Job Description of Critical Care Intensivist

[spinetime]

I've been exploring Anesthesia based career options for a while now, and the concept of CC has caught my eye. However, there's no real description of what these intensivists do. I understand they work in the ICUs, but what exactly are they doing there on a day-to-day basis?

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[timtye78]

My impression as a CA 2 AMG Anesthesia resident is purely a personal one.

At my institution we have two Anesthesiology/CCM attendings, and they both happen to be Non US physicians. They are very smart, and for the most part, are excellent teachers. They are very detailed in their treatment, which seems to be a recurring concept as I work with more and more intensivists (currently I happen to be on a Pediatric ICU rotation working with pediatric ccm-non-anesthesia attendings).

Attractive attributes of Anes CCM to me: Very sick patients, opportunities for many procedures in common with anesthesiology-CL,AL,intubations, vent management, resuscitations, transfusion medicine, pulmonary and cardiac medicine, post-op medicine, life-threatening diseases other than hemorrhaging parturients, eg acute respiratory distress,etc etc. ASA people seem to think it is the future direction for anesthesiologists. Fellowship is only one year long. Non-competitive currently-do it where you want to live. Maybe more respect as a physician later. Something to separate you completely from a CRNA. Opens the door to academics if you so desire etc. (as if it was hard to get a job at univ hosp anyways.)

Negatives to me:Currently finding its place as a specialty in private practice and even in academic setting. In my institution, Anes CCM docs take the pressure off the trauma surgeons by rounding, but it is clear that the trauma surgeons are considered 'the primary service' in the ICU. In private hospitals, it seems to be the pulmonologists who 'run' the ICUs out there, and I hear Anesthesiology CCM reimbursement is not super lucrative, either. I do not particularily enjoy the Infectious Disease aspect, and debating about how the cultures were drawn before or after the abx, or what abx, or what dose etc. etc.Oh yeah, do you like rounding, dictating, writing lists of orders, etc?

I am sure it would not *HURT* to do a ccm fellowship, but how much it would advance your career as an anesthesiologist is another question. But another question to ask is do you LIKE CCM? Would anyone even know what you were talking about if you told them you going to now become an ICU doc, and how is that different from the small-town internist/hospitalist who still runs the local little icu anyways?

Food for thought.

 

[bulgethetwine]

My impression as a CA 2 AMG Anesthesia resident is purely a personal one.

At my institution we have two Anesthesiology/CCM attendings, and they both happen to be Non US physicians. They are very smart, and for the most part, are excellent teachers. They are very detailed in their treatment, which seems to be a recurring concept as I work with more and more intensivists (currently I happen to be on a Pediatric ICU rotation working with pediatric ccm-non-anesthesia attendings).

Attractive attributes of Anes CCM to me: Very sick patients, opportunities for many procedures in common with anesthesiology-CL,AL,intubations, vent management, resuscitations, transfusion medicine, pulmonary and cardiac medicine, post-op medicine, life-threatening diseases other than hemorrhaging parturients, eg acute respiratory distress,etc etc. ASA people seem to think it is the future direction for anesthesiologists. Fellowship is only one year long. Non-competitive currently-do it where you want to live. Maybe more respect as a physician later. Something to separate you completely from a CRNA. Opens the door to academics if you so desire etc. (as if it was hard to get a job at univ hosp anyways.)

Negatives to me:Currently finding its place as a specialty in private practice and even in academic setting. In my institution, Anes CCM docs take the pressure off the trauma surgeons by rounding, but it is clear that the trauma surgeons are considered 'the primary service' in the ICU. In private hospitals, it seems to be the pulmonologists who 'run' the ICUs out there, and I hear Anesthesiology CCM reimbursement is not super lucrative, either. I do not particularily enjoy the Infectious Disease aspect, and debating about how the cultures were drawn before or after the abx, or what abx, or what dose etc. etc.Oh yeah, do you like rounding, dictating, writing lists of orders, etc?

I am sure it would not *HURT* to do a ccm fellowship, but how much it would advance your career as an anesthesiologist is another question. But another question to ask is do you LIKE CCM? Would anyone even know what you were talking about if you told them you going to now become an ICU doc, and how is that different from the small-town internist/hospitalist who still runs the local little icu anyways?

Food for thought.

At my institution, anesthesia grads serve as attendings in the PICU and the SICU. They might in the MICU if we didn't have such an oversupply.

Both in the PICU and SICU, they serve as attending of the primary team. That means they are responsible for global care of each patient. This is the blueprint, I believe, for so-called "closed units". That is, in a closed unit, ultimate decision making rests with the attending in the unit as opposed to, for instance, the trauma attending who might have been on call the night of an MVC. Of course, there is always close cooperation between the ICU team and the trauma team (or peds team, or whatever). But the point is the anesthesia attending has profound knowledge of all the aspects of care... wound care, infectious disease, CV, Resp... you name it. I come from an non-ansthesia background, and all I can say is: Impressive. I never feel, when I'm working with an IM-trained intensivist vs. an anesthesia-trained intensivist as if one or the other is better at the actual medical side... as some cynics might assume of anesthetists.

In the PICU, same thing (though I assume they have some peds training. I don't know if it is a peds residency, an anesthesia peds fellowship... I know one has an anesthesia-cardiology fellowship completed, but I don't if that is the only fellowship training he's had or what.)

There are also "open units" where the ICU team essentially coordinates things -- this is what it sounds like is occuring in the above posters example, i.e. the surgeons are "top dogs" and dictate orders, etc. on their patients leaving the ICU team to carry out the orders and be, basically, instruments in the day to day care and active only, really, when untoward or unexpected things happen. I think being an attending in an "open unit" is somewhat less involved because of the nature of the ICU set up, not whether or not you are primarily anestheisa, IM, or surgery trained.

 

[mytirf]

At my institution, anesthesia grads serve as attendings in the PICU and the SICU.

In the PICU, same thing (though I assume they have some peds training. I don't know if it is a peds residency, an anesthesia peds fellowship... I know one has an anesthesia-cardiology fellowship completed, but I don't if that is the only fellowship training he's had or what.)

The "Closed Unit" idea is especially true of PICUs and most often the attendings do have pediatrics training. Many have completed a CCM pediatric fellowship after anesthesia or most often peds residency then CCM fellowship. There are also some combined CCM/peds anesthesia fellowships. I think one of the great things about the "closed unit" concept is that while the surgeons definitely help in the care of the patient, the ultimate responsibility lies with the CCM doc, who therefore really is the primary for the patient. I think this is nice for families (esp. in the PICU) and generally a good thing for doctors because they can develop longer term relationships with patients (if you want a little of that but not to see the patient for the next 18 years). Anyways, there are certainly a lot of opportunities and I think anesthesia does offer a great deal of flexibility. I would however consider getting some pediatrics training if you want to work in a PICU, because taking care of a newborn with hydrops is certainly different than taking care of an 80 year old with CHF. Just my opinion.

Peace,

 

[Stitch]

The "Closed Unit" idea is especially true of PICUs and most often the attendings do have pediatrics training. Many have completed a CCM pediatric fellowship after anesthesia or most often peds residency then CCM fellowship. There are also some combined CCM/peds anesthesia fellowships. I think one of the great things about the "closed unit" concept is that while the surgeons definitely help in the care of the patient, the ultimate responsibility lies with the CCM doc, who therefore really is the primary for the patient. I think this is nice for families (esp. in the PICU) and generally a good thing for doctors because they can develop longer term relationships with patients (if you want a little of that but not to see the patient for the next 18 years). Anyways, there are certainly a lot of opportunities and I think anesthesia does offer a great deal of flexibility. I would however consider getting some pediatrics training if you want to work in a PICU, because taking care of a newborn with hydrops is certainly different than taking care of an 80 year old with CHF. Just my opinion.

Peace,

If you're going to do PICU you need to be pediatrics trained, period. It didn't used to be that way, but now it is. Though hydrops and newborn care is more of a NICU problem, you're right: there's a big difference from adult medicine. How you get PICU boarded can vary though. Most do three years of peds followed by three years of PICU fellowship, but there are a bunch who came from peds anesthesia, meaning they did adult anesthesia with a peds fellowship THEN did PICU. There are now a few programs which will double board you in peds anethesia and PICU after a five year fellowship (after a peds residency).

As for what they do, they manage very sick kids. They put in lines, manage ventilators, deal with end of life care. The nice thing about kids is they tend to do better than adults and have better recovery rates. They also handle complex post op cases from transplants to oncology. In some institutions they manage sedations, so you can see where anesthesia fits in.

Peds anesthesiologists are in high demand, and having critical care boarding gives you a great deal of job flexibility. Many can burn out of PICU whereas anesthesia seems to have a lower burnout rate. It's also quite financially sound.