home for PIOPED II. They're just collaborating institutions. Both are outstanding institutions but why are you guys acting like a bunch of.......

Both were/are NIH centered trials with multiple clinical sites throughout the country.

PIOPED II - The PI is Dr. Sarah Fowler from GW. She's not even a physician. The chair of the steering committee is Dr. Paul Stein from St. Joseph Mercy Oakland and the collaborating sites are:

George Washington University
Washington University
University of Calgary
Cornell University
Duke University
Emory University
Henry Ford Hospital
University of Michigan
Harvard University

PIOPED itself was also an NIH study, specifically Division of Lung Diseases, National Heart, Lung, and Blood Institute with many participating institutions.

Not related to the thread, but just to clarify. Sorry.
 

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docxter... absolutely - these are all multi-institutional studies and we are all collaborators... i was just making a silly rebuttal to a silly point about which institution does clinical research and the irrelevancy of it to the thread...

i am glad that U. of Pitt has such a strong program... I still feel that there is a huge difference between EM and IM/EM as far as critical care management - and i think few would argue with that...

and no, at MGH intensivists would not feel comfortable moving from unit to unit...
 

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Apollyon,
Actually it is not. The Critical Care shortage is getting a lot of press. CHEST just ran a 3 article assessment and White Paper this past month.

We have new allies in ABEM, SCCM, ACCP, ACGME and even ABMS. SCCM, ACEP and SAEM along with EMRA are working together on a position statement.

It really is beginning to look like "when" rather than "if".

The only way we can make this work is if interested residents LOUDLY voice their interest in pursuing a CCM fellowship. You need to bug your residency directors and EMRA. Join the ACEP critical care section or the Emergency Medicine section of SCCM. Let us know you are out there.

Just from the emails I'm getting from interested folks like yourself, I know there are quite a few interested if boarding or CAQ becomes a reality.


Keep your eyes and ears open........

Kyle
 
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Does this mean the ABIM might turn around? I thought that the IM CCM programs were the lion's share, but I found that there are 31 IM, 49 Anesthesia, and 81(!) Surgical CCM programs. According to ACEP, 14, 17, and 18 of these programs take EM grads. I, personally, have little interest in surgical CCM - post op infections, dehiscence, and fluid overload? No thanks (at least, not every single day).

A side issue - the ACCP - that's more of a transverse, instead of longitudinal organization, isn't it? I've seen EM, IM, CCM, Pulm, Cards, and CTSx & GSx people all as FCCP's. However, I think the EM folks were grandfathered in from IM. (ACCP is "American College of Chest Physicians".)
 

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Apollyon,

ABIM currently hasn't made any move to back down. Which is too bad. It affects more than just EM grads wanting to complete a CCM fellowship.

The survey of programs listed on the ACEP web site was compiled by David Huang and me with help of 2 other EM residents interested in CC. Rember the IM programs are just pure CCM programs. We didn't include the combined CCM/Pulm programs which ARE the lion's share of the programs. Check out the ACGME website for a breakdown of total number of programs and positions filled http://www.acgme.org/adspublic/

About the Surgical CCM, when was the last time you saw a patient in the SICU without medical problems? Remember, especially now with the aging population, these are medical patients with fresh scars. Not only do you have to know medicine, you need to know the nuances of the type of surgery. They pose their own challenges.

Initially I had the same opinion as you. I wanted the "intellectualism" of the MICU rather than a bunch of fluid resuscitation. After taking care of really sick SICU patients in various units over the past 3 years, I actually like this population better. They usually completely recover, unlike a lot of the MICU patients. Don't form strong opinions this early in your career.

I really don't understand your comment about ACCP. This is just another "club". If you want to pay them the dues, then just about any doc can join. I'm not sure what you mean about "grandfather" EM docs into this. A lot of EM docs (old ones) were Pulmonologists who just moonlit in the ER and this may be where you saw the association.

I dont know what FCCP is, but FACCP is a fellow in the American College of Chest Physians, FCCM is a fellow in Critical Care Medicine (SCCM), FACEP is fellow in American College of Emergency Physicians etc...

SCCM (www.sccm.org) is the society with opens to the multidisciplinary critical care medicine approach. We welcome everybody with an interest in delivering critical care, including respiratory therapists, nurses, paramedics etc...

ACCP (http://www.chestnet.org/) is traditionally filled with pulmonologists and thoracic surgeons with a new insurgance of pure CCM docs.

KG
 
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KGUNNER1 said:
I really don't understand your comment about ACCP. This is just another "club". If you want to pay them the dues, then just about any doc can join. I'm not sure what you mean about "grandfather" EM docs into this. A lot of EM docs (old ones) were Pulmonologists who just moonlit in the ER and this may be where you saw the association.

I dont know what FCCP is, but FACCP is a fellow in the American College of Chest Physians, FCCM is a fellow in Critical Care Medicine (SCCM), FACEP is fellow in American College of Emergency Physicians etc...

SCCM (www.sccm.org) is the society with opens to the multidisciplinary critical care medicine approach. We welcome everybody with an interest in delivering critical care, including respiratory therapists, nurses, paramedics etc...

ACCP (http://www.chestnet.org/) is traditionally filled with pulmonologists and thoracic surgeons with a new insurgance of pure CCM docs.

KG

I've seen the "FCCP" as "Fellow of the American College of Chest Physicians". What I meant was that most Colleges with Fellowships are longitudinal in that you had to publish in your field, in a relatively narrow set of journals (eg, not a lot of ob/gyns getting FAAP cert, or IM getting FACS), whereas the FACCP was open to a lot more fields. The EM docs I've seen as FACCP were IM guys grandfathered into EM. I see, though, that, as you say, just pay your money.

As far as SICU, my experience has been the Durham VA (ie, Duke surgeons and anesthesiologists on a VA population), so that may be a little narrow. Since I haven't done my SICU rotation yet (we rounded there on surgery), I DID see that, if medical problems were present, they were managed by surgeons and gas - take that at face value.
 

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I stand corrected. It's too late and to many letters. You are absolutely correct, FCCP is the "Fellow of the American College of Chest Physicians". I must have made up the FACCP from the alphabet soup of organization abbreviations floating around in my head at this hour.

Each "college" has it's own guidelines as how to make it to be a "Fellow". Usually you have to do something related to the base college. In this case that would be chest medicine or critical care. Many docs claim to be critical care docs. I think SCCM is actually more open to the non-traditional Pulm-CCM docs and CCM providers.

Hope your next SICU experience goes well. The VA can be a little misleading.

KG
 

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I'm a student wanting to go into EM/CCM and I was wondering if there is any advice for what to look for in a residency program in order to be best prepared for a CCM fellowship as an EM grad? The two fellowships that I've heard a little about that interest me most are the one at Maryland Shock Trauma and the one at Pitt. They seem to be the only ones that are VERY receptive (going so far as to advertise that fact) to EM grads and they both seem like great programs.

Should I look hard at the EM residencies at those institutions as well? Any opinion on 4 year vs 3 years?

Any favorite progrmas that do a really good job at preparing you for CCM?
 

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I can speak from both sides. I am origianlly IM/Peds trained, now doing an EM residency. EM is a natural for CCM, especially when you consider that anesthesiology is part of CCM, a non-diagnostic specialty. There may be certain aspects of critical care that we are not trained well in or not exposed to, but isn't that why we do fellowships ? IM/Peds, Cardiology, Pulmonary, Nephrology, surgery all have their strengths in CCM. In the private world most of the CCM is done by Pulmonary or IM/CCM. I have been consulted by anesthesia to code a post op pt. in the ICU..... go figure. I think the best mixes are IM/Pulm/CC, IM/Cards/CC, IM/CC, and EM/CC.
 

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jsmith123 said:
I'm a student wanting to go into EM/CCM and I was wondering if there is any advice for what to look for in a residency program in order to be best prepared for a CCM fellowship as an EM grad? The two fellowships that I've heard a little about that interest me most are the one at Maryland Shock Trauma and the one at Pitt. They seem to be the only ones that are VERY receptive (going so far as to advertise that fact) to EM grads and they both seem like great programs.

Should I look hard at the EM residencies at those institutions as well? Any opinion on 4 year vs 3 years?

Any favorite progrmas that do a really good job at preparing you for CCM?


It really doesn't matter where you go but when you look at the programs, pay very close attention to the acuity of patients. See how many patients are admitted to the ICU from the ED. Ask, during your interview, how long the average length of stay is for an ICU admission. You want the highest acuity with the longest length of stay in the ER. You don't want not-so-sick patients and when you get a sickie, they are whisked up to the unit.

Traditionally this has meant you need to go to an inner-city, big program. But the bed crunch is now starting to reach suburbia. So this may have changed. My bias is that the deeper in the city you go, the sicker they are and they stay longer in the ER. Also make sure that you have a mentor that is more than interested in critical care. Ideally you'd find a place that has EM/CCM trained folks that can help you through. We have 3 and are close to getting a 4th (I won't tell you where, sorry, but you could probably figure it out).

Do a 3 year program, and make sure you do 2 years in a fellowship so you can sit for European boards.

You can get an idea of what program will take an ER grad if you go to the ACEP CC section website.

Good luck and make sure you join the EMRA Critical Care interest group.

Kyle
 

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For KGunner and others, what do you think of ID and nephro in critical care? My home town has the nephro folks doing much of the ICU work but they are not cc trained. Are there people out there doing it formally? Where are they at? Does pulm really match up that much better with CC?
 

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augmel said:
For KGunner and others, what do you think of ID and nephro in critical care? My home town has the nephro folks doing much of the ICU work but they are not cc trained. Are there people out there doing it formally? Where are they at? Does pulm really match up that much better with CC?

Critical care is similar to EM such as every doc thinks he/she can do it without the training. Some EM docs have been doing it for many years and have learned the hard way, but are fairly competent now. These oldies are a dying breed and will be out of the ED in about a decade or so.

Critical care doesn't have that luxury yet. There just aren't enough CC docs. Does that mean a nephrologist can't take care of a critically ill patient? Not really, but most likely they'll consult the cardiologist, pulmonologist, and other similar single organ docs to help them out. A trained intensivist rarely needs to consult these guys, and when we do, we are the responsible point man for the team and organize all the care. So that means when the cardiologist comes by in the morning and orders lasix, the nephrologist won't be able to cancel it out by ordering fluid boluses!!

I think the single organ specialists do well when they take the extra year and complete a CC fellowship, especially at an intense program like Pitt. They bring a whole different experience to the group and we all learn from each other. But without the training and boards, who knows what you'll get and chances are they won't even know they're practicing 10 or 15 years (whenever their residency was) behind the times.

Kyle
 
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