Surgical/Anesthesia/Medicine CC from EM? Which to choose and why?

[muchasgraciasmuyamable]

Hey all,

Have been thinking a lot about pursuing a critical care fellowship after my EM residency, but am finding it hard to grasp the subtleties between the three different routes open to us. Can anyone shed some light on this? My biggest draw to CC is becoming an expert in resuscitation: procedural expertise, vent management, cardiopulmonary monitoring etc. Of course there are the classic multidisciplinary routes exemplified by Pitt, but what are the different flavors and drawbacks of each specific route? Coming from EM I'm more drawn to the "act now think later" which seems more surgical than the "think long and hard about your patients" stereotype you get with medicine. I'm also probably one of the few residents out there that still enjoys trauma and thinks it is a bit more complex than just the ATLS algorithm, so that makes the surgical programs more enticing, or at least the other routes with a few solid trauma rotations. But maybe anesthesia would provide the best balance between surgery and medicine realms?

The SCC fellowships obviously make me worried about being treated like a scut monkey for a year, but the UMD program seems solid and very EM friendly. Could somebody who has ever done the surgical prelim year for fellowship shed some light on how this time is structured?

Anybody who has gone through each respective route (ideally from EM), I would really appreciate your insight on this.

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[alpinism]

You’re going to do a CC fellowship to become an expert at resuscitation?

That’s literally the whole point of EM residency.

 

[Dr.CCM]

Hey all,

Have been thinking a lot about pursuing a critical care fellowship after my EM residency, but am finding it hard to grasp the subtleties between the three different routes open to us. Can anyone shed some light on this? My biggest draw to CC is becoming an expert in resuscitation: procedural expertise, vent management, cardiopulmonary monitoring etc. Of course there are the classic multidisciplinary routes exemplified by Pitt, but what are the different flavors and drawbacks of each specific route? Coming from EM I'm more drawn to the "act now think later" which seems more surgical than the "think long and hard about your patients" stereotype you get with medicine. I'm also probably one of the few residents out there that still enjoys trauma and thinks it is a bit more complex than just the ATLS algorithm, so that makes the surgical programs more enticing, or at least the other routes with a few solid trauma rotations. But maybe anesthesia would provide the best balance between surgery and medicine realms?

The SCC fellowships obviously make me worried about being treated like a scut monkey for a year, but the UMD program seems solid and very EM friendly. Could somebody who has ever done the surgical prelim year for fellowship shed some light on how this time is structured?

Anybody who has gone through each respective route (ideally from EM), I would really appreciate your insight on this.

Go medicine or anesthesia unless that sicu fellowship is really mapped out for you.

 

[The Knife & Gun Club]

Go medicine or anesthesia unless that sicu fellowship is really mapped out for you.

from a med student prospective - why is this a concern?

 

[Rekt]

from a med student prospective - why is this a concern?

SICU doesn't have a clue about EMs role. You'll essentially be equivalent to a surgical prelim.

 

[Dr.CCM]

from a med student prospective - why is this a concern?

Because the way that fellowship is done. You are only a fellow in the icu for one year and it is 9 months of surgical icus which don’t provide you adequate enough time taking care of micu and cvicu type patients. You need a breadth of exposure. In the medicine and anesthesia pathway, two years as a fellow. Anesthesia will do a min of 18 months icu as a fellow usually multidisciplinary medicine is min 12 but often does much more And also multidisciplinary . In the community, most icus are mixed med/surg/cvicu/neuro/ccu patients and you get everything.

 

[BlitheDilettante]

I'm an EM MS4 who wanna do IM-based CC.

At my school, an EM/CC attending just got kicked out of SICU after working there; I didn't know the reason. When I talked to him 1 year ago, he said he basically had little say in final management of surgical patients because of the surgeons. MICU at my hospital is very territorial, so he didn't get a job there either. Now he only does some time in Cardiac ICU and most time in the ED.

So yeah, n = 1 for me that SICU is not a EM/CC-friendly working environment.

 

[Lexdiamondz]

SICU doesn't have a clue about EMs role. You'll essentially be equivalent to a surgical prelim.

True.

Historically, most EM-CC trained docs were trained through surgical critical care programmes because they were generally less competitive and thus they were the most open to EM trained physicians prior to 2013 or so. That being said, the first year for alot of EM grads in SCC fellowships are just gen surg prelim years - the argument is you learn to manage surgical patients but the reality is that you end up doing alot of prelim level scutwork.

 

[TheSingularity]

Wow never knew about the SCC prelim year thing. Nuts. Why would anyone ever do this?

 

[Fox800]

Wow never knew about the SCC prelim year thing. Nuts. Why would anyone ever do this?

You shouldn't. The surgery training mindset is so hierarchical and malignant, just say no. What PGY-4/5 or mid-career physician returning to fellowship wants to be **** on by a general surgeon in the SICU who doesn't understand complex medicine? The SICU residents/attendings at my program had very poor understanding of medical problems that are bread-and-butter in the EM/IM world like managing atrial fibrillation with RVR. They would call down to the ED to speak to the EM attendings to figure out how to read an ECG. These are not the folks you want supervising you when you're managing heart failure, complex autoimmune/oncology/renal issues, obscure medical diseases etc.

IM-based is probably the best way to go, followed by anesthesia. I only say that because there seems to be a superiority complex in MICUs about IM-training, and anesthesia-based CCM programs tend to be more SICU/surgery heavy, and I'd avoid working with surgeons for that very reason.

 

[DrGasPasser]

I chose the anesthesia pathway because I enjoy taking care of surgical patients, especially those post complex cardiac/vascular and receiving mechanical circulatory support. After that, it was deciding on the program with mentorship, medical ICU exposure, etc.

I did not consider SCC programs for the reason previously described, namely the entire first year is some kind of nebulous rotating surgical “experience” instead of critical care.

 

[deuist]

What's really crazy is that even if you did a surgical internship prior to your EM residency, you still need to do the rotating first year. The only way out of it is to do both PGY-1 and PGY-2 in surgery prior to the EM residency. Crazier still is that gynecologists do not have this requirement and can go on to a 1 year SICU fellowship directly from the ob/gyn residency. It's rare, but I went to medical school with someone who did it.

 

[Lexdiamondz]

What's really crazy is that even if you did a surgical internship prior to your EM residency, you still need to do the rotating first year. The only way out of it is to do both PGY-1 and PGY-2 in surgery prior to the EM residency. Crazier still is that gynecologists do not have this requirement and can go on to a 1 year SICU fellowship directly from the ob/gyn residency. It's rare, but I went to medical school with someone who did it.

Yeah, I never really understood this, seeing as ObGYN doesn't even require ICU as part of their core curriculum, whereas EM requires 4 mos of ICU rotations and has many translatable skills as core competencies (airway management, etc)

 

[Dr.CCM]

You shouldn't. The surgery training mindset is so hierarchical and malignant, just say no. What PGY-4/5 or mid-career physician returning to fellowship wants to be **** on by a general surgeon in the SICU who doesn't understand complex medicine? The SICU residents/attendings at my program had very poor understanding of medical problems that are bread-and-butter in the EM/IM world like managing atrial fibrillation with RVR. They would call down to the ED to speak to the EM attendings to figure out how to read an ECG. These are not the folks you want supervising you when you're managing heart failure, complex autoimmune/oncology/renal issues, obscure medical diseases etc.

IM-based is probably the best way to go, followed by anesthesia. I only say that because there seems to be a superiority complex in MICUs about IM-training, and anesthesia-based CCM programs tend to be more SICU/surgery heavy, and I'd avoid working with surgeons for that very reason.

Are you EM/CC trained? Medicine and Anesthesia are equivalent depending on what you want to do. If you want to do academic IM, you should do IM pathway. If not it doesn’t really matter what your paper is from between the two.

 

[gro2001]

Perhaps this is just rehashing the same point, but another way of considering it is what kind of ICU style you want to practice in: open (where the intensivist is a consultant) or closed (where the intensivist is the primary). There are also some hybrid ones that don't fall completely into one or the other but are on a spectrum of openness.

MICUs seem to exist everywhere across the spectrum, but there are definitely fully closed MICUs
SICUs tend to skew further towards the open end of the spectrum, with many being purely open

By the way, another pathway to consider is neurocritical care. You can get boarded through that pathway too. Obviously much more focused and niche. There are some but not many EM docs doing it. Theres some TBI work to quench your trauma interest. Typically they are closed ICUs for the medical type patients (status, meningitis/encephalitis, strokes, myasthenic crisis, etc) and open for the surgical ones (SAH).

Some of the cool things about neurocrit is the immediacy of a lot of the pathology and the primacy of the exam in everything.

 

[DeadCactus]

Perhaps this is just rehashing the same point, but another way of considering it is what kind of ICU style you want to practice in: open (where the intensivist is a consultant) or closed (where the intensivist is the primary). There are also some hybrid ones that don't fall completely into one or the other but are on a spectrum of openness.

MICUs seem to exist everywhere across the spectrum, but there are definitely fully closed MICUs
SICUs tend to skew further towards the open end of the spectrum, with many being purely open

By the way, another pathway to consider is neurocritical care. You can get boarded through that pathway too. Obviously much more focused and niche. There are some but not many EM docs doing it. Theres some TBI work to quench your trauma interest. Typically they are closed ICUs for the medical type patients (status, meningitis/encephalitis, strokes, myasthenic crisis, etc) and open for the surgical ones (SAH).

Some of the cool things about neurocrit is the immediacy of a lot of the pathology and the primacy of the exam in everything.

Can you go straight from EM to neuro critical care or is this a subspecialty after a CC fellowship?

 

[SpacemanSpifff]

Can you go straight from EM to neuro critical care or is this a subspecialty after a CC fellowship?

Straight into the 2 year fellowship from residency. It's a separate critical care track.

 

[deleted547339]

Hey all,

Have been thinking a lot about pursuing a critical care fellowship after my EM residency, but am finding it hard to grasp the subtleties between the three different routes open to us. Can anyone shed some light on this? My biggest draw to CC is becoming an expert in resuscitation: procedural expertise, vent management, cardiopulmonary monitoring etc. Of course there are the classic multidisciplinary routes exemplified by Pitt, but what are the different flavors and drawbacks of each specific route? Coming from EM I'm more drawn to the "act now think later" which seems more surgical than the "think long and hard about your patients" stereotype you get with medicine. I'm also probably one of the few residents out there that still enjoys trauma and thinks it is a bit more complex than just the ATLS algorithm, so that makes the surgical programs more enticing, or at least the other routes with a few solid trauma rotations. But maybe anesthesia would provide the best balance between surgery and medicine realms?

The SCC fellowships obviously make me worried about being treated like a scut monkey for a year, but the UMD program seems solid and very EM friendly. Could somebody who has ever done the surgical prelim year for fellowship shed some light on how this time is structured?

Anybody who has gone through each respective route (ideally from EM), I would really appreciate your insight on this.

Where are you in your training? I did EM->CCM through medicine. Like most things in life, figure out your goal, then design your path there. Start with the end in mind.

 

[KeikoTanaka]

Very ignorant about this topic as a 2nd year Med student.

But, what exactly would a Surgical Fellowship even allow you to do as an EM Physician?

It seems like the only real reason for this fellowship would be if you're the single doc in the middle of North Dakota and you have no one else to rely on?

 

[Lexdiamondz]

Very ignorant about this topic as a 2nd year Med student.

But, what exactly would a Surgical Fellowship even allow you to do as an EM Physician?

It seems like the only real reason for this fellowship would be if you're the single doc in the middle of North Dakota and you have no one else to rely on?

This discussion is about surgically-based ICU fellowships. These training pathways allow fellows from an EM training background to work in the ICUs as critical care attendings (typically in SICUs)

 

[K31]

I’m one of the rare surgical critical care trained EM/CC physicians—I think at last count per ABEM there were 27 emergency physicians certified in SCC (I just finished fellowship so maybe I’m number 28?). I won’t lie, the first year of fellowship was difficult. We are allowed up to 3 months of ICU the first year of fellowship, I did 3 months of SICU. I also did a month each of Anesthesia and Neurosurgery, the remainder of the year was spent on various surgical services. When I was on those services, I was the one responsible for rounding on the ICU patients for that service.

My second year of fellowship was pretty standard—mostly SICU with some MICU, CVICU, Neuro ICU mixed in, plus a couple month of electives.

Now as to the question of why do a critical care fellowship. Does it make you a better resuscitationist? Probably, if only by virtue of the fact that you’ll be more comfortable with sick patients by virtue of greater exposure. I’m certainly more comfortable with the crashing patient than I was at the end of residency (especially trauma patients, as that was the majority of patients in the SICU in fellowship). However, critical care is more than resuscitation—as I frequently tell residents, being a good intensivist requires you to pay attention to the little details, in a way we frequently don’t (and don’t have time to) in the ED. By the end of fellowship, you need to be a well-rounded intensivist, not just a resuscitationist. You can be a good resuscitationist coming out of emergency medicine training. What a critical care fellowship should teach you is the breadth and the depth of ICU management, which includes the longitudinal care of the patient up to the time they leave the ICU, and not just the resuscitation phase.

 

[DrGasPasser]

Straight into the 2 year fellowship from residency. It's a separate critical care track.

You can also tack-on a 3rd year of neuro-crit to a traditional 2-year CCM fellowship to be able to sit for the neuro crit boards.

https://www.abem.org/public/docs/default-source/default-document-library/ncc-eligibility-criteria.pdf?sfvrsn=0