Discussion on Combined Emergency and Internal Medicine Residency and Critical Care Fellowship

welcome back everybody my name is dr khan kal and today i am joined by my good friend dr brad lickingston welcome brad hi and and um brad will be talking to us uh about em i am uh as a residency option and he does critical care right now so he'll do uh talk as uh ho talked us through regarding what's it like to be a critical care physician as well all right so brad tell us a little bit about your background and what do you do right now as your job so i grew up in north carolina and i went to ecu for medical school east carolina university and i liked i wanted to stick around north carolina so i decided to do a fellowship or residency at east carolina as well and one of the nice things that they offer is an emin combined program and when i initially started medical school i have a i was thinking that i was just going to do emergency medicine because i have a paramedic background i used to work ems and so i figured you know i was just going to do emergency medicine and that was going to be my career choice and i was going to be happy with that but when i was in medical school i was rotating through internal medicine and rotating through the icu and i was like you know what i kind of like that stuff too and so i decided that instead of doing just emergency medicine i wanted to broaden out my options and so fortunately uh ecu east carolina had an eminem uh program and so i fortunately got accepted and the rest is history yeah yeah brian and i trained together uh at uh east carolina invited i was right i was em uh myself and in my thought process like there is no way i'm gonna do two extra years so i was already a resident i was a one a first year resident by the time you got there and by the time you left i was like at your graduation saying goodbye you know i was still a resident when you left so that that did kind of suck so yeah yeah do you think the extra two years uh of training is well worth it if you do want to go um into the specialties or whatever you feel like you want to do with uh with your career yeah for me personally it was a great fit because i liked i like i truly enjoyed both aspects of both emergency medicine and internal medicine so for me it was totally worth it and especially now since i'm doing critical care i'm i'm critical care boarded and i'm actually adding on a neuro critical care fellowship because you just never can get too many fellowships and boards um the emergency medicine and the internal medicine just blend in perfectly if you're gonna do a critical care fellowship because you get the procedural aspects of emergency medicine and then you get the intellectual nerdy aspects of internal medicine and so critical care sort of fits all of that together so okay yeah uh you're a constant fellowship degree gainer yeah yeah yeah so let's talk a little bit more about e-m-i-m before we move to critical care once you graduate from eminem what do most people practice [Music] internal medicine or emergency medicine or both or do they go in fellowship like you did so when i graduated i actually started doing locums and when i was working as a locums i was doing emergency medicine work and internal medicine as a hospitalist and i was also doing some critical care work as well so i had the privilege of being able to take jobs where i was doing all three things and so if you're asking if the question is can you what are your options when you finish do people really do emergency medicine and internal medicine answers yes you can most people uh with your hospitalist job you typically work about one week a month and then you can set it up so that you do the rest of your time doing critical care um at the hospital where i trained that they offer this this possibility where your part-time emergency medicine and you're part-time hospitalist but it all works together where you have a full-time job kind of thing and so they set it up so that you can do emergency and emergency and internal medicine all together if you want to do that or you could just do lucums and just work a emergency medicine job somewhere and then a hospitalist job and you can change it up however you want to so it's completely doable depending on if you want to do academics or if you want to do just community they're both available to you however you want to do it so it gives you a nice flexibility to be able to do both if you wanted to completely doable i understood i understood um so it gives yeah the flexibility of that extra two years gives you essentially way way more options than i would have as a vm for sure because emergency medicine work and internal medicine work are two very very different things and so in the emergency department things are higher paced it's much more high stress it's high demand yeah and sometimes you just want to kind of take a break from that you just want to get away from that and just decompress a little bit and so that's where being a hospitalist where things are a little bit slower you have time to sit and talk with your patients and you have time to think through their problems it makes things a little bit uh easier it kind of changes things off it so it adds a little more variety instead of the whole high stress high workload emergency department kind of thing that you see okay okay uh thanks for that um so there's multiple avenues uh to getting to critical care and you don't have to do specifically i eminem correct that's correct so if you're truly interested in critical care there's a lot of ways that you can get to that destination if critical care is the specialty that you're looking at you can do it through emergency medicine just straight emergency medicine and then you can do critical care on top of that that's an additional two years of work you can do it through internal medicine which is another two years in addition to your internal medicine program you can do it through emiam that's going to be one extra year if you decided to do it that way you can do it through anesthesiology you can do it through surgery and so there's multiple multiple ways of getting to critical care if that's truly what you want now if you wanted to do palm critical care then i would recommend just doing internal medicine uh and just going through that avenue if that's what you wanted um but if you're just doing just critical care um many many ways of getting to that to that fellowship for that that board yeah so when you were a medical student did you always knew that you wanted to do critical care in the end or where there are other medical specialties or residencies you're also interested in as well yeah yeah so i started medical school thinking that i just wanted to do straight emergency medicine and that was all i wanted but when i did my medical school rotations i discovered that i kind of liked those other things i liked working in the icu as well um i liked seeing these critically sick patients who are just really sick and just seeing them get better there was a sense of satisfaction to me for the for seeing that and doing that and so that sort of um piqued my interest in that emergency medicine is great it's um it's an amazing fellowship it's an amazing job i highly recommend it but one of the downsides to emergency medicine is that you see the patient you figure out what the problem is and then you send them on and so you never really get to see like a lot of the great outcomes that sometimes you can with critical care so um i wanted to have both aspects of that and so that's why i i kind of ended up doing both so okay um would you have done anything differently along this path no i'm i i would if i had to go back and do it all over again i would totally do this again um i would do emergency medicine and internal medicine even though now like i'm primarily in critical care medicine like i feel like i have a good blend from both specialties that has prepared me to be a critical care physician and so i have the procedural aspects of emergency medicine and i have the medical background from internal medicine and they both kind of blend together and work really well on the critical care environment so i i have no regrets whatsoever of doing this okay thanks for that uh so what do you think are like the personal qualities or traits of a student to make a successful critical care physician so you have to be able to think on your feet you in the emergency department i mean you are well aware of this it's um there's constant interruptions there's constant um things that are going on that are sometimes out of your control so you always have to be able to manage your time well you have to be able to prioritize okay i'm going to see this patient i'm going to see this problem i need to address this first so you have to prioritize like what's the most important use of your time at that time what's the most critical things that you have to get done so um prioritizing your time is absolutely essential and both in emergency medicine and in critical care medicine you're working with very high intense high risk critically ill patients a lot of times and so a lot of times you're going to be in situations where you just don't feel comfortable you don't feel like you know you've got a good handle on what's going on and so another aspect of the job is i would say you have to eventually feel comfortable with being uncomfortable with the situations that you're dealing with and i don't know if that kind of makes sense the way i'm saying it but you have to be okay with the amount of stress and the amount of critical decision making that you have to deal with and so but it's all totally worth it it's it's not it's not anything that i would change or or alter about the field is just the reality of how emergency medicine is and how critical care medicine is you just have to deal with that environment yeah yeah i definitely agree with that you have to be able to be okay with the unknowns uh that's uh you may not be able to figure out but you will have to continue diagnosis and testings and treatments and hopefully yes yeah well so i appreciate that so what do you like the most regarding being a critical care physician uh for me i personally like seeing people get better so i like it when a patient comes into the icu on day one and they're just their own life support they're on the ventilator they're just you know sick and stink and they're gonna die unless you absolutely intervene and help them out and then four or five days later when you're still in the icu you get to see that patient you get to take them off life support you get to see them recover and they're working with physical therapy and they're making a comeback that for me is the greatest benefit that i see from working in critical care i genuinely enjoy seeing patients get better and so it's just knowing that these patients absolutely need you as a physician and just seeing the benefit and the good that you're doing for them as a doctor as a critical care doctor is the the biggest benefit that i get from it okay and on the other end of the spectrum what aspects do you dislike about critical care um i would say that it's not just critical care it's just medicine in general medicine is very tasky there's lots of little minutiae things that you wouldn't think about that you have to deal with like on a day-to-day basis uh does the patient have a diet does the patient have you know dvt prophylaxis does the patient have this and did you order this test and did you like it's just very tasky it's very um there's hundreds of little decisions that have to go into making um making it work on the floor you don't necessarily have this problem in the emergency department where you're just ordering your routine tests and then you find your problem and then you send them somewhere else or you fix the issue emergency methods and i find is not as tasky but critical care is definitely very tasky and you're constantly being interrupted by nurses because a patient may not be doing well in this room and so it's the interruptions and the taskiness of critical care in general that probably would be the thing i don't like the most okay all right and i always ask are there any myths that you think are unfair to critical care or you think are that are untrue myths yeah what do you mean not sure like orthopedics don't like uh to do medicine things like that uh no nothing i know of like there's this myth that um critical care doctors are apparently really smart and so uh completely not true that is not true at all but a lot of times um other like hospitalists especially they feel the need to come to me to ask about a question you know to ask a question about a patient who may not be doing very well and yeah they just want my opinion and i'm like you know i'm not any smarter than you are i have the same background that you do so you know what do you think and so um the myth is is that somehow critical care icu doctors are smart and that's not true we're just like everybody else i promise so all right fair enough you're able to um do a fellowship during as a or added on a fellowship even though you're a full-time attending how has critical care shape your work-life balance then i have a job where fortunately so in critical care i work an average of 140 hours a month so if you do critical care you're going to be working somewhere between 140 to 170 hours a month just depending on what your shifts are like fortunately i have a job that allows me to take all those hours and pack them all together and so i work all my 140 hours in a 10-day stretch and so i work for 10 days and it really sucks to work all those hours for 10 days but then the benefit is that i have close to 20 days off and so that has allowed me to pick up some extra time doing neurocritical care and learning more about that working towards getting that board to kind of help me to become a better critical care physician overall so um having a full-time job and a part-time fellowship is very labor-intensive and hour intensive so i'm still working on that work-life balance but um this isn't forever it's just going to be for another year or so so yeah yeah let's hope so until you pursue another fellowship [Laughter] i will graduate one day i promise well you already graduated i know but you know what i mean yeah yeah so how how has um critical care had how has it changed over the years and then can you discuss in light of cobit 19 as well and if you want to also discuss what you think the future of critical care will be uh so cobia 19 i mean even emergency met so emergency medicine internal medicine and critical care medicine coven 19 has completely hit all of them and so um you're directly in the front lines of coven 19 if you work in any of those specialties so you've seen plenty of covet i'm sure in the emergency department as an icu doctor i see plenty of covid in the icu and the hospitalists are managing all the non-icu covet patients so those are the top three specialties em i am in critical care that have been directly impacted by covid so we get lots of covet exposure uh lots of covid um exposure's not the right word but we see a lot of covet patients in terms of how things have changed or how i think it's going to change in the future i think you're going to start seeing more and more of a trend towards managing patients in an outpatient setting for example like heart failure patients we're getting much better at managing their symptoms and managing their problems before they get to the point that they have to come to the hospital and so with that said when people who are going to be admitted to the hospital they're typically going to be sicker i think in the future than they are today as we get better with outpatient management and outpatient follow-up and things like that and so i think in the future hospitalists are going to have to be more comfortable managing sicker patients and so i think you're going to see a trend where hospitalists are going to be managing patients more where they're critically ill where it would qualify as an icu patient there's a shortage of critical care doctors in the future um society of critical care medicine predicts that there's going to be a shortage in the next 20 years of icu critical care doctors so hospitalists are going to have to eventually step up and start taking care of these patients and i think you're going to see technology change in the future for critical care doctors especially in terms of like hemodynamic management and stuff like that so you might get a patient who's really really sick who's on multiple pressers and a lot of times it's hard to pin down is this person sick because it's a cardiac issue is this uh is it because of sepsis or is this like a multi-factor kind of thing and so i think in the future you're going to see hemodynamic monitoring and stuff like that sort of get better where it's going to be not as invasive you know whereas nowadays we have to do swans and stuff like that in the future i think you're going to see um better hemodynamics that doesn't require such invasive equipment and so not only that but in in other areas such as neurocritical care whether a person is like vasospasming you're going to see other technologies that are going to come forth to kind of make our jobs a little bit easier so yeah so you talked about technology what about the aspect of tele medicine as well so i've never done telemedicine but i've uh i know people who have and so i can't personally speak about telemedicine but it's become something that's been invaluable for smaller hospitals who can't hire a dedicated critical care intensivist to work in their icu where they might have nurse practitioners or they might have a hospitalist who sort of do the groundwork or the leg work and then they have a critical care physician who's on the other end of the phone so that they have a camera just like this and they can see the patient and they understand the vitals and they can talk to the intensivist and the intensivist sort of gives them advice on how to manage the patient and so it allows uh it's one potential way of fixing the shortage and critical care physicians that we're going to see in the future so you might see more of that as well i hadn't thought about that but that's a good point but i've never personally done it myself i'm actually interested in it i might want to do it one day so yeah and you touched upon nps and pas or what we call mid levels do you see do you work with them and then do you see their roles changing in the future uh yeah so um i work very closely with nurse practitioners in the icu and i think that they are absolutely invaluable in helping me manage the patients that i do so if i'm the only i see you attending and i have 24 or 30 patients that i'm managing i can't do it all by myself and so having one or two nurse practitioners there to kind of help with procedures to help with seeing the patients to help with um nursing pages and things like that becomes very very helpful um so in the icu nurse practitioners are absolutely invaluable you talked about a severe shortage of critical care physicians does that mean that you think in 10 15 years the job market will still be great um and there's a tremendous demand and a growing demand as our patient population becomes sicker for critical care physicians so i think if you specialize in any of those specialties you're going to do fine okay all right are there any additional resources that students can learn more about critical care any websites or um yeah so um if you're interested in emergency medicine of course there's uh imra there's uh american board of emergency medicine um there's those websites if you're interested in critical care there's um society for critical care medicine they have a lot of resources that you can look up such as they have their own textbook if you wanted to download that and just read that um there's tons of podcasts there's tons of like youtube videos people who make sort of foam free access to uh critical care stuff scott weingarten and all that kind of stuff he does a lot of critical care podcasts and things and so there's plenty of resources and plenty of things that you can look up if you're truly interested in that and if it's something that you really want to consider as a as a job opportunity in the future okay thanks for that and lastly my my last question is what's your number one tip for students who wants to go into critical care looking back now knowing that i was going to do critical care or emergency medicine i would say that when you're doing your rotations in medical school such as when you're doing your neurology rotations or you're doing an ob gyn rotation that i would learn as much as i can from those rotations while you're in that rotation and i get it you're not going to be an ob gyn doctor you're not going to be a neurologist but you are going to see ob gyn patients and you are going to see stroke patients when you're an emergency doctor or when you're an icu doctor and so now would be the time when you're rotating through those specialties to become familiar with the major points that you're going to see because emergency medicine and critical care medicine are so broad in what you're going to see in terms of the problems that the patients are going to have and it's good to have a really solid foundation on just about everything you could possibly encounter so when you're doing cardiology get really good at heart failure and get really good at managing heart attack patients and stuff so that would be my advice i would if you're going to do a very broad specialty such as that then i would take advantage of any rotations that you have and learn the most you can because they're going to be invaluable to you when you actually start practicing in the real world yeah yeah that's a great tip and now do you have anything else that you like to add that the viewers should know about critical care that i missed okay all right all right thanks brad and uh definitely thank you for taking a time uh to do this interview because you've just done a crazy schedule and being able to do this interview with me was freaking amazing anything for uconn i got you all right all right thanks uh thanks again

Channel: Khanh Cao MD

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Id: _YVLNbCMvbI

Length: 25min 24sec (1524 seconds)

Published: Thu Feb 18 2021