FM Critical Care Fellowships?

[MedicineDoc]

Idonttakecall why do you keep posting all these long posts when you in fact haven't even started residency. Isee you ignored my response to your lengthy post. You are a medical student. You don't know what you are talking about.

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[IdontTakeCall]

Idonttakecall why do you keep posting all these long posts when you in fact haven't even started residency. Isee you ignored my response to your lengthy post. You are a medical student. You don't know what you are talking about.

I didn't ignore your post I just though it didn't say anything useful. I am done with school, just waiting for July first so he's I guess that makes you technically correct I'm still a student on vacation for the next 3 months. Either way, it doest change the fact that I've worked win lots of residents from different programs and what I said was what I witnessed from my time. If I made this post 4 months from now as a resident would that change it's validity, not at all. My opinion is my opinion from my experience, you just disagree with it and that's fine. I guess I'll just revisit the thread on July first as a resident because according to your logic, my knowledge will be vastly different then...stop personally attacking me because we have differing opinions on the topic.

 

[IdontTakeCall]

Idonttakecall why do you keep posting all these long posts when you in fact haven't even started residency. Isee you ignored my response to your lengthy post. You are a medical student. You don't know what you are talking about.

I didn't ignore your post I just though it didn't say anything useful. I am done with school, just waiting for July first so I guess that makes you technically correct I'm still a student on vacation for the next 3 months. Either way, it doest change the fact that I've worked with lots of residents from different programs and what I said was what I witnessed from my time. If I made this post 4 months from now as a resident would that change it's validity, not at all. My opinion is my opinion from my experience, you just disagree with it and that's fine. I guess I'll just revisit the thread on July first as a resident because according to your logic, my knowledge will be vastly different then...stop personally attacking me because we have differing opinions on the topic.

 

[MedicineDoc]

I didn't ignore your post I just though it didn't say anything useful. I am done with school, just waiting for July first so I guess that makes you technically correct I'm still a student on vacation for the next 3 months. Either way, it doest change the fact that I've worked with lots of residents from different programs and what I said was what I witnessed from my time. If I made this post 4 months from now as a resident would that change it's validity, not at all. My opinion is my opinion from my experience, you just disagree with it and that's fine. I guess I'll just revisit the thread on July first as a resident because according to your logic, my knowledge will be vastly different then...stop personally attacking me because we have differing opinions on the topic.

In July you will be just a first year resident. You are arguing with people who take care of ICU patients all the time.

 

[IdontTakeCall]

You are a medical student. You don't know what you are talking about.

I see you are one of those residents who feel that when june 30th clicks over to july first, your medical knowledge quadruples and you can now step on all of the medical students forgetting you were one only a very short time ago. You are the resident we tell the PDs 'please dont put us with him he doens't value our opinion at all and feels students are all incompetent'. I'm done with this thread I voiced my opinions and you spit on them and in my face because I havent started residency yet and are thus 'beneath' your vast intelligence. Get over yourself prick and respect people for their opinions. I don't see attendings telling residents, what you think means nothing because you're just a resident. They just respectfully disagree. Thanks for your time o wise master.

 

[IdontTakeCall]

In July you will be just a first year resident. You are arguing with people who take care of ICU patients all the time.

If it said resident as my status you would not have known if I was a new intern or a third year all you would see is resident, and thus your response would have been undr the assumption that all residents regardless of where they are in training have the same validity in their opinions. What you are sir, is condescending.

 

[MedicineDoc]

I see you are one of those residents who feel that when june 30th clicks over to july first, your medical knowledge quadruples and you can now step on all of the medical students forgetting you were one only a very short time ago. You are the resident we tell the PDs 'please dont put us with him he doens't value our opinion at all and feels students are all incompetent'. I'm done with this thread I voiced my opinions and you spit on them and in my face because I havent started residency yet and are thus 'beneath' your vast intelligence. Get over yourself prick and respect people for their opinions. I don't see attendings telling residents, what you think means nothing because you're just a resident. They just respectfully disagree. Thanks for your time o wise master.

Do you really think it's appropriate for a medical student to post lengthy posts in the fm forum on how an entire specialty is unqualified for hospital work when it is clearly within our scope of practice and a large portion of us do this kind of work?

 

[IdontTakeCall]

Do you really think it's appropriate for a medical student to post lengthy posts in the fm forum on how an entire specialty is unqualified for hospital work when it is clearly within our scope of practice and a large portion of us do this kind of work?

Hospital work? Im pretty sure the thread said Critical Care. And from the conversations I have had with multiple FP attendings and Chief residents I have worked with, they have all said their needs to be more critical care training and inpatient medicine training as more and more of their graduates are leaving outpatient primary care and becoming hospitalists despite spending less than 1/4 the time in the hospital as their IM counterparts. Like I said, its my opinion from what I have seen and what I have been told by those who have practiced FP and precepted FP residents for many years. In 2 years I doubt my opinion will have changed but I guess it will be more prudent to post it then. Apparently this offeneded you so I apologize, I did not mean to put down your field and ability to care for patients, though clearly you are questioning mine.

 

[IdontTakeCall]

Better yet, next time ill just leave my status blank like yours and then you won't know Im a medical student and thus value my opinion more i guess...

 

[MedicineDoc]

I see you are one of those residents who feel that when june 30th clicks over to july first, your medical knowledge quadruples and you can now step on all of the medical students forgetting you were one only a very short time ago. You are the resident we tell the PDs 'please dont put us with him he doens't value our opinion at all and feels students are all incompetent'. I'm done with this thread I voiced my opinions and you spit on them and in my face because I havent started residency yet and are thus 'beneath' your vast intelligence. Get over yourself prick and respect people for their opinions. I don't see attendings telling residents, what you think means nothing because you're just a resident. They just respectfully disagree. Thanks for your time o wise master.

Does the patient magically become different once they hit the hospital? Hospitalization represents nothing more than a need for closer monitoring and possibly some supportive measures and definitive testing and possibly a procedure or two. There is nothing magic about the hospital or the icu. Vent management and pressor drips and more intensive nursing. The patient is the same and hospitalization is a continuation of outpatient care.

 

[MJB]

Technically, I've found that "hospital work" is a little "easier" than outpatient work.

As for the amount of CC and inpatient work between IM and FP residencies, the biggest reason for choosing FM versus IM was the fact that I didn't want that much inpatient/CC experience/torture.


To the derm guy, my "good lord" had very little to do with any posted content and everything to do with your attitude.

 

[Xerxes1729]

I'm doing EM, with an eye to a CCM fellowship. I see IDontTaleCall's point, regarding a fellowship that doesn't eliminate the need for the intensivist being of questionable worth. On the other hand, given all the battles EM has had to fight, I think those of us in it should be careful about trying to dictate other specialties' scopes of practice.

 

[IdontTakeCall]

I'm doing EM, with an eye to a CCM fellowship. I see IDontTaleCall's point, regarding a fellowship that doesn't eliminate the need for the intensivist being of questionable worth. On the other hand, given all the battles EM has had to fight, I think those of us in it should be careful about trying to dictate other specialties' scopes of practice.

You are correct there. As the ABIM/ABEM agreement to allow us to do CCM still hasnt had time to let the ink dry perhaps I should have chosen my words more carefully. Granted EM grads have been filling anesthesia and surgery CC spots for close to a decade. Either way this thread has turned into an arguement and has long past what the OP was searching for.

 

[lowbudget]

Well for starters, I think that there is a somewhat arbitrary eyeball test that you know it when you see it. If you are advertising yourself as a "skin specialist" or trying to pass yourself off as "fellowship trained in dermatology" then you are probably are going too far. This is what this thread is clearly about. People who want there to be a critical care fellowship so they can abandon fm and be a ccm doctor instead. Or likewise do a fellowship in any number of specialities from cardiology to gi so they can advertise as such and transition into a narrower specialty field.

So your issue is with advertisement, and not really with scope of practice or the actual care itself?

 

[lowbudget]

In another light I think of it like this, if after 3 years of residency trying to support my wife and kids on 45k a year or so while working 80 hours a week, I then say to my wife, honey, I know I'm now an attending and can go work and end this 11 year long run as a student and resident and start working on our 350k in student loans, but instead I'm gonna do a fellowship for 2 years at 55k or so a year again at the end of which I will not make any more money nor be able to realistically do anything different than before... But I'll have a much better knowledge base of my icu patients, which are a minisculy small percentage of the patients in my practice, but not be able run the icu and command the intensivists salary....she'll say good for you, I'll get the divorce papers drawn up.

Agree 100%. I wouldn't do a fellowship if there was no chance I'd be able to use it if I wanted to. Your point is logical and common sense.

If I were to do this hypothetical fellowship in critical care and the hospital I applied for privileges wouldn't grant it because I'm not IM/Pulm/CC but instead a "FM/CC", I would simply find another hospital where those privileges would be granted, right? It's simple as that.

This hypothetical fellowship wouldn't appeal to you if you wanted to work in a place where CC doctors are required to be IM/Pulm trained. *Therefore*, the purpose of the fellowship would be to train FP's who are in communities where there aren't enough IM/Pulm/CC doctors who would "run" the ICU (my definition of "running an ICU" = close it off such that all patients must have me consulted in order to get a bed in the ICU). There are a LOT of these communities out there in middle America where GIM and FP's serve as the primary attending and consult specialists appropriately. I know it's hard to imagine that when most of your training is in an academic medical center, but that's the reality.

The analogy is with EM/CC. Why would you do a fellowship in CC if the hospital/facility you worked at won't grant you CC privileges, or doesn't have CC capabilities at all? If you were EM/CC trained, you would look for a place that has a need for those skills, right? Well, the same is true for FM/CC. You can argue the "difference" between EM and FM all you want in academic terms, but in real life, outside of academia, we're just interested in taking care of our patients and our communities. So, if that means that my emergency room doctor has advanced training in critical care, THANK YOU! If my personal family doctor happens to also have critical care training, YES, can I be your patient! Because the alternative in some of these communities is that you have no one who is capable of doing critical care! And you/I end up transferring unstable patients or you/I end up asking families to sign out AMA or not-call-911-but-instead-drive-to-the-academic-medical-center (which I've done before to get patients to the appropriate level of care with the appropriate resources available).

So to answer Blue Dog's challenge to provide a compelling reason for FM route to "specialization", I say, well, it's to provide better care in communities where there are gaps in care.

 

[MedicineDoc]

Just to refute some of the misinformation posted by medical students on this thread I have looked over our curriculum and there are 5 months total of outpatient rotations. During these outpatient months residents still see their patients in the hospital, take quite a bit of hospital call, keep all the pts they admit until they are discharged, and do ER shifts from 5 pm to 10 pm several days per week during second year. Additionally, their is moonlighting in the ER and urgent care centers. Rotations include pulmonology, 2 months of cardiology, ortho, in patient/outpatient urology, inpatient/outpatient neurology, IM hospitalist, inpatient FM (same as hospitalist but different service), icu, inpatient/outpatient surgery, inpatient GI ect... We are in and out of the hospital and ER all day on just about every rotation. The clinic is adjacent to the hospital and we are constantly walking back and forth.

 

[jdh71]

I've been following the conversation for a few days, and I'm a pretty libertarian kind of a guy. I've got no real beef with FM taking care of their own patients in the unit in the abstract, especially as many have pointed out their ward months in residency in FM have prepared them to handle their ICU patients. So, assuming this is the basis for not needing the CC consult from the medicine peeps, what utility do you guys think that there is for someone to do an actual critical care fellowship at all. The two extra years are useless then? The next question from me, then, would be if the extra two years are NOT useless, then why become indignant with a mandatory consult for the sickest patients in the hospital?

 

[IdontTakeCall]

Just to refute some of the misinformation posted by medical students on this thread I have looked over our curriculum and there are 5 months total of outpatient rotations. During these outpatient months residents still see their patients in the hospital, take quite a bit of hospital call, keep all the pts they admit until they are discharged, and do ER shifts from 5 pm to 10 pm several days per week during second year. Additionally, their is moonlighting in the ER and urgent care centers. Rotations include pulmonology, 2 months of cardiology, ortho, in patient/outpatient urology, inpatient/outpatient neurology, IM hospitalist, inpatient FM (same as hospitalist but different service), icu, inpatient/outpatient surgery, inpatient GI ect... We are in and out of the hospital and ER all day on just about every rotation. The clinic is adjacent to the hospital and we are constantly walking back and forth.

Your curriculum is Very Very Very different from the normal FP residency curriculum. Take a look at 20-30 other programs besides your own. You will find they do far less than yours, that said it's good that yours does so much because it certainly makes you and your co-residents more prepared than the avg FP grad.

 

[MedicineDoc]

I've been following the conversation for a few days, and I'm a pretty libertarian kind of a guy. I've got no real beef with FM taking care of their own patients in the unit in the abstract, especially as many have pointed out their ward months in residency in FM have prepared them to handle their ICU patients. So, assuming this is the basis for not needing the CC consult from the medicine peeps, what utility do you guys think that there is for someone to do an actual critical care fellowship at all. The two extra years are useless then? The next question from me, then, would be if the extra two years are NOT useless, then why become indignant with a mandatory consult for the sickest patients in the hospital?

When I think back over all the icu patients I have had I really can't think of an instance where it would have been helpful to have a critical care fellow. If I needed renal, urology, cardiology or pulmonology I consulted them. If the patient needed to be shipped I shipped them ( we don't have neurosurgery).

 

[jdh71]

When I think back over all the icu patients I have had I really can't think of an instance where it would have been helpful to have a critical care fellow. If I needed renal, urology, cardiology or pulmonology I consulted them. If the patient needed to be shipped I shipped them ( we don't have neurosurgery).

So then it is your contention that a critical care fellowship is a useless waste of time then?

 

[MedicineDoc]

So then it is your contention that a critical care fellowship is a useless waste of time then?

No I can see where it might fit into a certain model of care but I never felt like we didn't have our bases covered at our hospital. I have seen the other side of it at another hospital where a critical care guy will give the world according to him routine with a flurry of orders for this and that. I question whether it accounted for much when it came down to patient outcome but it made for good drama when he was bitching out the IM resident. Whatever floats your boat.

 

[jdh71]

No I can see where it might fit into a certain model of care but I never felt like we didn't have our bases covered at our hospital. I have seen the other side of it at another hospital where a critical care guy will give the world according to him routine with a flurry of orders for this and that. I question whether it accounted for much when it came down to patient outcome but it made for good drama when he was bitching out the IM resident. Whatever floats your boat.

Might fit? Ok.

So is this critical care business merely a cynical ploy to keep FM and GIM out of the unit? I'm curious to your opinion as to why anesthesia, surgery, and IM all offer fellowships in and grant board certs in critical care then, if it's all a stage-show.

 

[MedicineDoc]

Might fit? Ok.

So is this critical care business merely a cynical ploy to keep FM and GIM out of the unit? I'm curious to your opinion as to why anesthesia, surgery, and IM all offer fellowships in and grant board certs in critical care then, if it's all a stage-show.

As I said we have pulmonology, cardiology, and anesthesia that fill whatever roll there might have been there. When you refer to critical care what specific function/procedure are you referring to?

 

[jdh71]

As I said we have pulmonology, cardiology, and anesthesia that fill whatever roll there might have been there. When you refer to critical care what specific function/procedure are you referring to?

I'm not sure if you're trying to dodge my question or sincerely do not understand what I am asking. If all you really need for critical care are the help of certain sub-specialists, then why do anesthesia, surgery, and IM all offer critical care specific fellowships and board certifications. Is it a cynical ploy?

 

[MedicineDoc]

I'm not sure if you're trying to dodge my question or sincerely do not understand what I am asking. If all you really need for critical care are the help of certain sub-specialists, then why do anesthesia, surgery, and IM all offer critical care specific fellowships and board certifications. Is it a cynical ploy?

Why don't you tell me you seem to be presenting yourself as the expert on critical care specialization. If you feel like you have some information that would contribute to this thread then spit it out. It is you who dodged the above question. Are you talking about treating sepsis, arrythmias, managing the vent, tube feeds?

 

[jdh71]

Why don't you tell me you seem to be presenting yourself as the expert on critical care specialization. If you feel like you have some information that would contribute to this thread then spit it out. It is you who dodged the above question. Are you talking about treating sepsis, arrythmias, managing the vent, tube feeds?

I haven't presented myself as anything. You seem to be getting defensive. Why? All I'm asking is: if a critical fellowship and specific critical critical care training are superfluous to treating patients in the unit because all you need are consulting sub-specialists, then why do you think that surgery, anesthesia, and IM all have critical care specific fellowships with a corresponding critical care board certification. What is it that they don't understand here? Is it a cynical ploy? I've simply been trying for three posts now to get you to address that question. And it now does appear that you have dodged the question. Which, to me, signals either 1) you do not want to answer the question, or 2) can't answer the question . . . though I did initially give you the benefit of the doubt that you did not understand what I was asking. I'm not sure if you're overcompensating here for feelings of insecurity, or are merely lacking in humility.

 

[VA Hopeful Dr]

I've been following the conversation for a few days, and I'm a pretty libertarian kind of a guy. I've got no real beef with FM taking care of their own patients in the unit in the abstract, especially as many have pointed out their ward months in residency in FM have prepared them to handle their ICU patients. So, assuming this is the basis for not needing the CC consult from the medicine peeps, what utility do you guys think that there is for someone to do an actual critical care fellowship at all. The two extra years are useless then? The next question from me, then, would be if the extra two years are NOT useless, then why become indignant with a mandatory consult for the sickest patients in the hospital?

I think many FPs are adequately trained for most ICU work. CC-trained IMs are just better at it. At my hospital, we usually consult CC if our unit patients get past a certain level of sick - attending dependent generally. I think that's the biggest difference, most FPs that I know even if they follow their own ICU patients still have a comfort zone and past that, we need a specialist just like with everything else we do.

 

[MedicineDoc]

I haven't presented myself as anything. You seem to be getting defensive. Why? All I'm asking is: if a critical fellowship and specific critical critical care training are superfluous to treating patients in the unit because all you need are consulting sub-specialists, then why do you think that surgery, anesthesia, and IM all have critical care specific fellowships with a corresponding critical care board certification. What is it that they don't understand here? Is it a cynical ploy? I've simply been trying for three posts now to get you to address that question. And it now does appear that you have dodged the question. Which, to me, signals either 1) you do not want to answer the question, or 2) can't answer the question . . . though I did initially give you the benefit of the doubt that you did not understand what I was asking. I'm not sure if you're overcompensating here for feelings of insecurity, or are merely lacking in humility.

The answer is I don't need a critcal care specialist where I work. If I were at a hospital where certain specialist did not perform certain functions then yeah maybe a critical care specialist might be needed. The same answer I gave you above. False argument techniques seem to be your specialty.

 

[jdh71]

I think many FPs are adequately trained for most ICU work. CC-trained IMs are just better at it. At my hospital, we usually consult CC if our unit patients get past a certain level of sick - attending dependent generally. I think that's the biggest difference, most FPs that I know even if they follow their own ICU patients still have a comfort zone and past that, we need a specialist just like with everything else we do.

I get that

 

[jdh71]

The answer is I don't need a critcal care specialist where I work. If I were at a hospital where certain specialist did not perform certain functions then yeah maybe a critical care specialist might be needed. The same answer I gave you above. False argument techniques seem to be your specialty.

Yes. It is the same answer. You unfortunately have the same problem, twice. You still did not answer the question I asked.

I also fail to see where your accusation about "false argument techniques" has any credibility. I've not made any arguments yet. All I did was ask you a question, which you have decided not to answer more than once. I think that speaks volumes.

 

[MedicineDoc]

Yes. It is the same answer. You unfortunately have the same problem, twice. You still did not answer the question I asked.

I also fail to see where your accusation about "false argument techniques" has any credibility. I've not made any arguments yet. All I did was ask you a question, which you have decided not to answer more than once. I think that speaks volumes.

You've hit upon about six false arguments. Here they are for your perusal. I'll leave it to you to identify them (ie failure to state, false question, argument by vehemence ect....)

http://www.don-lindsay-archive.org/skeptic/arguments.html#consequent

 

[jdh71]

You've hit upon about six false arguments. Here they are for your perusal. I'll leave it to you to identify them (ie failure to state, false question, argument by vehemence ect....)

http://www.don-lindsay-archive.org/skeptic/arguments.html#consequent

Dude, all I did was ask you ONE question which you have refused to answer, and after that I simply further requested an answering of my first question. None of that is a false argument or a fallacy. Are you always this much of an intellectually dishonest DB?

 

[MedicineDoc]

Dude, all I did was ask you ONE question which you have refused to answer, and after that I simply further requested an answering of my first question. None of that is a false argument or a fallacy. Are you always this much of an intellectually dishonest DB?

No " DUDE " I answered your question.

 

[jdh71]

No " DUDE " I answered your question.

No you haven't. Here is the question (again): "if a critical fellowship and specific critical critical care training are superfluous to treating patients in the unit because all you need are consulting sub-specialists, then why do you think that surgery, anesthesia, and IM all have critical care specific fellowships with a corresponding critical care board certification"? (quoted from above)

I don't even care if you speculate, but you've not answered that question. I'm not sure how you can even possibly think you've answered that question. You've reiterated to me how you work, but that not an answer to the question I asked.

 

[MedicineDoc]

No you haven't. Here is the question (again): "if a critical fellowship and specific critical critical care training are superfluous to treating patients in the unit because all you need are consulting sub-specialists, then why do you think that surgery, anesthesia, and IM all have critical care specific fellowships with a corresponding critical care board certification"? (quoted from above)

I don't even care if you speculate, but you've not answered that question. I'm not sure how you can even possibly think you've answered that question. You've reiterated to me how you work, but that not an answer to the question I asked.

Why do you feel it is my responsibility to answer your question? The pulmonologist I have worked with described it as a power grab and was grandfathered in. I don't have an opinion on it and it doesn't matter to me.

 

[Hernandez]

I see you are one of those residents who feel that when june 30th clicks over to july first, your medical knowledge quadruples .

Nope, it doesn't quadruple, interns are idiots too.....

I don't see attendings telling residents, what you think means nothing because you're just a resident. They just respectfully disagree.

I see attendings tell residents all the time that they're wrong and they need to stop acting like the know what the hell their doing and learn to ask for help cause their caviler attitude can kill people. I've made my point more than a few times when interns/residents overstep their bounds and do something stupid that could or did harm a pt.

No " DUDE " I answered your question.

I'm with JDH, I don't see a straight answer, just something about how the other subspecialties seem to have all the procedures covered and you saw a CC dude at another hospital give flurries of orders and bitch out IM residents......

 

[Hernandez]

Why do you feel it is my responsibility to answer your question? The pulmonologist I have worked with described it as a power grab and was grandfathered in.

and at somepoint an IM doc called subspecialization into cards/pulm/etc as a power grab as well....

 

[jdh71]

Why do you feel it is my responsibility to answer your question? The pulmonologist I have worked with described it as a power grab and was grandfathered in. I don't have an opinion on it and it doesn't matter to me.

Responsibility? I don't know about that, but I do think you have a lot of temerity pulling this new tactic after trying to lecture me about argument and debate.

You won't answer the question. Noted. Thanks.

 

[MedicineDoc]

Like I said our patients do fine without critical care specialists. That's the point. I'm not interested in your fascination with critical care as a subspecialty.

 

[Xerxes1729]

No I can see where it might fit into a certain model of care but I never felt like we didn't have our bases covered at our hospital. I have seen the other side of it at another hospital where a critical care guy will give the world according to him routine with a flurry of orders for this and that. I question whether it accounted for much when it came down to patient outcome but it made for good drama when he was bitching out the IM resident. Whatever floats your boat.

Before medical school, I worked in a small, rural hospital, so I'm definitely familiar with the fact that, outside of the academic tertiary center, patients get taken care of without a million subspecialists available 24/7.

But...

There is evidence that ICU staffing by intensivists, with either the closed unit or mandatory consult model, is associated with improved patient outcomes. The Leapfrog report on the issue (http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf) cites a variety of studies on the issue. Intensivist staffing is associated with lower mortality, which is pretty much the most important outcome in my book.

 

[IdontTakeCall]

medicinedoc you keep arguing about how YOU dont need CC people at your hospital and that YOU can handle everything and just consult Cards/Nephro when you need them, which is entirely missing the point of what I was trying to say earlier that now several other people have noted as well. What YOU are doing and are apparently accustomed to at YOUR program is NOT the NORM. 90% of the hospitals around the country have boarded intensivists staffing their ICUs. Whether they have medicine, FM, EM, anesthesia or whatever residency program in house, they still admit their patients to the care of the intensivist when they need an ICU bed. Whether YOU are capable of taking care of said patients without a CC boarded individual, which is not available as an FP, is irrelevant as it is not the standard of care around the country. Im glad you are capable of said care, my point was I don't see the AAFP or any other governing body granting fellowship spots and board certification in CCM to FP grads and allowing them to staff ICUs because a couple of programs like yours exist. The VAST majority of FP programs do not encompass the level of ICU training that yours apparently does. Do a search through FREIDA for the IM residencies in the country and the FP ones and then go to their websites and look at their curriculums. Average IM program has massive amounts more time in the unit and on the floors. Facts are Facts, I never said YOU were incapable of handeling your ICU patients, what I said was that the majority of FP grads will not have had the training required for it and thus are highly unlikely to be given the opportunity to become credentialed in Critical care which more and more hospitals are requiring in order to staff their ICU's.

 

[Hernandez]

. What YOU are doing and are apparently accustomed to at YOUR program is NOT the NORM. 90% of the hospitals around the country have boarded intensivists staffing their ICUs.

That number sounds fictitious.

 

[IdontTakeCall]

That number sounds fictitious.

It might not be as high as 90 but it is certainly more than 2/3. Either Pulm/CC, Straight CC post IM or now EM, EM with european CC boards or Anesthesia with CC are staffing the majority of spots. Their are most definitely more of them than their are people with no CC training other than what they received during their initial residency. I have yet to see one not CC board eligible, from one of the above named tracks in any of the 16 hospitals ive spent time in. A few of them had very skilled hospitalists mixed in covering a few shifts a month that they didnt have CC people for but very few.

 

[smq123]

I've been following the conversation for a few days, and I'm a pretty libertarian kind of a guy. I've got no real beef with FM taking care of their own patients in the unit in the abstract, especially as many have pointed out their ward months in residency in FM have prepared them to handle their ICU patients. So, assuming this is the basis for not needing the CC consult from the medicine peeps, what utility do you guys think that there is for someone to do an actual critical care fellowship at all. The two extra years are useless then? The next question from me, then, would be if the extra two years are NOT useless, then why become indignant with a mandatory consult for the sickest patients in the hospital?

I don't know, either.

Even if you DO do a lot of ICU as an FM resident, at some point, you'll probably need a specialist. In FM, you learn how to handle regular A-fib. Refractory A-fib, though, probably should be kicked up to the EP guy, who might be able to ablate it. We learn how to handle regular pregnancies. Complicated pregnancies, like triplets, gets kicked to OB/MFM. I don't see how this is different from asking a CCM-trained guy for help on a very sick ICU patient.

But after all of that, it still boils down in my mind to, if you wanted to do intensive care, why would you do a primary care residency? They are completely opposite styles of medicine. If I wanted to deliver babies all day and do C/s I'd have gone OB/GYN. If I wanted to sew in valves Id have gone surgery. You went primary care, stick with it. Lord knows we need more anyway or this whole damn health care system is gonna collapse.

Well, I can see some benefit to doing a CCM fellowship and being comfortable running an ICU, even if you don't ever ultimately do so.

Part of the thing about FM is learning how to be ready for anything - partly because of the nature of the specialty, but also because you may not know where you'll end up or what you'll be doing. In some places of the country, there AREN'T enough specialists, so FM ends up doing things that you might not expect - one of my attending's friends ended up in the boonies of Alaska, where there were only 3 physicians in the vicinity (all FM). If a pregnant woman came in and needed a STAT section and couldn't wait to be transported to a bigger hospital, then they all took turns being the primary surgeon, the 1st assist, and the anesthesiologist. (Seriously.) You do what you have to do, sometimes.

So, yeah, I can see the benefit of being very comfortable in the ICU, and comfortable with A-lines, central lines, drips, pressors, and intubation - at least enough so that you can stabilize a patient while Life Flight gets there. If you got that experience in residency, great. If not, and it's something that you want to acquire, then you just find other ways of getting it. Like a fellowship, if they offer something like it.

So, yeah, while you went into primary care, that doesn't mean that you will automatically be working in an outpatient office, doing outpatient medicine. For most, that's the case, but for a lot of people, it isn't.

Likewise, they aren't going to allow me to have an office seeing patients for their primary care nor handle continuity in obstetrics nor pediatric well child visits coming out of as an EM/CC attending, I will not have the experience nor the proper training, and I am ok with that.

I'm glad to see you say this. There are lot of people in the EM forum (granted, most of them are MS3s) who are convinced that they could easily manage someone's long term medical problems after finishing an EM residency, despite having zero experience with continuity clinic - a leap of logic that I fail to follow.

 

[Hernandez]

It might not be as high as 90 but it is certainly more than 2/3. Either Pulm/CC, Straight CC post IM or now EM, EM with european CC boards or Anesthesia with CC are staffing the majority of spots. Their are most definitely more of them than their are people with no CC training other than what they received during their initial residency. I have yet to see one not CC board eligible, from one of the above named tracks in any of the 16 hospitals ive spent time in. A few of them had very skilled hospitalists mixed in covering a few shifts a month that they didnt have CC people for but very few.

The last time I dug through the leapfrog data, the number was 24% if the number was as high as you say, I wouldn't be getting as many recruiting emails or calls on a daily basis as I ma now .

 

[VA Hopeful Dr]

That number sounds fictitious.

I agree. There are 10 hospitals in my state that have residency programs (6 of them FM only). Of those, only 2 have closed ICU/mandatory CC consult. I also know of 4 good sized hospitals that don't have residents and only 1 of them requires CC to be on board in the ICU.

 

[lowbudget]

The last time I dug through the leapfrog data, the number was 24% if the number was as high as you say, I wouldn't be getting as many recruiting emails or calls on a daily basis as I ma now .

Wow, that's interesting. You would think the way people talk about closed ICU's that it would be 90% or whatever. I think it's more than just putting a doctor through fellowship training to be honest. To close an ICU, you need a critical mass of patients, doctors with wide array of specialties, intensivists who can get along and figure out a coverage schedule, institutional support, and the right payer mix. You can make it happen at the university because the institution just makes it happen; but out in the community, it really has to be the perfect storm, which means there're lots of gaps.

I do have a fundamental disagreement with how family medicine residents are trained in critical care. I don't know the rationale in cutting back on the requirements back in 2005, but I don't believe these system-wide changes to close out ICU's are going to happen any time soon. Something like 40% of family physicians provide critical care with an additional 9% who do so with consultation. That's half of all family doctors out there. Now granted, these tend to vary depending on geography, but both new and old school FP's practice critical care medicine regardless.

Maybe these numbers reflect a "minority" (i.e. <50%) of family doctors but the numbers are quite significant if you think about how many patients each one of those doctors take care. If you compare these numbers against those who practice routine OB, it's comparable and should garner the same amount of attention. Certainly, critical numbers outpace the number of FP's who do C-sections, and yet there are a lot more obstetric fellowships geared towards training C-sections than there are critical care fellowships geared towards advanced practice. Maybe the explanation is that our current residency training is "good enough" when it comes to what we need to know in critical care, but I don't feel that our patients are well served when that knowledge becomes extinct and dies in family medicine because newer residents aren't trained properly at certain locales. For this reason, I think critical care fellowships fit the multidisciplinary/interdisciplinary approach to family medicine, and I think it fits within our scope of providing comprehensive care, and I think having academic family physicians trained in critical care is vital in training future family physicians in critical care to serve in the other 76% of the hospitals.

I don't think Pulm/CC, Surg/CC, MFM, Anes/CC, EM/CC or whoever is threatened by FM/CC if it were to happen. For me, without CC fellowship, I'm very comfortable getting people out of DKA because that's just how I trained, but ask me to run a vent on a refractory asthmatic, I'm going to ask for help to prevent a pneumothorax. If I had CC training, I don't think I would replace a pulmonologist, but I might be able to only call him/her if I couldn't get the asthmatic better in, say, 3 days. Where I practice, our ICU's are half-open and half-closed, and the closed ICU intensivists manage 30-35 beds which is a lot of beds (a busy hospitalist with 1 hospital to round between 8a-5p will have 40 patients). I sometimes question if the intensivist who is on is truly capable of managing all those beds at all times. Even they need to sleep/eat. And, since they hand off patients to their intensivist partners within their own group and with intensivists belonging to another group, I question whether or not they're giving proper hand-offs.

I don't think you can say, let's close off the ICU, only train Pulm/CC, Surg/CC and Anesthesia/CC and the magic bullet will solve our mortality/morbidity, our safety, and our job satisfaction problems. How long did it take EM to make that argument?

I think we can all agree that CC is multidisciplinary which by definition means more than one specialty. Barring FP's who are *interested* in critical care so that you can get into a pissing contest over who is "running" the ICU or who can call themselves a "critical care specialist" and who can't is all optics and does nothing to take care of the patient.

 

[jdh71]

Wow, that's interesting. You would think the way people talk about closed ICU's that it would be 90% or whatever. I think it's more than just putting a doctor through fellowship training to be honest. To close an ICU, you need a critical mass of patients, doctors with wide array of specialties, intensivists who can get along and figure out a coverage schedule, institutional support, and the right payer mix. You can make it happen at the university because the institution just makes it happen; but out in the community, it really has to be the perfect storm, which means there're lots of gaps.

I do have a fundamental disagreement with how family medicine residents are trained in critical care. I don't know the rationale in cutting back on the requirements back in 2005, but I don't believe these system-wide changes to close out ICU's are going to happen any time soon. Something like 40% of family physicians provide critical care with an additional 9% who do so with consultation. That's half of all family doctors out there. Now granted, these tend to vary depending on geography, but both new and old school FP's practice critical care medicine regardless.

Maybe these numbers reflect a "minority" (i.e. <50%) of family doctors but the numbers are quite significant if you think about how many patients each one of those doctors take care. If you compare these numbers against those who practice routine OB, it's comparable and should garner the same amount of attention. Certainly, critical numbers outpace the number of FP's who do C-sections, and yet there are a lot more obstetric fellowships geared towards training C-sections than there are critical care fellowships geared towards advanced practice. Maybe the explanation is that our current residency training is "good enough" when it comes to what we need to know in critical care, but I don't feel that our patients are well served when that knowledge becomes extinct and dies in family medicine because newer residents aren't trained properly at certain locales. For this reason, I think critical care fellowships fit the multidisciplinary/interdisciplinary approach to family medicine, and I think it fits within our scope of providing comprehensive care, and I think having academic family physicians trained in critical care is vital in training future family physicians in critical care to serve in the other 76% of the hospitals.

I don't think Pulm/CC, Surg/CC, MFM, Anes/CC, EM/CC or whoever is threatened by FM/CC if it were to happen. For me, without CC fellowship, I'm very comfortable getting people out of DKA because that's just how I trained, but ask me to run a vent on a refractory asthmatic, I'm going to ask for help to prevent a pneumothorax. If I had CC training, I don't think I would replace a pulmonologist, but I might be able to only call him/her if I couldn't get the asthmatic better in, say, 3 days. Where I practice, our ICU's are half-open and half-closed, and the closed ICU intensivists manage 30-35 beds which is a lot of beds (a busy hospitalist with 1 hospital to round between 8a-5p will have 40 patients). I sometimes question if the intensivist who is on is truly capable of managing all those beds at all times. Even they need to sleep/eat. And, since they hand off patients to their intensivist partners within their own group and with intensivists belonging to another group, I question whether or not they're giving proper hand-offs.

I don't think you can say, let's close off the ICU, only train Pulm/CC, Surg/CC and Anesthesia/CC and the magic bullet will solve our mortality/morbidity, our safety, and our job satisfaction problems. How long did it take EM to make that argument?

I think we can all agree that CC is multidisciplinary which by definition means more than one specialty. Barring FP's who are *interested* in critical care so that you can get into a pissing contest over who is "running" the ICU or who can call themselves a "critical care specialist" and who can't is all optics and does nothing to take care of the patient.

Just for the record, I think an FP/CC fellowship would be great thing. I didn't understand the resistance to to EM and critical care in the first place. My point here was largely that I think there is value to specific critical care training (and at least three other specialty boards do as well by granting a specific board certification, including the surgeons and the anesthesia folks and much of their "regular day to day" work is critical care for all intents and purposes), and to simply "poo-poo" that kind of expertise as unecessary or superfluous is either ignorant or frightening arrogant. Do docs in the community deal with what they have to because they have no choice? Of course, both FP, general internal med, and general surgery in smaller places without all of the extra resources. With that said IF our goal is to truly take the best care of patients, then it's definitely my argument that if available for acute, critical illness, then the specialist should be involved.

 

[MedicineDoc]

I said anesthesia, pulmonology, and cardiology filled the role at my hospital. I don't care what study anyone trots out unless it directly comparing my hospital to those with "critical care specialist" it doesn't represent a valid comparison. Your repetitious posts do not make you right. The people who die at our hospital are almost always the ones that would die anywhere regardless. Let's take the surviving sepsis campaign as an example of the great "achievement" of critical care societies. It is what we do but it is more a ritualistic way for those with severe sepsis to die than it is a way to make them live.

 

[jdh71]

I said anesthesia, pulmonology, and cardiology filled the role at my hospital. I don't care what study anyone trots out unless it's a study comparing my hospital to one with a "critical care specialist" it doesn't represent a valid comparison. You repetitious posts do not make you right.

Ironically enough . . . nether do yours

Haha