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EM-CC Medicine

Discussion in 'Critical Care' started by IH8ColdWeath3r, Mar 14, 2019 at 10:49 AM.

  1. IH8ColdWeath3r

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    Hey everyone,

    I am a PGY-2 EM resident interested in critical care. I know there are a handful of EM-CCM trained docs on this forum, and I was hoping to garner some insight.

    I have found that I really enjoy my time in the ICU, particularly as an intern but even more so this year as a PGY-2, where I was basically treated as a senior resident. I did the majority of the procedures myself and ran the codes, supervised the interns. I was given a lot of autonomy by the critical care fellows. I began comparing it to my EM shifts.

    I find that CC is more cerebral, there is time to actually sit down and review old consultation notes, old cultures, prior echos, and to make more informed decisions. I also found that I had much more meaningful discussions with families, because the pace was just different compared to the ER. I didn't feel like a cog in a wheel, churning through patients like I do in the ED.

    It is getting around the time where I need to decide if I should apply for fellowship. My residency program has a pure CC fellowship that is open to EM, and I have already met with the PD who knows me well (I worked with him several weeks on the unit). He encouraged me to apply and basically told me I would be a good fit.

    My decision to apply is purely because I enjoy critical care and think that it adds career longevity to my career. It would do nothing for me in terms of salary. Unfortunately, several of my attendings and one of my mentors discouraged me from doing it. They sited that it is very difficult to work as both an EM doc and an intensivist, and that no community hospital would hire me for 7 on/7 off schedule for two week of the month AND give me shifts in the ED, and furthermore, they asked me if I even wanted to work that much clinically coming out of residency. They told me that the only way to really swing both is to work somewhere academic, where one week out of the month I could work as an intensivist, and then work 8 or so ED shifts.
    I was also told that since the job will be an academic position, the salary will be significantly reduced when compared to working in a community setting.

    My question is, is it possible to work as an intensivist for 1 week out of the month in the community, and to then work 8 or so ED shifts a month? How many of you guys have a set up like this? Do you even get the benefits (health insurance, 401K, etc. ) since you technically are not a full time intensivist or a full time ED doc? I am interested in being a nocturnist so, would it be possible to get a gig where I work 1 week of nights as ICU doc and then have the remainder of my shifts scheduled in the ED?

    Would love to hear any other general advice from those who are currently EM-CC trained and working.

    TIA.
     
  2. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    As someone who is involved in looking for candidates for a group of pulmonary and critical care folks I know we’d consider offering a 0.5 FTE working one week a month to someone like you. 1/3 of those weeks would be nights. We cover 24/7. We’d need to figure how to handle the pulmonary consults (but this also a problem for an IM/CC person, so not totally unique). I don’t know if the bigger medical group would offer benefits (outside of medmal insurance) at 0.5 but you could probably then negotiate a better rate/salary but maybe. The suits have “tables”. You’d likely be offered 50%ile IM intensivist salary x 0.5 with some kind of production bonus probably staring at half the wrvu at the 50%ile on these notorious “tables”

    In my metro the EM folks are mostly one big group of some kind covering many hospitals. You’d need to negotiate ED shifts and job with them separately.

    But basically I don’t see see why it’s insurmountable. There is a lot of ICU work. We need the people.
     
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  3. CCM2017

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    Your attendings made some valid points but you shouldn't feel discouraged. I am IM-CCM but know a few EM-CCM docs. Interestingly the few that I know do not practice any EM anymore - unless they pick up some locum shifts on the side.

    1. Is it possible to find a way to practice both EM and CCM? Yes, there are a few on this forum that do it so it is not IMpossible.
    2. Is it common, especially outside of academia? Not at all, it is rare. Considering there is only ~150 EM-CCM physicians ever to be certified in the country since the creation of the pathway... EM-CCM on its own is not even common. However, as I mentioned in #1 it is not impossible considering there are a few on this forum that have found a way to practice both.
    3. It is true that compensation in academics will be lower than working outside of it.
    4. It probably wouldn't be very difficult to find a full time nights job as an intensivist - but keep in mind only large hospitals have the 24/7 intensivist model. Many small and medium sized community hospitals don't have intensivists inhouse at night.

    Bottom line - finding a way to practice both won't be as easy as finding a straight CCM or EM job but considering both fields are very much "in-demand", it shouldn't be impossible.
     
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  4. psychbender

    psychbender Cynical Member
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    I'm Anes-CCM, so I have many of the same problems. OP, at one of the places I recently interviewed (community hospital, no academic affiliations), they had an EM-CCM doc in the ICU pool, worked ED shifts the rest of the time. At another, they do not, but the ICU director would be open to it, and was excited to work with me as his first anesthesia-trained intensivist on staff. Both of these were in the Mid-Atlantic region.
     
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  5. OP
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    IH8ColdWeath3r

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    Thank you guys very much for your replies. I appreciate the insight.

    You mentioned " many of the small and medium sized community hospitalst do not have intensivists in house at night"? What happens if a patient decompensates, or they get an admit overnight and the patient is very unstable, requiring intubation/line/drips etc.

    You guys mentioned the jobs are very much in demand. I am finding that to be quite the contrary when it comes to EM. I was always told the there is a huge demand for BC/BE EM docs, and I have begun my preliminary search in the DFW (Dallas/Forth Worth) area and have found quite the contrary. The whole area appears to be saturated, so much so that two of my colleagues who graduated the year before me at reputable programs had a difficult time finding a job in Texas. I think a lot of this has to do with CMG takeover, and EM moving toward the anesthesia model of hiring mid-levels, so the ED doc takes on a more supervisor role.

    I am hoping that this trend does not continue into critical care. Many of the ED attendings I have talked to, and many on the EM docs forums express their concerns regarding mid-level infiltration purely as a cost-cutting mechanism by CMGs - which unfortunately at the end of the day affects job availability.
     
  6. EmergDO

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    I did some rotations at a hospital without full ICU coverage. The hospitalist manages these patients at night. As for lines/tubes, either they do the procedures or the EM or anesthesia doc (if they're in house) will come to the ICU to do them.

    That's a bummer to hear about EM though. It seems like there are still a zillion jobs up here in the NE but it still makes me nervous going into EM.
     
  7. CCM2017

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    At some small hospitals, hospitalists take care of most things at night but there is usually intensivists "on call" from home, and EM and anesthesiologists help with the procedures. Some places have midlevels in the unit at night or "eICU" where a CCM doc handles things via a camera and access to the hospital's EMR. All sorts of variations out there for smaller hospitals.

    Unfortunately, my best guess is that the trend of midlevel infiltration will continue in all fields except for maybe radiology, pathology, and the actual physical act of performing complicated surgery. My hope is that because most ICU patients, especially MICU type patients (which are the majority) are sufficiently complicated and sick enough, that patient families and hospitals will want direct physician involvement in their care. Midlevels also seem to take more of a "intern/resident" type role in the ICU and majority of the crucial decisions are still made by the attending physician who is involved in the care of each patient. But who knows what the future holds? They also already perform many basic ICU procedures. Also, there already are "corporate" entities in CCM... sound, ICC, adfinitas, apogee to name a few. Doesn't seem to be as bad as EM or anesthesiology but again, who knows what the future holds?

    All I can say for sure is, right now jobs are plenty, $ is good and midlevels are not causing as big of a problem as other fields. Future is unknown.
     
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  8. OP
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    IH8ColdWeath3r

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    At our hospital, there are CC fellows who are on for nights. There are no midlevels in the ICU. Attending coverage is only on during days. Although I have hear that there are places where there is an intensivist on 24/7. My question is, at institutions like that, does the night guy round and write notes on each patient in the unit also, or is he there basically to do all of the admission that come on at night and puts out the fires?
     
  9. DrGasPasser

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    There is a lot of talking in the EM community about market saturation. For years, we have been told that there would be a shortage of EPs for decades. Those studies were part of the reason for the explosion in EM training programs over the past 10 years. Now, we are realizing that the shortages exist only in less desirable parts of the country, and all of our growth has only served to saturate desirable areas. Producing more graduates will only worsen the market heterogeneity as the vast majority will continue looking for jobs in the same, desirable zip codes.

    When it comes to the EM-CCM balance, that is the elephant in the room as every graduate finishes their fellowship. Everyone I know doing this spends a lot of time and effort striking out the right balance for them. A common theme that I see in academics is that a 50:50 split is often the hardest to pull off, not because the clinical hours are hard to divide - it’s balancing the non-clinical responsibilities. Each department has their own meetings they want you to attend and metrics for promotion to meet and neither department does a good job talking to the other. A balance that is less even is is easier because one department is understood to be your primary responsibility.

    Finally, you need start preparing for fellowship right now if you are a PGY2 in a 3 year program graduating in 2020. You are effectively out of the running for anesthesia-CCM spots in 2020 since the interview season is just about over (applications were accepted in Nov 2018 and Match is May 2019). If you really want an anesthesia-CCM spot you could try to push through an application within the next couple of weeks, or sit out a year working as an ED attending and apply for 2021. The IM-CCM process for 2020 starts this Summer. Start talking to ICU faculty now who can provide your letters. Start working on your personal statement now and thinking about what you want in a program.
     
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  10. CCM2017

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    Bigger hospitals are more likely to have intensivists on 24/7. Night guy usually does admissions and "cross coverage". In a typical 24/7 set up, there are usually more intensivists on during the day than at night - for example 32 ICU patients, 2 intensivists who round and see patients during the day, 1 at night who does admissions and deals with ongoing management/deterioration of existing patients. There are lots of different variations.
     
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  11. OP
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    IH8ColdWeath3r

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    I am more interested in medical > surgical/anesthesia critical care programs. There are several in my geographic vicinity and as mentioned, one at my current institution. I have met with the PD and have letters, finishing my personal statement and touching up on my CV and ongoing research projects.

    my problem wont be getting my apps in in time (most deadlines are in June), but really, truly deciding if this is the right choice for me. The obstacles that you mentioned above give me thought and pause. Overall, I am leaning towards applying and doing the fellowship. Another question for you - if you went straight from EM to CC fellowship, did you find that your ED skills atrophied? My concern is the lack of kids, pregnant OB patients, ortho procedures and all of the other garden variety ED things that I wont see and manage while training as a fellow in the unit.
     
  12. Hamhock

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    Interestingly, we have 24h in-house coverage at smaller, community hospital that I work and "call from home" overnight coverage at the bigger more academic hospital (but lots of residents in-house).

    At the community hospital, the in-house overnight intensivist typically does the overnight admits/consults, completes the procedures that weren't finished in the daytime, and "puts out fires". During especially busy times, some of the patients will be intentionally left to the night doc for daily notes.

    I don't think your attendings have looked into the EM-CCM market and I highly doubt they have interviewed at very many places. They are most likely EM attendings who are familiar only with their system. They are probably trying to be helpful, but I doubt they have the information/knowledge to be giving advice with any authority.

    Of course, I too can only give my experience and relay what my EM-CCM friends have experienced.

    That said, every community hospital I have considered would LOVE for an EM-CCM doc to work both in the ICU and the ED. Some friends do this, but I am just not interested. I am only in the ICU but they previously would ask me weekly to work in the ED despite my refusals.

    And if you want to be an nocturnist, please give us a call immediately! :)

    One week of nights in the ICU and 8 EM shifts would be immediately accommodated. :)

    ...but here I do agree with your attendings. Try not to schedule too much work. Although I know of places that will gladly give you one-on/one-off in the ICU and then EM shifts sprinkled in between, that schedule sounds horrific to me. Please consider working way less than this.

    Finally, I wouldn't worry so much about health insurance and 401k at this point. It would require a whole other post, but the benefits of an SEP-IRA and 1099 tax-deductions should not be overlooked (and are often way better; depending on the size of your family and expenses).

    HH
     
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  13. OP
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    IH8ColdWeath3r

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    Thank you so much for your post. It is very insightful and gives me hope of finding a "perfect" job, whatever that means. For me, I have always been a night guy. In medical school, I slept during days, and studied at night. Same thing in residency, I much prefer working night shifts. I feel much more energized/awake - my only reservation of being a nocturnist, as an ED doctor anyway coming right out of residency, is the lack of resources that are available at night compared to the day (US, MRI, specialist consults, etc.), in a community setting at least.

    But yes, ultimately my ideal scenario would be one week of nights as an intensivist and then about 8 or so ED shifts on top of that so that I would be working ~15 shifts a month.
     
  14. psychbender

    psychbender Cynical Member
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    I cannot personally speak to the issue of EM skill atrophy, but two of my attendings in fellowship were EM-trained, and still worked in the ED at our academic institution. Neither of them expressed any concerns about loss of skills while they were in training. I know one of them picked up some rural EM shifts during elective rotations and weekends while he was a fellow, so I am sure that helped stave off some of the loss of skills.

    Coming out of fellowship, I felt a little rusty getting back into the OR, but it was not hard transitioning back. Then again, fellowship for me was only one year, and I had been practicing for several years between residency and fellowship.
     
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  15. psychbender

    psychbender Cynical Member
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    I wouldn't be too worried about applying late for anesthesia-based fellowships. A large number go unfilled each year, and often at good programs. A candidate that is uncertain now can still probably pick one up after the match in late May. Hell, right now there are 34 vacant spots for fellowships that would start July 2019.
     
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  16. DrGasPasser

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    Those vacancies are all for 1-year anesthesia spots. There are relatively few ABA-approved 2-year spots for EM candidates; most programs accepting EM applicants only have 1 or 2 per year. While the 1-year spots for anesthesiologists are not that competitive, the same cannot be said for the EM spots. EM applicants are applying for a relatively few spots and every year there are more and more EM applicants. A program would need apply to the ABA to get a 1-year spot converted to a 2-year EM spot. While this application may be a formality, securing funding for that second year is not.
     
  17. DrGasPasser

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    Your skills will not deteriorate in a meaningful way during fellowship, especially if you moonlight a bit during research/elective blocks.
     
  18. kimbosliced

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    I’m EM/CC.

    My job will be mostly CC 7/7 schedule but I’ll be picking up ER shifts on my weeks off. Plenty of PRN work if you want it.

    It is very difficult to find a true split outside of academics. I may have been able to swing it but honestly prefer CC significantly more than community EM.

    I don’t think you’d regret doing the fellowship but I’d suggest only doing if you like CC. The money is about the same depending on where you live but the work is more enjoyable and you have significantly more career flexibility. The EM market it saturated in many major cities now. CC doesn’t seem as bad.

    Mid levels are a part of CC too but their use is truly extenders of care whereas in EM they see patients under your license with you required to sign off on their charts by the CMG. You more than likely never saw the patient or were presented the patient because of the low acuity level. Some places the acuity level doesn’t matter and the mid levels see almost everything. You have no choice in this unless you choose not to work at that facility or that CMG but this practice is ubiquitous. You don’t really find this practice similar in CC in my experience.

    Your skills won’t atrophy but a lot of the customer service, PG metrics that don’t matter clinically, flow of the department with new protocols, etc you’ll be behind on. I will say the pedi thing is hit or miss depending on your residency experience. You may miss out on a lot of ortho but again not that bad if you plan to still practice EM now if you quit practicing EM for 5 years or so altogether and tried to come back you’d have a problem.
     
    #18 kimbosliced, Mar 14, 2019 at 11:43 PM
    Last edited: Mar 15, 2019 at 12:02 AM
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  19. OP
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    IH8ColdWeath3r

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    Thanks for your honest feedback. I really appreciate it. Yes, the arbitrarily signing off on mid-level charts really bothers me. One of my attendings last week had to sign off on a chart where the mid-level saw the patient and didnt staff with the attending. Long story short, the B-quant was too high for what the US was showing, and the read was not a definitive IUP. Patient came back two days later with an ectopic pregnancy that no longer could be managed medically with MTX. Read of a similar case in EM docs where patient actually had to get oopherectomy. I understand that this is an N = 2 but with more and more of these cases surfacing, with the reduced supervision or independent practice, makes me really reluctant to work with NPs. It's like giving someone the keys to your car and your license, and telling them "hey no worries if you wreck it, ill take the hit", except in this case it has to do with your medical license.

    How many CC shifts do you work per month then? are you working 14/month, and is it in a community or academic setting? What about it do you find more enjoyable?


    I found that CC has everything I enjoy about the ED (procedures, sick patients, meaningful conversations with families) without the ED BS. I found it much more cerebral and found that I enjoyed the extra time to make more informed decisions. I had a tough time going from my ICU month back to EM because I was so used to the sicks patients in the unit, and in my first shift back I saw the following CC - "dandruff", "dental pain", a patient with a treated UTI who was "weak" with normal labs, clean UA, who was not confused and could ambulate who family refused to take home and ended up being a social admit.
     
  20. engineeredout

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    EM/IM, CCM fellow right now so I can give you my perspective.

    I suspect that your attendings/mentors who discourage you from applying critical care are not EM-CCM themselves? It is difficult for someone not in the field to imagine wanting to do it. I mean why would you want to? EM is a pretty sweet gig on its own, where you can make good money for reasonable hours. Just like you know by now nobody in their right mind should go into medicine in general for the money, you would never do CCM for the money, you'd do it because you love the ICU.

    You can PM me if you want to discuss specifics of job opportunities for a split position, but I can definitely say yes there are split positions available out there, in both academic and community hospital settings. And you know what else? If you want to be somewhere and that position does not exist? You get them to create it for you. If you are seen as a potential asset to your future employer, they will figure out a way to make this work. I also know several EM-CCM people who after fellowship just decided they wanted to practice CCM primarily because they like it more, and they only occasional pick up an ED shift here or there.

    You mentioned adding longevity. I agree with this statement completely. I have already gotten to see from my varied background the opportunities that come open. I primarily moonlight in the ED, but I'm credentialed as a hospitalist as well. There are enormous opportunities that are floated in my direction just having that background, especially when they are shortstaffed ($$$$), and I know that being diversified was a major point of interest when I was on the interview trail for fellowship. I also think that splitting time up between the various worlds does help prevent burnout. Its amazing when I go back to the ED now for my part time moonlighting, how much less annoyed I get with the crazy people, the screaming druggies, the eight minutes of cold symptoms that required an ED visit etc. I get more than enough of my critical patient fill so I don't find myself missing out on it in the ED. Similarly, rounding in the ICU can get old after a while, the circle of chronically ill patients and death sometimes without feeling like we're making an appreciable difference, so I can take satisfaction out of diagnosing an OM in a child and moving them along quickly.

    EM-CCM is a growing community. I think emergency physicians can make great intensivists. Its not for everyone, its not a great financial decision, but if its what you love, it'll pay for itself many times over.
     
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  21. OP
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    IH8ColdWeath3r

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    Thank you for your perspective. I really needed to hear this. I will PM you.
     

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