To those of you who don’t know me, I am a Critical Care Medicine Physician. I love my job. You all should be able to clearly see that in the passion for my work. Why else would I be exerting all this effort on social media for almost free? If I won the lottery tomorrow, not that I even play, I would still work. This career gives me a sense of purpose that fulfills me. It give my life meaning. I hope that you find the purpose in your life that drives you. It is the cure for what ails you. Traveling and having time off is great, no doubt about it, but after a bit of time off I am itching to come back to work. The purpose of this post is to inform you that it’s not all sunshine and rainbows, though.
You have to figure out what negatives you can deal with. No job is perfect. No career is perfect. I have to be extremely careful here to not offend anyone. Please take this post lightly. It’s the time we live in that people find reason to get offended by anything. Like everything in life, there are good doctors, there are bad doctors. There are good nurses, there are bad nurses. Good RT’s and bad RT’s. There are good pharmacists, there are bad pharmacists. You see what I mean, right? My objective is to review some of the drawbacks of the career so that you cannot complain that you were never told.
Training to become a Critical Care Medicine Physician is a long journey.
The learning curve is steep. I have already covered the different tracts that one can pursue to get into critical care medicine on a previous post. If you’re a nurse looking into this, I can’t explain the steps necessary to be a critical care nurse. I don’t like speaking about things that I don’t know about. I defer to the experts on this. You’re looking at a minimum of 5 years after you finish medical school to train for this position. Another component is that it is extremely competitive to get into these Critical Care Medicine fellowships. I recall that there were over 200 applicants for the two spots when I thankfully got into my fellowship program.
If you choose to pursue fellowship, there is an opportunity cost. This was suggested by Gerald from Grepmed and is something that I regularly discuss with RN’s who are in their 30’s and want to go to MD/DO school rather than NP school. If you are an Internal Medicine doctor who wants to go to fellowship, you’re going to be losing about $200,000 per year while in fellowship rather than being a hospitalist. The quick and inaccurate math behind that includes a salary of $250,000 per year as a hospitalist versus $50,000 a year for PGY-4 and PGY-5. The salary increase over a hospitalist salary for an Intensivist will take several years to recover that opportunity cost.
People get sick 24 hours a day, 7 days a week. Nights and holidays included. You will most likely have to work nights. If you work at a place where there’s no in-house night ICU coverage, then it’s a place where you won’t have to really flex your muscles. Sometimes there’s an NP or PA who covers nights. If you’re an NP or PA looking at this path, same applies to you. You may have to cover nights depending on the practice you join.
The shifts are long. If you want a 9 to 5 job, this isn’t it. Shifts tend to be at least 10 hours although I did interview for a job that had three shifts, 7-3, 3-11, 11-7. My current gig is 8-6 and that’s a piece of cake. That means, though, that my night shifts are 6pm to 8am. Those 14 hours don’t exactly move quickly.
Working 7 shifts in a row is also grueling. People see the 7 on 7 off schedule as being on vacation half the time. Yes, this is true and I love the schedule, but when you are approaching day 6 and 7, you are utterly exhausted. Your brain has been taken through the ringer. There are few easy decisions. There are few patients who aren’t walking on a tightrope trying to die for lack of other terminology. The 7on 7off schedule means that you will work every other weekend. This limits your ability to socialize with normal people. Don’t think that you’re going to finish your 6th shift and then have the energy to want to talk to anyone. It really doesn’t happen.
For nurses, shifts are 12+ hours. But don’t think you can walk in at 7am and leave at 7pm. You need to get there early for a quick briefing and sign-out. Some people say that working 3 shifts a week is easy for nurses but, using my wife who is a critical care nurse as a point of reference, you get your butt kicked pretty regularly. There’s no such thing as getting out of work early either because you have something to do like take your car to the mechanic. You plan around your schedule. You also work weekends regularly, maybe nights.
Does your child have a sporting event or some sort of class? Forget being able to take them to it. Some of these after school activities will be missed. I don’t have children myself at the moment so others can get into this in a more elaborate manner than I can.
Lunch breaks for all those involved in patient care are a fantasy. I could fast for a whole shift easily as I’ve trained myself to not eat when the going gets tough. It’s not like you can get in your car and drive somewhere to get food with your friends. It doesn’t work that way. You get 30 minutes as a nurse in most places and the walk to your car is possibly 5-10 minutes alone. Thank goodness that capitalism created grub hub and uber eats. But yeah, you do not have a guaranteed lunch break. Keep bananas, protein bars, and nuts handy.
Pick your favorite holiday. Christmas, Thanksgiving, New Years, Fourth of July? Chances are you’ll have to work several of those. Will your significant other understand these caveats? Will they understand the insanity of your schedule? I am not saying that many of these are unique to the field, but rather things worth considering.
Doing the actual job of Critical Care
People are in your ICU because they are trying to die. Remember that there are numerous types of ICU settings: trauma, surgical, neuro, cardiothoracic, medical, onc, cardiac. You’re the one standing between life and death for many patients. They’re critical. It’s in the name. Critical care. Your job is to not let them. They are trying really really hard to do so, by the way. I’m only sort of kidding. This gig is pretty morbid. We have coping mechanisms. Just check out the medical meme pages.
The Business and Dynamics
There are multiple settings for intensive care units. Different ways that they are set up. If you’re in a closed ICU, you steer the ship. If you’re at a hospital with an open ICU, you may not have full control of the management of the patient. As an Intensivist, you’re not trained to share this responsibility with a hospitalist. It becomes a little limbo of figuring out how to play nice in the sandbox. There’s another scenario less discussed where sometimes there are multiple ICU groups at the same hospital and you have to seek out the consults. Hustle to keep yourself compensated.
On the flip side, other physicians will try to punt patients to you if they don’t know what is going on. You will be the dumping ground. You are the last line before the demise of a patient. Be prepared to receive phone calls with the person on the other line stating “I don’t know what’s going on”. You need to be able to say, okay, cool, and get to work. You will be called from outside hospital for a patient who has been there for a month and they’re looking to for a way out for that patient. They will give you any excuse. It’s quite frustrating. If someone straight up tell you that it’s a dump, perhaps you’ll have more respect for them.
Small margin of error
There is a very small margin of error in the practice of critical care. Patients are often at an extreme of what physiology can handle. For a nurse, if a bag of life-sustaining IV vasopressors runs out and they were too busy helping out in the next room, their patient can arrest. If you’re an Intensivist obtaining an airway and you can’t intubate them, they could die. The examples are endless. You will have that responsibility. Your conscience could eat you up. You’ll have to live with yourself and that mistake forever.
Continuing on with the small margin of error, this is a high intensity environment. Don’t think that there’s only going to be one patient who is crashing while another is waiting for their chance to crash. Nope. Sometimes it’s multiple people simultaneously consuming your mental bandwidth. It’s a high stress environment. Some people just can’t cut it. I’ve had people ask me if I thought that they were cut out for critical care and I have honestly answered no.
Some people cannot make decisions on the fly. Even fewer can make good ones. Not everyone can keep their composure when it’s hitting the fan. That’s a skill that needs to be developed and practiced often. When you see someone screaming and yelling during chaotic situations, that’s sometimes a sign of a lack of emotional intelligence and maturity. Sometimes it’s necessary to get the room in order, but that’s not something I personally do.
Liability as a reason to not do critical care
Not to mention the amount of liability that comes with it. Unfortunately, and I will go into this a bit more later, but most people do not think their family member is going to die. They think that they and their loved one is going to live forever. The words “intensive care” does not mean anything to them. If something starts heading in the wrong direction, they will blame you. They won’t blame the fact that they smoked 40 packs a day for 80 years and weight 3120 pounds. Nope, it’s your fault. Part of the lack of personal responsibility that has been lost in this culture.
They will threaten you with litigation whenever things don’t go the right way. I’ve been threatened even being in the ED upon assessing a patient for the first time. Talk about starting off the relationship on the right foot. Or when family members say “my friend is a malpractice attorney” or “their cousin is a lawyer”. Cool story, bro. I don’t care if they’re the some powerful person or a VIP in their own eyes, they’re getting the same exact treatment I give everyone else. My best.
Confusion regarding what you actually do
On a lighter side, most non-medical people will think you’re an ER doctor or ER nurse. Nothing against them, of course. Just the confusion is entertaining. Emergency and Intensive mean the same thing in their minds. Even my best friend who is an attorney finally learned what I did when COVID came around. Before that, he thought I was an ER doctor even though I had corrected him numerous times before. It’s simply lay person ignorance because they have no business knowing the dynamics. It’s like hospital staff in a non-teaching hospital not knowing the differences between intern, resident, and fellow or how all that works.
Becoming used to the chaos
You become so familiar and jaded to an extent taking care of the critically ill that you begin to take your developed skill set for granted. You see the nursing meme pages talk about how ICU and CVICU nurses talk down to med/surg nurses. The bullying is real, by the way. Numerous people commented on my instagram page about how bullying amongst nurses is one of their biggest peeves. I’ll get into that more later.
Keeping on the topic of being jaded, as an ICU doctor, I often take for granted my level of training and comfort around chaotic situations. It’s something I’ve been seeing every day for years now. I often take a deep breath when a colleague consults me for what I may consider to be something ridiculous but in reality they’re uncomfortable and want the best for their patient. I’m not perfect. I am trying to get better every day.
The ICU is the top of the food chain. I know I may catch heat for saying that but that’s where the sickest people in the hospital go. No offense to all the other units. Your role is 100% necessary and I am grateful you do that job But the biggest egos seem to gather in the ICU. You’re dealing with the top dogs (at least in our minds), the alpha males and females. You need to learn how to navigate the water with these personalities.
There are the physicians who have God complexes and think they’re better than everyone else, even when they’re clearly not. Those physicians, NP’s or PA’s who take overnight call but cannot be bothered via the hospital messaging system to do their job. You know, what they’re being paid to do.
Critical care nurses, at times, eat their young.
While I know numerous nurses who are much smarter than the average physician, there are many nurses who think they’re smarter than the doctors. There are the nurses who eat their young. The years I have spent with my wife have shown me the true colors of many nurses who have their cliques. It makes life very difficult to those who aren’t members of the clique. It’s like a sorority. I say that because there is a statical predominance of females in nursing. Don’t get mad at math. The nurse memes pages will support me on this.
There are nurses who are there to collect paychecks until they go to NP school or CRNA school with lackadaisical attitudes. I chuckle when they try to come back to ask for a job. You think we forget? I’m not going to go deeper into the nursing stuff because ultimately I am not one to judge. I have the highest respect for the majority of the nurses who I’ve worked with over the course of my career and it has been far more good than bad.
The brilliance of many nurses also means that need to be able to realize that they can point out your flaws/mistakes/ things you missed. If you can’t handle someone calling you out for a mistake, stay out of the ICU. No room for that here. Remember that we all practice extreme ownership of our patients. This can be used to your advantage if you’re smart. The team will save your butt. To learn more about appreciating nurses, CLICK HERE.
There are also numerous points of disagreement with other consultants regarding the best course of action. It takes a lot of intelligence to negotiate these interactions. You sometimes need these consultants to come through for you. It’s not like you can go to the alley and throw down as much as you may want to.
Death: The elephant in the room
Although death is one of the two guaranteed things in life, no one thinks it’s going to happen to them and their loved ones. This rears its head daily in the ICU. Again, these patients are at the extremes of their physiology and capacity of staying alive. We are the only thing standing between their death. It’s our responsibility to keep them alive when we can.
Truth is that sometimes we don’t know what’s the right thing to do. It’s beautiful at times when patients decide for themselves, but many times it doesn’t. What is the right thing to do regarding end of life? Are they really terminal? Is there certainty regarding their quality of life? We try to have the family assist us with these concepts but we are often left alone to try to determine them.
The feedback loop with your team.
This is where working with a close knit team helps out a ton. Speaking to your partners and nursing staff helps. Make sure you’re all on the same page. Make sure you’re not being unreasonable or insensitive. Bounce ideas and emotions off of each other. You need a foster and environment where you can do this. One cannot make these decisions on their own. You will run into many moral dilemmas.
We don’t want to cause harm.
You do feel like you’re torturing people every now and then. I’ll get more into the family dynamics later. But there are some patients who are ward the state whom you cannot get a hold of the responsible party in the middle of the night or you have to wait for a judge to appoint a legal proxy. It could become very frustrating. I’ll talk a bit more about futility in the next section.
People don’t die at home anymore.
Generally speaking, people don’t die at home anymore. They die in the ICU. This is something that is discussed by Atul Gawande in his book “Being Mortal” which explores death in Western Culture amongst other concepts. Instead of your 156 year old patient passing comfortably in their home, they are brought in for intubation, central lines, and vasopressors while the family discusses what to do next. It’s not easy. Then again, if you don’t do it, worry about litigation. They’ll throw negligence at you.
People who are doing better and recovering sometimes just decide to die for no apparent reason. This is extremely hard. You’re left scratching your head wondering what we could have missed. Why did they just die? Could this have been prevented? This happens to all of us. You will lose sleep because of this. You will blame yourself when this happens. It’s a large burden.
Young people dying.
Then you have people who are younger that you are dying in your ICU. Whether it’s metastatic cancer or now COVID you take it personal to attempt to save the persons life at all costs. At least to get them a little bit more quality of life before their time comes. You think about what you were doing at their age. It’s hard. They’ll never have a normal life in the case of terminal malignancies. Moving on from these tough cases is hard.
Family Dynamics: Why NOT Critical Care
Futility and emotional drain.
Just because you can do something to them does not mean you’re doing something for them. When you have a patient who has a tracheostomy, PEG tube, stage IV sacral ulcer, and a history of severe anoxic brain injury who is in septic shock for the third time this week and the family won’t let go of. Full code, bro. It sometimes feel like we are torturing people. It feels like we are doing things to them rather than for them. Them grimacing on the ventilator breaks my heart as well as that of my team. We have to train ourselves to become emotionless for the sake of mental sanity and self-preservation.
When you learn that the reason why the family is not allowing the patient to pass away naturally is because they’re counting on the government check to get by. Or when you have three adult children, two are out of town and one is the caretaker who has been carrying the burden of the patient for several years. When the time comes, the caretaker godsend of a child is ready to let the patient go while the family members from out of town who never visit say “they’re a fighter” and say full code, bro.
Endless family meetings
You will spend countless hours every week discussing care with family members who will not listen to your advice or medical recommendations. They at times chose not to abide by the wishes of the patient. By the way, most living wills are purposefully ambiguous. You could spend countless hours trying to be supportive with certain families discussing quality of life and outcomes, for example in severe anoxic brain injury patients, and they will continue to say that they’ve heard about miracles online. Dude, they were bed bound before they even had the cardiac arrest at the age of 162!
I am 100% supportive of families who are educated and look things up, but don’t bring me witchcraft. Don’t ask me to find a blender to give the patient wheat-grass juice through their PEG and threaten me when I say that we can’t do that. I’ll be happy explore alternative medicines because there’s much that I don’t know about and would like to learn. But there’s somewhere where I draw the line. There are phony doctors out there who sell consultations out there for brain dead folks giving families hope when two independent physicians have carried out full neurologic testing.
Verbal and physical assault. We understand that this is a very difficult situation, but don’t threaten me or my team. This stems from immature reactions and a lack of coping capacity from families. Society has failed these folks. Sometimes the patients don’t even tell their loved ones their underlying conditions or that they’re dying. Then when they show up to the hospital on their last days, the family is visibly upset and threatening saying that they were fine up to the day you or I started caring for them. This includes the litigation component that I had discussed earlier. Many nurses can attest to the violence they have suffered from either patients or their families. This doesn’t happen often, but it’s something to consider.
Concluding why you should NOT pursue critical care medicine.
I think I covered mostly everything I wanted to get off of my chest. Honestly, not trying to be dramatic. I promise that if you choose to go into critical care, it will be far more rewarding than you think. The plan is to create a post and podcast describing all the great things of critical care medicine. Much love.
Link to the first youtube video HERE.
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