Critical Care Fellowship FAQ

Adapted from ACEP’s Critical Care Section

Can an emergency medicine resident become board certified in critical care medicine?

Currently there is no ABEM examination for emergency medicine physicians in critical care. At this time, there are a number of factors contributing to the lack of a board certification pathway. One hurdle is the small number of trained and practicing critical care physicians with an emergency medicine background. It is fiscally impractical to develop and administer a board examination for a handful of physicians. Many of us believe that as more emergency medicine physicians become formally trained in critical care though, that ultimately this situation will change.

Another problem has been the historical background between emergency medicine and other inpatient specialties. Two good recent reviews of the development of emergency medicine and critical care medicine can be found in Academic Emergency Medicine in 2002 and 2005. However, significant progress has been made over the years. A recent jointly published white paper can be found both in the journal Critical Care Medicine and Annals of Emergency Medicine that calls for a review of the current training and certification opportunities in critical care medicine for emergency medicine physicians.

Other progress includes the joint American Board of Internal Medicine (ABIM) / American Board of Emergency Medicine (ABEM) approval of a triple certification for candidates who have completed six years of accredited training in internal medicine, emergency medicine and critical care medicine. This residency program would provide board eligibility in all three disciplines (critical care being administered under internal medicine). As of March 2006, there are programs at Long Island Jewish Hospital and Henry Ford Hospital. The program at Henry Ford Hospital is not currently accepting extra-mural applicants. Efforts are under way at the University of Pittsburgh to create another program, as well. Updated information on all programs is available at the ABIM website.

An alternative route is available for US emergency medicine physicians who complete an emergency medicine residency and then two years of critical care fellowship training. The European Society of Intensive Care Medicine allows US physicians who meet the above requirements to take their European Diploma in Intensive Care (EDIC) exam, the official standard of critical care competence for the European Union. Although the ESICM has a relationship with the US based Society for Critical Care Medicine and its examination is widely regarded as equally rigorous as its American ABIM exam, this should not be construed as formal board certification in the US.

Update:

Just this month, ABIM/ABEM have published entry criteria for taking a certification exam with ABIM.

Do Critical Care fellowships accept EM residents?

The quick answer is some do, some don’t. The April 1999 issue of Academic Emergency Medicine contains a list of the critical care fellowship programs that accept emergency medicine residents. The ACEP CCM Section website has a more recent list of the CCM fellowships willing to accept EM physicians (compiled in 2002). The Emergency Medicine Residents Association has an adapted list of these programs that are particularly interested in applications from emergency medicine physicians for critical care training. The Multidisciplinary Critical Care Training Program at the University of Pittsburgh Medical Center, the oldest, largest, and first fully independent, academic Department of Critical Care Medicine in the US, has accepted emergency medicine physicians into its fellowship program for 25 years and is actively recruiting more. It is a good idea to start looking as early as possible; one year before your anticipated graduation would not be too soon.

See below for a  list of programs that want EM applicants and gear their programs to us.

How long is a critical care fellowship?

Some programs are designed to provide a one year experience; other fellowships are two years in length. The advantages of a two-year fellowship are that it: 1) allows more training and diversity in your education, 2) puts you on an equal standing with other intensivists, and 3) allows you to sit for the European Diploma. The drawback of course is the need for an extra year of training. Because no standard exists for emergency medicine physicians seeking critical care training, there is no “right” answer. At the Multidisciplinary Critical Care Training Program in Pittsburgh, we encourage all emergency medicine critical care fellows to complete two years of training.

Will I be able to get a critical care job after fellowship?

Yes. Many emergency medicine physicians are currently employed as intensivists in both private and teaching hospitals, some even as medical directors. In addition, the field of critical care in general is facing a time of tremendous growth. The COMPACCS (Committee on Manpower for Pulmonary and Critical Care Societies) study published in JAMA demonstrated that there would be a growing need for intensivists in the near future. The Leapfrog Group, a consortium of Fortune 500 companies and healthcare consumers, has set three healthcare priorities for improvement in quality care, one of which is that all intensive care units be staffed by trained intensivists. In fact, the Leapfrog Group considers emergency medicine physicians with critical care training intensivists. With these powerful demographic and economic pressures, we anticipate a promising job market for critical care physicians, regardless of their base specialty.

Will emergency medicine training prepare me well enough to be a strong critical care fellow?

Yes. While other specialties bring their strengths into fellowship programs, your familiarity with handling critically ill patients at their initial presentation, experience with juggling multiple patients at once, and training in “sniffing out” the potential disasters from a sea of undifferentiated complaints will serve you well during fellowship. If you look at the core curriculums of emergency medicine and critical care, you will find that to a large degree our areas of knowledge overlap, particularly in the areas of resuscitation, technical skills needed for “crashing” patients (i.e., intubation, central lines, chest tubes), and exposure to both surgical and medical emergencies. Remember that nobody comes to a fellowship with nothing to learn.

How will a critical care fellowship enhance my career as an emergency physician?

Having a “niche” will always help your career, by keeping your interest level high, allowing greater research and administrative opportunities, and by making you a highly sought after expert in your field. Emergency toxicologists, pediatric emergency specialists, sports medicine emergency specialists, and hyperbaric emergency specialists exist, thrive, and add to the strength and breadth of emergency medicine. There is certainly room for emergency critical care specialists!

A recent NEJM paper demonstrated the importance of aggressive, early care for critically ill patients in the emergency department. By training in critical care, you will not only enhance your ability to manage critically ill patients, but will also be well positioned to coordinate the expanding role of emergency medicine in the care of the critically ill. With the increasing problems of overcrowding and long emergency department times, sicker patients will be in the emergency department and under your direct supervision, whether we feel prepared to care for them or not. Another possibility is the staffing of observation units by physicians with training in both emergency medicine and critical care.

Finally, working in both the emergency department and the intensive care unit may help prevent “burnout”, by offering a change of pace and different challenges on a daily basis. The more cerebral and controlled environment of the unit can be an interesting counter-balance to the frenzied and chaotic pace of the emergency department. Many of us find the combination of these two environments to be tremendously rewarding.

Which programs do you recommend?

These are the fellowships which I recommend for ED residents because they actively want as opposed to begrudgingly accept ED residents:

Shock Trauma Center (Baltimore)

Indiana University

University of Pittsburgh

Henry Ford

Cooper

Beth Israel (Boston)

University of Alabama

My friend, Seth Manoach, adds the following:

Stanford Anesthesia has always actively welcomed ER guys, and now, in their Pitt style multi-disc track they put out the welcome for us but say to apply under medicine

Hopkins Anesthesia’s director has said the same thing, they actively welcome ED applicants

Also Wash U St. Louis Anesthesia, actively welcomes and has had a two year track for EM people since the deal talk started

So is IM actually certifying us?

As of the San Fran ACEP SA in 2011, the answer is yes, but as usual the devil is in the details.

Announcement in IM throwaway where they also mention ED ICUs.

Letter from Pulm Crit Care Folks to ABIM

ABIM’s response

Where can I find additional resources?

• EMRA Critical Care Committee
• ACEP Critical Care Section
• SCCM Emergency Medicine Section
• C3MED