Qualification in neurocritical care

[Ttan]

IM trained docs are able to obtain training positions in neurocritical care fellowships. And if you do a critical care 2 yr fellowship, you can finish neurocritical care in 1 year.

How necessary would neurocritical care for 1 year be after finishing critical care for an IM doc, if you were interested in spending time in neuro ICUs?

Intensivists can place bolts, lumbar drains, EVDs, etc. Is the extra training important for the procedural end? Or can you get enough experience out of regular fellowship?

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[CCM-MD]

IM trained docs are able to obtain training positions in neurocritical care fellowships. And if you do a critical care 2 yr fellowship, you can finish neurocritical care in 1 year.

How necessary would neurocritical care for 1 year be after finishing critical care for an IM doc, if you were interested in spending time in neuro ICUs?

Intensivists can place bolts, lumbar drains, EVDs, etc. Is the extra training important for the procedural end? Or can you get enough experience out of regular fellowship?

In a lot of private settings, how much you get to do in the neuro ICU as an intensivist depends on the relationship you have with the neurosurgery group. In a lot of scenarios neurosurgeons are very protective of these procedures and you may not get to do much. In my regular CCM fellowship we got to place bolts but not lumbar drains or EVDs. In my opinion its not going to be worth doing an extra year of neurocritical care unless you are planning to spend majority of your time in a neuro ICU at an academic center after finishing.

 

[jdh71]

IM trained docs are able to obtain training positions in neurocritical care fellowships. And if you do a critical care 2 yr fellowship, you can finish neurocritical care in 1 year.

How necessary would neurocritical care for 1 year be after finishing critical care for an IM doc, if you were interested in spending time in neuro ICUs?

Intensivists can place bolts, lumbar drains, EVDs, etc. Is the extra training important for the procedural end? Or can you get enough experience out of regular fellowship?

Practically speaking you'll most likely need the fellowship to teach you these procedures, especially for ease of credentialing. You *might* find a neurosurgeon who will teach you in the private world, especially if they don't want to "waste" their time doing them (I'm sure bang for buck some surgeons would prefer to be "elbow deep" in a cranium or sleeping). You can however still do a lot of nonprocedural neuro critical care without the fellowship by just picking it up. I do a lot myself. The surgeon's I work with still prefer to do these procedures but I basically manage the rest of the patient and almost always I'm primary with these folks on my service.

 

[Ttan]

Practically speaking you'll most likely need the fellowship to teach you these procedures, especially for ease of credentialing. You *might* find a neurosurgeon who will teach you in the private world, especially if they don't want to "waste" their time doing them (I'm sure bang for buck some surgeons would prefer to be "elbow deep" in a cranium or sleeping). You can however still do a lot of nonprocedural neuro critical care without the fellowship by just picking it up. I do a lot myself. The surgeon's I work with still prefer to do these procedures but I basically manage the rest of the patient and almost always I'm primary with these folks on my service.

Is it worth taking the extra year? For experience, getting jobs, being well rounded, etc

 

[jdh71]

Is it worth taking the extra year? For experience, getting jobs, being well rounded, etc

I would say probably not worth it. But it might be to you from a procedural standpoint.

 

[Ttan]

I would say probably not worth it. But it might be to you from a procedural standpoint.

I see. And while on topics of extracurricular ICU training, how do physicians normally get into CT ICU management. I know there's a lot of material there that is not seen in medical ICU quite as much; VATS, ecmo, lung and heart post op management. Does additional training offer anything in the job market or ability to enter that field?

 

[CCM-MD]

I see. And while on topics of extracurricular ICU training, how do physicians normally get into CT ICU management. I know there's a lot of material there that is not seen in medical ICU quite as much; VATS, ecmo, lung and heart post op management. Does additional training offer anything in the job market or ability to enter that field?

If this is something you are interested in, choose a fellowship that trains you in it. Don't go to a program that trains you to be a MICU doc - you want to get well rounded training. In my 2 year CCM fellowship we did 4 months MICU, 2 months of CVICU, 2 months of SICU, 2 months Neuro/Trauma ICU, 4 months nights covering everything and rest electives. There are many that offer this. Find a program that lets you get this kind of training and you will come out being able to manage almost anything.

 

[AdmiralChz]

If this is something you are interested in, choose a fellowship that trains you in it. Don't go to a program that trains you to be a MICU doc - you want to get well rounded training. In my 2 year CCM fellowship we did 4 months MICU, 2 months of CVICU, 2 months of SICU, 2 months Neuro/Trauma ICU, 4 months nights covering everything and rest electives. There are many that offer this. Find a program that lets you get this kind of training and you will come out being able to manage almost anything.

Also very institution dependent. It seems that less and less IM-trained folks into CVICU in favor of Anesthesia (possible double-trained in CV/CCM) or Cardiologists/Surgeons. More and more Neuro ICUs are being managed by Neuro-trained intensivists. This likely is an anecdotal, academic phenomenon but something to consider. Most likely place for an IM-trained CC will be MICU by a mile, then SICU or CCU.

I am sure some of the CCM-trained folks on this board can expand on that more, much better than myself.

 

[jdh71]

I see. And while on topics of extracurricular ICU training, how do physicians normally get into CT ICU management. I know there's a lot of material there that is not seen in medical ICU quite as much; VATS, ecmo, lung and heart post op management. Does additional training offer anything in the job market or ability to enter that field?

I don't think the additional training helps with marketability, at least right now. Again, it's something you can pick up. You do a few cases and ask the surgeons how they like things managed and when they want to be bothered and once you see that most of these post of CV cases are kind of "conveyor beltish". Do this. Then do this. Then do this. Then send them somewhere else not there.

You will feel more comfortable starting if you have some training experience, but you can close that gap quickly even without a lot of time doing it.

 

[jdh71]

Also very institution dependent. It seems that less and less IM-trained folks into CVICU in favor of Anesthesia (possible double-trained in CV/CCM) or Cardiologists/Surgeons. More and more Neuro ICUs are being managed by Neuro-trained intensivists. This likely is an anecdotal, academic phenomenon but something to consider. Most likely place for an IM-trained CC will be MICU by a mile, then SICU or CCU.

I am sure some of the CCM-trained folks on this board can expand on that more, much better than myself.

In the community, you'll get tossed everywhere they want you and/or there are people who can't or won't deal with things. My CV surgeons manage their own service, closely. So we don't. My cardiologists are lazy af and I'm primary on all the sick hearts, vent or no vent. Same goes for the sick surgical cases, they end up on my service, especially if there is a weekend! I do work with a fantastic trauma group and they manage their own service as well, we consult for the some of the chronic medical illness stuff if it's a problem.

It does make me miss the ivory tower some, but I don't miss the sick BMT patients at all.

 

[CCM-MD]

Also very institution dependent. It seems that less and less IM-trained folks into CVICU in favor of Anesthesia (possible double-trained in CV/CCM) or Cardiologists/Surgeons. More and more Neuro ICUs are being managed by Neuro-trained intensivists. This likely is an anecdotal, academic phenomenon but something to consider. Most likely place for an IM-trained CC will be MICU by a mile, then SICU or CCU.

I am sure some of the CCM-trained folks on this board can expand on that more, much better than myself.

This may be the case at large academic centers. In my area, at non-academic centers, its mainly Pulm-CCM or IM-CCM trained folk managing everything. Dedicated Neuro ICUs are still few outside academic centers and those that I know of in my area are run by non-neurologists. Surgeons love having us manage the SICU so they can spend more time cutting people open. Anesthesiologists - even those trained in CCM prefer to spend time in the OR rather than in the unit.

 

[deleted547339]

High volume neuro-icus are usually neuro-ICU trained. I don't know that this is necessary, but that's what I've seen. Same for high volume cticus. They like Ct/CCM trained anesthesiologists.

I don't believe that you can do 1 extra year to get neuro-CCM, I think it's still 2, but I could be wrong.

Also, neuro ICU is the only place more depressing than the MICU.

 

[CCM-MD]

High volume neuro-icus are usually neuro-ICU trained. I don't know that this is necessary, but that's what I've seen. Same for high volume cticus. They like Ct/CCM trained anesthesiologists.

I don't believe that you can do 1 extra year to get neuro-CCM, I think it's still 2, but I could be wrong.

Also, neuro ICU is the only place more depressing than the MICU.

I know for sure you can get neurocrit boards after 1 year if you have done a 2 year CCM fellowship and there are programs that will let you do 1 year alone. One of my co-fellows did this. Also, there are tons of unfilled programs every year.

 

[deleted547339]

I know for sure you can get neurocrit boards after 1 year if you have done a 2 year CCM fellowship and there are programs that will let you do 1 year alone. One of my co-fellows did this. Also, there are tons of unfilled programs every year.

I thought this was recently changed. Oh well, I'd never do neuro CCM so never actually looked into it.

 

[CCM-MD]

I thought this was recently changed. Oh well, I'd never do neuro CCM so never actually looked into it.

I would never do a dedicated year in it either. But for someone reading this who is interested:

"10. I am a Critical Care Fellow. How do I become a Neurointensivist?

The UCNS offers certification in neurocritical care following fellowship training of one-year duration to candidates who have completed post-graduate fellowship training in anesthesia critical care, surgical critical care, or internal medicine critical care that requires at least six months of critical care training. Remember that the match for neurocritical care fellowships occurs a year prior to the start of fellowship training, and that applications through the SF Match are typically submitted at least 6 months prior to the match! Go to the SF Match website or contact individual programs directly to find unfilled (post-match) positions that might allow you to matriculate into a program without waiting for the next match cycle."

Source: http://www.neurocriticalcare.org/LinkClick.aspx?fileticket=XcNFOTAJmEc=&tabid=23324&portalid=61

 

[Ttan]

I know for sure you can get neurocrit boards after 1 year if you have done a 2 year CCM fellowship and there are programs that will let you do 1 year alone. One of my co-fellows did this. Also, there are tons of unfilled programs every year.

So, what's to stop someone from going out of IM residency and doing a 2 year neurocrit fellowship and being able to work both neuro icu and MICU/SICU?

 

[deleted547339]

So, what's to stop someone from going out of IM residency and doing a 2 year neurocrit fellowship and being able to work both neuro icu and MICU/SICU?

Following a strong, multidisciplinary CCM fellowship, you get broad training that will prepare you to take care of most micu/SICU issues. You may also get fair exposure to neuro patients. The converse is not true. Neuro CCM fellowships are almost exclusively neuro. You would lack the credentials and the knowledge/skill set to practice in a micu or SICU.

 

[jdh71]

So, what's to stop someone from going out of IM residency and doing a 2 year neurocrit fellowship and being able to work both neuro icu and MICU/SICU?

Actually in the "real world," probably not much. Especially with the current shortage of critical care physicians.

 

[CCM-MD]

So, what's to stop someone from going out of IM residency and doing a 2 year neurocrit fellowship and being able to work both neuro icu and MICU/SICU?

Nothing is stopping anyone from doing anything. You could do an IM or FM residency and work in a rural ICU as a hospitalist or even as an ER doc. Just don't expect to be paid the same or be hired in a decent sized city. Those willing to pay intensivist $ want physicians with critical care fellowship training & boards - neurocrit won't cut it. There is a reason why so many of these neuroCC fellowship positions are going empty.

 

[ArmyNeuroGuy]

I think that the training in neurocritical care at a high volume center is just as good as any surgical icu or miccu, we have take care of the same problems as all the other icu docs plus the neuro stuff that everyone else likes to ignore


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[Hamhock]

I think that the training in neurocritical care at a high volume center is just as good as any surgical icu or miccu, we have take care of the same problems as all the other icu docs plus the neuro stuff that everyone else likes to ignore
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I suspect you do not know what you do not know; because of lack of experience and training.

If your statement were even close to true, do you not think that every multi-disciplinary CCM training program would notice this and change their cirricula to match the neurocritical care training?

HH

 

[ArmyNeuroGuy]

The same applies to when you all like to say I can "pick up" that neuro stuff along the way


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[ArmyNeuroGuy]

And I will certainly agree that not all neurocritical care fellowships are the same and some get way better training than others which is why I said high volume center, I can't think of a single thing that the miccu would see that we didn't have in our icu, sepsis check, renal failure check, pulmonary firbroais check, heart failure check, plus I had to rotate through all those other ICU's also so not sure what else I'm supposed to know about but you name a medical problem and I have treated it along with worrying about their brain problems


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[CCM-MD]

I think that the training in neurocritical care at a high volume center is just as good as any surgical icu or miccu, we have take care of the same problems as all the other icu docs plus the neuro stuff that everyone else likes to ignore


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Most neuroICU programs are at "high volume" centers because only those have the ability to have NeuroICUs in the first place. And there's tons of these "high volume" center programs with open fellowship positions. One potential reason is lack of opportunities after completing - there's not as many neuro ICUs in the community.

There's no reason to get defensive about your training. NeuroICU training is great when it comes to training someone to run a neuroICU. It is not the same as thing as a multidisciplinary CCM fellowship. Perhaps some programs have more exposure to other parts of critical care medicine than others but don't go to a neuro program and expect to finish and be hired and paid as an intensivist to manage a medical/surgical/trauma/cardiac ICU. This is analogous to saying some anesthesia or internal/emergency medicine programs have very strong MICU/SICU/CVICU exposure, let's hire them to work as ICU docs there's no need for them to do a CCM fellowship. It's possible someone will hire a neurocrit trained person in desperate places but I have yet to see this happen because most of the neuroICU people I know are either neurologists or old intensivists who grandfathered into the certification.

Keep in mind neurocrit programs were initially designed by neurologists to train neurologists in neurocritical care, and they remain a majority of the graduates. Bottom line do a neuroICU fellowship to work in a neuroICU. Same goes for anything else. Don't train in urology to operate on prostates if you want to operate on the brain.

 

[CCM-MD]

I can't think of a single thing that the miccu would see that we didn't have in our icu, sepsis check, renal failure check, pulmonary firbroais check, heart failure check, plus I had to rotate through all those other ICU's also so not sure what else I'm supposed to know about

If this is what you think... there's no point in talking any further. You clearly know everything there is to know about the MICU with those 4 diagnosis.

 

[ArmyNeuroGuy]

That totally wasn't my point my point was that other people on the thread are saying you can pick up "neuro" stuff and be fine I'm arguing that's not true that's why we have evolved into our own icus, you prove my point by getting so defensive about the miccu, how do you think we feel when every other intensivist is just like brain stuff whatever we can figure that out when it's not true


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[CCM-MD]

NeuroICU training is great when it comes to training someone to run a neuroICU.

Above is what I said in my previous post. I don't think anyone is saying brain stuff is "whatever".

 

[deleted547339]

That totally wasn't my point my point was that other people on the thread are saying you can pick up "neuro" stuff and be fine I'm arguing that's not true that's why we have evolved into our own icus, you prove my point by getting so defensive about the miccu, how do you think we feel when every other intensivist is just like brain stuff whatever we can figure that out when it's not true


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I'm sorry, but being competent in a neuro ICU does not make you competent to work in another ICU. You really think being the best at taking care of strokes makes you qualified to take care of an acute liver failure, or a polytrauma, or pulmonary hemorrhage? Sure, neuroICU makes you competent to take care of acute renal failure or VAP, etc, but it doesn't make you competent to attend in other icus.

The difference between a neuro ICU attending working in a different ICU vs another intensivist working in a neuroicu is that a non-neuro ICU intensivist would presumably have a neurologist or neurosurgeon helping with the neuro issues.

 

[AdmiralChz]

And I will certainly agree that not all neurocritical care fellowships are the same and some get way better training than others which is why I said high volume center, I can't think of a single thing that the miccu would see that we didn't have in our icu, sepsis check, renal failure check, pulmonary firbroais check, heart failure check, plus I had to rotate through all those other ICU's also so not sure what else I'm supposed to know about but you name a medical problem and I have treated it along with worrying about their brain problems


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Am I reading this right? Neuro ICUs are very sepecialized and only neuro-ish stuff gets admitted there. Yes the patients can have co-morbidities but equating it to MICU/SICU rotations is irresponsible and alarming for a “Chief resident” to say.

No one is getting admitted up to the neuro unit after a heart transplant, severe GI bleed, CHF exacerbation, Stevens Johnson reaction, 80% TBSA burn, pneumonia from Influenza, pick any random primary diagnosis here...

I’m not a critical care physician but training should include a variety of rotations in different units to get a rounded education. Just focusing on one or two units (my residency’s program does something like 9 months in 2 units) is sort of a waste, IMO.

 

[bhaiyyaji]

an 80% TSBA burn isn't usually seen outside of a burns center anyways

 

[deleted547339]

an 80% TSBA burn isn't usually seen outside of a burns center anyways

In an ICU staffed by intensivists....

 

[eimaise]

If this is something you are interested in, choose a fellowship that trains you in it. Don't go to a program that trains you to be a MICU doc - you want to get well rounded training. In my 2 year CCM fellowship we did 4 months MICU, 2 months of CVICU, 2 months of SICU, 2 months Neuro/Trauma ICU, 4 months nights covering everything and rest electives. There are many that offer this. Find a program that lets you get this kind of training and you will come out being able to manage almost anything.

Good advice. I'd be interested to know which program you went to if you are willing to share. Couldn't private message you because it said your profile was restricted.

 

[CCM-MD]

Good advice. I'd be interested to know which program you went to if you are willing to share. Couldn't private message you because it said your profile was restricted.

I don't want to reveal where I trained for anonymity. But the few programs I definitely know that offer this type of training include UPMC, Montefiore, SLU, Baylor. I am sure theres others out there.

 

[eimaise]

I don't want to reveal where I trained for anonymity. But the few programs I definitely know that offer this type of training include UPMC, Montefiore, SLU, Baylor. I am sure theres others out there.

Thanks. That's helpful.

 

[chocomorsel]

I don't want to reveal where I trained for anonymity. But the few programs I definitely know that offer this type of training include UPMC, Montefiore, SLU, Baylor. I am sure theres others out there.

What's your primary specialty?

 

[CCM-MD]

What's your primary specialty?

Critical Care Medicine & Internal Medicine. I was referring to the internal medicine based critical care medicine programs at the institutions I mentioned previously.

 

[chocomorsel]

Thanks