IM vs. EM vs. Anesthesiology

[bashwell]

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.

Thanks @jdh71 always good to hear your perspective. Just curious, is IM/ID/cc do-able i.e. is it going to be tough to find a job that pays as well as IM/pulm/cc whether in PP or academics, as long as you're not looking to live in big popular desirable cities or areas like LA, NYC, etc.?

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[jdh71]

Thanks @jdh71 always good to hear your perspective. Just curious, is IM/ID/cc do-able i.e. is it going to be tough to find a job that pays as well as IM/pulm/cc whether in PP or academics, as long as you're not looking to live in big popular desirable cities or areas like LA, NYC, etc.?

Pays as well?? That's a bit of a nuanced question. You should get the market rate for *intensivist* work regardless. But total compensation? Probably less than with pulmonary vs ID. But it would all depend on how much ICU you do, how many ID consults you do, and if you had a clinic.

 

[jdh71]

Thanks @jdh71 always good to hear your perspective. Just curious, is IM/ID/cc do-able i.e. is it going to be tough to find a job that pays as well as IM/pulm/cc whether in PP or academics, as long as you're not looking to live in big popular desirable cities or areas like LA, NYC, etc.?

I'll clarify a bit further if you do a week on week off of critical care it would be the same salary as any intensivist for your market. Probably around 350k for that kind of work.

Now if you work maybe a week of ICU per month and make up the rest of your salary doing ID type of things then it will all depend on how many consult weeks/days in the hospital and how much clinic days/patients you see that will make up your final salary. I doubt you top doing just pure intensivist work.

 

[aalamruad]

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.

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.

lol