Critical Care

[extrachromasome]

I'm curious about Critical Care in academic and non-academic centers in Canada, especially BC/Alberta. If anyone has information regarding typical schedule and lifestyle, remuneration, anything else in general this would be helpful.

thanks

[cheech10]

Critical care is an extremely varied field with a number of different practice models. Just to list a few:

 

Non-academic-

Open ICU - functions as a consultant for difficult cases, admitting service cares for patient from day to day - becoming less popular as most ICUs move to a closed model.

Closed ICUs - intensivists are the primary physician for the patient from the moment they enter to the moment they leave their ICU. Different scheduling models exist, most are some variation of 1 week on/2 or 3 weeks off:

Daytime coverage (8-5), with nighttime coverage by internist who is in-house

24 hour coverage, with home call in smaller/lower acuity ICUs

24 hour coverage with in-house call, usually 1 in 2 for a week at a time

Some hospitals have outreach/rapid response teams, so time may be spent staffing these teams; the time committment is usually not huge

 

This work may (or may not) be combined with time in the physician's base specialty - medicine, surgery, anesthesia, emergency.

 

Remuneration is currently very good (at least in Ontario, where I'm most familiar) with a daily rate per patient and extra fees for procedures, as well as an on-call stipend for covering the ICU +/- rapid response. 15-30k per week of service is typical, depending on the number of beds in the ICU.

 

In academic centres, the model is similar to most closed ICU models, with the obvious exception of having residents do the in house call while you provide backup from home.

 

Let me know if you have more questions.

[leviathan]

Critical care is an extremely varied field with a number of different practice models. Just to list a few:

 

Non-academic-

Open ICU - functions as a consultant for difficult cases, admitting service cares for patient from day to day - becoming less popular as most ICUs move to a closed model.

Closed ICUs - intensivists are the primary physician for the patient from the moment they enter to the moment they leave their ICU. Different scheduling models exist, most are some variation of 1 week on/2 or 3 weeks off:

Daytime coverage (8-5), with nighttime coverage by internist who is in-house

24 hour coverage, with home call in smaller/lower acuity ICUs

24 hour coverage with in-house call, usually 1 in 2 for a week at a time

Some hospitals have outreach/rapid response teams, so time may be spent staffing these teams; the time committment is usually not huge

 

This work may (or may not) be combined with time in the physician's base specialty - medicine, surgery, anesthesia, emergency.

 

Remuneration is currently very good (at least in Ontario, where I'm most familiar) with a daily rate per patient and extra fees for procedures, as well as an on-call stipend for covering the ICU +/- rapid response. 15-30k per week of service is typical, depending on the number of beds in the ICU.

 

In academic centres, the model is similar to most closed ICU models, with the obvious exception of having residents do the in house call while you provide backup from home.

 

Let me know if you have more questions.

 

15-30k/week? Or did you mean per month?

 

I am really interested in critical care because I enjoy doing procedures as well as applying my knowledge of physiology. However, I've worried that only seeing really sick patients all the time, many of whom will die, might get a bit depressing in the long run and might make me unhappy. When I worked as a paramedic, it was weird because I would love days where I got to take care of really sick patients that required me to think on my feet, yet at the end of the day, I would come home feeling really crappy if things didn't go well. Is anyone out there in CCM able to shed some light on this?

[A-Stark]

From what I gather from the handful of intensivists I know, they tend to divide their practice between ICU and their base specialty (anesthesia, surgery, etc.). One of the general surgeons here splits his time between ICU, trauma service, and one of the surgery services. He does a crazy amount of call (1 in 3), thanks to those three different services, but also takes 8 weeks off each year and from what I hear has a pretty nice lifestyle.

[extrachromasome]

Thanks for the replies and info.

I guess CCM could be somewhat depressing, although most of the CC patients are older adults, and personally, I find I can deal with death of older individuals without it affecting me too much. Pediatric CC, on the other hand, practically makes me suicidal.

[cheech10]

15-30k/week? Or did you mean per month?

 

I meant per week. It's 200 to 300 per patient per day, if you have 15 beds and 7 days at 200, that's 21k (these numbers are easily verifiable, check the G codes in the fee schedule for Ontario). Then add all the procedures: bronchoscopy, chest tubes, perc trach, anesthesia for endoscopy, etc, and hospital on call stipend and rapid response stipend, if applicable, and you can easily surpass 30k. A larger ICU might have 20+ beds, but split the call 1 in 2 for that week, so adjust the figures accordingly. Of course, that only applies for the week you're on service, and most places have a 1 week in 3 rotation. Still, the remuneration is more than fair, and is also why many of the community ICU guys have abandoned their base specialty practice.

 

As for the depression issue, I haven't felt it much. The way I see it, if it wasn't for our work, these patients would be long dead, and so anything we accomplish is a huge positive for them and their families. Also, the ICU tends to be very calm compared to the severity of illness going on in it, and many families are relieved by this when their loved ones are transferred to the Unit. The frequent family meetings also help families come to terms with the dying process (usually). So for me it hasn't been a huge issue (although it sure has made me more aware of my own mortality).

 

N.B. - I'm an ICU fellow.

[Satsuma]

He does a crazy amount of call (1 in 3), [....] and from what I hear has a pretty nice lifestyle.

 

This made me laugh and just goes to show how a good lifestyle can mean so many different things to different people. Because for me, I can not see how 1 in 3 call can possibly equate to a good lifestyle!

[Lactic Folly]

Thanks for the replies and info.

I guess CCM could be somewhat depressing, although most of the CC patients are older adults, and personally, I find I can deal with death of older individuals without it affecting me too much. Pediatric CC, on the other hand, practically makes me suicidal.

 

In a trauma centre, many of the critical trauma patients will be young adults.

[A-Stark]

This made me laugh and just goes to show how a good lifestyle can mean so many different things to different people. Because for me, I can not see how 1 in 3 call can possibly equate to a good lifestyle!

 

I didn't say that *I* understood how it could be. The other staff general surgeons here do 1 in 7 or even much less. Eight weeks of vacation is very nice though!

[Satsuma]

Thought I would post this to just give an idea of how 1 staff I worked with this week does it

 

So base specialty = anesthesia with a fellowship in critical care

 

Does anesthesia at a teaching hospital 3 weeks out of the month and does ICU at a smaller community hospital 1 week of the month.

Because there are no residents/fellows in the community hospital - just the one doc for ICU in that 1 week - it would be impossible to do "call" in the traditional sense. So how that hospital works it is...the ICU doc works from approx 07h00-22h00 every day for the week. Overnight the doc covering internal medicine in the hospital also covers the ICU.

 

This sounds like one very long week to me. But this staff really seemed to love it!

 

Basically this staff said the as a minimum you'd have to work about 1 week a month in order to keep up your skills. And that any more than that would become more difficult to work in your other specialty, not to mention you would be very tired. Apparently 1 week a month is a pretty typical arrangement.

[ploughboy]

However, I've worried that only seeing really sick patients all the time, many of whom will die, might get a bit depressing in the long run and might make me unhappy.

 

I had similar concerns before doing a couple of ICU electives in med school. What surprised me was how many patients in the ICU *don't* die. I believe the number is 20-25% of Canadian ICU admissions die during their hospitalization, but of those a lot die on the floor after being discharged from ICU.

 

That sounds like a huge number, but when you view it as 75-80% of the sickest patients in the hospital getting "better" (where "better" = "at least stable enough to not need the resources of an ICU") it's actually kind of an encouraging number. It's nice to see somebody who was wicked septic, tubed, on pressors etc start to recover.

 

It can be really sad when things don't go well, or as somebody mentioned upthread when it's a young polytrauma trauma patient, maybe with a brain injury, who is facing a long course of rehab and whose whole life has been turned upside-down in an instant.

[leviathan]

Thanks for the insight plough, cheech et al. I think one thing that throws off my perception is that being a paramedic, I rarely got to see anyone get *better* beyond something like a hypoglycemic patient who wakes up after some D50.

 

Anyone who was very sick either died before I could transfer over care, or they got better in the hospital after I had left them. That meant there were some days when I'd go home and I would just generally feel depressed. Good point about lots of sick patients getting BETTER in ICU, though.

 

What's the competitiveness of critical care in Canada? Does that competition differ depending on if you're coming from EM vs. IM?

[cheech10]

Critical Care is not that competitive overall, although Toronto was pretty tough to get into this year. The issue in Southern Ontario is a severe lack of jobs at the moment, though. AFAIK, there are more jobs available elsewhere around the country.

[pinkyandthebrain]

Does anyone know if it's possible to do GIM with a ICU fellowship and practice as a GP on your off days? Does anyone know of any physicians that do this and what there typical schedule is like, i.e 1 week a month in an ICU in a hospital, 3 weeks/ month practicing as a GP etc?

 

Also, how common is it for intensivists to take 2-3 weeks off a month- i heard some actually do this ? Can you still earn a decent amount if you just work about 12-15 weeks of ICU a year?

 

Any help would be much appreciated,

 

Cheers!

[cheech10]

I think your question about GP/Family Med and ICU was answered in your other topic. Just to reiterate, you CAN, and many people DO, at least part time GIM in addition to ICU in their weeks off. Most do it as locums/call shifts, but you can do it as an office based practice, the scheduling is just more difficult.

 

As for taking weeks off, many intensivists do take 2-3 weeks off per month, and work 16-20 weeks per year. Financially, a week of ICU is comparable to 4 weeks of GIM, roughly 30k per week (depends on size of ICU, presence of call and rapid response stipends, turnover in the ICU, vs. the exact nature and volume of the GIM practice).

[leviathan]

So if lots of CCM people work 1 week per month, does that mean they live at the hospital for that entire week? Or what kind of hours are they doing during their week "on"?

 

How long is the CCM fellowship? 2 years or 1?

[A-Stark]

From what I understand, they will be on-call most of the time they're covering the ICU (or all the time?). However this might imply working for 17 weeks out of the year - making $400k as that's the FTE - and either taking time off or working in the base specialty the rest of the time. The fellowship is 2 years.

[gb35]

Can you do family and then a critical care fellowship?

 

I'm just thinking, with the crazy weeks/renumeration you're describing, you could do a couple years working in walk-ins and doing CC fresh out of residency to get some really great experience and build some capital to then open a practice in your desired location.

 

Or is that not feasible?

[boodog]

Does anyone know anything about Pediatric Intensivists? Apart from the obvious difference in age, I wonder do they do a similar amount of procedures like central lines, etc?

 

Also what is the work model like? 1 week on, 3 off? Or some sort of variation? Also, I have heard that for ICU/PICU in there is a general saturation of the market in terms of jobs, is this also true?

 

Thank you for your input guys!

[Tan008]

Can you do family and then a critical care fellowship?

 

I'm just thinking, with the crazy weeks/renumeration you're describing, you could do a couple years working in walk-ins and doing CC fresh out of residency to get some really great experience and build some capital to then open a practice in your desired location.

 

Or is that not feasible?

 

You can't do a fellowship out of Family Medicine. Most people go into ICU out of ER, Anesthesia, Internal, or even Surgery.

[gb35]

You can't do a fellowship out of Family Medicine. Most people go into ICU out of ER, Anesthesia, Internal, or even Surgery.

 

What about the 2+1 with FM/ER? Or do you need the 5 year?

[A-Stark]

5 year

 

I don't know much about the peds side of things, but generally speaking there are fewer jobs as there are far fewer critically ill kids. Thankfully!

[cheech10]

Lots of different models, depends on the size of the unit and staffing. Three that I've seen:

- 1 intensivist for the week, in house from 8-6, on home call overnight with the in house internist covering overnight

- 2 intensivists for the week (esp if it's a bigger unit), doing 1 in 2 in house call for the week, and going home mid-afternoon post-call

- night float/shift work

 

Each intensivist would work 1 week out of every 3 or 4, usually. If every 4 weeks, most would probably do some practice in their base specialty, or at least some administrative work, etc. Hours sound great compared to the remuneration, but the work is often very stressful with a lot of night/weekend coverage.

 

Job opportunities are very tight right now, even smaller cities are close to full. The only units hiring are ~6-8 bed ICUs that financially make little sense to staff with dedicated intensivists.

 

PICU is a different beast than adult ICU; I can't comment much on it.

 

Family docs cannot do an ICU fellowship, even with the 2+1 EM year. It's a RC accredited fellowship, so you need a RC accredited residency; a CCFP residency will not get you in.

[Tan008]

What about the 2+1 with FM/ER? Or do you need the 5 year?

 

Yeah, you can't really do a fellowship out of a 2+1. There are some Family Docs (2+1) that work in the ICU but they work there as "clinical associates", so they are not really running the show because they don't have the "official" training even though they might have the necessary expertise after years of practicing. Also, those jobs are really hard to come by and will probably be even harder in a few years because there is a fellowship program for ICU.

[leviathan]

Lots of different models, depends on the size of the unit and staffing. Three that I've seen:

- 1 intensivist for the week, in house from 8-6, on home call overnight with the in house internist covering overnight

- 2 intensivists for the week (esp if it's a bigger unit), doing 1 in 2 in house call for the week, and going home mid-afternoon post-call

- night float/shift work

Nice...that doesn't seem bad given you take the other 3 weeks off. And even with ICU work alone it seems like you could make a decent salary with that if you didn't want to work the other 3 weeks. But I'd probably guess most would still do some casual work on the other 3 weeks in their base specialty.