Friday, April 15, 2016

Q&A

I love getting comments on my posts, and I read all of them. Depending on how busy things are, though, I'm sometimes pretty late in replying. Here is a question posed by Ethan (thanks for the comment!). I'm posting it as a new post in case it helps any other readers.

Q: ...Looking ahead, I am very intrigued by the possibility of completing a critical care fellowship and practicing as a critical care anesthesiologist...If you ever have some time, I would be really curious to learn about your schedule on a monthly basis. Do you split time between the ICU and OR or do you work strictly in the ICU? Do your colleagues in critical care anesthesia have similar set-ups or is there some variation depending on the hospital system/institution? Any advice going forward would be appreciated.

Great question, but it's not really straightforward to answer. My advice is to talk to as many critical care intensivists as you can. In the U.S., most critical care units are staffed by pulmonologists (as opposed to Europe where last I checked, the ratio actually favored anesthesiologists). Particularly in private or community hospitals, a large proportion of departments are solely run by pulmonologists. I'm in a rare community hospital that actually has both anesthesiologists and pulmonologists in the ICU (and we are greatly outnumbered). Most places that have intensivists from different backgrounds (internal medicine, pulmonology, anesthesia, surgery, neurology) are large academic institutions or the VA. Keep this in mind if you choose the field; it's not easy to go into private practice and find a job that balances both specialties.

There are a number of reasons for this. Aside from historical or conventional reasons, money plays a big factor. Anesthesiologists can make more relative value units in the operating room than the intensive care unit. Private anesthesia groups don't have a large incentive for getting into the ICU. Most groups run lean in order to maximize revenue, and it's hard to organize scheduling between OR call and the ICU.

Nevertheless, I think it is important for anesthesiologists to be in the ICU (as well as those from all other backgrounds). The intensive care unit really requires a multispecialty approach, and we bring a lot of skills and knowledge to the table. Most community ICUs are mixed medical-surgical units, and we know the surgeons well. We understand the perioperative period best. We have special expertise in the airway, resuscitation, cardiopulmonary evaluation, and crisis management. But we also recognize our limitations; my medicine colleagues have more experience with other organ systems, interacting with other consultants, holding family meetings, etc. I strongly believe a multidisciplinary unit where all the attendings collaborate, especially in difficult cases, improves patient care, quality, and satisfaction.

In any case, the reality of it is that most anesthesia-trained intensivists who continue to practice critical care do so in academic or VA settings. However, I do know of some private practice anesthesia groups that are expanding their boundaries to cover the ICU. This is something strongly pushed by the American Society of Anesthesiologists, that we become physicians of the perioperative period, including covering critical care and pain management (the so called "surgical home" idea). It also integrates a private practice group with the hospital so that hospital administration recognizes what they bring to the table.

So regarding the specifics of your question - I spend the bulk of my time in the operating room. I spend about 20% in the intensive care unit, a 21 bed mixed medical-surgical-cardiothoracic unit. We cover a week of days at a time (Monday-Friday) during which I have no operating room responsibilities. We cover random night and weekend calls; if I'm on call for the ICU at night, I still have a day of cases in the OR (but it's usually light). We share this schedule with a group of pulmonologists who we have great relationships with. The schedule is made between the two departments so that my ICU and OR schedules don't conflict. I love my ICU time, and it reminds me of a lot of why I went into medicine, but it exhausts me. I enjoy my OR time as it tends to be a little less tiring.

Most critical care units have similar types of schedules. At my residency, for example, the ratio of anesthesia and non-anesthesia critical care faculty is about 50/50 so between two teams, there is almost always an anesthesiologist. They are on for a week at a time, and all the other weeks, they work in the OR, in teaching, or in administration. Nights and weekends are covered by random attendings who do work the daytime (but of course, nights and weekends are easier with residents).

Regardless of what you choose, when you finish, you'll get emails with locums tenens or per diem jobs, and the ICU ones are all quite similar: day or night shifts, usually a week at a time. Some look specifically for pulmonologists (to take pulm consults), others are open to any critical care trained physician.

I hope that helps! Please let me know what else I can answer. Thanks again for the comment.

7 comments:

Anonymous said...

Fantastic answer! Thank you, Dr. Chen! Just for fun, if you could have picked a different fellowship besides critical care, what would you have picked (e.g., pain, paeds)?

Craig said...

Good question! I probably would have gone into cardiac anesthesia. As you can probably tell, I like complex "bigger" cases. I really enjoy procedures, lines, and "sicker" patients. I strongly considered cardiac, especially given the interesting physiology, the ability to do TEE, and the similarities to ICU patients. The one thing I didn't like about cardiac anesthesia was the cath lab, and more and more procedures are being done in the cath lab (it's just not a place designed with anesthesiologists in mind, and I don't like being irradiated.

Anonymous said...

I've always wanted to see you do a post on what it's like to be married to another doctor. With the craziness of schedules on both ends, how do you find balance and time to be together?

Craig said...

That's a great question and I don't have a lot of wisdom on it yet. It's a work in progress - trying to communicate better, empathize with each other, compromise, and grow together. My schedule tends to be the more irregular one, but now that we are both out of training, it is easier (but not easy) to find balance. I know a lot of doctor-doctor couples and they all struggle with this. It is one of the hardest things to figure out.

Anonymous said...

Hi Dr. Chen,

Which resources did you find the most helpful/essential for CCM?
I am interested in critical care in the future and would like to get a head start in reading...

Would you recommend anything beyond the standard:
Marino's "The ICU book"
Owen's "The ventilator book"

Any insight would be appreciated, thank you!

P.S. What are your thoughts regarding O2 therapy and suppression of the hypoxic drive in chronic CO2 retainers? A practical case on your blog would be great!

Craig said...

Hmm...those are both good starting textbooks. I don't have a list of great starting textbooks. A lot of learning in the ICU is practical and on-the-job, so to speak. There is such a wide range of diseases, illnesses, medications, problems, and cases, that unlike other more narrow fields, you have to know a little of everything. What I general recommend for everyone is to get oriented to common sedatives (propofol, opiates, benzos, dexmedetomidine) and literature around sedation (daily wake-ups, minimizing sedation), ventilator modes/settings/how to interpret and report them, brushing up on reading chest X-rays, learning about ARDS (definition, low tidal volumes, things that work, things that don't work), thinking about CAP, HCAP, aspiration pneumonia, familiarizing with cardiovascular drips and pressors (when they are used, how they work, side effects), reviewing sepsis (especially since there are new definitions from a recent JAMA issue), and getting to know antibiotics/common bugs. As you can see, there's a whole lot to know - and way more beyond this (if you're in a place with lots of neuroICU, get to know subarachnoid hemorrhage, altered mental status, delirium, stroke management; if you see advanced cardiac life support like ECMO and VAD, you should get a basic understanding of that). For students, I get them to focus on simply gathering information, organizing by system, presenting succinctly in an organ based manner. The interpretation and coming up with a plan will come with time.

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With regard to CO2 retainers, I usually just target SpO2 88-92%; suppressing hypoxic drive to breathe can lead to acidemia, altered mental status, etc., but certainly don't tolerate hypoxemia.

Anonymous said...

Thank you for the helpful response!