Freaking Out a Bit About Starting Fellowship

[The Knife & Gun Club]

Logically I know I’ll probably be fine but with one month left in residency I’m definitely having a good solid panic session about starting fellowship next month.

I’m coming from an EM background into a multidisciplinary anes-CCM program where I’ll be doing a mix of Trauma, Surgical, Medical, Neuro, and Cardiac my first year.

Like most EM docs I have some general understanding of what happens in these units but just feel like there’s so much specialist specific knowledge there’s no way I’ll be able hang with the fellows with more focused training. I can’t imagine I’ll manage ARDS as well as a pulmonologist or abdominal compartment syndrome as well as a trauma surgeon.

I’ll be the sole PGY4 in my cohort, the majority of the co-fellows I’ll be with are PGY8s coming from gen surg.

I feel like I should probably be studying but am not even sure what to study beyond the usual general critical care texts.

I guess I’m not asking for any specific advice, more am just curious if anyone else coming from EM ever had this same feeling, and/or survived fellowship neuro-intact.

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[Tipsy McStagger]

How long is anesthesia based ccm for an em grad? It’s normal to be nervous, but are you trying to cram all that in a 1 year fellowship?

What you really need is exposure to continuity care with a large, sick patient census for a dedicated period of time. You also need people who really understand the physiology, and when enough is enough, to guide you through.

You'll never be a subspecialist, you'll never have as solid of an understanding of surgical critical care as a surgeon, because you don't operate. But the rest is fair game. You should be able to manage ARDS just as well as a pulmonologist, that's not where their education differs from yours. For complicated pulmonary issues you can always consult them going forward. You will figure out what you're comfortable with and what not several years into your attending-hood.

Your goal isn't to do an internal medicine residency for your fellowship, neither are you trying to do a surgical, anesthesia, trauma, ob residency for your fellowship. Your goal is to become a competent critical care physician. Learn what's important, what's not. Learn how to talk to families, and learn when to tell them there's nothing more that can be done. Learn patience, things take time to develop. Take a tactical pause. It's one of the largest advantages the ICU has over the ED - not everything needs an answer or explanation right now. You generally have time.

This takes time. I hope you have at least 2 years.

But to answer your question, it's normal to have some imposter syndrome. You will survive neuro-intact. How well prepared you'll be depends on many factors, some outside of your control. Your education continues into your years as an attending. Keep an open mind, be willing to be wrong, always have some degree of skepticism. Last of all stay humble, because you're going to be humiliated time and time again. If you tie your ego into being right all the time, you'll just be a shell of a person. If you aren't being humbled, you're just not paying close enough attention to what's really happening, or you have a serious mental block and misperception about your abilities.

 

[The Knife & Gun Club]

How long is anesthesia based ccm for an em grad? It’s normal to be nervous, but are you trying to cram all that in a 1 year fellowship?

What you really need is exposure to continuity care with a large, sick patient census for a dedicated period of time. You also need people who really understand the physiology, and when enough is enough, to guide you through.

You'll never be a subspecialist, you'll never have as solid of an understanding of surgical critical care as a surgeon, because you don't operate. But the rest is fair game. You should be able to manage ARDS just as well as a pulmonologist, that's not where their education differs from yours. For complicated pulmonary issues you can always consult them going forward. You will figure out what you're comfortable with and what not several years into your attending-hood.

Your goal isn't to do an internal medicine residency for your fellowship, neither are you trying to do a surgical, anesthesia, trauma, ob residency for your fellowship. Your goal is to become a competent critical care physician. Learn what's important, what's not. Learn how to talk to families, and learn when to tell them there's nothing more that can be done. Learn patience, things take time to develop. Take a tactical pause. It's one of the largest advantages the ICU has over the ED - not everything needs an answer or explanation right now. You generally have time.

This takes time. I hope you have at least 2 years.

But to answer your question, it's normal to have some imposter syndrome. You will survive neuro-intact. How well prepared you'll be depends on many factors, some outside of your control. Your education continues into your years as an attending. Keep an open mind, be willing to be wrong, always have some degree of skepticism. Last of all stay humble, because you're going to be humiliated time and time again. If you tie your ego into being right all the time, you'll just be a shell of a person. If you aren't being humbled, you're just not paying close enough attention to what's really happening, or you have a serious mental block and misperception about your abilities.

Thanks for the kind words and clarity. I appreciate it.

Luckily the fellowship is 2 years.

First year is 2 months Trauma, 3 months SICU, 2 MICU, 1 neuro, 1 CCU (medical/cardiology based) and 2 CVICU (surgery based).

After that it’s a second year to basically do whatever units or electives I want.

Thanks again. The imposter syndrome is real. Haven’t felt this way since I was an intern.

 

[Tipsy McStagger]

So you have 2 years, that is good. I guess I'd suggest soaking it all in your first year, then thinking about which type of ICU, or rather patient population you want to practice in. You can do anything from EM, but keep in mind if you choose to work primarily SICU/TICU/CVICU then you'll always be taking order from the surgeons, and many of those are things that are just plain wrong but you'll have to do it anyway. We all have our bias, and we all run to what we know. So when you introduce medical disease in a surgical population the waters get muddy and fast, but you'll never own the patient, and they'll never treat you like an equal.

I work SICU/TICU, CVICU, CIC, Neuro and of course MICU. CIC is probably the most interesting (for me anyway), CVICU is fairly straightforward but when those patients go down they go down hard. SICU/TICU is the most boring population for me, I just have no interest in those types of disease processes and trying to get the surgical team to communicate can be a challenge. Probably not universal, but it's my experience over a few different hospital groups.

So I try to stick mostly to the CIC, CVICU and Neuro icu (which I also hate, but I have to staff it). I didn't learn a ton of neuro in my fellowship so I basically had to learn it over the course of my first 2 years as an attending. There's too much niche ICU to learn in fellowship. So I'd suggest you narrow in on what you really like the most, and focus on that. The rest will come depending on what job you look for.

Also, if you're leaving academics, I don't know how eager community hospitals are to pay 2 docs for the price of 1. By that I mean, some hospitals may balk at hiring and EM-CCM SICU doc since you can't operate, can't take trauma/surgical call, and they'll need to employee a surgeon to cover that deficit. So job prospect may or may not be difficult, that one I'm not too sure about but maybe someone on here does mostly SICU/TICU in the community and can weigh in.

anyway like I said, you'll be fine.

 

[SurfingDoctor]

I remember seeing an attending I was fond of at a conference about 3 or 4 months into attending-ship?

His first comment to me… “Surfingdoc?! You look good. How does it feel to be an attending? How many people have you killed yet?”… ha, precious memories.

Actually, the best advice I’ve realized is that is better to bide your time and go slow. The younger people are aggressive and idealistic they have the right answer… yet that answer leads to CPR at a higher rate.

The patient doesn’t care about some metric of “less days of mechanical ventilation”… if they are dead.

 

[FiO2@21]

I've had existential crises of my own about this. Anesthesia-CCM intending to practice in a community setting (MICU, SICU, Neuro, CVICU).

I mentioned this recently to a Cardiology-trained attending. I'll try to regurgitate what he told me, but the bottom line is you have to know your strengths and weaknesses as you go through your fellowship. You'll have your strengths as an EM attending and will excel in certain things. There will be some things you'll shore up on as you finish your training.

And then there will be stuff you will need to ask for help with; during training and then after. This is why consults exist, this is why maintaining a great relationship with past, present, future colleagues is important. I'm not a cardiologist, I haven't spent years interpreting EKGs, echos.

As soon as you make peace with the fact that you can't do it all, you'll serve your future patients better.

Edit: Also you'll find plenty of community jobs. Just figure out where you're going and tailor your 2nd year to that.

 

[SpacemanSpifff]

Logically I know I’ll probably be fine but with one month left in residency I’m definitely having a good solid panic session about starting fellowship next month.

I’m coming from an EM background into a multidisciplinary anes-CCM program where I’ll be doing a mix of Trauma, Surgical, Medical, Neuro, and Cardiac my first year.

Like most EM docs I have some general understanding of what happens in these units but just feel like there’s so much specialist specific knowledge there’s no way I’ll be able hang with the fellows with more focused training. I can’t imagine I’ll manage ARDS as well as a pulmonologist or abdominal compartment syndrome as well as a trauma surgeon.

I’ll be the sole PGY4 in my cohort, the majority of the co-fellows I’ll be with are PGY8s coming from gen surg.

I feel like I should probably be studying but am not even sure what to study beyond the usual general critical care texts.

I guess I’m not asking for any specific advice, more am just curious if anyone else coming from EM ever had this same feeling, and/or survived fellowship neuro-intact.

What anesthesia program has both gen surg and EM applicants in the same cohort? Interesting combo.

These are normal feelings. Every training background brings their own skill sets to the beginning of training. You will be more polished when it comes to those moments where **** is hitting the fan than your cohort, probably more comfortable managing varied resuscitations, and exuding a sense of calm.

I think the things that we need to work on coming from EM are similar to what @Tipsy McStagger mentioned. You have the benefit of observing patients for extended periods, you don’t always have to do something right in the moment. Use that. Make an effort to pay attention to the details and especially trends over 12 to 24 hour periods. Learn from your cofellows and consultants on the nitty gritty details that don’t matter in the ED, but make a difference beyond the first 6 hours.

As I’m finishing my training I have similar feelings - most days I feel like I haven’t learned nearly enough in two years. So I’ll keep learning as an attending and just know that all I can do is my best.

 

[Siggy]

The patient doesn’t care about some metric of “less days of mechanical ventilation”… if they are dead.

On the other hand we know that aggressive ventilator liberation (a part of PADIS/A-F bundle) helps lower overall unit mortality rate and people are generally too conservative at getting people off vents. Forrest vs the trees, but we're paid to look at both the forest and the individual trees.

 

[SurfingDoctor]

On the other hand we know that aggressive ventilator liberation (a part of PADIS/A-F bundle) helps lower overall unit mortality rate and people are generally too conservative at getting people off vents. Forrest vs the trees, but we're paid to look at both the forest and the individual trees.

Like most of critical care, there’s generally no right one answer…

 

[The Knife & Gun Club]

What anesthesia program has both gen surg and EM applicants in the same cohort? Interesting combo.
.

Yea it is an interesting combo.

Basically it’s 7-8 trauma critical care spots through gen surg and 1-2 anesthesia critical care spots (usually filled by EM).

Everyone is grouped together for the first year for the critical care part then the second year the trauma people split off to go do operative stuff and I split off to do not operative stuff.

Hence the bit of trepidation, almost everyone I’m grouped with that first year has like 4+ years more experience.

 

[SpacemanSpifff]

Yea it is an interesting combo.

Basically it’s 7-8 trauma critical care spots through gen surg and 1-2 anesthesia critical care spots (usually filled by EM).

Everyone is grouped together for the first year for the critical care part then the second year the trauma people split off to go do operative stuff and I split off to do not operative stuff.

Hence the bit of trepidation, almost everyone I’m grouped with that first year has like 4+ years more experience.

I wouldn’t worry too much about it. Even with the extra training, your cofellows will not have significantly more knowledge in core critical care topics, especially outside the surgical setting.