Emergency Medicine into a Critical Care Fellowship

[EMfuture2017]

Hello everyone,

Thank you for your time in reading my post.

I am interested in going into a critical care fellowship after emergency medicine. Some of my programs are more top tier and would allow me to do so. however, I am really interested in staying in my home town for residency although no one has matched (or attempted to match) critical care fellowship from the program yet. There are no EM CC faculty either. How difficult would it be to match into a fellowship for CC from a program such as that and what kind of steps would I need to put forth in my first and second years of residency there to ensure I am able to meet my goal of CC?

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[deleted547339]

Hello everyone,

Thank you for your time in reading my post.

I am interested in going into a critical care fellowship after emergency medicine. Some of my programs are more top tier and would allow me to do so. however, I am really interested in staying in my home town for residency although no one has matched (or attempted to match) critical care fellowship from the program yet. There are no EM CC faculty either. How difficult would it be to match into a fellowship for CC from a program such as that and what kind of steps would I need to put forth in my first and second years of residency there to ensure I am able to meet my goal of CC?

Residency name isn't hugely important. Going to a residency with an EM/CCM advisor will make your life easier. It's important to work hard and do CCM research if interested in research. It's also important to know the acgme requirements for EM and try to make your curriculum fit that as closely as possible.

As with most things in this world, it can be more who you know than what you know.

 

[TheComebacKid]

It's a non-issue. We have an EM-CCM fellowship program at my institution. They accept people routinely from places all over the country, and from places where EM-CCM is not emphasized. To be fair, EM-CCM is very much still in its infancy, and there are many places in the country that do not have EM-CCM faculty.

After talking with my fellowship director, the number one thing they look for is interest in CCM. You can do this is in multiple ways, even without any EM-CCM faculty at your institution. Submit a blog post. Touch base with the medicine/surgical critical care folks at your institution and express interest. Get involved with CCM through EMRA. There are lots of things you can do.

 

[surely]

It's also important to know the acgme requirements for EM and try to make your curriculum fit that as closely as possible.

Thanks for your advice. I'm not the OP but I'm also potentially interested in Critical Care, and I'm confused by the part I quoted above. Which requirements are you referring to? The overall ACGME requirements that all EM residents must satisfy to graduate? Or are there specific ACGME requirements for EM residents hoping to go into Critical Care?

 

[Jabbed]

Thanks for your advice. I'm not the OP but I'm also potentially interested in Critical Care, and I'm confused by the part I quoted above. Which requirements are you referring to? The overall ACGME requirements that all EM residents must satisfy to graduate? Or are there specific ACGME requirements for EM residents hoping to go into Critical Care?

The big one is 6 months of off-service IM rotations, only 3 of which can be in the ICU.

 

[TheComebacKid]

The big one is 6 months of off-service IM rotations, only 3 of which can be in the ICU.

I could be wrong, but I think the requirement depends on whether you are applying to CCM fellowships through Anesthesia, Surgery or IM. Will defer that to TimesNewRoman as the critical care fellow on the forum.

 

[Jabbed]

I could be wrong, but I think the requirement depends on whether you are applying to CCM fellowships through Anesthesia, Surgery or IM. Will defer that to TimesNewRoman as the critical care fellow on the forum.

Sorry I should have clarified that I'm only familiar with the IM-based CCM fellowship requirements.

 

[SpacemanSpifff]

I could be wrong, but I think the requirement depends on whether you are applying to CCM fellowships through Anesthesia, Surgery or IM. Will defer that to TimesNewRoman as the critical care fellow on the forum.

As @Jabbed noted, the 6 months of internal med rotations, with at least three in the MICU, are the ABIM requirements. Surgery and Anesthesia pathway applicants have different requirements (see https://www.emra.org/committees-divisions/Critical-Care-Division/ for details).

 

[Petypet]

Sorry I should have clarified that I'm only familiar with the IM-based CCM fellowship requirements.

Can we apply to pulm/cc if we meet these requirements?

 

[Jabbed]

Can we apply to pulm/cc if we meet these requirements?

Nope.

 

[DO class of 2018]

I'm interested in possibly doing a critical care fellowship. There isn't a ton of information out there as it's a relatively new concept for EM docs to do this, but there's some. If anyone on this thread has done it, a question that comes to my mind is, while in the fellowship, are you still working in the ED? If so, how much? Thanks!

 

[TheComebacKid]

I haven't done one, but work with a lot of EM/CCM fellows. To answer your question, at our program at least, time in the ED is minimal during fellowship. You have some required time (I think approximately 1 month total over a 2 year fellowship) and then several months of elective time where you can choose to work in the ED should you please.

You've already spent 3-4 years working in the ED and learning how to work there. CCM fellowship is about getting down your ICU experience above all else.

 

[DO class of 2018]

Okay. My intention for doing a fellowship would be to work in both the ER and an ICU. I'd be worried about ER skills atrophy during those two years but anyways...

 

[TheComebacKid]

Are you in residency yet? If not, my advice to you is to match into EM residency. If CCM is on your radar, you can preferentially try to go to EM programs that will expose you better to CCM, although to be honest you can still match into fellowship regardless of where you train at for residency.

Get the EM thing down, let residency play its course. I came into residency thinking CCM was going to be a slam dunk but after 5 months of ICU rotations as a resident (and 2 more left to go), I am still struggling to figure out if it's for me.

 

[DO class of 2018]

I'm matching this period. EM residency is definitely priority number one, and I'm definitely paying attention to programs that have good ICU exposure. I do wonder if I should try to match at an institution that has a CC fellowship that is EM doc friendly. Thoughts on that?

 

[Jabbed]

I'm matching this period. EM residency is definitely priority number one, and I'm definitely paying attention to programs that have good ICU exposure. I do wonder if I should try to match at an institution that has a CC fellowship that is EM doc friendly. Thoughts on that?

In this boat currently. It seems that everyone that actually wants to do the fellowship has been able to secure it. For me, it's not make-or-break to have in-house fellowship options, although I do happen to really like a few of the places that offer it. There's also value in branching out for fellowship training to avoid the institutional bias that will come with completing 5-6 years of training in one hospital.

 

[Dr.CCM]

Usually not required ED time unless you have to “pay back” your department as shifts for your fellowship if they are supporting you financially during the fellowship

Your procedural skills won’t atrophy. You’ll do more procedures in the ICU than the ED typically and most of time they are harder. The main issues are speed/differentials/customer service. You lose those quickly.

Most fellowships I interviewed at didn’t care about moonlighting in an ED so you’ll have that as an option too.

It’s really not that difficult to match depending on the route. There aren’t many Anesthesia or Surgical accredited fellowships though so keep that in mind. Just get involved with research in the ICU and find some mentors even if they arent at your program and make sure your residency gives you a lot of exposure to the unit either as required or elective rotations.

EMRA has some great resources for those interested.

 

[deleted547339]

Usually not required ED time unless you have to “pay back” your department as shifts for your fellowship if they are supporting you financially during the fellowship

Your procedural skills won’t atrophy. You’ll do more procedures in the ICU than the ED typically and most of time they are harder. The main issues are speed/differentials/customer service. You lose those quickly.

Most fellowships I interviewed at didn’t care about moonlighting in an ED so you’ll have that as an option too.

It’s really not that difficult to match depending on the route. There aren’t many Anesthesia or Surgical accredited fellowships though so keep that in mind. Just get involved with research in the ICU and find some mentors even if they arent at your program and make sure your residency gives you a lot of exposure to the unit either as required or elective rotations.

EMRA has some great resources for those interested.

I would argue that my customer service skills are much better after a CCM fellowship. I can now say that my understanding of medicine and physiology is immensely improved and I think I will be a much more efficient EP. I’ve had the opportunity to see much more concentrated pathology.

Some programs require EM time, some encourage ED moonlighting, some allow moonlighting but keep the fellows too busy to do it. At first, I liked the idea of going to a program that requires EM time because of the worry of losing skills. The problem is this: they are getting attending work out of you without paying you for it. In the mean time, you are taking on all the responsibility and liability of an attending without any of the benefits, plus you’re giving up time to potentially learn more CCM.

Happy to answer any questions.

 

[gamerEMdoc]

Hello everyone,

Thank you for your time in reading my post.

I am interested in going into a critical care fellowship after emergency medicine. Some of my programs are more top tier and would allow me to do so. however, I am really interested in staying in my home town for residency although no one has matched (or attempted to match) critical care fellowship from the program yet. There are no EM CC faculty either. How difficult would it be to match into a fellowship for CC from a program such as that and what kind of steps would I need to put forth in my first and second years of residency there to ensure I am able to meet my goal of CC?

One of my residents matched in an EM CC fellowship in the first year of eligibility when we switch from an AOA to ACGME program. Fellowships in EM aren't very competitive. I wouldn't worry about it at all.

 

[deleted547339]

One of my residents matched in an EM CC fellowship in the first year of eligibility when we switch from an AOA to ACGME program. Fellowships in EM aren't very competitive. I wouldn't worry about it at all.

Ehhh...depends where you want to go. And CCM is definitely getting more competitive as EM->CCM is becoming less of an anomaly.

 

[gamerEMdoc]

Thats true, but the original poster seemed mainly concerned with just getting in. Sure, if you want to go to a prestigious place it’ll be more competitive, I think that’s common sense. But for the people who just want to match in any EM CC fellowship, I dont think the landscape is that competitive yet. Im not sure it ever will be. Most people just want to graduate in 3 years and get out and make a bunch of money.

 

[Dr.CCM]

Thats true, but the original poster seemed mainly concerned with just getting in. Sure, if you want to go to a prestigious place it’ll be more competitive, I think that’s common sense. But for the people who just want to match in any EM CC fellowship, I dont think the landscape is that competitive yet. Im not sure it ever will be. Most people just want to graduate in 3 years and get out and make a bunch of money.

The main problem we have is just that there aren’t TONS of places that actually think EM docs should do CC fellowships. Although there are over 50 CCM fellowships available to us , many of those have never taken an ER doc or even considered taking one. We aren’t typically the program directors of those fellowships.

 

[ABCDRE]

Any thoughts on whether or not the whole 3 vs 4 year thing matters to CCM programs ? Or anyone know if there is a difference in outcomes between applicants from 3 vs 4 year EM programs in terms of acceptance rates?

 

[SpacemanSpifff]

Any thoughts on whether or not the whole 3 vs 4 year thing matters to CCM programs ? Or anyone know if there is a difference in outcomes between applicants from 3 vs 4 year EM programs in terms of acceptance rates?

General prestige may have some influence, but there are plenty of well-respected 3 year programs out there. The big difference will be in satisfying the pre-requisites of the internal medicine pathway - tough to get 6 months of medicine out of a 3 year program when you may only have 1-2 months of elective time.

 

[deleted547339]

Any thoughts on whether or not the whole 3 vs 4 year thing matters to CCM programs ? Or anyone know if there is a difference in outcomes between applicants from 3 vs 4 year EM programs in terms of acceptance rates?

As above, doesn’t matter. And the acceptance rate data doesn’t exist, although I could speculate. There are some IM programs that will allow you to complete the prerequisites not completed in residency at the beginning of your fellowship without extending the duration. Everyone should meet the anesthesia prereqs. It will be tough though to apply because you apply 18 months out for anesthesia/CCM so you’re only a second year in a 3 year program.

 

[Situasian]

I think ABEM has to create its own certification pathway. Enough of us want to do it now I think. Regardless of pathway though, CCM is CCM and it should be multidisciplinary. No one specialty has ownership over critical care and we can all learn something from each other. SICU patients get medical diseases and MICU patient get surgical diseases.

6 months of medicine is tough unless we are counting MICU.

 

[deleted547339]

I think ABEM has to create its own certification pathway. Enough of us want to do it now I think. Regardless of pathway though, CCM is CCM and it should be multidisciplinary. No one specialty has ownership over critical care and we can all learn something from each other. SICU patients get medical diseases and MICU patient get surgical diseases.

6 months of medicine is tough unless we are counting MICU.

The rule as it currently stands is that you must do a total of 6 months of IM (not counting consult months), of which a minimum 3 months must be MICU or CCU.

 

[Petypet]

The rule as it currently stands is that you must do a total of 6 months of IM (not counting consult months), of which a minimum 3 months must be MICU or CCU.

I have done some searching, is there a general website that tells what counts for those 6 months of IM? Everything on ABEM just says 6 months wards. Do consult service, nephro, ID, pall care count? thx

 

[gutonc]

I have done some searching, is there a general website that tells what counts for those 6 months of IM? Everything on ABEM just says 6 months wards. Do consult service, nephro, ID, pall care count? thx

It's outlined in the post you quoted. If Renal is it's own inpatient service (and not just consult), it counts. Likewise for Cards, Hem/Onc and GI.

 

[deleted547339]

I have done some searching, is there a general website that tells what counts for those 6 months of IM? Everything on ABEM just says 6 months wards. Do consult service, nephro, ID, pall care count? thx

As gutonc said, you quoted your the answer.

 

[Petypet]

Its not official though. We have numerous grads out of our program that use consult services to satisfy the requirements, namely ID and nephrology. ABEM website only states six months of IM but doesn't break things down further.

 

[deleted547339]

Its not official though. We have numerous grads out of our program that use consult services to satisfy the requirements, namely ID and nephrology. ABEM website only states six months of IM but doesn't break things down further.

The ACGME pdf of ABIM-CCM clearly outlines the requirement. Whether or not the ACGME or your potential program director will track this closely is a different question.

 

[em_dream21]

The rule as it currently stands is that you must do a total of 6 months of IM (not counting consult months), of which a minimum 3 months must be MICU or CCU.

Can those 6 months of required IM be all in the form of critical care ICU time i.e. 4 months MICU, 1 month SICU, 1 month Neuro ICU?

 

[Hamhock]

Can those 6 months of required IM be all in the form of critical care ICU time i.e. 4 months MICU, 1 month SICU, 1 month Neuro ICU?

IIRC, NeuroICU and SICU don't count...these are not IM-based ICUs.

HH

 

[SpacemanSpifff]

Can those 6 months of required IM be all in the form of critical care ICU time i.e. 4 months MICU, 1 month SICU, 1 month Neuro ICU?

Nope. From ALiEM:
"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."
This is program-dependent, but can mean doing 3 months on non-consult medicine floor services (ex: a cardiology/renal/heme-onc floor month) as @TimesNewRoman stated above.

 

[surely]

"A fellow may complete this requirement while in fellowship, but may not supervise IM residents until it has been completed."

I wonder how many programs are flexible enough to allow their fellows to complete that requirement during fellowships. Like, is this a common approach, or do the majority of EM-trained CC applicants make sure they dedicate their electives to IM months during their residency?

 

[Birdstrike]

Hello everyone,

Thank you for your time in reading my post.

I am interested in going into a critical care fellowship after emergency medicine. Some of my programs are more top tier and would allow me to do so. however, I am really interested in staying in my home town for residency although no one has matched (or attempted to match) critical care fellowship from the program yet. There are no EM CC faculty either. How difficult would it be to match into a fellowship for CC from a program such as that and what kind of steps would I need to put forth in my first and second years of residency there to ensure I am able to meet my goal of CC?

Edit: Just realized the OP is from a year ago. Regardless, I'll leave my post, in case someone else is reading and wondering the same thing now.

If you excel in residency, you'll be accepted until a CC fellowship. Although it helps to take a known quantity, people one fellowship committees aren't going to limit themselves to a tiny sliver of residents that trained at their home program when they can find many people better from all over the country. You shouldn't box yourself in either. Go to a place that has CC but is malignant and gives you no time to study, and you underperform on the boards and you haven't helped your chances. Go to a place where you're unhappy, and as a result you rub people the wrong way, or keep to yourself and your letters of recommendations suffer, and you haven't helped your chances. If you can find the program that has the best of all possible worlds, then great. Go there. But otherwise, just go to the best and your favorite EM residency where you think you'll thrive and be most happy, and most successful. That's your best chance of thriving at the next level.

Hell, I got into a very competitive fellowship (not critical care) and not only did I not do residency there, I didn't even do their specialty. But I laid down a track record, that spoke for itself. Excel, and you will continue to excel. It's that simple.

 

[deleted547339]

I wonder how many programs are flexible enough to allow their fellows to complete that requirement during fellowships. Like, is this a common approach, or do the majority of EM-trained CC applicants make sure they dedicate their electives to IM months during their residency?

Most can make some accommodations. If you need 1, maybe 2 months, they can work it out. If you need 4, that would probably be a non starter.

The aliem post is just a direct quote from the acgme document.

Feel free to PM if anyone would like.

 

[Food]

I am a recent ED grad, currently applying for CCM spots with anesthesia. Feel free to DM - maybe I can answer some questions. I think it's a great idea, and am all for more of us choosing this path.

 

[Wroooong]

Critical care has been on my radar, but not enough to have a huge impact on my rank list. I just found out I've matched at a great university program with a neurocritical care fellowship that's open to EM grads. I'm not looking to make any more big moves for the sake of training (my wife and I are headed home for residency), so if I do CC it'll be through this program. My question is what's the utility/marketability of neuro vs doing anesthesiology/surgery/IM routes?

 

[deleted547339]

Critical care has been on my radar, but not enough to have a huge impact on my rank list. I just found out I've matched at a great university program with a neurocritical care fellowship that's open to EM grads. I'm not looking to make any more big moves for the sake of training (my wife and I are headed home for residency), so if I do CC it'll be through this program. My question is what's the utility/marketability of neuro vs doing anesthesiology/surgery/IM routes?

Wildly different. Doing neuroCC makes you (potentially) competent to work in only a neuro-icu. These only exist at large academic centers and are almost exclusively neurologists. If being in that city long term is your goal, doing neuro CCM is a bad idea unless it’s nyc, Chicago, LA, etc. Essentially, you are betting that upon completion of your fellowship, they will need a person to staff a single icu in a single institution that needs only 4ish faculty to be fully staffed. Plus, a lot of these patients are cva patients and they like stroke neurologists. This sounds like a bad idea all around.

If you want to do CCM and want to be in that area, your best bet is to simply do a well rounded CCM fellowship at a place like Pitt, WashU, Michigan, etc with the understanding that you are sacrificing short term happiness for your career.

 

[Wroooong]

Wildly different. Doing neuroCC makes you (potentially) competent to work in only a neuro-icu. These only exist at large academic centers and are almost exclusively neurologists. If being in that city long term is your goal, doing neuro CCM is a bad idea unless it’s nyc, Chicago, LA, etc. Essentially, you are betting that upon completion of your fellowship, they will need a person to staff a single icu in a single institution that needs only 4ish faculty to be fully staffed. Plus, a lot of these patients are cva patients and they like stroke neurologists. This sounds like a bad idea all around.

If you want to do CCM and want to be in that area, your best bet is to simply do a well rounded CCM fellowship at a place like Pitt, WashU, Michigan, etc with the understanding that you are sacrificing short term happiness for your career.

Thanks for the feedback. Yeah, that's more or less what I was afraid of. Even the EMRA page says the career option is essentially to be the 'stroke guy' in the ED haha. I'll have to see what happens during residency, I guess.

 

[AthleteDoc7]

Wildly different. Doing neuroCC makes you (potentially) competent to work in only a neuro-icu. These only exist at large academic centers and are almost exclusively neurologists. If being in that city long term is your goal, doing neuro CCM is a bad idea unless it’s nyc, Chicago, LA, etc. Essentially, you are betting that upon completion of your fellowship, they will need a person to staff a single icu in a single institution that needs only 4ish faculty to be fully staffed. Plus, a lot of these patients are cva patients and they like stroke neurologists. This sounds like a bad idea all around.

If you want to do CCM and want to be in that area, your best bet is to simply do a well rounded CCM fellowship at a place like Pitt, WashU, Michigan, etc with the understanding that you are sacrificing short term happiness for your career.

Do you feel that the other options (med/surg/anesthesia) are equal in terms of future job prospects, and neuro is the least useful? or is it more like MICU >> SICU=anesthesia >> neuro?

 

[deleted547339]

Do you feel that the other options (med/surg/anesthesia) are equal in terms of future job prospects, and neuro is the least useful? or is it more like MICU >> SICU=anesthesia >> neuro?

So there’s no “MICU” or “SICU”. You can get your boards through anesthesia, medicine or surgery. No one does surgery. The program matters more than name of the specialty board.

If you want to work in an academic MICU, you probably need medicine. For everything else, anesthesia is probably fine. And anesthesia at a top program will probably get you whatever you want if it’s well rounded.

Neuro, by definition, confines you to academic neuro icus. That’s really limiting. I feel confident if I had chosen to spend an extra 1-2 months in the neuro icu I would be more than capable to atttend in a nicu.

 

[Apollyon]

So there’s no “MICU” or “SICU”. You can get your boards through anesthesia, medicine or surgery. No one does surgery. The program matters more than name of the specialty board.

If you want to work in an academic MICU, you probably need medicine. For everything else, anesthesia is probably fine. And anesthesia at a top program will probably get you whatever you want if it’s well rounded.

Neuro, by definition, confines you to academic neuro icus. That’s really limiting. I feel confident if I had chosen to spend an extra 1-2 months in the neuro icu I would be more than capable to atttend in a nicu.

NICU to ANYBODY is "neonatal ICU". You know that.

 

[K31]

You can get your boards through anesthesia, medicine or surgery. No one does surgery.

Not nobody. Some of us are a special breed of crazy/stupid.

 

[deleted547339]

Not nobody. Some of us are a special breed of crazy/stupid.

Oh Lord, you’re one of them! Poor bastard, lol.

I think y’all number, what, about 30 in total?

 

[deleted547339]

NICU to ANYBODY is "neonatal ICU". You know that.

Context clues man. I was on my phone and it autocorrects “NeuroICU”.

 

[deleted547339]

I've been meaning to ask you- why not Garamond?

Uhhhhh....what?

 

[AthleteDoc7]

Not nobody. Some of us are a special breed of crazy/stupid.

someone fill me in lol, what makes going surgical crit care so much worse?