Discrimination against Anesthesia CCM docs

[spacegun]

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”?

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[Vermicious Knid]

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)

 

[deleted547339]

Any place with an IM residency will need IM-trained CC MDs to supervise the residents.

We understand and trust the process we went through.

That’s not true. Stop saying this.

 

[DrGasPasser]

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.

Critical Care Fellowship Program

The Critical Care Fellowship program is a one or two-year program offering a strong core of multidisciplinary critical care training.

school.wakehealth.edu

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.

 

[deleted697535]

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

 

[Splenda88]

The d***ck measuring contest continues.

 

[gulmohr]

The d***ck measuring contest continues.

I don't understand why there are 3 asterisks.

 

[psychbender]

I don't understand why there are 3 asterisks.

Obviously, his is longer.

 

[jdh71]

The d***ck measuring contest continues.

Seriously

 

[Nikj]

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]

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]

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.

 

[DrGasPasser]

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.

 

[deleted547339]

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.

Critical Care Fellowship Program

The Critical Care Fellowship program is a one or two-year program offering a strong core of multidisciplinary critical care training.

school.wakehealth.edu

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.

 

[deleted547339]

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.

 

[deleted171991]

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.

 

[CCM-MD]

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.

 

[deleted171991]

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 *****s 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 while the patient had CHF, and all he needed was diuresis (he had been brought on by the surgeon before I came on service). It took me one look to diagnose and fix what he had been meditating about for 2 days.

 

[CCM-MD]

It’s not him. It’s the *****s 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.

 

[DrGasPasser]

It’s not him. It’s the *****s 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.”

 

[jdh71]

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.

 

[Hamhock]

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

 

[deleted171991]

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.

 

[DrGasPasser]

Just to clarify and for honesty (based on your responses in other forums): are you EM or anesthesia? CCM fellowship trained?

HH

EM trained originally (and practiced for a long time). Now doing anesthesia-CCM fellowship.

 

[DrGasPasser]

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.

 

[fakin' the funk]

To be honest, I don't think very highly of them (they don't know the breadth of medicine that occurs on hospital floors--bad DKA, CHF etc). And I don't blame them. I don't know how to manage a complex airway (I'm an internist). I suppose they could/should gain this knowledge during their critical care fellowships, maybe some do, but the vast majority I meet are really lacking (again, I don't blame them, their baseline training was not designed for long-term hospital management of complex medical issues---that's the realm of internal medicine and general surgery).

And for that reason, I think critical care should only be done by Internists and General Surgeons: these are the folks that really know the hospital well (and it is important to know the entire hospital and the resources it can provide, not just the ICU), and know how to take care of patients for a more prolonged course (3-5 days in a unit, not just 3-5 hours in an OR).

I'm not gonna dunk on you, though you deserve it, but yeah bud you're just wrong on this.

* "Anesthesia intensivist doesn't know how a hospital works"
* "Anesthesia intensivist can't manage DKA and CHF"
These are ignorant comments.

I could toss off some bad stereotypes like "IM docs don't know how to do resuscitation" but after seeing triple lumen CVCs and vasopressors used in massive variceal hemorrhage by IM docs maybe I should work on those stereotypes...

 

[fakin' the funk]

And judging by some of the reactions above, that bias (for more medicine and surgical trained CC) does indeed exist and has been felt by others. The OP encountered it. At heart, I think it is a stupid bias, any physician well trained in CC should be allowed to do it, and I'd much prefer a EM- Anes- whatever have you- CC physician than a mid-level.

What if the bias exists because of people with misguided opinions on anesthesia intensivists like you?

 

[jdh71]

I’m so glad this thread got bumped

 

[Food]

well this is a depressing thread. I'm EM, worked for 2 years and now in year 1 of my 2 year fellowship at an anesthesia-CCM program. What are my job prospects like? haha. I hate the idea of going back for an additional 2 year ABIM-fellowship. A lot of EM-CCM programs offer spots to EM folks with either ABIM or ABA pathways but their fellowships are entirely the same (e.g. Wash U/Barnes Jewish - I interviewed there and think very highly of that program).

I find it typical of healthcare in America that on one hand, you have doctors in one specialty denigrating doctors in another, only to find that APPs are filling the gap, and slowly expanding their practice to the point where I'm really not sure what the point of an intensivist is. To supervise APPs who are doing the actual critical care? What's going to stop them from having independent practice in the ICU?

In my brief time working in the community, I was shocked by how little night intensivist (and sometimes day) coverage there is. Our hospitalists would admit the bread and butter MICU patients that I grew up seeing in the ED (bad DKA, septic shock, status epilepticus, COPD/asthma etc) and I would have to go upstairs to either intubate them, do their central lines etc since very few of the hospitalists were credentialed for this stuff. There is a huge need for intensivists and the sooner that medical directors pull their heads out of their assess and start hiring good doctors rather than those with the background from the specialty that is supposedly better at one thing or another, patients will do better.

In a tertiary care or larger community hospital - I wouldn't expect to be a core faculty or staff for a busy MICU. I would expect to be able to do night or weekend coverage though. Same with various specialties cross covering others. How is it better to hire a fresh PA-C to cover an entire service at night? It's funny because as an EM guy I can sort of see everyone's weaknesses and strengths. Not a single one of these specialties is 100% qualified for every critically ill patient that gets admitted to the unit. I see IM docs do stupid **** all day long. I see anesthesiologists in the ICU do funky things sometimes, same with surgery. There is no shortage of stupid things done in the ED by my fellow EM docs. The point of medicine should be to move beyond the high school era name calling and clique formation and actually support each other to provide better critical care. Isn't medicine supposed to be life long learning and all that crap?

(also if any of you know of any job prospects...)

 

[Dr.CCM]

well this is a depressing thread. I'm EM, worked for 2 years and now in year 1 of my 2 year fellowship at an anesthesia-CCM program. What are my job prospects like? haha. I hate the idea of going back for an additional 2 year ABIM-fellowship. A lot of EM-CCM programs offer spots to EM folks with either ABIM or ABA pathways but their fellowships are entirely the same (e.g. Wash U/Barnes Jewish - I interviewed there and think very highly of that program).

I find it typical of healthcare in America that on one hand, you have doctors in one specialty denigrating doctors in another, only to find that APPs are filling the gap, and slowly expanding their practice to the point where I'm really not sure what the point of an intensivist is. To supervise APPs who are doing the actual critical care? What's going to stop them from having independent practice in the ICU?

In my brief time working in the community, I was shocked by how little night intensivist (and sometimes day) coverage there is. Our hospitalists would admit the bread and butter MICU patients that I grew up seeing in the ED (bad DKA, septic shock, status epilepticus, COPD/asthma etc) and I would have to go upstairs to either intubate them, do their central lines etc since very few of the hospitalists were credentialed for this stuff. There is a huge need for intensivists and the sooner that medical directors pull their heads out of their assess and start hiring good doctors rather than those with the background from the specialty that is supposedly better at one thing or another, patients will do better.

In a tertiary care or larger community hospital - I wouldn't expect to be a core faculty or staff for a busy MICU. I would expect to be able to do night or weekend coverage though. Same with various specialties cross covering others. How is it better to hire a fresh PA-C to cover an entire service at night? It's funny because as an EM guy I can sort of see everyone's weaknesses and strengths. Not a single one of these specialties is 100% qualified for every critically ill patient that gets admitted to the unit. I see IM docs do stupid **** all day long. I see anesthesiologists in the ICU do funky things sometimes, same with surgery. There is no shortage of stupid things done in the ED by my fellow EM docs. The point of medicine should be to move beyond the high school era name calling and clique formation and actually support each other to provide better critical care. Isn't medicine supposed to be life long learning and all that crap?

(also if any of you know of any job prospects...)

You’ll be fine in the community especially coming from EM. Academics can’t speak to though.

 

[chocomorsel]

well this is a depressing thread. I'm EM, worked for 2 years and now in year 1 of my 2 year fellowship at an anesthesia-CCM program. What are my job prospects like? haha. I hate the idea of going back for an additional 2 year ABIM-fellowship. A lot of EM-CCM programs offer spots to EM folks with either ABIM or ABA pathways but their fellowships are entirely the same (e.g. Wash U/Barnes Jewish - I interviewed there and think very highly of that program).

I find it typical of healthcare in America that on one hand, you have doctors in one specialty denigrating doctors in another, only to find that APPs are filling the gap, and slowly expanding their practice to the point where I'm really not sure what the point of an intensivist is. To supervise APPs who are doing the actual critical care? What's going to stop them from having independent practice in the ICU?

In my brief time working in the community, I was shocked by how little night intensivist (and sometimes day) coverage there is. Our hospitalists would admit the bread and butter MICU patients that I grew up seeing in the ED (bad DKA, septic shock, status epilepticus, COPD/asthma etc) and I would have to go upstairs to either intubate them, do their central lines etc since very few of the hospitalists were credentialed for this stuff. There is a huge need for intensivists and the sooner that medical directors pull their heads out of their assess and start hiring good doctors rather than those with the background from the specialty that is supposedly better at one thing or another, patients will do better.

In a tertiary care or larger community hospital - I wouldn't expect to be a core faculty or staff for a busy MICU. I would expect to be able to do night or weekend coverage though. Same with various specialties cross covering others. How is it better to hire a fresh PA-C to cover an entire service at night? It's funny because as an EM guy I can sort of see everyone's weaknesses and strengths. Not a single one of these specialties is 100% qualified for every critically ill patient that gets admitted to the unit. I see IM docs do stupid **** all day long. I see anesthesiologists in the ICU do funky things sometimes, same with surgery. There is no shortage of stupid things done in the ED by my fellow EM docs. The point of medicine should be to move beyond the high school era name calling and clique formation and actually support each other to provide better critical care. Isn't medicine supposed to be life long learning and all that crap?

(also if any of you know of any job prospects...)

You can actually expect to be a core staff member at a community hospital MICU. Just won’t be easy.
If the contract is held by Pulmonologist they typically want to hire other pulmonologists so that they can also do floor pulmonary consults. And smaller hospitals want the pulmonologists for the same reason. To cover outpatient pulmonary as well as inpatient pulmonary. And of course the ICU.

Otherwise even some pulmonologists are bringing on straight CCM docs, to stay in the unit. I have to say that my experience on the interview trail is that IM people get preferential treatment.
I have been brought on by a CCM team that fortunately does not discriminate based on core certification.

However, I did not get offered other jobs because I believe I am an anesthesiologist.

 

[vector2]

You can actually expect to be a core staff member at a community hospital MICU. Just won’t be easy.
If the contract is held by Pulmonologist they typically want to hire other pulmonologists so that they can also do floor pulmonary consults. And smaller hospitals want the pulmonologists for the same reason. To cover outpatient pulmonary as well as inpatient pulmonary. And of course the ICU.

Otherwise even some pulmonologists are bringing on straight CCM docs, to stay in the unit. I have to say that my experience on the interview trail is that IM people get preferential treatment.
I have been brought on by a CCM team that fortunately does not discriminate based on core certification.

However, I did not get offered other jobs because I believe I am an anesthesiologist.

What kinda CCM job did you end up taking?

 

[chocomorsel]

Just regular mixed medical/Surgical but it’s multiple hospitals.

 

[Katheudontas parateroumen]

Just regular mixed medical/Surgical but it’s multiple hospitals.

Academic or private? Do you feel like you got a fair deal?

 

[chocomorsel]

Academic or private? Do you feel like you got a fair deal?

Private. I absolutely hate academics and do not have the personality to put up with the egotistical, rude personalities often found there. Nor the politics.
Yes I think I got a fair deal. It will be long 12 hour days, 13-15 days a month. We shall see how I adjust.
No 24 hour call which I absolutely hate, hate, hate. No crazy CRNAs some w bad attitudes. No grumpy surgeons rushing me. There will be mid levels though, in some settings so we shall see.

 

[deleted547339]

well this is a depressing thread. I'm EM, worked for 2 years and now in year 1 of my 2 year fellowship at an anesthesia-CCM program. What are my job prospects like? haha. I hate the idea of going back for an additional 2 year ABIM-fellowship. A lot of EM-CCM programs offer spots to EM folks with either ABIM or ABA pathways but their fellowships are entirely the same (e.g. Wash U/Barnes Jewish - I interviewed there and think very highly of that program).

I find it typical of healthcare in America that on one hand, you have doctors in one specialty denigrating doctors in another, only to find that APPs are filling the gap, and slowly expanding their practice to the point where I'm really not sure what the point of an intensivist is. To supervise APPs who are doing the actual critical care? What's going to stop them from having independent practice in the ICU?

In my brief time working in the community, I was shocked by how little night intensivist (and sometimes day) coverage there is. Our hospitalists would admit the bread and butter MICU patients that I grew up seeing in the ED (bad DKA, septic shock, status epilepticus, COPD/asthma etc) and I would have to go upstairs to either intubate them, do their central lines etc since very few of the hospitalists were credentialed for this stuff. There is a huge need for intensivists and the sooner that medical directors pull their heads out of their assess and start hiring good doctors rather than those with the background from the specialty that is supposedly better at one thing or another, patients will do better.

In a tertiary care or larger community hospital - I wouldn't expect to be a core faculty or staff for a busy MICU. I would expect to be able to do night or weekend coverage though. Same with various specialties cross covering others. How is it better to hire a fresh PA-C to cover an entire service at night? It's funny because as an EM guy I can sort of see everyone's weaknesses and strengths. Not a single one of these specialties is 100% qualified for every critically ill patient that gets admitted to the unit. I see IM docs do stupid **** all day long. I see anesthesiologists in the ICU do funky things sometimes, same with surgery. There is no shortage of stupid things done in the ED by my fellow EM docs. The point of medicine should be to move beyond the high school era name calling and clique formation and actually support each other to provide better critical care. Isn't medicine supposed to be life long learning and all that crap?

(also if any of you know of any job prospects...)

You’ll be fine. Don’t let it get to you. I did EM followed by CCM and am now core faculty at an academic Micu.

 

[Dam272]

Private. I absolutely hate academics and do not have the personality to put up with the egotistical, rude personalities often found there. Nor the politics.
Yes I think I got a fair deal. It will be long 12 hour days, 13-15 days a month. We shall see how I adjust.
No 24 hour call which I absolutely hate, hate, hate. No crazy CRNAs some w bad attitudes. No grumpy surgeons rushing me. There will be mid levels though, in some settings so we shall see.

Nice. Hopefully I get a gig like that after I graduate

 

[chocomorsel]

You’ll be fine. Don’t let it get to you. I did EM followed by CCM and am now core faculty at an academic Micu.

What dept were you under in fellowship? Anesthesia or Medicine?

 

[deleted547339]

What dept were you under in fellowship? Anesthesia or Medicine?

It was medicine, but my current employer never really asked, had never had an EM/CCM guy before and I’m not sure they even knew that you could go the other way.

 

[Hamhock]

What dept were you under in fellowship? Anesthesia or Medicine?

It was medicine, but my current employer never really asked, had never had an EM/CCM guy before and I’m not sure they even knew that you could go the other way.

Opinion and experience makes me think that an IM-based fellowship is important for future employers.

Additionally, I will say (less confidently), that there is a difference in training between the ABIM-based multi-disciplinary CCM programs and even the ABIM-based non-multi-disciplinary programs; never mind the anesthesiology-based CCM programs. I don't think this is too controversial. I sense anesthesiology-based CCM program focus on SICU patients.

Even though I think that anesthesiology-CCM docs can treat all MICU patients competently; I also see the IM-CCM director's perspective: In general, anesthesiology-CCM docs are trained differently and not for MICU patients.

...unless the anesthesilogist tained in a truly multi-disciplinary CCM program (rare).

Let us all eventually acknowledge the craziness should stop! We must work towards CCM training that is indeed multi-disciplinary. Grads from surgery, medicine, EM, and anesthesiology (?others) should be exposed and benefit from the same training (probably two years) and take the same boards.

HH

 

[psychbender]

I have a rather unpopular opinion that critical care should be a residency in it's own right, with rotations spent on the wards (medical and surgical), in the OR (anesthesia), ED, and with various medical and surgical subspecialties in addition to various units over a period of about five years. That would make for truly integrated and multidisciplinary training, but would restrict grads to just a single practice type, so there'd be no bailout in the event of burnout.

Failing that, a single body overseeing CCM fellowships (open to a wife range of specialities) that mandates training in a variety of units over a period of two years would accomplish most of the same objectives.

Sent from my SM-G930V using SDN mobile

 

[jdh71]

I don’t see any actual huge problems with critical care as a fellowship program through various different pathways.

this is all navel gazing from where I’m sitting

 

[Steege305]

I don’t see any actual huge problems with critical care as a fellowship program through various different pathways.

this is all navel gazing from where I’m sitting

Truth

 

[Hamhock]

I don’t see any actual huge problems with critical care as a fellowship program through various different pathways.

Isn't this entire thread an example of a huge problem with the currently fragmented critical care training in the US?

HH

 

[jdh71]

Isn't this entire thread an example of a huge problem with the currently fragmented critical care training in the US?

HH

this thread may speak to some bias but not any problems in training

 

[stillers]

Hey y'all,
Just want to know for any of y'all regular posters who have a part to do with hiring. I have sent out lots of feeler emails for jobs that are advertised for CCM only, not Pulmonary consult or outpatient consults. Only of course to get back "Sorry, we are looking for Pulmonary/CCM or people with an IM background".

I just want to get an idea of what you guys/gals think about anesthesiologist in the unit. Clearly many of you think we aren't up to par and/or want to hold on to your territory or there's something else. Ignorance of hospitals and recruiter I believe plays a role. Are there some disease processes/pathology that I am not as familiar with as an IM person? Yes, like some of the immunology/oncology diseases that immediately come to mind. But I can read and familiarize myself with stuff since I didn't get exposed to as much of that as the MICU intensivists.

I guess I am butt hurt for being discriminated against. Our anesthesia department ran the community hospital ICU with the usual bread and butter community admissions which is what is prevalent in the community and the type of jobs I have applied to. It also ran the Neuro ICU. But yet I am told by some of these hospitals that they are looking for someone with IM background AND a Neuro-CCM fellowship. Do these hospitals have any idea how many people, outside of neurology are actually doing a NeuroCCM fellowship?

I have had a few job offers but have gotten more rejections than offers simply because I don't have an IM background. It's quite annoying.

Would love to hear some HONEST responses please. As in, if you've had bad experiences with anesthesia CCM docs, or whatever.

I work in a large academic hospital. MICU staffed exclusively by IM (mostly Pulm-CCM) docs. Other ICUs staffed w/ mix of EM-CCM, anesthesia-CCM, surgery-CCM. I've learned a lot from the anesthesia docs and we all get along well. However, no way our MICU would hire anesthesia or EM-CCM trained physicians, and SICU/CTICU will not hire IM trained docs (not that they would want to work there anyway). I think this practice extends to some but not all community hospitals, but I know many around here that would probably hire you.

 

[CCM-MD]

I don’t see any actual huge problems with critical care as a fellowship program through various different pathways.

this is all navel gazing from where I’m sitting

Agree. Changing training and certification alone will not change the culture. Maybe different pathways are a benefit in some ways.

Canada has a single certification for CCM and having personally considered jobs there a couple of years ago, I can tell you that one particular academic institution preferentially recruits anesthesiology trained for the CVICU, and a couple of community hospitals specifically advertised wanting IM trained.

 

[DO class of 2018]

That’s not true. Stop saying this.

I thought this was the case also. Good to know it's not true, do you know where this rumor came from? I looked at the EMRA critical care pages and didn't see anything about it. But I have a vague recollection that I saw it somewhere that matters...

 

[deleted547339]

I thought this was the case also. Good to know it's not true, do you know where this rumor came from? I looked at the EMRA critical care pages and didn't see anything about it. But I have a vague recollection that I saw it somewhere that matters...

There is a policy that core faculty at a medicine residency must be internists. This has been wrongly interpreted. There is also a rule that the faculty in a ccm fellowship program must be boarded in ABIM-CCM or something substantially equivalent. I forget exactly what work they use, but it’s basically that as the text. If ABEM/ABIM CCM isn’t equivalent, I don’t know what it since it’s literally the same exact text. I think it follows that ABEM/ABA CCM is substantially equivalent since a couple places take fellows through the same curriculum but let them sit for different boards.

 

[icuanesthesiology]

I am an anesthesia trained intensivist. I cover a community hospital MICU. Like most community MICUs we are a mixed bag of SICU, CCU, CT surgical ICU, neuro, and of course medical. We have a VV-ECMO program and we are a fairly large and busy 55 bed ICU. We usually see between 12 and 20 patients a day. The patients, like every other referral center MICU are damn sick.
Having practiced in this environment for over 5 years I did enjoy the post about medical problems including DKA and CHF...wtf. I had never seen them before I started this job!!!! Come on you all...These are bread and butter medical problems for ALL medical specialities, from internal medicine to general surgery to EM. What’s amazing about all of these backgrounds is how they can illustrate the disease process in different ways depending on the context. A non critically ill CHF patient admitted for an acute exacerbation is treated differently than a person with an EF of 15% who is undergoing an ELAP for perforated bowel and is in new onset Afb and septic shock and needs to be operated on emergently. Which gives you the better background for a career in CCM? I propose neither. And it’s not like it is a zero sum game either. All of us, no matter what the specialty, spend some time during residency managing both types of patients. Do people actually believe an anesthesiologist has never covered patients on the floor? All training programs in some kind of adult field see the same medical problems...obesity, COPD, DM, CHF, CKD, afb, CAD, etc. All lead to a place where anyone can do a balanced fellowship in CCM and come out the similarly in the end. It’s the fellow who determines the training not the fellowship which determines the training. Is that fellow going to read a real textbook or are they going to learn from UpToDate or just do some practice questions. Is that fellow going to identify their clinical weaknesses and then seek out those patients in order to fill in the gaps? Is that fellow going to have a clock in clock out mentality?
Do I have certain weaknesses in my practice of medicine? Absolutely!! News flash...we all do. The complexity of the human body and it’s disease processes humble me on a day to day basis. What separates the good docs from the bad docs are not residency background, it’s those skills we are supposed to learn before medical school...grit, determination, hard work, politeness, working well with others, curiosity, humbleness, etc. Those are the skills which will make for successful training and practice. I acknowledged and continue to acknowledge my weaknesses as a resident, a fellow, and as a 5+ year practicing physician. I regularly read and continue to hone my skills.
When family members of nurses and physicians get admitted to our ICU I am requested more often than not. And it’s not because I am an anesthesiologist, it’s not because I am the smartest or the “best”. It’s because I care enough about my patients to sit down with them and communicate. It’s because I take time to listen to my colleagues about new ideas. It’s because I Acknowledge the human body has me beat and as such I have backup plans A through Z ready to go for when my initial plan doesn’t work out. It’s because I don’t want to become a dinosaur so I keep reading.
Someone up there said it right. It’s not the CCM docs from other specialties invading the kitchen. It’s NPs who get an online doctorate, form a medical society and then convince politicians that they are doctors too! That’s the real threat to our patients. We have NP’s in our unit who couldn’t even read the ICU book handbook. Not even Marino’s ICU book...the book my ICU attending a made me burn because they didn’t think worthy of a resident or fellow. No our NPs can’t even read the handbook of that handbook. And they are legally allowed to practice without physician oversight in our state...in any specialty. How ‘bout them apples.