IM vs EM residency for CC

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Nivens

Nivens

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Hi everyone. I'm a rising third year interested in critical care medicine (as far as I know). I have pretty much been set on IM throughout medical school, but found myself in an EM match panel a few weeks ago and the wheels started turning. I didn't realize you can get BC in CC through EM, and EM docs seem to get quite a bit of ICU time in residency. I like the "Jack of all Trades" spirit of ER, and the opportunity to see undifferentiated patients. As far as training is concerned, what are some pros/cons of the different approaches as they pertain to the intensivist's role?

Thanks in advance!
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I am relatively new to SDN and this is actually my first post. I am currently a PGY-3 resident and I also interseted in critical care. I have had the opportunity to work with IM/CCM, Anesth/CCM, surg/CCM, and EM/CCM and I can tell you from experience that each specialty brings a little something unique to the table. I dont think that one is particularly better suited for the job over another, but definately better suited for different types of intensive care units. As youll have seen repeated in this forum multiple times, Pulm/CCM are better suited to MICU, Surg/CCM and EM/CCM to surg/trauma, Anesth/CCM ive seen in every type of unit. I will say this one thing to differentiate, Pulm/CCM are better suited for the diagnostic work up and differential of comorbidities and their effect on the acute illness the patient is in the ICU for. However, they tend to be less confident procedurally and tend to consult more for Lines/chest tubes/so on. Visa versa for the other specialties. That is in no way a generalization or rule, but just my experience. I will say ive met some Pulm/CCM guys that are great with their hands, and i have met some anesth/em/surg/CCM guys that are great with diagnostics and differential. You get out what you put into it, no matter what specialty you come from. What i think is a better question to ask yourself is what do you want to do with your time when you are not on the unit? Are you looking for CCM only with a shift work set up? Do you want to have a clinic/do bronchs/PFTs/round on hospital patients? Do you want to take shifts in the ER? Do you want to be in the OR either operating or keeping patients alive during surgery? In the end, what you do and what you learn in CCM will be largely similar, its what you want the rest of your career to be that is different.
 
res60 said:
I am relatively new to SDN and this is actually my first post. I am currently a PGY-3 resident and I also interseted in critical care. I have had the opportunity to work with IM/CCM, Anesth/CCM, surg/CCM, and EM/CCM and I can tell you from experience that each specialty brings a little something unique to the table. I dont think that one is particularly better suited for the job over another, but definately better suited for different types of intensive care units. As youll have seen repeated in this forum multiple times, Pulm/CCM are better suited to MICU, Surg/CCM and EM/CCM to surg/trauma, Anesth/CCM ive seen in every type of unit. I will say this one thing to differentiate, Pulm/CCM are better suited for the diagnostic work up and differential of comorbidities and their effect on the acute illness the patient is in the ICU for. However, they tend to be less confident procedurally and tend to consult more for Lines/chest tubes/so on. Visa versa for the other specialties. That is in no way a generalization or rule, but just my experience. I will say ive met some Pulm/CCM guys that are great with their hands, and i have met some anesth/em/surg/CCM guys that are great with diagnostics and differential. You get out what you put into it, no matter what specialty you come from. What i think is a better question to ask yourself is what do you want to do with your time when you are not on the unit? Are you looking for CCM only with a shift work set up? Do you want to have a clinic/do bronchs/PFTs/round on hospital patients? Do you want to take shifts in the ER? Do you want to be in the OR either operating or keeping patients alive during surgery? In the end, what you do and what you learn in CCM will be largely similar, its what you want the rest of your career to be that is different.
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I have also worked with all 4 and I agree entirely.

I would add to that, not only what you want to do on your off weeks, but think about what you want to do when your 50 and do not want to be chained to the ICU anymore. Some people run the unit till they retire in their late 60s. Some are burnt out by 50. When you are done working long hours with very complicated dying patients, do you want to run a pulm clinic/sleep lab? Do you want to be a prn anesthesiologist just doing cases a few days a week? Do you want to join a gen surg practice or become a surgicalist or even a part-time surgeon helping cover call for a group of younger surgeons? Do you want to work a few EM shifts per month? The ICU training will be the same largely. Different subtleties with the way you go about your day and how you work up and care for patients, but at the end of the day they have the same disease processes and need the same therapies and you provide them regardless of what your pre-fellowship training was in. Personally, If I could have done it over I would have done Gas-CC. Would have just been the best fit for me. But it really doesnt matter so long as you get the boards and then a job.
 
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Bostonredsox said:
I have also worked with all 4 and I agree entirely.

I would add to that, not only what you want to do on your off weeks, but think about what you want to do when your 50 and do not want to be chained to the ICU anymore. Some people run the unit till they retire in their late 60s. Some are burnt out by 50. When you are done working long hours with very complicated dying patients, do you want to run a pulm clinic/sleep lab? Do you want to be a prn anesthesiologist just doing cases a few days a week? Do you want to join a gen surg practice or become a surgicalist or even a part-time surgeon helping cover call for a group of younger surgeons? Do you want to work a few EM shifts per month? The ICU training will be the same largely. Different subtleties with the way you go about your day and how you work up and care for patients, but at the end of the day they have the same disease processes and need the same therapies and you provide them regardless of what your pre-fellowship training was in. Personally, If I could have done it over I would have done Gas-CC. Would have just been the best fit for me. But it really doesnt matter so long as you get the boards and then a job.
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Thanks for the replies! I'm hoping third year clears things up a lot for me. Sitting here at 25, I don't love the idea of running a pulm clinic *ever*, but it's soo hard to predict how I'll feel at 50 or 60. Part of my problem is the University of Miami doesn't have an ER residency program, so I need to do at least 2 ER externships if that's the way I'm going to go, but I'm probably going to have to make that call before I know for sure if that's what I want bc of the way our curriculum is organized. But who knows, maybe the surgery bug will bite me and I'll go a completely different route. I really like differentials and the cerebral aspect of medicine... to a point. Then I want to DO something. I'm trying to strike a balance as best I can :thumbup:
 
I think the best question to ask yourself is: What specialty would you enjoy doing most (now and in the future) in the event you chose to not do the CCM fellowship?

Choose your primary field first, then the fellowship.
 
dotcb said:
I think the best question to ask yourself is: What specialty would you enjoy doing most (now and in the future) in the event you chose to not do the CCM fellowship?

Choose your primary field first, then the fellowship.
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This. Your job as a resident is to become an excellent clinician in your chosen specialty. A fellowship is really something to be added to build on these skills. Critical Care gives you a "certificate of added qualifications" and that really is what it is. First and foremost you will be an EP vs Internist. What would you rather be? Like the ED? Clinic with continuity? Feel like without that ID rotation your ability to start a CC fellowship will be hampered? You have some soul searching to do. Of course, there is always EM-IM which would give you both and then you can do it afterwards...
 
Hernandez said:
IM/EM-CC is ******ed if you ask me. IM/EM-pulm-CC even more so.....
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Why? It's a solid melding of acute resuscitation and diagnostic work-up skills with strong early procedural experience. I mean doing chest tubes as an intern is not going to happen as a categorical IM intern. Also if you do it right its only 6 years just like IM-Pulm-CC. What makes no sense?
 
inspirationmd said:
Why? It's a solid melding of acute resuscitation and diagnostic work-up skills with strong early procedural experience. I mean doing chest tubes as an intern is not going to happen as a categorical IM intern. Also if you do it right its only 6 years just like IM-Pulm-CC. What makes no sense?
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:laugh: I'm sorry but ER's job isn't diagnosis, it's stabilization, triage, and disposition. You will get plenty of procedure experience in most fellowships, and no, IM-EM is 5 years, so the best you'll be doing is 7 years.

Rock star? Hardly, 4 year ER programs call that 4th year the $150,000 mistake, throw in excess training that offers little benefit other than job placement if you're wishy-washy about what type of job you want.
 
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Hernandez said:
:laugh: I'm sorry but ER's job isn't diagnosis, it's stabilization, triage, and disposition. You will get plenty of procedure experience in most fellowships, and no, IM-EM is 5 years, so the best you'll be doing is 7 years.

Rock star? Hardly, 4 year ER programs call that 4th year the $150,000 mistake, throw in excess training that offers little benefit other than job placement if you're wishy-washy about what type of job you want.
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So you can now get all 3 in 6 years by two paths:

1) http://www.abim.org/certification/policies/combinedim/comccm.aspx
Combined EM-IM-CC training. Currently there are 3, I know of one program who is very shortly to be the 4th and another that's thinking about starting it.

2) Do EM/IM and then a 1 year Anesthesia CC fellowship under the recently developed guidelines that are supposed to be approved this April. https://www.abem.org/PUBLIC/_Rainbow/Documents/ABA-ABEM FAQs 9-21-12 FINAL-to post.pdf

I think you are not giving EM docs enough credit man. Yes triage is part of the job description and ultimately people are dispo'ed somewhere else for definitive care but diagnosis is certainly a huge part of the job description. No I do not order exhaustive workups in the ED and sometimes the final diagnosis is elusive initially but you do make diagnoses there.

Critical care is multidisciplinary and certainly EPs have something to contribute. The IM training is helpful in the broad subspecialty exposure but that 33% of ambulatory experience they make you do did not help develop intensivist skills. The fellowship helps focus everyone's unique skill set to make up an intensivist.
 
Majority of ER is ambulatory care.... I only do 1/2 day of clinic a week for 8 months out of each year. Hardly 33% of my training.
 
Well since I have a future Gas/CC doc here, how do you feel about your anesthesia training and how it has prepared you for the unit?
 
inspirationmd said:
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Critical care is multidisciplinary and certainly EPs have something to contribute. The IM training is helpful in the broad subspecialty exposure but that 33% of ambulatory experience they make you do did not help develop intensivist skills. The fellowship helps focus everyone's unique skill set to make up an intensivist.
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I'm not sating dont go Em-CC, I'm saying Em/IM-CC is ******ed as EM offers nothing unique that's worth the extra time unless you want to work in peds somehow. I certainly did not do 33% ambulatory in my IM training. I'd go as far as saying the EM guys see more low acuity ambulatory medicine than many IM residents do. The biggest thing that EM might have over IM is teaching efficiency.
 
Mainly airway, pharm, phys, knowing how to set up and trouble shoot monitors, sedation, pushing meds, titrating infusions with my own hands, working/fixing IV pumps and the ventillator. I was completely inadequate in terms of exposure to medicine. regardless anes dudes mainly work in neuro ICUs with the neurosurg calling final decisions, same goes for SICU. CC trained surgeons run SICUs mainly. The anesthesia "consultant" puts out fires and runs most things by surgeon (yes fights over extubation, trach, lasix, and IV fluids abound in that setting). Working under surgeons is not for me. So your knowledge should be adequate. For CVICU have fun working with those dudes. Troubleshooting ECMO is for perfusionists.
 
I still think IM gives the broadest base possible for going into critical care. As has been pointed out more than once almost anyone can get up to snuff handling "critical illness" itself by finished a fellowship through any of the pathways. There is much about critical care that is critical care is critical care is critical care - though it is nuanced. For instance, at one of my rotational sites we get quite a few post-op consults from the general surgeons - I can easily run the vent, pressors, abx, deal with fluid balance in these patients, but I don't have the same reflexes on certain post-op complications that someone from a surgical background would have. How should I know when a patient needs to go back to the OR for instance? (I will say if it's so obvious the internist can tell, the patient is probably beyond repair). Based on my experience the IM background guys are simply better at definitive diagnosis and long term treatment plan, especially in the MICU (duh). I also think we are better with sick hearts (not post-op hearts - there's a difference) and sick lungs on top of whatever else is going on. I think SICUs should be run by surgeons and I think it's kind of stupid to stick an internist anywhere near most post-op surgical or train wreck trauma patients - because as stated above, we simply lack those reflexes. The Gas guys seem to be the best at post-op hearts and lungs, including transplants of those organs - though interestingly enough though they are good at the physiology, their lack of understanding on general medical problems itself in any detail, I think puts gaps into their long term management moving out of the perioperative phase. The EM guys in my opinion tend to be kind of like the are in the ED - there is nothing wrong with the critical care per se, but often seem to lack that extra mile in diagnosis and long term planning ("not sick enough for the unit, transferring to the floor, medicine will have to figure out what's wrong - just like the ED, don't have to go home, but they can't stay here").

I'm not hating on anyone here, and, sure, I'm generalizing. We all know that surgeon who could be easily be an internist, or the pulm guy you wouldn't want anywhere near anyone you know or love. Or the gas or ED guy thinking around crazy corners to come up with diagnosis. I guess I'm just trying to point out that we will all come with our own "holes" in training. We will all, once fellowship trained, have the tools necessary to deal with critical illness, and it will be up to us to be both introspective and proactive about these things as professionals and get up to snuff with what we will need to finally bring everything we can to the table wherever we end up working.

I guess, in the end, I've said a whole lot to simply point out that if you're asking who makes the "better" critical care doc from IM, surg, gas, or EM, I think you're asking the wrong question and looking at it a bit backwards. We all need to check a little more ego, learn a little more from our other specialty homies, and deliver the best patient care we can.
 
jdh71 said:
I still think IM gives the broadest base possible for going into critical care. As has been pointed out more than once almost anyone can get up to snuff handling "critical illness" itself by finished a fellowship through any of the pathways. There is much about critical care that is critical care is critical care is critical care - though it is nuanced. For instance, at one of my rotational sites we get quite a few post-op consults from the general surgeons - I can easily run the vent, pressors, abx, deal with fluid balance in these patients, but I don't have the same reflexes on certain post-op complications that someone from a surgical background would have. How should I know when a patient needs to go back to the OR for instance? (I will say if it's so obvious the internist can tell, the patient is probably beyond repair). Based on my experience the IM background guys are simply better at definitive diagnosis and long term treatment plan, especially in the MICU (duh). I also think we are better with sick hearts (not post-op hearts - there's a difference) and sick lungs on top of whatever else is going on. I think SICUs should be run by surgeons and I think it's kind of stupid to stick an internist anywhere near most post-op surgical or train wreck trauma patients - because as stated above, we simply lack those reflexes. The Gas guys seem to be the best at post-op hearts and lungs, including transplants of those organs - though interestingly enough though they are good at the physiology, their lack of understanding on general medical problems itself in any detail, I think puts gaps into their long term management moving out of the perioperative phase. The EM guys in my opinion tend to be kind of like the are in the ED - there is nothing wrong with the critical care per se, but often seem to lack that extra mile in diagnosis and long term planning ("not sick enough for the unit, transferring to the floor, medicine will have to figure out what's wrong - just like the ED, don't have to go home, but they can't stay here").

I'm not hating on anyone here, and, sure, I'm generalizing. We all know that surgeon who could be easily be an internist, or the pulm guy you wouldn't want anywhere near anyone you know or love. Or the gas or ED guy thinking around crazy corners to come up with diagnosis. I guess I'm just trying to point out that we will all come with our own "holes" in training. We will all, once fellowship trained, have the tools necessary to deal with critical illness, and it will be up to us to be both introspective and proactive about these things as professionals and get up to snuff with what we will need to finally bring everything we can to the table wherever we end up working.

I guess, in the end, I've said a whole lot to simply point out that if you're asking who makes the "better" critical care doc from IM, surg, gas, or EM, I think you're asking the wrong question and looking at it a bit backwards. We all need to check a little more ego, learn a little more from our other specialty homies, and deliver the best patient care we can.
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Thanks for setting me straight. I'm only an MS2, and if I listen to my brain I know it's no big deal that I still have no idea what the next step for me is- I haven't done a single rotation, for all I know I could absolutely love radiology or OB- but every once in awhile I look around and it seems like EVERY one of my classmates knows (or thinks they know) what they want. It can be a bit panic-inducing. My fiancee is dead-set on ortho, so she's cranking out research and ECs and *killing* herself for the Step I- which she doesn't mind because she has a concrete goal to work towards. Even though in the back of my head I know there's a significant chance she'll change her mind and decide to be x y or z instead of an orthopod/surgeon, I envy her for having something tangible she can shoot for. Anyway, point taken, and I really like what an earlier poster said about thinking about what I'd like to do when I'm not in the Unit.

Med student now. Next, resident. Then and only then, fellow. Thanks everyone.
 
Fortunately, these 4 fields are quite different than one another. The choice of what you enjoy the most won't be that murky. You'll get adequate exposure to medicine and surgery, for sure. If your school doesn't have a mandatory anesthesia block in 3rd year, they may offer a 2 week "selective," or something like that for you to gain some exposure. You could also approach your EM department, express interest, and they'd likely let you do some shadowing shifts in the ED. It's good you're being proactive in selecting a field, but I think the choice will be clear when the time comes. I think physicians from any of these fields can make excellent intensivists. Do what you love and worry about the conclusion later.
 
VentdependenT said:
Majority of ER is ambulatory care.... I only do 1/2 day of clinic a week for 8 months out of each year. Hardly 33% of my training.
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So you did no dedicated ambulatory medicine blocks in all of residency? I am pretty sure there has been a push for the last several years for IM residencies to promote greater OP experience by increasing the amount of OP experience so ABIM mandated 33% of residency be OP now. Believe me if this wasn't being pushed I would be out of the clinic but I have seen it in ABIM guidelines and heard out the PD's mouth. Maybe you guys just got lucky.
 
Hernandez said:
I'm not sating dont go Em-CC, I'm saying Em/IM-CC is ******ed as EM offers nothing unique that's worth the extra time unless you want to work in peds somehow. I certainly did not do 33% ambulatory in my IM training. I'd go as far as saying the EM guys see more low acuity ambulatory medicine than many IM residents do. The biggest thing that EM might have over IM is teaching efficiency.
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EM has significant procedural advantages over the average IM residency. I can use U/S better, place a line faster (in all locations), have broader ICU exposure to draw from in pt management (ie.SICU, PICU), and am more comfortable running a code than the large majority of my IM colleagues. I can also intubate and have done crics which are skills that ABIM does not even say IM residents need to have. I have place more chest tubes than a lot of the Pulm-CC fellows and can manage them as a 2nd year resident. Yes you may get these things in fellowship but the key is earlier exposure in my opinion. Also, how many Pulm - CC fellows have cric'ed someone vs call anesthesia (actually want to know this)? I know the anesthesia residents did the few that needed to be done at my med school which was pretty strong for Pulm-CC.

The bottom line is I am going to be a very strong intensivist with the experience to work in most any ICU due to very broad based training that started from day 1. I also love the ED and the unpredictability of it so thats a nice bonus while also giving me a skill set that pays almost as much as intensivist jobs while I work toward my final goal. EM-IM was originally started with the goal of melding the skill sets of the two specialties (politics of that day aside). There has been recognition of the strength of the programs given the two new programs that popped up in the last 2 years.

The EM-IM training is synergistic and gives a strong set of skills for the budding EP who did not mind rounding and likes more differetial diagnosis training and critical care exposure or those who wish to be an Intensivist. If you are planning to be a Hospitalist then i think you don't need to do 5 years and categorical IM is good. I do think that EM-IM should not be a 5 year residency, prob 4.5 but that's for another day.
 
You're generalizing. And I will again argue that procedures do not make an intensivists, and I can promise that my IM residency procedure log is likely as impressive as yours and I ran as many if not more codes (actually ran, not just sit around and watch someone else do one). But that isn't the point of CC, you should consider any code or lost airway as a failure of prevention. I can teach any monkey to do a line, use and u/s or run a code or manage regular airways. And yet again, really the ER offers very little that I think IM/EM tract to CC is viable. One should really do either or, not both unless they really think theyre going to flip-flop between ER and ICU. But since you're missing the point, I'm not saying do IM--->CC only, I'm sayin don't do combined as none of the advantages you list are skills you can't or won't learn in fellowship.

Congrats on the cric, very very few physicians can say they've done one. I've been apart of 3, but when you have in house trauma-docs it's hard to argue with a pulm fellow Doing one. But keep in mind many places (like mine) are doing bedside perc tracs, so to pat yourself on the back and say you've got a skill that you won't see in fellowship is wrong, I damn near cric'd someone moonlighting a month or so back but managed to get a temporizing maneuver to work to get time for ENT to do a formal Trach. I'm comfortable with doing a cric if need be.
 
inspirationmd said:
So you did no dedicated ambulatory medicine blocks in all of residency? I am pretty sure there has been a push for the last several years for IM residencies to promote greater OP experience by increasing the amount of OP experience so ABIM mandated 33% of residency be OP now. Believe me if this wasn't being pushed I would be out of the clinic but I have seen it in ABIM guidelines and heard out the PD's mouth. Maybe you guys just got lucky.
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Ahh yes. I do 1 month of ambulatory clinic each year. Still doesnt add up to 33%.
 
Hernandez said:
You're generalizing. And I will again argue that procedures do not make an intensivists, and I can promise that my IM residency procedure log is likely as impressive as yours and I ran as many if not more codes (actually ran, not just sit around and watch someone else do one). But that isn't the point of CC, you should consider any code or lost airway as a failure of prevention. I can teach any monkey to do a line, use and u/s or run a code or manage regular airways. And yet again, really the ER offers very little that I think IM/EM tract to CC is viable. One should really do either or, not both unless they really think theyre going to flip-flop between ER and ICU. But since you're missing the point, I'm not saying do IM--->CC only, I'm sayin don't do combined as none of the advantages you list are skills you can't or won't learn in fellowship.

Congrats on the cric, very very few physicians can say they've done one. I've been apart of 3, but when you have in house trauma-docs it's hard to argue with a pulm fellow Doing one. But keep in mind many places (like mine) are doing bedside perc tracs, so to pat yourself on the back and say you've got a skill that you won't see in fellowship is wrong, I damn near cric'd someone moonlighting a month or so back but managed to get a temporizing maneuver to work to get time for ENT to do a formal Trach. I'm comfortable with doing a cric if need be.
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Couldnt agree more. Procedures are procedures and have nothing to do with clinical acumen. Look at all the midlevels doing em. CRNA's and ICU/SICU/CVICU NP's.

Glidescope has revolutionized the difficult airway. Again, not difficult.

Codes? not difficult. finding out WHY is the interesting part, thats what happens afterward. Do you cool em? Cut em? Cath em? you get the point. Its easy to dump in 2L of NS and start levophed and dump it off on the unit team.

Crics? never done one but have saved several pts from getting one.

We also do perc trachs but in reality if i have time ill have ENT or Surg do one so that i dont have to handle the complications.
 
Nivens said:
Part of my problem is the University of Miami doesn't have an ER residency program, so I need to do at least 2 ER externships if that's the way I'm going to go,
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I went to UM. You can talk to the EMSA president about shadowing in the ED. I set up those opportunities while I was there and I hope that the program is still running. Yes, you will need to do externships, but finding them won't be so difficult around the state of Florida as the other programs know that we don't have a residency. I suggest starting with UF-Jacksonville as a couple of UM grads end up there every year. During 4th year there is a required 2 week rotation in anesthesia, with plenty more opportunities to do further electives if you're interested in the field.

Don't worry if you don't know what you want to do. Many of my classmates changed their minds multiple times throughout medical school. Just make friends with attendings in every department so that you can get together rec letters in a hurry if needed.

And don't do EM/IM --> CC. That's 7 years with quite a bit of lost income.
 
Ehhh I plan on doing the EM/IM/CC pathway in 6 years as that is an option at my program. One additional year over EM/CC is not something I am particularly worried about.
 
as long as you are interested in critical care it really doesnt flippen matter how you get there. cant teach desire, and desire is what will make you a badass clinician.
 
Hernandez said:
You're generalizing. And I will again argue that procedures do not make an intensivists, and I can promise that my IM residency procedure log is likely as impressive as yours and I ran as many if not more codes (actually ran, not just sit around and watch someone else do one). But that isn't the point of CC, you should consider any code or lost airway as a failure of prevention. I can teach any monkey to do a line, use and u/s or run a code or manage regular airways. And yet again, really the ER offers very little that I think IM/EM tract to CC is viable. One should really do either or, not both unless they really think theyre going to flip-flop between ER and ICU. But since you're missing the point, I'm not saying do IM--->CC only, I'm sayin don't do combined as none of the advantages you list are skills you can't or won't learn in fellowship.

Congrats on the cric, very very few physicians can say they've done one. I've been apart of 3, but when you have in house trauma-docs it's hard to argue with a pulm fellow Doing one. But keep in mind many places (like mine) are doing bedside perc tracs, so to pat yourself on the back and say you've got a skill that you won't see in fellowship is wrong, I damn near cric'd someone moonlighting a month or so back but managed to get a temporizing maneuver to work to get time for ENT to do a formal Trach. I'm comfortable with doing a cric if need be.
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"We have defined "critical care medicine" as the triad of 1) resuscitation, 2) emergency care for life-threatening conditions, and 3) intensive care; including all components of the emergency and critical care medicine delivery system, prehospital and hospital."-Peter Safar

I stole the above from the Pittsburgh critical care website. As I stated and believe, critical care is a continuum that is often instituted in the ED but can be initiated on a regular floor patient and often culminates with ICU management ideally by a trained intensivist. I think that Pulm-CC is the most common model here so it is embraced most with some more recognition given to the other specialties as of late.

People always question my reasons for doing EM/IM. From my EM and IM advisors when I was in med school to my co-residents there has been a constant barrage of questioning of the utility of the combo. What I notice is that there is often a disconnect between what internists think ED docs do and vice versa. Internists think the ED job entails and vice versa. As Pulm-CC the reason I think you see no benefit is that you do not appreciate the differences in thinking and management style and how they can be synergistic with each other. I don't blame you for not understanding as you haven't done it and I will confess that I m may not be explaining it as well as I should be. You seem to have a bias that prevents you from seeing that they can add to each other. Fact is its a thing of beauty to see EM/IM faculty and my chiefs think through a critical patient or even a not so critical one. The same phenomenon is observed with Med/Peds which is part of why those programs continue to proliferate and be popular with MS4. Really if EM/IM was 4 years no one would say anything, its that 5th year that has people scratching their heads and saying "no way". Admittedly this is an unfounded opinion but I think I have talked to enough people where I can safely say it.

I wasn't trying to say that procedural ability makes the intensivist. That certainly is just one component of the job. However take a look at this: http://www.abim.org/certification/policies/imss/im.aspx#procedures

ABIM basically recommends 5 procedures for clinical competence for a very limited mount of procedures. You must have been at a outstanding IM residency where the Pulm-CC fellows must have just have everything to the IM residents to have more procedural experience than the experience gained in an EM residency. Even monkey's need to practice to maintain skills. i guess I am saying it's all additive man. Fellowship should be about cultivating additional knowledge and I think a combined residency can really help you start at a unique level. If we were talking about GI then I would likely agree with you that it is a waste of 2 years. But as the above quote states, EM and IM are both on the continuum of critical care and if that's what you are interested in then I think its a great way to go.
 
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inspirationmd said:
Haven't been able to find the link that states this is a priority for ABIM with IM residencies. Perhaps it just hasn't been implemented on a widespread basis yet. Idk
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1/2 day of clinic weekly for 3 years, one month of outpt rheum, endocrine and general med/geriatrics

12 months inpatient med
3 months nights
2 months ICU nights
3 months ICU days
2 cardio
2 nephro
1 month of ID, GI, Heme/onc, pulm, gen surgery, GYN, EM.
2 months CT surgery.

That's my residency. The 3 at the top are the only outpatient rotations I did/have done. I would say that turns out to be around 3/36.....8%.

Granted I am ABOIM and we have different rules/restrictions...or lack there of I should say.
 
inspirationmd said:
EM has significant procedural advantages over the average IM residency. I can use U/S better, place a line faster (in all locations), have broader ICU exposure to draw from in pt management (ie.SICU, PICU), and am more comfortable running a code than the large majority of my IM colleagues. I can also intubate and have done crics which are skills that ABIM does not even say IM residents need to have. I have place more chest tubes than a lot of the Pulm-CC fellows and can manage them as a 2nd year resident. Yes you may get these things in fellowship but the key is earlier exposure in my opinion. Also, how many Pulm - CC fellows have cric'ed someone vs call anesthesia (actually want to know this)? I know the anesthesia residents did the few that needed to be done at my med school which was pretty strong for Pulm-CC.

The bottom line is I am going to be a very strong intensivist with the experience to work in most any ICU due to very broad based training that started from day 1. I also love the ED and the unpredictability of it so thats a nice bonus while also giving me a skill set that pays almost as much as intensivist jobs while I work toward my final goal. EM-IM was originally started with the goal of melding the skill sets of the two specialties (politics of that day aside). There has been recognition of the strength of the programs given the two new programs that popped up in the last 2 years.

The EM-IM training is synergistic and gives a strong set of skills for the budding EP who did not mind rounding and likes more differetial diagnosis training and critical care exposure or those who wish to be an Intensivist. If you are planning to be a Hospitalist then i think you don't need to do 5 years and categorical IM is good. I do think that EM-IM should not be a 5 year residency, prob 4.5 but that's for another day.
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We have been down this road in other threads, but I wager you cannot place a line faster, in any location, nor are you more proficient with an US than I am. I have many EM friends who had very weak procedural training during residency because of the size of their program and or facility. Don't generalize. There are many of us with many 100s of procedures competed during IM residency, the same as you.

Second, airways are in fact a skill for all IM physicians and many of us have 70-80-90+ airways from residency. Crics are rare, I have not yet needed to perform one, but I took difficult airway so I can if one arises.

Lastly, I think EMCC and IMCC both make excellent, different, but still equal intensivists. I do not however, think an EMIMCC 6-7 year trained doc is any better than the EMCC or IMCC 5 year trained doc. Your better at EM then the IMCC guy and better at IM than the EMCC guy, but I would wager your all equal in CC, which is at the end, all that matters. But hell, if you got the extra years to spend training and can afford the interest rolling on your loans, all the power to you.
 
inspirationmd said:
"We have defined "critical care medicine" as the triad of 1) resuscitation, 2) emergency care for life-threatening conditions, and 3) intensive care; including all components of the emergency and critical care medicine delivery system, prehospital and hospital."-Peter Safar
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Besides pre-hospital, how is that much different than what I said?

inspirationmd said:
People always question my reasons for doing EM/IM. From my EM and IM advisors when I was in med school to my co-residents there has been a constant barrage of questioning of the utility of the combo. What I notice is that there is often a disconnect between what internists think ED docs do and vice versa. Internists think the ED job entails and vice versa. As Pulm-CC the reason I think you see no benefit is that you do not appreciate the differences in thinking and management style and how they can be synergistic with each other.
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There isn't a disconnect, on what we think happens, there is often a disconnect between what we are sold and what we see. What's synergistic about telling me not to leave the ER while I'm working on 3 bull**** admissions (1 was complete DNR, 1 was hemoptysis with > than 100cc blood {only if you include the saline, which was 99cc of it} or the normotensive septic pt with a normal lactic) so you can admit to me the person who literally just wheeled in that I've seen as much of as you have? Or calling for admits without any workup? Or never placing central lines? Etc. my ER is awful,

You keep saying that ER adds something to IM for CC, but I don't see what it could possibly be, procedures don't need 2 additional years to be taught, same for codes, I've told the guy from my shop who was I'm/EM who did pulm-CC afterwards he was insane but he will be doing ER work as well as CC.

inspirationmd said:
ABIM basically recommends 5 procedures for clinical competence for a very limited mount of procedures. You must have been at a outstanding IM residency where the Pulm-CC fellows must have just have everything to the IM residents to have more procedural experience than the experience gained in an EM residency. Even monkey's need to practice to maintain skills. i guess I am saying it's all additive man. Fellowship should be about cultivating additional knowledge and I think a combined residency can really help you start at a unique level. If we were talking about GI then I would likely agree with you that it is a waste of 2 years. But as the above quote states, EM and IM are both on the continuum of critical care and if that's what you are interested in then I think its a great way to go.
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I didn't have in house fellows where I trained, and I think that's a huge plus. But the ER there wasn't any better on they're admissions.
 
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I really love these inter-speciality pissing match threads. They provide much needed comic relief from step studying. But, on the real, somebody should sticky Vent's comment (is it even possible to sticky a comment?) cause it seems like people are constantly pitting IM v gas for better CC prep and finally we have a comment from someone who has done them both.
 
ihearttriangles said:
I really love these inter-speciality pissing match threads. They provide much needed comic relief from step studying.
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I feel like everything here on SDN turns into a pissing match one way or another. It's pretty ridiculous sometimes listening to others basically saying what my interests can or can not possibly be. I'm EM-IM and I plan on practicing both in the ED as well as on the floor as a hospitalist. And guess what, I'm sort of interested in CCM. Haters gonna hate when it comes to EM-IM, I guess.
 
I think JDH's previous post was one of the most intelligent, well-articulated posts I've read in quite some time. Perhaps rather than trying to figure out who's got the biggest nuts, people should just reread his post, because it speaks the truth.
 
Couldn't agree with you more there.
Whatever rocks your boats! No one is better that the other one In ALL areas/units.
Each has its strengths and weaknesses.
Can we all get a group hug now?
 
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