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Virginia Mason Franciscan Health Critical Care APP Fellowship in Tacoma


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57 minutes ago, dphy83 said:

I love the addition of a new program but the contractual obligation to remain for 2 years after completion is a buzzkill for me. That's exactly why I became disinterested in Emory. Just my personal opinion. For the right applicant sounds awesome though. 

I totally get it. 🙂

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35 minutes ago, rtPA20 said:

With the contractual obligation, what is the salary after completing the fellowship? Is it higher than what a starting Pulm/Cc app would begin at?

It is! Starting salary will be a little over double the stipend. In general we don't hire anyone with less than 3-5 years of ICU experience. Let me know if you have any questions regarding the remainder of the benefits etc!

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@MediMike
 

There is obviously more to being good at CCM than procedures, but what kind of procedure numbers can a fellow expect, and do you have minimums established for graduation?

Is the health system a 501c non-profit for those trying to qualify for PSLF?

I don’t think the 2 year contract is a deal breaker, but is there room for growth at facility since over 3 years most will have planted roots in the area and feel compelled to stay regardless. Teaching responsibilities? Committees? Admin?

I’m sure the level of responsibility depends on the resident, but will they be more intern level, or is there eventually opportunity for more fellow like opportunities such as taking ED triage or transfer calls, or learning more broad over arching management of the ICU?

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1 hour ago, LT_Oneal_PAC said:

@MediMike
 

There is obviously more to being good at CCM than procedures, but what kind of procedure numbers can a fellow expect, and do you have minimums established for graduation?

Is the health system a 501c non-profit for those trying to qualify for PSLF?

I don’t think the 2 year contract is a deal breaker, but is there room for growth at facility since over 3 years most will have planted roots in the area and feel compelled to stay regardless. Teaching responsibilities? Committees? Admin?

I’m sure the level of responsibility depends on the resident, but will they be more intern level, or is there eventually opportunity for more fellow like opportunities such as taking ED triage or transfer calls, or learning more broad over arching management of the ICU?

Great questions man, I can speak to some of this but not all as I am a cog in the machine rather than the driver 🙂

Procedures: I hate to use the phrase "ample" but it's true.  There will be minimum standards, and they are probably established already I simply don't have the information in front of me.  Anecdotally I had three intubations in a single shift the other day, central lines are around enough that I lean on the PICC nurses because I'm a little tired of them. Institutionally our group is a fan of arterial lines.  We have several interventional pulmonologists in our physician group, as such bronchs are widely available as well.  Chest tubes are hit or miss, believe there was talk about arranging time with surgery for greater exposure.  I don't do many as I work near exclusively nights but it seems the day team ends up performing a fair amount.  LP's are almost exclusively performed in the ED or via IR, we will occasionally do them.

We are a 501c3 organization.

Our group is fairly new to the system having only been around for ~5-6 years, in that time we have "infiltrated" multiple committees, participate in active teaching with nursing staff, take turns doing a journal club etc.  Our manager is a PA who was the prior medical director of the entire hospitalist group at one of our satellite hospitals, the medical director of our group is a PA and we have strong support from our physician colleagues in pursuing additional roles.  I'm currently performing some research in anticipation of revamping our code team for instance.

In regards to your final question the culture of our team is currently the attending for the day (or night) takes the initial call and then we manage it from there.  Managing the "bigger picture" of the ICU isn't something that we deal with on a regular basis. Plan will be for a gradual escalation of responsibilities to the point where you will be considered competent to practice autonomously upon completion.  (Not complete independence, merely functioning as a member of out team)

@EMEDPA one of our physicians is a CHEST certified ultrasound instructor who does a lot of teaching, not sure if there is plans for a formal U/S course or certification.  COVID killed our OR time this last year, we are fighting to get back in, the pulmonologists we work with are very skilled at airway management with excellent opportunities to practice.

Also, @rtPA20 I confirmed that starting salary post-fellowship will be $137,500.

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How many years has the fellowship been in place? Do by "new" you mean this will be the first class, or new in the sense where there has only been a few classes? What are some of the other benefits in addition to the stipend? How competitive is the selection process? Finally, what is the schedule/workload for the fellows such as hours? I have mainly been interested in Emergency Medicine fellowships, but this honestly sounds like a really good program. Thank you!

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  • 2 weeks later...

This sounds like an amazing learning opportunity, thank you @MediMike for the post.  I echo @grc3785's questions and have a couple more: 

Will the post-completion commitment be limited to the Tacoma location or will it span other VM locations?  If the latter, how much choice will fellows have in where they land? 

Any insight into the breakdown of time between clinical experiences vs. didactic? 

Thanks again!

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On 4/14/2021 at 2:55 AM, MediMike said:

@Randito if you're ever feeling the mood for a change Tacoma is a wonderful city.  🙂

Oh, I believe you and would love to move to the PNW. Doing an EM program a few years ago was pretty tough on the family, but now that we have 2 kids under 5, I think my wife would leave me😉 

Really sounds like a great program and I would highly encourage anyone interested in critical care to apply.

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  • 2 weeks later...
On 4/14/2021 at 10:29 AM, grc3785 said:

How many years has the fellowship been in place? Do by "new" you mean this will be the first class, or new in the sense where there has only been a few classes? What are some of the other benefits in addition to the stipend? How competitive is the selection process? Finally, what is the schedule/workload for the fellows such as hours? I have mainly been interested in Emergency Medicine fellowships, but this honestly sounds like a really good program. Thank you!

 

On 4/28/2021 at 11:55 AM, cynwash said:

This sounds like an amazing learning opportunity, thank you @MediMike for the post.  I echo @grc3785's questions and have a couple more: 

Will the post-completion commitment be limited to the Tacoma location or will it span other VM locations?  If the latter, how much choice will fellows have in where they land? 

Any insight into the breakdown of time between clinical experiences vs. didactic? 

Thanks again!

Sorry for the delay in responding folks! Life got a little lifey. 

This program is brand new, the fellows will be the first to go through. The benefits are listed on the website, include the stipend (which I think just got bumped up some to a weird number) as well as full medical and the listed classes.

Hours will vary based on what rotation your are on, I can't speak to what the weekly commitments will be but I'd expect 50-60+ hour weeks. No clue how competitive it's going to be, we'll see after the apps get in 🙂

The first cohort will ideally stay in the Tacoma/South Sound region after completion for the 2 year commitment. In all honesty we are hoping to be training folks who will be our coworkers for the future. Afterwards I'm not sure where the fellowship will go regarding placement, or if the 2 year commitment will stick etc. I'd imagine the organization would love to have our graduates fill needed spots in a variety of locations eventually.

I know that there will be several hours of didactics qMon as well as regular on shift teaching. I love me some whiteboard. In regards to sim time and the schedule for journal club I'm not entirely sure, I currently run the JC for our group on the 4th Thursday of every month, normally an hour or so with some frosty beverages via Zoom at the moment.

The advice I've given other applicants is as follows, and this is in no way punitive or intended to dissuade any particular individual:

If you are interested in emergency medicine, do emergency medicine. The flow, cognitive load, approach to management, diagnostics and treatments are all incredibly different between the two specialties. The entire focus is different when managing an ICU patient as opposed to one in the resus bay.

We definitely have those patients who are crashing and burning, we do chest tubes, intubate, bronch, place lines etc, but the mentality is different because that patient is yours for the next 12 hours at that point. There is no handing off to a different service. Guiding the trajectory of your patient for the long haul is the opposite of treat 'em and street 'em. We don't move meat here, we take the meat and make...alright I lost the metaphor.

What I'm saying is the people who are drawn to EM are drawn for a reason, you like to fix people in a fast paced environment. We don't really offer that, we offer complex pathophysiology, treatments with little to no evidence, long family conversations and patients who oftentimes don't get better.

But if you love physiology and being able to manipulate that physiology, can understand the mechanics of the human body, if you are able to sit down with strangers and make a connection for a difficult conversation, if you like being the person other people come to for answers and for help...then you're probably a good fit for the field. (As well as being procedurally oriented, quick thinking, fantastic resuscitationist, good at twiddling dials on a vent and understanding hemodynamics...) 😉

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  • 1 month later...

Hey all! I was just informed by the uppity ups that the deadline for apps is July 1 and they are scheduling interviews.  Any detailed questions should be directed to whoever the contact is on the web page as my involvement in the program is peripheral at best.

Good luck to all and I'm looking forward to working with some of you in the near future!

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On 5/7/2021 at 10:53 PM, MediMike said:

 

Sorry for the delay in responding folks! Life got a little lifey. 

This program is brand new, the fellows will be the first to go through. The benefits are listed on the website, include the stipend (which I think just got bumped up some to a weird number) as well as full medical and the listed classes.

Hours will vary based on what rotation your are on, I can't speak to what the weekly commitments will be but I'd expect 50-60+ hour weeks. No clue how competitive it's going to be, we'll see after the apps get in 🙂

The first cohort will ideally stay in the Tacoma/South Sound region after completion for the 2 year commitment. In all honesty we are hoping to be training folks who will be our coworkers for the future. Afterwards I'm not sure where the fellowship will go regarding placement, or if the 2 year commitment will stick etc. I'd imagine the organization would love to have our graduates fill needed spots in a variety of locations eventually.

I know that there will be several hours of didactics qMon as well as regular on shift teaching. I love me some whiteboard. In regards to sim time and the schedule for journal club I'm not entirely sure, I currently run the JC for our group on the 4th Thursday of every month, normally an hour or so with some frosty beverages via Zoom at the moment.

The advice I've given other applicants is as follows, and this is in no way punitive or intended to dissuade any particular individual:

If you are interested in emergency medicine, do emergency medicine. The flow, cognitive load, approach to management, diagnostics and treatments are all incredibly different between the two specialties. The entire focus is different when managing an ICU patient as opposed to one in the resus bay.

We definitely have those patients who are crashing and burning, we do chest tubes, intubate, bronch, place lines etc, but the mentality is different because that patient is yours for the next 12 hours at that point. There is no handing off to a different service. Guiding the trajectory of your patient for the long haul is the opposite of treat 'em and street 'em. We don't move meat here, we take the meat and make...alright I lost the metaphor.

What I'm saying is the people who are drawn to EM are drawn for a reason, you like to fix people in a fast paced environment. We don't really offer that, we offer complex pathophysiology, treatments with little to no evidence, long family conversations and patients who oftentimes don't get better.

But if you love physiology and being able to manipulate that physiology, can understand the mechanics of the human body, if you are able to sit down with strangers and make a connection for a difficult conversation, if you like being the person other people come to for answers and for help...then you're probably a good fit for the field. (As well as being procedurally oriented, quick thinking, fantastic resuscitationist, good at twiddling dials on a vent and understanding hemodynamics...) 😉

I would say there are 2 big differences in Critical Care and EM. In CritCare, you are as intrigued and fascinated seeing the same patient with a prolonged recovery day after day. In EM, we do love critical care, pathophysiology, turning dials, but lose interest after about an hour or 2 of that on the same patient. Stabilized? Did all the right things that will improve long term outcomes? Cool, done.

EM, at least good EM providers in my opinion, are equally interested in learning about other acute, but less life threatening disease. What's the NNT with antibiotics to prevent a case of rheumatic heart disease? What is the best migraine treatment? What can be done to help with back pain and not use opioids? What are the cellular mechanisms at play during cannabis hyperemesis syndrome? What are outcomes of loop drainage I&D vs just giving antibiotics? It's not all sexy procedures and life or death. A lot of what we do is being good stewards of healthcare costs and utilization. Don't get me wrong, critical patients are certainly one of the reasons I love EM. I'm just not as interested in the agonizing over every detail of their care for days on end. Critical care isn't so worried about the details of proper tinea versicolor treatment. It's a weird venn diagram of overlap between us. 

Just my opinion.

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20 hours ago, LT_Oneal_PAC said:

In EM, we do love critical care, pathophysiology, turning dials, but lose interest after about an hour or 2 of that on the same patient.

Which is why us EM folks hate holds.  ICU holds can be interesting, but take a fair bit of mental effort.  Holds for med surg, just a pain.  Holds for psyche beds - usually labor intensive agony.  Not only are the patients who are waiting not getting the best care (and the poor psyche patients really aren't getting any), but they're making it harder to get to the next undifferentiated patient who may be acutely ill, or may be just short on coping skills.

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  • 4 weeks later...
  • 4 weeks later...
On 4/7/2021 at 7:02 PM, MediMike said:

Evening folks!

My group has established a new CC APP Fellowship which will be accepting applications.  To my knowledge it's the only one in the PacNW.

Happy to (try) and answer any questions you may have!

https://www.chifranciscan.org/about-us/residencies/critical-care-app.html

How do the programs enforce the contract obligation post-training? Is it a dollar amount that has to be repaid?

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