M4 considering IM vs EM

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okudasai

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Hello all, I am an M4 who is currently in the bargaining stage of grief regarding my desire to do EM. My story is the usual one; scribed as a pre-med, loved my third year EM rotations, am a good personality fit, enjoy acuity and dealing with the undifferentiated patient, etc. I am also interested in IM and crit care, the latter of which I know is also available through EM. I also enjoy doing interventions and seeing them have an effect fairly quickly and initial stabilization of the very sick. I am also interested in crit care, and I had some notion of doing EM and go into a fellowship based on how bad the job market looks by the time I am graduating.

I like IM because there is still some acuity (can still run codes, deal with life-threatening pathology, etc.) and you still do care coordination, reassure/educate patients and families, etc. The main reasons I am wary of IM is that I don't think I am a very good personality fit, as in I dislike long, academic discussions about hyponatremia's differential, enjoy a fast pace of care, and in general prefer to spend more time "doing" rather than "thinking", if that makes sense. I am detail oriented to a certain extent, but perhaps not to IM level (who cares about diet orders, etc.) And of course, the long rounds and notes, though my hope is that as an attending I would be able to set my own pace. Would love to hear if these are valid concerens regarding going into IM.
 
Sounds like you would be a better fit for EM. If you are concerned about job prospects you can look into EM/IM (5 years) and then a crit care fellowship afterwards (which is another year).
 
PugsAndHugs said:
Sounds like you would be a better fit for EM. If you are concerned about job prospects you can look into EM/IM (5 years) and then a crit care fellowship afterwards (which is another year).
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I think my personality does lean in the direction of EM for sure. I would not be opposed to doing a combined residency, except my step 1 was a 219 so that makes that a much less likely possibility. I will still apply to combined programs but am not very confident that I will be getting an interview. Do you feel that the downsides of choosing IM that I am expressing (long rounds and notes, spending more time thinking, wanting a faster pace) are irreconcilable with my personality? I am somewhat concerned that I would either have personality clashes or would end up being dissatsfied as an IM doc, though I suppose I might fit in better in a CC enviroment which I could always do a fellowship in through either EM or IM.
 
An IM or CCM doctor that does things instead of thinking about them is a bad doctor. I would argue that is true even for EM--if you just order CT scans on everyone who walks in the door or write antibiotics for every case of the cold without exercising any thought then you are a bad doctor. A rapidly deteriorating patient is going to get a lot of stuff done quick and it is very dissatisfying to pan order everything but it is what tends to happen, real medicine is trying to pick everything apart later and get rid of stuff that has no benefit and offers potential harms as soon as possible.

To use your own example of hyponatremia:
1-EM needs to know when to give 3%, how to give it, when not to bolus fluids, where to send patient (outpatient followup, floor, ICU)
2-IM needs to know what the potential causes of hyponatremia are based on the clinical scenario presented and how to narrow down the cause while simultaneously executing a treatment plan for the most likely cause as well as how often to check sodium levels and how to react to changes and when to discharge
3-CCM needs to be able to do both of the above + know when it is appropriate to encourage adjusting goals of care (eg end stage cirrhosis or CHF)
 
chessknt said:
An IM or CCM doctor that does things instead of thinking about them is a bad doctor. I would argue that is true even for EM--if you just order CT scans on everyone who walks in the door or write antibiotics for every case of the cold without exercising any thought then you are a bad doctor. A rapidly deteriorating patient is going to get a lot of stuff done quick and it is very dissatisfying to pan order everything but it is what tends to happen, real medicine is trying to pick everything apart later and get rid of stuff that has no benefit and offers potential harms as soon as possible.

To use your own example of hyponatremia:
1-EM needs to know when to give 3%, how to give it, when not to bolus fluids, where to send patient (outpatient followup, floor, ICU)
2-IM needs to know what the potential causes of hyponatremia are based on the clinical scenario presented and how to narrow down the cause while simultaneously executing a treatment plan for the most likely cause as well as how often to check sodium levels and how to react to changes and when to discharge
3-CCM needs to be able to do both of the above + know when it is appropriate to encourage adjusting goals of care (eg end stage cirrhosis or CHF)
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You're absolutely right, I should have been more specific. I think what I was trying to refer to was the faster pace of EM, where you are usually making decisions and doing interventions over the course of a single shift rather than the course of several days as IM. I think being able to see the immediate impact of your interventions is very satisfying and my understanding is that you get more of that in EM as compared to IM, where you tend to see the changes occur over a few days. Certainly there is a great deal of thinking in both specialties, but with IM I feel that you generally are going to be doing that thinking and discussion over several days, whereas with EM you would be doing it a faster pace, which I think I might prefer.
 
chessknt said:
An IM or CCM doctor that does things instead of thinking about them is a bad doctor. I would argue that is true even for EM--if you just order CT scans on everyone who walks in the door or write antibiotics for every case of the cold without exercising any thought then you are a bad doctor. A rapidly deteriorating patient is going to get a lot of stuff done quick and it is very dissatisfying to pan order everything but it is what tends to happen, real medicine is trying to pick everything apart later and get rid of stuff that has no benefit and offers potential harms as soon as possible.

To use your own example of hyponatremia:
1-EM needs to know when to give 3%, how to give it, when not to bolus fluids, where to send patient (outpatient followup, floor, ICU)
2-IM needs to know what the potential causes of hyponatremia are based on the clinical scenario presented and how to narrow down the cause while simultaneously executing a treatment plan for the most likely cause as well as how often to check sodium levels and how to react to changes and when to discharge
3-CCM needs to be able to do both of the above + know when it is appropriate to encourage adjusting goals of care (eg end stage cirrhosis or CHF)
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Lol…should… but in the real world they consult endocrinology or nephrology… or usually both…I just ask that you know when to consult one or the other… not both.
 
okudasai said:
Hello all, I am an M4 who is currently in the bargaining stage of grief regarding my desire to do EM. My story is the usual one; scribed as a pre-med, loved my third year EM rotations, am a good personality fit, enjoy acuity and dealing with the undifferentiated patient, etc. I am also interested in IM and crit care, the latter of which I know is also available through EM. I also enjoy doing interventions and seeing them have an effect fairly quickly and initial stabilization of the very sick. I am also interested in crit care, and I had some notion of doing EM and go into a fellowship based on how bad the job market looks by the time I am graduating.

I like IM because there is still some acuity (can still run codes, deal with life-threatening pathology, etc.) and you still do care coordination, reassure/educate patients and families, etc. The main reasons I am wary of IM is that I don't think I am a very good personality fit, as in I dislike long, academic discussions about hyponatremia's differential, enjoy a fast pace of care, and in general prefer to spend more time "doing" rather than "thinking", if that makes sense. I am detail oriented to a certain extent, but perhaps not to IM level (who cares about diet orders, etc.) And of course, the long rounds and notes, though my hope is that as an attending I would be able to set my own pace. Would love to hear if these are valid concerens regarding going into IM.
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I would be very wary of pursing EM in its current state. Just go to the EM forums and there's a lot of discussion about how poor the job market is. And this will mostly likely affect those graduating from lower tier residency programs, and with a 219 step 1 it's going to be hard to match into a decently reputable program (though EM is expected to become less competitive in next few years if the job market remains the way it does). If the job market continues to the way it does there's a higher chance most new grads, especially those from lower tier programs, will have to take jobs in the less desirable (eg rural/underserved) areas or doing some else besides working in an ER.

Also EM and critical care have historically have some of the highest burnout rates in medicine (and unsurprisingly so). While the fast-paced work and procedures may look appealing as a medical student or pre-med, the day-to-day stressers can take a toll very quickly, such as being a "front line" provider for being first to deal annoying patients that walk in and the high malpractice liability that comes with treating high-acuity patients. This makes it unsustainable in the long run for a lot of empeople, that's why is non uncommon to see EM physicians either cut back on their clinical hours or switch to something less fast paced even just 5-10 years after residency. And with only EM treating, your options are much more limited down the line.

IM will probably not involve the long academic discussions in the daily practice of most physicians out there. This may be the case at academic medical centers while as a med student or resident, but on non-teaching services it's rarely the case. And with IM there are a lot more fellowship opportunities after IM residency than EM (including critical care) in case your interests change, the job market shifts, or you experience burnout in one area of IM.
 
collegestud2013 said:
I would be very wary of pursing EM in its current state. Just go to the EM forums and there's a lot of discussion about how poor the job market is. And this will mostly likely affect those graduating from lower tier residency programs, and with a 219 step 1 it's going to be hard to match into a decently reputable program (though EM is expected to become less competitive in next few years if the job market remains the way it does). If the job market continues to the way it does there's a higher chance most new grads, especially those from lower tier programs, will have to take jobs in the less desirable (eg rural/underserved) areas or doing some else besides working in an ER.

Also EM and critical care have historically have some of the highest burnout rates in medicine (and unsurprisingly so). While the fast-paced work and procedures may look appealing as a medical student or pre-med, the day-to-day stressers can take a toll very quickly, such as being a "front line" provider for being first to deal annoying patients that walk in and the high malpractice liability that comes with treating high-acuity patients. This makes it unsustainable in the long run for a lot of empeople, that's why is non uncommon to see EM physicians either cut back on their clinical hours or switch to something less fast paced even just 5-10 years after residency. And with only EM treating, your options are much more limited down the line.

IM will probably not involve the long academic discussions in the daily practice of most physicians out there. This may be the case at academic medical centers while as a med student or resident, but on non-teaching services it's rarely the case. And with IM there are a lot more fellowship opportunities after IM residency than EM (including critical care) in case your interests change, the job market shifts, or you experience burnout in one area of IM.
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Thank you for your detailed response. If I pursue critical care from IM, is it possible to do part time hospitalist or outpatient work in the event of burnout or of I just get tired of the ICU?
 
okudasai said:
Thank you for your detailed response. If I pursue critical care from IM, is it possible to do part time hospitalist or outpatient work in the event of burnout or of I just get tired of the ICU?
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You could… but it would hard to go back to outpatient anything after not doing it for a few years. You could do hospitalist but I think most intensivists would not consider that an improvement in quality of life.

You would be better off doing pulmonary and CCM, working a combined gig and have the option of doing pulmonary alone if you burn out.
 
Long rounds and notes are more of a residency thing I think. Once you’re an attending the notes are similar to ER in that you document enough for billing and enough of your thought process to CYA, but nobody gets paid to write a 3 paragraph essay that you’re taught to write in med school.

We get enough “undifferentiated” patients from the ED as IM docs to satisfy even Sherlock Holmes, IMO.
 
CCM-MD said:
You could… but it would hard to go back to outpatient anything after not doing it for a few years. You could do hospitalist but I think most intensivists would not consider that an improvement in quality of life.

You would be better off doing pulmonary and CCM, working a combined gig and have the option of doing pulmonary alone if you burn out.
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Gotcha, so definitely not the easiest route to go. The week on/week off schedule of hospitalists and intensivists does sound appealing, but I've heard the week of 12 hour shifts really drain you and so you spend half of the week off just trying to recover. How would that setup compare to EM shift work? In my mind, at least with 1 week on/off setup you don't do nights and it's a consistent schedule, but the continuous week of shifts is daunting. What has your experience been with the model?
 
HemeOncHopeful19 said:
Long rounds and notes are more of a residency thing I think. Once you’re an attending the notes are similar to ER in that you document enough for billing and enough of your thought process to CYA, but nobody gets paid to write a 3 paragraph essay that you’re taught to write in med school.

We get enough “undifferentiated” patients from the ED as IM docs to satisfy even Sherlock Holmes, IMO.
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Oh man, can't tell you how relieving that is to hear, since those were two of the things I was most dreading about IM. And if I am still able to deal with undifferentiated patients, then my main concerns regarding IM compared to EM would be the slower pace and personality fit. Thank you for your response, it was very helpful!
 
okudasai said:
Gotcha, so definitely not the easiest route to go. The week on/week off schedule of hospitalists and intensivists does sound appealing, but I've heard the week of 12 hour shifts really drain you and so you spend half of the week off just trying to recover. How would that setup compare to EM shift work? In my mind, at least with 1 week on/off setup you don't do nights and it's a consistent schedule, but the continuous week of shifts is daunting. What has your experience been with the model?
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Depending on where you work you will probably be doing at least some work at night as an intensivist. Whether that’s by being physically there at night or being on call from home with hospitalist/midlevel/eICU taking first call. Could you get a days only intensivist job? Maybe. But the ICU doesn’t stop being an ICU at night, so expect to do some night work. There are various ICU staffing models - week on/off is just one type, some places schedule scattered 3-5 day stretches, and there are also some rare Mon-Friday jobs with rotating weekend coverage.

Hard to compare ED and ICU like that but I would say on average an ED shift is much more painful than an ICU shift.
 
I’ve been a hospitalist for 6 years. I don’t have long academic rounds, nor do i enjoy long winded discussion about hyponatremia. Frankly, I have no interest in codes. I do find patient care to be generally very interesting. I’m is one of the few specialities that takes care of anyone.

I think that most people that want “fast paced” practice will start to want predictable lifestyle when they have a wife and kids, and start thinking about retirement. I do spent most of my time thinking, and most EM docs do too (or at least should).

Also, EM, you are expected to take night calls. I haven’t taken a night call in years. I might take the odd one, but it is completely voluntary.
I think there is more ways to practice IM that EM. While at this moment in time, EM makes more money, their job prospects aren’t looking great, and who is to say that IM won’t have a similar problem (though I think the broad nature of IM and multiple non-hospital based ways to practice will make changes in income and job opportunities less abrupt.
 
How much ED experience have you had as a med student? You have to keep in mind that while EM is pretty fun as a med student since they typically give you the more interesting patient presentations, it's not representative of real life EM or even EM residency. Spend a few weeks watching an ortho resident talk down to an EM attending, or watch an EM attending hear your explanation on why this patient's known chronic abdominal pain doesn't require imaging yet they go ahead and order a CT and you'll see what I mean.

The "acuity" in inpatient IM is by definition higher than the ED. The ED is only admitting 10-20% of patients in most hospitals, the rest either can safely have outpatient follow up or have a minor issue eg need med refills, whereas ~80% of inpatients meet inpatient level of care (it *should* be 100%, but, you know, real life). The ED, of course, does have more unpredictability, and you'll have to take care of kids, pregnant patients, and critically-ill patients, often in the same shift - groups that you generally won't see much in IM outside of dedicated ICU blocks and electives. And while unpredictability seems fun and exciting in your 20s, is this something you'd definitely want in your 40s? Your 60s?

Final thought: while I don't put much stock into predictions about the future of specific medical fields, it IS true that anyone perceived as being a generalist or depending primarily on hospitals for employment is pretty effed, from the threats of corporate takeover and midlevel encroachment. EM is getting hit hard on both counts, much more so than IM. For the record, I think CCM is next, but the beauty of IM is that you'll have three years of time to learn how to be a doctor before having to commit to a specialty, and once you do your range is extremely broad, eg you could do pulm-CCM, nephro-CCM, ID-CCM, cards-CCM, etc. and thus have other outpatient-heavy careers to "fall back on".
 
cardsperson said:
How much ED experience have you had as a med student? You have to keep in mind that while EM is pretty fun as a med student since they typically give you the more interesting patient presentations, it's not representative of real life EM or even EM residency. Spend a few weeks watching an ortho resident talk down to an EM attending, or watch an EM attending hear your explanation on why this patient's known chronic abdominal pain doesn't require imaging yet they go ahead and order a CT and you'll see what I mean.

The "acuity" in inpatient IM is by definition higher than the ED. The ED is only admitting 10-20% of patients in most hospitals, the rest either can safely have outpatient follow up or have a minor issue eg need med refills, whereas ~80% of inpatients meet inpatient level of care (it *should* be 100%, but, you know, real life). The ED, of course, does have more unpredictability, and you'll have to take care of kids, pregnant patients, and critically-ill patients, often in the same shift - groups that you generally won't see much in IM outside of dedicated ICU blocks and electives. And while unpredictability seems fun and exciting in your 20s, is this something you'd definitely want in your 40s? Your 60s?

Final thought: while I don't put much stock into predictions about the future of specific medical fields, it IS true that anyone perceived as being a generalist or depending primarily on hospitals for employment is pretty effed, from the threats of corporate takeover and midlevel encroachment. EM is getting hit hard on both counts, much more so than IM. For the record, I think CCM is next, but the beauty of IM is that you'll have three years of time to learn how to be a doctor before having to commit to a specialty, and once you do your range is extremely broad, eg you could do pulm-CCM, nephro-CCM, ID-CCM, cards-CCM, etc. and thus have other outpatient-heavy careers to "fall back on".
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Pulmonary is the only specialty that can be easily practiced simultaneously with CCM. All the ID and nephro trained intensivists typically work full time CCM because it’s very hard to find a job that allows one to practice CCM and something else outside of academia. Whether that something else is nephro or ID or EM or Anesthesia. Doing something totally different after a few years of practicing solely CCM is going to be challenging to put it lightly even if we ignore the credentialing/privileging issues.

Cards-CCM folks are rare birds typically found in ivory tower academia but can be a cool combo. But imagine managing VA ECMO for 5-10 years and then going back to doing risk factor modification in a general cardiology clinic.
 
CCM-MD said:
Pulmonary is the only specialty that can be easily practiced simultaneously with CCM. All the ID and nephro trained intensivists typically work full time CCM because it’s very hard to find a job that allows one to practice CCM and something else outside of academia. Whether that something else is nephro or ID or EM or Anesthesia. Doing something totally different after a few years of practicing solely CCM is going to be challenging to put it lightly even if we ignore the credentialing/privileging issues.

Cards-CCM folks are rare birds typically found in ivory tower academia but can be a cool combo. But imagine managing VA ECMO for 5-10 years and then going back to doing risk factor modification in a general cardiology clinic.
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Yeah I mostly brought nephro-CCM and ID-CCM up as those are the kinds of fields that people keep talking about potentially exploding in the future, but personally I agree, I think it's unlikely either will take off given the difficulty of having outpatient clinic with CCM in those fields. Cards-CCM is similarly hard to maintain, but even the most ivory tower cards intensivist has plenty of skills in their arsenal that reimburse well in the outpatient setting (TTE, TEE, RHC being the obvious ones).
 
cardsperson said:
How much ED experience have you had as a med student? You have to keep in mind that while EM is pretty fun as a med student since they typically give you the more interesting patient presentations, it's not representative of real life EM or even EM residency. Spend a few weeks watching an ortho resident talk down to an EM attending, or watch an EM attending hear your explanation on why this patient's known chronic abdominal pain doesn't require imaging yet they go ahead and order a CT and you'll see what I mean.

The "acuity" in inpatient IM is by definition higher than the ED. The ED is only admitting 10-20% of patients in most hospitals, the rest either can safely have outpatient follow up or have a minor issue eg need med refills, whereas ~80% of inpatients meet inpatient level of care (it *should* be 100%, but, you know, real life). The ED, of course, does have more unpredictability, and you'll have to take care of kids, pregnant patients, and critically-ill patients, often in the same shift - groups that you generally won't see much in IM outside of dedicated ICU blocks and electives. And while unpredictability seems fun and exciting in your 20s, is this something you'd definitely want in your 40s? Your 60s?

Final thought: while I don't put much stock into predictions about the future of specific medical fields, it IS true that anyone perceived as being a generalist or depending primarily on hospitals for employment is pretty effed, from the threats of corporate takeover and midlevel encroachment. EM is getting hit hard on both counts, much more so than IM. For the record, I think CCM is next, but the beauty of IM is that you'll have three years of time to learn how to be a doctor before having to commit to a specialty, and once you do your range is extremely broad, eg you could do pulm-CCM, nephro-CCM, ID-CCM, cards-CCM, etc. and thus have other outpatient-heavy careers to "fall back on".
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I agree with almost all of these points, and I think the biggest takeaway from this is that I think for a lot of people EM is the best specialty to be a medical student in, but that is not the same as being a resident or attending in EM.

I do think the death of "generalist" specialties has been predicted for a variety of reasons for about 70 years (often by specialists) and yet the demand for them (and the salary) is higher than ever. That being said, I don't really think of EM as a generalist specialty. True, EM is trained to see every sort of patient, but only in the very specific context of acute emergencies/risk stratification. As such, you can't really change your practice much in EM like you can with FM or IM. Those fields you have primary care, hospitalist, nursing home, urgent care, plus a zillion fellowships for IM and a few for FM. EM you have...the ER (or urgent care), plus maybe 2-3 fellowships (pain, sports, CC) that get you out of the ER.
 
EmergDO said:
I agree with almost all of these points, and I think the biggest takeaway from this is that I think for a lot of people EM is the best specialty to be a medical student in, but that is not the same as being a resident or attending in EM.

I do think the death of "generalist" specialties has been predicted for a variety of reasons for about 70 years (often by specialists) and yet the demand for them (and the salary) is higher than ever. That being said, I don't really think of EM as a generalist specialty. True, EM is trained to see every sort of patient, but only in the very specific context of acute emergencies/risk stratification. As such, you can't really change your practice much in EM like you can with FM or IM. Those fields you have primary care, hospitalist, nursing home, urgent care, plus a zillion fellowships for IM and a few for FM. EM you have...the ER (or urgent care), plus maybe 2-3 fellowships (pain, sports, CC) that get you out of the ER.
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Thanks to both of you for the description of EM; I agree that as a medical student its hard to find EM anything other than extremely fun, especially because it can often be where you first experience autonomy, feel that you are able to contribute to care to a greater degree when compared to previous rotations, etc. It is difficult to look past the rose-tinted glasses, but both of your responses have helped put some things into perspective. Other EM attendings I have worked with have also mentioned similar things about EM as well.
 
collegestud2013 said:
I would be very wary of pursing EM in its current state. Just go to the EM forums and there's a lot of discussion about how poor the job market is. And this will mostly likely affect those graduating from lower tier residency programs, and with a 219 step 1 it's going to be hard to match into a decently reputable program (though EM is expected to become less competitive in next few years if the job market remains the way it does). If the job market continues to the way it does there's a higher chance most new grads, especially those from lower tier programs, will have to take jobs in the less desirable (eg rural/underserved) areas or doing some else besides working in an ER.

Also EM and critical care have historically have some of the highest burnout rates in medicine (and unsurprisingly so). While the fast-paced work and procedures may look appealing as a medical student or pre-med, the day-to-day stressers can take a toll very quickly, such as being a "front line" provider for being first to deal annoying patients that walk in and the high malpractice liability that comes with treating high-acuity patients. This makes it unsustainable in the long run for a lot of empeople, that's why is non uncommon to see EM physicians either cut back on their clinical hours or switch to something less fast paced even just 5-10 years after residency. And with only EM treating, your options are much more limited down the line.

IM will probably not involve the long academic discussions in the daily practice of most physicians out there. This may be the case at academic medical centers while as a med student or resident, but on non-teaching services it's rarely the case. And with IM there are a lot more fellowship opportunities after IM residency than EM (including critical care) in case your interests change, the job market shifts, or you experience burnout in one area of IM.
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This is very true, I think it can moderate your decision. IM isn't always super academic, it is at the academic sites but in the community, IM staff can do whatever they want, including being efficient and timely. Also, subspecialties of IM can vary wildly so personalities in IM vary wildly.

With that being said, i wouldn't be too concerned about job market in the sense that if you do a good job as a resident you can still get a job. Don't extrapolate your step 1 score to thinking that all hope is lost if the job market isn't good.
 
okudasai said:
Thank you for your detailed response. If I pursue critical care from IM, is it possible to do part time hospitalist or outpatient work in the event of burnout or of I just get tired of the ICU?
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Yes. That is exactly why there are still so many people who do the PCCM (Pulm+CC) fellowship. As you want less and less acuity you transition to more of your pulm clinic. And since your time is split, you can build your outpatient panel over time. I know a good number of folks who now do mostly pulm clinic with ICU just sprinkled in (1wk every 3-4 months) because that’s what they want.
 
CopaceticOne said:
Yes. That is exactly why there are still so many people who do the PCCM (Pulm+CC) fellowship. As you want less and less acuity you transition to more of your pulm clinic. And since your time is split, you can build your outpatient panel over time. I know a good number of folks who now do mostly pulm clinic with ICU just sprinkled in (1wk every 3-4 months) because that’s what they want.
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This is exactly the advantage of Pulm+CCM. Hard to do this with any of the other combinations because jobs just don’t exist. 90% of the CCM jobs outside of academia are looking for a full time intensivist or a intensivist-pulmonologist duo.
 
CopaceticOne said:
Yes. That is exactly why there are still so many people who do the PCCM (Pulm+CC) fellowship. As you want less and less acuity you transition to more of your pulm clinic. And since your time is split, you can build your outpatient panel over time. I know a good number of folks who now do mostly pulm clinic with ICU just sprinkled in (1wk every 3-4 months) because that’s what they want.
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Sort of in the same vein, is it possible if someone is EM/CC to then switch to doing urgent care or part time ED work (though who knows if finding part time ED work will be possible with the upcoming job market concerns) if if they get tired of the ICU? That was the other path I was debating.
 
okudasai said:
Sort of in the same vein, is it possible if someone is EM/CC to then switch to doing urgent care or part time ED work (though who knows if finding part time ED work will be possible with the upcoming job market concerns) if if they get tired of the ICU? That was the other path I was debating.
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Honest answer:

In this day and age urgent care is staffed mostly by non-physicians. And the reason has nothing to do with patient outcomes or provider knowledge skill. It is ONLY because of the business of medicine and maximizing revenue.

So, by the time you would be thinking “hey I want to do some urgent care” (Aka after CC fellowship) the pay is going to be even lower for physicians. And the pressure / expectations to see more patients is going to be increased. It’s an urgent care, not an ED, so your business overloads just may expect you to see 20-24 patients in a 8 hr shift if that is what is in the waiting room.
 
CopaceticOne said:
Honest answer:

In this day and age urgent care is staffed mostly by non-physicians. And the reason has nothing to do with patient outcomes or provider knowledge skill. It is ONLY because of the business of medicine and maximizing revenue.

So, by the time you would be thinking “hey I want to do some urgent care” (Aka after CC fellowship) the pay is going to be even lower for physicians. And the pressure / expectations to see more patients is going to be increased. It’s an urgent care, not an ED, so your business overloads just may expect you to see 20-24 patients in a 8 hr shift if that is what is in the waiting room.
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I see, so it wouldn't be a good out from CC cause I would be just as busy if not more so. Man, I gotta say, it really sucks that EM has such limited flexibility/fellowships esp compared to IM. Thank you for the response!
 
cardsperson said:
Cards-CCM is similarly hard to maintain, but even the most ivory tower cards intensivist has plenty of skills in their arsenal that reimburse well in the outpatient setting (TTE, TEE, RHC being the obvious ones).
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Cards-CCM really should be advanced heart failure. Doing that gives you about 95% of what you need to know for critical care plus also gives you advanced heart failure training. Really, the biggest thing missing is tubes/vent and you can always call pulm to deal with that. AHF is way more marketable than cards-ccm since every major hospital is trying to get on that LVAD game. And you won't be dealing with much general cards clinic on your off time, it'll be sick heart failure folks.

I feel that cards CCM is for people who still don't know what to do and have major FOMO. In the process of FOMO, they actually miss out on the best parts of being a specialist/consultant.
 
My friend from medical school is now an EM/CCM physician.
When he was trying to decide how to choose between EM and IM, he said it was a no contest. There is no rounding in EM. That sold it for him.
 
aafisahar said:
Cards-CCM really should be advanced heart failure. Doing that gives you about 95% of what you need to know for critical care plus also gives you advanced heart failure training. Really, the biggest thing missing is tubes/vent and you can always call pulm to deal with that. AHF is way more marketable than cards-ccm since every major hospital is trying to get on that LVAD game. And you won't be dealing with much general cards clinic on your off time, it'll be sick heart failure folks.

I feel that cards CCM is for people who still don't know what to do and have major FOMO. In the process of FOMO, they actually miss out on the best parts of being a specialist/consultant.
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Agreed, advanced HF basically gives you the best physiology knowledge of any specialist IMO - with the possible exception of CT anesthesiologists, but their experience with medical issues is pretty crappy ie knowing who needs emergent PCI. Really the only benefit of CCM training is intubating crashing patients / bronching - I don't think vent management in and of itself is especially complicated in the cardiac population lol, usually you're dealing with run-of-the-mill pulmonary edema.
 
cardsperson said:
Agreed, advanced HF basically gives you the best physiology knowledge of any specialist IMO - with the possible exception of CT anesthesiologists, but their experience with medical issues is pretty crappy ie knowing who needs emergent PCI. Really the only benefit of CCM training is intubating crashing patients / bronching - I don't think vent management in and of itself is especially complicated in the cardiac population lol, usually you're dealing with run-of-the-mill pulmonary edema.
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Lol.
 
cardsperson said:
Not sure why this is lol. For a CCU intensivist, that is absolutely all you need out of any CCM training. People running other ICUs will obviously get more out of a CCM fellowship.
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In case you arent a troll that joined 2 weeks ago to spread the good word about how smart cardiologists are compared to the lesser mortals--When people are sick (yes even people in the CCU) more than one organ fails on a frequent basis. Watching cardiologists try to manage diabetes or antibiotics or sedation is extremely painful.
 
chessknt said:
In case you arent a troll that joined 2 weeks ago to spread the good word about how smart cardiologists are compared to the lesser mortals--When people are sick (yes even people in the CCU) more than one organ fails on a frequent basis. Watching cardiologists try to manage diabetes or antibiotics or sedation is extremely painful.
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Yes, because you need CCM fellowship to manage diabetes or decide on sedation /s

What's really painful is watching CCM struggle to get a Swan or pacer wire in, while the patient is actively decompensating. Or do a ****ty parasternal view of the heart with their low res ultrasound probes and claim "the EF looks amazing, I don't think this is a heart issue" while the patient has a flail mitral valve from MI (yes, real situation I saw).
 
CCM-MD said:
Too much ignorance to have any meaningful discussion. Hope you have more appreciation for your colleagues from other specialties, their training and what they bring to the table in the future.
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You're the one bringing "lol" to a comment thread. Anyway, all of this is a distraction from OP's question. My advice to OP (and any med students reading this) is to find a field that won't be taken over by midlevels in the next decade, since that'll be the time frame where you'll be getting your first big boy jobs. EM is clearly there already, and CCM will also be entirely midlevel in the next ~10-20 years, despite their expertise in managing diabetes and sedation.

Cardiology still has a ways to go although it'll come for us too eventually.
 
CCM-MD said:
Too much ignorance to have any meaningful discussion. Hope you have more appreciation for your colleagues from other specialties, their training and what they bring to the table in the future.
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I legit took over a covid managed by a cicu Intensivist on versed 30/hr for 2 weeks. This was at a top 10 academic hospital so basically genius level management because it’s ez
 
rokshana said:
Lol…should… but in the real world they consult endocrinology or nephrology… or usually both…I just ask that you know when to consult one or the other… not both.
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Meh, from a IM-CCM standpoint I actively try to avoid having endocrinology involved 99% of the time (no... I don't need help with DKA or hyponatremia. Also thank you endo for that lovely code last month. Who knew that 1/2NS +20KCL at 200 then 225 ml/hr in a patient with CKD would cause hyperkalemia? Rate was for severe hypercalcemia before anyone asks) and short of needing dialysis, I generally prefer not to have nephrology involved either.
 
Siggy said:
Meh, from a IM-CCM standpoint I actively try to avoid having endocrinology involved 99% of the time (no... I don't need help with DKA or hyponatremia. Also thank you endo for that lovely code last month. Who knew that 1/2NS +20KCL at 200 then 225 ml/hr in a patient with CKD would cause hyperkalemia? Rate was for severe hypercalcemia before anyone asks) and short of needing dialysis, I generally prefer not to have nephrology involved either.
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Ever any push back from the floor medicine team at the time of downgrade if “everything isn’t all wrapped up in a nice bow tie?”
 
NewYorkDoctors said:
Ever any push back from the floor medicine team at the time of downgrade if “everything isn’t all wrapped up in a nice bow tie?”
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Nope. At my fellowship and one of the hospitals I'm at now we just text the primary team. They may have a question, but as long as the patient is stable I haven't had any pushback. At my other current hospital we just downgrade.
 
Siggy said:
Meh, from a IM-CCM standpoint I actively try to avoid having endocrinology involved 99% of the time (no... I don't need help with DKA or hyponatremia. Also thank you endo for that lovely code last month. Who knew that 1/2NS +20KCL at 200 then 225 ml/hr in a patient with CKD would cause hyperkalemia? Rate was for severe hypercalcemia before anyone asks) and short of needing dialysis, I generally prefer not to have nephrology involved either.
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Nice that you do that…wish your brethren knew how to as well…usually I get the call from the icu because they stopped the gtt, then gave the sq insulin and dont understand why the pt is back in dka!
 
rokshana said:
Nice that you do that…wish your brethren knew how to as well…usually I get the call from the icu because they stopped the gtt, then gave the sq insulin and dont understand why the pt is back in dka!
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I prefer to just start lantus immediately. 0.15 u/kg/day on top of the drip. That way you don't have to deal with a bridge.

...unfortunately everyone else whines about running the titrated drip (which, arguably, shouldn't be titrated in the first place, but I've never seen a hospital not use a titrated drip for DKA. Hypertrig pancreatitis I force the non-titrated drip) with lantus, so I have to start it later.
 
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