Emergency 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 . 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 . 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 . 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 .
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 . Graduates from EM-SCC fellowships are eligible for board certification through the ABS.
Requirements for each program
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 . 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.
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 .
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
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.
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” . 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.
Most SCC programs accept applications through ERAS,  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) .
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:
- American Board of Emergency Medicine
- American Board of Surgery
- Surgical Critical Care Program Directors Society (SCCPDS)
- EMCC Fellowship