Life of Critical Care/intensivist

Discussion in 'Critical Care' started by TheCatHerder, Jul 10, 2013.

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  1. TheCatHerder

    TheCatHerder 2+ Year Member

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    Hey. Looking at critical care as a specialty, possibly through internal medicine or emergency medicine. I realize the fellowship hours can be rough but what about attending hours in academics or private practice? Anyone familiar with how most im/pulm guys structure their practices vs emergency med trained physicians? Thanks.
     
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  3. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    It's mostly shift work these days. Someone covers the days, someone covers the night. You move the meat and get paid pretty darn good considering. Week on, week off, is still pretty common for straight critical care. Expect to share weekends and holidays with whoever else is in the shift rotation. Expect to work at night some.

    I doubt there is any difference on the critical care side of things from the IM vs EM trained person. The EM person might still do some ED shifts, most IM CC people just work the unit.
     
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  4. bigtuna

    bigtuna Member 10+ Year Member

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    If you go the EM route, you're likely to work shifts in an ICU.

    IM/Pulm guys are more likely to have traditional schedules because they often have clinics, consults on the floor, etc though there are certainly IM/Pulm groups that do the shift work model.

    I'm in a pretty large private practice pulm/cc group. All of our ICU's are open units but we see nearly every patient there. Big mix of medical, neuro, surgical, trauma. We have 1 person on call each day. Everyone splits up rounding on the existing patients. The on-call guy takes the new stuff unless they get overwhelmed. During the day when you're not on call you're rounding on floor patients, doing procedures, seeing office patients. At night, there is a nurse practitioner in the ICU. If you're on call, you come see new patients and occasionally someone that is really crashing. The NP's can handle a lot of stuff - better than most IM residents. We average about 1 in 6 weeknights on call and 1 out of every 4 weekends.
     
  5. bronx43

    bronx43 Word. 10+ Year Member

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    It's kind of pathetic that critical care NPs are better than most IM residents. Just goes to show you that 95% of crap you learn in residency is ultimately useless for your career.
     
  6. bigtuna

    bigtuna Member 10+ Year Member

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    They just have more experience. That's all it is. We train them to do what we want and they do it.
     
  7. secants

    secants about:blank 10+ Year Member

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    Are EM/Anes CC folks trained to work in any ICU like MICU or is it really focused only on CTSICU stuff?
     
  8. gro2001

    gro2001 SOCMOB 10+ Year Member

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    Its probably not fair to judge the IM residents based on how well they handle the crashing patient (and I say this as an EM resident who has been known to occasionally poke fun of my IM colleagues). The overwhelming majority of their training is NOT in the care of the critically ill and crashing patients, so how could we expect them to handle it well when s*** hits the fan? It's like judging a fish on it's ability to climb a tree. If they were not able to treat diabetes or chronic hypertension in an outpatient or inpatient setting, THAT would be kind of pathetic. If they were able to handle any ICU disaster just fine, one would wonder why we have CCM fellowships at all!
     
  9. bigtuna

    bigtuna Member 10+ Year Member

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    I should probably rephrase what I said. The NP's are not better than an IM resident at formulating a diagnosis and treatment plan. They are also not very good at managing a truly crashing patient - as opposed to a critically ill patient. They are excellent at putting out fires at night so I can get some sleep and knowing when they need to call for help.
     
  10. bronx43

    bronx43 Word. 10+ Year Member

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    I wouldn't say that the overwhelming majority of our training is care of the non-critically ill patient. At most programs, 3 months of your time every year will be some kind of critical care, and another 3-4 months will be spent in a setting where you have the potential for critically ill patients (though I have to admit that your management in those situations is short-lived due to the patient being transferred to the MICU). Only 3-4 months of our time is spent outpatient yearly. That means that throughout our three year residency, we would have 9-10 months of critical care. I'm just surprised to hear that NPs are as proficient, if not moreso, at putting out fires in the critical care setting than IM residents.
     
  11. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    The difference becomes apparent in the 2-3rd year of residency. Experience + education tempered by training puts most far ahead of these experienced NPs by then.....
     
  12. gro2001

    gro2001 SOCMOB 10+ Year Member

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    Fair enough. The use of the term 'overwhelming majority' was overkill. Say just majority.
     
  13. Rivaroxaban

    Rivaroxaban 2+ Year Member

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    It doesn't seem to me that any residency spends the majority of their time with critically ill patients, but certainly IM should get a healthy exposure to it.
     
  14. gro2001

    gro2001 SOCMOB 10+ Year Member

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    In a way you are right, of course, otherwise there would not be a need for critical care fellowships. However, there are a couple of specialties that even at a resident level have a particularly heavy emphasis on the care of the critically ill:

    1) Emergency Medicine. While most patients coming to the ER do not require critical care, at least a few do everyday, so EM residents care for at least some critically ill patients every day. In the third year of our program we only see the super sick (and a lot of other programs have a variation of this set up). This is of course in addition to 4 months of dedicated ICU time, as well as multiple sim training curriculums and cadaver workshops targeted to teaching critical care and life saving procedures.

    2) Anesthesia. While the most of their patients aren't super sick either, they spend the majority of their training learning to completely take over the physiology of their patients. Their OR experience makes them masters at controlling airway, vascular access, administration of sedating and cardioactive medications. These all serve as a solid foundation for critical care.

    However, my only point was that it's NOT pathetic that an IM resident is not as good at putting out fires in the ICU compared to a good ICU NP. It's an unfair comparison that judges IM residents based on something that is not the core of their training. I was sticking up for them rather than suggesting they are somehow inferior because of less critical care training. Most have a different focus.
     
  15. Rivaroxaban

    Rivaroxaban 2+ Year Member

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    I don't think we're disagreeing. I think IM encompasses many of the things you listed, however. Our program requires 5 months of ICU time with 6 months as an option, in addition to workshops for airway and vascular management as part of the CCM curriculum. Certainly, time in the ICU as well as the CCU requires a foundational understanding of cardioactive medications in the patient with already aberrant physiology. I'm sure anesthesia is better at airways and EM runs more codes, but on the floor here, IM runs codes and in our units IM residents get first crack at airways. I would also venture to say that there is no better training base for learning management of complex, multi-organ pathology and the complications of chronic disease, which many (most?) ICU patients have.

    All the residencies have aspects, it seems to me, that are not really conducive to delving into critical care management, such as outpatient IM clinic. EM has 80% ambulatory medicine (our shop has a 20% admission rate, of which only a minority of that is admitted to the unit - and many times the MICU team comes down to do procedures if they are going to the unit), and the anesthesia folks don't routinely manage infectious disease or other long-term management issues unless they are in the unit, which IM does during > 2/3 of their residencies. Not to mention the significant time spent with otherwise healthy, outpatient (and sometimes inpatient) surgical candidates that are pre-screened for complexity.

    All that being said, as you mentioned, it seems every residency brings something to the table and by the end all CCM trained folks should be mostly equivalent. IM residents, from what I've seen, tend to differentiate themselves quickly. Those not interested in CCM or the critically ill can and do try to stay away from the unit and super sick patients. For those interested in it, there are definitely opportunities to get more comfortable with those patients. IM offers a lot of flexibility - so motivated IM residents should be better than an NP following an algorithm.

    But who knows...I'm just an M4.
     
  16. ihearttriangles

    ihearttriangles 5+ Year Member

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    I completely agree. All paths (Med/Gas/EM/Surg) bring certain skill sets and yet contain certain deficiencies when it comes to CCM. In fact, as a med student, I've been surprised at how little time is actually spent caring for critically ill patients in each of these individual residencies. At my med school which has one of the notorious knife and gun club EDs it seems like the ED residents spend 99% of their time doing non-critical care medicine. Many reasons: 1) The vast majority of patients who utilize the ED are underprivileged kids who can't read good and want to do other things well who just need a PCP. 2) We have a really advanced EMS system so out of hospital cardiac arrests are resuscitated OUT OF HOSPITAL and if they are unsuccessfully resuscitated then they are left on scene and if they are successfully resuscitated they are brought to the ED where they MIGHT receive a central line before being whisked away to the unit. I've yet to see a cardiac arrest come in who wasn't already intubated. Now, are there cardiac arrests that occur in the ED? Yes but, these are relatively rare. 3) Only upper levels get the procedures/run the codes. Your intern year is spent in the less acute area and only years 2 and 3 are you actually seeing the sicker patients. And this is in NO way meant to be a dis to EM residents. They are awesome, I love them etc.. I'm strongly considering EM as a possible career. I'm just saying that the management of critically ill patients tends to be something that happens mostly in the units and that all the possible residencies that lead you to CCM eligibility are pretty equivalent in the amount of time they spend training in the units so I think it is not fair to say that one is better than the others in preparing you for CCM.

    Which brings me to another point, why not just make CCM its own residency? Just like CT surg is moving towards its own residency instead of gen surg plus CT fellowship so too should CCM be its own residency.
     
  17. gro2001

    gro2001 SOCMOB 10+ Year Member

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    All these are great reasons for why IM still dominates the critical care world (by that I mean more intensivists in the US are pulm/CC based than anesthesia/surg/EM). IM is indeed a great potential starting points for someone interested in CCM. I am by no means an expert on IM residency curriculum, but it seems to me the program you describe is particularly focused on CCM. For comparison, the IM residents at both of the hospitals I rotate yet (both awesome IM programs by the way and have my greatest respect) NEVER intubate. Period. I agree, you can tell an IM resident interested in CCM early (especially on their ED rotation because they are the hardest to tell apart from the ED residents :laugh:), but just how an interested IM resident can find opportunities to become very strong in critical care by the end of his residency, one who is not interested can easily skid by with minimal critical care knowledge. And most are not interested. I imagine a motivated senior IM resident interested in critical care should be better than an NP. I think you will agree that the majority of IM residents are not, however, interested in critical care (interest in cards does not count).
     
  18. gro2001

    gro2001 SOCMOB 10+ Year Member

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    When the initial porposal for the board of Emergency Medicine was submitted to ABMS back in the early 70s, it was for a board of Emergency and Critical Care medicine. That was the interest of most of the 'grandfathers' of EM at the time. This was before IM, surg, anesthesia and peds had their own CC certifications. The proposal was rejected for a variety of reasons. A lot had to do with concern from IM folks who were afraid that it would allow for EM trained people to work in ERs, ICUs and segway into working on the floors. The next year, as the ABEM proposal was being edited, the IM, peds, surg and anesthesia organizations proposed and got their own CC certifications. This was a big blow to EM since you can not have a competing certification pathway within ABMS (you can't have another board training, ob-gyn's for example, and the 'fellowship' for FM physicians in EM is not part of ABMS for that reason). That's why the integrated CT surg pathway is that: it's not a residency in CT surg, you technically start a residency in gen surg, don't complete it, and go on to do a CT surg fellowship. There is already an equivalent 'fast track' pathway for IM where you can start a fellowship after your IM PGY 2 year. I don't think that's a good idea for everyone though. It makes sense to make CT surg as homogeneous as possible, but we want CCM to be as diverse as possible. The specialty is enriched by bringing in people from various backgrounds.
     
  19. Bostonredsox

    Bostonredsox 2+ Year Member

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    Both of you have clearly worked with very subpar IM residents. My skill set, as is that of my co-residents for the most part, is far beyond that of any CC NP.
     
  20. Bostonredsox

    Bostonredsox 2+ Year Member

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    I find this insulting, especially when I'm routinely called by EM attendings to come put in lines, chest tubes and intubate, prior to even being a third year IM resident. I have more cc experience, more procedures and an equivalent amount of "crashing patient experience" as the majority of EM residents. 4 of my roomates/close friends from med school are EM, i have more cc months and more procedures Than all of them, more than the third and fourth combined. Please don't generalize against senior IM residents. Some of us have had exceptional critical care training during residency
     
  21. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    Ugh.

    Guys.

    Critical care is NOT doing things to patients. Intubating, putting in tubes and lines is not critical care.
     
  22. B-Bone

    B-Bone Attending 10+ Year Member

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    I believe you have described your "exceptional" procedural skills on this forum AD NAUSEUM at this point. We get it. I think it is disingenuous and misleading to propose that your residency experience (at a small community hospital with a LOT of shi%*y physicians, by your own account) is typical of the average IM resident. At almost no institution would the ED EVER EVER EVER call an IM resident in to help (let alone primarily perform for them) any procedure. 80% of the senior medicine residents I supervised in the ICU as a resident were total crap at proecdures, with the other 20% being "reasonable". Additionally, their time scale for eval/management/tx was too slow for the ICU in general. Both of these things aren't really knocks on medicine residents; they're merely a function of the training they've had. It sounds like your residency experience is unique and likely better-than-average preparation for a critical care fellowship. This is not most medicine residents' experience, as least as I (and most other posters on this forum) have seen it.
     
  23. Dwindlin

    Dwindlin ASA Member 7+ Year Member

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    This.
     
  24. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    Well. To be fair to IM most of the people who go into that specialty are not interested in procedures or even critical care. So, it's not surprising at all that you find people who haven't done many lines or seem great at them yet. Lines are a nuanced procedure. You probably need around 100 before you're really actually "good" and them and can begin to think around complicated procedural corners. And airways? In this day and age intubations are done largely by gas or EM and we all know it (often by strict institutional policy) so it's really no shame I can think of to get down on IM because of their lack of airway experiences. It's the VERY motivated IM resident that gets any at all these days.

    And again I'll emphasize that with all that said critical care is NOT putting in lines and ET tubes.
     
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  25. inspirationmd

    inspirationmd 5+ Year Member

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    Have to agree with the previous posters. You have had what sounds like excellent exposure to critical care and procedures (largely due to your own motivation and interest) but this is not typical of the "average" IM residency. You mention the EM residents you know here and in other posts...what has the experience of your friends in IM programs been? Are the ones in other community programs getting the exposure you are touting? The ones in Academia? Between my IM program, my home med school, friends at unopposed community, friends at academic IM programs and residents I have met at conferences I do not think I have seen or heard of IM training that is in line with what you are saying. IABP placement as a 2nd year IM resident? Even with backup en route surely you must admit that is far outside what could be considered the norm.

    And JDH I say the above with recognition that Critical care is not all about procedures and that residents can only comprehend the nuances of critical care to a certain extent given that we can only learn so much about it while needing to learn the other general aspects of core IM, EM, Anesthesia, etc training. Fellowship is absolutely necessary.
     
    Last edited: Jul 14, 2013
  26. Dwindlin

    Dwindlin ASA Member 7+ Year Member

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    Absolutely agree with this as well. I don't think any one who is disagreeing with Boston is doing so to disparage IM.
     
  27. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    MOST of my IM class gave ****-all about procedures or critical care and avoided both like the herp. They were not "bad docs" but you only get good in medicine at what you do often because medicine is so very very nuanced. You can train any motivated person to do lots of different stuff - none of it magical but you need experienced people to show you and further personal experience to refine.
     
  28. Bostonredsox

    Bostonredsox 2+ Year Member

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    Fair enough.
     
  29. ihearttriangles

    ihearttriangles 5+ Year Member

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    Isn't it kind of about tubes/lines/procedures? Isn't that why patients get placed in the unit, for resuscitation/stabilization? Obviously, you need to have strong clinical reasoning in order to manage ABCs/other life threatening things (acidosis/electrolyte abnormalities) and appropriately manage the overall course of the patient but it seems like patients get sent to the unit because the floor teams don't have the abilities to resuscitate/stabilize (lack vents/adequate nursing coverage) patients and after they get appropriately stabilized they can get sent back to the floors where medicine or whoever else can figure out what the heck is exactly going on (if it remains a mystery). Of course, I fully accept that maybe from my med student perspective I am missing the bigger picture.
     
  30. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    Just as long as you accept it.
     
  31. ihearttriangles

    ihearttriangles 5+ Year Member

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    Can you please explain it to me? I'm really interested in critical care and my rotations just seem to give me brief glimpses into the seemingly mysterious world of critical care. So, I come here to ask questions and learn.
     
  32. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    The majority of procedures are not life saving, the real nuts and bolts is figuring out wtf is going on...quickly, and treating appropriately while doing what you can to minimize iatrogenic complications ......while stabilizing and doing procedures. It often isn't the presenting illness that kills critical care pts, it's the complications of being that sick in a hospital bed with us shoving tons of meds in people.

    The most common life saving procedure I do, are chest tubes (unless you wanna argue airway, then i might concede that)and the majority of those are directly related to positive pressure ventilation. Lack of an a-line never killed anyone, lack of a central line has only cause a few appendages to fall off, etc etc.
     
  33. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    To give a basic summarization . . .

    Resuscitation and stabilization occur pretty quickly or people die. I wonder why these patients can then often spend a couple of weeks in the ICU? (rhetorical question) Outside of the obvious - what puts the patient in the ICU, you also are responsible for: diagnosis, management of the basic alterations of physiology in the critically ill on top of mitigation of pathophysiology, nutrition, treating additional chronic illness, preventing any/further iatrogenesis, knowing appropriate end points, talking with families, and finally preparing the patient to leave the unit and knowing when it's appropriate for it to occur.
     
  34. thedrjojo

    thedrjojo Devout follower 7+ Year Member

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    For all this talk about what residency/specialty gets the most exposure, I will point out surg cc fellowships are 1 year and usually combo with trauma (meaning about 6 months or so icu...) while med/em/gas are, what, 3 years (granted often comboed with pulm...).. We have 5 years to get that exposure, so that sucks, and in the end of the day, it took us all 6 years to get there. I agree 100% with jdh though, cc/icu is not about procedures, and doing procedures is not critical care... Cc is the thought process and management to reverse the procedures...

    Every institution is different... ER isn't allowed to put in chest tubed without surgery supervision... The med icu never puts in there own chest tubes, nor manage a patient with a tube... I've been called several times for lines in the micu... I know this isn't commonplace, but, as everyone said, thinking how things are run in your shop is evidence of how the world works is dumb
     
  35. Dwindlin

    Dwindlin ASA Member 7+ Year Member

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    Anesthesia is a year.
     
  36. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    Everyone else CAN get done by the end of PGY5 in both anesthesia, IM, and 3 year EM now . . . plus technically an OB/GYN who wnated to do a critical care year could be done in 5 too.

    After a better sleep last night I'm beginning to appreciate the argument made by those doing 4 year EM residencies . . . though . . . the 4 year residency length is hardly the fault of the fellowships - maybe one more reason to avoid a 4 year EM residency if you want to fellowship??
     
  37. thedrjojo

    thedrjojo Devout follower 7+ Year Member

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    Well, damn, I guess that puts that to rest... I really wish surgery could streamline their **** more... Is gas 1+3 or 1+4? And I still don't understand how a residency can be 3 or 4 years long :shrug:
     
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  38. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    ER is one of the only ones I know that can be 3 or 4 years long, that's due to a quirk of history. All programs use to be 4, but then for whatever reason they dialed down to 3 but some smaller programs decided they didn't have enough exposure I guess and kept it at 4
     
  39. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    basic gas is intern + 3

    I think if you go back and look at the history MOST residencies were 5 total years, but in the 70's they tried to streamline a few into "categorical" residencies which shortened some.

    I don't know.

    I mean, I assume surgery is still so long due to the complicated and intricate nature of the procedural work.
     
  40. Dwindlin

    Dwindlin ASA Member 7+ Year Member

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    Yeah hopefully my post wasn't confusing. Anesthesia is 4 years, and CC is an additional year for 5 total if coming from an anesthesia pathway.


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  41. thedrjojo

    thedrjojo Devout follower 7+ Year Member

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    Indeed, particular with the 80hr work week decreasing case load for graduating chiefs by significant levels... There is an argument, though, for people to focus on the area of surgery they intend to focus and not be as broadly skilled... If you are going to be a practicing ct surgeon, is that colon resection all that valuable? Do I as a potential transplant surgeon really need to operate on the thyroid? So, people advocate tracking into 3+3 or 4+2 pathways
     
  42. jdh71

    jdh71 epiphany at nine thousand six hundred feet 10+ Year Member

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    Makes a lot of sense, but ALL academic programs like lots of worker bees. Heh.
     
  43. thedrjojo

    thedrjojo Devout follower 7+ Year Member

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    yup... although one of the people interviewing for our chair position (they made everyone interviewing give a grand rounds) who gave a talk "future of surgical education" did say there is a growing movement in the American College of Surgeons to potentially go in that way
     
  44. Trogghunter

    Trogghunter 7+ Year Member

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    Is there a way for a hospitalist to do critical care with minimum fellowship time nowadays? My step dad and some colleagues as well as some of my attendings covered ICU as hospitalists some years ago. Not sure if this still exists but I'd like to do it. They said that it still happens, but I've never seen it.

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  45. Bostonredsox

    Bostonredsox 2+ Year Member

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    This is essentially what my job wil be starting in july. Week on week off, probably alot of night shifts if we move to 24/7 unit attending like I hope to. I obviously am not fellowship trained yet. So yes these jobs exist. but I will not call myself an intensivist, it would be an insult to those who have compelted the training, but rather a CC hospitalist. pay wont be the same, skills are not the same. But yes the job is the same so yes you can do it. obviosuly not in academia. there are plans/potential for an abbreviated one year CCM fellowship for IM hospitalists with 3 years attending experieince but it is a ways off still, if it comes to fruition at all.
     
  46. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    Why would you hope to so that?
     
  47. Icefrog

    Icefrog 7+ Year Member

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    Slight off-topic, but I am doing an anesthesia-CCM 1 year fellowship. Do you want approximately what time during the year we should expected to start looking for/receiving job offers? Any insignt appreciated. Thanks!
     
  48. Bostonredsox

    Bostonredsox 2+ Year Member

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    one, I like nights.

    two, in thwe current system, the ICU has an attending to itself 7a-7p. (8-19pts)
    at night, one hospitalist covers the 90-125 floor pts, the unit patients, and the avg of 16 ED admissions. that sucks. Would be nice if they combined the SDU and ICU census's at night onder once ICU attending and left the floors and ED admits to a second. would be safer for patients and make the night hospitalist shift not so hellish.

    on another note hern, do you think its possible, if I hit whatever number the number happens to be, to get credentialled for theraputic bronchs? Dont care about biopsy and such, but more or less just, "Im the ICU attending, my patients on the vent and starting to crash, xray shows huge plug, can I theraputiclly lavage them to improve ventilation". that would be the extent of the privaledges.
     
  49. Hernandez

    Hernandez Paranoid and Crotchety... 10+ Year Member

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    Completely depends on the politics. As a pulm doc, to get credentialed, I only had to show 10 bronchs in last 2 years at my hospital, but they also specify fellowship trained. I doubt many hospitals would give even therapeutic bronch credentials out without fellowship
     
  50. Bostonredsox

    Bostonredsox 2+ Year Member

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    unfortunate but understandable. without inhouse pulm me being able to do a theraputic bronch at 2am for a decompensating vent patient would prevent the back up call intensivisit from having to come in for a 2 minute procedure.
     
  51. gro2001

    gro2001 SOCMOB 10+ Year Member

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    What if you were to 'diagnostically' lavage them and they were to get better after you've lavaged out the mucous?
     

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