Charting a Path in ID Critical Care

Paul Sax: [00:00:14] Hello, this is Doctor Paul Sax. I'm editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk ID podcast. Today I'm joined by Doctor Matthew Brigmon. He's an assistant professor of medicine at the University of Texas, San Antonio. And he's double boarded in both infectious disease and critical care. And that will be the topic of our discussion today. Matthew, welcome.

Matthew Brigmon: [00:00:35] Thank you for having me, Paul.

Paul Sax: [00:00:36] So let's start at the beginning. What made you decide to train in both ID and critical care? Was this a deliberate plan from the start, or did you start with one and then go to the other? What was the story?

Matthew Brigmon: [00:00:47] So when I was in medical school, I always enjoyed ID, and that was sort of also sewed into me by my mother, who was a pharmacist, and my dad, who's an environmental microbiologist. So I always wanted to do that. And then during residency, I enjoyed ID because the ID was the guy who's going to figure this out. He's the guy who knows what's going on, sort of the second best specialist in every specialty, right? The second best cardiologist, second best nephrologist.

Paul Sax: [00:01:13] And we're the ones who go and look at the echo. But we're not cardiologists.

Matthew Brigmon: [00:01:17] Right. So I always loved that aspect when I'd watch the ID doctors. But then when I was also resident, I did enjoy ICU a lot because you got to do something now. It's very pathophysiological basis. It's like, you know, regular internal medicine on steroids. During my ID fellowship was at the beginning of Covid, so Covid was about to hit. We were preparing, and I'm sure everybody remembers and has PTSD from all the meetings. I had prepared a 33 page document on all the SARS-CoV-2 treatments and what happened and all these things.

Paul Sax: [00:01:44] Just 30 pages.

Matthew Brigmon: [00:01:45] Yeah, just 30 pages.

Paul Sax: [00:01:46] [laughs]

Matthew Brigmon: [00:01:46] Because I couldn't do anything. A lot of my studies were on hold. We were sort of everything was getting quiet. So I said, well, I got to get busy. So I kind of wrote this whole thing, presented it to the pulmonary care doctors, and they said, thank you. We'll take it into account. They sort of ignored some of the recommendations, although in all honesty, I wasn't right about all of them either, but still. That's when I kind of felt like I always wanted to do ICU. And how can they listen to me? And that would be training ICU.

Paul Sax: [00:02:10] So at this point, you're an ID fellow. You're in the last stages of your ID fellowship, but you now still have a whole nother fellowship you have to do.

Matthew Brigmon: [00:02:18] Yes. So that is very difficult. Any residents or fellows that might be listening to this would understand that when you're trying to find a list of the ID critical care places, it's not very easy. You go to my iris and it'll say certain amount of programs. You go to websites and there's no good place to get all that information. And then there is a certain perception of ID doctors of us not being very proceduralist or very hands on. So yeah, there are a lot of fellows that I say, hey, you want to do ID critical. They're like, I don't want to stick a needle in anybody. No thank you. But that was a task in itself. And I kind of got lucky and falling into doing my ICU fellowship at the University of Texas. But then I ended up staying on staff.

Paul Sax: [00:02:57] So there must be something you get out of ICU that you don't get an ID, and vice versa.

Matthew Brigmon: [00:03:03] It's funny you say that because I don't do any outpatient clinic, because I would just not have any time. But when I'm in the ICU, I get that we got to do something now, what's going on with the patient? Not just infectious diseases. Although a lot of people in the ICU have infectious disease problems. But there's an aspect of like, yes, this is something different. This is, you know, I got to do something now. And then after my two weeks, I do a two-week block. I'll get the itch of like, ah, this too much. This is there's a lot of sad things going on. You're feeling a little overwhelmed. And I want to go back to the ID service where I can sit back and think and make up plans and review data and then after I'm two weeks on that, I'm like, I need some action. Rinse and repeat.

Paul Sax: [00:03:41] Take me through the clinical reasoning. What does your training in ID do for you in the ICU? And conversely, what does your training in critical care do for you as an ID doctor?

Matthew Brigmon: [00:03:54] I do notice that when I'm in the ICU, I have to restrain my ID brain a little because there'll be somebody who comes in, you know, in shock. And everybody put them on antibiotics. And I'm saying, you know, where's the infection? But it's more of a life or death gamble of are you right or wrong? So I have to sort of like say, okay, here's your 48 hours of antibiotics while we figure it out. I'm not going to stop them right away. When I'm in the ID service, I'll be like, we consulted, things have happened. We've got a lot of information, a lot of data. And I can say it's okay to stop the antibiotics at this point. So I have to be a little less aggressive with my ID brain.

Paul Sax: [00:04:29] In the ICU you do. Definitely. But there's this classic conflict. We get consulted on a febrile patient in the ICU. They're still critically ill. They've been on broad spectrum antibiotics and they're not getting better. And the cultures are all negative. And we might say to the critical care folks who might say, look, you can stop the antibiotics. And they say, we don't want to stop, too sick. And by the way, can we add micafungin? So how do you bring those two together?

Matthew Brigmon: [00:04:56] I think over a period of time I've quelled that fear. So a lot of what we do in the ICU is like a fear based economy, right? Like, what if it's this? What if it's that? I've had a lot of the pulmonary fellows tell me that they appreciate me telling them it's okay to stop antibiotics, even in a critically ill patient.

Paul Sax: [00:05:12] Great.

Matthew Brigmon: [00:05:12] So I think we've actually gotten better. ICU pharmacists sometimes will. Tell me, Doctor Bregman, you're the only one that I have to tell to put on more antibiotics. [laughs] And I'm like, I don't know, you know. So I think my brain is still very much alive. And I have been teaching people it's okay. Like your scans don't show anything and your cultures are negative. It's something else, right? And you have to really get rid of that anchor bias of the white count did go down after we started the meropenem, so maybe that was what did it.

Paul Sax: [00:05:37] Not just time.

Matthew Brigmon: [00:05:38] Right, right.

Paul Sax: [00:05:38] Okay, so imagine you're a medical resident who, like you, really liked both ID and critical care. They want explicitly to pursue this training pathway. How do they do it?

Matthew Brigmon: [00:05:50] Good thing you asked me because you found me. Because I started a post in the IDSA forums about ID critical care society. We don't have a home, right? As an ID critical care. You know, I'm part of chest, part of ID, IDSA. Some people are a part of SCCM and IDSA. Some aren't part of IDSA, and they're just SCCM. And so I had raised a question about a separate society for ID critical care. And that's when IDSA and Ryan Maves reached out to me about starting a steering committee for ID critical care. And that's what we're trying to do now is we're trying to make a repository. So we currently have a list of all of the ID critical care programs that are combined.

Paul Sax: [00:06:30] Just give me an idea. How many is it? Approximately.

Matthew Brigmon: [00:06:32] I feel like it's about 60 programs.

Paul Sax: [00:06:36] Wow. That's more than I expected.

Matthew Brigmon: [00:06:37] So there is. And this specifically the training is when you have critical care, a lot of ID programs are having trouble filling. One of the things that helps fill is having subspecialty tracks.

Paul Sax: [00:06:46] Yes.

Matthew Brigmon: [00:06:47] For transplant, immunocompromised patient, MSK, epidemiology, HIV. And critical care, adding critical care to your subspecialty list increases your applicant pool rate and your match rate. So we want to be able to show that through the steering committee and have a place where you can go. Because I signed up for the IDSA mentorship program when I was a fellow, and they couldn't find an ID critical care doctor for me to talk to. I recently pulled the data from ABIM, and there was an article, I think, in 2016 that talked about people that were trained in ID critical care. It was 196 people that were duly ordered an ID in critical care. Recently, Brian Maves reached out, and there's only 205 that hold credentialing in both. And part of that is because finding the fellowship is difficult, and then finding a job that you want is also difficult.

Paul Sax: [00:07:32] Aha. Here's a very blunt question that has to do with a topic that in academic medicine we don't talk about enough, which is money. Clearly a critical care doctor is paid more per unit time worked than an ID doctor. What's to stop someone who's double boarded from just doing all critical care?

Matthew Brigmon: [00:07:52] That's obviously an issue. So I can speak to job searches. When I was trying to find the job that I have now, where I can really do the the ideal job, I think of what an ID critical care doctor would want to do would be half ID, half ICU. I would reach out to places, wouldn't get answers, or I would reach out and they'd say, like, oh, join our ID faculty, then we'll work you into the ICU. Or I would get offers for just the ICU in like the private world, and then we'll work in some ID stuff, right. So if pulmonary, let's say pulmonary critical care only did pulmonary consults. They would probably make as much money as ID.

Paul Sax: [00:08:25] Yeah.

Matthew Brigmon: [00:08:26] But the ICU adds a lot to the RVU. Like one ICU node is probably five ID consults.

Paul Sax: [00:08:32] Yeah I haven't done the math, but I know it's significantly more.

Matthew Brigmon: [00:08:35] Exactly.

Paul Sax: [00:08:37] In your institution, would you say you have a home? Is it an academic home? Is it ID or is it pulmonary critical care medicine or is it both?

Matthew Brigmon: [00:08:46] So ID is my primary home because I did my ICU fellowship where I am practicing. My pulmonary colleagues are fantastic and I go back and forth through both of them. It is tough. Sometimes I have to have two faculty meetings on at the same time and then I'm like, oh, what are they talking about? You know.

Paul Sax: [00:09:01] Are you the only person in your division?

Matthew Brigmon: [00:09:04] [nods head]

Paul Sax: [00:09:04] Yeah, we have three in our health care system that I'm aware of. I'm just going to give shout outs to them because they're all outstanding. Doctor Chanu Rhee, Doctor Lisa Bell and Doctor Deb Hung, and they each say they've derived a tremendous amount from being double boarded in these two fields. Now, you mentioned Covid-19, and boy, did we work closely with our ICU during that time, our ICU doctors and pharmacists and nurses. You mentioned the experience you had. Do you think it has ultimately helped us work together better or same, or are we back to baseline, or is there a kind of lingering support system in place for the two fields to get along better?

Matthew Brigmon: [00:09:44] You know, I've been in multiple institutions, and I do think it's sort of institution dependent. I think where we are, we do work really well together, but I've definitely seen places where it can be a little more contentious between the two. We all have egos of we want to be the one that's right. It really is dependent. Now I feel that, you know, I did my fellowship of ID during the beginning of Covid, and then I did my ICU training during Covid. Yes. So I got to see its ugly face in two different facets. I guess I felt more cheerful and less hopeful during it, and I felt more hopeful afterwards. Okay, but I do think there's a public perception and there's a professional perception. We're having trouble making those two meet at this time.

Paul Sax: [00:10:23] Just a small parenthetical comment that I'm sure you're going to agree with. I hope you're going to agree with is don't you feel enormous relief that those hyperinflammatory, desperately ill patients in the ICU from Covid 19 are really a thing of the past?

Matthew Brigmon: [00:10:39] Yeah, they are, because it's not in numbers. There's still a patient or two you have in the ICU that are similar to.

Paul Sax: [00:10:45] Yes, it brings back terrible memories, but an entire ICU filled with patients like that. Thank goodness for the immune system because even though it may not be sterilizing immunity, it certainly has moderated the severity. All right, last question and then I'll give you a chance for final comments. I want you to design a fellowship that really integrates the two things. And the person ends up leaving double board certified. How many years? How do you split the time?

Matthew Brigmon: [00:11:13] I do think the three-year model works.

Paul Sax: [00:11:16] Okay.

Matthew Brigmon: [00:11:16] I think, though, that if you're going to do it critical care as a resident or fellow, generally what you're going to do is you're going to do two years of ID, maybe a couple ICU rotations, and then it's a whole year of concentrated ICU. It would be nice to have a model like pulmonary critical care where you're doing ID, but you're also doing ICU throughout the whole fellowship. And I don't think universally were there. Every place is different. University of Pittsburgh has a different model than University of Indiana, than Rutgers than UC San Antonio. And we're trying to work through getting a fellowship. And that has been a debate. Ideally, I think it would be a lot of ID your first year, maybe when ICU block and then a couple more your second year with some nights where you have to fight for your life, and then third year maybe switching to a more ICU intensive.

Paul Sax: [00:12:03] And maybe those ID critical care doctors don't have to have an outpatient rotation during the entire two years of their ID fellowship. Maybe just one year. I mean, I'm trying to think of ways to making space for the ICU and the nighttime call.

Matthew Brigmon: [00:12:17] I understand what you're saying, but I think there's still the outpatient HIV. We have an HIV primary service that I do sometimes. I still miss the outpatient HIV. Having a patient that you like brought from the brink, and then now they're your friend. I don't get to enjoy that as much as I did in fellowship.

Paul Sax: [00:12:33] Any final comments?

Matthew Brigmon: [00:12:34] I did want to say that like, I think ID ICU has its place in the critical care training. I don't think we're necessarily better than others. You know, if I have a patient that has really bad ILD or really bad asthma, I'll reach out to my pulmonary folks. You know if I need, if someone's got a persistent pneumothorax, I'm going to talk to my interventional pulmonology guys. We have a couple nephrology critical care guys. So if I, you know, I have some weird hematuria that I'm just trying to, you know, figure out, I'll talk to them. So there's always something. Now, that being said, I think we do have a very good niche. You know, about 70% of people in the ICU will be on antibiotics, probably about 60-70% of them need that. And then they're also at high risk for infection complications being in the ICU. So I do think that we have a very big role in having something in there, but I think there's still a lot of advocacy, a lot of issues to figure out. There's, you know, if a resident or fellow wanted to find a job now, he could reach out to me, he could reach out to Ryan Maves and we could give him pointers, but we're not going to be able to find him or her. A they got a spot for you. They got a spot for you. I think it's still not as easy as it would be if you were a pulmonary critical care trained. And we're hoping to maybe change that over time. Not saying that we're better, but I think there could be benefit to having an ID critical care person on everybody's.

Paul Sax: [00:13:48] You offer a distinctive set of skills, and that's clear from my colleagues.

Matthew Brigmon: [00:13:52] And also our ID critical care steering committee, it's not just two people that are critical care trained. We also want to bring people that. One of my colleagues, Joe, who's in um, at Brooke Army Medical Center, he studies a lot of ECMO infections. That would be somebody that'd be great to have because those are still-

Paul Sax: [00:14:07] Oh my goodness, yeah.

Matthew Brigmon: [00:14:08] We still don't know what to do with those. Yeah. And he's doing a lot of work on that.

Paul Sax: [00:14:11] Yeah. You don't know either what to do with them, right?

Matthew Brigmon: [00:14:12] Or people that tend to work in transplant ICU or someone that has a critical care medicine focus. You know, we don't want to just be ID critical care people. We want people that are also interested in critical care medicine from an ID perspective. And then I would like to thank, if you don't mind, people in the steering committee that are helping me. I also want to thank everybody who responded to me in my post.

Paul Sax: [00:14:29] Oh yeah, it was very popular.

Matthew Brigmon: [00:14:29] Yeah, it was pretty popular. It kind of took me by surprise. So Rodolfo Alpizar, he's our vice chair. We have Brian Maves, I mentioned a couple times. Kelly Calcutt, whom I know. Gavin Harris, Kadri Samir, Paritosh Prasad, Chanu Rhee, and then Benoit Dansky and IDSA.

Paul Sax: [00:14:49] Excellent. Listen, I really enjoyed this conversation. As a reminder, I've been talking with Doctor Matthew Brigmon. He's a double boarded ID critical care guy from the University of Texas, San Antonio. Thanks so much.

Matthew Brigmon: [00:15:00] Thank you.