Graduating IM Resident, thinking about Anesthesia

[void88]

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OP, you haven’t really expressed why you are even considering CCM versus IM. Do you even like it? How did you enjoy your MICU rotations?

CCM is more pathophys heavy compared to IM. It has procedures. You have to learn airway management and ventilators which I really enjoy. I used to enjoy MICU rotation when I used to be on call and get to stabilize the patients in the beginning. Especially, because you get to do procedures. Didn’t enjoy days When I had patients who have been in ICU for many days for some reason.

 

[chocomorsel]

CCM is more pathophys heavy compared to IM. It has procedures. You have to learn airway management and ventilators which I really enjoy. I used to enjoy MICU rotation when I used to be on call and get to stabilize the patients in the beginning. Especially, because you get to do procedures. Didn’t enjoy days When I had patients who have been in ICU for many days for some reason.

Well, if you like CCM a lot more than IM, then I would just do the fellowship. I wouldn't even bother with the Pulm/CCM part personally if you don't like pulmonary. Just straight CCM as that will save you one year. You will get procedures in the unit yes, but I personally hate doing procedures other than intubating in the ICU. That's because I have been spoiled doing them in the OR where it's so much more efficient and we have good assistants that and I don't have to worry about a damn consent. And I already have so much to do in the Unit anyway including my never ending notes.

 

[GravelRider]

I think @GravelRider is a good source for someone who did anesthesia after IM. But I seem to remember he wished he had done pulm cc instead?

I sent him my advice. Yes, I usually do recommend an IM fellowship in this situation, but my recommendation is a little more nuanced than that. People outside of IM don’t always realize how competitive certain IM fellowships can be. This often means you have to jump through hoops to prove your worthiness...in other words you might need to do research for a year. Pulm/CCM has increased in competitiveness in recent years and while not on GI and cardiology level, is no sure thing either. In some situations it is easier to get an anesthesia residency and you’ll be practicing sooner than if you would have done a 3 year pulm/CCM fellowship after a “research” year.

So yes, for hospitalists they should explore all options within IM (including primary care, which is a better situation than hospitalist), but it might make more sense to apply for anesthesia. For IM residents considering a switch, I recommend them pursuing an IM fellowship 100%.

 

[Test Boy]

Why is that? I always thought CCM is an extension of Anesthesia outside of OR.

Not really. You just have to shadow an anesthesiologist for several days and see for yourself. Some similarities but a lot of differences.

 

[jthedestroyr]

Pretty sure, IM to CCM is much more attractive than anesthesia to CCM.
They prefer the IM trained doc's to run an ICU.

100%. Choco and I trained at a place that gave great IM ICU experience for community ICU, but I still get discriminated against. Recently was told they wouldn’t even present me at a location since I was anesthesia-ccm and I needed 3+ years before they’d consider anesthesia ccm(much less after pandemic though).

I am currently doing MICU only between 2 large universities as locums and love it. Prior I was anesthesia and icu, and I hated every minute working with crna despite my group was private and we hired them. I am not sayin we don’t have similar issues in the ICU, but nobody questions an ICU attending like the CRNA do in the OR, then have the circulators behind your back thinking the CRNAs do everything. I never get valued in anesthesia despite managing sick patients unlike in the icu. I feel respected and valued in the icu.

Even dated an OR nurse who felt like this, and I told her she had no idea how big they **** up (we see it in the icu after they’ve been dumped off). Not saying physicians don’t either, but crna routinely did crazy things then drop and run away from the icu patient as soon as possible without any regard.

The pay for academic micu is terrible but you’ve got great support. Academic anesthesia pay still is way better, but you’ve got to suffer doing anesthesia.

I know many of my colleagues love anesthesia, but I personally wished I had done Pulm ccm.

 

[epidural man]

I

Hello, everyone! Currently, I'm PGY-3 IM Resident hoping to graduate this summer. Throughout my training, I have had an interest in Critical Care and enjoyed Managing airways during my Anesthesia rotation at the end of my PGY-2 year. I really enjoyed Anesthesia. Now I am having trouble deciding to what route should I go for.

I can either apply for Pulmonary/CC or just CC fellowship this year and work as a Hospitalist for one year. Or, I can just apply for Anesthesia and do one year of Critical Care after that. Ideally, I would want to have either Pulmonary or Anesthesia with Critical Care just to avoid burnout 10 years down the road.

Given that I have finished residency in Internal Medicine, will I have a better chance matching to Anesthesia? I feel like I've got more chance of matching in Anesthesia vs. Pulmonary Critical Care Medicine.

I am really stressing out and I realize that I should have made decision earlier (like last year) about these things. Please any kind of guidance would be greatly appreciated. I have average scores but no RED flag.

Thanks

im sorry I’m late to the party and I hope you aren’t done deciding but please listen to me. 🙂 I only read about 5 responses of this 3 page discussion - but everyone kept saying “do Pulm/CC. That is completely wrong. I have no idea what they are talking about. Those who suggested that usually have great suggestions on here too. WTF?

Medicine sucks. Anesthesia is awesome. It’s really one of the only tolerable things in medicine.

Also, don’t stress.
Lots of people practice then leave their field to come to anesthesia. So just chill.

make the right decision of course, but when the time comes, come do an anesthesia residency and if you still want, do a CC fellowship.

My sister’s goal was to do critical care. And she does that now (yeah! Achieved her goal). And she thanks me every time I talk to her for talking her out of her IM residency she had lined up. She loves anesthesia.

 

[Mman]

That's because I have been spoiled doing them in the OR where it's so much more efficient and we have good assistants that and I don't have to worry about a damn consent.

When I was a resident we had to get a generic ICU consent form for each admission (obviously usually from a family member) that consented them to basically everything we might ever do to them over the next month. Art line, CVP, PA cath, TEE, Intubation, bronch, thoracentesis, etc. Can't remember if it went as far as things like ECMO but basically.

 

[nimbus]

Why is that? I always thought CCM is an extension of Anesthesia outside of OR.

That is false but the inverse is true. Anesthesia is an extension of CCM in the operating room.

 

[chocomorsel]

When I was a resident we had to get a generic ICU consent form for each admission (obviously usually from a family member) that consented them to basically everything we might ever do to them over the next month. Art line, CVP, PA cath, TEE, Intubation, bronch, thoracentesis, etc. Can't remember if it went as far as things like ECMO but basically.

The nurses are very helpful with the consents in the community hospitals. But it’s still a pain when you need to do a procedure now and you gotta ask for permission. WTF? The only procedure that doesn’t require it is intubation. I guess because they know that’s a life and death situation. Except other procedures aren’t exactly for the fun of it. If you are bleeding and need blood I don’t need to ask for permission. So f king stupid. A CVC big Mack so I can rapidly transfuse your ass? Nope, not that either. I do a lot more emergent necessities than probably most.
I remember those forms now that you mentioned it. Those residence catch all forms would be nice.

 

[Mman]

If you are bleeding and need blood I don’t need to ask for permission. So f king stupid.

I live in an area with a reasonably large Jehovah's Witness population. I find it odd as hell, but many of them say let me die instead of giving me that bag of PRBCs.

 

[chocomorsel]

I live in an area with a reasonably large Jehovah's Witness population. I find it odd as hell, but many of them say let me die instead of giving me that bag of PRBCs.

Brainwashed by their Bible. Sad.

 

[Mman]

Brainwashed by their Bible. Sad.

I don't judge people for their beliefs, but I personally find it stupefying. But as long as they make their wishes crystal clear preop, I have no qualms about letting someone bleed to death if that is their wish. My favorite is when they qualify it by telling me there are "other things" I can give them instead of blood. Leads to a fun discussion about how giving you crystalloid (or whatever) doesn't carry oxygen around you body and you still die. Some of them seem quite surprised by the fact you could actually bleed to death without a transfusion.

 

[GassYous]

I

im sorry I’m late to the party and I hope you aren’t done deciding but please listen to me. 🙂 I only read about 5 responses of this 3 page discussion - but everyone kept saying “do Pulm/CC. That is completely wrong. I have no idea what they are talking about. Those who suggested that usually have great suggestions on here too. WTF?

Medicine sucks. Anesthesia is awesome. It’s really one of the only tolerable things in medicine.

Also, don’t stress.
Lots of people practice then leave their field to come to anesthesia. So just chill.

make the right decision of course, but when the time comes, come do an anesthesia residency and if you still want, do a CC fellowship.

My sister’s goal was to do critical care. And she does that now (yeah! Achieved her goal). And she thanks me every time I talk to her for talking her out of her IM residency she had lined up. She loves anesthesia.

He doesn't want to do anesthesia. He was thinking of going into critical care through anesthesia.

 

[GassYous]

I don't judge people for their beliefs, but I personally find it stupefying. But as long as they make their wishes crystal clear preop, I have no qualms about letting someone bleed to death if that is their wish. My favorite is when they qualify it by telling me there are "other things" I can give them instead of blood. Leads to a fun discussion about how giving you crystalloid (or whatever) doesn't carry oxygen around you body and you still die. Some of them seem quite surprised by the fact you could actually bleed to death without a transfusion.

The lowest hemoglobin I've had in a guy that was still alive was a jehovah's witness. It bottomed out at 3. He was still technically alive for a few days but passed in the unit.

 

[chocomorsel]

The lowest hemoglobin I've had in a guy that was still alive was a jehovah's witness. It bottomed out at 3. He was still technically alive for a few days but passed in the unit.

It was God’s will.

 

[chocomorsel]

I don't judge people for their beliefs, but I personally find it stupefying. But as long as they make their wishes crystal clear preop, I have no qualms about letting someone bleed to death if that is their wish. My favorite is when they qualify it by telling me there are "other things" I can give them instead of blood. Leads to a fun discussion about how giving you crystalloid (or whatever) doesn't carry oxygen around you body and you still die. Some of them seem quite surprised by the fact you could actually bleed to death without a transfusion.

I had a talk w a wife away from the husband and promised her he wouldn’t know and she was all for some blood. Some of these poor people are held hostage by their families and they don’t believe in that s hit.

 

[jthedestroyr]

I

im sorry I’m late to the party and I hope you aren’t done deciding but please listen to me. 🙂 I only read about 5 responses of this 3 page discussion - but everyone kept saying “do Pulm/CC. That is completely wrong. I have no idea what they are talking about. Those who suggested that usually have great suggestions on here too. WTF?

Medicine sucks. Anesthesia is awesome. It’s really one of the only tolerable things in medicine.

Also, don’t stress.
Lots of people practice then leave their field to come to anesthesia. So just chill.

make the right decision of course, but when the time comes, come do an anesthesia residency and if you still want, do a CC fellowship.

My sister’s goal was to do critical care. And she does that now (yeah! Achieved her goal). And she thanks me every time I talk to her for talking her out of her IM residency she had lined up. She loves anesthesia.

I couldn’t disagree more having done anesthesia then a ccm fellowship.

the pandemic changed the game and allowed us to come into other ICUs that previously didn’t happen. None the less, it’s still harder to break into the MICU if you want.

For me personally, I’d much rather take the micu headaches than staffing SICU/CT ICU. I guess each to their own. I mean if you like back seat drivers, I guess the SICU and CT ICU is the place to be ! Right @FFP ? 🙂

I found it completely counter to my belief of good practice care of sticking me head in the sand while supervising crna in order to tolerate working with them. My first job even if you go back and look at my posts touted “strong crna,” even strong crna is code for arrogant and does not know their limitations which is dangerous for patients. Practicing anesthesia, you’re doing that everyday.

I just really don’t experience that dynamic in the MICU with my PA/NPs. Yes they still make mistakes, but they don’t come with the defiance you see with crna in the ORs.

you can also scale back icu time as pulm ccm and do pulm only aka no call. It’s hard to find no call or limited call in anesthesia.

 

[jthedestroyr]

The lowest hemoglobin I've had in a guy that was still alive was a jehovah's witness. It bottomed out at 3. He was still technically alive for a few days but passed in the unit.

3.6 due to being a insanely hard cross match (took multiple cross states to find a few units). He would come in routinely under 5, but got to mid 3s and wouldn’t accept anything other than the exact match.

 

[nimbus]

I had a talk w a wife away from the husband and promised her he wouldn’t know and she was all for some blood. Some of these poor people are held hostage by their families and they don’t believe in that s hit.

In residency we had a young, unconscious trauma patient who’s family was adamant about him not receiving blood. Fortunately he didn’t need any blood. But when he woke up he said, “ I don’t believe in that s***!”

 

[Ronin786]

I'm surprised nobody has mentioned this, but Anesthesia-CCM makes a decent amount more than PCCM. I know at my shop it's a good $150k difference.

I know money isn't everything, but over a 20 year period that's 2.1MM after Uncle Sam's cut. Much more if you invest wisely. How much "respect" is worth retiring 5-10 years later?

 

[void88]

He doesn't want to do anesthesia. He was thinking of going into critical care through anesthesia.

I do like Anesthesia.

 

[chocomorsel]

I'm surprised nobody has mentioned this, but Anesthesia-CCM makes a decent amount more than PCCM. I know at my shop it's a good $150k difference.

I know money isn't everything, but over a 20 year period that's 2.1MM after Uncle Sam's cut. Much more if you invest wisely. How much "respect" is worth retiring 5-10 years later?

The combo? In academics or PP?
Because Pulm CCM docs make a nice chunk of change. Especially if they work hard. Greater than 500 easily. I would venture to say that they make more and finding a combo Anes/CCM job outside of academics is difficult to do.

 

[epidural man]

He doesn't want to do anesthesia. He was thinking of going into critical care through anesthesia.

That’s the point. Does anyone spend 100% of their time in the ICU? If so, that’s a rarity I would think. Am I wrong? ICU seems to always be something people do in addition to their primary duties.

And so what I told my sister, who like the OP - had a primary goal of being an ICU doc - think about what you will be doing when NOT in the ICU. And anesthesia is 1000x better than seeing COPD patients in clinic, or refilling blood pressure medicine in the IM clinic.

 

[jthedestroyr]

That’s the point. Does anyone spend 100% of their time in the ICU? If so, that’s a rarity I would think. Am I wrong? ICU seems to always be something people do in addition to their primary duties.

And so what I told my sister, who like the OP - had a primary goal of being an ICU doc - think about what you will be doing when NOT in the ICU. And anesthesia is 1000x better than seeing COPD patients in clinic, or refilling blood pressure medicine in the IM clinic.

I do 100% icu and gave up anesthesia back in January after doing combo. I took a huge, huge pay cut, despite finding one of the few PP ccm jobs. There is always a price to pay when the salaries hit a certain range.

Choco I think is doing the same, but please correct me if I’m wrong.

PCCM makes peanuts in academics from what I’ve seen and yes SOME anes-ccm can make more in ACADEMICs but there is a trade off (working SICU/CT ICU). BUT the PCCM guys make maybe 1 week of icu a month at best in academics. It’s opposite in community icu for everyone.

People that aren’t CCM don’t understand the nightmare of the CT ICU and most SICUs. Even the attitudes of surgery-ccm is, “this patient came to be operated by surgeon xyz, im just here.”

That attitude makes being a good CCM doctor with too many cooks in the kitchen difficult. Specially with a surgeon that did 2 months of SICU as a PGY-2 and thinks that’s similar to a fellowship trained CCM physician.

 

[Katheudontas parateroumen]

I do 100% icu and gave up anesthesia back in January after doing combo. I took a huge, huge pay cut, despite finding one of the few PP ccm jobs. There is always a price to pay when the salaries hit a certain range.

Choco I think is doing the same, but please correct me if I’m wrong.

PCCM makes peanuts in academics from what I’ve seen and yes SOME anes-ccm can make more in ACADEMICs but there is a trade off (working SICU/CT ICU). BUT the PCCM guys make maybe 1 week of icu a month at best in academics. It’s opposite in community icu for everyone.

People that aren’t CCM don’t understand the nightmare of the CT ICU and most SICUs. Even the attitudes of surgery-ccm is, “this patient came to be operated by surgeon xyz, im just here.”

That attitude makes being a good CCM doctor with too many cooks in the kitchen difficult. Specially with a surgeon that did 2 months of SICU as a PGY-2 and thinks that’s similar to a fellowship trained CCM physician.

Do you feel like community mixed Med/surg ICUs are like that too? Too many cooks in the kitchen for both the hospitalists or surgeons budding in?

 

[Katheudontas parateroumen]

Also for OP, I think if you do anesthesia CCM, I believe that since you’re primary IM trained you’ll still have easier gateway into doing MICU or academics as well. I know one attending who was IM trained, did anesthesia residency and anesthesia based CCM fellowship. He now splits OR with mixed Med surg community ICU (no more general medicine or outpatient things). He seems happy with it.

 

[spacegun]

I sent him my advice. Yes, I usually do recommend an IM fellowship in this situation, but my recommendation is a little more nuanced than that. People outside of IM don’t always realize how competitive certain IM fellowships can be. This often means you have to jump through hoops to prove your worthiness...in other words you might need to do research for a year. Pulm/CCM has increased in competitiveness in recent years and while not on GI and cardiology level, is no sure thing either. In some situations it is easier to get an anesthesia residency and you’ll be practicing sooner than if you would have done a 3 year pulm/CCM fellowship after a “research” year.

So yes, for hospitalists they should explore all options within IM (including primary care, which is a better situation than hospitalist), but it might make more sense to apply for anesthesia. For IM residents considering a switch, I recommend them pursuing an IM fellowship 100%.

Good points. Just a slight clarification which I think adds to your point, but judging by the NRMP fellowship match data in 2020 and most recently 2021, it looks like pulm/cc is at least on par with GI and cards now, according to percentages matched (e.g. in 2020 pulm/cc was only second to GI in percentage matched). To be fair, maybe the average GI and cards candidates are still more competitive than the average pulm/cc candidate, needing more research, etc.

 

[vector2]

I do 100% icu and gave up anesthesia back in January after doing combo. I took a huge, huge pay cut, despite finding one of the few PP ccm jobs. There is always a price to pay when the salaries hit a certain range.

Choco I think is doing the same, but please correct me if I’m wrong.

PCCM makes peanuts in academics from what I’ve seen and yes SOME anes-ccm can make more in ACADEMICs but there is a trade off (working SICU/CT ICU). BUT the PCCM guys make maybe 1 week of icu a month at best in academics. It’s opposite in community icu for everyone.

People that aren’t CCM don’t understand the nightmare of the CT ICU and most SICUs. Even the attitudes of surgery-ccm is, “this patient came to be operated by surgeon xyz, im just here.”

That attitude makes being a good CCM doctor with too many cooks in the kitchen difficult. Specially with a surgeon that did 2 months of SICU as a PGY-2 and thinks that’s similar to a fellowship trained CCM physician.

In my experience ACCM folks will only get a modicum of respect and deference in the more ivory towerish CT ICUs if they're both cardiac and CCM trained. When you work with those egomaniacs in the OR most of them realize there or at least have some understanding that their job is impossible without you, especially when it comes to making diagnoses and managing some of the sicker cardiac pts coming off pump. And then in the ICU, they know the cardiac trained folks usually have a better understanding of the sequelae from any surgical difficulties in the OR which could be manifesting now in the ICU.

That's not to say there aren't purely CCM trained folks who aren't exceptional CT intensivists, but I would caution that many CT surgeons, especially the more dickish ones, are mostly going to treat you like the dulcolax prescriber.

 

[sluggs]

I did straight ccm after IM. I trained in MICU, but also in CTICU, Neuro ICU and SICU. I had a lot of exposure to anesthesia ccm sttendings, and I also id 3 months of anesthesia as electives. This multidisciplinary approach was a phenomenal learning experience-- integrating different perspectives. Anesthesia taught me how to get to the bedside and do hands-on care. Medicine taught me how to read and apply evidence based concepts. Neuro taught me neuro. You may want to try straight ccm!

 

[jthedestroyr]

Do you feel like community mixed Med/surg ICUs are like that too? Too many cooks in the kitchen for both the hospitalists or surgeons budding in?

MICU is closed period. When i was private, I was a unique setup, but yes, those particular surgeons didn’t really want to deal with icu stuff period. In academics, I’ve seen they love getting way too involved.

 

[jthedestroyr]

In my experience ACCM folks will only get a modicum of respect and deference in the more ivory towerish CT ICUs if they're both cardiac and CCM trained. When you work with those egomaniacs in the OR most of them realize there or at least have some understanding that their job is impossible without you, especially when it comes to making diagnoses and managing some of the sicker cardiac pts coming off pump. And then in the ICU, they know the cardiac trained folks usually have a better understanding of the sequelae from any surgical difficulties in the OR which could be manifesting now in the ICU.

That's not to say there aren't purely CCM trained folks who aren't exceptional CT intensivists, but I would caution that many CT surgeons, especially the more dickish ones, are mostly going to treat you like the dulcolax prescriber.

Totally agree, but I’ve still seen CT surgeons get particular nasty to a CT-CCM trained attending in a way I’ve never seen someone talk to any other Intensivist. That was my wake up call that I want nothing to do with CT ICU.

I want to stress my anesthesia background has been amazing for managing sick patients, not freaking out in emergency situations, etc. I would say the real best training for combo ICU is IM-EM combo residency. If you want to do anesthesia to ccm, you need an anesthesia program that is very, very medicine heavy intern year, then pick a medicine heavy ICU fellowship.

 

[Ronin786]

The combo? In academics or PP?
Because Pulm CCM docs make a nice chunk of change. Especially if they work hard. Greater than 500 easily. I would venture to say that they make more and finding a combo Anes/CCM job outside of academics is difficult to do.

I'm talking about academics.