Why go into Pulmonary and/or Critical Care Medicine?

The decision of whether to sub-specialize is individual and complex. However, most residents pondering fellowships have certain considerations in common. They center on the nature of subsequent practice, employment opportunities and lifestyle. In addition, those considering an academic career may be drawn to specific research topics or questions.

Nature of Practice

In my experience, the majority of those seeking fellowship training in Pulmonary and Critical Care Medicine (P/CCM), when asked to describe what drew them to the field, cite the practice of critical care as determinative. The ICU requires the physician to understand and deal with a wide variety of illness affecting multiple organ systems. Thus, training in critical care medicine really does represent an "Added Qualification," as it builds on the general training of Internal Medicine. The procedural aspect of ICU medicine is also appealing to many.

Most applicants for fellowship have had positive experiences on ICU rotations and feel that intensive care suits their personality. These physicians are often described by their attendings as both thoughtful and decisive. The ICU demands the ability to make decisions in the face of uncertainty, but also requires a sound understanding of physiology and complex reasoning skills.

Pulmonary medicine offers the opportunity for continuity care in dealing with patients with chronic lung disease as well as certain diagnostic challenges. Pulmonary medicine also requires a sound understanding of physiology. Pulmonologists are likely to perform and interpret pulmonary function tests, cardiopulmonary exercise tests and sleep studies as part of practice. Outpatient procedures, including diagnostic and therapeutic bronchoscopy, can make up a significant portion of some pulmonary practices.

Employment Opportunities

While being drawn to the practice of P/CCM is crucial to ultimate success, prudence demands that those considering such training also be concerned about long-term prospects for employment. The early and mid-1990s saw a decrease in opportunities for sub-specialists of all kinds, but this trend has reversed over the last several years. With respect to P/CCM specialists in particular, a recent manpower study published in (COMPACCS) JAMA has suggested an increasing demand over the next two to three decades. The accuracy of such studies is largely dependent on the validity of a series of assumptions that go into the modeling, but the outlook for both academic and private practice jobs in P/CCM is currently quite positive. Trends in sleep medicine, the hospitalist movement and percentages of ICUs staffed by intensivists will also affect the demand for P/CCM-trained physicians over the next several decades.

Lifestyle

Just as P/CCM covers a wide variety of clinical arenas, the lifestyle of physicians trained in P/CCM varies greatly. The practice of critical care medicine generally carries with it long hours and an inherent unpredictability. The work is of high intensity, a characteristic that draws many to the field, but ultimately causes some to shift to more predictable and less acute practice options. Some ICUs are now staffed in shifts, much like an emergency department, allowing for a predictable schedule while maintaining continuity of care to some degree.

Pulmonary practice tends toward the outpatient with inpatient consultations. The balance between pulmonary and critical care responsibilities is highly variable. Sleep medicine also represents an outpatient practice filled largely by practitioners who have pulmonary training.

Does Pulmonary Training Always Come with Critical Care training?

There are three main options for fellowship training in Pulmonary and/or Critical Care Medicine.

1. Combined Pulmonary and Critical Care Training Programs: These programs require a total of 3 years training, with at least 18 months of clinical training (6 pulmonary, 6 critical care and 6 combined). Up to 18 months of research may be part of the fellowship training, and many programs allow for extension of research training beyond 3 years. Successful completion of an ACGME-accredited fellowship allows the physician to sit for both the Pulmonary Board exam and the certificate exam for added qualifications in Critical Care Medicine.

2. Pulmonary Training Programs: Accredited programs in Pulmonary Medicine require a 24-month fellowship, with at least 12 months of clinical training, with the remainder of time devoted to research training. Completion of an ACGME-accredited Pulmonary fellowship allows a physician to sit for the Pulmonary Board exam, but NOT for the Critical Care certificate exam.

3. Critical Care Training Programs: There are several pathways by which a physician who is board-certified in Internal Medicine may become eligible to sit for the certificate exam in Critical Care Medicine: (a) A 1-year clinical fellowship in Critical Care after completion of another fellowship (e.g. 3-years of Cardiology); (b) A two-year Critical Care fellowship; or (3) A 2-year fellowship in General Internal Medicine that has at least 6 months of critical care AND the completion of a 1-year clinical Critical Care Fellowship. Thus, Pulmonary training is not required in order to be certified in Critical Care Medicine.

More information on the requirements for sitting for Board exams is available from the American Board of Internal Medicine, www.abim.org.

How Do I Apply for a Fellowship in Pulmonary and Critical Care Medicine?

Most Pulmonary and Pulmonary and Critical Care Training Programs participate in the National Residency Matching Program, www.nrmp.org/fellow/. Since 2003, the Electronic Residency Application Service has been available to P/CCM programs and applicants. Dr. Molly Osborne provides a summary of the service on this site. Not all programs currently participate in the ERAS program, so applicants may need to complete both a general and several program-specific applications. Even within ERAS, individual programs may still have specific application requirements, but in general will ask candidates for basic information about education and accomplishments, a personal statement of career objectives and several letters of reference, often including the medical school dean's letter. Upon receipt of completed applications, most programs will invite particular individuals to visit for interviews. The cost of these interviews is borne by the applicant. After interviews are completed, both applicants and programs submit rank lists. The Match takes place in the early summer one year prior to the starting date.

A general timeline for the application process appears below. It is important to remember that each program will have its own deadline for completed applications.

How Should I Go about Choosing a Fellowship Program?

Over 100 institutions offer fellowship training in Pulmonary and/or Critical Care Medicine. An applicant must narrow down his or her choices, if not initially, at least when the time to interview comes around. Exploring options in advance will help minimize costs associated with interviewing and maximize the chances of matching with the program that is best for you.

First, it is important to identify what you want from a training program. Are you planning an academic career or a future in community practice? Do you want a large program with multiple hospitals or a smaller or single-institution program? What type of research do you want to do? Are you willing to go anywhere if the training is excellent or are you limited in terms of where you are willing to live?

Once you have identified the type of program that fits your needs, begin to research your options.

Ask Pulmonary faculty in your residency training program. You can get a sense of the overall quality of training programs by asking faculty in P/CCM which programs they believe are best and why. Start with the faculty you will be asking for letters of reference. If you are interested in a particular program, try to speak with someone who trained there. Remember that you will be sampling local opinions.

Ask current fellows. If you are at an institution with its own P/CCM fellowship program, the fellows will have recently completed the process you are just now embarking on. Ask them where they interviewed and what their impressions were.

Ask what other applicants were saying about particular programs.

Request information. When you contact programs for applications, you will generally receive additional information about the institution and training program. If you have specific questions, contact the program director.

Visit the division or program website. This site provides direct links to many Division and program websites.

Programs will invite only candidates that they feel have a reasonable chance of matching with them. The interview process offers candidates a chance to directly assess individual programs.

What Should I Expect From the Interview?

The interview process is vital to finding a fellowship that not only provides you with the kind of training you are seeking but is also a place you are glad to be working. During the interview you should meet not only with faculty members but with one or more current fellows. Do some research before you visit a program. If there are faculty members doing clinical work or research of particular interest to you, ask specifically to meet with them. If you know of fellows who came from your residency program, contact them. In addition to asking specific questions, also try to get a general feel for the program and whether you think you would fit in. Remember, you will spending at least three years in a program and you should feel comfortable working with the people there.

How Should I Decide on my Rank List?

After you have interviewed at all of the programs you are considering, you will need to complete your rank list and submit it to the National Residency Matching Program. The relative weight you give to the various strengths and weaknesses of individual programs will depend on what is most important to you. I always advise applicants not to ignore their overall gestalt about a program when they are formulating their Pro/Con lists. At times, questions or concerns may arise after the interview process, and it is perfectly appropriate for you to contact a program director subsequently. This is a good time to talk again with those trusted faculty members at your own institution about your impressions.

For the match to work well, it is necessary that all parties respect the integrity of the match process. While it is perfectly appropriate to express a high degree of interest in a program and to let the program director know of your interest, all parties should avoid making explicit comments about rank order. Communication between programs and applicants after the interview varies greatly between programs. A lack of contact should not lead you to believe that a program is not going to rank you highly. From an applicant’s perspective, there is no disadvantage to ranking programs in order of your preference, even if you think the likelihood of matching with your first choice is not high. You should also rank all programs that you would be willing to join. Listing only one program because you are under the impression that you are sure to match there may result in you not matching at all.

What Happens after the Match?

Applicants that did not match and programs that did not fill are notified the day prior to the Match. Applicants who match will be contacted by the training program to sign a letter of commitment. In the spring before the fellowship begins, more communication with the training program will take place in order to facilitate licensing, credentialing and other transitional issues. Many programs will provide an orientation prior to the start of clinical responsibilities. But sometime after July 1, one year after the match, it will be time to get down to the business of learning Pulmonary and Critical Care Medicine.

(12/01), (12/04), (12/06)

Last reviewed: February 2015