For the past decade, a new kind of physician, board certified in both emergency medicine and either pediatrics or internal medicine, has been forging a fresh path in medical practice. The road these dedicated physicians take is not an easy one, but it can provide them with innovative career opportunities as well as a chance to practice their specialties in ways unheard of previously.
Carey D. Chisholm, MD, the residency director of the emergency medicine/pediatrics program at Indiana University School of Medicine Clarian-Methodist Hospital, runs the oldest existing program in the nation. “I would characterize it as a tremendous success,” he said of the program that began in 1990. “It benefits both the pediatrics and the emergency medicine program because we are training a group of people who can carry their knowledge across specialties.”
The idea is a fairly new one. It was little more than a decade ago that the American Board of Emergency Medicine, the American Board of Internal Medicine, and the American Board of Pediatrics gave their respective blessings to the idea of combined residencies. While the programs attract considerable interest from medical school graduates, each accepts no more than two new residents each year.
At the University of California-Olive View, Pamela Dyne, MD, runs the emergency medicine/internal medicine program that accepted its first two residents in 1996. “UCLA had a prior version of an IM/EM program that was underway for several years and closed, graduating its last graduate in 1994,” she said. It closed, she said, because it appeared that applicants were losing interest.
“We created our new program because we saw there were potentially strong applicants. We decided that creating the combined program would be ideal for accomplishing the mission of our categorical program. The combined residents would be helping us teach all the residents. They are ideal sorts of leaders and teachers and academics,” she said.
“We get great applicants, and we get a lot of them, in the neighborhood of more than 50 for the two positions. Because the program is so challenging, we apply pretty strict academic standards,” said Dr. Dyne. Often, she said, applicants themselves realize that they are not ideal for the program and drop out of the pool. “This isn't for people who cannot decide between medicine and emergency medicine,” she said. “Often, once they realize that, they withdraw their applications.”
“We get top people in this program, but that is not to say that people who are not in the top of their classes shouldn't apply,” she said. However, those who come should be willing to work.
Dr. Chisholm agreed that his pediatrics/emergency medicine residents bring a lot to the program as well. “Our fourth- and fifth-year residents bring in a lot of pediatric knowledge,” he said. The fifth-year students actually run a pediatric resuscitation lecture series for other emergency medicine residents and a similar program for pediatric residents, he said.
Best and Brightest
Peter DeBlieux, MD, the emergency medicine residency director at the Louisiana State University-Charity Hospital, said he is a dedicated advocate for his combined residency program. “Before I [trained] here, I had wanted to do a combined program,” he said. “I had done a fellowship in pulmonary medicine.”
He said he was attracted to the combined emergency medicine/internal medicine program because he “was interested in keeping some of our best graduates around.” He said emergency medicine typically attracts stronger applicants than internal medicine. “We devised this program with the dean's office and internal medicine department to encourage some of our best and brightest to stick around,” Dr. DeBlieux said.
Those who commit to the combined programs agree to stay in their residencies for five years. Those who do residencies in both internal medicine and emergency medicine will have completed at least two and half years of accredited training in each specialty in the program. Those in the combined pediatrics-emergency medicine residencies are required to have a similar amount of training. Although the combined program is shorter by a year than taking the two residencies separately, the amount of learning is about the same, the residency directors said. The 36-month emergency medicine training requirement is met by 30 months of emergency medicine training and six months of training appropriate to emergency medicine obtained in the other specialty. The 36-month requirement in the other specialty is met in the same way.
Being in the combined program eliminates some of the flexibility enjoyed by residents in the categorical emergency medicine program, said Dr. Dyne of UCLA-Olive View. “Our categorical residents have elective time that the combined residents don't,” she said. “They do lose that. It's a pretty rigorous program. You have to learn and to read a lot. You are learning a huge volume of information [in the combined program]. That is why we select smart people who are capable, and have a proven track record of doing multiple things at once. You have to decide whether to read Harrison's or Rosen, knowing you have to learn all of it. That's a lot of information to learn.”
“They are generally very motivated,” said Brian Euerle, MD, the emergency medicine residency director at the University of Maryland Medical System. “In general, they are high achievers who have done well in school, and they kind of enjoy a challenge.”
The programs themselves offer considerable advantages, said Dr. DeBlieux. “There are two big selling points. From an academic standpoint, there is the ability to be double board certified in five years. For an additional year, they are double boarded. It is incredibly attractive to those who are willing to train in our four-year categorical program.”
Although most people think that residents in combined programs are planning to go into academic medicine, Dr. DeBlieux's experience is different. “Rural Louisiana has plenty of opportunity for people with double board certification,” he said. “They can work in an emergency department and have a clinic simultaneously. Some people are doing things like that.”
Dr. Euerle said some of the students who have graduated from his program have gone into academics. “It is one of the natural things to think that these people would be great to coordinate and serve as a link between two departments in an academic medical center.”
The double boarding is an advantage for residents who are seeking an academic career, said Dr. Dyne. “It allows one to apply for fellowships that are medicine-based such as cardiology, infectious diseases, or critical care. You can marry that with emergency medicine.” She said some emergency physicians are actually triple boarded, with additional work in a subspecialty.
Physicians who are certified in emergency medicine and internal medicine can combine a career as a hospitalist with that of emergency physician, she said. “One of our graduates will probably do that. Our first actual graduate of the program graduated this year, and he has taken a position on the faculty here in both emergency medicine and internal medicine. He will be working in both areas. It is just ideal, and we are thrilled,” she said. “In the class behind him, one plans to be a hospitalist and an emergency physician in the community. The other one wants to be an academic and specialize in infectious disease as well.”
Another group drawn to the program is those who plan to do relief work after graduation, joining a group such as Physicians without Borders. “Someone who can do primary care on top of emergency care is very versatile in a less resource-rich environment,” said Dr. Dyne.
Dr. Chisholm has seen a 50–50 split among graduates of his program. The first class was graduated in 1995, he said. Those who go into a community practice will often find themselves taking responsibility for pediatrics in the group, he said. The physician with training in emergency medicine and pediatrics will do quality assurance and education in pediatric care for the group. Those who go into academics usually have dual appointments in the departments of emergency medicine and pediatrics, he said.
Those who are double boarded in pediatrics and emergency medicine can also become pediatric hospitalists, he said. “They have a unique perspective on the patient in today's health care system because they understand the continuum from prehospital care all the way to treatment in the hospital,” he said.
“We devised this program with the dean's office and internal medicine department to encourage some of our best and brightest to stick around.” - Dr. Peter Deblieux
“It benefits both the pediatrics and the emergency medicine program because we are training a group of people who can carry their knowledge across specialties.” - Dr. Carey Chisholm
“In general, they are high achievers who have done well in school, and they kind of enjoy a challenge.” - Dr. Brian Euerle
“They are ideal sorts of leaders and teachers and academics.” - Dr. Pamela Dyne
“I hope more people will do this,” he said. “Our graduates are in incredible demand. On average, they have six job offers when they graduate from their residencies.”
Those who are double boarded in pediatrics and emergency medicine might be asked why they simply don't do fellowships in either pediatrics or emergency medicine after finishing residency in the other field. Dr. Chisholm said that is the road some people take. However, a person who does that will find it difficult to receive acceptance from the specialty in which he did not complete a residency, he said. An emergency physician who does a pediatric fellowship “will never be accepted by pediatricians,” he said. “They will face discrimination from a number of children's hospitals as well.”
Those who are double boarded will not face that problem because they are both emergency physicians and pediatricians. “They are in the best position to cut through the rhetoric,” said Dr. Chisholm. “They understand both groups and are part of both specialties.”
“However, something to keep in mind about a pediatrics/emergency medicine combined program is that it does not make you eligible for the board in pediatric emergency medicine,” said Dr. Euerle. “You are eligible for straight pediatrics board certification and for certification in internal medicine. If you want to be eligible for the board in pediatric emergency medicine, you would have to do a fellowship.”
“I don't think that will change in the next few years,” he said. Previously, Dr. Euerle said, physicians completing an emergency medicine residency and then a pediatrics residency could be boarded in pediatric emergency medicine, but “that period is over, and you can no longer do that.”
The number of programs that provide combined residencies wax and wane. Hennepin County Medical Center, for example, ended its combined pediatrics-emergency medicine residency two years ago because of cuts in the funding for graduate medical education put into place by the federal Health Care Financing Administration. The federal government cuts funding for graduate medical education in half after the third year of residency.
The combined program in emergency medicine and internal medicine at Albert Einstein College of Medicine also is no longer accepting new residents, a spokeswoman for the college said. The issue of HCFA funding varies with the school, said Dr. Dyne. “For us, it's not a very big issue because of the structure of our salaries. Olive View, from which we derive half of our salaries, gets no Medicare dollars,” she said. “However, UCLA is affected by the 50 percent cut in funding but to a lesser extent. We are pretty protected.”
Her facility had a pediatrics/emergency medicine program, she said, but that program ended because of differences in styles between the two programs. She said when residents said they were unhappy with the way that program was running, they closed it. Dr. DeBlieux said he would like to have a combined pediatrics/emergency medicine program, although the finances would make it impossible to fund a program at this time. “What we are dong is graduating residents and funneling them to pediatrics,” he said.
A combined program needs a champion, said Dr. DeBlieux. “The downfall of many programs has been when the categorical program director doesn't believe in the combined program,” he said. “I not only believe in the program, but I support it wholeheartedly.”
Two periods during the combined residency are the most difficult, said Dr. Euerle. “One is that the residents find themselves switching back and forth every three to six months. They get used to one group of colleagues and then they have to switch. It is hard, especially the first two times. Another disadvantage is that at the end of three years, these residents see the friends they started with graduating, and they still have two more years of residency. It can be a little disheartening for them.
“The national dropout rate has been higher from these programs. People start them with all intentions of finishing. Then they find they like one specialty better than the other, and they don't want to put in the extra time. We have had problems with people leaving the program. That can be difficult.”
Despite the difficulties, most residency directors with such programs said they are worthwhile. “I'm a little surprised that it hasn't caught on in more places,” said Dr. Chisholm.