When David T. Huang, MD, MPH, completed his multidisciplinary critical care fellowship at the University of Pittsburgh Medical Center in 2003, the next logical step was to become board certified in critical care medicine. But there was just one problem: At the time, no critical care medicine board certification examination was available to emergency physicians.
“Pittsburgh let me train there, but there was no American test that I could take. Our chair trusted me and recruited me to stay on as faculty, but he felt it would be useful for me to have some sort of certification,” Dr. Huang recalled. So off he went to Amsterdam for a written test and then to the U.K. for the oral component of the European Diploma in Intensive Care Medicine [EDIC] exam. “The British examiners were all very confused as to why I'd gone all that way to take their exam. When I told them, they were still confused.”
Dr. Huang's strange journey to emergency medicine/critical care medicine has been shared by more than a few emergency physicians. (Acad Emerg Med 2010;17:325.) Some improvements were made in the path from emergency medicine to critical care medicine certification. A 2005 white paper endorsed by several emergency medicine societies and the Society for Critical Care Medicine helped move the process forward. (Crit Care Med 2005;33:2104; Ann Emerg Med 2005;46:217.) But the process still needs significant improvement, leaders in the field said.
Emergency physicians have been receiving critical care medicine fellowship training for decades; indeed, Pittsburgh's program has been offering this track since 1976, but it was only in April 2010 that the American Board of Emergency Medicine reached an accord with the American Board of Internal Medicine to jointly sponsor the critical care medicine subspecialty. That gave EM residents access to training in two-year critical care internal medicine-sponsored fellowships on completion of their EM residencies and a pathway to become certified in internal medicine-critical care medicine.
“That allowed programs like mine to start getting these types of trainees,” said Stephen M. Pastores, MD, the director of the critical care medicine fellowship at Memorial Sloan Kettering Cancer Center in New York and a board certified internist, pulmonologist, and intensivist. “Before that, because my positions are all accredited, I could not train someone from emergency medicine because they didn't have a pathway to take an exam and be certified.”
Dr. Pastores' program added its first EM fellow in 2012, a trainee who completed a four-year emergency medicine-internal medicine program. Not to be outdone, the two other specialties with authority over critical care medicine — surgery and anesthesiology — announced in 2013 that they would offer certification pathways of their own for emergency physicians.
“Anesthesiology's critical care fellowship program is two additional years, like internal medicine. For those who train in surgery, there is a very interesting nuance,” said Dr. Pastores. “They need to do two years of training, and the first year must be a categorical surgical residency training. After that year, the trainees can then do one year of a surgical critical care fellowship. Both years have to be in the same program at the same hospital.”
Dr. Pastores and colleagues from the Critical Care Societies Collaborative (CCSC) Task Force on Critical Care Educational Pathways in Internal Medicine called for these divergent pathways to be harmonized in Critical Care Medicine. (2014;42:1272.) Despite these new options for certification, many minefields still lie in the path for EM/CCM training. Most notably, Dr. Pastores said, internal medicine/critical care imposes a cap on the number of EM residents each program can accept — no more than 25 percent of the fellows in the CCM program can come from emergency medicine. “I have 10 fellows, so that means I can have no more than two a year,” he said.
The collaborative's statement calls for this cap to be loosened, perhaps to 50 percent. “These are highly desirable recruits from emergency medicine, and we should be opening doors, not putting up barriers,” Dr. Pastores said. “There are currently 33 standalone programs in internal medicine/critical care in the country, which means that probably only about 50 EM graduates each year can be admitted to internal medicine-based critical care fellowships.”
The surgical and anesthesia fellowships have no caps, but Dr. Pastores said surgery's requirement for a categorical year of general surgical training may drive away qualified, passionate EPs. Faculty restrictions also apply for the internal medicine/critical care medicine programs: Clinical faculty must be trained and boarded in critical care under the internal medicine umbrella. “You can't come from any other program. Our fellows rotate in cardiothoracic, surgical ICUs, and neurosurgical ICUs at Cornell, and they are supervised and taught by anesthesia intensivists, surgical intensivists, and neurointensivists, but none of those can be considered key clinical faculty. We would like to see the ACGME relax this rule, too.”
Two emergency physicians from Washington University in St. Louis responded to the CCSC statement by calling for even more sweeping changes. (Crit Care Med 2014;42:e677.) Brian Fuller, MD, an assistant professor of emergency medicine and of anesthesiology-critical care, and Brian Wessman, MD, an assistant professor of emergency medicine and anesthesiology and a director of the critical care medicine fellowship, called for eliminating all medical and surgical requirements for EM graduates to fulfill prerequisite and other nonfellowship rotations, calling this “not supported by evidence.”
“Emergency medicine graduates thus far have a 100 percent pass rate on the ABIM CCM board examination,” Dr. Wessman said. Even the EM graduates who were grandfathered in between 2011 and 2014 — physicians who did two years of critical care training and were practicing as intensivists and who were allowed to sit for the exam without the additional requirements of specific IM training — passed at 100 percent. “The national board rate for IM graduates passing is about 90-91 percent. This is something we should be proud of as a specialty.”
Emergency medicine has just as much claim to appropriate expertise in critical care medicine as any of the three specialties, Dr. Wessman said. “This is a core specialty where for three or four years the residents basically initiate critical care. No other residency has you taking care of strokes and seizures, asthma attacks and COPD, pneumonia, bacterial infections, acute sepsis, and gunshots, car accidents, and stab wounds. All these things come through the ED, and with boarding times in most EDs hours to days, often critical care patients are managed by the emergency medicine team for as many as 24 hours until they go to the ICU. I can't think of any other specialty that gets that broad exposure to critical care.”
Every specialty within critical care medicine has its strengths and weaknesses, Dr. Wessman said. He noted that the multidisciplinary fellowship at Washington University in St. Louis has trained surgery, anesthesia, and EM fellows in critical care medicine since 2009. “Surgical residents don't have any great exposure to obstructive lung pathology, like bad asthma or COPD, acute heart attacks, or a big stroke. In emergency medicine, it's not like we do a lot of parenteral or enteral nutrition orders. But that's part of what a critical care fellowship training program is supposed to do: identify weaknesses and create a curriculum that makes you a well-rounded intensivist.”
The overarching theme of the Society of Critical Care Medicine is that intensivists should all work together, Dr. Wessman said. “Given that all the projections are that we will have a serious shortage of critical care specialists by 2020, we need to find ways to get more intensivists trained, certified, and ready to treat these patients. In my opinion, this should include the specialty of EM/CCM.”