Critical Care / ICU workload and salary in community

[Aconitase]

Hi everyone,

 

Long time reader and first time poster here! Thanks so much  

 

Have a question about ICU in terms of outlook and workload. I am an IM resident who has not done any ICU rotations as yet. 

 

I have a friend who finished his and he had a long talk with his attendings and fellows before he left about career planning. He is now full blown ICU. 

 

They talked about community ICU in particular and the workload and salary. The basic points were:

 

-ICU weeks (7 days) pay about 25-30k a week 

-work consists of mainly rounding with a coffee and family meetings

-nights are spent at home while the GIM in the ER does the hard work

-pretty standard is to work 18-20 weeks a year of ICU and 12 weeks of base speciality (ie ER or GIM shifts). That’s almost 20 weeks a year off and a salary of about 600k!

 

I am not sure if this is real or just academic doctors that are saying the grass is greener on the otherside? If it is his sounds incredible. Lots of time off, incredible pay, no overhead and night work all done by someone else. Even days it sounds like lots of time to eat lunch  and have a coffee etc. 600k with 20 weeks off - sign me up!

 

I was was thinking of setting up a community ICU elective in the GTA is this is true - anyone have any suggestions if this is all true?

 

thanks

[ACHQ]

A few points to note

- most GTA community hospital ICUs are 15+ beds. That’s a lot of extremely sick patients to round on (I’m not sure if they have more than one icu attending on at a time though, I would assume no), plus day time admissions/consults, could end up being an extremely busy and tiring week (which is why they do 1 week on 3–4 weeks off). (Don’t think they have plenty of time to just chill around)

- From speaking with staff community icu guys, most do 12-16 weeks I think alongside their base specialty. (So potentially more time off) but I think most fill that time off with their base specialty 

- There are absolutely 0 jobs in the GTA and a backlog of several grads from the past 5 years still trying to find permanent spots.

- The guys that do GIM + ICU in the community have to cover GIM call when there not in the icu (e.g. the hard stuff at night you talk about). Call coverage is variable and depends on the size of the call pool.

[Lactic Folly]

Not sure if some of our IM/CC people can chime in. If you're curious, I agree the best idea is to book an elective.

To me, doing overnight admissions pales in comparison to how tough I imagine family meetings can be. Worst case - end of life disputes and lawsuits that end up in the media...

Plus, who would cover overnight issues and procedures for the patients already in ICU?

[A-Stark]

12 hours ago, Aconitase said:

-ICU weeks (7 days) pay about 25-30k a week 

-work consists of mainly rounding with a coffee and family meetings

-nights are spent at home while the GIM in the ER does the hard work

That's probably better pay than is typical (and would be for a big unit). It otherwise sounds like you were talking to academic intensivists. While in the GTA many GIM staff will be in the hospital most of the night dealing with emerg consults, the ICU staff doesn't get to lie in bed all night and actually needs to, you know, come in. The pampered academic types who have their fellows deal with everything are something of an exception - I tend to think they are overpaid relative to the "value" of their academic responsibilities. 

12 hours ago, Aconitase said:

I am not sure if this is real or just academic doctors that are saying the grass is greener on the otherside? If it is his sounds incredible. Lots of time off, incredible pay, no overhead and night work all done by someone else. Even days it sounds like lots of time to eat lunch  and have a coffee etc. 600k with 20 weeks off - sign me up!

Given that the traditional model is 7 days/night of coverage straight, I'm not sure where you've gotten this idea. If you're on call in a community hospital, there is no "someone else" to do all your overnight work. 

[Aconitase]

8 hours ago, A-Stark said:

That's probably better pay than is typical (and would be for a big unit). It otherwise sounds like you were talking to academic intensivists. While in the GTA many GIM staff will be in the hospital most of the night dealing with emerg consults, the ICU staff doesn't get to lie in bed all night and actually needs to, you know, come in. The pampered academic types who have their fellows deal with everything are something of an exception - I tend to think they are overpaid relative to the "value" of their academic responsibilities. 

Given that the traditional model is 7 days/night of coverage straight, I'm not sure where you've gotten this idea. If you're on call in a community hospital, there is no "someone else" to do all your overnight work. 

I don’t know. Like I was saying it was what the academic guys were saying. The fellows had done locums and said that while they are on call at night they never really have to go in as the GIM in ER will admit and cover all new admissions. 

 

I just wanted to know can I actually only work 20-30 weeks a year and make 600k. Seems too good to be true 

[Aconitase]

16 hours ago, Lactic Folly said:

Not sure if some of our IM/CC people can chime in. If you're curious, I agree the best idea is to book an elective.

To me, doing overnight admissions pales in comparison to how tough I imagine family meetings can be. Worst case - end of life disputes and lawsuits that end up in the media...

Plus, who would cover overnight issues and procedures for the patients already in ICU?

I think they do cover overnight issues for their patients but the GIM handles all new admits. I haven’t don’t my ICU rotation and while those patients are super ill I would imagine most of the the procedures are done during working hours. 

 

Just surpised its home home call and they may only need to come in a couple of times a week

[Aconitase]

17 hours ago, ACHQ said:

A few points to note

- most GTA community hospital ICUs are 15+ beds. That’s a lot of extremely sick patients to round on (I’m not sure if they have more than one icu attending on at a time though, I would assume no), plus day time admissions/consults, could end up being an extremely busy and tiring week (which is why they do 1 week on 3–4 weeks off). (Don’t think they have plenty of time to just chill around)

- From speaking with staff community icu guys, most do 12-16 weeks I think alongside their base specialty. (So potentially more time off) but I think most fill that time off with their base specialty 

- There are absolutely 0 jobs in the GTA and a backlog of several grads from the past 5 years still trying to find permanent spots.

- The guys that do GIM + ICU in the community have to cover GIM call when there not in the icu (e.g. the hard stuff at night you talk about). Call coverage is variable and depends on the size of the call pool.

Is the job market that bad  

 

seems terrible for everything with decent pay like cardio, GI, nephro, and now ICU

[quackster]

On 3/7/2018 at 9:06 AM, Aconitase said:

 

I am not sure if this is real or just academic doctors that are saying the grass is greener on the otherside? If it is his sounds incredible. Lots of time off, incredible pay, no overhead and night work all done by someone else. Even days it sounds like lots of time to eat lunch  and have a coffee etc. 600k with 20 weeks off - sign me up!

 

This is not true. I would not call ICU a specialty where you can drink coffee all day and take a long lunch. One sick patient in the ICU can eat up your entire day. Never mind that the ICU can be emotionally exhausting (which is partly why I imagine most intensivists don't do it 100% of the time). 

I would do your ICU rotation and see whether you like the day to day of it. I would not pick it a priori because someone told you it was a nice life with good money. Patients in the ICU deserve a physician who wants to be there and who is ready to meet the demands of all that comes with caring for the sickest patients. 

[#YOLO]

LOL...

[Aconitase]

4 hours ago, quackster said:

This is not true. I would not call ICU a specialty where you can drink coffee all day and take a long lunch. One sick patient in the ICU can eat up your entire day. Never mind that the ICU can be emotionally exhausting (which is partly why I imagine most intensivists don't do it 100% of the time). 

I would do your ICU rotation and see whether you like the day to day of it. I would not pick it a priori because someone told you it was a nice life with good money. Patients in the ICU deserve a physician who wants to be there and who is ready to meet the demands of all that comes with caring for the sickest patients. 

Thanks. I will do that. Does anyone have a lead on a good community ICU rotation?

 

i didn’t mean to make it sound like you don’t work hard at all  However when you round you can drink a coffee while you work and usually there is time to get lunch I would think  it’s not a surgical liflestyle but has surgical money  

 

i don’t want to make it seem like I just want the money but is disheartening to see so many GIM subspecialties with no jobs and the only ones left have poor pay. There really aren’t a lot of options left for those that want a decent paying job anymore. 

[ACHQ]

11 hours ago, Aconitase said:

Is the job market that bad  

 

seems terrible for everything with decent pay like cardio, GI, nephro, and now ICU

Yes the job market is one of the worst for Internal medicine. 

 

Can someone clarify overnight icu coverage? At least from talking to recent GIM guys that locum in GTA community hospitals (North YorkGeneral, Toronto East General, St joes, etc...) The GIM on call covers new consults from the ER, ward issues+emergency’s AND covers the icu for new admits and/or patients already in the ICU who decompensate. Sounds prettty rough but that’s what they said....

[Aconitase]

24 minutes ago, ACHQ said:

Yes the job market is one of the worst for Internal medicine. 

 

Can someone clarify overnight icu coverage? At least from talking to recent GIM guys that locum in GTA community hospitals (North YorkGeneral, Toronto East General, St joes, etc...) The GIM on call covers new consults from the ER, ward issues+emergency’s AND covers the icu for new admits and/or patients already in the ICU who decompensate. Sounds prettty rough but that’s what they said....

This is amazing!! That’s what I heard! Dump on the GIM guy and sleep in your bed. ICU all the way!!

[Aconitase]

Anyone have a lead on a community elective in the GTA? I want to get out there and see if this is all for real and what the job market is like 

[Edict]

On 3/8/2018 at 6:10 AM, Aconitase said:

Is the job market that bad  

 

seems terrible for everything with decent pay like cardio, GI, nephro, and now ICU

If there is a golden gem in the mine, by the time the information spreads to us lowly plebs, the gem is gone. 

 

[thestar10]

On 3/8/2018 at 6:04 PM, Aconitase said:

This is amazing!! That’s what I heard! Dump on the GIM guy and sleep in your bed. ICU all the way!!

When you are going to be working non-stop throughout the night (GIM), might as well have good billings. When you are staff busy can be good.

[ACHQ]

13 hours ago, Aconitase said:

I want to get out there and see if this is all for real and what the job market is like 

This isn't just me saying it. You can search the forum for posts from others who have said the same thing. This is NOT a new issue. Jobs in ICU (anywhere academic, community) have been hard to come by for more than 5 years now. Several staff, clinical associates, fellows, and residents have echoed this to myself and peers. My friends who are applying to ICU for fellowship all know this.

There are some ICU staff on this board (although I'm not sure how frequent they visit). Cheech10 and Ploughboy could give us a staff perspective

[Aconitase]

22 minutes ago, ACHQ said:

This isn't just me saying it. You can search the forum for posts from others who have said the same thing. This is NOT a new issue. Jobs in ICU (anywhere academic, community) have been hard to come by for more than 5 years now. Several staff, clinical associates, fellows, and residents have echoed this to myself and peers. My friends who are applying to ICU for fellowship all know this.

There are some ICU staff on this board (although I'm not sure how frequent they visit). Cheech10 and Ploughboy could give us a staff perspective

Yeah I looked through yesterday and see this. 

 

I guess I want to do an elective and see how it goes and if I like the community work and also see if these ICUs envision hiring and also how billing works (ie are these rumours of anesthesia billing and 30k weeks and huge CCRT stipends, etc) real or just “fellow talk”. 

 

I would never do academic ICU but for community it seems perhaps like it’s a great high paying option with quite a few weeks off so I wanted to see if anyone knew a good site to try in the GTA. 

[keith_015]

Disclaimer: I am an ICU fellow.

The overnight community experiences I have seen:

1 - 20 bed ICU + 8 bed step down. Overnight coverage from HMO + resident. Attending nearly never called overnight. Funding for overnight came from CCRT funding pool.

2 - 8 bed ICU with flex up to 10. Overnight coverage by IM pool with ICU attending filling in 3 nights of 7 while on service. Home call, but busy enough that you would be in hospital at least 2-3 times a night. Coverage of IM consults from ER as well on call nights. 

3 - 8 bed ICU with flex up to 12. In house overnight coverage by ICU attending 3-4 nights while on service, otherwise outside ICU trainee or ICU staff coverage. No overnight IM call. Variable overnight admits 0-4. Coverage of Code Blue 24/7.

3 - 8 bed ICU. Overnight coverage by HMO. Attending called for all admits and facilitating transfers to Tertiary hospitals. ICU not in Ontario, funding model for attendings are salaried.

 

The business of a particular ICU can vary. It depends on how big/busy your hospital is and how many services are provided. If you have a lot of surgical programs, especially Gen Sx, Ortho, with overnight coverage, it will be busier. If you unit has CRRT coverage for the catchment area, you will be busier. On the flip side, the less your hospital has, the less acuity you might tie up. Not all community hospitals have telemetry or a CCU, so you may be stuck watching a rapid AF patient. Not all communities have step downs, and you can be stuck watching a medicine level patient if the wards are tight for beds. Depending on how "community" you are, you may not have a lot of consultative services, and everything is on you. Yes, you probably can drink coffee in the morning during rounds moving from bed to bed in the hallway pushing a cart while listening to nurses' reports and writing orders. A good ICU physician will actually go into the the room and examine the patient themselves, which I see often being relied upon the nurses' assessments. Any time it gets busy though, you will not be able to sit down. Sometimes you manage a patient for hours just trying to stabilize them. There can be a lot of frustration trying to get a patient transferred to a higher level hospital for services like neurosurgery. From what I have seen in these ICU's, the ICU physicians will have 1 week a month, rarely 2, working more 12-15 weeks a year.

 

As for billing, you can go through the Ontario physician schedule of benefits to get a sense on billing. You are billing there based on per day account. Whether the patient is vented or not will change the amount paid. You have to get creative to make a living in some of these smaller ICUs. Billing for things like procedures is a must, but per time spent, is low in compensation. Family meetings should also be billed. Really, you should have over 10 beds to make a higher level pay for ICU. For #2 above, the compensation is ~$15k/wk (or $180k for 12 weeks), and it is the overnight IM consults that help pay the bills.

 

If you want to do an elective, you should choose a hospital, reach out to the education liaison for that hospital who can help put you in touch with the ICU's Director who can help arrange an elective. Many hospital websites have information on size, services, ICU beds, etc. which can help you decide if that is a place you want to experience. Otherwise, you can see if the hospital is affiliated with a University and speak with the school's electives coordinator to help facilitate an elective.

 

The job market is not great, even in community. A rare opportunity pops up here and there. To stay academic, you have to provide something really special for the group there to want to keep you, which often means a good portfolio of research or potential for research. A lot of fellows end up doing the Clinical Investigator year to help do that. A lot of the people who don't stay academic try to make their way into community, but again opportunities are rare.

[futureGP]

I feel like ICU is so variable depending on the size of your hospital. I figure most of the GTA hospitals are pretty good size and can be considered community-academic if they have >10 vented beds.

I can't buy that in >10 vented community ICUs that there is no intensivist overnight. Most of these GTA hospitals are very sizable and would have many emergencies overnight that would demand an in-house intensivist or at least CCRT with ICU attending on-call at home on standby.

The ICUs where I've rotated through which are in smaller communities that have at any time 2-3 vented patients with 7-8 telemetry patients tend to be better in terms of lifestyle but definitely doesn't pay as well as the bigger ICUs.

The ICU weeks that pay 25-30k are probably larger ICUs with >10 vented patients who need full overnight care in sizable community-academic centres with probably pretty regular CCRT emergencies overnight. OHIP billing code suggests $300 or somewhat per critical care patient per day so you would estimate 10-15 fully-vented/supported patients a day which is certainly not a lifestyle ICU to cover.

I've rotated and shadow-billed in communities where you could clear ~15k a week as a royal college IM covering a 18-20 patient ward list and not have to deal with much of an emergency overnight. You'd be done rounding by 2-3 pm everyday and could try to fit in a few private clinic patients to increase the billing a bit.

[Aconitase]

On 5/28/2018 at 2:36 AM, futureGP said:

I feel like ICU is so variable depending on the size of your hospital. I figure most of the GTA hospitals are pretty good size and can be considered community-academic if they have >10 vented beds.

I can't buy that in >10 vented community ICUs that there is no intensivist overnight. Most of these GTA hospitals are very sizable and would have many emergencies overnight that would demand an in-house intensivist or at least CCRT with ICU attending on-call at home on standby.

The ICUs where I've rotated through which are in smaller communities that have at any time 2-3 vented patients with 7-8 telemetry patients tend to be better in terms of lifestyle but definitely doesn't pay as well as the bigger ICUs.

The ICU weeks that pay 25-30k are probably larger ICUs with >10 vented patients who need full overnight care in sizable community-academic centres with probably pretty regular CCRT emergencies overnight. OHIP billing code suggests $300 or somewhat per critical care patient per day so you would estimate 10-15 fully-vented/supported patients a day which is certainly not a lifestyle ICU to cover.

I've rotated and shadow-billed in communities where you could clear ~15k a week as a royal college IM covering a 18-20 patient ward list and not have to deal with much of an emergency overnight. You'd be done rounding by 2-3 pm everyday and could try to fit in a few private clinic patients to increase the billing a bit.

I just did my community ICU and it was amazing. This information while accurate I think misses a lot of what I saw

 

some things I figured out:

 

a) it is more work but you can round with a coffee but usually long days and families can be difficult and draining

 

b) billings are topped up with a lot of “crafty” things such as hypothemria (200bucks for signing a piece of paper) and anesthesia where they help provide sedation for their colleagues procedures (way easier than it sounds since patients are already vented and sedated). I asked why we needed to give the anesthesia as it seemed lame and they all laughed and did the Johnny Manziel money dance. Such a cool group! Basically they all make way more than day codes alone and the CCRT stipend is really high

C) jobs see hard to come by and most docs are young and hungry

d) night call was all the GIM. I took first call and hardly ever got pages and never had to go in. Showed up around 8 and the GIM has done all the work and handed them over 

 

it was so cool - amazing billing’s, weeks off and fun exciting work. Was definitely harder than I thought but way more lonely than I thought and way easier nights 

[A-Stark]

I always have coffee with me apart from when I can't. But I'm APP so I don't get to bill as such. It is helpful when GIM does much of the overnight admitting, but I always go and see the patient myself - I don't think it's appropriate to rely on someone else's assessment when I'm assuming care, but then this whole "independent practice" thing is kinda new. 

And it is lonely! But there's something to be said for doing everything yourself. And when Thursday afternoon comes you get to peace out and avoid the place for a while (provided there's no IM call coming up soon...). 

[eph]

Sorry for bumping an old thread.

Has the ICU jobs market improved any bit in Ontario?