Help with post-fellowship job decision (EM/CCM)

[InFactotum]

I am finishing my fellowship in CCM via an anesthesia program in June, my residency training is EM. I am trying to find a 50/50 ICU/EM split.

Majority of my training has been in the cardiac ICU, and I think one day I'd like to end up in a cardiac ICU , but have not found a position in my region yet.

Current options:
1) Stay at home program working 50/50 EM/SICU (~7-8 EM shifts, 8 hours long; 7 days in mixed trauma/surgical ICU followed by week off)

Pros: Know the hospital well, money is decent for an academic center​

Cons: ~1 hour commute so would have to maintain a 2nd apartment away from my wife during the ICU shifts realistically, and probably during some ED shifts​

2) Major academic program in the same city as my wife working 50/50 EM/MICU (8 EM shifts, 8 hours long; nocturnist MICU position with 6 overnights in a row followed by week off)

Pros: I know the EM PD well and he is a great mentor and expect I can be involved significantly in the residency. Household name of hospital may benefit me in future jobs?​

Cons: Pay is poor compared to option 1, but average for the area in academics. Pure nocturnist MICU position sounds rough long term.​

3) 0.5FTE EM position at either of the above hospitals and find a locums ICU gig to cover the other 0.5FTE (eg 13 weeks of ICU)

None of the above options sound great, and none are ultimately what I think I want to do (EM/Cardiac ICU).

I am tempted towards option 3, and wait for a cardiac ICU position to open up in my city, but my major concern is if I work in a community ICU that I will have trouble getting hired into an academic position later on.

Any advice is appreciated.

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[Dr.CCM]

I’m EM/CCM too but community based. I’m mostly just ICU and prn EM. I’d say expand your search. You should be able to find what you want in academics and the private world. I’d say more than the other units the cvicu is a use it or lose it kind of thing unless it’s a high acuity mixed micu that has cardiac patients with all the devices you just won’t see Tandems, VA/VV, impellas, total hearts, etc outside of that place.

I’d also say that you are EM fellowship trained with a real, accredited fellowship similar to Tox and I guess Pain, not to offend the other ones but you have significantly more training in medicine and that medicine will be used daily in ER residencies. You have a lot to teach residents because of this. You’ll always be valued for an academic EM job. Just don’t quit working in an ED and maybe stay loosely connected to the world with doing some case reports, mentoring, setup an elective rotation etc. I hope that helps. I know there a few academic EM/CC attendings here that may have a different perspective.

 

[InFactotum]

I’m EM/CCM too but community based. I’m mostly just ICU and prn EM. I’d say expand your search. You should be able to find what you want in academics and the private world. I’d say more than the other units the cvicu is a use it or lose it kind of thing unless it’s a high acuity mixed micu that has cardiac patients with all the devices you just won’t see Tandems, VA/VV, impellas, total hearts, etc outside of that place.

I’d also say that you are EM fellowship trained with a real, accredited fellowship similar to Tox and I guess Pain, not to offend the other ones but you have significantly more training in medicine and that medicine will be used daily in ER residencies. You have a lot to teach residents because of this. You’ll always be valued for an academic EM job. Just don’t quit working in an ED and maybe stay loosely connected to the world with doing some case reports, mentoring, setup an elective rotation etc. I hope that helps. I know there a few academic EM/CC attendings here that may have a different perspective.

By expanding my search, do you mean geographically? In my city, I've reached out to every academic center with a cardiac unit, and none have positions available, which means moving to option 3 and finding a cardiac unit somewhere else in the country while practicing EM here. That is another concern of mine, losing my skillset of taking care of that patient population, which is certainly very unique. It must be bad timing or something, but in my city there are at least 5 academic centers with cardiac ICUs, and none are hiring.

 

[TheComebacKid]

Why can't you just take option 1 or 2 with the plan to work for a year, and wait for an cardiac ICU position to open up at those institutions or elsewhere?

Full disclosure, I'm not doing CCM or in any way affiliated with the fellowship training pathway, but I flirted with CCM for awhile. After talking with some of the fellows at my home program, they all universally hated the community ICU experience and felt that they were routinely transferring patients due to lack of resources i.e. continuous EEG monitoring, surgical subspecialty support etc. I guess it depends on the community ICU you are at, but the ones in my area aren't managing much more than DKA and your average COPD'er on BIPAP. I would guess it would be easy to lose some of the skills you learned in fellowship, but I'm not sure.

For me personally, option 2 sounds the best (no long commute), and I like the week on/off but I get why it's not everyone's cup of tea. However, none of the EM/CCM faculty at my shop truly have "a week off". That time is spent fulfilling their ED clinical requirement, research and other academic commitment.

Also, I don't know how it is in your shop, but overnight in the MICU where I'm at the attending is basically just around for new admits and helping put out any major fires (i.e. intubation for decompensating patient etc). It's a busy unit, but often full especially overnight with ED boarders, and much of the time the attendings manage to get a handful of hours of sleep while the fellow runs the unit. I would take that over day shift and constant rounds/family discussions etc, but that's just coming from an EM person who hates rounding for hours.

 

[deleted547339]

Why can't you just take option 1 or 2 with the plan to work for a year, and wait for an cardiac ICU position to open up at those institutions or elsewhere?

Full disclosure, I'm not doing CCM or in any way affiliated with the fellowship training pathway, but I flirted with CCM for awhile. After talking with some of the fellows at my home program, they all universally hated the community ICU experience and felt that they were routinely transferring patients due to lack of resources i.e. continuous EEG monitoring, surgical subspecialty support etc. I guess it depends on the community ICU you are at, but the ones in my area aren't managing much more than DKA and your average COPD'er on BIPAP. I would guess it would be easy to lose some of the skills you learned in fellowship, but I'm not sure.

For me personally, option 2 sounds the best (no long commute), and I like the week on/off but I get why it's not everyone's cup of tea. However, none of the EM/CCM faculty at my shop truly have "a week off". That time is spent fulfilling their ED clinical requirement, research and other academic commitment.

Also, I don't know how it is in your shop, but overnight in the MICU where I'm at the attending is basically just around for new admits and helping put out any major fires (i.e. intubation for decompensating patient etc). It's a busy unit, but often full especially overnight with ED boarders, and much of the time the attendings manage to get a handful of hours of sleep while the fellow runs the unit. I would take that over day shift and constant rounds/family discussions etc, but that's just coming from an EM person who hates rounding for hours.

Nah man. That’s not just for EM alone. I’m EM/CCM. I LOVE the nights where I just put out fires, supervise procedures and get a nap.

 

[ShockIndex]

I am finishing my fellowship in CCM via an anesthesia program in June, my residency training is EM. I am trying to find a 50/50 ICU/EM split.

Majority of my training has been in the cardiac ICU, and I think one day I'd like to end up in a cardiac ICU , but have not found a position in my region yet.

Current options:
1) Stay at home program working 50/50 EM/SICU (~7-8 EM shifts, 8 hours long; 7 days in mixed trauma/surgical ICU followed by week off)

Pros: Know the hospital well, money is decent for an academic center​

Cons: ~1 hour commute so would have to maintain a 2nd apartment away from my wife during the ICU shifts realistically, and probably during some ED shifts​

2) Major academic program in the same city as my wife working 50/50 EM/MICU (8 EM shifts, 8 hours long; nocturnist MICU position with 6 overnights in a row followed by week off)

Pros: I know the EM PD well and he is a great mentor and expect I can be involved significantly in the residency. Household name of hospital may benefit me in future jobs?​

Cons: Pay is poor compared to option 1, but average for the area in academics. Pure nocturnist MICU position sounds rough long term.​

3) 0.5FTE EM position at either of the above hospitals and find a locums ICU gig to cover the other 0.5FTE (eg 13 weeks of ICU)

None of the above options sound great, and none are ultimately what I think I want to do (EM/Cardiac ICU).

I am tempted towards option 3, and wait for a cardiac ICU position to open up in my city, but my major concern is if I work in a community ICU that I will have trouble getting hired into an academic position later on.

Any advice is appreciated.

I’m liking option 1 to be honest. It’s a known entity. Let them know that you are interested in some CVICU time and I bet they will keep you in mind when someone retires, takes FMLA, etc. A one hour commute seems rough, but I have friends in major cities who sit in NY, DC, Boston, and LA traffic for 1-2 hours each way, every day. Hell, it took my wife an hour to drive 10 miles from South Charlotte to Uptown in rush hour, and she did that commute for a decade.

Finally, that 50/50 split seems like a great idea now but I’m curious about how you feel in a year. All of my friends have cut their EM time back to less than 0.3 FTE. They all said that coordinating the academic obligations between 2 departments that didn’t communicate well resulted in an unsustainable work/life balance.

 

[InFactotum]

Appreciate everyone's opinions thus far. Any input on the downside to pursuing option 3 (0.5FTE EM at academic center and locums ICU)?

 

[Angry Birds]

Appreciate everyone's opinions thus far. Any input on the downside to pursuing option 3 (0.5FTE EM at academic center and locums ICU)?

Benefits?

EDIT: I mean to say, will you miss out on benefits offered for being full-time at either job, i.e. health insurance?

 

[InFactotum]

Benefits?

EDIT: I mean to say, will you miss out on benefits offered for being full-time at either job, i.e. health insurance?

Yea, I'm not too worried about insurance, my wife has a secure job with pretty ridiculous insurance benefits so I will be staying on her plan. Lack of retirement benefits seems like a downside, but I don't intend to do this for more than a couple years and can probably make up for that through an increase in pay allowing me to put more into savings.

I'm more concerned about ability to get back into an academic ICU setting in the future. I figure a week of nights where I won't see my wife (given her schedule) isn't majorly different than working for a week away in another state.

 

[subnaucticmed]

I’m EM/CCM too but community based. I’m mostly just ICU and prn EM. I’d say expand your search. You should be able to find what you want in academics and the private world. I’d say more than the other units the cvicu is a use it or lose it kind of thing unless it’s a high acuity mixed micu that has cardiac patients with all the devices you just won’t see Tandems, VA/VV, impellas, total hearts, etc outside of that place.

I’d also say that you are EM fellowship trained with a real, accredited fellowship similar to Tox and I guess Pain, not to offend the other ones but you have significantly more training in medicine and that medicine will be used daily in ER residencies. You have a lot to teach residents because of this. You’ll always be valued for an academic EM job. Just don’t quit working in an ED and maybe stay loosely connected to the world with doing some case reports, mentoring, setup an elective rotation etc. I hope that helps. I know there a few academic EM/CC attendings here that may have a different perspective.

I'm a current CCM fellow and wanted to ask more about this. I know very little about the community EM/CCM market and was wondering what tips you had if you wanted to get a primarily community CCM job. Are there specific groups to reach out to (e.g. Sound Physicians) or should you just reach out to community hospitals in the area? How hard is it to do primarily community CCM and supplement with some PRN shifts or some lecturing in a local academic center? I'd be interested in exploring a community CCM practice before (or if) I commit to academics.

 

[ShockIndex]

Appreciate everyone's opinions thus far. Any input on the downside to pursuing option 3 (0.5FTE EM at academic center and locums ICU)?

It all depends on what that department considers a FTE in terms of clinical hours. Many academic EM programs use roughly 150 hours per month. Assuming that the EM 0.5 FTE is all clinical, the biggest downside that I see is that you will have no time to pursue scholarly activity after you schedule your ICU time. That is to say, 1 FTE in academics generally starts at 60-70% clinical time to allow the faculty member to pursue scholarly activity. For example, my FTE started with 90 clinical hours per month and I had to bust my ass to get grants, teaching buy-down etc. That clinical time got reduced as I earned grant funding which allowed me to further develop my niche. Without that protected time for scholarly activity, what will you bring to the table in terms of a unique academic skill to sell yourself for that full-time appointment in a few years?

Put another way, I’m concerned that you might not be selling yourself to your complete potential. Even worse, I’d hate to see you putting yourself in a position 3 years from now where you have no unique academic skill set because you have spent 75 hours per month in the ED and 50 hours per month in the ICU with no time to spare for developing an academic niche.

Brian Wessman is the CCM PD at the Washington Univ. and he gives a great talk about CCM-trained EPs needing to sell their unique skill set and positions will get made even if one does not exist. If you want an academic career, you need to really develop an academic niche with your elective time in this last year. Get on some research projects, get involved in education, etc.

 

[InFactotum]

It all depends on what that department considers a FTE in terms of clinical hours. Many academic EM programs use roughly 150 hours per month. Assuming that the EM 0.5 FTE is all clinical, the biggest downside that I see is that you will have no time to pursue scholarly activity after you schedule your ICU time. That is to say, 1 FTE in academics generally starts at 60-70% clinical time to allow the faculty member to pursue scholarly activity. For example, my FTE started with 90 clinical hours per month and I had to bust my ass to get grants, teaching buy-down etc. That clinical time got reduced as I earned grant funding which allowed me to further develop my niche. Without that protected time for scholarly activity, what will you bring to the table in terms of a unique academic skill to sell yourself for that full-time appointment in a few years?

Put another way, I’m concerned that you might not be selling yourself to your complete potential. Even worse, I’d hate to see you putting yourself in a position 3 years from now where you have no unique academic skill set because you have spent 75 hours per month in the ED and 50 hours per month in the ICU with no time to spare for developing an academic niche.

Brian Wessman is the CCM PD at the Washington Univ. and he gives a great talk about CCM-trained EPs needing to sell their unique skill set and positions will get made even if one does not exist. If you want an academic career, you need to really develop an academic niche with your elective time in this last year. Get on some research projects, get involved in education, etc.

Thanks for this insight. To be honest, my program doesn't do a great job at discussing these kind of aspects of academic medicine (i.e. teaching buy-down, etc), so I feel a bit ignorant in this area.

As far as a niche is concerned, my interests include TEE/TTE and ECMO and teaching. I'm not going to be a researcher, at least not as a PI for prospective research. I do see how it would be harder to develop a niche if I have a foot in two different hospitals.

 

[ShockIndex]

Thanks for this insight. To be honest, my program doesn't do a great job at discussing these kind of aspects of academic medicine (i.e. teaching buy-down, etc), so I feel a bit ignorant in this area.

As far as a niche is concerned, my interests include TEE/TTE and ECMO and teaching. I'm not going to be a researcher, at least not as a PI for prospective research. I do see how it would be harder to develop a niche if I have a foot in two different hospitals.

No worries - most people learn how to live in the academic jungle through trial and error while wasting years in the process.

If I may, let me pass on some advice that was given to me by someone who is currently sitting on top of an academic empire. He told me to ask myself what I wanted to accomplish, and then go to the place that has the best resources and mentorship track records to do exactly that. In other words, you are most likely to succeed in academics when you are surrounded by people who can mentor you and a place that can fund you. When I told him that I wanted to excel at critical care research, he told me to look at the place dominating that research landscape, and seriously consider if I was committed to that goal if I didn’t at least interview at the places dominating research funding. That meant uprooting my family after being an attending for 15 years and moving 500 miles...

At the risk of coming across as mean, let me ask you - how serious are you about developing your niche as an authority in advanced echo, ECMO, and teaching if you are working ICU locums, or MICU nights? I submit that MICU nights and locums moves you away from that goal; it’s not even treading water since you are talking about perishable skill sets and advancing technology.

I completely understand that you’ve got a wife with a career. She gets a vote too. Just think carefully about what is possible and reasonable considering the sacrifices that you’ve made to get this far.

 

[Dr.CCM]

I'm a current CCM fellow and wanted to ask more about this. I know very little about the community EM/CCM market and was wondering what tips you had if you wanted to get a primarily community CCM job. Are there specific groups to reach out to (e.g. Sound Physicians) or should you just reach out to community hospitals in the area? How hard is it to do primarily community CCM and supplement with some PRN shifts or some lecturing in a local academic center? I'd be interested in exploring a community CCM practice before (or if) I commit to academics.

I’d find out where you want to live, look for the groups in that area or hospitals and cold call. See if they want full time CCM. Coming from IM or EM only, you are at a disadvantage a bit in the community as a lot want Pulm too for clinics/Pulm consult.
Locums is pretty good right now too for CCM. Something to consider.

 

[InFactotum]

No worries - most people learn how to live in the academic jungle through trial and error while wasting years in the process.

If I may, let me pass on some advice that was given to me by someone who is currently sitting on top of an academic empire. He told me to ask myself what I wanted to accomplish, and then go to the place that has the best resources and mentorship track records to do exactly that. In other words, you are most likely to succeed in academics when you are surrounded by people who can mentor you and a place that can fund you. When I told him that I wanted to excel at critical care research, he told me to look at the place dominating that research landscape, and seriously consider if I was committed to that goal if I didn’t at least interview at the places dominating research funding. That meant uprooting my family after being an attending for 15 years and moving 500 miles...

At the risk of coming across as mean, let me ask you - how serious are you about developing your niche as an authority in advanced echo, ECMO, and teaching if you are working ICU locums, or MICU nights? I submit that MICU nights and locums moves you away from that goal; it’s not even treading water since you are talking about perishable skill sets and advancing technology.

I completely understand that you’ve got a wife with a career. She gets a vote too. Just think carefully about what is possible and reasonable considering the sacrifices that you’ve made to get this far.

Don't think you're coming across that way at all. It's an important question I need to answer for myself, and I've tried being introspective on this issue to figure out where I really stand. I believe I am serious about it... I have gone out of my way and spent extra hours to be more involved in ECMO and to learn TEE in my program, but I do get discouraged when roadblocks keep getting thrown up to me furthering this craft (in fellowship, but also with lack of positions). That said, within my geographic constraint, there is no CVICU positions available to me as EM/CCM, I've spoke with the directors of every CVICU in my city. Either they aren't hiring, or they aren't hiring someone from EM (i.e. only anesthesia).

The spot at my home program is SICU, with the hope that eventually someone in the CVICU leaves so I can take their spot. Similarly, the MICU nights position would be with the hope that someone in their CVICU leaves (I've spoken with the CV director and he said he'd "keep me in mind", and the MICU director and chair their know that my ultimate goal is CVICU). I certainly have a bigger advantage at my home program where they know me.

And yea, to your last point, my wife gets a vote and it's a big one. I've had her move states/jobs twice, and deal with me living apart for nearly two years now (see each other one day a week basically due to the hours here/commute), and she's excelling in her position lately, so I can't ask her to uproot right now for my aspirations, as much as I want to, as I know for a fact there are at least two positions in the country that are exactly what I'm looking for. Maybe in a few years when she is ready to move on...

 

[ShockIndex]

A couple of other things to consider no matter where you land. First, be sure to find out what that 0.5 EM FTE entails in terms of clinical hours per month. The same goes for the SICU; my experience is that Departments of Surgery and EM very often have vastly different concepts of what a FTE entails in terms of clinical hours. EM-CCM faculty with their FTE’s being split by 2 departments are at particular risk of being overworked clinically and not given enough time to develop their academic interests - especially when the other department is surgery and their Chair plans to crush you to make up for the fact that you will not be generating OR revenue. I’m particularly worried about that 0.5 EM FTE since most of your interests are geared toward CCM. Unless you plan to bring ECMO/ECPR and TEE to the ED (something being done at a handful of centers), that 0.5 FTE in the ED sounds like a lot to me.

Second, most academic positions have tracks for career progression - education, research, admin, etc. If so, talk too your Chairs about a track that best fits your career goals. Then, make sure that you have a mentor.

I know you said that research is not your gig, but everyone in academics must have some scholarly output, otherwise they are stuck in Assistant Professor mode for the rest of their careers. That could be novel educational programs or clinical pathways that are publishable. I’d try to collaborate on some clinical research or education projects with CVICU faculty so that you have an attachment to that group and have a foot in the door. For example, developing an ECMO/ECPR protocol for the ED in conjunction with the CVICU faculty keeps you in the mix.

As for your commute, hopefully you can find a place between your job and you spouses. I like that you are being fair to her career goals. Being a good husband is just as important as being an outstanding academic intensivist.