Critical Care Subspecialization in Emergency Medicine
Evie Marcolini, MD FAAEM; Michael Winters, MD FAAEM
Posted: 09/14/2010
Abstract and Introduction
Introduction
The American Board of Emergency Medicine (ABEM) recently announced an agreement with the American Board of Internal Medicine (ABIM) to co-sponsor internal medicine (IM)/critical care medicine (CCM) certification (
www.abem.org/public). This agreement provides emergency medicine (EM) residency graduates access to training in two year critical care fellowships sponsored by internal medicine (IM) programs. As a result, EM graduates will be eligible for certification in IM/CCM.
The American Boards of Surgery and Anesthesiology have declined pursuit of a similar agreement and requested there be no grandfathering availability to EM graduates who have completed surgical or anesthesia critical care programs.
This agreement is a landmark step in ABEM's pursuit of critical care board certification. Some in the EM community do not favor the agreement that ABEM has brokered with ABIM, inasmuch as it does not benefit those who have trained in surgical/anesthesia-sponsored fellowships and it makes the surgical/anesthesia critical care fellowships less competitive for future emergency medicine graduates. To understand and fully appreciate the agreement that has been made, it is important to review the parallel development of EM and critical care as board certified specialties. This summary is based on an article by Somand and Zink, published in
Academic Emergency Medicine in 2005.
[1]
In 1961, Dr. James Mills, a general practitioner in Arlington, Virginia, opened the first full-time EM practice. By 1968, the American College of Emergency Physicians (ACEP) was formed. At the same time, the concept of a critical care unit (CCU) was coalescing as an evolution from the post-anesthesia care unit. In 1970, the Society for Critical Care Medicine (SCCM) was founded. One of the 29 physicians who founded SCCM was Dr. Peter Safar, an anesthesiologist and leader of the critical care movement, whose definition of critical care was a triad of 1) resuscitation, 2) emergency medical care for critical illness or injury and 3) intensive care. Today the clinical distinctions of care are blurred, because the general lack of ICU beds requires longer stays in the ED for many critically ill patients, requiring emergency physicians to call on their critical care knowledge base and skills frequently.
In 1972, ACEP, SCCM and the University Association for Emergency Medical Services formed the Federation for Emergency and Critical Care Medicine, the purpose of which was to promote EM and CCM within the American Medical Association (AMA). This union helped ACEP win the designation of a provisional section on emergency medicine by the AMA in 1973, but the collaboration prematurely dissolved as EM and CCM each continued to seek primary board recognition. The hosts of the AMA-sponsored Workshop Conference on Education of the Physician in Emergency Medical Care, held in Chicago in 1973, agreed that EM training followed by a critical care fellowship was highly desirable. As a result of discussions at this conference, SCCM accepted two years of EM residency as a prerequisite for admission to a critical care fellowship.
ABEM was formed in 1976. Three years later, it was approved as a conjoint (modified) board of ABMS, making EM the 23rd medical specialty in the United States. This was indeed an accomplishment, but its stature as a conjoint board precluded the board from issuing certificates of special qualifications. At the same time, CCM was also pursuing primary board status. Its first attempt failed, so critical care was designated as a multidisciplinary subspecialty of the existing primary boards: anesthesia, internal medicine, pediatrics and surgery. The task of reaching consensus among the four primary specialties on training and testing criteria for primary board status proved to be too much. In 1983, ABIM withdrew from the Joint Committee on Critical Care Medicine and submitted a separate application to certify its own subspecialists. The other specialties followed suit, leading to the creation of four subspecialties having certification processes for critical care subspecialty board certification, with no accommodation for ABEM diplomates to sit for critical care board certification.
In 1986, in keeping with the goal of pursuing CCM as a subspecialty of EM and considering the breakup of critical care subspecialty into four different boards, ABEM modified its pursuit and applied for a certificate of added qualification to ABMS. IM and pediatric leaders opposed the certification because they "viewed the critical care issue as a way for EM to get 'the camel's nose under the tent' of inpatient medicine and worried that if EM were granted the ability to train in CCM, inpatient care by emergency physicians could someday follow.
[1] ABIM proposed a combined EM/IM training program to provide an avenue for EM physicians to pursue critical care board certification and announced plans to apply for an added certification in "emergency internal medicine." ABEM decided to put the critical care issue on the back burner and pursue primary board certification through ABMS. ABMS had clarified that a conjoint board was allowed to issue certificates of added qualification but not special qualification. In 1987, ABEM gained unanimous approval of its application for primary board status from the ABMS executive committee, but a small majority of the full delegation rejected the application. Not only did ABEM miss its goal of primary board status, but critical care certification remained on hold, and ABEM watched the boards of internal medicine and pediatrics continue to pursue subspecialization in emergency internal medicine and emergency pediatrics.
Realizing a pivotal point for EM, the president of ABEM, Dr. Judith Tintinalli, and its executive director, Dr. Benson Munger, went to the ABIM summer conference. They realized that concessions needed to be made to preserve the ability of ABEM to become a primary specialty, so they assured ABIM that ABEM had no interest in inpatient care, agreed to the principle of combined EM/IM and EM/Pediatrics programs, and withdrew the application for certificates of added qualification in critical care. As a result, ABIM reversed its opposition to primary board status for ABEM, and in 1989 ABEM was approved by ABMS as a primary board, bringing to fruition two decades of effort.
Critical care has been defined as the delivery of medical care to "any patient who is physiologically unstable, requiring constant and minute-to-minute titration of therapy according to the evolution of the disease process."
[2] It has been shown that staffing ICUs with dedicated intensivists saves money, reduces mortality and shortens length of stay. The Leapfrog Group, a voluntary organization that leverages health care purchasing power to influence quality and affordability, has as one of its quality and safety practices staffing of ICUs by intensivists. This group acknowledges that EM physicians who have completed a critical care fellowship meet the definition of intensivist.
Currently, there are 155 EM residencies with 4,981 filled positions. These graduates will compete with 22,829 graduates of 381 IM residencies for 33 IM-sponsored CCM fellowships. Programs that train EM graduates in critical care have 20 to 24 slots specifically intended for emergency physicians. In addition, there are six more slots in programs that do not specifically intend emergency physician enrollment. These slots are not all in IM-sponsored critical care programs, so many graduates understand they will not be eligible for board certification. Of the CCM fellowship programs open to emergency physicians in 2008–2009, affiliations were as follows: 8 EM, 23 surgery, 14 medicine and 20 anesthesia.
Two other options are open to emergency physicians who have completed a critical care fellowship. The European Society of Intensive Care Medicine (
www.esicm.org) allows American emergency physicians to sit for the European Diploma in Intensive Care Medicine in Europe, and the United Council of Neurologic Subspecialties (
www.neurocriticalcare.org) allows fellowship-trained emergency physicians to sit for subspecialty certification in neurocritical care through either a fellowship or practice track. This practice track availability will be offered only through 2012.
Emergency medicine and critical care share a long and dynamic history in patient care as well as the pursuit of ABMS recognition. Physicians interested in combining a career in emergency medicine and critical care medicine sit on the cusp of a monumental movement that is gaining interest as well as importance; as the population ages, U.S. legislators struggle to reform health care, and critically ill patients spend longer times in EDs. Emergency physicians interested in critical care medicine now have the opportunity to continue toward a goal that was set when the specialty of EM was founded.
- Somand D, Zink B. The influence of critical care medicine on the development of the specialty of emergency medicine: a historical perspective. Acad Emerg Med 2005; 12:879–883.
- Brilli RJS. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001; 29:2007–2019.
