Im/CC vs IM/Pulm CC

[medigull]

What are the job prospects currently for a pure IM/CC intensivist? Is there any advantage to getting the Pulm/CC if you are looking to just do intensivist work?

Im just wondering because clinic does not equal fun but the ICU is fun.

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[Hernandez]

go to healthecareers.com and you'll see that far and away the majority of the listings are for pulm-cc followed by a distant 2nd for CC, doing the 3 year instead of the 2 opens up your options significantly. I know a few people who only completed 2 of the 3 years for various reasons and one ended up taking a hospitalist position despite being incredibly intelligent and capable with good references.

 

[sunset823]

what about if you want to be in academics? I find the ICU really cool, but pulm pretty boring. If the job prospects in academia were that bad with just ICU, I might go for another subspecialty (or specialty all together).

 

[Hernandez]

what about if you want to be in academics? I find the ICU really cool, but pulm pretty boring. If the job prospects in academia were that bad with just ICU, I might go for another subspecialty (or specialty all together).

I was like y'all once, most of my co-fellows too, now we appreciative the non-ICU time. I can't do only CC, it gets boring after a while.

 

[AFSmiley]

General consensus from people I've talked to is that it would limit things a bit as most groups are Pulm/CC and look for someone who can step in and do both, if not sleep as well. However, if you don't like Pulm, don't do it.

I envision myself trying to find a gig where I get in with a group's rotation for ICU coverage, then doing something a little more Generalist inbetween- Primary Care or Hospitalist or something. I might have to work for two different groups but its doable.

 

[jdh71]

what about if you want to be in academics? I find the ICU really cool, but pulm pretty boring. If the job prospects in academia were that bad with just ICU, I might go for another subspecialty (or specialty all together).

I was like y'all once, most of my co-fellows too, now we appreciative the non-ICU time. I can't do only CC, it gets boring after a while.

Agreed 1000%

The ICU seems so crazy and awseome at first blush, but after awhile becomes a bit formulaic, barbaric, and just plain annoying. Look, if the animals from surgery, gas, and EM can do it, it's not rocket science. Can't breath? Ok, we'll breath for you. Blood pressure low? Ok we'll make it higher. Infected? Ok, you get abx. Can't tell if you're infected? Ok, you get abx. Procalcitonin low? Can't be 100% sure and nervous? You get abx!! Yawn. Rinse. Repeat. Repeat at 3AM. Repeat at 2AM. Repeat during kid's birthday. Repeat during aniverssary dinner.

Don't get me wrong. I really like critical care, but for the most part once you start getting comfortable, it begins to be more of a "job" and less of an exciting experience.

The more you do pulm the cooler it becomes, I promise. The cases are way more complex and puzzling, and I think more intellectually rewarding.

 

[jdh71]

General consensus from people I've talked to is that it would limit things a bit as most groups are Pulm/CC and look for someone who can step in and do both, if not sleep as well. However, if you don't like Pulm, don't do it.

I envision myself trying to find a gig where I get in with a group's rotation for ICU coverage, then doing something a little more Generalist inbetween- Primary Care or Hospitalist or something. I might have to work for two different groups but its doable.

There is currently enough mercenary work to go around. I don't know if we'll be able to count on that into the future, but probably will. If I was going to do straight ICU, I'd keep myself as much an independent contractor and as little a hospital employee as possible.

 

[AFSmiley]

There is currently enough mercenary work to go around. I don't know if we'll be able to count on that into the future, but probably will. If I was going to do straight ICU, I'd keep myself as much an independent contractor and as little a hospital employee as possible.

Roger that. I think about opening up my own little practice on my land. On my off ICU days,....see 10-12 patients a day, at my pace...look up what i want, lunch with the wife back home, etc.

 

[Intensivist]

l diasgree with jdh71 b/c the way you explained intensive medicine is not medicine at all, you sounded more like a mid level now, with all due respect to midlevels. Critical care takes care of pts with complex morbities, and figures out a way to diagnose and treat complex patients. Not every patient that comes in is a puzzle, but more frequently then, for example, in pulm, they are. It's only matter of how holistic you want to treat your patient or just be a resuscitation provider, which is though as it is, but with time it gets much easier.
You're maybe working in open unit where actaully all you do IS what you wrote. In that case l feel sorry for you and your unit.

 

[jdh71]

l diasgree with jdh71 b/c the way you explained intensive medicine is not medicine at all, you sounded more like a mid level now, with all due respect to midlevels. Critical care takes care of pts with complex morbities, and figures out a way to diagnose and treat complex patients. Not every patient that comes in is a puzzle, but more frequently then, for example, in pulm, they are. It's only matter of how holistic you want to treat your patient or just be a resuscitation provider, which is though as it is, but with time it gets much easier.
You're maybe working in open unit where actaully all you do IS what you wrote. In that case l feel sorry for you and your unit.

I'm not sure what kind of "puzzle" you may be referring to. It usually pretty obvious from a big picture standpoint why a patient is in the unit - can't breathe, pressure sucks, septic, etc. The specifics of which are mostly tedious details that most of the time have nothing whatsoever to do with critical care in the least . . . "Oh this patient has cardiogenic shock from STEMI, with a balloon pump, on pressor for a likely sepsis they got from a pneumonia vs uti vs line infection, now going into ARDS and renal failure, on CRRT, with a gap and non-gap acidosis from all the saline and elevated lactate." Where's the puzzle and wonderment? Keep the patient alive, and keeping the patient alive IS critical care, and one of the reasons midlevels can do it. There's almost never anything magical or complex about the diagnosis, and even if there was, treatment is largely the same.

I work in a closed uint, and I take patients that were dead and make them alive. I try and figure out why, but it's not magic or mysterious. The reasons people get sick enough to get stuck in an ICU is largely boring and mundane. Even the transplant patients with their weird bugs, immunosuppression, and outrageously deranged lab values don't change much of what is done in an ICU. Though we did see an HLH last week which was the most interesting thing I've seen in a long time in the unit - ID pretty much shat bricks when we took the patient off of abx and started steroids.

Saving lives, curing dz, and otherwise simply living the dream.

 

[Hamhock]

I'm not sure what kind of "puzzle" you may be referring to. It usually pretty obvious from a big picture standpoint why a patient is in the unit - can't breathe, pressure sucks, septic, etc. The specifics of which are mostly tedious details that most of the time have nothing whatsoever to do with critical care in the least . . . "Oh this patient has cardiogenic shock from STEMI, with a balloon pump, on pressor for a likely sepsis they got from a pneumonia vs uti vs line infection, now going into ARDS and renal failure, on CRRT, with a gap and non-gap acidosis from all the saline and elevated lactate." Where's the puzzle and wonderment? Keep the patient alive, and keeping the patient alive IS critical care, and one of the reasons midlevels can do it. There's almost never anything magical or complex about the diagnosis, and even if there was, treatment is largely the same.

I work in a closed uint, and I take patients that were dead and make them alive. I try and figure out why, but it's not magic or mysterious. The reasons people get sick enough to get stuck in an ICU is largely boring and mundane. Even the transplant patients with their weird bugs, immunosuppression, and outrageously deranged lab values don't change much of what is done in an ICU. Though we did see an HLH last week which was the most interesting thing I've seen in a long time in the unit - ID pretty much shat bricks when we took the patient off of abx and started steroids.

Saving lives, curing dz, and otherwise simply living the dream.

Yeah - protocolized work is just for midlevels...as is most of simmered medicine...that's why docs spend four years in med school, think beyond Byrne's box, and contribute to both patient care and science...CCM demands a doc...demands novel thinking...demands research...demands new thinking...anyone can think like a mechanic (tank empty = fill it)...but novel therapies don't come from midlevels and agressive CCM comes from docs who see the forest

HH

 

[jdh71]

Yeah - protocolized work is just for midlevels...as is most of simmered medicine...that's why docs spend four years in med school, think beyond Byrne's box, and contribute to both patient care and science...CCM demands a doc...demands novel thinking...demands research...demands new thinking...anyone can think like a mechanic (tank empty = fill it)...but novel therapies don't come from midlevels and agressive CCM comes from docs who see the forest

HH

Of course the research is done by physicians. I can't give you any points for stating the obvious.

However, I do wonder what has all of that "novel thinking" currently gotten us? Outside of the dialysis machine, respirator, vasopressor agents, and antibiotics, what new "novel therapy" or "novel thinking" has shown any real uncontested improvement in critical medicine where it counts: mortality and length of stay in the ICU? Early goal directed therapy? Xigris? Most of the garbage we do isn't some kind of "well-thought out forrest type of plan" based on foundational physiologic principles in the face of life threatening pathophysiology that has been painstakingly thought out in each and every individual case, but rather stuff that someone's clinical trial somewhere was able to show enough statistical significance to get published in a high enough impact factor journal that it was able to matter.

Yes there is forest, but it's largely irrelevant to what we do and the standard operating procedures in the ICU. Understanding the forest and being able to think about the forest, does nothing for those pesky trees!

I just don't pretend critical care is something that it's not.

 

[Doctor4Life1769]

Agreed 1000%

The ICU seems so crazy and awseome at first blush, but after awhile becomes a bit formulaic, barbaric, and just plain annoying. Look, if the animals from surgery, gas, and EM can do it, it's not rocket science. Can't breath? Ok, we'll breath for you. Blood pressure low? Ok we'll make it higher. Infected? Ok, you get abx. Can't tell if you're infected? Ok, you get abx. Procalcitonin low? Can't be 100% sure and nervous? You get abx!! Yawn. Rinse. Repeat. Repeat at 3AM. Repeat at 2AM. Repeat during kid's birthday. Repeat during aniverssary dinner.

Don't get me wrong. I really like critical care, but for the most part once you start getting comfortable, it begins to be more of a "job" and less of an exciting experience.

The more you do pulm the cooler it becomes, I promise. The cases are way more complex and puzzling, and I think more intellectually rewarding.

In Europe, ICUs are ran primarily by anesthesiologists. So, I'd like to think that anesthesiologists trained in this country ought to be just as qualified to work in the ICU after doing a CC fellowship.

 

[jdh71]

In Europe, ICUs are ran primarily by anesthesiologists. So, I'd like to think that anesthesiologists trained in this country ought to be just as qualified to work in the ICU after doing a CC fellowship.

I think you missed my point there entirely champ.

I have zero clue how you think your comment is in any way relevant to what was said.

 

[Hernandez]

agressive CCM comes from docs who see the forest

HH

eh, it's nice to step away on occasion from cc. I love CC, but there are times when I'm annoyed that I've got yet another central line to put in a septic pt at 2 in the morning. or that an incompetent floor IM resident demands to move a pt to ICU for monitoring with no indication for ICU level care.

 

[Doctor4Life1769]

I think you missed my point there entirely champ.

I have zero clue how you think your comment is in any way relevant to what was said.

To me, it seemed like you were saying, "hell, if these guys can do it, anyone can, it's not that hard." Hence my reply.

 

[jdh71]

To me, it seemed like you were saying, "hell, if these guys can do it, anyone can, it's not that hard." Hence my reply.

That was what I was saying, and I still find zero relevance to your earlier post.

 

[mrpankration]

This question is for the current Pulm/CC fellows, now that you are fellows has your perspective on Pulm/CC changed at all from when you were a resident? Knowing what you know now would you change your mind about Pulm/CC fellowship? Thanks in advance for any input.

 

[Intensivist]

Look, l'm not saying CC isnt primarily about resuscitation in general, but often pt's come to icu with no specific cause, let's say pt's has sepsis due to some infection, might be UTI but not sure, or some unexplained LOC or whatever. Not every patient is diagnosed up to admission to unit.

 

[Hernandez]

This question is for the current Pulm/CC fellows, now that you are fellows has your perspective on Pulm/CC changed at all from when you were a resident? Knowing what you know now would you change your mind about Pulm/CC fellowship? Thanks in advance for any input.

Nope, I still love it, the only thing that's changed is I appreciate the pulmonary aspects more now. Granted I'm saying this with the perspective that I jut got done with essentially 2 months of micu back to back if you consider how much call I too before and right after my micu month. And now I'm back in a neuro unit so I'm a little tired of icu at the moment

Look, l'm not saying CC isnt primarily about resuscitation in general, but often pt's come to icu with no specific cause, let's say pt's has sepsis due to some infection, might be UTI but not sure, or some unexplained LOC or whatever. Not every patient is diagnosed up to admission to unit.

The 3 of us aren't really arguing, I wouldn't want a nurse running an icu either, but frankly at times it does feel like all damn day it's gomer with sepsis secondary to uti, or resp failure due to pna in a gomer, or sepsis secondary to line infection in esrd gomer. By far and away that is our pt population and you dont see the young pts who's long term out come we can change much comparatively. Over all I'm saying, that at least for myself, keeping the appropriate level of intensity needed to run and icu is nit something I now see myself being able to do as my primary job until I retire.

 

[jdh71]

This question is for the current Pulm/CC fellows, now that you are fellows has your perspective on Pulm/CC changed at all from when you were a resident? Knowing what you know now would you change your mind about Pulm/CC fellowship? Thanks in advance for any input.

Nope. Not at all. While I'm sure not all fellowships are created the same, and there will be a difference between being an attending and a fellow, I actually like getting up and going into work most days now. I fell in love with critical care medicine like most of us did, and I still like it a lot, but, and I didn't know this as a student, pulmonary medicine is awesome. There still isn't any other fellowship I'd want to do more. In fact if it wasn't this, maybe a hospitalist gig, but now that I get more of a sense of what they do, for me, I don't think I could have done that kind of work either. So, I'm glad I've done what I've done.

As far as changes, I find the ICU less exciting overall than I did earlier in residency. There are still tense moments of course, and the work we do is obviously life or death, so have to be done with that in mind, but I find things a little more mundane. I'm hoping to arrange my schedule in the next few years to get time in the SICU, CTICU, TraumaICU, and NeuroICU so that I can enough experience to keep my future dance card interesting enough. And I began to appreciate pulmonary more in residency, but I just love it now.

 

[AquaFortis]

jdh and Hernadez, could you both share what you like about pulmonary medicine? I tend to hear things like "Isn't it just all COPD and lung Ca patients who should have stopped smoking" about pulm, though granted that is from M3/M4s . I'm an M2 so I have little perspective on the specialty other than time I have spent on a preceptorship in the ICU.

 

[jdh71]

jdh and Hernadez, could you both share what you like about pulmonary medicine? I tend to hear things like "Isn't it just all COPD and lung Ca patients who should have stopped smoking" about pulm, though granted that is from M3/M4s . I'm an M2 so I have little perspective on the specialty other than time I have spent on a preceptorship in the ICU.

Pulm was very UNinteresting as an M2. I still remember those days. COPD is your bread and butter for sure, much the way the cardiologists have CAD, but you've also got pulmonary hypertension, multiple different weird and rare infections of the lungs (histo, blasto, PJP, etc.), occupational lung diseases, drug induced lung disorders, interstitial lung diseases, rheumatoid diseases of the lungs, obstructive sleep apnea (and most sleep disorders actually come through pulm - though pulm is not the only avenue to sleep medicine). We help with bx of lung lesions if we can, but most cancer is handled by the surgeons (if possible) and the oncology guys, so we do see a good bit of lung cancer, but I always kind of felt we were little impotent to do anything about it. You get very good with chest CT and chest Xray, as good as just about any given radiologist after some time. Bronchoscopy is just cool - maybe after I've done a few hundred I won't find them enjoyable, but right now I like them.

 

[Hernandez]

jdh and Hernadez, could you both share what you like about pulmonary medicine? I tend to hear things like "Isn't it just all COPD and lung Ca patients who should have stopped smoking" about pulm, though granted that is from M3/M4s . I'm an M2 so I have little perspective on the specialty other than time I have spent on a preceptorship in the ICU.

Copd and asthma can feel tedious at times but there are those you do help. The ILDs are fun to find and treat, my personal favorite is mycobacterium (both MTb and non-mtb). Probably the best thing is the field is starting to grow and our knowledge base is increasing and it seems to ms that were getting close to many new breakthroughs

The technical advancements in bronchoscopy is also very cool.

 

[mrpankration]

jdh and Hernandez, thanks for responding to my question. Another question for you guys, do you guys feel that you get good critical care cardiology training as part of a pulm/cc fellowship or would that be reserved for only for people doing cards?

 

[Hernandez]

jdh and Hernandez, thanks for responding to my question. Another question for you guys, do you guys feel that you get good critical care cardiology training as part of a pulm/cc fellowship or would that be reserved for only for people doing cards?

Personally i don't get great cards-cc since there is a separate CCU which is ran by cards, we are consulted on pretty well every ccu pt but we run everything else, but I'm not great with iabp, trans-venous pacers, etc etc.

That will be program dependent, but personally I get a sick sense of pleasure walking into to ccu and telling cards it's all the heart and the lungs are an innocent bystander. Facetiously of course.....

 

[jdh71]

jdh and Hernandez, thanks for responding to my question. Another question for you guys, do you guys feel that you get good critical care cardiology training as part of a pulm/cc fellowship or would that be reserved for only for people doing cards?

As hern pointed out, this is location dependent. Where I'm currently rotating cardiology doesn't run a primary service, so we are both CCU and ICU. They do consult. Two other rotation sites I will go to are like this. At the University Cards has their own service and staffs their own CCU (we do often get consulted when vent management gets beyond the basics)