This post is a rebuttal to my original post on why you should NOT pursue Critical Care. In reality it was not supposed to be a deterrent, but rather to be completely transparent as to what you can realistically expect out of the career in critical care. Most of this applies to the role of being a physician as it is the direct perspective I have. At the same time, my wife is a Critical Care nurse which has afforded me perspectives which I will attempt to comment about. Ultimately, though, I cannot speak for nurses and other personnel who contribute to the ICU team. I know it’s said plenty of times but you’re meeting patients and their families on the worst day of their life. You have the direct privilege to work hard to make it better.
Why you should pursue critical care
Training to become a Critical Care Medicine Physician is a long journey.
I must say, fellowship is fun. If you do pure CCM after Internal Medicine like I did, the two years go by extremely quickly. Where I trained, I was treated as faculty more than a trainee. You’ll find yourself socializing with your attendings far more than residency. The line blurs a bit. Some attendings are looking at you like someone who they can work with and hire when your training is done. Receiving the training in Critical Care where you can take care of pretty much any type of critically ill patient is an incredible feeling. It’s extremely empowering in the confidence and personal strength form. Watching how green you were walking into fellowship and how hardened you’ve become over those years of training makes it all worthwhile. Then when you start your first job after training where it all clicks is an amazing feeling.
Supplementing the financial opportunity cost of fellowship
I mentioned in my post against doing critical care that you’ll miss out on potentially $400,000 of income during those two years. There’s a rebuttal to this, obviously. Most programs also allow the opportunity to moonlight which helps mitigate some of the income difference. During my second year of fellowship, I almost matched my salary from fellowship by moonlighting. I worked my butt off, but you’re in control of your own destiny.
You get time off for “research” which you can leverage as you please. Work on research during the morning while covering an admitting shift for a local hospitalist group in the evening? Don’t mind if I do! Not to mention will earn a larger salary as an intensivist compared to a hospitalist. How much more depends on your market and a number of variables, of course. The opportunity cost is higher, yes, but you’ll recoup the money over the course of your career. It’s a marathon after all, not a sprint.
Training programs for PA/NP’s
There are new, exciting, training programs for PAs and NPs which help hone the skills sets of these practitioners. I can’t say I know too much about this so I will withhold commentary but a simple google search will provide some results for critical care fellowship programs for nurse practitioners and physician assistants.
The emotional benefits of additional training
You’ll find joy in training, at least I did. You’ll develop lifelong friends and relationships. I, for example, try to have a yearly vacation with my co-fellow from training. You’ll have better and more lucrative job opportunities. And you’ll remember that money isn’t everything. Job and career satisfaction is everything. You’ll be part of a small close knit community of Intensivists where we all take care of each other.
There’s a massive Intensivist shortage throughout the country. We need help. People are living longer. They’re dying in the ICU and not at home. We’re always going to be needed. COVID showed us this as in many places that were hard hit had physicians and clinicians who are not ICU trained caring, the best they could, for patients who were incredibly ill.
There are Internal Medicine and Family Medicine-trained hospital medicine physicians managing ICU’s at smaller community hospitals. They do a really good job much of the time and fill a large void, but I sympathize for these fine clinicians because they really don’t have all the training and/or resources. I often get phone calls from these shops seeking advice on how to take care of x, y, or z problem. Most of the time I transfer the patient over when they’re in way over their heads. We need more Intensivists out there.
For nurses, the ICU is a place of much turnover. Like I have mentioned before, many ICU nurses go towards NP or CRNA school. That means lots of openings. That’s an opportunity for you. The pandemic was a great example of how the amount of skilled and trained nurses were in shortage. We need great nurses to be able to take care of our people.
The 7-on 7-off schedule is AMAZING. I personally love it. Sure, it has some drawbacks as mentioned, but the fact that you can get on a plane on Monday or even Sunday night, stay somewhere during weekday flight prices and lower hotel rates. Win, win, win. You can relax on a plane while you recover. You can go to the grocery store when everyone else is working. You can go to the beach when it’s empty, if that’s your thing. The pros outweigh the cons in my opinion. Being able to tune out for a week at a time is great for your mental health. It helps restore the sanity from the intensity of the everyday job. Usually around day 6 and 7, I am itching to get back to work. Maybe that’s because I’m 3+ years out of training and haven’t gotten tired of it yet.
Working night shifts
When you work nights, you may be able to get some sleep here and there. Your shop may vary. Obviously you need to be ready to get up and work if you’re taking in-house call, don’t be a bad person, but there are some good nights where you can sleep the whole night and boom, free day off! These are rare but you’re getting paid to sleep. There’s a term when you moonlight called “sleep for dollars”. Those gigs exist in some places where they need a warm body to be present at night. You obviously have to be ready to work though. I don’t know where any of these said places are, though. Let me know if you find one. Some places have an NP or PA covering nights and you have to be immediately accessible over the phone or need to come in. Be prepared for that, too.
Nights are often also slower than day shift, depending on where you work, of course. You may not have to round on your patients and for the most part the mentality is to hold down the fort and put out fires. Long discussions with families and updates don’t typically happen at night. You can leverage this down time to read a book, pay bills, watch a movie, work out in the call room, amongst other activities. Obviously patient care comes first. People who are listening to this and are appalled need to take a step back and think of all the times they play on their phone while at work. Take a chill pill.
If you don’t want to work nights, you can look for opportunities at facilities where they have tele-ICU coverage at night. At these places the ED team takes care of the necessary procedures and the hospitalist holds down the fort for the admissions. Or you can look into doing tele-ICU yourself! This is likely going to be a more popular option as time passes. I’ve done this before in one of my moonlighting gigs. Let’s just say that the 8 hours went by rather quickly and the compensation was lucrative.
If you are a nurse or RT, yes, you’ll have three typically grueling days on. But then you have 4 days off to do whatever you want. Pick up an extra shift and make some more money? Done. Quick vacation? Done. Days off during the week to run errands. My wife who is a nurse and I coordinate our schedules to capitalize on this.
Night differential in compensation
Working nights and weekends typically comes with a differential financially. Some people love working nights. If you’re a physician, you can become a nocturnist and you’ll make quite the premium financially. Nurses and other staff also earn extra compensation for working night shifts. Not to mention that there are some handsome bonuses at some institutions when you sign on to work nights.
Working 10+ hour shifts.
As a physician, working the long shifts helps you retain ownership of the patients. Fewer handoffs lead to fewer issues. Residency and fellowship trains you to be able to cover the long shifts without any challenges. Critical care nurses, respiratory therapists, and other teammates generally have 12 hour shifts. As this becomes the normal, you won’t see it as it being an eternal proposition. The shifts sometimes go by rather quickly if acuity is high.
Doing the job of critical care.
Business and dynamics
Do you have an inclination towards business? Pursue private practice. Do you want to join a practice where you just show up to your shift, do your job, and walk out? Join a hospital-owned practice. Want to join an academic hospital? You have the opportunity to do that too! Lots of options for your needs and desires. Don’t want to touch patients? Try tele-ICU! I personally work in a private practice group that is subcontracted to cover the ICU’s at several hospitals. I cannot get into too much detail about this but there is a lot of transparency regarding the operational costs of running the pulmonary clinic and paying the salaries of numerous people on the staff. This is would be rather eye-opening in the amount spent to comply with regulations for those who want to reduce the cost of healthcare.
Open ICUs, where you comanage patients with a hospitalist, have the advantage where you may not need to do transfer summaries, med recs on admission, H&P’s. You won’t get calls for melatonin, for example, in the middle of the night. You won’t have to worry about diabetes management. Your focus will be on the the critical components of patient management. If you’re working in a closed ICU, its all on you and your direct team.
It’s quite empowering when a consultant calls you to ask for help. It’s a good feeling when you have the level of training to be able to take care of anyone. It’s also a great opportunity to help educate your colleagues and work together to better care for patients early rather than waiting too long. Also it’ll build a great level of trust between the colleagues. The opportunity for open discussion is amazing. The chances of being dumped on decrease dramatically when you have open lines of communication. There’s a lot of camaraderie in all that. I personally love my hospitalist buddies. Several of which are social media celebrities!
I commented on the small margin of error
Having a narrow window to save a life is a challenge, no doubt about it. You become used to this. You’re trained for this. It hones your brain. You become more effective and efficient. Bigger stakes, bigger victories. There’s a saying by the great David Goggins where he makes references to the big wins as deposits in the cookie jar. When the going gets tough, you reach into the jar and take one out.
There’s a High Stress Environment in the Critical Care Career
It’s a high stress environment, but you’re trained to handle it. Sometimes even conditioned to handle it. Things you never thought you were capable of doing will come as second nature. You will be calm at your baseline heart rate while others panic around the room. At that time, your presence will be calming for those around you. Other physicians will trust you to take care of their patients. Every now and then you’ll get a call from a physician who you don’t get along with asking you to take a look and help them. It’s a nice feeling to be able to help them and more importantly, the patient. It mends the old wounds and discord.
You may have a less stressful life in another subspecialty. Let’s be honest, though. People find stress in any situation. APP’s, are you going to be a glorified scribe or are you going to manage patients? It’s not like you’re going to scope someone as a GI APP. Correct me if I’m wrong. But as an ICU APP you will intubate, place central lines, chest tubes, have the difficult conversations with families, and enjoy the glory of the big wins. Recently, an NP student placed his first chest tube and performed an intubation within the span of two days.
Remember this is a recruiting pitch. I may be embellishing a bit for the sake of having some fun with it.
The level of training that it requires to make one proficient at their craft in this critical care career is, in my opinion, a cut above every other. Subspecialists, generally speaking, tend to worry about their one organ system. Neurologists, Cardiologists, Gastroenterologists, etc. As an Intensivist, one has to be proficient at every single organ system (except dermatology and ophthalmology, don’t ask me a single thing about those). When the consultant comes to see the patient, the Intensivist typically already knows what they want from them. Cardiology, please take this patient down for a cath. GI, please scope this person. They’re now appropriately resuscitated after their GI bleed. Nephrology, please dialyze this person. I’m obviously oversimplifying but you understand the point. Love my colleagues. I am not throwing shade at them.
You’re dealing with the best so that pushes you to be the best.
You get to deal with the best Critical Care nurses. They can watch the ICU for you if you have to step off the floor for an emergency elsewhere. You have each other’s cell phone number. When you see your phone ring and the charge nurse is on the caller ID, you know something bad is happening. Lots of trust. You work with the best respiratory therapists. The ones who make amazing suggestions on ways to manage the ventilators. They may also have some strategies in their back pocket which you are unaware of.
Education is coming fast in the ICU. We’re cutting edge around these parts. Always new technology for us to play with to optimize patient care and improve outcomes. New tests. New treatments. It’s exciting stuff.
The big saves/wins
There are some people who arrive in such a state of illness they you’re sure they’re not doing to make it. This part cannot be highlighted enough. When you have a patient who is on the brink of death, you and your team are able to bring them back from certain death, it is the most rewarding aspect of this career. I am someone who feel that having a sense of purpose is one of the factors of life that makes it worthwhile. Having a sense of purpose provides a sense of fulfillment that sometimes monetary income cannot provide. You can get a $200 bonus and you feel good about it for a little while, but knowing that you directly saved someones life due to your aggressive management of a patient will stay with you forever.
You and your team can reminisce on those huge wins. Remember that guy or gal who we saved? It definitely helps the ego, especially when you cannot save everyone. I have had numerous big saves in my career. I remember each and every one of them clearly. My mom reminds me often to write down the huge wins but I think that’s too much. The big wins are also great to remember when things are tough, and they will get tough.
It is rewarding when these patients come back to the ICU to visit. I ran into a patient and his wife who I took care of while I was a fellow. She immediately recognized me when I was buying a suit. My mom saw as this lady came up to me, verify who I was, and give me a hug. It was a proud moment for my mom. The actual patient had no idea who I was, though, which was quite comical but understandable. He was on the brink of death.
Death in the Critical Care Career
We save many people but unfortunately many people die in the ICU. We are all going to die one day. Those of us who are in these parts of healthcare see death regularly. I hate to say it but seeing someone who has passed becomes ordinary as we pronounce them. As we watch people pass in different manners, whether it be while receiving chest compressions during a code or a compassionate extubation, we constantly think about our own mortality and that of our family members and loved ones. We know what we would want.
When the transition to comfort measures is made, or a patient who is a DNR is passing away in my ICU on the ventilator, I personally look at the patients vital signs and their face. Make sure, the best I can, that they’re not suffering. Make sure they brow isn’t furrowed. Make sure they aren’t tachycardic. Involving the family I ask them if it looks like their loved one is suffering because they know better than I what their facial expressions are.
To see someone pass comfortably, in the presence of their family without suffering is as beautiful as it can be for something that is inevitable. The alternative is a lot worse. We don’t want anyone to die with us doing chest compressions. I can dig far deeper into this but there are so many differing philosophies that I will not impose my thoughts on this on others more than I have already.
Family Dynamics: People who love their loved ones.
To see a family come together, despite their differences, in difficult times is rewarding. Sometimes you’ll have a very sick person who is on life support and the family will tell you to do what you can to reasonably buy time for them to arrive to the bedside. They mention that they’re actively getting in the car from another state or jumping on a plane. They keep their word and allow them a final goodbye. There have been numerous times where I have done what I can to buy the patient an extra few hours (while avoiding suffering of course) to allow the family to get there. Sometimes it does not work, though.
Having the patients family at bedside throughout the ICU course is invaluable. I train them at what I’m looking for. What the ventilator settings are. What the drips their loved one are on are for. If the vasopressor requirement goes up, they know things are worse. If the vent settings are improving then things are heading in the right direction. They know that unless the PEEP 5 is and the FiO2 is less than 50%, chances are I’m not thinking about extubation. But in that process, one can build trust as they become part of the team. If things go south, they see it happening. They recognize the sense of urgency or disappointment in our voices. The family knows that we have done everything in our power to save the life of their loved one. Stopping aggressive management and transitioning toward comfort measures becomes a fluid process.
When the patient passes peacefully in your ICU, the family comes out and gives the staff huge hugs of how grateful they were that you and your team took such good care of them. It’s real love, guys. Real appreciation. We all bicker about nonsensical stuff all the time and every day. But when you are hugged by otherwise complete strangers thanking you for allowing their loved one with peace, dignity, and their family by their side is a invaluable.
I know we want to save everyone but the truth is that we can’t. We should strive to make sure we do everything as perfectly as we can while we try to save their life, which is why all of us are here, but we can’t win them all.
Career fulfillment in this Critical Care Career
I am currently 3.5 years into being a Critical Care Specialist. It is November of 2020. I have zero regrets of the journey I have been on to get me to where I am today. People are easily able to identify how passionate I am about my career, I mean that’s why I do all these different things to expand our knowledge in the specialty and encourage you to join in on the experience. I likely missed many points in this post but please recognize that I am human and I make mistakes. I meant everything in this post with the best intentions although someone will also misconstrue a point to make it seem bad. Don’t forget that we should also be appreciating our nurses. CLICK HERE for a paper on that topic.
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I’ve seen this plenty of times. You’ve seen this as well, right? Is there a name or physiological explanation for this that I don’t know about? Is this formally described in some literature somewhere? Share your craziest story with us (that’s HIPAA friendly, of course). Hope you all have a great weekend. 💪🏼💪🏼💪🏼
If it seems like I am trying to recruit you to come into the world of critical care, you’re right. I am. I encourage you to do so after learning the drawbacks as well as the benefits from this career. No job is perfect, but it seems like this job and life was created for me.
Article Shared on IG on 1/31/22
Curtis JR. Life lessons after a career in intensive care medicine. Intensive Care Med. 2022 Feb;48(2):257-258. doi: 10.1007/s00134-021-06567-z. Epub 2021 Nov 8. PMID: 34748040.
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