EM/IM/CC Purpose and Practice Models?

[IR3A4]

Hey all,

Got to do a crit care rotation and fell absolutely in love. It checked every single one of my boxes (minus being able to talk to patients since most are sedated/vented but it's still rewarding talking to families). I was initially on the EM train coming into med school but what with the doom and gloom as well as now my interest in CC I've been able to stifle it... somewhat. I know there are a couple of EM/IM/CC programs in the country. What does one's career look like after doing one of these programs? Are there any unique opportunities offered to this route over the PCCM route (outside of being able to work in the ED). If I go the IM route I would do Pulm/CC but frankly outside of the procedures I'm not that interested in other aspects of pulm such as clinic (I love being in the hospital >> clinic). I'm also interested in somethings you get to see a lot in the ED (ultrasound, tox, etc).

Anyways hoping to get some people's input.

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[chessknt]

Hey all,

Got to do a crit care rotation and fell absolutely in love. It checked every single one of my boxes (minus being able to talk to patients since most are sedated/vented but it's still rewarding talking to families). I was initially on the EM train coming into med school but what with the doom and gloom as well as now my interest in CC I've been able to stifle it... somewhat. I know there are a couple of EM/IM/CC programs in the country. What does one's career look like after doing one of these programs? Are there any unique opportunities offered to this route over the PCCM route (outside of being able to work in the ED). If I go the IM route I would do Pulm/CC but frankly outside of the procedures I'm not that interested in other aspects of pulm such as clinic (I love being in the hospital >> clinic). I'm also interested in somethings you get to see a lot in the ED (ultrasound, tox, etc).

Anyways hoping to get some people's input.

No reason to do EM/IM/CCM--makes no sense at all. The procedural aspect is not really what critical care is about and over-focusing on this is normal early in training but in retrospect the procedures are not what make you a good clinician but rather the case complexity and exposure you had to people who really know what they are doing.

Pulm offers an exit from the hospital which might not seem appealing now because you havent had the **** beaten out of you by the administrators and nurse managers that are in charge of everything in a hospital but give it enough time, maybe after you have to miss a kids birthday or recital or 4 because of call and that boring old clinic can look pretty appealing.

 

[IR3A4]

No reason to do EM/IM/CCM--makes no sense at all. Pulm offers an exit from the hospital which might not seem appealing now because you havent had the **** beaten out of you by the administrators and nurse managers that are in charge of everything in a hospital but give it enough time, maybe after you have to miss a kids birthday or recital or 4 because of call and that boring old clinic can look pretty appealing.

Thanks for the input! I've definitely heard that one before and do need to remind myself to keep a clear head. I'm a non-trad (33) who did construction for over a decade, and people are just telling me "you got yourself beat up physically now why do you want to do it again mentally??"

Would you personally still do PCCM if you could do it all over? If not, what would you have done (in medicine)

 

[chessknt]

Thanks for the input!

Would you personally still do PCCM if you could do it all over? If not, what would you have done (in medicine)

I didnt have the scores but derm/ortho simply because I could retire faster or move to a part time gig and not have to work. Derm can sell so much cash only cosmetic crap and will earn multiples of anything I ever will--medicine doesnt compensate you for doing something useful or important, it is good to learn that now.

Within IM I should have done cards or heme onc because they have more ability to function in an outpatient setting and earn ancillary revenue by running imaging/cath/infusion center. Allergy is good too because their patients all have insurance. If you have someone else who is going to be earning the majority for your household and your job is more of a hobby then find something you like. Being anchored to the sickest patients in the hospital who inevitably have the ****tiest insurance is not a recipe for financial success or even fulfillment after the pandemic turned so many people in to these pseudo-science demanding tyrants that basically dictate their care. Since the pandemic I have had so many more people with families trying to micromanage everything going on from blood draw timing to feeding tube rate increases and I have stopped caring and let them do whatever they want and just put in the chart that it is all being done at the family's insistence and they have refused my medical advice because I truly do work in McDonalds.

 

[IR3A4]

medicine doesnt compensate you for doing something useful or important, it is good to learn that now.

Dont worry, I fortunately knew that going in.

And thanks for the input. I fortunately have mostly everything open for me (if I supplemented the research side) but found derm dreadfully boring, despite how enticing it is monetarily.

Cards & Heme/Onc though are actually on my short list, and will remain there should I go the IM route.

 

[chessknt]

Dont worry, I fortunately knew that going in.

And thanks for the input. I fortunately have mostly everything open for me (if I supplemented the research side) but found derm dreadfully boring, despite how enticing it is monetarily.

Cards & Heme/Onc though are actually on my short list, and will remain there should I go the IM route.

It honestly doesnt matter if it is boring, once you find your area and open up your practice selling sculpted abs and wrinkle lasers or whatever dumb **** they have now you'll be finding your Lambo far more interesting than any possible work subject.

 

[IR3A4]

It honestly doesnt matter if it is boring, once you find your area and open up your practice selling sculpted abs and wrinkle lasers or whatever dumb **** they have now you'll be finding your Lambo far more interesting than any possible work subject.

already secured that lambo off a 1.2 mil SPY play fortunately

 

[chessknt]

already secured that lambo off a 1.2 mil SPY play fortunately

If money is no object why let doom and gloom scare you off in em?

 

[CCM-MD]

Don’t do IM/EM/CCM. Waste of time, near impossible to practice all 3 together. Pick one.

For now I remain happy in CCM. Half a mil for 15 days a month is nice. Future of the specialty is uncertain too many corporations and more midlevel encroachment is inevitable. But every specialty has its pros and cons.

 

[bronx43]

already secured that lambo off a 1.2 mil SPY play fortunately

You got 1.2M at 33 from doing construction? damn we all done messed up doing this medicine bs

 

[IR3A4]

You got 1.2M at 33 from doing construction? damn we all done messed up doing this medicine bs

Nah, option plays aka gambling I got really lucky in several times.

 

[IR3A4]

If money is no object why let doom and gloom scare you off in em?

Not the doom and gloom about money, doom and gloom about what EM is becoming and it becoming something completely different than what drew people to it originally, and also jobs where I want to practice.

 

[chessknt]

Not the doom and gloom about money, doom and gloom about what EM is becoming and it becoming something completely different than what drew people to it originally, and also jobs where I want to practice.

Huh? That is all linked. If you're willing to let the hospital pay you 105k for 40 hrs a week like a mid-level I'm sure you'll be able to do any job you want in em.

 

[IR3A4]

Huh? That is all linked. If you're willing to let the hospital pay you 105k for 40 hrs a week like a mid-level I'm sure you'll be able to do any job you want in em.

I should probably not say money is no object, just not as big of an impact. 1.2 million only goes so far, especially since a decent chunk went to paying off undergrad, grad, and med school.

 

[chessknt]

I should probably not say money is no object, just not as big of an impact. 1.2 million only goes so far, especially since a decent chunk went to paying off undergrad, grad, and med school.

That is less than a years revenue for a derm or onc practice owner or a productive orthopod. That's 5-7 years for a fam med working with a needy population or 4 years for general pulm seeing all Medicare.

 

[IR3A4]

That is less than a years revenue for a derm or onc practice owner or a productive orthopod. That's 5-7 years for a fam med working with a needy population or 4 years for general pulm seeing all Medicare.

That's well and good, but frankly I don't need to be making 1.2mil a year. Making it on what was objectively a foolish financial play that paid off was great, rid me of financial burden, but my life doesn't significantly change between 300-400k/yr to 1.2 mil a year. Especially after growing up on a household income of 65k in a large city (edit: yes yes around drug and alcohol use as well if we are having a suffering competition haha). Rather be doing something I find fulfilling in life.

From our messages it's clear we are two different people, which is fine everyone floats their own boat, and I may very well have a different perspective in the future but that's just not where I stand today.

 

[chessknt]

That's well and good, but frankly I don't need to be making 1.2mil a year. Making it on what was objectively a foolish financial play that paid off was great, rid me of financial burden, but my life doesn't significantly change between 300-400k/yr to 1.2 mil a year. Especially after growing up on a household income of 65k in a large city. Rather be doing something I find fulfilling in life.

From our messages it's clear we are two different people, which is fine everyone floats their own boat, and I may very well have a different perspective in the future but that's just not where I stand today.

I grew up on less than that on public assistance around drugs and alcohol abuse and I thought the same thing when I was early on too. It is why I didn't really care and went the pulm route when everyone else was doing cards and onc in my program--i liked the ICU and it was fun.

But now I see these same people missing no holidays with the family, working no nights, building businesses worth 8 figures all while earning multiples of what I do because of the way the game is rigged against hospital based specialties or non procedural specialties that predominantly treat old people. My patients rarely care or express any appreciation for my help. Endless emails, committees full of useless bloat and bull**** that have no bearing on useful patient care, inbox messages, readmission rates blah blah blah. The admin and CMS certainly don't care.

You're going to do whatever and good luck to you but know that you will not be the same person 8 years from now and that 300k paycheck is going to look weak sauce knowing you could have done a lot better if you had made different choices because in the end it just turns in to a job. Em and ccm are dependent on the hospital which is really bad for the future I think. Pulm isn't but is extremely vulnerable to cms pay cuts which seem neverending.

 

[grt398]

If you're going to do CCM, I still recommend the PCCM route if possible. It opens the most job opportunities by far, and you can find plenty of positions with very minimal clinic (as few as two half days/month) or even no clinic at all (just ICU + inpatient pulm consults). And lots of private practices want you to be able to do pulm consults.

 

[bronx43]

I grew up on less than that on public assistance around drugs and alcohol abuse and I thought the same thing when I was early on too. It is why I didn't really care and went the pulm route when everyone else was doing cards and onc in my program--i liked the ICU and it was fun.

But now I see these same people missing no holidays with the family, working no nights, building businesses worth 8 figures all while earning multiples of what I do because of the way the game is rigged against hospital based specialties or non procedural specialties that predominantly treat old people. My patients rarely care or express any appreciation for my help. Endless emails, committees full of useless bloat and bull**** that have no bearing on useful patient care, inbox messages, readmission rates blah blah blah. The admin and CMS certainly don't care.

You're going to do whatever and good luck to you but know that you will not be the same person 8 years from now and that 300k paycheck is going to look weak sauce knowing you could have done a lot better if you had made different choices because in the end it just turns in to a job. Em and ccm are dependent on the hospital which is really bad for the future I think. Pulm isn't but is extremely vulnerable to cms pay cuts which seem neverending.

I totally agree with the majority of your sentiments, though I would say that most “8 figure businesses“ in healthcare are built on sand. It’s totally different from a normal business where you can generate that revenue and profit with little to no third party risk. Everything in healthcare is reliant on holding out your hand begging for scraps from CMS. It just so happens that some get more scraps than others.

I’m fairly confident in my forecast that you’ll see the house of cards collapse for healthcare over the next 2-3 years. For a lot of these procedural fields, the pain may be a lot higher due to a higher starting position.

 

[KGUNNER1]

Hey all,

Got to do a crit care rotation and fell absolutely in love. It checked every single one of my boxes (minus being able to talk to patients since most are sedated/vented but it's still rewarding talking to families). I was initially on the EM train coming into med school but what with the doom and gloom as well as now my interest in CC I've been able to stifle it... somewhat. I know there are a couple of EM/IM/CC programs in the country. What does one's career look like after doing one of these programs? Are there any unique opportunities offered to this route over the PCCM route (outside of being able to work in the ED). If I go the IM route I would do Pulm/CC but frankly outside of the procedures I'm not that interested in other aspects of pulm such as clinic (I love being in the hospital >> clinic). I'm also interested in somethings you get to see a lot in the ED (ultrasound, tox, etc).

Anyways hoping to get some people's input.

First post in a long time. Enjoy seeing that this is still being discussed on SDN. Back in the day I was trying to convince everyone that "boards were coming...". A lot has changed, but many things haven't.

IR3A4 you as a good question. If you are straight IM, then you can do a CC fellowship and flip between Hospitalist and ICU schedules if you really love that. Most intensivists I know wouldn't. You might find more value in the community though, not much in the academic world.

Pulmonary offers the most job options, but it's only worth it if you really like pulmonary. If you don't, then you'll be spending a significant part of your time just "punching the clock".

Some really cool and interesting combinations have been Nephrology and Cardiology along with CCM. 2 years of fellowship followed by 1 year of CC fellowship. Many academic shops are wanting cardiologists trained in CC to work/run their CCU. Nephrologists are excellent intensivists and if you really enjoy that, it seems like they can find nephrology jobs everywhere. CC is always going to be tough to find in academics.

Good luck!

Cheers,
Kyle