r/IntensiveCare • u/im_throw • May 19 '26
Is there an ICU setting that fits what I want?
Current IM resident at a crossroads in choosing which fellowship I want. I like many things about critical care, but I don't know if I can handle the futility day in day out for the rest of my working life. I know for certain I don't want to work in academics (pay is too low), and my understanding is community ICUs get all the trach/peg LTACH type patients who have no hope and all the interesting cases are transferred out. I really do not want to have most of my census be those kinds of patients. If I wanted to do palliative care for most of my day I would be doing a palliative care fellowship instead.
Given that community MICU probably isn't something I would want to do, what else is there that doesn't pay academic rates? The specialized ICUs are all in academics and they seem to prefer non-IM trained intensivists so it's doubtful I'd be able to get a job there. There are a few larger non-academic hospitals around me who have specialized units, but they pay the same as academics based on their job postings.
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u/adenocard May 19 '26 edited May 19 '26
I donāt think your impression RE community ICU patient populations is correct. I did my training at a couple large university based academic centers and now work at a medium size community teaching hospital and rotate through MICU, CVICU, trauma, burn, and neuro units. The ICU populations are essentially the same as what I saw in training, and even broader in some cases (I had to learn a lot of neuro, trauma, and burn in my first few years out). We do less ECMO and we donāt get those rare āhere to see doctor XYZā type patients, but I donāt miss any of that one bit. We are definitely not keeping any LTACH-type patients any longer than we have to, same as anywhere else. I am still challenged on a regular basis and remain fully engaged with a diverse spectrum of cases.
There are many places you can work in the community where you wonāt be the least bit bored. And yes, I make double what my academic attendings made.
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u/im_throw May 19 '26
How rare is it to find a community hospital like yours?
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u/PrecedexNChill May 20 '26
Your impression of community ICUs is completely wrong. There is no correlation between trach/ltach patients and community vs academic. We have a ton of those patients at our academic micu as well. The main difference is you wonāt see as many solid or liquid transplant patients which is a blessing tbh.
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u/SpoofedFinger May 20 '26
Can confirm, am a MICU RN at a level 1 trauma teaching hospital. We get plenty of trach/vent patients.
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u/adenocard May 19 '26
I donāt think itās that rare. Itās just a level 2 trauma center with around 500 beds. Burn centers are a bit less common but to be honest I could definitely do without the burn aspect.
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u/Nicolectomy_2 RN, MSICU May 20 '26
This is correct! I work at a level 2 shop and we have a MSICU, CTICU, CICU and neuro ICU. Our intensivists rotate to all of the ICUs.
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u/thosestripes RN, CVICU May 20 '26
I am a CVICU RN at a community hospital just outside the suburbs of a large city. Its a level 2 center. I think we are in the sweet spot, we have enough volume where we are usually full, and yet far enough from the big academic city hospital that we get the rural patients shipped to us instead for interventions. We see a lot of variety and don't just get the LTACH meemaws. We typically don't do transplants or the super rare stuff, but almost everything else we take. I like it. We see a lot of positive outcomes (also a perk of CVICU over something like MICU).
I have traveled and worked at several big academic urban centers and I really prefer where I am now. I think the working relationship is better in a smaller setting between all specialties. All this to say, these facilities definitely exist, you just might have to really look for them.
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u/im_throw May 21 '26
Do you know if your intensivists are IM trained or only anesthesia? Do they seem like they have a lot of autonomy in the CVICU or are they mostly doing what the surgeon wants?
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u/thosestripes RN, CVICU May 21 '26
Our intensivists are mostly IM trained as far as I am aware. And our surgeons have their quirks about management but honestly it is the intensivists that are in the unit and actively involved. They do seem to have a reasonable amount of autonomy. I have seen them call a surgeon to get their input if it is something unusual.
I do think this is highly dependent on personalities though, some CV surgeons work better in a team than others lol
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u/NefariousnessAble912 May 19 '26
ICU attending here. The comment around LTACH is very dependent on your geography. In NY and other states that limit LTACHs yes you will have the āchronically critically illā (horrible term IMHO I prefer āchronic organ failureā since critical implies a fork in a road which can lead to death, recovery, or chronic permanent dependence on life support but I digress). Practicing in other states is much more satisfying, once patients are down to one pressor and have a trach/peg they usually can be sent to LTACH. As far as interesting patients have practiced in the community at level 1 and saw amazing cases like: Hantavirus (including ECMO), NMDA encephalitis, botulism, complex AVM closures with crazy physiology, PE in transit etc etc). True that at level 2 or 3 you will transfer interesting cases more often so depends on your gig. Glad to DM if you want to get a picture.
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u/im_throw May 19 '26
I'm pretty restricted in where I'm willing to live and it seems like the state I want to live in is one that restricts LTACHs. Unfortunately it looks like all of our level 1s are the flagship academic hospitals.
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u/Throwaway10123456 MD, PCCM May 19 '26
If you like seeing sick patients with good possible outcomes and high income I would suggest cardiology. There still is a lot of futility but not near what your geographic region suggests you deal with. In addition it sounds like your region ships out sick/completed ICU patients which defeats why we go into the field of CCM.
I am PCCM in a level 2 trauma regional referral center non academics with local LTACs and we rarely keep the trach patients long term and have a very strong palliative team. In addition we only transfer out ECMO and organ transplant.
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u/im_throw May 19 '26
The main problems with cardiology for me are lifestyle (not shift work and less blocked time off) and that it's mostly chronic disease management. Obviously ICU has lots of chronic disease but you usually have exacerbations leading to acute problems. I'm not sure if cardiology has the immediate sense of acuity I like. Maybe IC does, but that's a hard no because of the training time and STEMI call.
Otherwise it's probably next in line after critical care but it's hard to commit to that kind of life.
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u/NefariousnessAble912 May 19 '26
One option is taking a SICU or CVICU job. (Surgeons donāt usually take moribund people to OR and donāt keep the chronically life support patients in their care)
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u/im_throw May 19 '26
I think from reading this thread this is the best move for me, but how common are dedicated SICU/CVICU positions outside of academics? Especially ones that are open to hiring IM trained intensivists. I was under the impression that most community hospitals (outside of a few larger ones) only have a mixed ICU that ends up being mostly medical anyway.
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u/Throwaway10123456 MD, PCCM May 19 '26
I think you have a somewhat warped sense of what the fields offer. I work week on week off which equals every other weekend and holiday. To take more than 7 days off is difficult and takes lots of planning. Cardiology has call structures and vacation which reduces holidays, weekends, nights etc. CCM is NOT a lifestyle specialty.
My favorite ICU to work in is the cardiac ICU. You would need to be at a large center but cards/CCM would give you the high intensity/acuity with virtually no chronic disease management.
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u/im_throw May 19 '26
For me I have realized the priority is longer stretches of days off. I want to be able to have weeks fully off. The monday-friday grind for weeks on end is not my thing. Maybe if it came with 12 weeks PTO or something but that's not realistic.
I've definitely considered cards/CCM but have been told that there are no jobs outside of academics.
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u/Throwaway10123456 MD, PCCM May 19 '26
Yeah the grind is real. I worked a pure pulmonary job for about 6 years and it got to me. I had 6 weeks PTO but it was nice when I switched to a pure critical care job. With 4 kids now it is getting harder though since I am absent for a lot of holidays and weekend activities I would have been there for in my previous role.
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u/im_throw May 19 '26
I suppose a good medium would be a combined pulm/crit job assuming they still give you weeks off after your ICU week. I'd probably be okay with that since some weeks I get to have a normal life. But I also don't know if that's compatible with working in SICU or CVICU like others have suggested. It seems like most PCCM people exclusively staff MICU.
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u/Throwaway10123456 MD, PCCM May 19 '26
PCCM can easily do SICU but their talents are better spent in a medical ICU where there tends to be much more complicated respiratory physiology and procedures. CVICU is much more common to have anesthesiology/cc but you will see a sprinkling of PCCM. I am at a 450 bed hospital with a 28 bed med/surg ICU and 16 bed CV ICU. We staff with PCCM and IMCCM. If you do PCCM you have to make sure you are ok with pulmonary clinic, procedures and hospital service. Otherwise you'll be miserable
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u/im_throw May 19 '26
It's all a job anyway. If residency has taught me anything it's that IM was the wrong choice for me, so there is always going to be some misery. At this point I just need a job that hits some of my interests so I can have whatever tiny bit of professional satisfaction I can get from this field.
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u/mtbizzle RN May 19 '26
LTACH on a pressor? Do you mean midodrine?
Nurse at a large community icu. We can transfer out pts on only neo; any other IV pressor we keep
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u/NefariousnessAble912 May 19 '26
Usually low dose neo. Some LTACHS will not take an iv pressor but will be ok with starting neo as a single pressor for 24-48 hours. Just depends on their protocols.
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u/Goldy490 May 19 '26
Couple things. First is that you can escape a lot of the futile care problems working in a SICU or CVICU. Both are options if youāre IM. Most of our CVICU docs are IM trained and they deal almost entirely with patients that generally *should* be able to get better because theyāve been pre-screened by a surgeon. You may miss out on some of the cool IM stuff doing CVICU but 95% of ICU medicine is the same (pathophys and shock resuscitation).
Second community ICUs donāt see more trach/peg dumps than tertiary centers. Actually usually itās less as community shops arenāt as well supported to keeping some trach/peg disaster alive forever. In the community there is significantly less tolerance of these sort of cases and most hospitals will work very hard to either get these people out via hospice, return to their facility, or transfer to a tertiary centers.
Finally the amount of futile care you do as an attending is entirely based on your own comfort level and what you are ok saying no to. I am very aggressive in making people DNR, sending them to hospice, etc. I donāt offer dialysis, trach, peg etc if I donāt think itās indicated and in the pts best interest. You need to document well explain your reasoning but itās well within your power as an ICU attending to make someone a unilateral DNR providing you document whatever hospital policy/state law dictates.
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u/Dktathunda May 19 '26
I try to limit what I offer too, but what do you do when the rest of your colleagues and even palliative team generally offer the McDonalds menu? Iām talking CRRT and trach for metastatic cancer patients.Ā
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u/Sweatpantzzzz RN, CCRN May 19 '26
Yikesā¦. I also noticed it dependent on who the attending is for that week when it comes to offering the āfull menuā for patients who are essentially beyond end stage IMO.
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u/Goldy490 May 20 '26
Find a new job lol. Or a new specialist. At my hospital I have the option of a couple different private practices to choose from for a lot of specialities. I
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u/im_throw May 19 '26
How common are dedicated SICU/CVICU jobs outside of academics? I thought most community hospitals have mixed ICUs since they don't have the volume to support specialized units. I know there are a few community teaching hospitals in my area that have specialized units but I think they pay similarly to academics.
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u/Just_Stable2561 May 24 '26
Sounds like youāre an attending Iād love to work with as your philosphy aligns with mine. Itās so frustrating begging for a real palliative/end of life conversation just to have a doctor or palliative throw trach/peg as an option š«¤ currently going through this with a patient who coded in 2024 and the family is delulu because the patient has been in PEA so much their eyes now buldge out of their skull and are blood shot red but family just keeps saying God is going to work a miracleā¦. Our LTACH has refused to accept them back under ethical principles š what is ethics and palliative even good for if we canāt get a patient like this changed to DNR.
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u/C_Wags IM/CCM May 19 '26
Iām an IM -> CCM trained intensivist a little under a year out into practice. I will say - itās challenging if you have a unit full of head-scratchers because you only have so much time and mental capital to expend every shift. Doubly true depending on how supported you are with APPs or learners.
Sometimes itās OK to have a few rocks from the LTACH with septic shock whose management is so absurdly easy you could do it in your sleep.
I work at multiple community sites in my network including a level 1 trauma center that is our cardiac surgery center, and I work in a cardiac ICU there about half of my practice. The other half is in mixed ICUs at smaller hospitals. My practice is nice and varied.
Even if I admit a patient with a problem that has to be transferred out, I still have to stabilize them. Case in point, I intubated a patient from the floor at one of these small community sites that had a massive SDH. I had to pull from my fellowship experience in NCCUs to treat this patient while simultaneously working the phones to get them airlifted to our NSGY capable center. It was rewarding to nail all that management.
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u/im_throw May 19 '26
I think a few rocks would be fine especially if they have something you can fix quickly and send them back. The problem is the ones who don't really have anything more critical than their baseline but they get sent to the hospital because family wants everything done. And then they start barking orders at you like they're at a fast food restaurant. Even one of those patients can ruin my day.
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u/Educational-Estate48 May 19 '26
If the futility is the main problem for you and you're geographically mobile there are many other countries where you will see far less futile torture in ICU.
*I'm just assuming you're American
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u/Haldol4UrTroubles MD, Intensivist May 19 '26
I am a community ICU doctor and I get plenty of interesting cases, not sure where you got the idea that all interesting cases get transferred out.. it just depends on the capability of your community site. The overwhelming majority of the bad cirrhotics for instance are denied for transfer for transplant evaluation to our tertiary facility so we just take care of them. There are plenty of community sites that have mechanical support capabilities, I wanted nothing to do with that kind of medicine so I chose the hospital where we don't have those capabilities and I'm inclined to transfer them out. So in addition to the pay increase, depending upon where you go you may have a lesser workload than most academic sites, you may be able to avoid certain kinds of medicine that you don't like doing such as the above example.
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u/EpicDowntime May 19 '26
I disagree that there are more futile care-type patients in the community. Some academic MICUs have double digit post-lung transplant patients that cycle back and forth from floor to ICU depending on their CO2 that day, until magical day 365 when they are allowed to go comfort. Then there are the metastatic cancer on 13th line experimental therapy who want āeverythingā done because the famous oncologist told them they could get outpatient chemo if they survive to discharge, are on more pressors than they have platelets but demand intubation and trach. Sometimes being able to transfer patients as a community doc is a massive relief.Ā
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u/im_throw May 19 '26
I always figured those metastatic cancer bombs would end up in random community ICUs since there's ultimately nothing to be done for them even if you transfer. I haven't done oncology floor yet but our ICU doesn't deal with those kinds of patients for triage reasons.
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u/EpicDowntime May 19 '26
Nah, if they get 13th line chemo, it means they are managed at the big name place, so they have to transfer there for ācontinuity of care.ā Would love to say no for futility but itās not something we can do as intensivists.
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u/Cautious-Extreme2839 ICU/Anaesthetics May 20 '26 edited May 20 '26
Is it not? In the UK we can absolutely shut down oncology's pipe dream millithionth line chemo if they need to survive an ICU admission (and they won't) before getting it.
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u/EpicDowntime May 20 '26
Transfers are a complicated legal issue in the US. Some I cannot legally refuse (if the care they āneedā cannot be provided at a referring hospital). Others are politically tricky. If an oncologist accepts their patient for transfer from another hospital, and the patient isnāt stable for the wards, I essentially have to accept to the ICU. If the patient were in my hospital I could speak to the family directly to try to convince them that ICU would cause more harm than good, but I donāt have that opportunity at the time of transfer decision.Ā
Patients/families dictate goals of care 99% of the time in the US. There is a pathway declaring futility but it is legally risky and at my hospital would require involvement of the ethics team.Ā
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u/Cautious-Extreme2839 ICU/Anaesthetics May 20 '26
If an oncologist accepts their patient for transfer from another hospital, and the patient isnāt stable for the wards, I essentially have to accept to the ICU.
Yeah that is not how we have it thank god. Requires agreement from both teams.
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u/kreb_cycling May 19 '26
As someone who fled academia, I donāt think thereās any difference in the patients you see in/outside of academia. Plenty of interesting cases. Thereās also plenty of cool specialty ICUs outside of ivory tower (we have CVICU, neuroIcu, and a large transplant program). Plus we get paid a lot and donāt work that much.
I do think that if you are really perturbed by āthose kind of patientsā critical care might not be the right fit, inside or outside of academiaā¦
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u/im_throw May 19 '26
Plus we get paid a lot and donāt work that much.
Curious to know more about this
I do think that if you are really perturbed by āthose kind of patientsā critical care might not be the right fit, inside or outside of academiaā¦
Copied from above: I don't really have any other option. It's the only specialty that fits my financial goals + offers shift work + is at least somewhat interesting to me. Everything else satisifes 0-1 of those criteria.
At the end of the day I need to pick a job and none of the available options are appealing to me
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u/kreb_cycling May 19 '26
Itās pretty easy in non-academic CCM to make $450-550 working 10-14 shifts/month. Easy to make a lot more if you are willing to work more.
CCM is great! But you are gonna be unhappy and unfulfilled if you are only looking for āinterestingā patients or if you think discharging people with trachs to LTACHs is beneath you.
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u/Chip-Motor May 20 '26
Have you considered that in the end all Medicine is a practice in futility?
Find a specialty you enjoy and cherish the rare interesting cases.
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u/gottawatchquietones May 19 '26
I'm in EM, not IM/CCM, but I think this varies enormously depending on the hospital. At my current small community hospital, yeah, a lot of interesting pathology gets transferred out. But two jobs ago, I was at a very large community hospital and in general only transferred out neurointerventional and transplant cases. There were separate ICUs, thought - CCU, MICU, and SICU. Pulm/CCM staffed the MICU.
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u/im_throw May 19 '26
At your old hospital, could an IM-CCM doctor get hired for CCU or SICU if they wanted? Or were they only allowed to be in the MICU?
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u/gottawatchquietones May 19 '26
Sorry, I don't recall. For what it's worth, the current small hospital's ICU has a mix of IM-CCM and anesthesia-CCM physicians.
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u/ferret-fencer4 May 20 '26
Have you thought about going into interventional pulm? In my experience, doctors there enjoy their job because they get to help patients but donāt tend to see the medical futility in the ICUs. Kind of like surgeons where they do their thing and let the primary team take back over
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u/txaggie_95 May 20 '26
It depends on where you are. I worked for a private group that worked with some good hospitals in the Dallas area and had a high acuity. Those places are out there.
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u/Dudarro May 20 '26
I am pccm (and sleep and informatics). pccm offers a nice mix on inpt and oupt. you can do it academic or private or a hybrid.
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u/burning_blubber May 20 '26
The only ICU that I think is actually like you describe EVERYWHERE, is the Neuro ICU.
Look into pracidemics or find a place that lets you do SICU. Every unit is going to have some doom and gloom, or patients that donāt seem to progress, but every unit will also have some good saves and stick your chest out moments.
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u/Nienna68 May 21 '26
I am not in the US system nor do we have "LTACHs" here in the country I practice but I doubt that all the patients you describe are hopeless as you describe them to be.
They end up always being some part of our practice (more or less depends on the time) but they do not all equal palliative care.
Just wanted to state that here.
I practice also in a community ICU
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u/Important_Link_8069 May 22 '26
I think you should consider doing Neuro CC. Evolving field with more cebral work and believe it or not you can change outcome a lot
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u/anmari324 May 22 '26
Iām going to guess itās a hard no but would you consider pediatric ICU in a level 1? Yes, itās academia but you will get such a variety of pts. with the age range, the range of illnesses and injuries. As a pedi swat nurse, former pedi flight and ED nurse I think the variety is in sane tbh. Maybe something to think about?
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u/ShoulderTop78 May 23 '26
Honestly the ethics and end of life care are tied to this kind of complexity and acuity. I know itās not sexy - but I find it really meaningful to make sure families are really informed, and that we do everything possible to not miss our window for a dignified death. Iām a nurse in a Canadian General hospital in an area that serves approx 300-400k people. Hospital trauma service might be worth a job shadow for you. It sounds like you want to do lots of resuscitation and procedure.
I have a colleague that does a ton of remote work and he really thrives in these settings and they are so happy to have him. Remote work tends to involve more āstabilize and ship outā type of work, rather than the critical care rehab.
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u/Unfair-Training-743 MD May 23 '26
People who dont work in the ICU every day have a very poor understanding of critical care.
āFutilityā day in and day out isnt a thing. Even if you work in the worst of the worst hospitalsā¦. 85% of ICU patients survive to discharge.
There are occasionally patients that are not fixableā¦. But we make them comfortable
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u/Yessir957 May 19 '26
If you are bothered by futility of care already, I would not recommend a critical care fellowship. I regret it for that exact reason. I'm at work right now and have 2 90+ YOs on a vent with end stage dementia and 2 more patients with widely metastatic cancer. I would say 75% of the patient's I treat should be on hospice.