EM Pain Fellowship vs CC? Kind of want out of EM. Any advice?

[Dr.CCM]

You seem a bit angry about something and many of your questions seem rhetorical, but I’ll do my best to try and answer them

Yes, time will be split between ICU and clinic. There has be a slow move towards the development of Post-ICU care clinics, I have been in touch with a few hospitals that are very supportive of the idea. You are right that they have run into issues with funding over time. The clinic I envision will likely begin as a traditional pain clinic with a slow referral of post ICU patients. Once the clinic has been built up or reimbursements change in a away that makes post ICU care solely sustainable then will transition to a main focus of post ICU care.

Also, thank you for the advice. I understand the barriers and sacrifice necessary to make a novel idea no longer novel.

I realize that much of medicine nowadays is based off capitalism and profits. But unfortunately, some important aspects of patient care are non-profitable until you show the true importance of it.

You also seem to be very concerned about my quality of life and financial well being, and to have some distain towards academia or “ivory tower”. If it reassures you, I did work in the community for many years in order to pay off my loans and to invest a considerable amount of money to where I could be financially comfortable and allow my money to make money.

I hope this answers most of your questions, I’m sure that I may have overlooked some, as much was said. And finally, thanks for the words of encouragement

I’m EM/CC too. Is your plan to do 1 week unit then pain clinic for a week or two and then EM? I like your idea of your referral network but so many patients we send out of the unit don’t have chronic pain from their initial insult that required ICU admission. I work in a community med/surg icu. It might be better to just own/staff a bunch of LTACs or SNFs imo. Are you just giving them your info once you send them to floor? Is it mostly trauma/surgical base where you practice in CCM? Or lots of cancer? I’ve consulted pain management one time during fellowship/attending life in the ICU. And that was per policy. I don’t think I would ever refer any of the patients I’ve treated in the ICU to a pain clinic after they leave the ICU. This is interesting though.

I will say people who quote that you are making a 1 million dollar commitment, that’s if you can stomach EM full time. Many can’t. You’ll have more longevity in CC or Pain than a pit EM DPC without a doubt in the community. You may end up earning significantly more because you enjoy your job and aren’t looking to retire immediately after starting your career so you actually have a 30-40 year career. This is a very interesting pathway.

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[dchristismi]

Actually, this integration of a post ICU clinic with ongoing care probably more the role of Palliative than pain, and one such integration was presented at the AAHPM meeting and it was with a burn unit... that was the first time I'd heard of post-ICU syndrome, although it makes perfect sense that someone - especially with a LONG ICU stay would need ongoing care beyond just pain. I mean, it's really PTSD. Palliative does all of that and can do it well. I know this was an academic center, and they did utilize a lot of ancillary services that wouldn't typically be seen in a pulm clinic.

 

[Groove]

You seem a bit angry about something and many of your questions seem rhetorical, but I’ll do my best to try and answer them

Yes, time will be split between ICU and clinic. There has be a slow move towards the development of Post-ICU care clinics, I have been in touch with a few hospitals that are very supportive of the idea. You are right that they have run into issues with funding over time. The clinic I envision will likely begin as a traditional pain clinic with a slow referral of post ICU patients. Once the clinic has been built up or reimbursements change in a away that makes post ICU care solely sustainable then will transition to a main focus of post ICU care.

Also, thank you for the advice. I understand the barriers and sacrifice necessary to make a novel idea no longer novel.

I realize that much of medicine nowadays is based off capitalism and profits. But unfortunately, some important aspects of patient care are non-profitable until you show the true importance of it.

You also seem to be very concerned about my quality of life and financial well being, and to have some distain towards academia or “ivory tower”. If it reassures you, I did work in the community for many years in order to pay off my loans and to invest a considerable amount of money to where I could be financially comfortable and allow my money to make money.

I hope this answers most of your questions, I’m sure that I may have overlooked some, as much was said. And finally, thanks for the words of encouragement

Don't take it personal, I'm just speaking my thoughts. I don't have much of a filter posting on SDN after a long shift. I envy your idealism. I guess I'm more of a cynical, skeptical pragmatist. I'm probably way too risk averse to branch out like some of you seem to have done with your careers on here. Good luck to you!

 

[Franzd'Epinay]

Yes, time will be split between ICU and clinic. There has be a slow move towards the development of Post-ICU care clinics, I have been in touch with a few hospitals that are very supportive of the idea. You are right that they have run into issues with funding over time. The clinic I envision will likely begin as a traditional pain clinic with a slow referral of post ICU patients. Once the clinic has been built up or reimbursements change in a away that makes post ICU care solely sustainable then will transition to a main focus of post ICU care.

I have not heard of this before. What are some of thee things that you want to provide to post-ICU patients in the clinic that their PCP can't?

 

[dchristismi]

From Weill Cornell, for example (copied from their website), which is a Pulmonary/Critical Care outpatient service. Since this is a relatively newly recognized problem, using a multidisciplinary team familiar with the nuances of ICU care and having a lot of time seem key.

ICU Care after the ICU​

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Our expert, critical-care trained physicians, nurse practitioners, and psychologists will work with you to evaluate your physical, emotional and cognitive needs.​

​

We take a holistic approach to care after the ICU. In addition to a thorough medical exam, basic pulmonary and strength testing, we screen for anxiety, depression, sleep disorders and PTSD.​

​

We ensure you are taking the right medicines, have all the equipment you need at home and are referred to appropriate specialists, including physical therapy, acupuncture and mental health services.​

​

What is Post-Intensive Care Syndrome? (PICS)​

​

Post-Intensive Care Syndrome (PICS) can be identified by the following symptoms:​

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· Physical limitations. After critical illness, some people are unable to return to work or to care for themselves without help.​

​

· Cognitive impairment. People who survive critical illness may notice new problems with memory and complex decision making.​

​

· Mental health issues. After an ICU stay, people are at risk for Post-Traumatic Stress symptoms, depression and anxiety as well as poor sleep.​

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· Underlying medical conditions. Chronic medical problems may be diagnosed while in the hospital or may be exacerbated by critical illness​

​

Who is affected by PICS?​

​

If you were diagnosed with sepsis, septic shock, delirium or severe respiratory failure on mechanical ventilation (a ventilator), you may be at risk for PICS.​

​

What to Expect During Your Visit​

​

· Visits may last up to 2 hours​

​

· Meetings with one or two physicians, a nurse practitioner, a psychologist and other medical staff​

​

· Testing including blood tests, pulmonary function tests, and a walking test to assess distance walked in 6 minutes and need for oxygen​

​

· Referrals to physical therapy, if needed, and to other physician specialists if you don't already have expert care for your specific needs​

​

· Communication with you and your family or loved ones. We will stay in touch with your primary doctor to help coordinate your care.​

​

Our Weill Cornell Medicine Partners​

​

We partner with experts and specialists across Weill Cornell Medicine to provide comprehensive, individualized care. Our partners include:​

​

· Integrative Health and Wellbeing​

​

· Center for Sleep Medicine​

​

· Collaborative Care Center​

​

· Program for Anxiety and Traumatic Stress​

 

[swamprat]

Ok since I’m actually a pain doc I will say that it is an extremely dumb idea. I don’t see any ICU patients in the clinic- at least not from discharge from ICU. I see chronic back pain due to an accident or being old. I do injections and write medications. Nothing to do with ICU

 

[RandomChaos]

I’m EM/CC too. Is your plan to do 1 week unit then pain clinic for a week or two and then EM? I like your idea of your referral network but so many patients we send out of the unit don’t have chronic pain from their initial insult that required ICU admission. I work in a community med/surg icu. It might be better to just own/staff a bunch of LTACs or SNFs imo. Are you just giving them your info once you send them to floor? Is it mostly trauma/surgical base where you practice in CCM? Or lots of cancer? I’ve consulted pain management one time during fellowship/attending life in the ICU. And that was per policy. I don’t think I would ever refer any of the patients I’ve treated in the ICU to a pain clinic after they leave the ICU. This is interesting though.

I will say people who quote that you are making a 1 million dollar commitment, that’s if you can stomach EM full time. Many can’t. You’ll have more longevity in CC or Pain than a pit EM DPC without a doubt in the community. You may end up earning significantly more because you enjoy your job and aren’t looking to retire immediately after starting your career so you actually have a 30-40 year career. This is a very interesting pathway.

I probably will not do too much EM. But, yes I will do a week in the ICU and then clinic. Similar to how a Pulm/CC schedule is for clinic. In general, up to 50% of ICU patients go on to develop chronic pain, it tends to be a bit under recognized. However, pain will not be my entire focus. My main focus will be Post-ICU care, and Pain will be my way of getting into the clinic. The Pulm/CC groups that are developing Post-ICU care clinic do not focus solely on pulmonary issues, they focus on the overall Post-ICU care.

In regards to referral base, most of the hospitals that I have spoken to about this are 100% behind this idea. So, most of the referrals will eventually come from incorporating the discharge planner.

Finally, I agree, you would not be consulting pain service while in the ICU often, to be diagnosed with Chronic Post-ICU Pain it needs to be ongoing for 3 months, usually long after you've seen them last. Again, this is more to enhance Post-ICU care than to solely focus on pain.

Also, thanks for the encouraging words. It's a new path, but I think it can be turned into something.

 

[RandomChaos]

I have not heard of this before. What are some of thee things that you want to provide to post-ICU patients in the clinic that their PCP can't?

I think dchristismi summed it up with his post.

 

[RandomChaos]

Ok since I’m actually a pain doc I will say that it is an extremely dumb idea. I don’t see any ICU patients in the clinic- at least not from discharge from ICU. I see chronic back pain due to an accident or being old. I do injections and write medications. Nothing to do with ICU

I agree that most pain docs that are not specifically looking for ICU patients won't find them. But, I am certain that if you look into some of your newer patients history, that they will have a recent ICU stay that triggered their issue. Also, if you are not targeting Post-ICU patients or have no understanding of Post-Intensive Care Syndrome then I agree you should NOT be seeing or treating Post-ICU patients. You see chronic back pain, do injections and write medications because that is the patient population you are looking to serve. I am looking to serve Post-ICU patients, not only their pain needs, but also all of the other sequelae that come with an ICU stay.

 

[swamprat]

I agree that most pain docs that are not specifically looking for ICU patients won't find them. But, I am certain that if you look into some of your newer patients history, that they will have a recent ICU stay that triggered their issue. Also, if you are not targeting Post-ICU patients or have no understanding of Post-Intensive Care Syndrome then I agree you should NOT be seeing or treating Post-ICU patients. You see chronic back pain, do injections and write medications because that is the patient population you are looking to serve. I am looking to serve Post-ICU patients, not only their pain needs, but also all of the other sequelae that come with an ICU stay.

That’s totally fine but I guess what I’m saying is an ACGME pain fellowship isn’t going to train you for that. You probably would be better off going on your own and learning as you go. A pain fellowship will teach you about med management and driving a needle under flouro for bread and butter pain patients

 

[Apollyon]

I think dchristismi summed it up with his post.

Dude, "he's" a "she". You didn't tag it correctly. The "d" in @dchristismi doesn't stand for "Dave".

 

[deuist]

most of the hospitals that I have spoken to about this are 100% behind this idea.

That's because they won't have to pay for your lost income from taking on a second fellowship. From the advertisement listed above, there are no pain management docs listed as being a part of the group, meaning that their presence must not be that important.

 

[Franzd'Epinay]

That's because they won't have to pay for your lost income from taking on a second fellowship.

I don't understand the point you're making. When does a hospital ever pay for lost income during fellowship?

 

[deleted547339]

OP - take it from one of the few EM/CCM folks. This is a bad idea for many reasons. It sounds cool to you but won’t work for many reasons. If you want advice, take it. Find another path. If you want to start a thread to tell everyone more experienced than you that you know more than everyone else, so be it.

 

[Groove]

Why not go big and do a third fellowship in hyperbarics? Incorporate HBOT with all those PICS patients in the Pain clinic. Make it rain lost dolla$ for another year.

 

[deuist]

I don't understand the point you're making. When does a hospital ever pay for lost income during fellowship?

They don't. That's why they're on board with it. I'm sure hospitals would love to credential the IM/EM/cards/gynecologist, but they aren't paying any extra, and now that IM/EM/cards/gynecologist has missed out on several years of lost income. My point is that saying hospitals are receptive to bringing someone on board doesn't hold a lot of weight.