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Applying to EM-Critical Care Medicine Fellowships: What you need to know

2017-03-05T14:18:38+00:00

VentEmergency physicians (EPs) have been successfully training in and practicing critical care in the ICU for decades, though until recently board certification remained closed to EPs. In the last few years, however, we have seen monumental changes in training opportunities for EPs, including national standardization of training programs, and most importantly, the establishment of three distinct pathways to board certification. Though the details of some of these pathways are still being worked out, much more concrete arrangements have been reached in the last 6 months. If you are an EM resident interested in applying to critical care fellowships, this is what you need to know.

Paths to board certification

Three training paths to board certification in critical care exist for EPs. Historically, many EM-CCM physicians have been trained through Surgical Critical Care (SCC) programs. This avenue continues to be available, though some of the details have recently changed. In addition, Internal Medicine (IMCCM) and Anesthesia (ACCM) programs now may also accept EM-trained applicants, and EPs trained through these programs are eligible for board certification.

All the paths described here apply equally to EPs who completed or will complete either 3-year or 4-year residency training programs.

Internal Medicine – Critical Care Medicine (IM-CCM)

In September 2011, the American Board of Medical Specialties (ABMS) approved a joint program between the American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM). Since then, EPs can now become board certified in IM-CCM. After completing an ACGME accredited IM-CCM fellowship, ABEM certified EPs can sit for the IM-CCM boards, and then receive diplomas issued by ABEM. Training programs must be 24 months in duration: 12 months of direct clinical training and 12 months of research [1]. ACGME-accredited IM-CCM fellowships may (but need not) accept EM-trained residents, but these programs must have 75% of their positions filled by IM residency graduates [2]. This represents a continued obstacle to EM-trained applicants, as programs may want to accept an EM applicant but may be unable to, if doing so exceeds the 25% EM limit. As of the writing of this article, there was no plan to amend this. EM applicants should be aware of this limitation when applying to programs.

Anesthesiology – Critical Care Medicine (ACCM)

In June 2013, the ABMS approved board certification in EM-CCM through ACCM. As with IM-CCM, after completing a 24-month ACGME-accredited ACCM fellowship, trainees sit for the ACCM board exam and receive diplomas through ABEM. Most ACCM fellowships for anesthesia residency graduates are 12 months. As such, fellowship programs interested in accepting EM-trained fellows must first apply to the American Board of Anesthesiology (ABA) and have prior approval of a 24–month training curriculum before trainees can qualify for certification [3]. As with the SCC route (discussed below), the ABA and the ACGME believe EM-trained candidates require additional training in surgical diseases to adequately manage critically-ill surgical patients. As such, a large component of the first 12 months of ACCM fellowship curricula for EM-trained candidates will involve rotations on primary surgical services [4].

Obtaining prior approval from the ABA requires an important effort from the program. As such, only programs that are actively interested in incorporating EM-trained fellows into their community will do so. Many programs will choose not to seek ABA approval. Interested EM applicants should contact individual programs before applying to ensure prior-approval is complete, and to obtain details on the content of the curriculum.

Surgical Critical Care (SCC)

Historically, most EM-CCM physicians have been trained in surgical critical care fellowships, thanks in large part to a committed group of trauma surgeons who recognized the inherent strength of EPs as intensivists and actively sought out EPs for their SCC training programs. A formal arrangement now exists that allows EPs to train in and obtain board certification in SCC.

As of February 2013, the American Board of Surgery (ABS) and the ACGME have agreed upon a 24-month curriculum for EPs to be trained in SCC. The first 12 months will be a unique preparatory year in advanced preliminary residency in surgery, followed by a traditional 12 months of surgical critical care training. Both parts of the training program must be completed at the same institution. As with the ACCM pathway, the thinking here is that EM-trained applicants require more exposure to the management of surgical diseases than they are exposed to through residency alone [5]. Graduates from EM-SCC fellowships are eligible for board certification through the ABS.

Requirements for each program

IM-CCM

To be eligible for IM-CCM fellowship training, an EP must have graduated (or be on track to graduate) from an ACGME-accredited EM residency-training program. In addition, the applicant must have completed 6 months of training in “direct patient care” in internal medicine with three of those months having been completed in a Medical ICU [2]. What exactly “direct patient care in internal medicine” means is somewhat program dependent, but is generally accepted to mean you must rotate on a service that is led by an IM (or IM subspecialty) attending (i.e ward medicine, cardiology, infectious diseases, etc). A fellow may complete this requirement while in fellowship, but may not supervise IM residents until it has been completed.

ACCM

Applicants to ACCM fellowships must be graduates of ACGME-accredited EM residency-training programs and have completed 4 months of critical care training while in residency [6].

SCC

The main requirement for the SCC pathway is the completion of the advanced preliminary residency in training in surgery. As with the other tracks, applicants must be graduates of (or soon-to-be graduates of) ACGME-accredited EM residencies. There are no additional requirements.

How to apply

IM-CCM

Though some (but not all) programs accept application packets through ERAS, there is no formal match process for IM-CCM. Programs review applications, invite candidates for interviews, then extend invitations to join the program. In general, applications are submitted in the early fall (August – September) and offers are made in mid-October. Each program works a little bit differently. Interested applicants should contact individual programs to ask if they accept applications through ERAS, when applications should be submitted by, and when offers are typically made.

ACCM

The time line for applying into ACCM fellowships is somewhat accelerated, though much more structured. To start work on July 1st, 2015, applicants will be matching in May 2014 through the “San Francisco Match” [7]. All ACCM programs (as of 2013) are using a “Common Application Form”. Applicants send a completed form to each program they are interested in applying. The interview process takes place in the winter. Rank lists are due in May.

SCC

Most SCC programs accept applications through ERAS, [8] though some may not. Interested applicants should contact individual programs to check. To start in July 2014, applicants matched in October 2013 through the NRMP (the standard match program used for most residencies) [9].

Please note: “Grandfathering” pathways exist for internal medicine (IM-CCM) and anesthesiology (ACCM), but will not be available for surgery (SCC). This article focuses on pathways to board certification through training in fellowship programs and will not discuss Grandfathering. Read more here:

Resources

References

  1. ABEM Document on IM-CCM Eligibility (Feb 2012)
  2. ABEM FAQ Document on IM-CCM
  3. ABEM Document on Anesthesiology-CCM
  4. EMCrit AACM Program Requirements
  5. American Board of Surgery and CCM
  6. ABEM Document on ACCM Eligibility (July 2013)
  7. Anesthesia and Critical Care Fellowship
  8. Surgical Critical Care and NRMP Match
Julian Villar, MD MPH

Julian Villar, MD MPH

Clinical Fellow, Critical Care Medicine
Stanford University;
Emergency Physician,
San Francisco Veterans Affairs Medical Center and
Mercy Medical Center, Merced CA
  • Thanks for breaking this down! Clears up the confusing process quite a bit.

  • Emcrithopeful

    1. How do the IM-CC programs count the max of 25% EM fellows per program? Is this over a certain number of years? Most IM-CC programs have only 1-3 spots/yr so I’m not sure how we would be allowed to only hold 25% of those spots at a single program if even one EM resident was allowed in.

    2. What do these IM-CC programs look for in EM grads?

    • Luke Duncan, MD

      The 25% rule is very program dependent from the PD’s that I have spoken to…ultimately, it is designed to force the program directors of CCM programs to take IM grads over EM grads on a consistent basis, regardless of credentials. The problem is that bigger programs may take 2/4 EM fellows and then be forced to take none the next year. ABIM has a history of protecting their own interests of educating IM docs in fellowship programs. Keep in mind that there have only been 2 years of IM-CCM fellows with this requirement so it’re really still being worked out.

      The pre-requisite 6 months of internal medicine experience is arbitrarily designed to make the pathway a bit less desirable by potentially prolonging the fellowship by a few months to meet the graduation requirements. The PD’s that I interviewed with apologized and offered to work out a way to make it as painless as possible.

      PD’s look for interest, enthusiasm, some defined career goals, publications/research of some sort (not requisite) and good letters of recommendation from both ED and ICU docs. A chief resident year never hurts either.

  • Wendy Chang

    Great explanation of the IM-CCM, ACCM, and SCC pathways now available
    for EM residents.

    I’d like to add that a 4th critical care pathway is available in Neurocritical Care (NCC) via the United Council for Neurologic Subspecialties (UCNS). NCC fellowships are 24 months in duration, and open to residents of a variety of backgrounds including Neurology, Neurosurgery, Anesthesiology, IM, and EM. Application begins 18 months prior to start of fellowship with rank list and match completed via SF Match in June, 12 months prior to start of fellowship.

    If any residents are interested in learning more about the subspecialty of NCC and NCC fellowship training, feel free to contact me (em.ncc.md@gmail.com). I currently practice 50:50 EM and NCC at the University of Maryland.

  • Christine Shiffer, ABS

    Here is a link to the Surgical Critical Care information for EM graduates on the American Board of Surgery website:
    http://www.absurgery.org/default.jsp?certsccce_abem

    • Michelle

      Thanks Christine! Adding to the list of resources above.

  • Jason Sanders

    I’d also encourage people to look at the joint white papers on this subject that were published in 2005 in Critical Care Medicine (tinyurl.com/medop9y) and Annals of EM (tinyurl.com/jwyflkx). The papers are now 8 years old but provide excellent framing for the history and future of this workforce/training evolution.

  • Luke Duncan, MD

    I’m a EM/Surgery Crit Care fellow currently in my first year of training.

    There are still a number of hurdles along this pathway, which aren’t apparent at first glance…namely funding, confusing application processes and a healthy dose nepotism. I contacted many programs about applications and about 40% were met with silence. I applied to a number of programs through ERAS (CCM) and interviewed at a few (many had filled their quotas outside of the match with internal candidates). In the end, I tried to pull every string that I could to get into unfilled surgical critical care spots, but many programs didn’t have the funding at the time for the prelim year and were (and still are) scrambling to figure out how to make the prelim year happen. One of my co-residents applied this past year and found similar frustrations in the application process.

    The best pieces of advice that I can give:
    1) Patience is a virtue- this application process is a LONG haul that is still evolving as you’re applying. Don’t burn yourself out early on. If things don’t work out on your first cycle, don’t give up!!!

    2) Start early- especially for anesthesia programs! I’m talking 2 years ahead of time for the anesthesia pathway because of the evolving requirements. The more organized you are, the better off you’ll be!

    3) Find a mentor- My mentors have been my biggest advocates. They’re your foot into the small world of EM/Crit Care docs and a few emails can open up doors that you’d never expect.

    4) Network- This is a tiny world that is rapidly growing with a lot of awesome folks who are willing to help you out. Getting involved with the ACEP’s Critical Care Section, EMRA’s Critical Care Section and SCCM’s Emergency Medicine Section will get you face to face some of the biggest names in EM/CCM. Talk to EM/CC fellows about their journey. Go to the Critical Care Section meetings at every event you can get to.

    Best,
    ~Luke

  • Patrick Ardron-Hudson

    Any updates to how the application process or requirements have changed in the last few years?

    • Julian Villar

      ey Patrick

      I am am more familiar with IM fellowships, so here is what I know.

      For the IM CCM fellowships, not much has changed. Per the 2016 ACGME guidelines, you need 6 months of “direct patient care experience in emergency medicine”, and 3 of those should be in the MICU. If you haven’t completed those by the time you start fellowship, then the first months are devoted to completing this prereq. IM fellowships are 24 months, 12 of ICU and 12 of research and elective. If you have not completed the prereqs by the time you start, the first few months do not count towards your 12 month of ICU, so you get less elective time.

      Regarding the application process, IM fellowships for EM grads are non match. Applications start in the summer, interviews in the fall, to start July 1st the following year.

      Hope this helps, let me know if I can help further

  • Jonathan

    As someone who will be applying for a CCM fellowship was wondering if you had anything to offer in terms of selecting an IM v/s Anes pathway to CCM certification. I’ve asked around and read up on the limited information available online but still don’t a clear understanding of +/- of each. Specifically, in terms of post fellowship practice environments (MICU/SICU/CVICU) as well as opportunities in academic settings.

    • Good questions, but these questions are outside the scope of our EM world over here! Wish we could help more. Good luck!