spacegun

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I find this thread hilariously inaccurate, although that is probably because I am practicing in a country where intensivists are primarily from an anesthesia background (although those from medicine/EM background are increasing in numbers_
Most places in Europe have intensivists from an anesthesia background, and they are not practicing at a 'lower level' than those in the USA. Training structure and the ICU set up appears to be different too. In the UK for example there arent typically separate MICUs and SICUS (rather a combined medical/surgical ICU) so perhaps all intensive care trainees are necessarily exposed to a wide variety of medical AND surgical pathology. Training time is much longer as well in the UK (with at least a mandatory year in medicine if coming from a non internal medicine background) as intensive care is a 4-5 year fellowship after core training. Perhaps things are much different in the USA...
You’re comparing apples to oranges (US to UK/Europe) then faulting the apples for being “hilariously inaccurate”?

 

Vermicious Knid

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You’re comparing apples to oranges (US to UK/Europe) then faulting the apples for being “hilariously inaccurate”?

Fair enough..I guess what I found inaccurate was the idea that those from an anesthesia background are somehow worse off by default. Looking back I'm not sure anyone said that...lol
For reference, I am an IM resident applying to CCM this year (i.e. not even from an anesthesia background)
 
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That’s not true. Stop saying this.
I’m curious as to where this notion originated? I don’t doubt you as the 2-year CCM program at Wake Forest has been administered out of their Department of Anesthesia; is IM accredited; uses ERAS and proprietary applications instead of the SF Match, accepts IM and EM applicants; and has faculty with both EM, IM, and anesthesia backgrounds.


Thus, you are clearly correct as this program has had this rather unique structure for a while. So, it’s unlikely that they are just flying under the ABIM radar since they are pretty well regarded.

The other related rumor is that IM-accreted programs must have at least 75% of their slots occupied by internists. This also appears incorrect (or unenforced) as I’m aware of a program that has half of their spots filled by EM-trained fellows.

I ask because I’m in the anesthesia-CCM pipeline and never had to deal with those shenanigans. Thanks.
 

Newtwo

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You’re comparing apples to oranges (US to UK/Europe) then faulting the apples for being “hilariously inaccurate”?
There has been a quite strong assertion on this thread that anesthesia intensivists are sub standard compared to im based.

To put it bluntly that is ****ing ridiculous.
How is that apples and oranges? Side of the Atlantic is irrelevant really. There are im intensivists in every country. I just don't think they think like this


The sheer level of incompetence I've seen with tubes and needles going into the wrong place in the hands of im fellows in our unit is astounding.
Some one on here just said they did 30 tubes and think they're qualified to handle an airway. Another said at 300 that if they couldn't get it noone could. That's basically 8 months of anesthesia residency aka a baby.

Twice this calender year 2 diff im staff pushed 100 roc into a suspected tamponade. It went as you'd expect both times

We all make mistakes, I don't think our background speciality dictates this. I definitely don't think im are any better than us in the unit
 
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Nikj

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As a second year med student, after reading all these posts, wouldn't someone who intends on going CCM greatly benefit from going to a combined IM/Anesthesiology residency? Really leaves a lot of options open while getting great exposure to both sides.
 

jdh71

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There has been a quite strong assertion on this thread that anesthesia intensivists are sub standard compared to im based.

To put it bluntly that is ****ing ridiculous.
How is that apples and oranges? Side of the Atlantic is irrelevant really. There are im intensivists in every country. I just don't think they think like this


The sheer level of incompetence I've seen with tubes and needles going into the wrong place in the hands of im fellows in our unit is astounding.
Some one on here just said they did 30 tubes and think they're qualified to handle an airway. Another said at 300 that if they couldn't get it noone could. That's basically 8 months of anesthesia residency aka a baby.

Twice this calender year 2 diff im staff pushed 100 roc into a suspected tamponade. It went as you'd expect both times

We all make mistakes, I don't think our background speciality dictates this. I definitely don't think im are any better than us in the unit
Too many people conflate doing procedures to critical care - those two things are not the same thing. Procedures are something that you do in critical care but are not even close to being all or even most of critical care.

Critical care is getting a (usually) very sick patient from the point of presentation to stabilization to out of the unit (one way or the other). Everyone shows up to a training program with certain skill sets that are going to be better than others from different backgrounds. Fellowship is supposed to smooth much of this over and produce a competent physician who can then learn on their own whatever other important things they need to know as they work and their practice environment dictates and or requires.

We can also all list the nonsense we’ve seen non-our specialty colleagues do in certain nuanced situations where we had more knowledge or better instincts. It’s a meaningless anecdotes. Should I list the number of times I’ve had to clinch a niche diagnosis that none of my non-pulmonary colleagues picked up or figured out in bad hypoxic respiratory cases and these patients were turned around and saved with the appropriate medications or interventions?

This thread was about bias. And it currently exists in this country. I think most of us this that bias is unwarranted. Let’s now stop using this thread as an excuse to crap on other specialties or it will turn into a thread where we all just crap on each other.

It’s (ostensibly) a free country, a free internet, and a free web forum so you can do what you want.
 

jdh71

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As a second year med student, after reading all these posts, wouldn't someone who intends on going CCM greatly benefit from going to a combined IM/Anesthesiology residency? Really leaves a lot of options open while getting great exposure to both sides.
Would be a nice niche background residency to wander into a critical care fellowship but probably unnecessary overall. I’d only do it if you have significant interest in actually doing both.
 
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As a second year med student, after reading all these posts, wouldn't someone who intends on going CCM greatly benefit from going to a combined IM/Anesthesiology residency? Really leaves a lot of options open while getting great exposure to both sides.
The case for combined residency training prior to critical care fellowship was probably strongest for the EM/IM curriculum back before EM training alone had a pathway to board certification. That training still has merit, but the case for it is less pressing now that EM training can feed directly into medicine, surgical, neuro, and anesthesia CCM fellowships with Board eligibility.

While IM/anesthesia combined residency training would allow an applicant to apply to both medicine and anesthesia CCM fellowships, the fellowship durations and core content (MICU vs SICU vs CVICU) are different depending on the pathway. Yes, there are some true multidisciplinary fellowships out there, but the average anesthesia and IM fellowship are typically very different. Thus, it is very possible that an IM/anesthesia dual trained physician who opts for the shortest CCM pathway via a 1-year anesthesia fellowship will face the same discrimination (to the extent that it exists) since their fellowship training will focus on non-medical ICUs and result in anesthesia-CCM Board certification. Perhaps they could mitigate this to some degree by completing a 2-year IM-CCM fellowship, but we are now talking about 7 years of post-graduate training.

My personal opinion is that this discrimination is getting better but does exist and is multifactorial in its reasoning. In the community, most of the CC coverage is provided by Pulm/Crit groups who prefer to hire what is familiar such as partners who can cover pulm clinic. Carving out special schedules and pay is tedious unless the doc is going to provide some extra value such as nocturnist or weekend coverage. There is also a probably some element of a “rent control” phenomenon of protecting their salaries. In academics, the division has more to do with the trend toward further sub specializing care.

For the applicant, dual training has some real challenges in its practical application of dividing effort. This is especially true when it crosses departments. Serving dual masters who have their individual (and sometimes competing) agendas and requirements can be a PITA.
 

TimesNewRoman

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I’m curious as to where this notion originated? I don’t doubt you as the 2-year CCM program at Wake Forest has been administered out of their Department of Anesthesia; is IM accredited; uses ERAS and proprietary applications instead of the SF Match, accepts IM and EM applicants; and has faculty with both EM, IM, and anesthesia backgrounds.


Thus, you are clearly correct as this program has had this rather unique structure for a while. So, it’s unlikely that they are just flying under the ABIM radar since they are pretty well regarded.

The other related rumor is that IM-accreted programs must have at least 75% of their slots occupied by internists. This also appears incorrect (or unenforced) as I’m aware of a program that has half of their spots filled by EM-trained fellows.

I ask because I’m in the anesthesia-CCM pipeline and never had to deal with those shenanigans. Thanks.
The 75% rule is averaged over 5 years. I believe it’s still enforced.

There is (or was) a rule that “core faculty” had to be IM boarded. It says nothing about all faculty. It says that core faculty must have ABIM-CCM board eligibility/certification “or something deemed equivalent” by ABIM (or some permutation of that language). Since ABEM literally takes the same test, it’s obviously equivalent.
 

TimesNewRoman

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There has been a quite strong assertion on this thread that anesthesia intensivists are sub standard compared to im based.

To put it bluntly that is ****ing ridiculous.
How is that apples and oranges? Side of the Atlantic is irrelevant really. There are im intensivists in every country. I just don't think they think like this


The sheer level of incompetence I've seen with tubes and needles going into the wrong place in the hands of im fellows in our unit is astounding.
Some one on here just said they did 30 tubes and think they're qualified to handle an airway. Another said at 300 that if they couldn't get it noone could. That's basically 8 months of anesthesia residency aka a baby.

Twice this calender year 2 diff im staff pushed 100 roc into a suspected tamponade. It went as you'd expect both times

We all make mistakes, I don't think our background speciality dictates this. I definitely don't think im are any better than us in the unit
So I’m a baby - cool. Name calling, what a cool way to have a discussion.

I’ll make one point and leave this alone. There is a huge difference between deliberate practice and simply doing something. The concept of 10,000 hours is wrong. If it’s not, the CRNA who has been doing it 15 years is more qualified than the aba boarded attending who is fresh because they have more tubes.

What matters in acquiring a skill is not simply numbers, it’s focused practice, getting feedback, directed study, etc. I am confident with my ability to get an airway after doing a robust EM and interdisciplinary CCM fellowships. I’ve carefully learned the skill. The anesthesiologists I know in fellowship implicitly trusted me. Can be hard for you to understand because you don’t know me. But there is a difference, volume inaccurately practiced doesn’t help. And neither does name calling.
 

FFP

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As a second year med student, after reading all these posts, wouldn't someone who intends on going CCM greatly benefit from going to a combined IM/Anesthesiology residency? Really leaves a lot of options open while getting great exposure to both sides.
The patients would benefit. The person wouldn’t. Every extra year of training costs many hundreds of thousands in missed future income. Not worth it.
 
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There is a bias and as mentioned, it is primarily because there just aren’t many anesthesiologist-intensivists working in non-academic settings.

The bias is worsened by a few bad apples in an already limited sample... like one of my current partners who’s just a terrible doctor. This guy did an anesthesiology residency and critical care fellowship in his home country. He came to the US and repeated his residency in anesthesiology followed by another CCM fellowship. You would expect this guy to be a rockstar and he probably could have been if he actually tried.

He trained at a big name program and joined my 450 bed community hospital (42 icu beds) only because they were sponsoring his visa waiver. He has a “I’m too good to be here” kind of attitude and has had several complaints. He was actually supervising IM residents initially but that ended quickly because he was treating the residents poorly.

There are definitely noticeable differences in the care he provides. I took over a patient he was seeing, he had written “ARDS due to CHF exacerbation”... wtf?. When asked about it, he said he thought the patient had ARDS because the patient had a P/F less than 300. He does some other questionable stuff and definitely asks for some unusual consults that irritate some of the physicians.

I’m sure much of this is specific to this particular individual because I encountered some strong anesthesia intensivists in training. But in an already small sample size of community anesthesia intensivists, a few bad apples like this can really affect the perception. Like most, my current gig is pulmCC mostly with a few of us non-pulmonary IM intensivists. We also have a nephrology-CC guy. Highly unlikely that they will hire another anesthesia guy if they can help it.
 
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Wiseguy
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There is a bias and as mentioned, it is primarily because there just aren’t many anesthesiologist-intensivists working in non-academic settings.

The bias is worsened by a few bad apples in an already limited sample... like one of my current partners who’s just a terrible doctor. This guy did an anesthesiology residency and critical care fellowship in his home country. He came to the US and repeated his residency in anesthesiology followed by another CCM fellowship. You would expect this guy to be a rockstar and he probably could have been if he actually tried.

He trained at a big name program and joined my 450 bed community hospital (42 icu beds) only because they were sponsoring his visa waiver. He has a “I’m too good to be here” kind of attitude and has had several complaints. He was actually supervising IM residents initially but was kicked off the faculty because he was treating the residents poorly.

There are definitely noticeable differences in the care he provides. I took over a patient he was seeing, he had written “ARDS due to CHF exacerbation”... wtf?. When asked about it, he said he thought the patient had ARDS because the patient had a P/F less than 300. He does some other questionable stuff and definitely asks for some unusual consults that irritate some of the physicians.

I’m sure much of this is specific to this particular individual because I encountered some strong anesthesia intensivists in training. But in an already small sample size of community anesthesia intensivists, a few bad apples like this can really affect the perception. Like most, my current gig is pulmCC mostly with a few of us non-pulmonary IM intensivists. We also have a nephrology-CC guy. Highly unlikely that they will hire another anesthesia guy if they can help it.
It’s not him. It’s the morons who teach in some big academic surgical icus. One of my colleagues, with a big Ivy diploma on her, made the same mistake. I didn’t feel inclined to explain to her why she had no friggin’ idea what ARDS meant.

These cacademic surgical icus also produce the geniuses who fluid resuscitate based on base deficit.

On the other hand, I have met some internists who were totally off the track, including an Ivy pulmonologist who kept wondering about complicated pulmonary pathologies (he was the surgeon’s consultant, not mine) while I was diuresing liters off the patient and he was getting better and better every day. The pulmoologist kept writing in his notes “patient getting better for unknown reasons, continue observing (no steroids indicated)”, because he was so fixated on the lungs in a CHF patient. The patient went from 90% FiO2 to room air just with diuresis, and still he couldn’t see the link.
 
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It’s not him. It’s the morons who teach in some big academic surgical icus. One of my colleagues, with a big Ivy diploma on her, did the same mistake. I didn’t feel inclined to explain to her why she had no friggin’ idea what ARDS meant.

These cacademic surgical icus also produce the geniuses who resuscitate based on base deficit.

On the other hand, I have met some internists who were totally off the track, including an Ivy pulmonologist who kept wondering about complicated pulmonary pathologies (he was the surgeon’s consultant, not mine) while I was diuresing liters off the patient and he was getting better and better every day. The pulmoologist kept writing in his notes “patient getting better for unknown reasons, continue observing (no steroids indicated)”, because he was so fixated on the lungs in a CHF patient.
100% agree that stupidity is not specialty specific. :bang:
 
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It’s not him. It’s the morons who teach in some big academic surgical icus. One of my colleagues, with a big Ivy diploma on her, did the same mistake. I didn’t feel inclined to explain to her why she had no friggin’ idea what ARDS meant.

These cacademic surgical icus also produce the geniuses who fluid resuscitate based on base deficit.

On the other hand, I have met some internists who were totally off the track, including an Ivy pulmonologist who kept wondering about complicated pulmonary pathologies (he was the surgeon’s consultant, not mine) while I was diuresing liters off the patient and he was getting better and better every day. The pulmoologist kept writing in his notes “patient getting better for unknown reasons, continue observing (no steroids indicated)”, because he was so fixated on the lungs in a CHF patient. The patient went from 90% FiO2 to room air just with diuresis, and still he couldn’t see the link.
I’m not so sure it has anything to do with academic vs. community either. I think the real problem from the anesthesia side is that CCM fellowships are nowhere near as competitive as pain, peds, and cardiac. Far too many programs are not filling which means more questionable candidates will get training positions.

I was on the credentialing committee at a pretty big place. It’s not hard to spot problem docs. The signs and symptoms are there if people are willing to acknowledge them. The problems come when Chair’s are desperate to start up some niche sub-specialty or program directors need warm bodies and don’t want to wind up on the list of “Open Positions.”
 
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jdh71

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Often the “academics” are too filled with the physician scientists. These people are brilliant in their own ways but often just not as clinically adept especially in today’s complicated illnesses.

Most of the real training happens in the hands of the clinical instructors.
 

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I’m not so sure it has anything to do with academic vs. community either. I think the real problem from the anesthesia side is that CCM fellowships are nowhere near as competitive as pain, peds, and cardiac. Far too many programs are not filling which means more questionable candidates will get training positions.

I was on the credentialing committee at a pretty big place. It’s not hard to spot problem docs. The signs and symptoms are there if people are willing to acknowledge them. The problems come when Chair’s are desperate to start up some niche sub-specialty or program directors need warm bodies and don’t want to wind up on the list of “Open Positions.”
Just to clarify and for honesty (based on your responses in other forums): are you EM or anesthesia? CCM fellowship trained?

HH
 

FFP

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I’m not so sure it has anything to do with academic vs. community either. I think the real problem from the anesthesia side is that CCM fellowships are nowhere near as competitive as pain, peds, and cardiac. Far too many programs are not filling which means more questionable candidates will get training positions.

I was on the credentialing committee at a pretty big place. It’s not hard to spot problem docs. The signs and symptoms are there if people are willing to acknowledge them. The problems come when Chair’s are desperate to start up some niche sub-specialty or program directors need warm bodies and don’t want to wind up on the list of “Open Positions.”
I said academic because all surgical and anesthesia critical care programs I know about are academic. Sadly, the surgical world is full of knee-jerk people who know about as much physiology as the best of us have forgotten. The medical world is not that far behind either; some of the intensivists and big name program pulm fellows in my hospital are scary dumb.

The topic of this thread is sad because some of the best intensivists I have encountered had had multidisciplinary exposure and experience. Having anesthesiologists in the micu, especially in academic ones, would only make everybody better doctors and improve patient care. Multidisciplinary CCM education should be an ACGME requirement.

While I agree that some anesthesiologists go into critical care for other reasons than love for the specialty, e.g. visa issues (and that most programs are easy to get into, including mine), they are very easy to weed out during a proper interview. Just look at the CV and the timeline, and ask them about their favorite professional books, blogs, podcasts, or how they would approach various bread and butter cases. The passion, or the lack of it, should be obvious.

To me, not interviewing an anesthesiologist for a MICU position speaks volumes about the intellectual laziness and/or incompetence of that department chief. I am not sure if s/he’s not doing all anesthesiologist-intensivists a service; nothing more painful than working for a Dunning-Kruger type of boss.
 
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I said academic because all surgical and anesthesia critical care programs I know about are academic. Sadly, the surgical world is full of knee-jerk people who know about as much physiology as the best of us have forgotten. The medical world is not that far behind either; some of the intensivists and big name program pulm fellows in my hospital are scary dumb.

The topic of this thread is sad because some of the best intensivists I have encountered had had multidisciplinary exposure and experience. Having anesthesiologists in the micu, especially in academic ones, would only make everybody better doctors and improve patient care. Multidisciplinary CCM education should be an ACGME requirement.

While I agree that some anesthesiologists go into critical care for other reasons than love for the specialty, e.g. visa issues (and that most programs are easy to get into, including mine), they are very easy to weed out during a proper interview. Just look at the CV and the timeline, and ask them about their favorite professional books, blogs, podcasts, or how they would approach various bread and butter cases. The passion, or the lack of it, should be obvious.

To me, not interviewing an anesthesiologist for a MICU position speaks volumes about the intellectual laziness and/or incompetence of that department chief. I am not sure if s/he’s not doing all anesthesiologist-intensivists a service; nothing more painful than working for a Dunning-Kruger type of boss.
My last EM job was at an academic healthcare system that was trying to survive in today’s healthcare landscape by scooping up smaller, community hospitals. This gave the academic EM faculty an opportunity to pull a few shifts at a community hospital and I took full advantage. I think (hope) that it kept me grounded, procedurally sound, and focused on fundamentals. I think their anesthesia-ICU group was attempting the same thing first with telemedicine and a plan to expand to community ICU consults.

While I’m a long way off from looking for my first CCM job, I really hope this “side effect” of healthcare consolidation catches on in systems with an academic anesthesia-CCM core. It might be a great way to solidify one’s practice habits and independence while still maintaining academic ties.
 
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