FM to CC?

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andrewsmack05

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Hello,

I am not exactly sure of where to post this. I asked for permission to get into the practicing physicians but have not been responded to. I am looking for a possible "reality" check and since many of you are learned individuals, I value the opinion of several posters on here. I am currently 33 yo, I graduated at an FM residency this past July. I did not choose the IM route prior because our experience was not that great and I was not exposed to CC at that time. Long story short, the residency that I graduated was an unopposed residency. I did over 13 months of inpatient medicine, we ran surgery and trauma's in the hospital, and I have 4-5 months of ICU time (I chose elective time in there). I graduated with an interest in CC and they elected to keep me on as a "fellow" in their ICU because of how competent I have been. I have over 30 excel pages of procedures that I have done just from residency. Central lines, arterial lines, intubation, ventilator mgmt, thoracentesis, paracentesis, chest tubes, lumbar punctures, thoracotomies (Yes, you read that right, I have 5 of these under my belt), transvenous pacers, swan-ganz catheters, and therapeutic bronchoscopies. I literally do most everything myself. Since I graduated I have worked in our ICU for 1 week/month as my "fellowship." COVID hit. I have been working in COVID ICU units from California to Texas, and to WV. There was a time in December I was a night doc to relieve the ICU physician in Texas because they only had one ICU physician on for 7 days/24 hours and I went into help for the COVID response. This hospital had converted not one but all 6 of its floors to ICU floors. Since there was only one CC doc on, this meant that we were regularly running anywhere between 40-70 ventilators at any one time. At least 3 Code Blues every night (interestingly all of the cardiac patients who came in same day is what it felt like). What I am trying to say there is that I didn't need the help of the CC physician or consultants. As I came to the east coast, there is much more malignancy against FM trainees for whatever reason, I get it. Everything is very specialized on the east coast to where it feels that the specialization works against itself. I digress, perhaps another time I will vent further. Anyways, I have found that I really enjoy CC and I have never really grasped onto outpatient medicine. Although, I do feel like it is the most important field, (Go ahead and argue with me on that) I am caught between this and the lack of opportunity for people that come from an unopposed FM residency and try to further themselves in a respected field. This was a long winded diatribe in order to hopefully reach out to see if there has been anyone in the same situation. I have contemplated going back and doing another residency (IM I would think), but the idea of redoing residency is very daunting and I hate the construct of residency. It would be nice to segway of having FM residents who meet certain criteria allowed to do fellowship in CC. However, it seems that the ABIM has been hesitant to do this. I am looking to see if there are any other options that people may have found out there (i.e. possibility of practicing underneath the "umbrella" of other CC physicians). The other caveat to this is that if I go back to do residency there is no guarantee I would make it into CC. I abhor research and my steps are not that great (208/222) step1/2 respectively. Perhaps this is just a venting thread. But, I am looking to see if anyone else has been in the same situation. Thank you all for taking the time to read this and I look forward to your response!

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Reach out to anesthesia critical care fellowships and see if any of them will take you.

Go to the San Francisco match website and look up programs that did not fill last year and start reaching out to those programs. Anesthesia Critical Care Medicine is not a popular subspecialty and they’re always programs that are unfilled. The question is are they allowed to fill them in with family medicine? Because some take EM. The match is almost here for ‘this year so after that you can reach out to the current programs that don’t fill. This happens in April.
I have heard through the grapevine of OB and FM doing critical care fellowships. I don’t know how they did it though but I would guess through Anesthesiology.
I honestly don’t know but I would try that first.
Good luck and keep us posted.
 
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Hello,

I am not exactly sure of where to post this. I asked for permission to get into the practicing physicians but have not been responded to. I am looking for a possible "reality" check and since many of you are learned individuals, I value the opinion of several posters on here. I am currently 33 yo, I graduated at an FM residency this past July. I did not choose the IM route prior because our experience was not that great and I was not exposed to CC at that time. Long story short, the residency that I graduated was an unopposed residency. I did over 13 months of inpatient medicine, we ran surgery and trauma's in the hospital, and I have 4-5 months of ICU time (I chose elective time in there). I graduated with an interest in CC and they elected to keep me on as a "fellow" in their ICU because of how competent I have been. I have over 30 excel pages of procedures that I have done just from residency. Central lines, arterial lines, intubation, ventilator mgmt, thoracentesis, paracentesis, chest tubes, lumbar punctures, thoracotomies (Yes, you read that right, I have 5 of these under my belt), transvenous pacers, swan-ganz catheters, and therapeutic bronchoscopies. I literally do most everything myself. Since I graduated I have worked in our ICU for 1 week/month as my "fellowship." COVID hit. I have been working in COVID ICU units from California to Texas, and to WV. There was a time in December I was a night doc to relieve the ICU physician in Texas because they only had one ICU physician on for 7 days/24 hours and I went into help for the COVID response. This hospital had converted not one but all 6 of its floors to ICU floors. Since there was only one CC doc on, this meant that we were regularly running anywhere between 40-70 ventilators at any one time. At least 3 Code Blues every night (interestingly all of the cardiac patients who came in same day is what it felt like). What I am trying to say there is that I didn't need the help of the CC physician or consultants. As I came to the east coast, there is much more malignancy against FM trainees for whatever reason, I get it. Everything is very specialized on the east coast to where it feels that the specialization works against itself. I digress, perhaps another time I will vent further. Anyways, I have found that I really enjoy CC and I have never really grasped onto outpatient medicine. Although, I do feel like it is the most important field, (Go ahead and argue with me on that) I am caught between this and the lack of opportunity for people that come from an unopposed FM residency and try to further themselves in a respected field. This was a long winded diatribe in order to hopefully reach out to see if there has been anyone in the same situation. I have contemplated going back and doing another residency (IM I would think), but the idea of redoing residency is very daunting and I hate the construct of residency. It would be nice to segway of having FM residents who meet certain criteria allowed to do fellowship in CC. However, it seems that the ABIM has been hesitant to do this. I am looking to see if there are any other options that people may have found out there (i.e. possibility of practicing underneath the "umbrella" of other CC physicians). The other caveat to this is that if I go back to do residency there is no guarantee I would make it into CC. I abhor research and my steps are not that great (208/222) step1/2 respectively. Perhaps this is just a venting thread. But, I am looking to see if anyone else has been in the same situation. Thank you all for taking the time to read this and I look forward to your response!

I believe you would get 1-1.5 years of credit for your FM residency if you decided to do an IM residency. So it wouldn't be an entire residency all over again, provided you can find a program - those scores might be a limiting factor. But like you said, there is no guarantee that you would get a fellowship spot as both Pulm-CCM and CCM (via IM) are competitive currently. Sounds like you are doing what you want already. Perhaps you don't need to go back to training. I think you might be able find jobs where you can do ICU work as a hospitalist without needing to go back to training. Especially if you're willing to work nights, I think you will find many nocturnist-hospitalist jobs that involve covering the ICU even in bigger metros. These night hospitalist jobs also pay pretty well according to some posters on this website.
 
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If you feel the need for a board certification, then yes, the language on the American Board of Anesthesiology website is very vague in terms of eligibility to sit for their Critical Care exam, but I think it's purposeful and works in your favor. Even if it didn't work out to make you board eligible, doing a fellowship at least provides some data to any potential employers in your future and is probably worth the pursuit.

In a more global sense, I don't see the need for a pathway from FM to CCM - you are undoubtedly a rare breed, probably the only FM person I've ever heard of that did FM that didn't absolutely love outpatient medicine and detest most in-patient care
 
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There are CCM fellowships that will take you-- maybe anesthesia or surgery. University of Florida sometimes take FM to CCM. There is not, to my knowledge, a US board that you cold sit for thereafter, but there is I believe a European board of criticism care you could take. Might be hard to get an academic job in the US, but you will find plenty of community hospitals that would hire you.
 
Thank you all for your responses, I really appreciate your help and insight! It at least gives me hope. I'm not interested in an academic job at this point sluggs. I just want to take care of critical patients because I just feel that I would not be happy if I were not working critical care. Once again, thank you all
 
Thank you all for your responses, I really appreciate your help and insight! It at least gives me hope. I'm not interested in an academic job at this point sluggs. I just want to take care of critical patients because I just feel that I would not be happy if I were not working critical care. Once again, thank you all

Try this one
 
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If you feel the need for a board certification, then yes, the language on the American Board of Anesthesiology website is very vague in terms of eligibility to sit for their Critical Care exam, but I think it's purposeful and works in your favor. Even if it didn't work out to make you board eligible, doing a fellowship at least provides some data to any potential employers in your future and is probably worth the pursuit.

In a more global sense, I don't see the need for a pathway from FM to CCM - you are undoubtedly a rare breed, probably the only FM person I've ever heard of that did FM that didn't absolutely love outpatient medicine and detest most in-patient care
Many of us like both!

And OP, hospitalist in open ICU seems to be the easiest bet. Tons of jobs out there that essentially require you to do procedures/full scope type of practice in the ICU. Almost all of them gladly take FM too. Obviously, this job would include lots of regular floor patients too.
 
I would say you should temper your enthusiasm of your experience significantly. Many people conflate procedures and taking care of sick people often with providing good critical care. I work with a FM residency and many of them “love critical care” and want to work somewhere they take care of patients in an icu. I can say that nearly all of them (probably all) would be dangerous if left alone in an icu. You don’t know what you don’t know.

The “right” way to do this wold be IM->CCM but that’s another at least 4 years of your life and no guarantee. If you really want to be a good icu doctor, and not just run a lot of vents; you need fellowship training. Period. If I were you, I would try to find someone to train me then take the European boards - it won’t make you equivalent to an IM/CCM trained ABIM certified person, but it will make you competent and allow another tier of hospitals to hire you.
 
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I would say you should temper your enthusiasm of your experience significantly. Many people conflate procedures and taking care of sick people often with providing good critical care. I work with a FM residency and many of them “love critical care” and want to work somewhere they take care of patients in an icu. I can say that nearly all of them (probably all) would be dangerous if left alone in an icu. You don’t know what you don’t know.

The “right” way to do this wold be IM->CCM but that’s another at least 4 years of your life and no guarantee. If you really want to be a good icu doctor, and not just run a lot of vents; you need fellowship training. Period. If I were you, I would try to find someone to train me then take the European boards - it won’t make you equivalent to an IM/CCM trained ABIM certified person, but it will make you competent and allow another tier of hospitals to hire you.
And why is your IM>CCM the "right" way to do this? Why can't he find another pathway that is also "right?"
CCM falls under more than just IM.
 
And why is your IM>CCM the "right" way to do this? Why can't he find another pathway that is also "right?"
CCM falls under more than just IM.

Sure, but he expressed no interest in being an anesthesiologist or a surgeon and both of those pathways are longer.

And, frankly, I think the more time spent in the icu, the better. You will likely spend the most time in the icu this way given the 2 year fellowship.

Also, note I am suggesting IM->CCM which isn’t what I did. It’s not “my way” - I did EM->CCM and I’m not suggesting this route.
 
Sure, but he expressed no interest in being an anesthesiologist or a surgeon and both of those pathways are longer.

And, frankly, I think the more time spent in the icu, the better. You will likely spend the most time in the icu this way given the 2 year fellowship.

Also, note I am suggesting IM->CCM which isn’t what I did. It’s not “my way” - I did EM->CCM and I’m not suggesting this route.
He can likely get into an anesthesiology fellowship and that is the shortest route. Will be two years.
 
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He can likely get into an anesthesiology fellowship and that is the shortest route. Will be two years.

I've had an IM resident try. He was willing to go anywhere but couldn't do it. Below from ACGME program requirements for anesthesia CCM.

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I would say you should temper your enthusiasm of your experience significantly. Many people conflate procedures and taking care of sick people often with providing good critical care. I work with a FM residency and many of them “love critical care” and want to work somewhere they take care of patients in an icu. I can say that nearly all of them (probably all) would be dangerous if left alone in an icu. You don’t know what you don’t know.

The “right” way to do this wold be IM->CCM but that’s another at least 4 years of your life and no guarantee. If you really want to be a good icu doctor, and not just run a lot of vents; you need fellowship training. Period. If I were you, I would try to find someone to train me then take the European boards - it won’t make you equivalent to an IM/CCM trained ABIM certified person, but it will make you competent and allow another tier of hospitals to hire you.

I can respect that. At the current institution where I am practicing, they have had a few FM docs practice under the guidance of CC trained docs. My mentor is an anesthesia trained CC doc. I sort of fed into this training under other CC docs. I have continued to work in the ICU (we are not a tertiary center by any stretch but we are a level II trauma center and I do take care of A LOT of intracranial bleeds, all of the vented COVID patients right now, the disaster surgery patients that come up.) Yes, I do have someone who I can fall back on and be able to have answer questions that I have and we go over our plans together. I completely understand your concern of being dangerous in the ICU. A previous poster mentioned an "open ICU." I have had some experience with this as well. I am not as fond of this model because there are too many "cooks in the kitchen," too many people changing orders on a singular patient. I believe that this IS dangerous. Like I said above I have an anesthesia/CC doc who is training me. We work together a couple of weeks out of each month at my home institution. I probably should have mentioned this before it seems. We work through rounds and we talk about plans, we go through why and why not we do things. The only time I have "ventured" out on my own has been in these COVID emergency situations where they have NO ONE at these critical access hospitals and have been forced to take care of sick patients because of the tertiary centers they send people to had been full. People they are not equipped or trained to take care of. If I wasn't there at these times, I would venture that there would be a lot of senseless deaths. What I mean by that is that the hospitalists or whoever it was taking care of these people did not have the training I had (sorry if this sounds self-righteous, it is not my intent). I did this for a while and then a MUCH larger center had asked for my help because they got word of the work that I was doing at the critical access hospital. I am not one to "toot my own horn" but I feel put in the position that I am going to have to "sell" myself so to speak. I like to work. I like to work hard.

"Many people conflate procedures..." - again, I agree with you. I just find that doing procedures is an adjunct to my happiness. I love doing stuff to people IF it makes them better AND they actually want that intervention. But, it is PART OF but not all of what CC, I understand.
 
He can likely get into an anesthesiology fellowship and that is the shortest route. Will be two years.

Agreed. That’s exactly what I said, that he should find someone who will train him then take the European boards because he won’t be eligible for any US board - that will likely be, de facto, an accm program.
 
Agreed. That’s exactly what I said, that he should find someone who will train him then take the European boards because he won’t be eligible for any US board - that will likely be, de facto, an accm program.
Actually that is not “exactly“ what you said. It seems that is what you were implying. So thanks for clarifying that you meant a de facto ACCM program.
Clearly OP doesn’t care to measure up against an “IM CCM certified ABIM person” since that seems to be your measuring stick. He just wants extra fellowship training in CCM from whatever angle he can get it.
 
I believe you would get 1-1.5 years of credit for your FM residency if you decided to do an IM residency. So it wouldn't be an entire residency all over again, provided you can find a program - those scores might be a limiting factor. But like you said, there is no guarantee that you would get a fellowship spot as both Pulm-CCM and CCM (via IM) are competitive currently. Sounds like you are doing what you want already. Perhaps you don't need to go back to training. I think you might be able find jobs where you can do ICU work as a hospitalist without needing to go back to training. Especially if you're willing to work nights, I think you will find many nocturnist-hospitalist jobs that involve covering the ICU even in bigger metros. These night hospitalist jobs also pay pretty well according to some posters on this website.
No, you get the maximum of half a year of FM residency validated toward IM. You can get an additional 6 months of FM training validated if you did IM rotations with a program that had an IM residency and did it with their department identical to an IM resident (ie, supervised by IM PD and for the same hours IM residents do it). From IM to FM you can get a year or a little more validated
 
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I can say that nearly all of them (probably all) would be dangerous if left alone in an icu. You don’t know what you don’t know.
I am genuinely curious: do you have the same sentiment towards midlevels being left alone in the ICU? If so, do you make those concerns known to the appropriate admin?

In my hospital we have one intensivist who works a lot, but obviously can't cover 24/7. Hospital rule forbids FM hospitalists from covering and only allows IM hospitalists to cover. Which none of them want to so we have mostly unsupervised PAs and NPs working a disturbing number of shifts.

It will never cease to amaze me when I see physicians disparage other physicians in the current midlevel takeover of medicine.
 
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I am genuinely curious: do you have the same sentiment towards midlevels being left alone in the ICU? If so, do you make those concerns known to the appropriate admin?

In my hospital we have one intensivist who works a lot, but obviously can't cover 24/7. Hospital rule forbids FM hospitalists from covering and only allows IM hospitalists to cover. Which none of them want to so we have mostly unsupervised PAs and NPs working a disturbing number of shifts.

It will never cease to amaze me when I see physicians disparage other physicians in the current midlevel takeover of medicine.

Glad I can amaze you. Also, glad you can take my remarks as disparaging - if you think me saying a doc without adequate training is dangerous is disparaging, you have incredibly thin skin. Guess what, if I tried to go to the OR and operate or provide anesthesia, I would be dangerous, too. That’s not a nasty thing to say about me - I just don’t have that training. I’m a really good doctor, just not that kind of doctor. Take as much offense as you’d like, because you seem to be manufacturing it when none was intended.

We have a lot of NPs, but they certainly aren’t unsupervised and we train them. Could they make the same mistakes and be dangerous? Absolutely, but that’s why they are mid levels who are closely supervised. If they decide to do something stupid, I have many lines of defense - bedside RN, pharmacist, etc all know they can call me. Plus we round several times a day where I make clear my intent on the patient’s care. Not to mention, 99% of the bad ideas that come from NPs and PAs get brought to my attention before being implement - “hey doc, what do you think about xxxx?” That is very different than someone without adequate training being unsupervised.
 
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Glad I can amaze you. Also, glad you can take my remarks as disparaging - if you think me saying a doc without adequate training is dangerous is disparaging, you have incredibly thin skin. Guess what, if I tried to go to the OR and operate or provide anesthesia, I would be dangerous, too. That’s not a nasty thing to say about me - I just don’t have that training. I’m a really good doctor, just not that kind of doctor. Take as much offense as you’d like, because you seem to be manufacturing it when none was intended.

We have a lot of NPs, but they certainly aren’t unsupervised and we train them. Could they make the same mistakes and be dangerous? Absolutely, but that’s why they are mid levels who are closely supervised. If they decide to do something stupid, I have many lines of defense - bedside RN, pharmacist, etc all know they can call me. Plus we round several times a day where I make clear my intent on the patient’s care. Not to mention, 99% of the bad ideas that come from NPs and PAs get brought to my attention before being implement - “hey doc, what do you think about xxxx?” That is very different than someone without adequate training being unsupervised.
You're dancing around the issue with addressing it. The fact remains, there are loads of independent midlevels in ICUs. The attending rounds at 9am until 1130am. Then they're either semi-present or take off in the afternoon. Often they don't hang around overnight.
So there are a lot of (virtually) independent midlevels in ICUs.
Why aren't you on a major crusade against them first?
 
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You're dancing around the issue with addressing it. The fact remains, there are loads of independent midlevels in ICUs. The attending rounds at 9am until 1130am. Then they're either semi-present or take off in the afternoon. Often they don't hang around overnight.
So there are a lot of (virtually) independent midlevels in ICUs.
Why aren't you on a major crusade against them first?

Why does everyone have to move the goal posts and look for reasons to be offended and throw shade on people. Im not on a crusade against anyone. I’m just a doc trying to make a living to support my family. OP asked for input on what he should do. I was (am) just trying to be helpful and someone
 
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I just don’t have that training.
Right. But FM docs do have that training. And from what it sounds like, OP has more than most IM docs.

Your argument is fascinating as on the one hand, you find FM docs incompetent and dangerous, and therefore presume they should be precluded from entering a CC fellowship (as evidenced by your initial advice for OP to return to residency and do IM). On the other hand, you're A-ok with the 500 hours of shadowing that NPs get in their "clinical education" as sufficient to be trained in how to run an ICU all on their own.

Our profession is doomed until physicians like yourself can see how the disparaging of fellow physicians only does harm and allows this midlevel takeover to go full throttle. OP is clearly more than qualified to enter a CC fellowship and ought to be able to as the FM doc that he is. Period.
 
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Why does everyone have to move the goal posts and look for reasons to be offended and throw shade on people. Im not on a crusade against anyone. I’m just a doc trying to make a living to support my family. OP asked for input on what he should do. I was (am) just trying to be helpful and someone

You can't say why an FM who is obviously competent in the ICU shouldn't be practicing there while letting a midlevel work independently for 21 hours of the day.

We actually keep moving the goal posts for doctors. By needing endless years of added training and considering literal physicians unqualified to do xyz work. But then we let midlevels with a miniscule fraction of the training of a generalist step in, get on the job training for 110k/year (with benefits and 9-4pm), and then operate like a PGY5 fellow shortly after.
 
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You can't say why an FM who is obviously competent in the ICU shouldn't be practicing there while letting a midlevel work independently for 21 hours of the day.

We actually keep moving the goal posts for doctors. By needing endless years of added training. But then we let midlevels with a miniscule fraction of the training of a generalist step in, get on the job training for 110k/year (with benefits and 9-4pm), and then operate like a PGY5 fellow shortly after.

Ok. You guys are nuts. I’m going to say this and then be out. Forget the fact that you two are running off an academic icu attending who actually knows what he is talking about and trying to give good advice.

No, I do not consider an FP doc competent to practice in the icu because they did 4-5 months as a resident. That is laughable. I did 4-5 months as a resident too. Was I competent? Heck no. Guess what? Most anesthesiologists, internists, emergency medicine docs and surgeons spend that much or more time in the icu. You know what they have to do in order to be safe? Fellowship. I did about 22 months of icu time in my fellowship after my 6 months of residency training in the icu. So OP is “obviously competent” doing about 15-20% of the amount of time I spent training. What do you think, I could do maybe 2 months of family med and call myself competent?

FP docs entering fellowship is a whole different deal. I have no problem with it. But the rules are what the rules are. I was giving OP advice. Find a fellowship program that will take him. All the IM programs fill and are competitive. No chance they would take someone who can’t sit for the ABIM boards. ABA is less competitive and probably would take him. He should do that and take the European boards.

I never once said mid levels should be allowed to practice independently or compared FPs to mid levels. Would I take OP over any of my mid levels in the icu? Yea, probably, but that wasn’t the question. I consider a mid level a perpetual mid-level resident - some a little closer to senior, some more likely an intern based on IQ and history. If the OP wants to find a job as a mid level, great, he is significantly overqualified for that. But that’s not what he or she wants, it’s to be an intensivist. I’m sorry your upset that 1) it takes hard work and focused study to be competent intensivist and 2) mid levels work in icus.

You people are crazy. I’m an ER doc. We were historically kept out of critical care and had to bootstrap fellowships and sit for the European boards before making our own seat at the table. I’m telling OP to do exactly what my predecessors did. Keep putting words in my mouth, whatever, im out.
 
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Idk how this thread became a midlevel vs. FM doc dick measuring contest. The beef is not with the critical care specialists commenting on this thread. Majority of us are employed and don’t have control over how the ICUs are staffed - hospital admin decides this. I am sure there are hospital administrators that don’t want to pay for an intensivist and are willing to staff an ICU with an FM/IM doc that’s not trained in CCM and if the doc is willing to take the liability go right ahead. No one on this thread can really do anything about that regardless of what their opinion is. Same thing goes for the midlevels you are seeing floating around, it’s all up to hospital admin. I don’t like them just as much as you do.
 
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I would say you should temper your enthusiasm of your experience significantly. Many people conflate procedures and taking care of sick people often with providing good critical care. I work with a FM residency and many of them “love critical care” and want to work somewhere they take care of patients in an icu. I can say that nearly all of them (probably all) would be dangerous if left alone in an icu. You don’t know what you don’t know.

The “right” way to do this wold be IM->CCM but that’s another at least 4 years of your life and no guarantee. If you really want to be a good icu doctor, and not just run a lot of vents; you need fellowship training. Period. If I were you, I would try to find someone to train me then take the European boards - it won’t make you equivalent to an IM/CCM trained ABIM certified person, but it will make you competent and allow another tier of hospitals to hire you.
I don't know how you can read this comment and not see it as disparaging toward family physicians and the training they get.

Mods, will the above poster be kindly told to stop with the personal attacks or will his unhinged attack towards other posters be allowed to fly?

The fact remains that many FM programs offer intense and comprehensive ICU training and those residents ought to be respected enough to be allowed into IM-CCM fellowships. That is the entirety of my point.
 
I don't know how you can read this comment and not see it as disparaging toward family physicians and the training they get.

Mods, will the above poster be kindly told to stop with the personal attacks or will his unhinged attack towards other posters be allowed to fly?

The fact remains that many FM programs offer intense and comprehensive ICU training and those residents ought to be respected enough to be allowed into IM-CCM fellowships. That is the entirety of my point.
Go petition the ABIM about it then, nobody here can do anything about it. I'll spoil the result for you--you won't win. PCCM is quite popular in IM, they don't need more applicants.

If you want to do CCM you need to get your board to sponsor a training program or go in to surgery, anesthesia, IM, or EM (or neuro if you want to work in a neuro ICU only). You can think you know enough and don't need the training and nobody here is going to convince you otherwise so go have at it and if you end up in court one day I hope you have the humility to settle because I can't imagine an easier way to win a trial then to emphasize practicing outside of your scope which, for better or for worse, is defined by your board not by your own sense of knowledge.
 
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I don't know how you can read this comment and not see it as disparaging toward family physicians and the training they get.

Mods, will the above poster be kindly told to stop with the personal attacks or will his unhinged attack towards other posters be allowed to fly?

The fact remains that many FM programs offer intense and comprehensive ICU training and those residents ought to be respected enough to be allowed into IM-CCM fellowships. That is the entirety of my point.
Nothing about that post was disparaging to FPs (I am one and it didn't bother me at all) any more than my saying an EP would be unsafe working in a primary care clinic.

You can make the argument that under certain circumstances FPs should be allowed to match into CCM fellowships, that's not entirely unreasonable. But that's not where things are right now.
 
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I am genuinely curious: do you have the same sentiment towards midlevels being left alone in the ICU? If so, do you make those concerns known to the appropriate admin?

In my hospital we have one intensivist who works a lot, but obviously can't cover 24/7. Hospital rule forbids FM hospitalists from covering and only allows IM hospitalists to cover. Which none of them want to so we have mostly unsupervised PAs and NPs working a disturbing number of shifts.

It will never cease to amaze me when I see physicians disparage other physicians in the current midlevel takeover of medicine.
Where is this? Why haven’t they brought in a Locums?
Maybe I can help. I have a few licenses. I am always looking for extra non agency work if I can find it.
 
Where is this? Why haven’t they brought in a Locums?
Maybe I can help. I have a few licenses. I am always looking for extra non agency work if I can find it.

Probably don’t want to pay for a locum. Typical admin move, let the physicians take on extra liability: let patient care suffer and collect the profits. I don’t think they will be able to afford you :laugh:.
 
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Why does everyone have to move the goal posts and look for reasons to be offended and throw shade on people. Im not on a crusade against anyone. I’m just a doc trying to make a living to support my family. OP asked for input on what he should do. I was (am) just trying to be helpful and someone
Could you elaborate as to why you think they are dangerous? If the OP spent five month in the ICU you think he is dangerous to manage a small ICU in a critical access hospital like he's talking about where the complex cases get shipped out anyway? I honestly didn't know critical access hospitals had ICU, but then again, I have never been inside one.
 
Could you elaborate as to why you think they are dangerous? If the OP spent five month in the ICU you think he is dangerous to manage a small ICU in a critical access hospital like he's talking about where the complex cases get shipped out anyway? I honestly didn't know critical access hospitals had ICU, but then again, I have never been inside one.
Nope. Won’t do it - won’t give more fuel for nonsense accusing me of discriminating against FPs. Happy to talk about it through DM if you’d like.
 
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Nope. Won’t do it - won’t give more fuel for nonsense accusing me of discriminating against FPs. Happy to talk about it through DM if you’d like.
It was really more meant to ask as to whether it was because they were trainees and didn't have more than whatever obligatory ICU months are required for FM. Which I would guess in FM would be two months max. I would think the IM people with minimal months would be just as dangerous as well. I would think FM in general would mostly hate the ICU.
Just saw the DM thing, so sure. DM me.
 
Right. But FM docs do have that training. And from what it sounds like, OP has more than most IM docs.

Your argument is fascinating as on the one hand, you find FM docs incompetent and dangerous, and therefore presume they should be precluded from entering a CC fellowship (as evidenced by your initial advice for OP to return to residency and do IM). On the other hand, you're A-ok with the 500 hours of shadowing that NPs get in their "clinical education" as sufficient to be trained in how to run an ICU all on their own.

Our profession is doomed until physicians like yourself can see how the disparaging of fellow physicians only does harm and allows this midlevel takeover to go full throttle. OP is clearly more than qualified to enter a CC fellowship and ought to be able to as the FM doc that he is. Period.

The difference is that mid-levels are generally closely supervised, and are expected to follow well defined algorithms with no discretion allowed. Or very little discretion.

The problem is that FM/IM trained physicians working in ED departments, or non critical-care people in ICU's, actually think that they know something about medicine, and they apply their knowledge of completely unrelated areas of medicine in situations where it is no longer valid.

In the ED, I don't care a whit what you did about potential UTIs in your outpatient practice. It is completely irrelevant to the ED environment. Completely.

A bit dated now, but I don't care that you always used Demerol in your outpatient practice; you better not be using it in the ED.

I tell the mid-levels the limit for scripts for renal colic is 10 Percocet 5/325. They obey. Then I have the FM guy writing 90 oxy 30's to opioid naïve patients. (Or probably worse, to those who aren't.)

Give me the choice between the person who does exactly what I want, or gets fired, and the physician who doesn't know the limits of their knowledge, and I will take the mid-level "every day of the week and twice on Sunday."

A little knowledge is a dangerous thing.

The primary difference is that mid-levels are generally willing to accept strong limits/guidelines/procedures/algorithms on their practice. Or they are gone. Other specialties think they are "physicians" and balk. Therefore, the latter are generally more dangerous than the former.

Let me make a GME analogy: There is no surgical program in the country that would take me as a PGY-1. Or as a NP/PA. I know infinitely more medicine, and have far more experience than anyone they could get in that position. But in the strange universe where I would want to apply, the attendings would know that I am far too set in my ways and wouldn't do it their way. That is the deal breaker.

Now, this presents an extreme view, but it is the basic reason why mid-levels are treated differently than non-specialist physicians.

Let me make an outpatient analogy:

Lets say that you are looking for a practice manager. A former physician who lost his medical license applies and is the best qualified candidate. Would you hire him? In reality, I bet not. You probably realize the problem is that he is going to want to do things "his" way; not "your" way.
 
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It was really more meant to ask as to whether it was because they were trainees and didn't have more than whatever obligatory ICU months are required for FM. Which I would guess in FM would be two months max. I would think the IM people with minimal months would be just as dangerous as well. I would think FM in general would mostly hate the ICU.
Just saw the DM thing, so sure. DM me.
The minimum requirements are either 1 month/100 hours or 15 ICU patients.

if you have an open icu, an inpatient heavy residency, and use all of your elective time in the ICU an FM resident could end up with four months of pure ICU time and a fair number of ICU patients on regular inpatient months. But that is going to be a blindingly small minority of family medicine residents who pulled that off.

And if you're not at a large hospital, the ICU patients just aren't going to be as sick as those at a tertiary or higher center are.

My wife is internal medicine, and when we compared the types of patients that we had when we were working in the ICU hers were markedly sicker than mine.
 
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The minimum requirements are either 1 month/100 hours or 15 ICU patients.

if you have an open icu, an inpatient heavy residency, and use all of your elective time in the ICU an FM resident could end up with four months of pure ICU time and a fair number of ICU patients on regular inpatient months. But that is going to be a blindingly small minority of family medicine residents who pulled that off.

And if you're not at a large hospital, the ICU patients just aren't going to be as sick as those at a tertiary or higher center are.

My wife is internal medicine, and when we compared the types of patients that we had when we were working in the ICU hers were markedly sicker than mine.
Interesting. Thanks for explaining again as you've told me before but I had forgotten.
Now were you working in the same hospital as wife during training and you were assigned less sick patients? Or in different hospitals?
 
How is it that any time FM comes up in any forum this guy is here trying to burn down the NP/PA establishment, one thread at a time? Classic.
 
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How is it that any time FM comes up in any forum this guy is here trying to burn down the NP/PA establishment, one thread at a time? Classic.
I'm not sure who you're talking about, but it can't be me as this is the first SDN post that I've commented on midlevels. Whoever this person is, though, I applaud them. As someone who has sat back and watched the older generation of physicians sell out our profession for a few extra bucks, the midlevel issue certainly hits home. And nothing changes until more people speak up and demand change.

It's especially disheartening to see it come from emergency physicians, where new grads are struggling to find jobs and wages actively get driven down year after year, all whilst "seasoned" physicians go online to crusade for why midlevels are so great and why physicians that aren't them are so dumb and dangerous. :rolleyes:
 
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I'm not sure who you're talking about, but it can't be me as this is the first SDN post that I've commented on midlevels. Whoever this person is, though, I applaud them. As someone who has sat back and watched the older generation of physicians sell out our profession for a few extra bucks, the midlevel issue certainly hits home. And nothing changes until more people speak up and demand change.

It's especially disheartening to see it come from emergency physicians, where new grads are struggling to find jobs and wages actively get driven down year after year, all whilst "seasoned" physicians go online to crusade for why midlevels are so great and why physicians that aren't them are so dumb and dangerous. :rolleyes:
Most of us know exactly who he is talking about. It’s not you.
 
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Interesting. Thanks for explaining again as you've told me before but I had forgotten.
Now were you working in the same hospital as wife during training and you were assigned less sick patients? Or in different hospitals?
Different hospitals. Mine was a 400 bed level 2 trauma center, unopposed FM residency. 3 ICUs that we worked in (CVICU was just for post-CABG patients) with somewhere around 30-40 beds. There was a private hospitalist group that did the majority of admissions, we'd get 6-8/day, anything past that they did so our ICU patients came from those patients.

Hers was a 1100 bed level 1 with most of the usual residency programs. 4 ICUs with a total of around 80-90 beds (they didn't usually staff the SICU). Every single non-surgical ICU admission was handled by the IM resident CC team. So even if the acuity in the ICUs was similar, she saw all of the ICU patients in her hospital while I was limited to the patients our service admitted who needed ICU level care.
 
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The difference is that mid-levels are generally closely supervised, and are expected to follow well defined algorithms with no discretion allowed. Or very little discretion.
This is categorically false. There are A LOT of 100% independent midlevels in small EDs around the country. This isn't even anything new. And there are A LOT of midlevels who operate virtually independent in ICUs in large community hospitals overnight. The idea of calling the attending overnight is not common. Rural ORs also use CRNAs with 100% independence. They get some monthly chart review by an anesthesiologist and that's it.

You're taking your personal 1:1 experience with midlevels and assuming that's how it works nationwide. Yet there are ER docs and ICU docs on this (heavily biased) forum that will even admit that there are an enormous number of midlevels (a huge percentage) that for all realistic purposes, work independently.
The problem is that FM/IM trained physicians working in ED departments, or non critical-care people in ICU's, actually think that they know something about medicine, and they apply their knowledge of completely unrelated areas of medicine in situations where it is no longer valid.

In the ED, I don't care a whit what you did about potential UTIs in your outpatient practice. It is completely irrelevant to the ED environment. Completely.

A bit dated now, but I don't care that you always used Demerol in your outpatient practice; you better not be using it in the ED.

I tell the mid-levels the limit for scripts for renal colic is 10 Percocet 5/325. They obey. Then I have the FM guy writing 90 oxy 30's to opioid naïve patients. (Or probably worse, to those who aren't.)

Give me the choice between the person who does exactly what I want, or gets fired, and the physician who doesn't know the limits of their knowledge, and I will take the mid-level "every day of the week and twice on Sunday."

A little knowledge is a dangerous thing.

The primary difference is that mid-levels are generally willing to accept strong limits/guidelines/procedures/algorithms on their practice. Or they are gone. Other specialties think they are "physicians" and balk. Therefore, the latter are generally more dangerous than the former.

Let me make a GME analogy: There is no surgical program in the country that would take me as a PGY-1. Or as a NP/PA. I know infinitely more medicine, and have far more experience than anyone they could get in that position. But in the strange universe where I would want to apply, the attendings would know that I am far too set in my ways and wouldn't do it their way. That is the deal breaker.

Now, this presents an extreme view, but it is the basic reason why mid-levels are treated differently than non-specialist physicians.

Let me make an outpatient analogy:

Lets say that you are looking for a practice manager. A former physician who lost his medical license applies and is the best qualified candidate. Would you hire him? In reality, I bet not. You probably realize the problem is that he is going to want to do things "his" way; not "your" way.
I've seen the exact opposite of the examples you're describing too. I think what you don't understand is that generalist docs see midlevels working 100% independently on their shifts then wonder why they can't do a job when there is work-demand for it. What that means is, there is X demand of work that the specialists in that field cannot fill (commonly seen in open ICUs for examples or smaller EDs). That X demand is then given to a midlevel to do, with a "supervising" doc who 95% of the time is providing literally zero supervision. I'm not sure how else to emphasize this, there is no real supervision in these autonomous midlevel jobs.

Different hospitals. Mine was a 400 bed level 2 trauma center, unopposed FM residency. 3 ICUs that we worked in (CVICU was just for post-CABG patients) with somewhere around 30-40 beds. There was a private hospitalist group that did the majority of admissions, we'd get 6-8/day, anything past that they did so our ICU patients came from those patients.

Hers was a 1100 bed level 1 with most of the usual residency programs. 4 ICUs with a total of around 80-90 beds (they didn't usually staff the SICU). Every single non-surgical ICU admission was handled by the IM resident CC team. So even if the acuity in the ICUs was similar, she saw all of the ICU patients in her hospital while I was limited to the patients our service admitted who needed ICU level care.

You can flip that too. There are a lot of IM residencies in smaller community hospitals. The small minority of FM docs going for these jobs that we're discussing will be those who come from a background of much better training. It's self selection so it's a moot point.
 
I tell the mid-levels the limit for scripts for renal colic is 10 Percocet 5/325. They obey. Then I have the FM guy writing 90 oxy 30's to opioid naïve patients. (Or probably worse, to those who aren't.)
If you seriously think that MDs and DOs are the issue with over-prescribing of opiates, and that NPs and PAs are not, then you sir are entirely out of touch with the reality of medicine in this country.
 
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If you seriously think that MDs and DOs are the issue with over-prescribing of opiates, and that NPs and PAs are not, then you sir are entirely out of touch with the reality of medicine in this country.
Or that midlevels are actually following attending instructions on what to prescribe. I've yet to be in a hospital or clinic across several states where the midlevel even ran something by an attending, that wasn't somewhat specialized or fairly complex. So the idea that opiate prescription will be tightly regulated by the attending in house (who cannot be FM/IM btw lol) is nuts.
 
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Or that midlevels are actually following attending instructions on what to prescribe. I've yet to be in a hospital or clinic across several states where the midlevel even ran something by an attending, that wasn't somewhat specialized or fairly complex. So the idea that opiate prescription will be tightly regulated by the attending in house (who cannot be FM/IM btw lol) is nuts.
You’re a second year resident at best. Your « experience » is MARKEDLY limited.
 
I am going to say that while there are dangerous FM CCM docs out there, there are just as equally if not worse midlevels running wild out there who are probably just as clueless or worse and certainly not being adequately supervised.
I worked w midlevels in my last travel assignment. It’s great in the daytime because I am there and we run over all the patients and they present to me etc.
But at night the NPs worked under their own licenses even though I was supposed to “supervise” and sometimes did crazy stuff. They were supposed to call me with big issues and one of them did mostly and the other had a big ego, loved to hear himself talk and was always coming up w plans at night that didn’t help in the daytime. In fact they set the patient back many times. And the good one half the time didn’t listen and did his own thing even after being instructed on what to do at night.
I prefer working alone, then next working alongside the midlevel and not “supervising” from home.
 
I am going to say that while there are dangerous FM CCM docs out there, there are just as equally if not worse midlevels running wild out there who are probably just as clueless or worse and certainly not being adequately supervised.
I worked w midlevels in my last travel assignment. It’s great in the daytime because I am there and we run over all the patients and they present to me etc.
But at night the NPs worked under their own licenses even though I was supposed to “supervise” and sometimes did crazy stuff. They were supposed to call me with big issues and one of them did mostly and the other had a big ego, loved to hear himself talk and was always coming up w plans at night that didn’t help in the daytime. In fact they set the patient back many times. And the good one half the time didn’t listen and did his own thing even after being instructed on what to do at night.
I prefer working alone, then next working alongside the midlevel and not “supervising” from home.
Your experience is by and large the normal across this country, despite some in this thread incessantly arguing against reality.
 
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I am going to say that while there are dangerous FM CCM docs out there, there are just as equally if not worse midlevels running wild out there who are probably just as clueless or worse and certainly not being adequately supervised.
I worked w midlevels in my last travel assignment. It’s great in the daytime because I am there and we run over all the patients and they present to me etc.
But at night the NPs worked under their own licenses even though I was supposed to “supervise” and sometimes did crazy stuff. They were supposed to call me with big issues and one of them did mostly and the other had a big ego, loved to hear himself talk and was always coming up w plans at night that didn’t help in the daytime. In fact they set the patient back many times. And the good one half the time didn’t listen and did his own thing even after being instructed on what to do at night.
I prefer working alone, then next working alongside the midlevel and not “supervising” from home.

FM CCM docs? Never heard of one. Or do you mean IM/FM docs playing intensivist without the training due to hospital admin not wanting to pay for one.
 
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