Critical Care

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Dawg_MD

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Any idea how I coud go about mixing critical care with primary care? I really enjoy the challenge of taking care of seriously ill patients in the ICU/CCU but I really like the continuity of care and the freedom of an Internist. Any suggestions on how to get the best of both worlds?

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I worked with a pulmonary/critical care doc who had a few primary care patients too. It's definitely doable. I think that it's very common for physicians to work certain months in critical settings and spend certain months doing other things. Doing critical care all year must be very tiring. After you complete your IM training, you will be qualified to see primary care patients irrespective of what fellowship you choose to do. However, you should recognize that a lot of the out-patient work in things like pulmonology can be very similar to primary care work, except you don't have to worry about retaining and keeping up to date with general internal medicine practice guidelines. I think that this is a preferable situation because I'm certain that most doc's knowledge of general IM becomes dated or the doc can't retain as much of general IM after completing a fellowship.
 
Hospitalists often do quite a bit of critical care and continue to use gen med skills. More recent studies, including a meta-analysis, suggest that patient care, cost -effectiveness and outcomes are improved with the use of a dedicated intensivist, in a closed ICU model, although this is not entirely feasible for many hospitals. CCM fellowships exist, but most CCM is tied w/ training in pulmonary medicine. The gaps between outpatient medicine and inpatient care has grown immensely, hence the evolution of the hospitalist. Your best bets these days for the "jack-of-all-trades" type of internal medicine, are in smaller markets with smaller hospitals w/ an active ICU.
 
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correct me if I'm wrong, but a hospitalist is NOT a critical care doc. From what little I've seen a hospitalist covers the non-ICU areas and an intensivist is restricted to the ICU. Maybe I'll find out in a few weeks - I'm shadowing in the ICU with my research advisor.
 
A hospitalist is not a critical care doctor unless he has obtained training and accreditation for it, however most IM training programs encorporate about 6 months of ICU training, and just through the breadth and depth of medical training are optimally suited to advanced training in the ICU. Depending on the hospital, intensivist physicians may not always be available and the ICU duties may swing to the hospitalist du jour. An open ICU model is described as one where the floor physician continues primary control and care of his patient in the ICU, often times obtaining the service of a staff intensivist for complex cases or vent management. A closed ICU, which has been shown to be superior in terms of cost savings and overall care, involves handing over the care of one's patient to the covering intensivist and his team/colleagues. This is probably the the model which you have been observing.
Right now, Pulm/CCM docs are in demand, esp. because they can staff closed ICUs. This is ultimately a cost cutting move as ICU care is expensive and the use of the intensivist often streamlines use of resources. However, don't be surprised if you do see hospitalists doing ICU care...there just aren't enough CCM trained docs out there right now.
 
anybody know how much CC docs (or pulm/CCM) make? I'm guessing it's more than a gereral IM doc since ICUs are supposedly stressful. And I'm guessing it depends on the mix of outpatient/pulm/ICU duties.
 
Yup, there are currently many hospitalists covering for ICU's. Remember that ICU's need 24 hr physician coverage, so many states only require the ICU to be covered by a critical care trained doc for 8 hrs per day because there simply aren't enough ICU docs around. Also remember that a community ICU is a very different environment then an academic ICU, many patients who are put into community ICU's would be managed on the general floors of academic centers. Therefore, it's not unreasonable for hospitalists to be covering these patients. Reimburesement is higher for care of patients in the ICU which translates into higher reimbursement for CC physicians. Avg salaries are 180-220K depending on the number of months you work and the number of patients you take care of (size of ICU), etc. Pulmonary docs also make some money doing those bronchs in the ICU too, which supplements their income over that of a hospitalists.
 
can anybody describe the number of procedures a critical care doc (+/- pulm) does compared to a gereral internist? Are the procedures of those typically seen in the ED?

and can anybody comment on the resuscitation skills of critcal care docs and the need for these skills (real or perceived)? From what I've heard it's the anesthesiologists who claim to be the next best thing since Jesus (and ER docs according to Michale Crighton), although they surely aren't the only ones running codes. Is resuscitation a major part of critical care medicine?

As you can probably tell, I'm very interested in CC for a variety of reasons but I'm a clueless MS1.

Thanks!
Adcadet
 
Resuscitation and running codes is a pretty big part of CC medicine. Actually, the MICU team at my school is supposed to be one of the primary responders to every code blue in the hospital and my understanding is that once they arrive, they take over. They do a lot of procedures besides bronching patients in the MICU, a lot of patients needs things like catheters and lines placed along with lumbar punctures. Anyways, my MICU rotation isn't until later this year, so I can't answer all of your ICU questions, but my understanding is that doing an anesthesia rotation is part of just about every CC fellowship so they get a good amount of practice intubating. I think that anesthesiologists on a whole are still probably the best at getting it though, since they get practice all day every day when they work in the OR.
 
Originally posted by Adcadet
can anybody describe the number of procedures a critical care doc (+/- pulm) does compared to a gereral internist? Are the procedures of those typically seen in the ED?

and can anybody comment on the resuscitation skills of critcal care docs and the need for these skills (real or perceived)? From what I've heard it's the anesthesiologists who claim to be the next best thing since Jesus (and ER docs according to Michale Crighton), although they surely aren't the only ones running codes. Is resuscitation a major part of critical care medicine?

Like Kalel was saying, CCM docs get plenty of practice tubing people. I?d put on them on about the same level as EM guys, but a notch below the gas passers. CCM docs definitely get to do lots of cool procedures, though. At my institution, in addition to doing all of the normal stuff like lines, bronchs, ET tubes, thoracentesis, and LP?s, they also do perc-trachs and put in chest tubes. Haven?t seen them do a sternotomy yet a la ER, but other than that, they do as many procedures as any non-surgical specialty. As far as codes go, the ICU team runs the codes at my place with anesthesia there just to put the tube in. Half the time we?ve already got it in by the time they show up.
 
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