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Anesthesia Critical Care Medicine

Authors

Ryan Dick-Perez, DO
Clinical Assistant Professor
Department of Emergency Medicine
Division of Critical Care, Department of Anesthesia

Natalie Htet, MD, MS
Critical Care Fellow
Stanford Hospital

Ann Tsung, MD
Recent Graduate of Anesthesia Critical Care Medicine Fellowship at 
Barnes Jewish Hospital - Washington University in St. Louis
Board Certified in Emergency Medicine and Anesthesia Critical Care Medicine

Faculty Editor

Brian Wessman, MD, FACEP, FCCM
Section Chief, EM/CCM
Program Director, Critical Care Medicine Fellowship
Associate Professor of Anesthesiology and Emergency Medicine
Washington University School of Medicine in St. Louis

INTRODUCTION

Description of the specialty
Anesthesia critical care medicine (ACCM) is a critical care subspecialty fellowship offered to graduates of residency training in anesthesiology, emergency medicine (EM), surgery, surgical subspecialties, and Ob/GYN. The focus of ACCM is the care of the critically ill patient with a specific focus on surgical, trauma, and medical related critical care pathology, although a variety of focused and broad-based critical care training models exist. After completing fellowship training, emergency medicine-critical care medicine (EM/CCM) candidates sit for the anesthesia critical care medicine examination to become a board-certified critical care physician (intensivist) after applying through the American Board of Emergency Medicine (ABEM); similar to fellowship graduates of internal medicine CCM (IM/CCM) training programs (both groups apply through ABEM for ABMS formal certification).

History of the specialty/fellowship pathway
ACCM started with the improved care of the critically injured trauma patient during World War II. The anesthesiologist who took care of the patient during the initial stabilizing surgery continued to care for them as they left the operating theater and proceeded to newly designed shock and recovery units. The American College of Anesthesia began offering the critical care medicine exam in 1986. There are now 57 ACCM ACGME-approved fellowships that offer critical care medicine training.

In 2013 the anesthesia pathway became the newest option for EM-trained physicians to enter a critical care medicine fellowship. Currently, EM physicians entering an ACCM fellowship must complete two consecutive years of fellowship training at an ACGME accredited ACCM fellowship that has an American Board of Anesthesiologists (ABA)-approved EM/CCM training curriculum. 

Why residents choose to follow this career path
The educational goals for emergency physicians entering an ACCM fellowship are to assure competency in all realms of critical care medicine, including the care of surgery, trauma, and medical critical care related conditions. This is appealing to many applicants who want their training to be focused on the critical care management of a broad multidisciplinary range of patients.

How do I know if this path is right for me?
ACCM is a great option for people who would like to be proficient in the care of both medical and surgical intensive care unit (ICU) patients. Depending on your program’s EM/CCM curriculum, you will receive multidisciplinary exposure to the care of surgical ICU, medical ICU, and specialty ICU patients. Additionally, you will be exposed to advanced airway techniques, surgical procedures/pathology, organ support devices, and gain advanced experience in hemodynamic monitoring and management. 

Career options after fellowship
Career options are broad, with intensivists working in mixed multidisciplinary intensive care units, surgical ICUs, cardiothoracic ICUs, neurosurgical ICUs, and medical ICUs. There are both academic and community hospital positions available, but you will likely have to approach the medical directors in the ED and ICU yourself. Additionally as the number in intensivist trained emergency medicine physicians increases, various ED-ICU models are being developed.There are also groups like CEP America, Kaiser, and Intermountain Health (to name a few) who staff both specialties.

Splitting time between departments
ACCM physicians with a core residency background in anesthesiology often split clinical time between the ICU and operating room (OR) in academic settings or in managed health care corporations. In large academic centers, this model works well for EM physicians as well (substituting ED time for OR time). In the community setting, this may be more difficult, because most private EM groups don’t staff ICUs. But with creativity and flexibility, a variety of career options can be created (ie, splitting time between staffing groups, institutions, or clinical areas).

Academic vs. community positions
Academic institutions generally have more academically diverse patients, strictly because of the increased number and variety of specialties caring for patients. Academic centers may also have additional educational and research opportunities that community centers may not have. Community-based fellowships, however, may allow for more autonomy and bedside procedures when it comes to caring for patients, as some subspecialties may not be as readily involved in daily care.

IN-DEPTH FELLOWSHIP INFORMATION

Number of fellowship programs
Currently, more than 25 ACCM programs have approved EM/CCM curriculum tracts.

Differences between programs
ACCM fellowship programs are structured around the 1-year fellowship clincal curriclum that anesthesia trained fellows complete: 12 months long, 9 of which must be spent caring for ICU patients, but not necessarily in the surgical ICU. ACCM programs differ in the surgical subspecialties that are available, medical ICU (MICU) experience, and opportunities for elective time. Programs also differ in how they fulfill the required ICU time. Of note, ACCM programs can offer no more than two months of dedicated research time during the fellowship training.

Length of time required to complete fellowship
All ACCM fellowships with an approved EM/CCM tract have a 2-year training cycle.

Skills acquired during fellowship
During fellowship, you will become an expert in resuscitation, procedures, and the long-term management of critically ill patients in surgical and medical units. Some ACCM programs also offer specific cardiothoracic intensive care unit and neurosurgical intensive care unit opportunities. Some programs also offer additional opportunities to perform advanced procedures (ie, echocardiogram, percutaneous tracheostomy, intracranial pressure monitor placement) with the goal of proficiency and future credentialing.

Typical rotations/curriculum
Curricula vary in both the core ICU time and elective time. Most ACCM fellowships offer the EM trainee multidisciplinary clinical exposure with required clinical ICU time in various settings (surgical ICU, medical ICU, cardiothoracic ICU, neuro ICU, coronary care unit, etc.). Similar to residency, you will have a block schedule. Typical elective rotations options might include nutrition, palliative care, bronchoscopy, advanced airway management, trauma, ultrasonography (transthoracic echocardiogram and transesophageal echocardiogram), extracorporeal membrane oxygenation (ECMO), hematology/blood bank, and other pertinent critical care electives, depending on the location.

Board certification afterwards?
After successful completion of the 2-year fellowship (and completion of your primary EM certification process), you are eligible to sit for the ACCM boards. Once passed, you will obtain board certification as an intensivist through the American Board of Emergency Medicine. This is similar to the IM/CCM certification process.

Average salary during fellowship

Salaries for fellows will vary. Since you are in an ACGME-accredited program, your salary will generally follow the same structure as resident salaries and benefits at that institution. Fellows are generally paid at their corresponding postgraduate year level (PGY-4s, 5s, 6s), established by the local GME office. Most programs will allow you to supplement your income with moonlighting (under standard ACGME duty hours regulations).

PREPARING TO APPLY

How competitive is the fellowship application process?
It is competitive to get accepted into a critical care fellowship. Since this is a relatively new specialty for EM physicians, there are a growing number of ACCM programs approved for emergency physicians, yet it remains competitive. Current match statistics can be found on the “Statistics” tab at https://www.sfmatch.org/SpecialtyInsideAll.aspx?id=25&typ=1&name=Critical%20Care%20Anesthesiology#.

Requirements to apply
Emergency physicians must have completed four months of critical care training during residency (this is a standard EM training (RRC) requirement).

Anesthesia CCM Fellowship programs use the San Francisco Match (SF Match). It is important for you to register with the match (typically opens Nov 1st, 1.5 year prior to expected start date). You should also contact the program coordinator at the programs of your interest ahead of time (remember, the program coordinator is often your first and potentially last contact person at the program; be respectful). There is a $100 registration fee with SF Match.

There is no centralized application process for ACCM; however, there is a common application form found on the Society of Critical Care Anesthesiology (SOCCA) website and on the SF Match website. All programs require this common application form. Some programs will also request supplemental application materials (this is usually done after they review your common application form).

You will need to polish your resume, write a personal statement, request letters of recommendation (LOR: 1 should be from your program director; at least 1-2 should be from a practicing intensivist but the more the better), gather medical school diploma, USMLE reports, in-training exam reports, etc. These materials are uploaded into SF Match which then distributes your materials to the ACCM programs you select.  Typically your letter writers will upload their LOR into the SF Match system.  Again, please also be aware that the application process starts early.

Research requirements
There is no specific research requirement. However, having a strong research experience and/or academic project in critical care medicine can make your application highly competitive and may be more strongly considered for research-heavy fellowship programs.

Suggested elective rotations to take during residency
Experience various ICU settings at the beginning of residency. You should understand the positives and negatives of being an Intensivist and solidify your interest in critical care. Remember, CCM training is more than just “fun” procedures.  Rotations in the medical ICU, cardiac ICU, surgical ICU, neurological ICU, and pediatric ICU will allow you to witness the daily routine of an intensivist. As you approach your PGY2 or PGY3 year, you may plan to do an elective month in an ICU.

Suggestions on how to excel during these elective rotations
Books, articles, and podcasts can improve your knowledge in the care of critically ill patients (see list of additional resources at end of this chapter). It is also important to be a good team player with all members of the critical care team. Ask the respiratory therapist and nurses for their opinions and suggestions. Thoroughly know your patients and their current issues on rounds. Make sure you assimilate the data and identify the current CCM diagnosis.  Be willing to do procedures, show up early to pick up patients, and be excited to learn about your patients.

Take notice of how your attendings start their day. Does he or she come one hour early to review all labs and imaging? Some may even examine all the patients and start interventions prior to rounds. Ask them for their routine and the tricks they have found to be useful for daily rounds. As a resident on the rotation, very often you are only focused on the patients you have. Once you start gaining comfort and experience in the ICU, try to step in the shoes of the attending. Focus on every patient on rounds, know who the sickest ones are every day, and have a disposition plan days in advance. Actively initiate family discussions, palliative care consults, and code status talks. When a new patient is admitted, plan in your head how the trajectory of the patient will be, and have back up plan A, B, C in case patient status deteriorates or changes. For example: “If levophed requirement hit 0.3 mcg/kg/min, we will add a second agent, perform a bedside ultrasound, and if the ultrasound shows this, we will do XXX.”

Should I complete an away rotation?
It is neither common nor required to do an away elective in ICU. If you would like to get a different set of ICU experience than what your residency program offers, you may contact the fellowship program of your interest. You should however plan this well ahead of time.

What can I do to stand out from the crowd?
Your application should demonstrate you as a competent, well-rounded, and reliable physician. You should have meaningful activities in critical care medicine. You might get involved in a research or academic project starting early in your intern year. Almost all fellowship programs will ask for your research experience and competitive applicants have research abstract presentations or publications. It is also worthwhile to reach out to a mentor in critical care medicine (strong letters of recommendation are paramount). Consider attending a national conference that offers an EM/CCM section. Getting involved in hospital committees can be worthwhile. You should have strong board exam scores, in-training exam scores, and letters of recommendation.

Should I join a hospital committee?
Getting involved in hospital committees related to ED and ICUs can expose you to the administrative side of hospitals and allow you to understand the roles of intensivists/ED physicians beyond the patient care.  This will also allow you to be involved in improving critical care medicine care at your local hospital and is a nice addition to your CV.

Publications other than research
It is good to have publications, including blog posts, podcasts, book chapters, and magazine articles.

How many recommendations should I get? Who should write these recommendations?
You will need at least 3 letters of recommendations. One letter from your program director is a requirement for all programs. You will also need 1-2 letters from intensivists. You can get one from your research mentor as well. These should be strong recommendations from authors who know you well. It can be helpful to help draft information or experiences that you want them to include in your LOR.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, but you need to make this time after residency valuable. Get involved in writing and/or research in critical care medicine. Join a critical care committee at your hospital. Become or remain involved in national CCM organizations during this time. Unplugging from critical care medicine will not look good on your application. In general, working as an attending is not a bad idea and will help your skills as a clinician. Make sure you have a critical care medicine mentor that will help ensure that you make this time productive and demonstrate your continued interest in critical care medicine

What if I’m a DO applicant?
There is an osteopathic pathway in critical care medicine, but it can be difficult. Email individual programs to ask if they accept DO candidates (and COMLEX scores). If you are a DO but trained in an allopathic program, it is easier to apply to allopathic CCM programs.

What if I am an international applicant?
Contact programs directly to inquire whether or not they accept international applicants.

APPLICATION PROCESS

How many applications should I submit?
You should apply only to programs you are interested in working as a fellow. However, if your goal is to get accepted into any program or if you are concerned about the strength of your application, then you should plan on applying to many programs. ABA and EMRA Match each offer a list of approved 2-year curriculum ACCM training programs.

How do I pick the right program for me?
The program of your interest should offer multidisciplinary critical care that matches your career goals, train you to be a well-rounded intensivist, and complements your future career goals. Some programs will require you to work in the ED, and some will have no EM time unless you moonlight. Look at individual programs and evaluate whether they have trained emergency medicine graduates in the past or if they have emergency medicine-critical care medicine faculty, as prior experience may make your fellowship training more valuable.

Common mistakes during the application process

  • Being late. Don’t wait; apply early.
  • Rushing your letter-writers. Give them plenty of time.
  • Shading the truth on your CV. Honesty is the ONLY policy.
  • Not enlisting help. Get your mentors involved early. A personal connection from your mentor to a program of your interest is extremely valuable.
  • Stressing out. Be flexible and have a positive attitude.

Application deadlines
ACCM programs typically start accepting applications in December/January (1.5 years prior to the fellowship start date). Individual programs have their own deadlines. Interviews are on a rolling basis (check with individual programs), with the interview season between December and May. The SF Match takes place in May (13 months prior to fellowship start date).

Tips for writing your personal statement

Your personal statement should be a professional and eloquent explanation of your interest in critical care medicine, your career goals, and accomplishments. Rather than restating your resume, explain things that set you apart from others. Share an interesting story or experience. Often this will translate to further conversation on your interview day. Be prepared to talk about your personal statement. Request feedback on your personal statement from your mentors.

Is this a match process?
Yes. ACCM participates in a match process.  You will need to register with SFMatch. The match happens in May (13 months prior to your fellowship start date).

Exceptions to the Match
There are 6 agreed-upon instances where a program and an applicant may agree to a position outside of the match. But both program and applicant must still enroll in the match.

  1. Applicants who are in active military service at the time of application.
  2. Applicants who are making a commitment to come to the institution of the CCM fellowship for more than one year. (Some ACCM programs have interpreted this to include EM/CCM applicants).
  3. Applicants who are enrolled in an anesthesiology residency outside of the USA at the time of the application.
  4. Applicants who reside outside the USA at the time of application or who are not eligible for ABA certification due to non US training
  5. Applicants whose spouse or partner is applying for a GME-approved post graduate training program in a medical specialty in the same region as the CCM fellowship
  6. Internal candidates

Complete exceptions can be viewed on the SOCCA Match Exceptions page.

What happens if I don’t obtain a fellowship position?
Since ACCM match happens in May, you will still have time to explore options. If you are still interested in a specific ACCM program, it may be beneficial to reach out to them and express your continued interest (and that you didn’t match). Training spots do open up due to unforeseen issues. You may also decide to apply through other pathways which usually open after July: Surgery or Medicine. You should honestly review your application packet together with your mentor. If needed, consider a year of strengthening your application by gaining further experience in critical care medicine or a skill-set pertinent to this specialty (i.e., ultrasound or EMS), prior to applying again. Remember, you are still going to be a well-trained emergency medicine physician with a good job market and a good lifestyle.

INTERVIEW PROCESS

How do I stand out from the crowd?
Get to know any alumni from that program, as it may be brought up during interviews. Read about the program prior to the interview and be ready with questions. At minimum, review their website so you can speak intelligently about the program and the curriculum (and potential flexibility), relationships with other services, etc. Additionally:

  • Be a member of SCCM, ACEP critical care section, SAEM critical care section, and/or EMRA – critical care committee. Also consider joining SOCCA.
  • Have publications in critical care medicine literature.
  • Make sure you have recommendation letters from other intensivists and not only from EM faculty.
  • Compile ample experience in critical care medicine through rotations and elective rotations.

What types of interview questions are typically asked?

  • What are your career goals?
  • How are you planning on incorporating EM with CCM?
  • State your goals/reasons for pursuing a career in critical care or emergency care.
  • List and describe the 3 most challenging aspects you see as a critical care and emergency care physician.
  • What do you see as the differences between your current role and your role in critical care or emergency care?
  • Explain how you interact with a multidisciplinary team.
  • How did you deal with a bad interaction that you have had?
  • Tell me about a critical care medicine patient experience.
  • Tell me more about XXXX from your personal statement.

How many interviews should I go on?
Typically try to go to all of them so you will have all options; this will also help you gain an understanding of the different types of programs and curriculums that exist. Do not rank a program that you didn’t visit; you never really know a program until you are actually there.

PREPARING FOR FELLOWSHIP

Important skills to practice while in residency to prepare for fellowship

  • Be the best emergency physician you can to serve as a foundation for fellowship.
  • Be ready to pass your EM boards, because you will take them in the fall of your first year in fellowship.
  • For CCM boards…both SCCM and Chest have board-review style critical care medicine questions available.

Tips on how to succeed as a fellow

  • Sort out life-matters early: you will definitely be busier than you were in residency.
  • Consider setting up moonlighting opportunities ahead of time after you receive your match results, medical license, DEA, and approval from your fellowship program. Sometimes hospital credentialing and state license application can take over a year. However, remember that different programs have different policies regarding moonlighting. Regardless, all moonlighting hours are counted against GME work hour regulations.
  • Do not be afraid to ask CCM Attending questions for your understanding. Ask every Attending what their daily routine is and how they organize the data about their patients. 
  • Be cordial with all the support staff. Ask the nurses, techs, respiratory therapist, and other ancillary staff for their opinions.
  • Manage early morning non-urgent distractions well. You will eventually develop your own style. The golden 1-2 hours pre-round is when you need to focus, gather all the information, and examine the sickest if not all the patients. Sometime the team members may come up to ask you questions that are not urgent and may interrupt your flow. After each interruption it will take you a few minutes to regain focus. You will find on certain days after being interrupted five times in thirty minutes, you will run out of time to review your patients. This of course does not apply to sick patients who need your attention.
  • For every patient prior to rounds, you should have the plan of the day and disposition.
  • Arrive prepared to discuss the logic behind your plans/thoughts.
  • If you are in charge of day rounds, have back up plans for the night team.
  • Walk around the unit multiple times throughout the shift if time permits. Facetime with nursing, families, and at the bedside is paramount for success as an Intensivist.
  • Update the family as often as possible. Build a connection with your team, patient, and family.
  • Human connections can help decrease burnout and give you a sense of satisfaction and fulfillment. Two years is a long time to work in the ICU. Remember burnout happens when you cannot do the things you value most (hobbies, family time, etc). Reorganize your time outside of fellowship to allow these experiences. 

CONCLUSION

Textbooks to consider reading

Additional resources

Board prep for anesthesia 

National organizations

  • SCCM
  • ACEP – Critical Care Section
  • EMRA Critical Care Committee
  • SAEM- Critical Care Section
  • SOCCA

Conferences

  • SCCM and SOCCA all have annual conferences.
  • SCCM also offers an ECMO course that is worth considering.
  • ACEP/SAEM offer critical care medicine section/committee meetings, which are all fantastic ways to network and get more involved with this specialty.

How to find a mentor
Any EM-CCM physician at your program would be your best option. Also check out this CCM virtual mentorship website, which links interested EM physicians with EM-CCM mentors.

If interested, Dr. Wessman can be contacted at: Brianwessman@wustl.edu.