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CA-3, Cedars Sinai Los Angeles
For anesthesiology residents the ICU is polarizing: some seem to love it and some can’t wait until their rotation ends. Some medical students chose anesthesiology for its direct nature. In the operating room you don’t have to wait for nurses to come back from their break to draw labs, rounding doesn’t exist, and you don’t have to talk with consultants all day. The operating room is the most hands-on place in the hospital. What more could you want?
My residency required five ICU months: medical ICU (MICU), surgical ICU (SICU), and neurosurgical ICU (NSICU) during my intern year, another month in the surgical ICU as a CA-1, then finally one month in the cardiac surgical ICU (CSICU) as a CA-2. I enjoyed the complex patients, complex treatment plans, and complex negotiations required to care for the sickest patients in the hospital. Plus, I could go to the bathroom whenever I wanted!
As a CA-2, I applied for critical care fellowship, also called anesthesiology critical care medicine (ACCM). At the end of my CA-2 year, I matched at Baylor College of Medicine/Texas Heart Institute in Houston, Texas. Here is what I learned along the way.
Intensivists tend to be energetic, curious, and insightful. They have broad knowledge of every organ system, deep knowledge of pathophysiology, and the intelligence to apply that knowledge to unique clinical scenarios. Besides large scheduled surgeries such as cardiac surgery and esophagectomies, ICU admissions are not planned; they occur because of unexpected life-threatening emergencies. You have to enjoy uncertainty, acuity, and difficulty.
One of my most memorable patients was a healthy young woman with a venous malformation on he left leg who developed uncontrollable chest wall hemorrhage after breast augmentation surgery. Over her five days in the ICU we gave her 60 units of blood products and caused iatrogenic TRALI before we finally stopped the bleeding using heparin. Turns out, acute events such as surgery can trigger a localized intravascular coagulopathy inside venous malformations that consume clotting factors and cause uncontrollable bleeding. Heparin stopped the localized coagulation cascade within hours. In the ICU, heparin can be a treatment for hemorrhage!
Critical care is one of the most dynamic fields of medicine. Anything can happen at any time. You have to figure out what the problem is and how to treat it before your patient dies in front of you. You will see complications you didn’t know existed or have never been reported. Does this challenge make you excited? Or would you rather focus on a single patient in the operating room?
Personally, I enjoy the challenge of critically ill patients. Solving challenging medical problems under time pressure makes me excited to wake up in the morning.
In OR anesthesia, your responsibilities are specific and defined. The ICU is a little different because you are the captain of the ship. You will lead a team rather than carrying out a specific, defined role. Every problem is by definition your problem.
You also control the agenda. Physicians, nurses, administrators, respiratory therapists, and your friend’s cousin all want their issues addressed immediately…however you only have finite time. If you can’t prioritize the most important parts of patient care the patient will die. If you under-communicate, important issues will be unresolved. If you over-communicate, you will waste time perseverating on minor details, which means you won’t have time to address the truly important issues. Efficient communication is key.
Your leadership role also means resolving disputes between team members. Diplomacy and tact are key in these situations. Can you convince a surgeon who is wrong in a given situation that their opinion is incorrect without insulting them? Can you work with a diverse set of personalities who may or may not like each other? Can you give feedback in a direct, constructive, helpful manner? Sometimes the ICU is more politics than medicine.
Honestly, I enjoy the politics of the ICU. I like figuring out individual psychologies then organizing them into a cohesive team. Convincing everyone to work together feels like solving a psychology puzzle.
Applications are accepted through the San Francisco match system starting in November, interviews are offered on a rolling basis until April, then match day is in late May of the following year. The match rate is between 90-100%. There are usually unfilled programs every year, however, the most competitive programs always fill up.
ACCM programs vary a lot. Some focus on NSICU, some SICU, some MICU, and others CSICU. Your personal statement should specifically state what you want from an ICU fellowship. What ICU experiences most resonated with you as a medical student and resident? What do you want to do with your fellowship? Where do you see yourself in 5 years? A specific personal statement and targeted application increases the probability of you and your perfect program finding each other.
Before I applied I knew I was interested in the CSICU so I purposely applied to 14 institutions with advanced cardiac surgery programs. I interviewed at five then matched at the Texas Heart Institute. I ranked Texas Heart Institute first because it had the most exposure to mechanical circulatory support devices, a robust TTE curriculum, and plenty of ECMO patients. I was very happy with the result!
SF match requires three letters of recommendation: one from your program director and two from attendings with direct knowledge of your clinical abilities. On your ICU rotations show up early, work hard, be flexible, and have a good attitude. The ICU is like a small town: your reputation can make or break you. One of my letters specifically mentioned how much the nursing staff enjoyed working with me.
ICU attendings usually work shifts so finding mentors can be challenging. In order to facilitate more longitudinal relationships you can present case reports, do research, or ask your program director for additional ICU rotations. I wrote an IRB-approved study with one of my letter writers and did OR cases with the other. I’m glad I was able develop relationships with my mentors a year before applications opened. If you think you might be interested in ACCM tell your program director so he or she can help you find opportunities.
Critical care will always be in demand. Right now, the demand is so high NPPs (non-physician providers) are employed by hospitals to offset the shortage of intensivists. After fellowship, applicants generally receive multiple offers in a variety of settings. You will also have the option of practicing OR anesthesiology.
Critical care jobs in community settings tend to be a mix of MICU and SICU. Due to differences in billing, critical care generally grosses less money than OR anesthesiology. For this reason, private groups tend to be focused on the operating room. Finding a private practice job with both OR and ICU is possible but more difficult than in academia.
Large academic institutions tend to be more specialized and more accepting of anesthesiologists splitting time between the OR and ICU. Critical care anesthesiologists might do high-acuity OR cases then take care of the same patients in their respective ICUs. Examples are a SICU attending doing liver transplant cases or a CSICU attending doing cardiac cases.
Critical care trained anesthesiologists might also choose to do 100% OR anesthesiology. They are often held in high esteem by their colleagues and given more challenging cases. Regardless of your practice setting, the ACCM fellowship gives you versatility inside and outside the operating room.
My end goal is to do 50% cardiac OR and 50% CSICU at an academic institution. In order to do this, I applied for cardiac fellowship in my CA-3 year.
Nabil Othman, MD is a CA-3 at Cedars Sinai in Los Angeles. He aspires to complete his ACCM fellowship at the Texas Heart Institute in Houston followed by a cardiac fellowship. He blogs at www.airwaybagelcoffee.com
Date of Publication: Spring 2021
