Questions about neurocritical care as a med student

[Doctoscope]

---

Members don't see this ad.

I'm a medical student and I'm really starting to get attracted to critical care, and ultimately I would like to end up as an ICU physician.

I know that there are many ways to work in a crit care setting, but I don't really like the OR (anesthesia -> CCM is out), EM doesn't interest me, and the thought of doing 3 years of IM and potentially not matching PCCM/CCM scares me since I would personally not be happy as a hospitalist (I'm a DO, and from what I understand it'll be a tougher match as a DO).

I know that you can also go from neuro -> NCC to work in neuro ICU, and I had some questions about it.

1) Is NCC more of an academic job market, or are there plenty of opportunities in the community? In the community, how much can you expect to make as a neurointensivist? I'll probably have like $400k in debt...

2) Is it possible to do NCC along with general neuro, like IM doing pulm with CC? It seems like a good backdoor for when you're older and want to cut back on ICU time.

3) Is NCC on the same level of competitiveness as going from IM -> PCCM?

4) Are you happy as an NCC doc? Is this something you'd recommend to incoming med students, or is it better to take the "risk" with IM -> PCCM?

Thank you for your help.

 

[DrMetal]

I'm a medical student and I'm really starting to get attracted to critical care, and ultimately I would like to end up as an ICU physician.

I know that there are many ways to work in a crit care setting, but I don't really like the OR (anesthesia -> CCM is out), EM doesn't interest me, and the thought of doing 3 years of IM and potentially not matching PCCM/CCM scares me since I would personally not be happy as a hospitalist (I'm a DO, and from what I understand it'll be a tougher match as a DO).

I know that you can also go from neuro -> NCC to work in neuro ICU, and I had some questions about it.

1) Is NCC more of an academic job market, or are there plenty of opportunities in the community? In the community, how much can you expect to make as a neurointensivist? I'll probably have like $400k in debt...

2) Is it possible to do NCC along with general neuro, like IM doing pulm with CC? It seems like a good backdoor for when you're older and want to cut back on ICU time.

3) Is NCC on the same level of competitiveness as going from IM -> PCCM?

4) Are you happy as an NCC doc? Is this something you'd recommend to incoming med students, or is it better to take the "risk" with IM -> PCCM?

Thank you for your help.

The best intensivists are those trained in either Internal Medicine or General Surgery. (EM/Anes are great for managing patients in acute situations . . . not so good at taking care of a complicated diabetic for 5 days).

And I'm still not sure how neurology worked its way into critical care. Working in a stroke unit? Great, can you fix the stroke? No. Any 'fix' is done by IR or neurosurgery. Any ensuing respiratory distress and/or organ dysfunction is handled by Internal medicine trained physicians.

 

[CCM-MD]

I'm a medical student and I'm really starting to get attracted to critical care, and ultimately I would like to end up as an ICU physician.

I know that there are many ways to work in a crit care setting, but I don't really like the OR (anesthesia -> CCM is out), EM doesn't interest me, and the thought of doing 3 years of IM and potentially not matching PCCM/CCM scares me since I would personally not be happy as a hospitalist (I'm a DO, and from what I understand it'll be a tougher match as a DO).

I know that you can also go from neuro -> NCC to work in neuro ICU, and I had some questions about it.

1) Is NCC more of an academic job market, or are there plenty of opportunities in the community? In the community, how much can you expect to make as a neurointensivist? I'll probably have like $400k in debt...

2) Is it possible to do NCC along with general neuro, like IM doing pulm with CC? It seems like a good backdoor for when you're older and want to cut back on ICU time.

3) Is NCC on the same level of competitiveness as going from IM -> PCCM?

4) Are you happy as an NCC doc? Is this something you'd recommend to incoming med students, or is it better to take the "risk" with IM -> PCCM?

Thank you for your help.

My biases upfront: IM trained, boarded in CCM and NCC. I work in an academic neuro ICU and do a lot of community intensivist work on the side.

1. If you're going the a neurology --> NCC path, expect to work in an academic hospital or select large tertiary care community hospitals. These big centers are where neuro ICUs are located. Most community hospitals don't have neuro ICUs, and neurology is inadequate base training to manage patients well in a medical/surgical/CV dominated community ICU. You'll very make similar money to CCM/PCCM. The academic side typically pays less than the community for both, but you'll typically have much more trainee/midlevel support.

2. Yes. I have seen this and its great to have an option to deescalate in the long run. Whether it's pulmonary or something not as intense within neurology. Its also smart to keep these skills up from the beginning, so you're not having to relearn a completely new subspecialty 20 years into your career.

3. NCC is not competitive. There are frequently empty NCC fellowship positions, you can look at the statistics on the SF match website.

4. If you're an AMG, you shouldn't have any problem matching PCCM. As long as you can match an academic IM residency, you'll get a PCCM spot somewhere. If you're an IMG or DO, and not competitive for an academic IM residency, PCCM/CCM still can be done from the community but will require more work. On the neurology side, as long as you can match neurology, you're basically guaranteed a NCC spot somewhere. All this is with the caveat that you still want to do NCC after completing neurology. I think there are many more opportunities on the neurohospitalist and stroke neurology side, lots of outpatient opportunities, neurointerventional is an option as well. Pretty much every hospital needs an inpatient neurologist. I think both NCC and PCCM are good fields, depends on what you like more. NCC will limit you to big centers that have neuro ICUs.

 

[Doctoscope]

My biases upfront: IM trained, boarded in CCM and NCC. I work in an academic neuro ICU and do a lot of community intensivist work on the side.

1. If you're going the a neurology --> NCC path, expect to work in an academic hospital or select large tertiary care community hospitals. These big centers are where neuro ICUs are located. Most community hospitals don't have neuro ICUs, and neurology is inadequate base training to manage patients well in a medical/surgical/CV dominated community ICU. You'll very make similar money to CCM/PCCM. The academic side typically pays less than the community for both, but you'll typically have much more trainee/midlevel support.

2. Yes. I have seen this and its great to have an option to deescalate in the long run. Whether it's pulmonary or something not as intense within neurology. Its also smart to keep these skills up from the beginning, so you're not having to relearn a completely new subspecialty 20 years into your career.

3. NCC is not competitive. There are frequently empty NCC fellowship positions, you can look at the statistics on the SF match website.

4. If you're an AMG, you shouldn't have any problem matching PCCM. As long as you can match an academic IM residency, you'll get a PCCM spot somewhere. If you're an IMG or DO, and not competitive for an academic IM residency, PCCM/CCM still can be done from the community but will require more work. On the neurology side, as long as you can match neurology, you're basically guaranteed a NCC spot somewhere. All this is with the caveat that you still want to do NCC after completing neurology. I think there are many more opportunities on the neurohospitalist and stroke neurology side, lots of outpatient opportunities, neurointerventional is an option as well. Pretty much every hospital needs an inpatient neurologist. I think both NCC and PCCM are good fields, depends on what you like more. NCC will limit you to big centers that have neuro ICUs.

Thanks for your insight. Idk if you can provide info on this, but is dual applying academic IM/neuro a thing? Maybe that way, I'll have the option to end up in critical care somehow.

Also, how is the CCM only route vs. PCCM coming from IM in terms of fellowship competitiveness and job market?

 

[CCM-MD]

Thanks for your insight. Idk if you can provide info on this, but is dual applying academic IM/neuro a thing? Maybe that way, I'll have the option to end up in critical care somehow.

Also, how is the CCM only route vs. PCCM coming from IM in terms of fellowship competitiveness and job market?

It is a thing but there are very few and IMO combined residencies are a waste of time. You’re going to end up working in one field, just pick it now.

CCM should theoretically be less competitive than PCCM, but in reality is similar or more because of the fewer CCM only spots and the abundance of nephro/ID fellows gunning for them.

Like I said before, I wouldn’t worry so much about matching, especially if you’re an AMG. NCC and PCCM are very similar lifestyle and compensation wise, pursue what interested you the most, and don’t waste time with combined residencies.

 

[CCM-MD]

I think I maybe misunderstood your question, if you’re talking about applying to both IM and neurology separately in the match, then yes it can be done. I would probably avoid applying to both at the same institution.

 

[jthedestroyr]

The best intensivists are those trained in either Internal Medicine or General Surgery. (EM/Anes are great for managing patients in acute situations . . . not so good at taking care of a complicated diabetic for 5 days).

And I'm still not sure how neurology worked its way into critical care. Working in a stroke unit? Great, can you fix the stroke? No. Any 'fix' is done by IR or neurosurgery. Any ensuing respiratory distress and/or organ dysfunction is handled by Internal medicine trained physicians.

I absolutely disagree. It depends on your training. Complicated DM patient = snooze.

How about taking care of a hunt head 4 SAH that has pneumonia, then managing your fluid balance for spasm versus them going into DI for 10days. My partner this year had one bad DI patient that literally was putting out 40-50L UOP a day. Yes, I am not even joking.

I am Anesthesia-CCM and I run a combo MICU-Neuro ICU.

My icu training, Anesthesia ran the Neuro ICU. I was trained and still read imaging nearly as good as the endovascular neurosurgeons at least in making calls for CTA/CTP.

Neuro ICU in the community is none existent unless you find a unicorn job. My prior boss created the current situation, unfortunately it took one change of admin to ruin a nearly brilliant unit that ran amazing for 15 years.

If you want to do Neuro ICU, unfortunately you’ll need to do another 1 year of Neuro ICU after normal ICU now. I feel I learned on the job with a strong mentor that built on a good fellowship.

Neuro ICU when you’re making stroke calls is incredibly stressful, much much more stressful than anesthesia or the CV ICU. It is very easy to kill a Neuro patient if you don’t act correct, or you miss evolving exams (going into vasospam, obstructive hydrocephalus on a SAH, etc).

 

[gulmohr]

It is a thing but there are very few and IMO combined residencies are a waste of time. You’re going to end up working in one field, just pick it now.

CCM should theoretically be less competitive than PCCM, but in reality is similar or more because of the fewer CCM only spots and the abundance of nephro/ID fellows gunning for them.

Like I said before, I wouldn’t worry so much about matching, especially if you’re an AMG. NCC and PCCM are very similar lifestyle and compensation wise, pursue what interested you the most, and don’t waste time with combined residencies.

*EM as well.

 

[CCM-MD]

*EM as well.

Good point. Interest from EM residents has increased further, given the current state EM is in.

 

[jthedestroyr]

EM has to do 2 years of ICU though. I believe if you want to do neuro ICU from EM it’s 2 + 1. That would be painful !

 

[DrMetal]

How about taking care of a hunt head 4 SAH that has pneumonia, then managing your fluid balance for spasm versus them going into DI for 10days. My partner this year had one bad DI patient that literally was putting out 40-50L UOP a day. Yes, I am not even joking.

Uh yeah, those are surgical and medical things.

Neuro ICU in the community is none existent unless you find a unicorn job.

And what does that tell you? Maybe "Neuro-ICU" should never have been created as a specialty in the first place.

Neuro ICU when you’re making stroke calls is incredibly stressful, much much more stressful than anesthesia or the CV ICU. It is very easy to kill a Neuro patient if you don’t act correct, or you miss evolving exams (going into vasospam, obstructive hydrocephalus on a SAH, etc).

All of which a good Medicine-trained intensivist can do.

Look, lets be honest here: All of the ICU-creep that we've seen over the last 14 years is because people aren't happy with their parent specialty.

 

[jthedestroyr]

The best intensivists are those trained in either Internal Medicine or General Surgery. (EM/Anes are great for managing patients in acute situations . . . not so good at taking care of a complicated diabetic for 5 days).

And I'm still not sure how neurology worked its way into critical care. Working in a stroke unit? Great, can you fix the stroke? No. Any 'fix' is done by IR or neurosurgery. Any ensuing respiratory distress and/or organ dysfunction is handled by Internal medicine trained physicians.

All of which a good Medicine-trained intensivist can do.

Look, lets be honest here: All of the ICU-creep that we've seen over the last 14 years is because people aren't happy with their parent specialty.

I disagree. I have never seen a medicine doctor besides my boss whose very niche walk into a Neuro ICU.

Let’s be honest here, only in the US are ICU ran my medicine. The rest of the world it’s all anesthesia ran, but the US anesthesiologist got greedy. I take personal offense you think it’s either medicine trained or surgery.

The surgeons get annoyed when any complex medical issues pop up and medicine people don’t understand surgery dynamics of of these populations or vast majority don’t.

Anesthesia CCM does phenomenally well in Neuro ICU and we excell in hybrid environments

 

[DrMetal]

Let’s be honest here, only in the US are ICU ran my medicine.

Yeah imagine that. Well, since the United States tends to be on the forefront of healthcare innovation/delivery, maybe we should follow its suit. There's a reason why people flock here from India and China to train, not the other way around.

In any case, should I ever need one, I'll take my chances in an American ICU (ironically the intensivist will be an anesthesiologist that night).

The surgeons get annoyed when any complex medical issues pop up and medicine people don’t understand surgery dynamics of of these populations or vast majority don’t.

Yeah, and so they work together, Medicine and Surgery.

I take personal offense you think it’s either medicine trained or surgery.

No you don't. You've been offended by much worse. And if you're truly 'offended', then my point resonates.

 

[gulmohr]

Have worked with great and some not-so-great intensivists with anesthesia, pulmonary, medicine and surgery backgrounds. Very small sample size but anecdotally, neurology based ICU docs a bit weaker. This is based on on my very limited experience during fellowship where the neurocritical attending would send the PCCM fellow to fix vent dyssynchrony while they conducted table rounds looking at brain scans.

Admittedly, I am far less comfortable than neurology trained people at deciphering the subtleties of brain MRIs but I think that's why good neurologist consultants are worth their weight in gold. The same could conversely apply to neuro-intensivists consulting for other organ systems I suppose.

 

[gulmohr]

Unrelated thought: People who voluntarily choose to work in burn units. What are they made of?! Gd heroes.

 

[RemyMcswain]

The best intensivists are those trained in either Internal Medicine or General Surgery. (EM/Anes are great for managing patients in acute situations . . . not so good at taking care of a complicated diabetic for 5 days).

And I'm still not sure how neurology worked its way into critical care. Working in a stroke unit? Great, can you fix the stroke? No. Any 'fix' is done by IR or neurosurgery. Any ensuing respiratory distress and/or organ dysfunction is handled by Internal medicine trained physicians.

My goodness. The amount of truly awful medical Intensivists I’ve encountered…

I have worked with all kinds of icu physicians from all different backgrounds. I’ve worked with great neuro icu attendings. I also worked with fantastic EM ICU folk who way more diligent and meticulous than many of my IM colleagues.

 

[DrMetal]

fantastic EM ICU folk who way more diligent and meticulous

They're also better looking and nicer than most crotchety Medicine and Surgery types. Also better golfers: I played a round with a EM ICU, was a +2 handicap, vs my +20. I should've practiced golf more during residency, but I had so many ICU rotations . . .

 

[dozitgetchahi]

My goodness. The amount of truly awful medical Intensivists I’ve encountered…

I have worked with all kinds of icu physicians from all different backgrounds. I’ve worked with great neuro icu attendings. I also worked with fantastic EM ICU folk who way more diligent and meticulous than many of my IM colleagues.

Erm.

EM/ICU and anes/ICU are very different flavors of doctor vs IM/ICU. And I completely agree with @DrMetal that they have a different, more short-term perspective than IM trained doctors.

That said, my experience as a physician is that there have been way more ****ty doctors of all stripes in practice than I was expecting to see when I started this process. So what you are seeing may just be a sample size issue. In America, for reasons not completely clear to me, lots of
doctors suck.

 

[Radetzky]

The discussion about background is pointless. The more ICU you do the better you get at it be it neuro, cardiac, MICU or SICU, regardless of what other specialty you've done. It's ICU not rocket surgery.

The only caveat is that you don't get to call yourself an intensivist if you can't manage an airway.

 

[The Knife & Gun Club]

The discussion about background is pointless. The more ICU you do the better you get at it be it neuro, cardiac, MICU or SICU, regardless of what other specialty you've done. It's ICU not rocket surgery.

The only caveat is that you don't get to call yourself an intensivist if you can't manage an airway.

Agree with the above. The people that are good at ICU are good at it because they do a lot of ICU in training and exert the effort to become good intensivist.

I would point out that being an intensivist is one job and being an internist/surgeon/anesethionogist/neuro/EM doc is a different one. People will bring their background with them to the unit and should be cross trained to competently handle any arena they are placed in.

Critical care is a lot more than managing just sick medicine patients, or sick surgery patients. It’s the principles of managing the aspects of critical illness that come with the sickest patients of every specialty.

So unless you plan on working in a hospital that doesn’t do surgery, doesn’t see bad neuro, cardiac, and trauma cases, etc thinking that critical care should be the arena of only medicine trained people is short-sighted

 

[gro2001]

I'm a medical student and I'm really starting to get attracted to critical care, and ultimately I would like to end up as an ICU physician.

I know that there are many ways to work in a crit care setting, but I don't really like the OR (anesthesia -> CCM is out), EM doesn't interest me, and the thought of doing 3 years of IM and potentially not matching PCCM/CCM scares me since I would personally not be happy as a hospitalist (I'm a DO, and from what I understand it'll be a tougher match as a DO).

I know that you can also go from neuro -> NCC to work in neuro ICU, and I had some questions about it.

1) Is NCC more of an academic job market, or are there plenty of opportunities in the community? In the community, how much can you expect to make as a neurointensivist? I'll probably have like $400k in debt...

2) Is it possible to do NCC along with general neuro, like IM doing pulm with CC? It seems like a good backdoor for when you're older and want to cut back on ICU time.

3) Is NCC on the same level of competitiveness as going from IM -> PCCM?

4) Are you happy as an NCC doc? Is this something you'd recommend to incoming med students, or is it better to take the "risk" with IM -> PCCM?

Thank you for your help.

1) The job market is smaller over all compared to CCM (far fewer hospitals have a neuroICU (or any other specialized ICU) compared to a general ICU. It does skew more heavily academic, though more community hospitals are opening up neuroICUs as it becomes an expectation for comprehensive stroke centers.

2) You can a bit, though I don't know how necessary or desirable that is. A few of my colleagues take general neurology call. Another transitioned to being a neurohospitalist. I don't know anyone who has gone to a full on general neurology outpatient practice, though I don't think that's impossible.

3) I don't think NCC is particularly competitive. Like CCM, some specific programs are very competitive and others have unfilled spots regularly. Easy enough to match somewhere, but I dont know that you just want to match anywhere.

4) I love the field and am very happy. Though I think med students should pick their base specialty based on how much they like that before thinking about fellowship. If you like neuro more than IM. If you like IM more, do that. Both specialities have a path to critical care.

 

[gro2001]

Erm.

EM/ICU and anes/ICU are very different flavors of doctor vs IM/ICU. And I completely agree with @DrMetal that they have a different, more short-term perspective than IM trained doctors.

That said, my experience as a physician is that there have been way more ****ty doctors of all stripes in practice than I was expecting to see when I started this process. So what you are seeing may just be a sample size issue. In America, for reasons not completely clear to me, lots of
doctors suck.

I've worked in both the US and overseas (where I worked with docs from all over the world, lots of UK/commonwealth, Middle East, Africa, South Asia), and my impression is that there are ****ty doctors everywhere, in about similar proportions. The best and the ****tiest doctors were all outside the US though. The minimum bar is a bit higher and more solid in the US given how standardized medical training is. But I still do encounter idiots pretty frequently.

 

[Doctoscope]

1) The job market is smaller over all compared to CCM (far fewer hospitals have a neuroICU (or any other specialized ICU) compared to a general ICU. It does skew more heavily academic, though more community hospitals are opening up neuroICUs as it becomes an expectation for comprehensive stroke centers.

2) You can a bit, though I don't know how necessary or desirable that is. A few of my colleagues take general neurology call. Another transitioned to being a neurohospitalist. I don't know anyone who has gone to a full on general neurology outpatient practice, though I don't think that's impossible.

3) I don't think NCC is particularly competitive. Like CCM, some specific programs are very competitive and others have unfilled spots regularly. Easy enough to match somewhere, but I dont know that you just want to match anywhere.

4) I love the field and am very happy. Though I think med students should pick their base specialty based on how much they like that before thinking about fellowship. If you like neuro more than IM. If you like IM more, do that. Both specialities have a path to critical care.

Thank you. Looks like you're a neurologist, so I was wondering if I could ask you how much $ one could expect as NCC vs. stroke/neurohospitalist. The thought paying off my debt + supporting other family members is scaring me a bit, and I just want to know I can do both from either path.

 

[gro2001]

Thank you. Looks like you're a neurologist, so I was wondering if I could ask you how much $ one could expect as NCC vs. stroke/neurohospitalist. The thought paying off my debt + supporting other family members is scaring me a bit, and I just want to know I can do both from either path.

Actually I am an emergency physician, and still split my time between the neuroICU and the ER (80% ICU, 20% ER).

Not super familiar with the neurology job market overall, so take this with a grain of salt, but my general impression is that the pay is comparable to slightly better than stroke and quiet a bit better than neurohospitalist.

For EM it seems slightly better pay in neurocrit than EM, though with more (but way chiller) hours. At this point I feel I am losing money with every ER shift I do, but that is mostly because of the RVU component of my ICU job vs the flat hourly rate in the ER.

Though all of this could be just regional.

 

[jthedestroyr]

Actually I am an emergency physician, and still split my time between the neuroICU and the ER (80% ICU, 20% ER).

Not super familiar with the neurology job market overall, so take this with a grain of salt, but my general impression is that the pay is comparable to slightly better than stroke and quiet a bit better than neurohospitalist.

For EM it seems slightly better pay in neurocrit than EM, though with more (but way chiller) hours. At this point I feel I am losing money with every ER shift I do, but that is mostly because of the RVU component of my ICU job vs the flat hourly rate in the ER.

Though all of this could be just regional.

Funny, that’s why I switched back to anesthesia only since I was losing money doing ccm lol!