Gen. Surg/Surgical Critical Care vs. IM/Pulm/CCM

[sozme]

Ignorant medical student (M3) here trying to figure out what I want to do when I grow up. Can you help me understand the difference between these two paths based on my rather broad and perhaps infantile career goals? Any suggestions would be nice as well.

The only thing I know I want to do is take care of the sickest patients with the greatest amount of autonomy (i.e. not serving as a middle man who organizes a parade of sub-specialists). Now of course most intensivists serve in consultant roles only for the duration of critical illness, which is what I would be fine doing. What would be hard for me is to have to give up/defer to other people because the patient becomes too sick for me to manage (except in those minority cases where they need neurosurgery or IR or w/e). Hopefully that makes sense...

I really like IM in theory (probably would hate some aspects of IM residency though). I like the MICU though (based only on my experience as a medical student). I like working up a differential, slightly more longitudinal care, becoming intimately familiar with the associated toys (ventilators, ultrasound, RRT, even ECMO at some places), procedures (intubation, etc.). I assume surgical intensivists would have all of these tools but I'd imagine to a slightly less degree? I have also heard that the IM/CCM/Pulm path allows one the greatest flexibility in terms of the patients and conditions they can manage.

I think what I like most about surgery is that they seem more or less autonomous. What I mean is that surgeons don't need internists co-managing their patients anywhere near as much as internists need surgeons. That appeals to me (probably a personality defect/control issue). There is also not as much concern about non-physician (NP/PA) creep in surgery like there is in virtually every corner of internal medicine. That being said, I have not had much exposure to a real SICU managed exclusively by surgeons. I also have absolutely no idea how much I would like a general surgery residency as opposed to an IM residency. From what I hear, GS residency is a nightmare... but is this really overstated or dependent on location?

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[RustBeltOnc]

The only thing I know I want to do is take care of the sickest patients with the greatest amount of autonomy ...I really like IM in theory (probably would hate some aspects of IM residency though)...I think what I like most about surgery is that they seem more or less autonomous. .....I also have absolutely no idea how much I would like a general surgery residency as opposed to an IM residency. From what I hear, GS residency is a nightmare... but is this really overstated or dependent on location?

The key thing here is that CC medicine is difficult to do forever, and in the community (like much of medicine) it is similar to the movie "Ground Hog Day". I think that you will be better able to decide about this during/after residency. IM is much shorter and has interesting fellowship options and personality-wise there's a place for everyone. With GS - you have to like the OR.

 

[doc05]

the issue of "autonomy" as an intensivist really depends on your local practice environment, rather than specialty (medical or surgical).

also keep in mind that the "autonomy" in running the SICU isn't always really autonomy. you may be the "surgical intensivist", but many surgeons will want to manage their own patients, and "co-management" can become difficult.

and yes, GS residency is a nightmare.

 

[dienekes88]

Ignorant medical student (M3) here trying to figure out what I want to do when I grow up. Can you help me understand the difference between these two paths based on my rather broad and perhaps infantile career goals? Any suggestions would be nice as well.

The only thing I know I want to do is take care of the sickest patients with the greatest amount of autonomy (i.e. not serving as a middle man who organizes a parade of sub-specialists). Now of course most intensivists serve in consultant roles only for the duration of critical illness, which is what I would be fine doing. What would be hard for me is to have to give up/defer to other people because the patient becomes too sick for me to manage (except in those minority cases where they need neurosurgery or IR or w/e). Hopefully that makes sense...

I really like IM in theory (probably would hate some aspects of IM residency though). I like the MICU though (based only on my experience as a medical student). I like working up a differential, slightly more longitudinal care, becoming intimately familiar with the associated toys (ventilators, ultrasound, RRT, even ECMO at some places), procedures (intubation, etc.). I assume surgical intensivists would have all of these tools but I'd imagine to a slightly less degree? I have also heard that the IM/CCM/Pulm path allows one the greatest flexibility in terms of the patients and conditions they can manage.

I think what I like most about surgery is that they seem more or less autonomous. What I mean is that surgeons don't need internists co-managing their patients anywhere near as much as internists need surgeons. That appeals to me (probably a personality defect/control issue). There is also not as much concern about non-physician (NP/PA) creep in surgery like there is in virtually every corner of internal medicine. That being said, I have not had much exposure to a real SICU managed exclusively by surgeons. I also have absolutely no idea how much I would like a general surgery residency as opposed to an IM residency. From what I hear, GS residency is a nightmare... but is this really overstated or dependent on location?

Anesthesia/Critical Care/Cardiac Anesthesia.

Attend in the CVICU at a fairly busy University hospital where they do LVADs, heart transplants, lung transplants, open thoracoabdominals, and type A dissections. Honestly, you may get over the whole "I want to take care of the sickest patients ever" phase of your life, and doing it this way you could move out of the ICU and just do cardiac or thoracic anesthesia. Or even go on to a community CVICU where it's mostly uncomplicated AVRs and CABGs.

 

[Semmelweis]

First figure out if you want to do surgery or not. GS residency is probably among the toughest training program you can go through. If you have no interest in surgical diseases or in operating then you will never make it through a 5 year GS residency to even consider a SCC fellowship.

That said, I'm doing a trauma/cc fellowship now after 5 years of GS. We do take care of the sickest patients in the hospital and own them from the second they roll into the trauma bay. We rarely consult medical specialties from the trauma ICU, but we do work with the neurosurgeons and orthopedists a lot.

 

[DoctwoB]

First figure out if you want to do surgery or not. GS residency is probably among the toughest training program you can go through. If you have no interest in surgical diseases or in operating then you will never make it through a 5 year GS residency to even consider a SCC fellowship.

That said, I'm doing a trauma/cc fellowship now after 5 years of GS. We do take care of the sickest patients in the hospital and own them from the second they role into the trauma bay. We rarely consult medical specialties from the trauma ICU, but we do work with the neurosurgeons and orthopedists a lot.

Outside of nearly brain-dead TBIs, its hard to say that trauma has the sickets patients. For the most part they have good hearts, livers (though some have drank them away), etc. It's actually one of the reasons I really liked surgical critical care, you have many people who start out relatively healthy, have a severe acute insult (blood less, sepsis, etc.) that they have a chance of recovering from. I'd certainly characterize the CT-ICU patients or MICU end-stage liver disasters as "sicker," but I'd much rather manage a trauma or bowel perf patient.

To the OP: Do you want to be a surgeon that also does critical care or a full-time intensivist? If the latter, you'd be much better served by IM/CCM or anesthesia/CCM.

 

[ACSurgeon]

Outside of nearly brain-dead TBIs, its hard to say that trauma has the sickets patients. For the most part they have good hearts, livers (though some have drank them away), etc. It's actually one of the reasons I really liked surgical critical care, you have many people who start out relatively healthy, have a severe acute insult (blood less, sepsis, etc.) that they have a chance of recovering from. I'd certainly characterize the CT-ICU patients or MICU end-stage liver disasters as "sicker," but I'd much rather manage a trauma or bowel perf patient.

To the OP: Do you want to be a surgeon that also does critical care or a full-time intensivist? If the latter, you'd be much better served by IM/CCM or anesthesia/CCM.

- SICUs admit all end stage liver disease patients at busy transplant centers (even patients who are not candidates for txp).

- SICU patients show up as "one of the sickest patients in the hospital" but actually have a chance of becoming better with appropriate care

- @sozme SICU autonomy is with trauma patients and patients operated on by your partners. I don't think any transplant, surg onc, or vascular surgeons are gonna give you their critically ill patients and walk away. They will be there demanding things that are often outdated and as an intensivist you feel obliged to let them do what they want. So from that standpoint there is more being be middle man than micu (many MICUs are truly closed units)

-GS residency is tough. It's become very doable in recent years. It's especially not terrible if you're at a reasonable program. No matter what, you will work much harder in residency and get chewed out more in surgery than medicine. Even our nicest attendings are rougher around the edges than your average internist. You develop thick skin and adjust to where it doesn't bother you.

- you have to love surgery more than pretty much anything else in life to get through residency without being scarred. Some of the happiest residents were those with minimal real-life commitments who didn't have to feel guilty to stay late and operate or take care of sick patients. I'm married and have a very supportive wife, and to that end, my residency experience has been overwhelmingly positive. I've enjoyed it, and know many others who have. I also know many more who were miserable. You gotta make sure you love it.

 

[RustBeltOnc]

This thread and the OP's interests are pretty typical of the thought process of the student that matriculates into IM. Basically, IM is a great path for someone who is not yet "differentiated." This is seen in all med schools in a large fraction of students. It's normal.

 

[Semmelweis]

Outside of nearly brain-dead TBIs, its hard to say that trauma has the sickets patients. For the most part they have good hearts, livers (though some have drank them away), etc. It's actually one of the reasons I really liked surgical critical care, you have many people who start out relatively healthy, have a severe acute insult (blood less, sepsis, etc.) that they have a chance of recovering from. I'd certainly characterize the CT-ICU patients or MICU end-stage liver disasters as "sicker," but I'd much rather manage a trauma or bowel perf patient.

This seems like semantics, but really bad trauma patients roll in to the ER trying to die from the get-go. Granted, they tend to have fewer serious chronic diseases, but actively dying patients are (to my mind at least) the sickest patients in the hospital.

 

[doc05]

Something for the OP to consider....

It's unlikely that the attending job you take will be 100% crit care. That would mean being on-call for the ICU all the time. More likely you'll find a job doing 1 or 2 weeks per month covering the ICU. So perhaps better to think about what you'll be doing on "off" weeks - pulmonary outpatient? anesthesia? surgery?

 

[ACSurgeon]

Something for the OP to consider....

It's unlikely that the attending job you take will be 100% crit care. That would mean being on-call for the ICU all the time. More likely you'll find a job doing 1 or 2 weeks per month covering the ICU. So perhaps better to think about what you'll be doing on "off" weeks - pulmonary outpatient? anesthesia? surgery?

Actually- a lot of community critical care jobs are now 11-14 shifts per month (12 hour shifts) is full time. Now one can supplement their income doing "other stuff" but you don't really have to.

 

[ACSurgeon]

Nope not at my hospital, and we are a busy transplant center. Liver bombs go to the MICU until they head to the OR for transplant.

YMMV

 

[WinslowPringle]

Do you like to operate?
a. Love it! --> GS residency --> fellowship
b. Like procedures and the OR, but not in love with the big whacks--> Anesthesia --> fellowship
c. Some procedures are neat. Rounding is more awesome, though. --> IM --> fellowship


As an M3, though, aren't you still pretty early in the year? Wait until you've rotated through IM, Anesthesiology (do your best to make this rotation happen, not all schools regularly offer it), Surgery. If you can, try to rotate through both the SICU and MICU.

I'm only just starting month three of GS residency and have loved it - so far. Most people in my residency program seem pretty okay with residency most of the time; nothing is great 100% of the time. GS residency is do-able and can be relatively enjoyable if it's what you love and if you're in a good program that suits you well enough. Long hours, yes, but not universally a nightmare.

Oh, and yes, the SICU gets all the fun toys the MICU gets. Pretty certain our intensivists don't get them to any lesser degree than MICU.

 

[Undecided15]

I am in a similar situation as OP. Can someone clarify what the actual career choices/day to day is for surgical CC, such as how much time is spent in the OR vs SICU, etc? I have not yet had my GS rotation, but have enjoyed the limited exposure I've had to the OR so far, and of the rotations I've had, IM/ICU has been my favorite. As a DO, I need to try to figure out what I want to do soon before setting up my 4th year auditions so any input would be greatly appreciated. Thanks.

 

[ACSurgeon]

I am in a similar situation as OP. Can someone clarify what the actual career choices/day to day is for surgical CC, such as how much time is spent in the OR vs SICU, etc? I have not yet had my GS rotation, but have enjoyed the limited exposure I've had to the OR so far, and of the rotations I've had, IM/ICU has been my favorite. As a DO, I need to try to figure out what I want to do soon before setting up my 4th year auditions so any input would be greatly appreciated. Thanks.

The job options will vary drastically. Some models:

- trauma/acute care surgery (ACS)/critical care (CC): you'll do 2-3 of those with your ICU time consuming as much or little time as you want (job restrictions permitting). This job will be at level 1 or 2 trauma center. Many jobs will be academic, some community. You might have the option or be required to have an elective general surgery practice in addition.

- elective general surgery practice with 1 week of CC per month. You just wouldn't schedule clinic or cases during your CC time if your ICU is busy.

- ACS/CC: similar to first "model" but at hospital that isn't a trauma center.

We can't really tell you how much time you'll spend doing what. I can tell you that you can probably find a job to accommodate whatever vision you have for how to divide your time. CC bills well so as long as you're generating RVU's and pulling your weight (this will mean different things at different institutions), then you'll be fine.

If you take a job with a significant trauma component, you'll spend a lot of time managing non-operative patients, and most of your time in the OR will be with acute care cases. If you take a job with an elective general surgery practice, you'll be in the OR several days per week. If you do acute care surgery at a busy hospital, you'll operate daily while not in the ICU.



Feel free to PM me with specific questions.

 

[Undecided15]

Thank you very much for your reply! Once I get a little more experience in GS I will likely have more questions. I appreciate your offer.

 

[HooliganSnail]

This seems like semantics, but really bad trauma patients roll in to the ER trying to die from the get-go. Granted, they tend to have fewer serious chronic diseases, but actively dying patients are (to my mind at least) the sickest patients in the hospital.

I know we all like to think that these fascinating "trauma patients" are teetering on the edge, but only by the skill of the physician teams do they continue to live every day, but it just isn't true.

Trauma patients come in four main varieties

1. Dead - Dead on scene, injuries massive, no chance. Often don't even come to hospital. Sadly way to many of these patients

2. Alive, banged up, broken in places, but no head injury, and will recover in time with many screws and plates in bones....Admit to floor, trauma attempts to turf to Ortho as soon as possible

3. Alive, Head injury. Very sad, but with varying degrees of outcome, almost none that we have any control over. Neurosurg intervention (or not). Mainly admit to ICU, neurochecks, keep lytes where they need to be. PM/R, PT/OT, long road to recovery. Not any gen surg managment (surgically at least)

4. The golden trauma case - Massive splenic lac, bleeding from bowel, kidney lac. Ex Lap, find the bullet, repair the damage, save the world, get the girl. The thing we all imagine trauma would be ( and how it is ALWAYS portrayed on TV). The ones who would have died, but we were able to get them to the OR and now they are going to pull through. A feel good case (unless they also have a number 3). These cases are actually rare though.

Most trauma comes down to one simple question. How badly did you get injured? What I have realized is that very little of what we do matters very much, it really is all about the nature of your injuries and whether your body can heal itself, or not.

 

[intmed2014]

IM resident here...I have done Trauma/CC research in med school in addition to Trauma Surgery rotation and Surgical ICU Rotation in med school. Of course as a IM resident, I have been an intern as well as an upper level. Intensivists are the kings of medical knowledge (in IM and Surgery alike) but even the most skilled clinicians need help on a fairly regular basis at a huge medical center.

Many patients in surgical ICU are followed by ortho, ENT, PRS and NSG. These specialties often have significant input into the management and this was welcomed by the surgical intensivists (Gen Surg, Anesthesia, EM-CC). Rounds were often interrupted as attendings had to oversee senior residents place trach-PEGs, bedside laparotomy etc.

Medical ICUs are fairly closed and medical intensivists are comfortable with most things but still consulted CC-nephrology for dialysis, surgical fields for procedures, GI for endoscopy. These are the patients with multiple medical comorbidities and management is fairly complex (only rotation where I have thought back to first year biochemistry). Rounds are not as long as surgical ICU rounds as attendings did not need to supervise procedures. Intensivists also help manage HF and CCU patients but are not technically primary at my hospital.

IM-->Pulm/CC is a much easier training route. My hardest month as an IM resident is prolly akin to an average GS month...never broken duty hours yet. I would recommend spending time with residents and attendings in both fields before deciding.

 

[Semmelweis]

I know we all like to think that these fascinating "trauma patients" are teetering on the edge, but only by the skill of the physician teams do they continue to live every day, but it just isn't true.

Trauma patients come in four main varieties..

How often do you take care of level 1 traumas in the trauma bay? When they arrive they certainly are often teetering on the edge at least in my experience. They don't always require an operation, but when they come in with MAPs in the 50s and a lactate of 10 it certainly is all about the skill of the team to be able to start immediate resuscitation and figure out why - fast.

Granted, once they make it past the initial "golden hour" and get to the unit, they tend to sort themselves into your different categories. What kills patients on the last spike on the trimodal distribution (sepsis, multi-organ failure, etc) is certainly improved with quality ICU care, but that's less sexy than an emergent trauma laparotomy.

 

[HooliganSnail]

How often do you take care of level 1 traumas in the trauma bay? When they arrive they certainly are often teetering on the edge at least in my experience. They don't always require an operation, but when they come in with MAPs in the 50s and a lactate of 10 it certainly is all about the skill of the team to be able to start immediate resuscitation and figure out why - fast.

Granted, once they make it past the initial "golden hour" and get to the unit, they tend to sort themselves into your different categories. What kills patients on the last spike on the trimodal distribution (sepsis, multi-organ failure, etc) is certainly improved with quality ICU care, but that's less sexy than an emergent trauma laparotomy.

Every day. Sometimes twice.