Nephrology-CC combination fellowship

[timurx]

I'm in the process of being highly considering a Nephrology fellowship that will also accommodate my interest in critical care as well. My end goal is to be boarded in both Nephrology and CC, being trained at a big academic institution.

My question is for anyone else who's done or know of a similar course where by a non-pulmonary/CC fellow (such as renal in my case) incorporate CC into their training to complete a 3 year double curriculum. How well are you trained from the CC side given you are not a Pulm/CC fellow? I am concerned that since I am not a Pulm/CC fellow and this program does not have a stand alone CC fellowship, I might be tossed aside in regards to my education. In other words, I'd like to ensure that I'd be adequately trained in the typical CC curriculum, including chest tubes/intubations/advanced vent management/etc that typically any Pulm/CC fellow would learn too but since the faculty would be Pulm/CC, I'm curious if I would be given the adequate curriculum to be as well trained in CC as their own fellow would be (obviously not going to know output Pulm and related non-ICU pulmonary stuff, but talking about what needs to be known from CC standpoint).

Reasonable concern? Thoughts in this regards? I want to ensure I know what I am getting into beforehand.

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[deleted547339]

I'm in the process of being highly considering a Nephrology fellowship that will also accommodate my interest in critical care as well. My end goal is to be boarded in both Nephrology and CC, being trained at a big academic institution.

My question is for anyone else who's done or know of a similar course where by a non-pulmonary/CC fellow (such as renal in my case) incorporate CC into their training to complete a 3 year double curriculum. How well are you trained from the CC side given you are not a Pulm/CC fellow? I am concerned that since I am not a Pulm/CC fellow and this program does not have a stand alone CC fellowship, I might be tossed aside in regards to my education. In other words, I'd like to ensure that I'd be adequately trained in the typical CC curriculum, including chest tubes/intubations/advanced vent management/etc that typically any Pulm/CC fellow would learn too but since the faculty would be Pulm/CC, I'm curious if I would be given the adequate curriculum to be as well trained in CC as their own fellow would be (obviously not going to know output Pulm and related non-ICU pulmonary stuff, but talking about what needs to be known from CC standpoint).

Reasonable concern? Thoughts in this regards? I want to ensure I know what I am getting into beforehand.

Find a program with a stand alone CCM fellowship. This isn't the complete list, but a good place to start:

https://services.aamc.org/eras/erasstats/par/display8.cfm?NAV_ROW=PAR&SPEC_CD=142

There are plenty of programs with strong CCM programs for nonpulmonologist.

 

[deleted171991]

Why would you go this way? Why swim against the tide? It will be more difficult for you to find a job where you can practice both specialties (so you'll waste 2 years of training and $$$ for nothing). Even in academic places, it won't be easy to work for 2 different departments/divisions. People from both sides will look at you wondering what kind of animal you really are, a nephrologist or an intensivist, which one you are good at and which one not?

Make up your mind which one you like more, and stick with that one. Do yourself a favor and don't stand out. The two specialties are not even related; it's not like you would be doing palliative-CCM or pulm-CCM, or anesthesia-CCM, or EM-CCM (or maybe ID-CCM). Some ICUs don't even consult nephrologists when ordering/managing CRRT.

Just my 2 cents. It will be your headache, not mine.

 

[Nephro critical care]

I am a nephrology critical care physician and I would not recommend this combination to anybody. I started out as a nephrology fellow and then got into a critical care program and did a 2 year fellowship. CC is much harder to do in a year than nephrology, with learning intubations, lines, chest tubes etc and then all the CC management . If are already adept at lines and intubations then the learning curve is less steep but otherwise it will take you some time to get comfortable. Nephrology by itself I feel is a one year fellowship , once you learn dialysis which won't take you more than a week you have learned 50% of nephrology.

The job market for nephrology-CC also sucks there are hardly any jobs for the combination. I in the end took up an intensivist job as pay was much better and work was less. But now I am slowly losing my nephrology skills I can't manage a glomerulonephritis by myself although I can dialyze anyone and manage hyponatremias just perfectly as you get these all the time in CC.

The long and short of it is that if you are IM and want to do CC ; research , publish , build contacts and try to get into pulmonary critical care. That's where the money and job market is .

 

[CCM-MD]

I'm in the process of being highly considering a Nephrology fellowship that will also accommodate my interest in critical care as well. My end goal is to be boarded in both Nephrology and CC, being trained at a big academic institution.

My question is for anyone else who's done or know of a similar course where by a non-pulmonary/CC fellow (such as renal in my case) incorporate CC into their training to complete a 3 year double curriculum. How well are you trained from the CC side given you are not a Pulm/CC fellow? I am concerned that since I am not a Pulm/CC fellow and this program does not have a stand alone CC fellowship, I might be tossed aside in regards to my education. In other words, I'd like to ensure that I'd be adequately trained in the typical CC curriculum, including chest tubes/intubations/advanced vent management/etc that typically any Pulm/CC fellow would learn too but since the faculty would be Pulm/CC, I'm curious if I would be given the adequate curriculum to be as well trained in CC as their own fellow would be (obviously not going to know output Pulm and related non-ICU pulmonary stuff, but talking about what needs to be known from CC standpoint).

Reasonable concern? Thoughts in this regards? I want to ensure I know what I am getting into beforehand.

1. It will be very difficult to find a job that lets you practice both nephrology and critical care after completion of training. You will probably end up practicing CCM alone. The whole idea of "when I burn out of CCM I will do nephrology" is stupid. Good luck making the switch after not practicing nephrology for years.

2. Interest in critical care is rising and there are only ~25 stand alone internal medicine based critical care fellowships in the entire country. I interviewed this year and was actually surprised to have encountered a couple of cardiology fellows. I am very glad to have gotten into a program I liked.

3. Although arguable, I think 1 year of training in critical care after nephrology may not allow you to become adequately trained - especially when it comes to procedural training. Anesthesiology and surgery can get away with 1 year training but you may not be able to.

Having recently gone through the process my advice to you is that if your intention is to practice CCM eventually - forget about nephrology and apply to both 2 year CCM and Pulm/CCM programs in the next match.

 

[Nephro critical care]

I would argue for doing pulmonary critical care rather than CC alone . CC jobs are hospital employed whereas pulm CC jobs can be private so you can be your own master rather than dancing to someone else's tune . There are probably double as many jobs in pulm - CC as compared with CC. Pulm CC will have edge over me every time dealing with pulm issues although after sometime with my greater CC experience I will be better at hemodynamics / ID / neuro management.

CC is still a glorified hospitalist with same family / social issues. Stress is higher although I have heard that malpractice is same or less than that of a hospitalist ; why I don't know. I think burnout in CC is higher as compared with pulm-CC as you can always after your week in the ICU be able to go back to outpatient and look at PFTs / prescribe Advair and read sleep studies.

 

[deleted171991]

Stress is higher although I have heard that malpractice is same or less than that of a hospitalist ; why I don't know.

I had the same surprise when I heard that there was less malpractice than in anesthesiology. Then I was explained that families already expect the worst when a patient goes to the ICU, so they will rarely blame the hospital for a bad outcome.

 

[Nephro critical care]

It's still a little bit surprising that the malpractice is lower. In the ICU margin of error is much lower, any error of judgement will lead directly to death while as a hospitalist or as an outpatient it mostly leads to ICU transfer . Yes by the time of ICU transfer the patient is already so sick that the diagnosis is already obvious.

 

[deleted171991]

It's still a little bit surprising that the malpractice is lower. In the ICU margin of error is much lower, any error of judgement will lead directly to death while as a hospitalist or as an outpatient it mostly leads to ICU transfer . Yes by the time of ICU transfer the patient is already so sick that the diagnosis is already obvious.

I think it's more that the family gets to see the hard work and gets a different appreciation for the team.

 

[CCM-MD]

I would argue for doing pulmonary critical care rather than CC alone . CC jobs are hospital employed whereas pulm CC jobs can be private so you can be your own master rather than dancing to someone else's tune . There are probably double as many jobs in pulm - CC as compared with CC. Pulm CC will have edge over me every time dealing with pulm issues although after sometime with my greater CC experience I will be better at hemodynamics / ID / neuro management.

CC is still a glorified hospitalist with same family / social issues. Stress is higher although I have heard that malpractice is same or less than that of a hospitalist ; why I don't know. I think burnout in CC is higher as compared with pulm-CC as you can always after your week in the ICU be able to go back to outpatient and look at PFTs / prescribe Advair and read sleep studies.

1. Regardless of the specialty I think a majority of us will be hospital employed in the next decade. I know some very happy hospital employed Pulm/CC doctors at my hospital. Many of them practice CCM alone and do not do any Pulm work for various reasons.

2. The trend is going away from the traditional model of a private Pulm/CC group rounding in an open ICU and leaving to do consults/clinic even at smaller hospitals in my area.

3. Compensation favors ICU work than pulmonary.

4. 2 year CCM fellowships seem to give more exposure to CVICU, NeuroICU and SICU whereas in many of the Pulm/CC programs I interviewed at training was largely in the MICU.

5. I think both Pulm/CC and CCM alone are wonderful choices training depending on what one wants to do eventually. To the OP: you decide whether you would like to work 14 shifts a month in an ICU and get the rest of the month off or work 1 week a month in the ICU and do Pulm the rest of the time.

 

[so4u2004so]

1. Regardless of the specialty I think a majority of us will be hospital employed in the next decade. I know some very happy hospital employed Pulm/CC doctors at my hospital. Many of them practice CCM alone and do not do any Pulm work for various reasons.

2. The trend is going away from the traditional model of a private Pulm/CC group rounding in an open ICU and leaving to do consults/clinic even at smaller hospitals in my area.

3. Compensation favors ICU work than pulmonary.

4. 2 year CCM fellowships seem to give more exposure to CVICU, NeuroICU and SICU whereas in many of the Pulm/CC programs I interviewed at training was largely in the MICU.

5. I think both Pulm/CC and CCM alone are wonderful choices training depending on what one wants to do eventually. To the OP: you decide whether you would like to work 14 shifts a month in an ICU and get the rest of the month off or work 1 week a month in the ICU and do Pulm the rest of the time.

Is there a difference in salary? Also wanted to know if you have a base salary of 350 k CC how much more above tgat you will make by doing procedures in an average private practice?

 

[CCM-MD]

Is there a difference in salary? Also wanted to know if you have a base salary of 350 k CC how much more above tgat you will make by doing procedures in an average private practice?

248.6k more. Give or take 200k.

 

[spacegun]

248.6k more. Give or take 200k.

You can make approximately $550k ($350k + $200k) doing procedures in an average private practice setting for critical care? Or do you mean $550k for doing procedures in pulmonary and critical care in private practice? That just seems so high. Not that I would complain!

 

[CCM-MD]

You can make approximately $550k ($350k + $200k) doing procedures in an average private practice setting for critical care? Or do you mean $550k for doing procedures in pulmonary and critical care in private practice? That just seems so high. Not that I would complain!

It was sarcasm.

 

[Nephro critical care]

Median 50th percentile for CC is $380 K.

 

[CCM-MD]

Median 50th percentile for CC is $380 K.

Not sure where that is from but it is close to what I have seen from MGMA 2016 - median is 398k.

 

[Nephro critical care]

CC billing is pretty good. My calculation is that if you work 7 on 7 off i.e 182 shifts a year and have a census of 12 and 3 new admits , you bill $627,000 a year. And this is without any procedures central lines/intubations/bronchs which would be extra.

 

[so4u2004so]

CC billing is pretty good. My calculation is that if you work 7 on 7 off i.e 182 shifts a year and have a census of 12 and 3 new admits , you bill $627,000 a year. And this is without any procedures central lines/intubations/bronchs which would be extra.

woow so if that is with out procedures how did you get this difference from 300.000 base salary to 627,000? is that Nephro CC? Private? How much procedures add? Does it make a difference if I do Pulmonary as well or Interventional pulmonary?

 

[Nephro critical care]

Well just do the math. I am in Minnesota and 1 RVU is $69.48. One CC note is 4.5 RVUs. So 14 pts * 4.5 RVUs * $69.48 * 182 shifts = $ 796,657.57 . I am not adding procedures to keep things simple and be conservative but that would be extra. And this is not Neph/CC. Just CC billing.

 

[maverickdoc]

Well just do the math. I am in Minnesota and 1 RVU is $69.48. One CC note is 4.5 RVUs. So 14 pts * 4.5 RVUs * $69.48 * 182 shifts = $ 796,657.57 . I am not adding procedures to keep things simple and be conservative but that would be extra. And this is not Neph/CC. Just CC billing.

What you bill is not the same as what you get

 

[Nephro critical care]

What you bill is not the same as what you get

That is true. But probably on billing of $800,000 you should get $500,000 conservatively. So all those who think why critical care median salaries are $395,000, this is why.

It's not easy though in CC if you are seeing a census of 12 critically ill pts with 3 new admits couple of intubations , central and arterial lines.

 

[so4u2004so]

That is true. But probably on billing of $800,000 you should get $500,000 conservatively. So all those who think why critical care median salaries are $395,000, this is why.

It's not easy though in CC if you are seeing a census of 12 critically ill pts with 3 new admits couple of intubations , central and arterial lines.

If you are taking care of patients in the ICU and writing an informative note this should bill as critical care and you should get the 4.5 RVUs I guess? the part that might be difficult to measure is probably the procedure part, family meetings etc.. you might count that you have done it but the billing because of time spent with family for example might not count it. Just a thought

 

[Nephro critical care]

I usually don't bill family time. Nearly all people get the 30-40 minute billing time just to stay below the radar. I used to think I was cheating when I was billing CC time while I was lining/tubing the patient and gathering info/managing at the same time and later I discovered I was managing labs and hemodynamics all the while I was lining and that's why it was taking me longer. Heck even while I am dictating a note
(which takes me sometimes 15 minutes) I am focusing my thoughts and formatting a plan on a critically ill patient.
If I bill someone for more than 75 minutes its usually an additional 60 minutes. These are usually the patients who kept me up all night with their management.