Fellowship Dilemma: GIM vs ICU vs Cardio

[wishingwell]

Hi all,

I'm hoping someone can guide me to help me make a decision. I have enjoyed all 3 specialities during my rotations, specifically in my 2nd year where there is a step up to autonomy and little less scut work. I have spoken to fellows in each speciality.. most of them provided basic pros and cons, but some how, I can't seem to pick. Ideally, I want lifestyle balance, comfortable income, career longitiviety and flexibility, and some shifts where I can work in critical care settings at least while I am relatively young.

Currently, I am leaning towards either GIM vs Cardio. Would love to go into ICU directly but no one has been optimistic about jobs directly out of fellowship. Plus, as someone not interested in research, I am not sure what do most Intensivist do after their 1 week inpatient service.

I also fear dual applying as with limited electives, I can only do 2 cardio and 1 GIM as potential plan but don't want to go unmatched.

Any guidance would be helpful! DMs welcomed.

[ACHQ]

2 hours ago, wishingwell said:

Hi all,

I'm hoping someone can guide me to help me make a decision. I have enjoyed all 3 specialities during my rotations, specifically in my 2nd year where there is a step up to autonomy and little less scut work. I have spoken to fellows in each speciality.. most of them provided basic pros and cons, but some how, I can't seem to pick. Ideally, I want lifestyle balance, comfortable income, career longitiviety and flexibility, and some shifts where I can work in critical care settings at least while I am relatively young.

Currently, I am leaning towards either GIM vs Cardio. Would love to go into ICU directly but no one has been optimistic about jobs directly out of fellowship. Plus, as someone not interested in research, I am not sure what do most Intensivist do after their 1 week inpatient service.

I also fear dual applying as with limited electives, I can only do 2 cardio and 1 GIM as potential plan but don't want to go unmatched.

Any guidance would be helpful! DMs welcomed.

I'm at GIM staff at a community large community hospital in the GTA.

If you *truly* liked all three in terms of mental/emotional stimulation equally, then I would suggest going into the one that has the best job prospects (ahem... ahem... GIM) and pay (Cardio> ICU > GIM). But I think if you do prefer one from a non-monetary, non-job prospect standpoint then I would still say go for that because: I have friends in cardio that were able to land jobs (even though during residency we were told there were no cardio jobs...). ICU definitely is more limited, but again since I've been out some of the large hospitals have been hiring a few ICU docs (but the pool of available ICU trained physicians is probably plentiful). So you can't just base it off of that. But if you truly can say to yourself that I like cardio=GIM=ICU, then definitely GIM has a leg up on them in terms job prospect.

I'll give you the pluses for ICU and Cardio OVER GIM first (as a NON-ICU/NON-cardio outsider):

- The good thing about doing an ICU fellowship is that you can still do GIM if you don't land a job and locum in ICU (still very much available) until you do. The same with cardio, you can locum, do GIM and even be in a cardio clinic, until a cardio hospital based job opens up for you.

- Pay in cardio is BANK. why do you think people go into it?? ahahhaha kidding (only half). If you truly practice in the full breadth of cardio both inpatient and outpatient, especially if you have a clinic where you run cardiac diagnostics (treadmill stress tests, echo stress tests, nuc scans, holters etc...) then you are looking at easily 700-900k/yr, but then you pay about 20-33% overhead (but still thats like 500-700 k a year)

- Pay in ICU is also lucrative, and likely to go up in the next iteration of the schedule of benefits. Its not just ICU weeks that can pay, but CCRT weeks, and especially the CCRT stipend that you can for call is $$$/year. Most ICU guys make between 500-700k a year, and usually dont have any overhead.

- It's sometimes nice to be an expert in the area, walk in answer a question and walk away not having the MRP responsibility (although some places have cardiologist on the ward as MRP, and of course in the CCU). Cardio has that over ICU and GIM. Although I think I'm pretty respected by my sub-specialty colleagues overall I do think there is a mentality to "look down upon" GIM's (this can bother some people, doesn't really bother me)

- Most/all cardio on call are at home at night, the GIM will admit to the ward/CCU, and cardio will consult later, which is a plus as opposed to being in house like GIM (and nowadays especially at the larger/teritary sites ICU). That being said, the CCU doc will have to come in for true emergencies (tamponade patient requiring a tap, temp wire insertion for pacing etc...) although usually those are rare occurrences. They also will field all the CCU pages, so they probably do get called in the middle of the night. Also if I need a bit of advice over the phone at 3 am, they have to be available (which they are).

- Burnout in real in all those specialities, but particularly in ICU and GIM. good thing about ICU (and GIM) is you can just take time off without having to worry about coverage (as long as its approved by your hospital group... which most cases I don't see a problem)

 

GIM OVER Cardio/ICU:

- We definitely see more breadth then cardio (who see CAD/Chest pain, NSTEMI/STEMIs, CHF, and Arrythmias like 90% of the time). If you are happy with not having to see Sepsis again, or Pneumonias or GI bleeds, or Pancreatitis, or delirium or DKA or weird inflammatory stuff, then sure cardio is the way to go. But if you like seeing ANYTHING (and EVERYTHING) GIM has that over Cardio. I would say ICU obvoiusly has that over Cardio too, and is equally as broad as GIM.

- We have NO overhead. As long as you are a hospital based GIM you pay 0% in overhead even for clinic. Even accounting for this a cardio probably makes more than me, but not sure by how much (same advantage goes to ICU)

- We aren't tied down for vacation as we don't necessarily own our clinic patients. This can be an issue with cardio, to take prolonged periods of time off is hard unless you find someone to cover your clinic. This issue is big more so for family doctors, but can also exist for subspecialists to some degree. Again ICU has this same advantage.

- Job market is very good for GIM. Not sure how long it will last, but it seems most GIM's coming out now want to locum first for a bit before committing anywhere. Our site is always hiring GIMs. Anyone now can likely get a job right after finishing residency with no issues, where as in cardio you basically have to do at least one fellowship (all my cardio friends did to get there job). ICU jobs come and go, and there are alot of young looking for work ICU docs.

- I like the different types of roles I can play in GIM (similar to Cardio), where i can do inpatient MRP work, ED consults, clinic and inpatient consult service. Unless ICU does GIM on the side, they are just doing ICU weeks and CCRT.

Hope this is helpful.

[wishingwell]

@ACHQ Thank you so, so much for your response! You have given me incredible insight so far!

May I ask few follow up questions?

1. I was told post ICU fellowships, one have to do more sub fellowships to secure a job. Is that right?

1.1. Furthermore, how common is it for ICU or Cardio grads to do GIM shifts/clinics as I was told its quite rare?

2. Any thoughts on pursuing 4 year GIM and then an ICU fellowship?

[ACHQ]

5 hours ago, wishingwell said:

@ACHQ Thank you so, so much for your response! You have given me incredible insight so far!

May I ask few follow up questions?

1. I was told post ICU fellowships, one have to do more sub fellowships to secure a job. Is that right?

1.1. Furthermore, how common is it for ICU or Cardio grads to do GIM shifts/clinics as I was told its quite rare?

2. Any thoughts on pursuing 4 year GIM and then an ICU fellowship?

1. I haven't heard of this.... maybe in academic centres where they have trauma ICU's or Neuro ICU's, or CVICUs, but general MSICU's in the community there should be no reason why you can't get a job, its more of an issue of having a job available as opposed to credential creep... (for now)

1.1. GIM ER/ED consult shifts, not that uncommon. There are tons of fellows that do this in their PGY5+ year. In terms of once you are done also common to locum in GIM as those are the most available ER/ED shifts (and also help pay the bills). Clinics are a bit harder to come by because mostly will be ran by the core GIM group. That being said if you were fully committed to doing both ICU and GIM (not so much cardio cause you would have your own cardio clinic presumably) then you could likely do clinics.

2. I wouldn't do that, you'll be wasting a year, and would have to do 2 years of ICU ontop of that, trust me being a resident sucks balls, and you want to get that hell over with as staff life is better. If you are torn between GIM and ICU, it might make more sense to do ICU that way you can always fall back on GIM if need be (a lot of my ICU colleagues do a mix of ICU and GIM). That is if you like ICU enough, if you feel that would be too much to do 2 years of fellowship just to end up mostly doing GIM anyways then it may not be worth it. IF you know you just wanted to do GIM then just do the 4 year program and land a job

 

Note: this is for community sites in the GTA, I can't comment in other provinces or academics.

[futureGP]

I think it boils down to what flexibility you want.

 

Cardio - 6 years + 1-2 more at least for fellowship even in community (Echo, EP etc).

    Benefits are great pay, flexibility in practice setting (pure outpt running echo/stress/holter on anxiety patients, or inpt acuity with CCU/critical work). It is a long residency with long hours. Job market is not bad given there is plenty of low risk cardio clinics. You just have to like seeing young healthy anxious pts with chest pain. 
 

GIM: 4 years of training. No need for 5th year. But if you like cardio, you can probably do 5th year and do bunch of electives in cardiovascular prevention clinic etc and get comfortable with stress test/holter, evidence etc. 

   benefit is you have the breadth of GIM, but you will be tied to doing call if you are with a hospital. Outpatient private GIM clinic is virtually non-existent unless you like seeing the crumbs left over after FPs can’t find a subspecialist to refer to anymore (eg, chronic fatigue, random vague symptoms)

      You can probably do a lot of outpatient cardiology without ability to read echo as GIM, but you will never be ‘it’ and will always work with a Cardiology group if you are in a competitive market in big cities. Diff story if you go to small city.

 

For ICU, I personally wouldn’t recommend it up-front as you can always do ICU after Cardiology or GIM if you want. I have def seen people do ICU after 4-year GIM if they changed their mind. Job market is not great - you will most likely be locuming at several hospitals to fill your time. But who cares, as long as you fill your time, you’ll make money. 
 

 

If I were in your situation, unless you really like the breadth of GIM, I would do Cardiology assuming you are happy doing general cardio seeing Afib, NSTEMI, CHF etc. at least now there are many jobs, flexibility of work setting and great income.

 

 

One more thing, I wouldn’t give so much weight into overhead. Yes GIM/ICU have 0 overhead if you are purely hospital-based but that also means you have less control over your work (how many pts you see a day, how busy your clinic is, how many weeks you get etc). You have no great exit strategy if you decide you hate hospital life at 50 yo for eg.

However if you own an efficiently run cardiology practise, remember your overhead won’t be fixed at 25%. The more you bill, the percentage will go down. It is not uncommon to imagine 10-15% overhead once you have an efficient practice and esp if you share with a colleague. And later you can wind down or quit hospital altogether if you hate politics etc.

[GIMPCx]

On 1/23/2023 at 4:02 PM, ACHQ said:

1. I haven't heard of this.... maybe in academic centres where they have trauma ICU's or Neuro ICU's, or CVICUs, but general MSICU's in the community there should be no reason why you can't get a job, its more of an issue of having a job available as opposed to credential creep... (for now)

1.1. GIM ER/ED consult shifts, not that uncommon. There are tons of fellows that do this in their PGY5+ year. In terms of once you are done also common to locum in GIM as those are the most available ER/ED shifts (and also help pay the bills). Clinics are a bit harder to come by because mostly will be ran by the core GIM group. That being said if you were fully committed to doing both ICU and GIM (not so much cardio cause you would have your own cardio clinic presumably) then you could likely do clinics.

2. I wouldn't do that, you'll be wasting a year, and would have to do 2 years of ICU ontop of that, trust me being a resident sucks balls, and you want to get that hell over with as staff life is better. If you are torn between GIM and ICU, it might make more sense to do ICU that way you can always fall back on GIM if need be (a lot of my ICU colleagues do a mix of ICU and GIM). That is if you like ICU enough, if you feel that would be too much to do 2 years of fellowship just to end up mostly doing GIM anyways then it may not be worth it. IF you know you just wanted to do GIM then just do the 4 year program and land a job

 

Note: this is for community sites in the GTA, I can't comment in other provinces or academics.

ICU seems to be a nice mix of time off and no overhead. They also can often do GIM as well

[NoMatchNoProblem]

Is it possible to complete two subspecialties at different points in your career?

Like for example, say I choose the GIM/ICU route now, then 10-15 years from now I decide that I want something different in life, can I apply to cardiology and complete a second fellowship and reinvent my career?

Have you heard of anyone doing this?