Difference between surgical vs. medical intensivist

[cabernet]

Currently, I am doing a surgical ICU rotation. I work with very intelligent and capable surgical attendings but I can't help but feel that there is quite a bit of medical knowledge lacking in them.

To compare a SICU attending vs. a medical critical care attending: to become board certified SICU attending, you complete a one-year fellowship in Trauma/CC. However, for most of that year, many programs train the fellows moreso in trauma than critical care, so they aren't really doing one FULL year of critical care. So a pulmonary/CC fellow has THREE years of training. Would that not make a medical intensivist WAY more qualified in critical care than a surgical intensivist?

I think surgeons are, in general, more competent to treat a sick patient but how in today's medicine, most surgical patients are over 80 years old with multiple medical problems, yet my attendings have trouble reading EKG's, knowing which chronic anti-hypertensives to use, how to treat concurrent heart/renal failure patients, complex medical diseases, etc. We know how to resusticate/pound fluids/when to take patients to the OR, but outside of that, I feel that my surgical attendings are "winging" it when it comes to managing medical patients. Am I missing something?

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[Smurfette]

Wrong. Surgery critical care is a 1 year fellowship, which includes, I believe, 2 months of trauma ICU rotation. Where I am, the critical care fellow on trauma does not operate and just does patient mgmt (keep in mind that anesthesiologists also can do critical care fellowships, and surg crit care programs also can accept--though not commonly--people from OBGyn and neurosurg).
Trauma surgery is also a 1 year fellowship, but is separate from critical care fellowships. Trauma/Critical care combo fellowships are 2 years (now evolving into 2 year 'acute care fellowships').
I can't speak for your attendings...most of ours could quote critical care literature ad nauseum.

Keep in mind that surgery residents do WAY more critical care time in residency that medical residency (I personally did about 30 weeks of dedicated ICU rotations in my second year alone, and always have a few ICU patients on whatever my current service is that I am managing as well...as well as trauma and transplant rotations where most patients are ICU patients). Pulm/crit care fellows also do ward/consult rotations and outpatient clinics, so they are not in an ICU full time during their 3 year fellowship. It's just a difference in how residencies are set up...surgery critical care is shorter because residents have more of a background to begin with, and because they aren't also doing pulmonology on top of critical care. Also, complicated surgical patients and complicated medical patients are different...medical intensivists aren't as comfortable managing tubes and drains and giving huge amounts of fluids for abdominal sepsis as the SICU guys are...and the SICU guys aren't as comfortable managing the COPD-ers and pulm HTN patients.

 

[Winged Scapula]

The OP is correct.

There are 1 year Trauma/CC fellowships (my ex did one at Baltimore Shock Trauma) in which you spend 9 months doing Trauma (although you do CC during your trauma rotations as well) and 3 months on CC only. There is a 2nd year option which is mostly for research, but the single year makes you eligible to sit for the SCC boards. There are also 1 year SCC fellowships with the option for a second year; not all SCC fellowships are 2 years in length.

See: http://www.trauma.org/archive/resources/fellowships/fellowships.html#TC

However, I agree with Smurfette, that the length of time a general surgery resident spends in the SICU vastly exceeds what the IM residents spend in the MICU; many do not feel the need to complete CC fellowships to be adequately trained.

As for knowing what anti-hypertensives are used for chronic management, is that really a focus of ACUTE care? Chronic conditions and complex medical diseases are not the focus of critical care, so surgeons would not be expected to know how to manage those, any more than a pulmonologist would know how to manage chronic surgical diseases. If the OP's attendings are unable to read EKGs, I suspect that is an anomaly as most general surgery residents and certainly the attendings would be able to.

The focus is different and should not be interpreted as any less or more valuable.

 

[SocialistMD]

To compare a SICU attending vs. a medical critical care attending: to become board certified SICU attending, you complete a one-year fellowship in Trauma/CC. However, for most of that year, many programs train the fellows moreso in trauma than critical care, so they aren't really doing one FULL year of critical care. So a pulmonary/CC fellow has THREE years of training. Would that not make a medical intensivist WAY more qualified in critical care than a surgical intensivist?

As Smurfette said, you aren't seeing the full picture, and fellowship experience and rotations vary by location. The surgical ICU fellows here do nothing but work in the ICU (either surgical or cardiothoracic, with potential elecitves in the MICU or PICU) for their year. They do not operate at all. Pulmonary/CC fellows spend "3" years in fellowship, but 18 months of that are doing research with no patient care and about half of the remaining 18 months are spent doing pulmonary rotations (depending on program).

The second thing you need to understand is that medical intensive care patients are very different in physiology than are surgical patients, hence the two different units. Surgical patients have different fluid requirements and changes in their vital signs can mean different things entirely. Surgeons tend to be more aggressive in terms of vent management/weaning (based on my experience) than medical intensivists because we don't intubate chronic COPDers because we don't electively operate on those we don't think we will be able to extubate.

yet my attendings have trouble reading EKG's, knowing which chronic anti-hypertensives to use, how to treat concurrent heart/renal failure patients, complex medical diseases, etc.

First, I think your experience is the exception to the rule. As noted before, most surgical intensivists take their intensivist role very seriously and know how to read all but the most complex EKGs (which is true for the medical intensivists I know, too) and know how to take care of the patient with multisystem organ failure, both acute and acute on chronic. Second, and getting back to my point about the MICU vs. SICU patients, patients in the SICU don't need tinkering with their home medications, so knowing which chronic meds to use is irrelevant.

 

[cabernet]

Surgeons tend to be more aggressive in terms of vent management/weaning (based on my experience) than medical intensivists because we don't intubate chronic COPDers because we don't electively operate on those we don't think we will be able to extubate.

That is just untrue. People who end up in the SICU tend to be emergent/semi-urgent patients. Therefore, SICU patients are just as random with their medical co-morbidities compared with the MICU patients.

Furthermore, you cannot differentiate between MICU and SICU patients. We get plenty of patients who were on the MICU service, obtain a problem that requires surgery, and end up in the SICU. Also, old patients are involved in MVCs, falls, etc. and end up in the Trauma ICU as well.

Anyways, COPD is NOT a contraindication to an operation. You can't say "sir, you have COPD so we can't remove your colon cancer"

 

[SocialistMD]

That is just untrue. People who end up in the SICU tend to be emergent/semi-urgent patients. Therefore, SICU patients are just as random with their medical co-morbidities compared with the MICU patients.

Allow me to clarify. We tend not to intubate bad COPDers because we tend not to electively operate on them. Yes, we do intubate patients for emergent surgeries that may otherwise not have been intubated. And, yes, medical comorbidities can be a contraindication to an operation and we can say "sir, you have very bad COPD and won't survive or won't come off the vent postop, so we want you to seriously consider what you want" and we can refuse to operate. It comes back to having better judgment and not being just a technician (discussed in threads previous).

Furthermore, you cannot differentiate between MICU and SICU patients. We get plenty of patients who were on the MICU service, obtain a problem that requires surgery, and end up in the SICU. Also, old patients are involved in MVCs, falls, etc. and end up in the Trauma ICU as well.

Actually, having worked in both, I can. Yes, there are patients who are in the MICU and end up in the SICU, but those patients constitute less than 5% of MICU patients and, thus, don't represent the majority of MICU patients. I never said our patients weren't sick, I simply said the physiology of the post-op patient is different from that of the standard MICU patient, and I'm not wrong. When the vented MICU patient with COPD comes over to the SICU with acalculous cholecystitis, (1) we didn't intubate them (making my statement true) and (2) their physiology is now different than it was when they just had an acute exacerbation of their chronic respiratory problem.

 

[SLUser11]

Allow me to clarify....

I wouldn't bother.....it's not like you'll change cabernet's opinion, regardless of how much experience and data you have. He/she created an account specifically to argue that medicine is better than surgery. It's too emotional of a topic for him/her to allow any rational discussion.

I remember a thread in the somewhat recent past where a GI fellow came in to the surgical forums to argue that surgeons shouldn't be doing scopes, and a huge pissing match ensued......I anticipate a similar outcome in this thread.


I do, however, agree with everything you guys have said. We have much more exposure to ICU care as residents, and we take care of a different patient population, so it's comparing apples to oranges as far as quality.



Just found the old GI vs. surgery threads:

GI vs. Surgery

Want to Operate, not sure on what

 

[cabernet]

He/she created an account specifically to argue that medicine is better than surgery. It's too emotional of a topic for him/her to allow any rational discussion.

No I am definitely not saying that medicine is better than surgery. Far from it!!! In fact, if I were to have a family member with an MI, CVA, COPDer, etc., at my hospital, I would send them to the SICU, even if they don't have any surgical issues. I think that the surgical service is way better at resuscitating and treating ANY patient. I am skewed in part because I am a surgical resident, but I have been consulted on far too many MICU patients left to die due to tachycardia/anuria/sepsis that was poorly treated. They spend TOO much time talking and not enough time doing anything.

However, I am also a perfectionist. I want to know more medicine than my medicine counterparts, especially in an ICU setting. So, if surgical attendings claim to be intensivist, then I feel that there's more to know than the resusitation phase. When do you start antibiotics? How do you work up a leukocytosis/fever? How do you treat the dysrhythmias? How do you work up acute renal failure properly? I'm sure that there are some amazing surgical intensivists out there, but by and large, I have only seen my attendings treat without the proper workup. I would like to move more away from the surgeon's addage of "never in doubt, sometimes right".

I am only stating these points because of what I've learned (or not learned) in six ICU months. As I have periodically reviewed how to workup certain disease process (via uptodate/harrison's/marino), there's way more to know/do than what I've been doing for my patients.

 

[SLUser11]

No I am definitely not saying that medicine is better than surgery. Far from it!!! In fact, if I were to have a family member with an MI, CVA, COPDer, etc., at my hospital, I would send them to the SICU, even if they don't have any surgical issues. I think that the surgical service is way better at resuscitating and treating ANY patient. I am skewed in part because I am a surgical resident, but I have been consulted on far too many MICU patients left to die due to tachycardia/anuria/sepsis that was poorly treated. They spend TOO much time talking and not enough time doing anything.

However, I am also a perfectionist. I want to know more medicine than my medicine counterparts, especially in an ICU setting. So, if surgical attendings claim to be intensivist, then I feel that there's more to know than the resusitation phase. When do you start antibiotics? How do you work up a leukocytosis/fever? How do you treat the dysrhythmias? How do you work up acute renal failure properly? I'm sure that there are some amazing surgical intensivists out there, but by and large, I have only seen my attendings treat without the proper workup. I would like to move more away from the surgeon's addage of "never in doubt, sometimes right".

I am only stating these points because of what I've learned (or not learned) in six ICU months. As I have periodically reviewed how to workup certain disease process (via uptodate/harrison's/marino), there's way more to know/do than what I've been doing for my patients.

This sounds like a specific problem with your intensivists rather than a problem with surgical critical care nationally.

In our SICUs, we practice evidence-based medicine, and we're current on the literature. We're compulsive about knowing everything about the patient, and we know how to get them past the resuscitation phase into the recovery phase. Most residents that I've interacted with from other programs have similar approaches.

What was it like at your medical school? Also, just out of curiosity, are you at a community program or academic program? What region of the country are you in?

 

[Winged Scapula]

Huh...I agree with SLUser.

Knowing how to manage arrythmias, when to start antibiotics, work up a fever or leukocytosis, etc. are all BASIC elements of critical care that I would expect your attendings and residents to know.

Is it possible that they just use clinical experience rather than EBM and just "do" rather than try and analyze before act, so it appears they don't know?

I find this pretty odd as well.

 

[SocialistMD]

Ditto the above; it sounds like a problem with your attendings rather than the way surgeons practice intensive care medicine at most hospitals.