sozme

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Made a pro/con list for each. Ultimately my goal is to do critical care, since that is what I have found most exciting/interesting during clinical years.

Please tell me what you think. Please tell me where you think I am delusional, etc.


Internal Medicine then Pulmonology/CCM

· Pros
o Has a decent amount of what I love about medicine from an intellectual standpoint.
o Best medical management preparedness for CCM.
o Most well-established pathway currently for CCM.
o Moderately good variety in IM.
o Get the excitement/joy of ordering tests, working people up, managing their meds, etc.
o Most frequent patient contact, most longitudinal care with patients (not a complete pro).
o Would have option for part-time outpatient treatment to avoid burnout (pulmonology).
o Lowest malpractice costs relative to other options.
o Probably best option for teaching medical students if at that type of program.
o Lots of other subspecialty options if I change my mind.


· Cons
o Lowest opportunity to learn the procedures and various tools (i.e. ventilators, ultrasound, etc.) I really want for CCM (before fellowship).
o Would have to fall back on general IM if fellowship doesn’t work out (which would be bad).
o Most frequent patient contact, most longitudinal care with patients (not a complete con).
o Long fellowship (3 years). 6 years total.
o Lots of social work non-sense that would drive me crazy.
o Play 2nd fiddle to every other specialty in the hospital (until fellowship and after).
o Lots of care coordination (until fellowship and after).
o Certain outpatient IM rotations could get old and annoying relatively quick.
o Not well-valued by hospital administrators (largely seen as replaceable by nurse practitioners with 1/6th the education). Not very much political power in the hierarchy.

Emergency Medicine then CCM

· Pros
o Probably the most fun residency of all options.
o Probably the greatest day-to-day variety of all options.
o Decent but not amazing procedural preparedness for CCM.
o Good experience taking care of emergent medical problems.
o Medium-length training. (2 year ABIM-CCM fellowship or surgical critical care fellowship). Residency + fellowship = 3 + 2 = 5 years.
o Shift-work.
o Personality fits in generally well with other EM physicians.
o Extremely well compensated (, for now.)

· Cons
o Being a lifeguard at the shallowest end of the gene pool (drug-seeking trash, bums, workers comp scammers, etc.)
o Probably would get burned out the fastest of all options.
o Not the greatest medical management preparedness for CCM.
o Basically 90% primary care.
o Strictly limited to hospital work even with fellowship.
o Lower but still decent amount of social work.
o Moderately valued by hospital administrators (somewhat seen as replaceable by nurse practitioners with 1/6th the education). Not very much political power in the hierarchy (but still more than IM).

Anesthesiology then CCM

· Pros
o Has the MOST of what I love about medicine from an intellectual standpoint (physiology and pharmacology). Love ventilators, ultrasound, procedures, etc.
o Best procedural preparedness for CCM.
o Lots of time in the OR (not necessarily a complete pro)
o Highest stress consults (difficult/botched airways) = Most opportunities to knock it out of the park in a bottom of the 9th, bases loaded situation.
o Very well compensated (as of right now).
o Medium-length training. Residency + fellowship = 4 + 1 = 5 years.
o Option to add pain management for 1 year fellowship if I completely lose my mind.
o Best specialty path to CCM in terms of diversity of options later on (high-acuity SICUs, CTICU, Neuro ICU, MICU, etc.)
o Extremely well compensated (, for now.)
o Least social work garbage of all options.

· Cons
o Not the greatest medical preparedness for CCM.
o Don’t get the excitement/joy of ordering tests, working people up, managing their meds, etc.
o Lots of time in the OR (not necessarily a complete con)
o Playing 2nd fiddle to surgeons. Dealing with surgical egos.
o Dealing with CRNAs.
o Highest stress consults (difficult/botched airways) = Most opportunities to fall flat on your face when everyone’s counting on you to fix their problem.
o Moderately high malpractice costs.
o Least amount of direct patient interaction.
o Not as many opportunities in private practice compared to traditional IM/CCM/Pulm route.
o Not at all valued by hospital administrators (seen as very replaceable by nurse practitioners with 1/6th the education – already happening or happened in many places). Pretty much no political power in the hierarchy.
 
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Cyal

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You can do a critical care fellowship after anesthesia, unless you really like pulmonology.
 
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sozme

sozme

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Dont forget about surgery as a route.
Already had it written out, but I generally am considering that the least of the 4 right now. Our GS rotation at our school is completely awful and not representative of what GS is actually like (or so I've been told by many including our own admin.)

General Surgery/Surgical Critical Care
· Pros
o Generally highly valued and least replaceable from a hospital politics stand-point.
o Don’t have to deal with competition from or forced to supervise mid-levels (comma yet period).
o Good compensation/income (for now).
o Possible to add trauma surgery? (or get it as part of a surgical critical care fellowship?)
o Don’t have to play 2nd fiddle to anyone.
o My learning style fits well with being yelled at, mocked, humiliated, etc.

· Cons
o Has the least of what I love about medicine (physiology and pharmacology) from an intellectual standpoint.
o Probably a half-way decent amount of social work.
o Would lose the medical management aspect for the most part.
o Have to deal with the most outrageous reimbursement schemes from the .gov
o Very limited in terms of type of CCM work (SICU only I would imagine).
o Longest residency (5 years) before starting fellowship. Surgical critical care varies in duration.
o General surgery residency greatly limits personal/family time.
o Highest malpractice costs.
o Most irritating consults.
o Reimbursement for general surgery is on the decline.
 

NontradCA

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o Being a lifeguard at the shallowest end of the gene pool (drug-seeking trash, bums, workers comp scammers, etc.)
If only we could treat narcissistic, entitled pricks who've never experienced hardship their whole life- or puppy dogs.
 

Tenk

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A lot of what you say about EM is not that accurate.

90% primary care is nowhere near reality. We have some yes, but nobody calls their doctor's office to schedule their MI.

EM physicians can work tons of places that are not hospitals: urgent care, most any country on the planet, a cruise ship, life flight, etc.

We have less social work than IM. I know this because I punt tons of social work onto IM daily through admissions. (sorry bros)

Our political power is gaining, we are a semi-new specialty afterall.

Lastly, my job is not being a lifeguard at the lowest end of the genepool. Yes, I see some patient's who may not have the social background of many of the members of this board, but that doesn't mean my job lacks meaning, dignity or reward. I love my job and I help people of all social-economic backgrounds on a daily basis. Sometimes it's just a simple boo-boo on a kids forehead. Sometimes I bring them back to life. It's fun and rewarding. You just have to have the right attitude for it.

My 2 cents.
 

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EM/IM/CCM: 6-7 years
Also EM patient demographics are variable based on location and practice setting. The "lifeguard at the shallow end of the gene pool" is typically considered trauma surgery.
 
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The million $ question is: Will EM compensation stay the same or even get better in the next 10 years? My gosh! This is the hot ticket in medicine now...
 

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The million $ question is: Will EM compensation stay the same or even get better in the next 10 years? My gosh! This is the hot ticket in medicine now...
Em compensation should be a lot higher than it is. It's only this low because there are too many middlemen sticking their hands into doctor's pockets
 
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W19

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Em compensation should be a lot higher than it is. It's only this low because there are too many middlemen sticking their hands into doctor's pockets
These jobs are offering 350k+/year with benefit and partnership track... 12 shifts/month and some of these jobs I was checking out are in best suburbs in south FL... Can it get any better than that?
 

Maruko

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Why is EM becoming so hot?
 

kenjixshadow

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These jobs are offering 350k+/year with benefit and partnership track... 12 shifts/month and some of these jobs I was checking out are in best suburbs in south FL... Can it get any better than that?
Yes, but many of these jobs are high acuity. I bet the one you looked at was 12 hrs shift. If you go by Birdstrike's law of EM work, 12 x 12 = 144 x 1.5 = 216 hrs amount of work per month in other specialty. Furthermore, EM is a specialty for the young. You hardly ever see any attending above 50 working full time. Btw, according to WCI, 350k a year is underpaid. :laugh:
 
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Psai

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her post just states EM salary & benefits. but why is EM in great demand now?
Because anesthesiology and radiology are sucking while em has a great future as people will always need emergency physicians.
 
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W19

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Yes, but many of these jobs are high acuity. I bet the one you looked at was 12 hrs shift. If you go by Birdstrike's law of EM work, 12 x 12 = 144 x 1.5 = 216 hrs amount of work per month in other specialty. Furthermore, EM is a specialty for the young. You hardly ever see any attending above 50 working full time. Btw, according to WCI, 350k a year is underpaid. :laugh:

See @W19's post
I don't think Birdstrike's formula is true for all EM docs... The jobs I was talking about are in upper middle class neighborhood community hospitals where EM doc 'probably' won't deal with train wreck on a daily basis... 300k+/year was the minimum I saw (and these were 10 shifts/month); a few of them were in the 400k/year... One can't get any better lifestyle than that in medicine even if you have deal with graveyard shifts occasionally...
 

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her post just states EM salary & benefits. but why is EM in great demand now?
I guess it's supply and demand... I was talking to a MS4 at my school whose dad is a FM doc doing EM in rural CA... He told me his dad works 2-24hrs/shift per week for $180/hr... and they let him sleep on the job....
 
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Maruko

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The million $ question is: Will EM compensation stay the same or even get better in the next 10 years? My gosh! This is the hot ticket in medicine now...
it's hard to predict the future.
Anesthesia used to be a hot specialty --> then a lot of people get into it --> it's leveling off now.
 

Cyal

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Because anesthesiology and radiology are sucking while em has a great future as people will always need emergency physicians.
How are anesthesia and rads are sucking?
 

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I think these are some reasons why med students are picking EM. It's not a perfect or comprehensive list by any means i.e. I might be wrong. But for what it's worth:

-EM is a relatively short residency (most 3 yrs, some 4 yrs). You don't have to study for years and years to master a narrow field and become a specialist (e.g. neurosurgeons, cardiologists). (Not to take away from the fact that EM is a specialty in emergency medicine.)
-It's perceived to be "lifestyle friendly" by many med students. For better or for worse, the current (my) generation wants to have a life outside of medicine.
-Relatively good pay.
-Procedures, which many med students perceive to be fun.
-Variety, able to see and do a little bit of everything.
-Flexible, able to work in many different settings and in many different locations around the world.
-Little overhead compared to many specialists who have to set up and rent their own office, hire staff, regularly buy medications and equipment, etc.
-Acute medicine, which is perceived by many med students in their 20s to be exciting.
-In a sense, FM and EM are both quite similar. It's not a perfect way to look at things, but I tend to think of both FM and EM as the same specialty ranging along a spectrum: FM is on the chronic end, while EM is on the acute end. Obviously this simplifies things, but I think it's at least a helpful start to frame it this way.
-EM is a lot more clinical sciences focused, and less basic sciences focused, which many med students perceive to be more interesting, more hands-on, etc.
-I suspect there's a cultural aspect to why EM is so popular too. It's in a lot of ways a very "American" specialty. Whereas in the UK and some Commonwealth nations EM isn't quite as sought after perhaps due in part to their own culture.
 
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kenjixshadow

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it's hard to predict the future.
Anesthesia used to be a hot specialty --> then a lot of people get into it --> it's leveling off now.
This is false. The main reason anesthesia is dying off because of CRNA.
 
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How are anesthesia and rads are sucking?
Anesthesia: pay going down. autonomy going down. stupid quality measure. crnas gaining ground. management groups buying up practices. job market not as good. leadership is horrible and focusing on nonsense like getting more money for their organization, building new headquarters, making crappy, expensive simulations mandatory (this was changed), trying to make anesthesiologists do clinic for free in a misguided attempt to outmaneuver the aana when the training itself should set them apart.

radiology: prospect of teleradiology replacing in house radiologists. decreasing pay for reading scans. fellowship is de facto mandatory meaning at least 6 years of training after medical school. lots of liability for "misreads"
 

bashwell

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Anesthesia is dying for a lot of reasons. Some are: managing CRNAs as part of the ACT; AMCs taking over; not a patient-facing specialty; increased hours, decreased pay; ASA leadership has no idea what it's doing (e.g. proposing PSH); far less good partnership tracks for decent private practices that will treat you well and not sell out to AMCs or hospitals; a lot more employee positions in the future rather than partnerships.
 

bashwell

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@Psai has a good list for both anesthesia and radiology.

I'd add to radiology that there's worsening lifestyle. Maybe in the past radiology used to be "lifestyle friendly," but today not so much. Expect at least 50+ hrs per week, often working late nights, some weekends too.

Also the volume in radiology is increasing, which means the radiologist is expected to read more and more per day. They can't be too slow, there's pressure to pick up the pace. I've heard average is like 125-150 reads per day (plus reporting on each) if doing CTs. MRIs won't be as many of course, but that's because they're not easy reads.

Plus you have to know so much. It's tons of studying. Many radiologists will tell you the extra year of fellowship is definitely needed just to better master the material.

In the end, just do what you can enjoy and that can hopefully best afford you the kind of life you want.
 
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W19

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@Psai has a good list for both anesthesia and radiology.
Also the volume in radiology is increasing, which means the radiologist is expected to read more and more per day. They can't be too slow, there's pressure to pick up the pace. I've heard average is like 125-150 reads per day (plus reporting on each) if doing CTs. MRIs won't be as many of course, but that's because they're not easy reads.
Plus you have to know so much. It's tons of studying. Many radiologists will tell you the extra year of fellowship is definitely needed just to better master the material.

In the end, just do what you can enjoy and that can hopefully best afford you the kind of life you want.
I don't know if many can enjoy something doing it >60 hrs/wk while someone is on their tail making sure that they meet or surpass some BS metrics...
 

bashwell

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I don't know if many can enjoy something doing it >60 hrs/wk while someone is on their tail making sure that they meet or surpass some BS metrics...
You mean for IM, rads, or anesthesia? :) Sadly, they each could involve all this...

EM has its Press Ganey too, which is just as much BS, and having to do rotating shifts for the rest of one's career (if working full time) is probably similar enough to working 60 "regular" hrs per week!

But anyway, yeah I totally agree with you. There's no ideal or perfect specialty out there. Even something like derm has its own pressures. It's more about minimizing what you hate and maximizing what you at least can tolerate, in order to (hopefully!) give you more or less the kind of life you want. Maybe I'm not the best person to listen to though because I'm jaded with medicine.
 
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ACSurgeon

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I don't think Birdstrike's formula is true for all EM docs... The jobs I was talking about are in upper middle class neighborhood community hospitals where EM doc 'probably' won't deal with train wreck on a daily basis... 300k+/year was the minimum I saw (and these were 10 shifts/month); a few of them were in the 400k/year... One can't get any better lifestyle than that in medicine even if you have deal with graveyard shifts occasionally...
And this is why burn out in EM is so high despite working less hours per week/month than others.
 
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bashwell

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Here's a decent option for those who might be interested: Move to Australia or New Zealand to practice EM or anesthesiology.

I know of several American (and Canadian) emergency physicians and anesthesiologists who have moved to Australia and NZ. In both Australia and NZ the lifestyle for anesthesiology and EM is far better than in the US. I don't know NZ as well, but I know in Australia the pay isn't as much as in the US, although it's still not too bad by any means! (Still $300-$400k, although different "packages".) No BS metrics for how quickly you move the meat (Press Ganey), the patient population is generally far more appreciative, no CRNAs to manage, you do your own cases, most attending EPs rarely if ever work graveyard, in fact from what I've seen they usually work 4 days per week x 10 hrs per day during regular hours up and never past midnight even at the latest (and one of the days is a non-clinical day where you teach med students or residents or "research" i.e. go to the beach just kidding), there's a lot more respect for you as a physician, lots of other little perks (e.g. CME is better in a lot of different ways), etc.
 
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And this is why burn out in EM is so high despite working less hours per week/month than others.
Well... After making bank for at least 10 years one can work 2 days/wk making 200k... I agree that no specialty is perfect in medicine now.
 

QualityProcess

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some of these jobs I was checking out are in best suburbs in south FL... Can it get any better than that?
My opinion... yes, it can get a lot better than S florida. Traffic and people can be terrible. So humid for 10 months out of the year that you practically swim to work. Litigation is a way of life. S florida is the epicenter of the ambulance chasing bottom-feeder law school graduate.

That said, our 2 month long 70 degree winters are really, really nice.
 

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My opinion... yes, it can get a lot better than S florida. Traffic and people can be terrible. So humid for 10 months out of the year that you practically swim to work. Litigation is a way of life. S florida is the epicenter of the ambulance chasing bottom-feeder law school graduate.

That said, our 2 month long 70 degree winters are really, really nice.
It's actually 7 months... It is not humid in S. FL from November thru March... I guess since I am not an outdoor person, the humidity does not bother me that much... I agree with you about the litigation and bottom-feeder law school grad aspects of the state. The legislature has to control these scums...
 
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cbrons

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Internal Medicine then Pulmonology/CCM

· Pros
o Has a decent amount of what I love about medicine from an intellectual standpoint.
o Best medical management preparedness for CCM.
o Most well-established pathway currently for CCM.
o Moderately good variety in IM.
o Get the excitement/joy of ordering tests, working people up, managing their meds, etc.
o Most frequent patient contact, most longitudinal care with patients (not a complete pro).
o Would have option for part-time outpatient treatment to avoid burnout (pulmonology).
o Lowest malpractice costs relative to other options.
o Probably best option for teaching medical students if at that type of program.
o Lots of other subspecialty options if I change my mind.


· Cons
o Lowest opportunity to learn the procedures and various tools (i.e. ventilators, ultrasound, etc.) I really want for CCM (before fellowship).
o Would have to fall back on general IM if fellowship doesn’t work out (which would be bad).
o Most frequent patient contact, most longitudinal care with patients (not a complete con).
o Long fellowship (3 years). 6 years total.
o Lots of social work non-sense that would drive me crazy.
o Play 2nd fiddle to every other specialty in the hospital (until fellowship and after).
o Lots of care coordination (until fellowship and after).
o Certain outpatient IM rotations could get old and annoying relatively quick.
o Not well-valued by hospital administrators (largely seen as replaceable by nurse practitioners with 1/6th the education). Not very much political power in the hierarchy.
Not sure the procedure part matters, because at some IM residencies you can do a lot of procedures. It seems like it is more program-dependent.
 

Maruko

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there are PA and NP working in EM, too. why are EM doctors not worried about them as anesthesiologists worry about CRNA?
 

Mad Jack

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The million $ question is: Will EM compensation stay the same or even get better in the next 10 years? My gosh! This is the hot ticket in medicine now...
When everyone else is running toward something, I generally run away. Look at anesthesia and rads, for instance...
 

Mad Jack

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there are PA and NP working in EM, too. why are EM doctors not worried about them as anesthesiologists worry about CRNA?
Because they can't treat the complex cases, or sort the difficult from the complex, which can put your hospital at massive risk of a lawsuit. A physician screws up, he's taking the great. A hospital-employed midlevel screws up, the hospital is defendant number one because they generally set the protocols up under which the midlevel operates. That NP misses a single MI or stroke, and you're out enough money to pay ten doctors.
 

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Because they can't treat the complex cases, or sort the difficult from the complex, which can put your hospital at massive risk of a lawsuit. A physician screws up, he's taking the great. A hospital-employed midlevel screws up, the hospital is defendant number one because they generally set the protocols up under which the midlevel operates. That NP misses a single MI or stroke, and you're out enough money to pay ten doctors.
I have also seen that argument in the gas forum...
 

Mad Jack

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I have also seen that argument in the gas forum...
Anesthesia in its current form is far more safe than emergency medicine from a liability standpoint. We have safe, effective drugs and excellent monitoring equipment. When your patient goes under, you know why they are doing so, and every patient has been thoroughly evaluated beforehand. Furthermore, in states where CRNAs have independent practice, they do not operate under protocol, but rather as an independent provider. If something goes wrong, there's usually a preoperative consult that was at least done by a physician that you can cite as erroneous if you're looking to shift blame.

In EM, literally anything could come through the door. The protocols are only any good if you can sort out what ones to use, there are no preoperative consults, there is no prior medical clearance, etc. These PAs and NPs are thrown into a world of extreme breadth, far beyond that of anesthesia, since -literally anything- can come through the door. EM is one of those fields where having a physician there actually makes sense- you've got patients that can look well but be extremely sick, look extremely sick but be very well, that could have taken a gunshot wound to the chest or have some obscure pathology. You need someone that can make the right decisions quickly, and if they make the wrong decisions and use the wrong protocol- as will eventually happen with a midlevel- you're either losing money on unnecessary care or losing money to lawsuits.
 

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When everyone else is running toward something, I generally run away. Look at anesthesia and rads, for instance...
I am beginning to see this trend in psych as well... I will see what the next 'charting the outcomes' will say.
 

Mad Jack

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Someone above mentioned EM/IM/CC, just wanted to pop in and say its an awesome combo. That is all, carry on.
Good to know you're happy with the EM/IM/CC path sylv! Do you feel like the lack of pulm will hurt you, or that the added variety of training with EM will give you a boost when it comes time to apply for your first job as an attending?
 
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bashwell

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This entire thread is worth reading because it's about a dentist who is thinking about going to med school and becoming an anesthesiologist so several anesthesiologists (attendings) give him their opinion about why it's not a good idea to go back to med school to become an anesthesiologist. Here is an example:
Stresses as anesthesiologist:
Productivity pressure-surgeons want you available for them when it is convenient, not when they are scheduled only. They don't want any downtime during their day, want to quit cutting, call family say "everything went well" and start cutting while assistant closes first. Hospital wants you always there "just in case"
Employer stress-you are likely to supervise and/or employ CRNAs. Second to physicians they are the most entitled people you will meet. "It is 15:33 and I was supposed to be done at 15:30, I am not staying to finish the 5 more minutes" this is despite making 150-200k a year and time and a half for those extra 15 min.
Medical stress-patients will have bad outcomes, potentially death despite you trying your best. You may even hasten that process, and you have to live with it. You will frequently take poor candidates to be even getting out of bed, and ushering them through assassination attempts by surgeons.
Patient stresses-the expectation of many is that you will get them through surgery without pain, nausea, and will smile at them as they treat you with disrespect.
Lifestyle stress-no set end time, your last scheduled case ends at 14:00? Well the surgeon just clipped an artery and vascular is coming for 4 more hours, then there is a stat cesarean section. Call. Etc.
 
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sylvanthus

Attending
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Sep 9, 2008
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Good to know you're happy with the EM/IM/CC path sylv! Do you feel like the lack of pulm will hurt you, or that the added variety of training with EM will give you a boost when it comes time to apply for your first job as an attending?
Not worried about the lack of pulm. Im not a fan of clinic. I also don't plan on working at an academic center so the lack of pulm wont really effect me. Likely I will work in a rural area and also do locums so think it will work out well.
 
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jdh71

Grim Optimist.
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Dec 14, 2006
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You don't have to do pulmonary with the critical care coming out of IM.

You can do the 3+2 = 5 years to CCM.

(or alternatively finish *any* of the other fellowships plus one year critical care fellowship - I know a guy finishing critical care this year after doing IM + GI + Liver Transplant [not the optimum pathway for everyone, obviously])

Your most options in critical care *when you are done* currently lies with IM to critical care. Outside of academic centers I don't see this changing too much over the next 5 to 10 years just based on the bias I see in recruiting, but you never know. My group is always looking for someone to cover more nights and weekends.

I know. I know. At least three of you will quote me to tell me about some gig that breaks this mold. I promise. I know. Motivated people find jobs. Your anecdote(s) doesn't invalidate the current generalization.

FWIW, I don't think there is a "best" pathway to critical care. You learn your practice environment. Good training out of any of the basic pathways will lead you to being a fine intensivist regardless (with the exception of surgical critical care - it's not that they can't, they just really don't do much outside of surgical critical care as *surgeons*). Pick the basic training pathway you like the best and don't overthink it. If you don't like the OR or the pace of the ED, go IM. If rounding and gomers make you irate, then do anesthesia. If you are an adrenaline junkie and invented snorkleskiing, then EM for you.