Discrimination against Anesthesia CCM docs

[Colorado outliers]

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.

Probably a coincidence, but wasn't that crazy ICU doc in Columbus who was giving massive Fentanyl doses anesthesia trained? Just wondering if that is scaring off some community hospitals.
Personally I haven't had any bad experiences w/ anesthesia-CCM docs, although at my hospital they work primarily in the cardiothoracic ICU and most are cardiac anesthesia trained also. None of them round in the MICU (and I'm pretty sure none of them want to).

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[RemyMcswain]

Probably a coincidence, but wasn't that crazy ICU doc in Columbus who was giving massive Fentanyl doses anesthesia trained? Just wondering if that is scaring off some community hospitals.
Personally I haven't had any bad experiences w/ anesthesia-CCM docs, although at my hospital they work primarily in the cardiothoracic ICU and most are cardiac anesthesia trained also. None of them round in the MICU (and I'm pretty sure none of them want to).

Friend, there are sociopaths in every field of medicine. This has nothing to do with him being an anesthesiologist.

 

[Colorado outliers]

Friend, there are sociopaths in every field of medicine. This has nothing to do with him being an anesthesiologist.

Where did I make such a bold claim?

 

[jdh71]

Friend, there are sociopaths in every field of medicine. This has nothing to do with him being an anesthesiologist.

I think you missed his point.

 

[RemyMcswain]

I think you missed his point.

I suppose. Not sure why an isolated incident would turn off a community hospital to hiring an anesthesia-ICU physician.

 

[chocomorsel]

I think you missed his point.

What was his point? Maybe I missed it too.

 

[jdh71]

What was his point? Maybe I missed it too.

That simply because this was a anesthesia trained CC doc who got in trouble, it might put off some people. It’s not necessarily rational but you can see how someone might connect those dots.

 

[chocomorsel]

That simply because this was a anesthesia trained CC doc who got in trouble, it might put off some people. It’s not necessarily rational but you can see how someone might connect those dots.

That just happened in the past couple of years. I have been eyeing CCM jobs for years and most still post for Pulmonary CCM and have for ever. Not just CCM.
I think that would be a stretch. Any sociopath could kill some patients intentionally.

 

[jdh71]

That just happened in the past couple of years. I have been eyeing CCM jobs for years and most still post for Pulmonary CCM and have for ever. Not just CCM.
I think that would be a stretch. Any sociopath could kill some patients intentionally.

Sure. I was simply clarifying the point.

I don’t know that I’m convinced the guy in this case was a “sociopath.”

 

[chocomorsel]

Sure. I was simply clarifying the point.

I don’t know that I’m convinced the guy in this case was a “sociopath.”

Yeah. You are probably right. He was a misguided angel of mercy. Can’t do that in this country.

 

[jdh71]

Yeah. You are probably right. He was a misguided angel of mercy. Can’t do that in this country.

“fentanyl” is also political poison right now

I think fentanyl and even fentanyl infusions aren’t euthanasia and should and could work very well for the dying. I do NOT use them for this exact reason.

Though I think in the cases related to this guy he did give some eyebrow raising bolus doses. But other than that if the patient was dying and was on comfort care, I don’t know that as a CC doc I can get too outraged. Yes, we don’t put people down. We provide “comfort” and the secondary effects of our comfort medications will hasten death. I know some think this is a distinction without meaning. I’m not convinced. I think it is an important distinction. But I still don’t think this guy should be crucified based on what I know about the case.

 

[chocomorsel]

“fentanyl” is also political poison right now

I think fentanyl and even fentanyl infusions aren’t euthanasia and should and could work very well for the dying. I do NOT use them for this exact reason.

Though I think in the cases related to this guy he did give some eyebrow raising bolus doses. But other than that if the patient was dying and was on comfort care, I don’t know that as a CC doc I can get too outraged. Yes, we don’t put people down. We provide “comfort” and the secondary effects of our comfort medications will hasten death. I know some think this is a distinction without meaning. I’m not convinced. I think it is an important distinction. But I still don’t think this guy should be crucified based on what I know about the case.

He will be crucified because this is America and we always want heroics for everyone and if we hasten death without the family consent, some consider it murder. Even though there is no other alternative.

 

[jdh71]

He will be crucified because this is America and we always want heroics for everyone and if we hasten death without the family consent, some consider it murder. Even though there is no other alternative.

pretty much

 

[ShockIndex]

He will be crucified because this is America and we always want heroics for everyone and if we hasten death without the family consent, some consider it murder. Even though there is no other alternative.

There is still a nugget in me that thinks that we may someday find a middle ground and consensus between heroics for everyone vs. active euthanasia with a milligram of fentanyl.

 

[Hamhock]

It's a lot easier to see our job as relieving suffering and promoting human flourishing.

Within this context, 1000mcg fentanyl or so much more is not ethically challenging. Who hasn't had a patient on 300 mcg/hr infusion fentanyl and then needed much much more to minimize suffering after the "terminal extubation"?

HH

 

[ShockIndex]

It's a lot easier to see our job as relieving suffering and promoting human flourishing.

Within this context, 1000mcg fentanyl or so much more is not ethically challenging. Who hasn't had a patient on 300 mcg/hr infusion fentanyl and then needed much much more to minimize suffering after the "terminal extubation"?

HH

Before going off on a tangent, let me say that I don’t think that Dr. Husel’s actions have anything to do with the uphill battle that anesthesia intensivists face getting jobs outside of surgical and CVICUs. IMHO, it has a lot more to do with the fact that anesthesia-CCM fellowships have traditionally focused on those ICU populations, and (to a lesser extent) medical intensivists are financially incentivized to limit their labor pool.

Having said that, I’m not aware of any instance among the 25 counts in his indictment where Husel appropriately escalated therapeutics. Instead, he gave massive, single doses of fentanyl to patients without their consent, and in a manner that is most reasonably understood as an effort to end their life. This includes a 2 mg dose of fentanyl for a patient who was relatively opiate naive. Keep in mind that neither the family nor the patient were involved with this decision or prepared for the immediate death that resulted. Personally, I suspect this guy had a God complex and enjoyed the power that these actions afforded him.

 

[Colorado outliers]

Before going off on a tangent, let me say that I don’t think that Dr. Husel’s actions have anything to do with the uphill battle that anesthesia intensivists face getting jobs outside of surgical and CVICUs. IMHO, it has a lot more to do with the fact that anesthesia-CCM fellowships have traditionally focused on those ICU populations, and (to a lesser extent) medical intensivists are financially incentivized to limit their labor pool.

Having said that, I’m not aware of any instance among the 25 counts in his indictment where Husel appropriately escalated therapeutics. Instead, he gave massive, single doses of fentanyl to patients without their consent, and in a manner that is most reasonably understood as an effort to end their life. This includes a 2 mg dose of fentanyl for a patient who was relatively opiate naive. Keep in mind that neither the family nor the patient were involved with this decision or prepared for the immediate death that resulted. Personally, I suspect this guy had a God complex and enjoyed the power that these actions afforded him.

I agree, although it came to mind I don't really think Husel's stuff has anything to do with the OP's predicament in most markets (as long as you are not in Columbus)
Also agree that Husel's use of massive fentanyl doses in opioid-naive patients, without knowledge of family, is not defensible. Not sure if these were the circumstances in every case.
Personally, don't think pharmacy/nursing would ever agree to administer such large doses at our hospital. If someone (even an attending) tried to order it, I don't think it would happen.

 

[leviathan]

Just to offer a different perspective, my ICU is often heavily occupied by patients waiting for transfer to the wards who are well outside of their critical illness, and strictly are internal medicine patients at this point. We routinely have people waiting so long for transfer that they just get discharged home from the ICU. I would be less confident in a non IM trained intensivist managing these patients, whether it be gen surg or anesthesia or otherwise. On the other hand, I would still gladly hire an intensivist with anesthesia or other backgrounds, as long as they know their limitations and can ask for advice (or consult) as needed.

I'm not sure if that's the reason you were getting resistance from hospitals, but just one other possibility to consider.

Otherwise, I agree with the sentiment that we all enter critical care training with different strengths/weaknesses and we address those weaknesses before finishing. In my case I spent several months in my fellowship doing anesthesia and a difficult airway rotation so I was more comfortable with that aspect.

 

[MoMoGesiologist]

Just to offer a different perspective, my ICU is often heavily occupied by patients waiting for transfer to the wards who are well outside of their critical illness, and strictly are internal medicine patients at this point. We routinely have people waiting so long for transfer that they just get discharged home from the ICU. I would be less confident in a non IM trained intensivist managing these patients, whether it be gen surg or anesthesia or otherwise. On the other hand, I would still gladly hire an intensivist with anesthesia or other backgrounds, as long as they know their limitations and can ask for advice (or consult) as needed.

I'm not sure if that's the reason you were getting resistance from hospitals, but just one other possibility to consider.

Otherwise, I agree with the sentiment that we all enter critical care training with different strengths/weaknesses and we address those weaknesses before finishing. In my case I spent several months in my fellowship doing anesthesia and a difficult airway rotation so I was more comfortable with that aspect.

Sounds like your ICU sucks... agreed that many of us wouldn’t want to manage floor patients and their chronic illnesses.

 

[leviathan]

Sounds like your ICU sucks... agreed that many of us wouldn’t want to manage floor patients and their chronic illnesses.

The ICU is great, but it's the hospital that sucks. No ward beds= patients never transfer out until more ICU patients get admitted.

 

[CCM-MD]

The ICU is great, but it's the hospital that sucks. No ward beds= patients never transfer out until more ICU patients get admitted.

I think this is becoming a common problem. Open is better in these situations, the ability to "sign off" is nice. I've never had to discharge someone. Some places have hospitalists take over the management of patients with transfer orders out of the ICU.

 

[jdh71]

I think this is becoming a common problem. Open is better in these situations, the ability to "sign off" is nice. I've never had to discharge someone. Some places have hospitalists take over the management of patients with transfer orders out of the ICU.

This is what we have decided to do where I work, and our hospitalists are reasonably happy enough to have the work. We both agree that due to our slower reflexes on disposition to anywhere but an LTAC that patients will leave the hospital faster with the hospitalists picking up their care with them in the ICU then us spending another day rounding and holding pattern.

 

[John Red]

Current EM resident considering CCM and was perusing the forums when I came across this thread. Appreciate all the insights so far. Curious of this bias extends to EM-CCM coming from anesthesia vs medicine pathways, and whether that should be a factor when consider fellowship options

 

[deleted547339]

Current EM resident considering CCM and was perusing the forums when I came across this thread. Appreciate all the insights so far. Curious of this bias extends to EM-CCM coming from anesthesia vs medicine pathways, and whether that should be a factor when consider fellowship options

Depends what you want to do.

 

[ShockIndex]

I’m

Current EM resident considering CCM and was perusing the forums when I came across this thread. Appreciate all the insights so far. Curious of this bias extends to EM-CCM coming from anesthesia vs medicine pathways, and whether that should be a factor when consider fellowship options

I’m EM trained in a CCM fellowship. I think the calculus is a little different for us but the bias in the community might still be there since we are relatively new. This is because many community shops are staffed by pulm-crit groups who are unsure of how EM-CCM doctors will fit in their structure (no pulm clinic, how do we accommodate ED shifts, etc).

On the other hand, our CCM board certification is administered through ABEM regardless of training pathway. Our 2nd year electives are very good at rounding out our experience and giving us a much more multidisciplinary perspective (I’ll have 5-6 months of MICU experience; most anesthesiologists have 1 at my program). EM-CCM fellows looking for community jobs generally advertise themselves as EM-CCM trained (as opposed to coming from an anesthesia program) and leverage relationships developed with the pulm-crit faculty from our time in the MICU for our letters of recommendation and job searches.

In other words, community-bound EM-CCM fellows do their research, have good references from pulm-crit faculty, and know how to sell their unique background to pulm-crit groups.

 

[PikminOC]

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).

Bwahaha. They are hiring np and dnp in these positions

 

[CCM-MD]

I’m EM trained in a CCM fellowship. I think the calculus is a little different for us but the bias in the community might still be there since we are relatively new. This is because many community shops are staffed by pulm-crit groups who are unsure of how EM-CCM doctors will fit in their structure (no pulm clinic, how do we accommodate ED shifts, etc).

On the other hand, our CCM board certification is administered through ABEM regardless of training pathway. Our 2nd year electives are very good at rounding out our experience and giving us a much more multidisciplinary perspective (I’ll have 5-6 months of MICU experience; most anesthesiologists have 1 at my program). EM-CCM fellows looking for community jobs generally advertise themselves as EM-CCM trained (as opposed to coming from an anesthesia program) and leverage relationships developed with the pulm-crit faculty from our time in the MICU for our letters of recommendation and job searches.

In other words, community-bound EM-CCM fellows do their research, have good references from pulm-crit faculty, and know how to sell their unique background to pulm-crit groups.

To me personally, like you said, multidisciplinary training is more valuable than whether one is anesthesia or IM. Regardless, there will be people who will evaluate based on name alone. ABEM administers the cert but whether you did IM or anesthesia is clearly stated, if you're boarded. And if one is not/first job, I bet people will be interested in what training one did. There are ~150 EM-CCM certified since the pathway was created and I suspect many of those stayed in academics. I had an EM/IM attending during my fellowship who was awesome. But it is uncommon in the community setting and I wouldn't be shocked if there is bias. Especially considering ICU docs have poor interactions with ER docs from time to time...

 

[John Red]

Depends what you want to do.

assuming full time ICU...

 

[ShockIndex]

assuming full time ICU...

I think that he means what type of patients do you want to treat? Do you want to treat perioperative critically ill patients found in SICUs and CVICUs? If so, anesthesia CCM is probably your best bet. If you want a more medically oriented, community ICU population, then I’d choose IM. Either way, you need to make sure that you have a well-rounded fellowship experience and know how to sell yourself to future employers if you want to venture into the community.

Having said that, I get the impression that these biases do exist but are becoming less important as we get more EM grads. For example, I met a fellow at UC Denver who was taking a community ICU job in CO after an anesthesia-CCM fellowship. I know a academic health systems where the anesthesia-CCM faculty primarily staff the CVICU at the academic mothership, but also provide supplemental staffing at a mixed population community ICU within the system. This type of interbreeding is likely to grow because it is a very good thing for patients, doctors, and hospitals.

 

[chocomorsel]

All of a sudden, no one cares that my background is in an anesthesiology.

And even my non CCM friends are getting offers to work in the Unit.

Desperate times? Guess I must be desperate measures.

Bur for the record I had three job interviews lined up for a combo job that have now been postponed due to Covid and traveling. One pulmonary group was even going to interview me.

 

[deleted697535]

I got a bell from 3 very smart and snooty Intensivists to tube this covid whale yesterday.

I made them beg me to tube him lol.

Not so effing smart are ye now boys.

There is absolutely no doubt who the airway experts are anymore.

 

[Splenda88]

I got a bell from 3 very smart and snooty Intensivists to tube this covid whale yesterday.

I made them beg me to tube him lol.

Not so effing smart are ye now boys.

There is absolutely no doubt who the airway experts are anymore.

Was there ever any doubt?

 

[deleted697535]

Some juniors aka internal med staff Intensivists thought so.

 

[chocomorsel]

Was there ever any doubt?

Uhmm, the anesthesia department were never called to to MICU to assist with even the most difficult intubations while I was a fellow. I heard of horror stories and it was all related to the Pulmonologists being territorial and not needing help.
So yeah, some people think they don’t need our assistance and they too are the airway experts.

I however was talking about working in the ICU.

 

[deleted697535]

LOL those guys would straight up kill a dude on induction, then run the code with an lma, call it, document it and carry onto the next patient. Without calling anyone, us, ent no-one.

I got called one evening to ICU & there was an r3 medicine resident and staff down there trying to put a double lumen into a guy with hemoptysis. It was unbelievable.
Neither had ever done one before. No paralysis. Blood on the roof, the windows, the corridor, everywhere

 

[Colorado outliers]

LOL those guys would straight up kill a dude on induction, then run the code with an lma, call it, document it and carry onto the next patient. Without calling anyone, us, ent no-one.

I got called one evening to ICU & there was an r3 medicine resident and staff down there trying to put a double lumen into a guy with hemoptysis. It was unbelievable.
Neither had ever done one before. No paralysis. Blood on the roof, the windows, the corridor, everywhere

Your institution sounds bad, but keep in mind not every place functions like this. Having a resident intubate by themselves is nuts. No way they should not be calling you from the get go.

I work at a large MICU. Fellow + attending (mostly pulm-CCM) does all intubations w/ VL, bougie always at bedside if needed, disposable bronch available. I've had to call difficult airway (ENT and trauma surgery) to take someone to the OR, but never anesthesia in our unit.

Anesthesia (and probably EM) will always be better than me at DL. I'm not an 'airway expert' although I can probably fiberoptically intubate as quickly as anyone. But, if I can't intubate with bougie or bronch, this something I've anticipated and difficult airway team is already there.

We have a very collegial relationship with anesthesia, mutual respect. Practically if I called them routinely for airways in the MICU, this would not work. They are perfectly happy to let us manage our own airways, but we are also not routinely calling them after 3 failed attempts.
I'm sure this is not the case everywhere.


At this point, anyone who is critical care trained should not be struggling to find work

 

[MoMoGesiologist]

I got a bell from 3 very smart and snooty Intensivists to tube this covid whale yesterday.

I made them beg me to tube him lol.

Not so effing smart are ye now boys.

There is absolutely no doubt who the airway experts are anymore.

Ooh how did you make them beg?? I will live vicariously through you. I have a coworker who just thinks he knows everything...

 

[deleted697535]

Is it FFP? He suspected this was an epidemic before anyone else was thinking that way

 

[Splenda88]

Is it FFP? He suspected this was an epidemic before anyone else was thinking that way

Even before Trump.

 

[deleted547339]

Your institution sounds bad, but keep in mind not every place functions like this. Having a resident intubate by themselves is nuts. No way they should not be calling you from the get go.

I work at a large MICU. Fellow + attending (mostly pulm-CCM) does all intubations w/ VL, bougie always at bedside if needed, disposable bronch available. I've had to call difficult airway (ENT and trauma surgery) to take someone to the OR, but never anesthesia in our unit.

Anesthesia (and probably EM) will always be better than me at DL. I'm not an 'airway expert' although I can probably fiberoptically intubate as quickly as anyone. But, if I can't intubate with bougie or bronch, this something I've anticipated and difficult airway team is already there.

We have a very collegial relationship with anesthesia, mutual respect. Practically if I called them routinely for airways in the MICU, this would not work. They are perfectly happy to let us manage our own airways, but we are also not routinely calling them after 3 failed attempts.
I'm sure this is not the case everywhere.


At this point, anyone who is critical care trained should not be struggling to find work

Same. I don’t mean this to sound arrogant, but I would probably cric/trach before calling anesthesia. It’s not that I don’t respect them and wouldn’t call them, it’s just that I would never think to do it. We manage all of our own airways in the MICU and always have. I’ve never heard of a significant airway problem in our unit, although we have a very highly functioning icu.

 

[Angus Avagadro]

LOL those guys would straight up kill a dude on induction, then run the code with an lma, call it, document it and carry onto the next patient. Without calling anyone, us, ent no-one.

I got called one evening to ICU & there was an r3 medicine resident and staff down there trying to put a double lumen into a guy with hemoptysis. It was unbelievable.
Neither had ever done one before. No paralysis. Blood on the roof, the windows, the corridor, everywhere

Yikes!

 

[Angus Avagadro]

Same. I don’t mean this to sound arrogant, but I would probably cric/trach before calling anesthesia. It’s not that I don’t respect them and wouldn’t call them, it’s just that I would never think to do it. We manage all of our own airways in the MICU and always have. I’ve never heard of a significant airway problem in our unit, although we have a very highly functioning icu.

I dont think you are being arrogant and are probably pretty skillful. Airway disasters are not common and there are lots of cool tools now at your disposal.
If you haven't had an airway go south, you haven't done enough to see one yet. Trauma centers and pediatric centers probably see the most difficult airways. Most anesthesiologists will only have a handful of airways gone bad in their careers. One thing I do know, anesthesiologists hate being handed a bloody laryngoscope. I wouldn't hesitate to consult them early.

 

[ShockIndex]

There is absolutely nothing wrong with phoning a friend where there is time and an anticipated difficult airway. One of my partners received a very nice letter from the Chairs of Anesthesiology and ENT when she wisely called ENT and anesthesia to the ED for a patient with a previously undiagnosed supraglottic mass gone awry. The patient could not be fiber-optically intubated from above and could not be placed in a recumbent position without airway obstruction. She likely saved this guys life by performing a quick NP scope, recognizing the problem, and notifying all of the resources so they everyone knew what was waiting for them. Having Chairs from multiple departments recognize her efficiency and teamwork was outstanding in building goodwill between specialities.

Part of being good is being able to take care of business 99.99% of the time while still being self-aware for that 0.01% where you are in over your head.

 

[nimbus]

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).

Yet somehow anesthesiologists know how to manage bad DKA and CHF at 3am when that patient gets dead bowel. Sorry but that is bread n butter anesthesia.

 

[ShockIndex]

Yet somehow anesthesiologists know how to manage bad DKA and CHF at 3am when that patient gets dead bowel. Sorry but that is bread n butter anesthesia.

Perhaps people should stop assuming what others know or their capabilities.

 

[deleted697535]

Yet somehow anesthesiologists know how to manage bad DKA and CHF at 3am when that patient gets dead bowel. Sorry but that is bread n butter anesthesia.

Defintely dont bother wasting time on @DrMetal . That persons obviously beyond stupid

 

[Katheudontas parateroumen]

All of a sudden, no one cares that my background is in an anesthesiology.

And even my non CCM friends are getting offers to work in the Unit.

Desperate times? Guess I must be desperate measures.

Bur for the record I had three job interviews lined up for a combo job that have now been postponed due to Covid and traveling. One pulmonary group was even going to interview me.

Do you think this overall bodes well for those of us entering Anesth-CCM fellowship for jobs in the near future?

 

[chocomorsel]

Do you think this overall bodes well for those of us entering Anesth-CCM fellowship for jobs in the near future?

Honestly it’s ignorance from recruiters and administrators as well as preferential treatment from pulmonologists to their. colleagues.
Also, often times the hospitals want a two-fer with pulmonary consults being done part of the time.
Doors are opening up and people are getting less ignorant and less discriminatory.
Hopefully Covid helped.

 

[jdh71]

Honestly it’s ignorance from recruiters and administrators as well as preferential treatment from pulmonologists to their. colleagues.

It's not really preferential treatment, but rather finding a place in a model that is already built around pulmonary being part of the equation.

 

[CCM-MD]

It's not really preferential treatment, but rather finding a place in a model that is already built around pulmonary being part of the equation.

My personal experience is that there are also ccm only (no pulm consults) gigs out there that prefer IM trained for whatever reason. I have even seen some that are openly advertised that way. On the flip side, I see more and more ads specifically stating they don’t care what one’s primary specialty is as long as ccm boarded.