the road to critical care

[deleted9493]

I am curious as to what the views of others are concerning the potential pathways to becoming a critical care physician. Off the top of my head, I can only think of surgery, internal med. (pulm.), and anesthesiology routes. Of these, which do you think is most conducive to producing excellent intensivists?

I guess I'm hoping to start a discussion on the pros/cons of each specialty...as they pertain to future pursuit of critical care practice. I appreciate your input!

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[IMGforNeuro]

There is a neurocritical care fellowship after neurology residency, but that is specific to neuro.

 

[apma77]

any route is OK but i think anesthesia is the way to go for critical care, that way you have a life also and can enjoy your work

 

[gaslady]

Pediatric critical care can be done through Pediatrics or anesthesia. I think neonatal is only through Peds, but I'm not sure. ICU is very stressful and having a backup career or something else to spend part of your time doing, such as anesthesia is a good idea.

 

[DireWolf]

There are three main routes to ICU (although there are other ways):
1. Anesthesia
2. IM -> Pulmonology/Critical Care
3. EM -> Critical Care

I would say all three have the same benefits/downfalls.

1. Training is about the same length for each route = 4 (+/- 1) years.
2. Same hours, responsibilities, pay, etc.


The only difference is that if you get sick of critical care, what would you like to do instead? OR Anesthsia, IM, or EM.

 

[NaeBlis]

There are three main routes to ICU (although there are other ways):
1. Anesthesia
2. IM -> Pulmonology/Critical Care
3. EM -> Critical Care

I would say all three have the same benefits/downfalls.

1. Training is about the same length for each route = 4 (+/- 1) years.
2. Same hours, responsibilities, pay, etc.


The only difference is that if you get sick of critical care, what would you like to do instead? OR Anesthsia, IM, or EM.

Great point. Critical care has high burn out rate, and people often retire from it when they get older. So you have to decide what to retire into, anesthesia, general im, pulmonology (if you go the cc + pul route).

 

[KGUNNER1]

Just to clarify a few statements from earlier posts.

1. ANY specialty can do a critical care fellowship if that fellowship will take you.

2. The most common pathways are Surgery, IM, Anesthesiology, Peds.

3. After completing the above residencies, CC fellowships are 1, 2, 1, 3 years respectively.

4. Currently there are 3 CAQ (certificate of added qualifications) recognized by Surgery, Anesthesiology, and Peds. IM has recently converted their CAQ to a "board" regulated by ABMS and ABIM. The others do not have to answer to ABMS. It makes no difference in getting a job at all if you have a CAQ or a "board".

5. Ob/gyn grads can do a CC fellowship in either an Anesth or Surg program and sit for their respective CAQ exam.

6. As for IM, the most traditional route is combining Pulm with IM for a total of 3 years. If you don't like pulm, you can do any other speciality combined with CC for 3 years total. If you don't want another speciality, you can just do a 2 yr CCM fellowship after your 3 years of IM. You can get jobs with any route, however, they will be easier to find with the Pulm/CCM training because a lot of programs want you to cover Pulm clinic, sleep, PFT lab etc...

7. ER and Neuro can do CC fellowships. Currently no CAQ or Boards exist in the states. Grads can take the European "boards". There is very little problem or "resistance" from someone trained in a reputable program with these backgrounds and jobs can be easily found.

8. Burnout can be an issue. Critical Care is moving to more shift work, so burnout in the future will be less. Very few Anesth. docs are going into CC currently. Only about 40 - 50 a year. There are much more lucrative jobs with better hours for Anesth. You really have to love the unit.

9. Traditional surgery route is combined with Trauma training. There is no "boards" or CAQ for trauma surgery, just Critical Care.

10. What is the best way to train? In a multidisciplinary program where you get a BROAD experience from several specialties. Probably the most well known and "gold standard" for the multidisciplinary program (yes I am biased) is the Univ. of Pittsburgh. www.ccm.upmc.edu. You have to love your base training to be a good CCM doc. It really doesn't matter. You'll learn what you need to know in fellowship, if it is a good one. Each base speciality brings a different talent to the table.

Check out the Pitt website. It is full of information. www.ccm.upmc.edu.

Also check out the Society of Critical Care Medicine's website. They also have a lot of information. www.sccm.org.

If anybody has any questions, feel free to contact me off the list.

Good luck,
Kyle

 

[deleted9493]

Some solid information here, folks. Thanks to all but I especially applaud the writing of Kgunner.

 

[2ndyear]

Glad to see some good critical care discussion going on here. I just read an article in the local paper about Leapfrog and how that impacts ICU's. Basically studies have shown that having an intensivist staffed ICU saves hospitals money and patients get better quicker. There is a big push to get 24 hr. intensivist coverage in most big ICU's. The article made a point of saying how hard it was to recruit and retain people who wanted to do critical care. I think this is going to be a real booming area in the next few years, so definately consider it if you haven't chosen a specialty yet! In fact the available jobs already far outnumber the fellows that are being produced. As mentioned previously, only 50 anesthesiolgists per year are taking ICU fellowships. I matched anesthesiology this year and am considering an ICU fellowship. In terms of hours, it's becoming more and more like ER: shift work. This can be a big draw to the specialty as students consider lifestyle issues a lot when picking a career. By the way, since this is a frequently asked question in many forums, around here (midwest) ICU docs make $1000 per shift plus procedures.

 

[IMGforNeuro]

Does that mean $1000 per day assuming one shift per day. If you include procedures then it could be even more.
How long are the shifts and how many per week?
Do you also have an idea about neurocritical care?

 

[KGUNNER1]

Does that mean $1000 per day assuming one shift per day. If you include procedures then it could be even more.
How long are the shifts and how many per week?
Do you also have an idea about neurocritical care?

Salaries vary between positions. I think $1,000/day is about average. Some private practice groups build in an incentive plan. This is to encourage the intensivist to take time and document well so the group can get reimbursed. This isn't intended to increase procedures. Usually the incentive plan is something like: once your collections pay for your salary for the year, you get to take home 40% of the remainder of the collections. Of course this number is negotiable. Most shifts are 10-12 hours. It is VERY difficult to get in a group that can easily cover 24/7. There is a shortage and just not enough intensivists to cover this much.

What do you want to know about neurocritical care? Here is a very good website. http://www.neurocriticalcare.org/index.php
Tom Bleck from UVA is probably the most well known neuro-intensivist. I'm sure he'd welcome any questions. There are fellowships popping up everywhere. There are no boards or CAQ, so you'll have to travel to Europe if you aren't already boarded in IM/CCM, Surg/CCM, or Anes/CCM.

You don't necessarily need to do a special neuro-ICU fellowship. IMO, if you are a neurologist, you already know more about the brain than just about any other specialty. So you should get a very well rounded multidisciplinary ICU experience, such as Pitt www.ccm.upmc.edu. I know I sound like an advertisement for Pitt, but this is probably the most well known multidisciplinary program in the country.

Plenty of jobs whatever road you take.

Kyle

 

[Gator05]

Peds critical care can't be done via anesthesiology, unless you have completed a peds residency prior/after CA1-3 years.

Disappointing, I think, considering the high burn-out rate and (relatively) low-interest in peds critical care (my understanding; hopefully am wrong!).

 

[KGUNNER1]

Peds critical care can't be done via anesthesiology, unless you have completed a peds residency prior/after CA1-3 years.

Disappointing, I think, considering the high burn-out rate and (relatively) low-interest in peds critical care (my understanding; hopefully am wrong!).

Correct. Like all the other Peds fellowships, it is also 3 years (1 yr doing research).

KG

 

[augmel]

Some peds critical care fellowships will accept anesthesiologists without having done a peds residency. UT Southwestern is one of them.

http://www8.utsouthwestern.edu/utsw/cda/dept113231/files/122201.html

 

[sean wilson]

"ICU docs make $1000 per shift plus procedures."

Perhaps, but residents in gas at Mt. Sinai in Manhattan make this after taxes on a 24-hour moonlighting shift. Unless you're billing $$$ for the procedures, I'd call this not a great deal financially-speaking.

 

[KGUNNER1]

Salary varies quite a bit. Academic places range from probably around $150k - $220k. Private practice around $180k to $300k. It all really depends on your payor mix, where you practice and if you have an incentive plan built into your contract.

Obviously not nearly as lucrative as Anesthesiology, hence you have to really need to love to practice it.

KG

 

[IMGforNeuro]

What do you think would be the salary in neurocritical care in academics as well as private practice, considering that it has more neurologic base ?

 

[KGUNNER1]

No different than other types of critical care. Critical care is reimbursed on time. If you document that the patient was "very sick" and critical care was warranted, Medicare and other 3rd party payors will let you really define it, as long as the medical record backs it up.

If you spend between 30-74 min with a patient, not including procedures, you get to bill for critical care time, the code is a 99291. This reimbursement varies but usually is anywhere between $180 - $350. If you spend more than the 74 min, then you get to add 30 min increments at slightly lower rate. This is within a 24 hr period.

So the way you make critical care pay for itself is by having 10-12 patients that you can consistently bill 99291 codes for. Procedures are a nice little extra, but that is not really where the consistent cash comes from.

This applies to critical care in the ED, Floor (waiting to go to the ICU) and ICU. It doesn't matter between SICU, Trauma or MICU.

Now if you get into a group where the neurosurgeons are their own department and they are in a nice cushy suburb where everyone has insurrance, you will obviously make more $ in the ICU. Many times the Neurosurgeons don't want to worry about the ICU and will turn it over to a unit director etc... If the monies come back entirely to the CCM group, then your salaries could substantially increase.

KG

 

[Adcadet]

Kyle,
can you comment on ER/IM training? What does that allow you to do? Would an ER/IM trained doc almost be a competent CCM doc without the need for a fellowship? Do you think the ER background (in addition to the IM) adds much to the practice of CCM?

I'm doing CCM research this summer and am very interested.

Thanks!
Adcadet

 

[KGUNNER1]

Kyle,
can you comment on ER/IM training? What does that allow you to do? Would an ER/IM trained doc almost be a competent CCM doc without the need for a fellowship? Do you think the ER background (in addition to the IM) adds much to the practice of CCM?

I'm doing CCM research this summer and am very interested.

Thanks!
Adcadet

All IM/EM training does is allow someone to do 2 residencies in 5 years. Since I was actually interested in IM as well as EM, and knew I was going to do critical care, I figured the combined program would give me many more options and a nice variety once I was finished. I was correct on both assumptions.

Anyone definetly needs to do a Critical Care fellowship before they can really understand the nuances of Critical Care. Sure, any Monkey can do procedures and any Surgical Intern can give fluid to a hypotensive patient, but you really need to do this day in and day out for 1-2 years to really develop a strong fund of knowledge and patient management skills over a broad range of disease states.

I think the EM background always puts a "sense of urgency" in the back of my mind when I round. There is none of this "wait until tomorrow and re-evaulate" mentality which occurs in other specialties. The ER is full of critically ill patients and it is a lot of fun to "bring the unit down" to the ER. Some of my most memorable resuscitations were in the ER.