Internal Medicine - Critical Care

[hungrydoc710]

I've always wanted to stay general - internal or general surgery - now that I feel myself pulling away from surgery, I'm focusing on my opitons in internal. I've never felt really compelled by one system or another, which made me ponder maybe I'll just stay as a general internist, but honestly I still want to be specialized and have the earning power pf over 300K.

All I know is that it is more common to go pulm-CC route, but they are pure CC fellowships (much les of them), which seems much more inticing to me.

Does anyone have any knowledge on getting a internal med-CC pure fellowship as far as board scores, research, competitiveness, etc.?

Cheers.

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[InternistDO]

Unless you have a deep deep hatred of the lungs, Pulm/crit will give you a higher earning potential (pulm = more procedures) and more career flexibility (there are plenty of hospitals that only hire dual boarded people for the ICU so they can also cover pulm clinic) than straight critical care.

However, if you want to do only critical care they tend to be less competitive because of the above reasons. There's no hard data because they don't participate in the NRMP fellowship match.

 

[DrStephenStrange]

I would probably check the internal med and/or Critical care sub-forums with that question. Just in case you don't get the answers you need here.

 

[Neopolymath]

Just trust me on this, you want to do pulm-CC not IM-CC. It is a much better path with additional skills and career choices.

 

[hungrydoc710]

Just trust me on this, you want to do pulm-CC not IM-CC. It is a much better path with additional skills and career choices.

Will def keep an open mind

 

[group_theory]

It's only 1 extra year to do pulm-ccm than to do straight ccm.

As for job options - depends on where you are joining - large systems can afford to have pure ccm (such as academic hospitals or larger health systems). Most SICUs are staffed by anesthesia-ccm or trauma. Most MICU are staffed by pulm-ccm, and if it is staffed by a private group, they may want someone who is pulm-ccm so that they can provide pulmonary coverage. Not saying you can't find a job (far from it, there is a shortage of invensivist, as well as pulmonologists) but your options are wider if you have both instead of one.

No data but from word of mouth - straight ccm fellowships is easier to obtain than pulm-ccm fellowships. CCM fellowships is outside NRMP so it's more like a typical job interview (with offers/acceptance) than the match (which PCCM goes through - you apply, interview, rank, and match)

 

[Spectreman]

I've always wanted to stay general - internal or general surgery - now that I feel myself pulling away from surgery, I'm focusing on my opitons in internal. I've never felt really compelled by one system or another, which made me ponder maybe I'll just stay as a general internist, but honestly I still want to be specialized and have the earning power pf over 300K.

All I know is that it is more common to go pulm-CC route, but they are pure CC fellowships (much les of them), which seems much more inticing to me.

Does anyone have any knowledge on getting a internal med-CC pure fellowship as far as board scores, research, competitiveness, etc.?

Cheers.

My IM preceptor is a hospitalist at my site and did no fellowship, pulled 325k last year and is going to start rounding at a rehab in town to clear 400k. Loves his life, ultra chill schedule, in around 8:30 and gone by 2:30 every day. Stays for admit call for like 3 hours every 10 days. Never takes night call. Dude’s 34 and only 3 years out of residency.

 

[Neopolymath]

My IM preceptor is a hospitalist at my site and did no fellowship, pulled 325k last year and is going to start rounding at a rehab in town to clear 400k. Loves his life, ultra chill schedule, in around 8:30 and gone by 2:30 every day. Stays for admit call for like 3 hours every 10 days. Never takes night call. Dude’s 34 and only 3 years out of residency.

One can also do the initial medical H/P for psychiatric hospital patients. Apparently at a lot of facilities like these small behavioral hospitals the patients are "medically cleared" before transfer so they are really simple patients to handle for some quick case. Complicated patients either don't get transferred there or get shipped out if they decompensate past the facility's capabilities.

The rehab center gig is popular near me and these people are cleaning up.

 

[Neopolymath]

It's only 1 extra year to do pulm-ccm than to do straight ccm.

As for job options - depends on where you are joining - large systems can afford to have pure ccm (such as academic hospitals or larger health systems). Most SICUs are staffed by anesthesia-ccm or trauma. Most MICU are staffed by pulm-ccm, and if it is staffed by a private group, they may want someone who is pulm-ccm so that they can provide pulmonary coverage. Not saying you can't find a job (far from it, there is a shortage of invensivist, as well as pulmonologists) but your options are wider if you have both instead of one.

No data but from word of mouth - straight ccm fellowships is easier to obtain than pulm-ccm fellowships. CCM fellowships is outside NRMP so it's more like a typical job interview (with offers/acceptance) than the match (which PCCM goes through - you apply, interview, rank, and match)

You also have pulm clinic to fall back on should you get burned out/want to slown down near retirement etc.

 

[Mass Effect]

To add to the chorus, I agree that you can make good money as an IM hospitalist. But also, make sure you choose your specialty because you like it, rather than the money, especially something like CC.

 

[Spectreman]

One can also do the initial medical H/P for psychiatric hospital patients. Apparently at a lot of facilities like these small behavioral hospitals the patients are "medically cleared" before transfer so they are really simple patients to handle for some quick case. Complicated patients either don't get transferred there or get shipped out if they decompensate past the facility's capabilities.

The rehab center gig is popular near me and these people are cleaning up.

That’s basically what he does and I gotta say it feels like just a way to get your hand in the cookie jar. By the end of our days I was often like “okay, I don’t feel like we actually contributed anything to the care of these patients, buuut we wrote a note and discharged some gents soooo good for us - k let’s go workout.”

you basically get the “who the heck is this?” From patients all day. I know I’m being a turd and it’s important work, but that’s just how I felt during a lot of the rotation.

 

[Peach Newport]

I keep getting told that for anyone who really loves CC, anesthesia-CC is the way to go, much better than the IM route unless you really want to do outpatient pulm. Makes sense to me - more experience with raw physiology/pharmacology, ability to do both micu and sicu, and (IMO) a more interesting residency with higher earning potential.

Someone please correct me if I’m wrong.

 

[Neopolymath]

I keep getting told that for anyone who really loves CC, anesthesia-CC is the way to go, much better than the IM route unless you really want to do outpatient pulm. Makes sense to me - more experience with raw physiology/pharmacology, ability to do both micu and sicu, and (IMO) a more interesting residency with higher earning potential.

Someone please correct me if I’m wrong.

You will very likely not be able to land a MICU job as an anesthesia-CC trained doc, particularly in the community. Anesthesia-CC docs are largely stuck in open SICUs dealing with surgeons that act even worse than they do in the OR and are often relegated to academic jobs (which is not really desirable for most people on its own.)

The vast majority of ICUs are controlled by IM trained physicians and they protect their own and their turf. Yeah, in pretty much every other country anesthesia controls the ICUs and their training is likely more ideal in some regard but it's just the way it is. I encourage anyone who doesn't believe me to read the anesthesia subforum for 5 minutes. It's easily the best subforum on this website, frankly.

 

[fldoctorgirl]

My IM preceptor is a hospitalist at my site and did no fellowship, pulled 325k last year and is going to start rounding at a rehab in town to clear 400k. Loves his life, ultra chill schedule, in around 8:30 and gone by 2:30 every day. Stays for admit call for like 3 hours every 10 days. Never takes night call. Dude’s 34 and only 3 years out of residency.

What part of the country is this? I think I remember where you go to school but not sure.

 

[Spectreman]

What part of the country is this? I think I remember where you go to school but not sure.

Southeastern, GA/FL/AL

 

[hungrydoc710]

Southeastern, GA/FL/AL

SC student over here. Did not realize a general hospitalist could pull those numbers even in the south.
Good to know though, even though I plan to train back MI, a move back out here would can def be on the cards.

 

[BobbyKoch]

out of curiosity, how does the topic of compensation come up with preceptors/attendings? maybe I'm naive but I just can't really imagine asking anyone how much money they make. conversely, I can't recall anyone ever just offering this information, at least in a professional setting like a hospital/clinic.

 

[Drrrrrr. Celty]

out of curiosity, how does the topic of compensation come up with preceptors/attendings? maybe I'm naive but I just can't really imagine asking anyone how much money they make. conversely, I can't recall anyone ever just offering this information, at least in a professional setting like a hospital/clinic.

It comes up. Just not with Med students. Most attendings have opinions on specialties and they offer their insights including on the topic of payment.

 

[Drrrrrr. Celty]

To add to the chorus, I agree that you can make good money as an IM hospitalist. But also, make sure you choose your specialty because you like it, rather than the money, especially something like CC.

Agreed. Honestly by the time you're doing your medicine residency you'll find out what your competency is for different specialties and find yourself enjoying certain patients more than others. From there depending on how much you work you'll be able to land a career that makes you as much money as you want.

 

[Drrrrrr. Celty]

I keep getting told that for anyone who really loves CC, anesthesia-CC is the way to go, much better than the IM route unless you really want to do outpatient pulm. Makes sense to me - more experience with raw physiology/pharmacology, ability to do both micu and sicu, and (IMO) a more interesting residency with higher earning potential.

Someone please correct me if I’m wrong.

The Pulm aspect is actually part of how they become more marketable tbh. Pulmonary consults are a lot of money and probably aside from nephrology the most common consulted group on the average patient. As far as the ICU, most people in ICUs are there for pulmonary etiologies either due to pulmonary cardiac arrest, ARDS, or respiratory failure.

 

[Neopolymath]

The Pulm aspect is actually part of how they become more marketable tbh. Pulmonary consults are a lot of money and probably aside from nephrology the most common consulted group on the average patient. As far as the ICU, most people in ICUs are there for pulmonary etiologies either due to pulmonary cardiac arrest, ARDS, or respiratory failure.

PFTs are easy, easy money... especially when you have medical students interpreting all of them for the practice and you just look them over. Ask me how I know.

 

[Hippocrates II]

Also worth keeping in mind that if money is the primary motivator for specializing, the (relatively...) early salary of IM is very valuable. Making $200k+ per year over a fellow for 3 years early in your career is worth a lot, depending on how you model your assumptions. When I ran the numbers, it was worth around another 100k/year on top of the typical IM salary, but that will vary depending on what you think you would invest, how much your investments would return, and so forth. I'm not motivated enough to extrapolate out for each career, but I imagine the net worth between an internist and many specialists becomes a lot closer when you factor that in.

 

[Drrrrrr. Celty]

PFTs are easy, easy money... especially when you have medical students interpreting all of them for the practice and you just look them over. Ask me how I know.

For outpatient clinic yes. Inpatient consults are also very easy money and sometimes save the hospital money because it's cheaper for the hospital to do an in room chest tube than it is to book IR or gen surgery for the chest tube.

 

[Drrrrrr. Celty]

Also worth keeping in mind that if money is the primary motivator for specializing, the (relatively...) early salary of IM is very valuable. Making $200k+ per year over a fellow for 3 years early in your career is worth a lot, depending on how you model your assumptions. When I ran the numbers, it was worth around another 100k/year on top of the typical IM salary, but that will vary depending on what you think you would invest, how much your investments would return, and so forth. I'm not motivated enough to extrapolate out for each career, but I imagine the net worth between an internist and many specialists becomes a lot closer when you factor that in.

Specializing is not really worth the money outside of Pulm/Crit, Heme/Onc, Cardio, or GI. Every other specialty you're likely breaking even with hospitalist or pcp ex rheumatology and A&I or you're going to make less Endo, ID, geri/pallative.

That being said subspecialization is about getting a lifestyle, a specific set of problems you find stimulating, and often being outpatient with limited call. It can be more sustainable for some people than 7 on 7 off.

 

[Drrrrrr. Celty]

Is there a big difference in salary between IM vs CCM-only fellowship trained IM docs? I know many ID/Nephrologists end up doing it.

It's a salary boost and long term it nets a good gain. It's just not as desirable as Pulm/Crit. Like my institute only hires Pulm/Crit physicians because we have fellowship and busy pulm consult service. Critical Care/ X subspecialty is a weird area and I'm not too familiar with it.

Crit care along however is less competitive than pulm/crit.

 

[Rogue42]

It's a salary boost and long term it nets a good gain. It's just not as desirable as Pulm/Crit. Like my institute only hires Pulm/Crit physicians because we have fellowship and busy pulm consult service. Critical Care/ X subspecialty is a weird area and I'm not too familiar with it.

Crit care along however is less competitive than pulm/crit.

I mean how much does Pulm/CC make? Couldn’t an individual go EM -> fellowship CC for a total of 5 years instead of 6, make more money and still be an intensivist?

 

[InternistDO]

I mean how much does Pulm/CC make? Couldn’t an individual go EM -> fellowship CC for a total of 5 years instead of 6, make more money and still be an intensivist?

The salary boost is the pulm part compared to straight critical care. So you can do EM-->CC, but you're in the same boat as IM-->CC except that you can work in the ED (which in some places pays more than CC).

Obviously all will give you a perfectly good salary, but if you're already doing IM-->CC, why not add an extra year and make yourself more markable to jobs that only hire pulm boarded, and potentially a salary bump from doing pulm procedures?

 

[spacegun]

I mean how much does Pulm/CC make? Couldn’t an individual go EM -> fellowship CC for a total of 5 years instead of 6, make more money and still be an intensivist?

N=1. I know a pulm/cc attending in the Midwest who told me he pulled in about $700k/year over the last 3 years doing 7 days on/off ICU with inpatient pulm consults and another ~5 days outpatient pulm. He gets the rest of the month off. He says he could work more if he wanted but he doesn't so he gets on average ~10-11 days off per month. He hates outpatient pulm and this year he didn't do any outpatient pulm at all, only ICU and inpatient pulm consults, and he expects to make around $550k this year. He did say if he did only outpatient pulm (no ICU) he thinks he could make $350k-$400k but he doesn't like outpatient pulm. He doesn't look that old, maybe mid or late 30's at most.

 

[group_theory]

N=1. I know a pulm/cc attending in the Midwest who told me he pulled in about $700k/year over the last 3 years doing 7 days on/off ICU with inpatient pulm consults and another ~5 days outpatient pulm. He gets the rest of the month off. He says he could work more if he wanted but he doesn't so he gets on average ~10-11 days off per month. He hates outpatient pulm and this year he didn't do any outpatient pulm at all, only ICU and inpatient pulm consults, and he expects to make around $550k this year. He did say if he did only outpatient pulm (no ICU) he thinks he could make $350k-$400k but he doesn't like outpatient pulm. He doesn't look that old, maybe mid or late 30's at most.

Definitely doable, but with that salary, you're on the top end of the bell curve for income for a pulm/CCM guy. Likely impossible in academia to make that much, even as division chief or even medicine chair, unless you have other senior administrative duties (ie dean of the medical school, chief medical officer, etc) OR you have heavy sponsorship from pharmaceutical/industry

But in private practice, as a 1099 contractor, or a single person LLC, esp working mostly in the hospital (ie little to no cost overhead to worry about in running an office), it's possible to top $500k, esp if you pile up the critical care billing time, as well as procedures ... definitely not hard during the covid pandemic where intensivists are urgently needed everywhere (and hospitals are willing to pay top money for locums)

If you also own the ancillary services (being paid to read PFT, being paid to perform PFT), and maybe a sleep lab (PSG or home PSG), that brings in additional income.

MGMA data for pulmonologists for 2019 is around $406k total compensation.


Just my humble opinion (as a pulm-crit guy)

 

[spacegun]

Definitely doable, but with that salary, you're on the top end of the bell curve for income for a pulm/CCM guy. Likely impossible in academia to make that much, even as division chief or even medicine chair, unless you have other senior administrative duties (ie dean of the medical school, chief medical officer, etc) OR you have heavy sponsorship from pharmaceutical/industry

But in private practice, as a 1099 contractor, or a single person LLC, esp working mostly in the hospital (ie little to no cost overhead to worry about in running an office), it's possible to top $500k, esp if you pile up the critical care billing time, as well as procedures ... definitely not hard during the covid pandemic where intensivists are urgently needed everywhere (and hospitals are willing to pay top money for locums)

If you also own the ancillary services (being paid to read PFT, being paid to perform PFT), and maybe a sleep lab (PSG or home PSG), that brings in additional income.

MGMA data for pulmonologists for 2019 is around $406k total compensation.


Just my humble opinion (as a pulm-crit guy)

Thanks this is helpful information to know! He's definitely in private practice and also in a small or medium sized Midwestern town (I'll just say he's in a state that starts with the letter "I") so that might be another reason he makes so much with a relatively decent schedule? He doesn't do any sleep but he did say the ~3-5 days of outpatient pulm/month are locums even though his own hospital asked him to see outpatient pulm patients (I guess because locums pay better?). But he said he stopped doing outpatient pulm this year because he didn't like it. And he said he has family in CA and looked into working in CA but he got a worse deal (and a higher cost of living in CA of course) so he just stayed in the Midwest after doing his fellowship in the Midwest.

 

[group_theory]

Keep in mind the high burnout rate amongst intensivists. According to a survey, 45% of adult intensivists acknowledge severe burnout.

Having outpatient work breaks up the intensity and monotony, and is a good option as you get older and want to dial back on critical care work

On another note - due to the nationwide pandemic and surge, the ICU nurses were talking about how they were getting offers to work as a travel ICU nurse, and offering up to $8000/week for those gigs.

That's a lot of money. But then I pulled out the calculator and did the math ... and realized I make more than that per week. Can't complain about the job


Reference:
Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action. Crit Care Med. 2016 Jul;44(7):1414-21. doi: 10.1097/CCM.0000000000001885. PMID: 27309157.

 

[spacegun]

Keep in mind the high burnout rate amongst intensivists. According to a survey, 45% of adult intensivists acknowledge severe burnout.

Having outpatient work breaks up the intensity and monotony, and is a good option as you get older and want to dial back on critical care work

On another note - due to the nationwide pandemic and surge, the ICU nurses were talking about how they were getting offers to work as a travel ICU nurse, and offering up to $8000/week for those gigs.

That's a lot of money. But then I pulled out the calculator and did the math ... and realized I make more than that per week. Can't complain about the job


Reference:
Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action. Crit Care Med. 2016 Jul;44(7):1414-21. doi: 10.1097/CCM.0000000000001885. PMID: 27309157.

Of course, $8K/week working 52 weeks is $416K/year (which obviously no one in their right mind would do).

However, MGMA median for ccm only (no pulm) is about the same (~$400K/year) but for approximately half the year (e.g. 7 days on/off for the year). That's approximately $15K/week.

 

[spacegun]

It’s a much better gig for nursing than for medicine at that price point, because you’ve got to remember that’s for full time work. And full time is only 36 hours/week on three 12s.

So. What this practically looks like is they’re getting $8k/week, and if they structured their weeks to to Thurs-Sat, then Sun-Tues and repeat, that’s working six days on and eight days off, rotating. Or just working something like Sun-Tues every week, your choice. It’s only 12 days of work per month regardless.

Also - that $8k might just be the compensation and might not include the housing and meal stipends - so the housing and food could be free and that $8k is just going straight in their pockets.

I thought about taking a year-long leave of absence from med school to pick up on that travel pay, because I have exactly the experience they’re looking for (five years in a mostly respiratory MICU in a tertiary referral center) LMFAO.

I guess if we really want to compare, then we probably need specific details. Like I think a more fair comparison would need to say what a critical care physician can make on travel pay too, if the physician gets anything for housing, food, etc. (like the ICU nurse does).

If it's $8k/week for about 12 days of work per month, then it's about $1,333/day for the ICU nurse, I think ($16,000 divided by 12 days)? In comparison, the critical care physician making $400,000/year and working (say) 15 days per month, it'd be about $2,222/day, wouldn't it? Maybe my math is wrong.

If you're also an ICU nurse and a med student, then I definitely agree it'd be a huge temptation to take a LOA from med school to work for that kind of money! I guess you could use the time to do research to get into a competitive specialty too! It'd be seriously really tempting if I had your background! 🙂