What Does a Pulm Critical Care Medicine Doc Do?

Session 57

Dr. Tom Bice is an academic pulmonary critical care physician in North Carolina. Today, we talk about pulmonary critical care and what you should be doing if you’re interested in it. Tom has been out of fellowship for four years now.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:03] Dr. Bice’s Interest in Critical Care Medicine

Not being able to decide on one topic in medicine, Tom knew he wanted to do a little bit of everything. And he has mild to moderate ADD. He also considered emergency medicine early on, but he found he didn’t enjoy people showing up at 3 am with significantly non-emergent problems.

So when he was doing his rotations in surgery and medicine, he realized that all of the patients and disease processes that were cool ended up in the ICU. What cemented his decision was his OB rotation. A young 26-year-old lady with sickle cell anemia came in at 29 weeks pregnant and went to the emergency section.

This lady ended up in the unit for several days and intubated with septic shock. He was a third-year medical student at that time, and he was the one from their team working with the patient. And he realized he loved every minute of it. In fact, the attending OB was one of those who wrote letters for his residency. Since then, he got hooked.

I was hooked. Right away, I just loved the excitement of the physiology and needing a broad swath of knowledge about the various systems.Click To Tweet

In short, it was the acuity that actually drew him toward critical care medicine. He had this notion that patients are going to need you when they come to see you. But that’s not always the case in emergency medicine.

[04:55] Types of Patients Seen in Critical Care Medicine

At a large academic medical center, they have different ICUs for all the different patient types. Tom works predominantly in the medical ICU. But they also have the cardiac ICU, neuro ICU, surgical ICU, and cardiothoracic ICU (where he spent his first two years out of fellowship).

In the medical ICU, they see patients with sepsis and septic shock of some kind. You also have those with liver failure, drug overdoses, and problems where you can’t figure out what’s wrong but they look really bad. The commonality between all those patients is the need for fixing some deranged physiology.

The commonality between all the medical ICU patients is the need for fixing some deranged physiology.Click To Tweet

Neuro intensivists tend to go through neurology or emergency medicine and then do nuero critical care. The cardiothoracic ICU uses a bit of everyone including anesthesia and critical care. Cardiac ICU does cardiology and pulmonary critical care too.

During fellowship, you’re required to do so many months of ICU that you can go and work in any kind of ICU necessary. Having done a lot of moonlighting during fellowship, he saw that at the bigger community-based academic programs, intensivists round on all those ICU patients providing critical care.

[09:15] Typical Day and Week in Pulmonary Critical Care

When Tom is on service, his typical week would have him working from 7 am to 7 pm for seven days. And for the weekends, the ICUs have to have two attendings on, so they split it between the two of them every other day.

Tom tries to keep his rounds short. There’s a lot of work that needs to be done—procedures, consults, and activities for patients. Then before he leaves for the day, he ensures he has followed up with everything and that whatever action plans needed to happen are in motion.

When Tom is on service, his typical week would have him working from 7 am to 7 pm for seven days.Click To Tweet

[10:35] Is Pulmonary Critical Care Heavy on Procedures?

Critical care includes a lot of procedures, with a caveat: You can do as many or as few procedures as you want, to an extent. It depends on how hands-on you want to be. But if you don’t like procedures, then it’s not the specialty for you.

Especially in pulmonary critical care, they do thoracentesis and chest tubes as well as intubation, lumbar punctures, and more.

If you really don't like procedures, then critical care is probably not the specialty for you.Click To Tweet

[12:00] Pulmonary Critical Care Lifestyle Balance

Tom says he has a lot of work-life balance. The lifestyle is actually why he chose academic critical care over private practice.

He probably would have enjoyed private practice critical care for 2-3 years. But he enjoys about 12 weeks of ICU time per year. And in academics, the rest of his time can be non-clinical, doing research. His focus is clinical research, so it’s still patient-focused. But the 24/7 grind is not as constant as in the ICU.

When he’s home, he’s really home. So he likes shift work. In fact, most of critical care is moving that direction around the country. In their state, what he notices is very much a day group and a night group. You’re on when you’re on, and you’re not when you’re not. So it’s easy to maintain balance that way.

You're on when you're on, and you're not when you're not.Click To Tweet

[13:45] What Are Residency and Fellowship Like for Pulmonary Critical Care?

Tom cites a few options available now. When he started his fellowship, he knew he was going to keep doing research and stay in academics, so he did a three-year internal medicine residency and then a two-year critical care fellowship only. Another option is for one extra year, you do pulmonary. This is mostly determined on whether you like clinic or not.

People who do critical care only tend not to have clinic hours because there’s no ICU follow up per se. But if you want some of that longitudinal relationship with patients, you can do that extra year of pulm. So that would be three years after internal medicine residency, totaling to 6 years after medical school.

How Competitive Is Pulmonary Critical Care Fellowship?

Pulmonary critical care is getting more competitive, but it’s not like cardiology, GI, or oncology. Tom describes it as being competitive enough that it requires some degree of forethought. He also thinks you have to have some research exposure if you want to go to an academic-type program.

Critical care is getting more competitive, but it's not like cardiology, GI, or oncology.Click To Tweet

[17:24] Bias Against DOs in Pulmonary Critical Care?

Tom has not seen any bias against DO doctors in critical care. In fact, a couple of his absolutely favorite attendings from residency were DOs that did pulmonary critical care. They’ve interviewed plenty of DOs at his program, too. To them, it’s just another way of getting the same training.

Subspecialties in Pulmonary Critical Care

There are further subspecialization opportunities in pulmonary critical care, both on the pulmonary care side and the critical care side. Under pulmonary, there’s interventional pulmonology, which is more procedure-based.

There are no formal NRMP matching programs for lung transplants, but there are a few places that offer fellowships and subspecialty training in that. There are not set training programs, but they are niches within pulmonary medicine.

As with every area of medicine, subspecialization in critical care continues to evolve.Click To Tweet

[20:10] Working with Primary Care and Other Specialties

Pulmonary critical care doctors do have interactions with primary care doctors on the pulmonary side. One of the situations they often run into with primary care doctors is the shortness of breath consultations. Cardiology and pulmonary both like to point the finger in the other direction when it comes to this. Tom’s advice to primary care doctors is that it’s probably a little both of the lungs and the heart causing shortness of breath.

Other specialties he works with include nephrology. One-third of patients through the ICU require dialysis at some point. Tom also underlines the importance of having a good relationship with critical-care-trained surgeons, who are different from your general surgeons. Sometimes, it’s knowing when not to take the patient to the operating room. And sometimes, it’s knowing that you need to take a patient to the operating room no matter what. He also works with GI/hepatology.

In the medical world, having good relationships with your critical-care-trained surgeons makes a big difference.Click To Tweet

Outside of critical care, there are other opportunities that are available. Pulmonary gets involved with high-altitude medicine, which also includes diving (low-altitude medicine). Personally, Tom has had some experience traveling and training in resource-poor environments. Knowing how to provide critical care in those environments can be very handy.

You can also do research. Critical care is a relatively new specialty. So there’s still a ton that we don’t know about how to do things right. You can also do quality and leadership initiatives through that.

[23:40] What He Wished He Knew About Critical Care Medicine

The one thing he didn’t know as much early on about critical care is how much time you spend with the families of dying patients. He’s glad that he enjoys having those conversations about end-of-life care and the family’s expectations about what’s going to happen.

Most of our medical training is about finding and fixing the problem. But there's so much of the time when we just can't.Click To Tweet

Tom wishes more primary care doctors would start those conversations in clinic early, so patients and their families know what to expect. But it’s difficult because people change right up until the last minute.

[25:20] What He Likes Most and Least About Critical Care

What Tom likes the most about critical care is that there’s always something to do. It’s always a busy specialty. There’s always going to be sick patients. And the acuity never stops because once you get one patient better, there’s going to be three more waiting in line.

The acuity never stops in critical care because once you get one patient better, there will be three more waiting in line.Click To Tweet

What he likes the least is that the ICU never closes. You’re going to work in the ICU on Christmas and all the other holidays at some point. Know that going in.

Would He Choose Pulmonary Critical Care Again?

Ultimately, if he had to do it all over again, he still would choose the same specialty. Tom wishes to tell students who might be interested to explore this field that they’d love to have you. Contact your local critical care doctor for a rotation. It’s a good time even if it’s busy.

[29:30] Is Pulmonary Critical Care Right for You?

Most medical students that love a little bit of everything go into emergency medicine. Yet, there’s also this subsection of students who love the high-acuity stuff.

Go back and listen to Episode 2 of Specialty Stories where I interviewed an emergency medicine doctor. He said that the high-acuity stuff only comprises a small percentage of an emergency physician’s job. So if you like the high-acuity stuff and you like a bit of everything, pulmonary critical care might be the specialty for you.

If you know a physician you want to be interviewed on Specialty Stories, shoot me an email at ryan@medicalschoolhq.net.