Raghu Seethala, MD
Associate Editor, The Unit
Editor’s Note: This article is the first in a 3-part series on Life After Fellowship. This series will explore how to find the right job after fellowship and considerations for new graduates on practice life.
Part I: Types of Critical Care Jobs
Part II: Getting the Right Job
Part III: How to Structure a Job for Professional Satisfaction
You are in your last year of a critical care medicine (CCM) fellowship. You have spent countless hours and nights mastering the intricacies of ventilator management and the art of vasopressor usage. At this point you can intubate a patient, place a sterile central line and arterial line, and have the mean arterial pressure above 65 mm Hg for any patient in less than 30 minutes! All your hard work during the past 5-6 years is about to pay off. You are going to be an attending and conquer the frontier of EM-CCM! But wait ... what’s next? What kind of job are you going to get? How do you go about finding this job? How do you stay happy and have a long and fruitful career? EM physicians have pursued CCM training as far back as the 1970s, but much has changed in the past few years. What lies ahead for you? We have put together a series of articles to address this important topic. We interviewed several experienced EM-CCM clinicians and combined their wisdom into these articles. This first article will focus on the type of jobs and opportunities available for EM-CCM trained physicians.
What kinds of jobs exist for EM-CCM trained physicians?
There are several different EM-CCM job models. They can broadly be broken down into which discipline you practice and the teaching status of your hospital. Within each of these categories there is much variation, but it’s useful to think about these general distinctions when looking for jobs.
EM only – A recent survey by Mayglothling et al demonstrated that approximately 20% of emergency physicians (EPs) practice solely in the ED after completing a CCM fellowship.1 Typically they staff the ED as any other EP in the group. Many EDs have a dedicated area to care for critically ill patients. EM-CCM physicians may be scheduled to work the shifts that include the resuscitation area more than their colleagues. They typically have their niche as the “critical care guru” in the ED. Often they will take on other administrative roles in the department such as ICU liaison. They are involved in the development of critical care protocols and pathways, and QI projects involving critical illness (ie, sepsis, post-cardiac arrest, trauma, etc.). Additionally they will provide didactics regarding resuscitation/CCM topics. These roles are not restricted to academic practices only; in a community hospital setting, having extra training gives the EM-CCM physicians added qualifications to seek leadership positions. Their experience and training in the ICU often gives them a seat at the table on hospital-wide committees.
One of the biggest benefits for this type of job is seeking employment in one department. You have only one boss, one paycheck, and one schedule. It is easier to find this type of job as you are pursuing a traditional job search path for an EP. One disadvantage can be if in a few years you decide you want to practice CCM again, it may be difficult to find a job without having had any recent CCM job experience.
EM/CCM split – The same survey reported that approximately half of EPs that have completed CCM fellowships elect for a split EM/CCM position.1 Many go into a CCM fellowship because this is the type of job we envisioned ourselves having, but this can be the most difficult type of job to find. The split can vary from 90% CCM/10% EM to 10%CCM/90%EM and everything in between. A common schedule is to set a number of weeks per year dedicated to the ICU, and then ED shifts spread throughout the remainder of the time. An example of this could be working 1 week per month in the ICU, and then 2-3 ED shifts per week for the remainder of the month. EM-CCM physicians have obtained positions staffing all the various ICUs in existence. The majority of them practice in surgical/surgical ICUs. This is probably a result of the majority of the early EM-CCM pioneers completing surgical CCM fellowships, but others practice in medical and medical/surgical ICUs. Some hospitals, especially academic centers with internal medicine (IM) residencies, may be reluctant to have a non-IM CCM-trained EP staff their MICU because of perceived ACGME requirements for IM residents, but this is somewhat hospital-specific. But this is not true for all hospitals and there have been academic centers that have staffed their MICU with a surgery CCM or anesthesia CCM trained EPs.
There are several different payment models for an EM/CCM split position. One model has the EM-CCM physician housed in the ED with a contract from the ED. The ICU then pays the ED for the clinical time provided by the physician. Most hospitals do not have a department of Critical Care Medicine, so it’s usually the department of Surgery, Anesthesia, or Medicine that is paying the ED for the hours worked by the EM-CCM physician. Under this model the EM-CCM receives one paycheck from the ED. Another model is that the physician’s salary comprises, essentially, 2 jobs; the ICU (surgery, anesthesia, or medicine) pays them and the ED pays them, with one department sponsoring the physician and paying benefits. Depending on the split, EM-CCM physicians can also be primarily employed by Surgery, Anesthesia, or Medicine, and moonlight in the ED. There are many different options for splitting time between EM and CCM. It is important to keep this in mind and remember all the other specialties that practice CCM have been finding creative ways to split their time as well.
Practicing in the ED and the ICU can be rewarding. It may help reduce physician burn out, having the hectic pace in the ED balanced by the intellectual controlled schedule of the ICU. These positions also give more exposure and presence of the ED in the hospital. On the other hand, it is usually more difficult to find this job since you are generally approaching two different departments for a part-time job. Additionally, scheduling can be more difficult. For example, you may have to work a certain number of weekends and holidays for both departments and that can become hectic for you and confusing for the schedulers. You are usually going to be expected to go to both sets of faculty meetings, journal clubs, resident lectures, etc. It can sometimes be difficult to advance your career if you are working for two bosses. Despite this, the EM-CCM split position is the most common type of job that is sought and will likely continue to be so.
CCM only – About a quarter of EM-CCM physicians go on to only practice in the ICU. Under this model, they are fully employed by the department that runs the ICU. They are no different than the other inpatient intensivists. A full time intensivist schedule may consist of 20 to 26 weeks per year spent clinically working in the ICU. Usually, if these physicians choose to go back to practicing some EM, it is not difficult to find a position.
Academic vs. Community:
All of the job types described above can exist in an academic or community setting. Most (65%) EM-CCM physicians practice in an academic setting. In Mayglothling’s survey, 17% of EM-CCM trained physicians practiced in an academic-affiliate hospital and 18% practiced in a straight community hospital.1 There are many differences between academic and community jobs. In academic jobs, a significant portion of time will be dedicated to nonclinical duties including research, teaching, clinical innovation, and administrative duties. Community jobs tend to be more clinical practice based with opportunities to get involved in administration or quality improvement not mandatory. Compensation will differ between the two as well, with community jobs usually paying more. Academic affiliate hospitals are sometimes a nice compromise, for those that like to teach and would like to still have some resident or medical student exposure, but not necessarily get caught up in the rigors of academic advancement. Ultimately the decision will lie with you and what you find most rewarding at the end of the day.
What is the job market like?
For the past decade we have heard so much about how critical care services in the US have exponentially been growing. The population has been aging and increasingly using these services. There have been many papers describing the huge shortage of intensivists and the need to open new training pathways. This makes it sound like it should be real easy to find a job! But it may not necessarily be easy to find the exact job you want. The need is for intensivists, not necessarily split practice EM-CCM physicians. Additionally, the need is in the community settings and rural areas. The academic hospitals where many EM-CCM physicians train and would like to stay are saturated. It can be difficult to fit into their ICU block rotation schedules. With national research funding being cut significantly, many of the academic physicians are being forced to work more clinically, resulting in fewer job opportunities at these centers. That being said, there is still a huge job market, but prospective applicants should consider being flexible.
What does the future hold? … ED ICUs!
The ED ICU may be the wave of the future. An ED ICU is a unit within the ED that has capabilities similar to those of the ICU, in terms of monitoring, equipment, and staffing. A hybrid model of resuscitation area and ED ICU is becoming more popular, and this may truly be an untapped market for EM-CCM trained physicians. As we mentioned earlier, many EDs have dedicated resuscitation areas already, but true ED ICUs are few and far between. EM-CCM physicians would be ideal to staff these units. Weingart et al provides an excellent summary of the different ED intensivist models and describes the capabilities of an ED ICU.2 These units function as units for new critically ill patients being brought into the ED or for patients who decompensate while being cared for in the main ED. The units are equipped to care for the patient after the first hour of illness and would serve as a safety net for hospitals with ICU capacity issues. Some patients will be cared for aggressively for 4 to 6 hours, rapidly improve, and no longer need the ICU level of care.
Several hospitals in the country have dedicated resuscitation ED ICUs, including Henry Ford Hospital, Stony Brook University Hospital, and Elmhurst Hospital Center. Most recently, the University of Michigan launched the grand opening of its Emergency Critical Care Center (EC3). The financial success of these units remains to be seen. ED administrators will be concerned regarding the bottom line of these units and how to make them profitable. How many patients need to be seen? How many procedures need to be performed? What is the optimal length of stay (LOS) for these patients? Whether or not these ED ICUs are practical will likely depend on the individual hospital. They may be more sensible in hospitals with long ED LOS for ICU-bound patients, while not so sensible for hospitals with minimal ICU boarding time. Another option is to have an actual ICU, owned and operated by the ED, similar to observation units that are run by the ED. This ED ICU would be separate from a resuscitation bay and actually be the final destination of the patient and staffed only by CCM trained EPs. The goal patient population for this unit would be patients we suspect would require less than 48 hours of critical care. During times of extreme census it could serve as overflow for longer-term ICU patients. At this time we are unaware of any ED ICUs like this in the US.
Regardless of the finances of these units, it seems like the resuscitation ED ICU would be a rewarding unit in which to work. These units truly integrate the two specialties that we have trained in. We shall wait and see if these ED ICUs are successful and become more abundant. This may be the ideal position for the next generation of EM-CCM physicians.
Dr. Seethala would like to acknowledge Dr. Jay Falk and Dr. Timothy Ellender for their insight in preparing this article.