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Internal Medicine Critical Care Medicine

Authors

Tanya Belle, MD
Emergency Medicine Resident
University of Connecticut

Jared DiBenedetto, MD
Emergency Medicine Resident
University at Buffalo, Jacobs School of Medicine and Biomedical Sciences

Drew Schoenling, MD
Emergency Medicine Resident
Henry Ford Hospital

Faculty Editor

Krystle Shafer, MD
Director of ED Critical Care
Co-Director EM Medical Student Rotation
Critical Care Intensivist, OHICU and MSICU
Clinical Faculty, Department of Emergency Medicine
Wellspan York Hospital

Special thanks to our 1st edition writing team

Lillian Emlet, MD, MS, FACEP
Danish S. Malik, MD
Krystle Shafer, MD

INTRODUCTION

Description of the specialty
On Sept. 21, 2011, the American Board of Subspecialties voted to allow critical care medicine as the 7th subspecialty for emergency physicians. Since then, the American Board of Emergency Medicine (ABEM) and the American Board of Internal Medicine (ABIM) have reached an agreement that allows EM-trained physicians who complete an Internal Medicine-Critical Care Medicine (IM-CCM) fellowship to sit for the CCM board certification. Thus, the EM physician who completes a fellowship and passes the boards can become a board certified medical intensivist.  

Of special note, there is currently a shortage of intensivists – it is estimated that only 1 in 3 patients admitted to the Intensive Care Unit (ICU) are treated by an intensivist. At the same time, the demand for intensivists is increasing as the population ages. The dual trained EM-CCM trained physician uniquely addresses the growing intensivist shortage, and helps to strengthen the delivery of critical care in the emergency department.  

History of the specialty/fellowship pathway
Despite multiple hurdles, more than 140 emergency medicine physicians since the 1970’s have trained in and are practicing critical care medicine today. In the past, EPs would take the European Society of Intensive Care Medicine board certification examination, which was accepted as an equal standard. It was these successful physicians who chose to pursue critical care medicine despite not having an officially-recognized pathway for board certification within the U.S. that paved the way for the current acceptance of the subspecialty. 

Why do residents choose this career path?
EM-trained individuals who seek IM-CCM fellowships are typically those who seek to improve the integration of critical care practices in the ED to ensure a seamless delivery of care to the critically ill patient. With an aging population and the increasing prevalence of ED boarding, EPs will have greater exposure to critically ill patients than ever before. Advanced training in critical care medicine will give EPs advanced training in the skills necessary to improve the delivery of care to these patients.

Residents who choose to pursue IM-CCM fellowships are ultimately credentialed as medical intensivists, which is defined as a physician focused on comprehensive care of the critically ill medical patient. IM-CCM fellows may choose to gain additional exposure to surgical patients in mixed medical-surgical ICUs or through surgical ICU rotations.

Individuals who choose this route of training are those who not only enjoyed their ICU experiences, but who also envision themselves leading an ICU team, planning day-to-day patient care and discharges, and being intimately involved with the spectrum of biopsychosocial patient care. CCM is a specialty that requires its practitioners to be meticulous in their knowledge of their patients and ensuring that all their needs are met efficiently, as intensivists are expected to manage multiple unstable patients simultaneously.

Career options after fellowship
Some physicians may want to practice only critical care medicine or only emergency medicine after fellowship. Other physicians, however, prefer to split their time between two departments. Many hospitals have allowed EM-CCM physicians to split time between two departments, but there are also plenty of hospitals unaware of such a model. You may need to sell yourself and the model to potential employers, and show how this arrangement would benefit the hospital system. Be aware that once you pave the way, you are setting the example for future EM-CCM physicians in that health system. However, some hospital systems may not be ready and you might not get the deal you are looking for. The best thing to do is solicit help from others who have already paved the way and can give you first-hand advice. Focus on finding a place where you can grow as faculty, with the infrastructure to support your professional goals. Do not be afraid to cold-call programs, as job openings are not always openly advertised. Send your CV to employers and ask for time to chat. Make your goals clear – both to yourself and to your employer – from the onset.

One promising development in EM-critical care is the emergency department (ED) ICU. An ED ICU is an ICU-like unit, with similar capabilities and staffing, that lies within the ED. These units would serve to provide maximal resuscitation to the critically ill patient within the first hours of their medical care. The idea is, that after a few hours of aggressive resuscitation, some patients may improve and would no longer require ICU level of care. The EM-CCM physician would be uniquely positioned to staff these units, with training focused on the identification, resuscitation, and management of the critically ill patient. While the concept of the ED ICU is appealing to many CCM-minded EPs, there remain many political, financial, and logistical questions that require answering until ED ICUs become a widely available career opportunity.  

Splitting time between departments
You can decide that you want to practice both emergency medicine and critical care as an attending, and it is important decide what mix you would like. Some physicians are contracted for a 50-50 split between the two departments, some are contracted for 75-25, etc. Many physicians find working in both fields highly satisfying and helpful in preventing burnout. It is possible to have a dual career in both academia and in community hospitals.

Be aware that the hours of a full-time EM physician are different from the hours of a full-time intensivist. Thus, try and avoid having one department “buy your time” from the other in terms of hours, because each department has separate ideas of what full-time means. The best way to do this is to figure out the expectations in terms of hours, salary, productivity, and clinical time for full-time physicians within each individual department, and then take percentages from that. 

Make sure the kind of split you choose is sustainable, with flexibility in your contract to make alterations if needed. Hospital employee groups are the easiest to be hired in because otherwise you are trying to convince two independent groups to hire you. When independent groups are unavoidable, sometimes you may be hired primarily within EM and then fight for ICU time, or you may be hired primarily by ICU and then later obtain time in the ED (perhaps via moonlighting). Sometimes you may need to be employed by two different institutions to get your goal jobs, but this is not ideal.

Academic vs. community positions
There are important distinctions to make between community and academic medicine. Community jobs tend to focus more on clinical practice, and have optional opportunities to get more involved in administration or quality improvement. Academic positions, on the other hand, tend to have a significant portion of time dedicated to nonclinical commitments such as teaching, research, and administration. EM-CCM physicians may opt to find a niche as the critical care expert of their department; developing new critical care protocols/pathways, and developing CCM-based quality improvement projects. Academic centers have ICUs that are highly segmented, whereas in the community the patients are often grouped only into medical or surgical, or in a combined medical-surgical ICU. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
At the writing of this, 35 programs offer CCM fellowship opportunities according to ERAS. 28 of these programs participated in the 2018 match cycle. There are other programs that may accept applicants outside the ERAS match that should be contacted individually. EMRA also has a list of IM-CCM fellowship opportunities.

Length of time required to complete fellowship
2 years

Typical rotations/curriculum during fellowship
ABIM CCM policies require all critical care fellowships to provide 12 months of clinical experience. Six months of these are required to be devoted to the care of critically-ill medical patients. Programs will have small differences between which ICU setting they divide these months of critically ill clinical experience. For example, surgical units are often comprised of half medical patients and programs may choose to have two “surgical” units count as one month of medical ICU time. Other supporting rotations programs choose to include may include pulmonology, infectious disease, cardiology rotation etc and a variable amount of time set for research, electives, and vacation.

Differences between programs
All programs will train you to be an excellent intensivist. There will be varying experience among programs training emergency graduates, so assess if a program can tailor critical care education to emergency graduates. Determine whether the program uses fellows in supervisory roles or as hands on workers. You should evaluate each program’s non-ICU schedules and electives to find those allowing you to pursue specific interests or strengthen areas where you have little experience (i.e. extracorporeal membrane oxygenation (ECMO), Bronchoscopy, Research, Education, Ultrasound, Palliative care.) In addition, the ill patient population can vary between programs based on supporting specialties. Strong transplant surgery, interventional cardiology, cardiothoracic surgery, burn center, cancer care, and infectious disease programs will create variations between illness and therapy common at different programs. It is also important to consider the size of each institution’s ICU as well as night coverage. Some hospitals may have a single team, 12 bed ICU, while others can have 50+ beds split among teams but cross covered by 1 fellow overnight supervising residents. Consider the division of care between the ED and ICU. Programs with strong EM residencies may perform a majority of acute critical care while programs with weak or no residency may involve you performing procedures and directing care as soon as the patient is deemed critically ill.

Skills acquired during fellowship
Each program will provide an excellent baseline training to deliver high quality critical care. You will improve your already strong training in resuscitation and develop a predictive thought process of the patient’s care during hospitalization, assessing potential needs and complications. Through didactic sessions and clinical training, you will obtain in-depth knowledge about the physiology, clinical presentation, and treatment of disease states that lead to life-threatening illnesses. You will also become an expert at many technical skills, especially central line placement, airway management, bronchoscopy etc. Remember to ask programs about ED exposure/moonlighting when interviewing. While this is not the focus of fellowship, when possible it is important to maintain your skill as an emergency physician if planning to split your practice afterwards.

Board certification afterwards?
Yes. Current pass rate for EM-CCM trained graduates is 100%. 

Average salary during fellowship
Salary will be in accordance with ACGME for a PGY4-6 respectively with small variations. Ask each program about specific benefits provided.  

PREPARING TO APPLY

How competitive is the fellowship application process?
With the increased interest and growing acceptance of EM graduates in critical care medicine, EM-CCM fellowships have steadily become more competitive. In that regard, it is suggested by many program directors that preparations begin as early as your first year of residency. 

Requirements to apply
The only requirement to apply is that applicants must complete a residency in either emergency medicine or internal medicine. Be aware that you will need to upload your medical school transcript and dean’s letter into ERAS. All of your USMLE step scores will also need to be uploaded, inclusive of your Step 3 score. Some programs also require copies of your in-service scores so remember to keep copies of these through the years. ABIM requires for emergency medicine applicants to have six months of direct patient care experience in internal medicine, of which three months must have been in a medical intensive care unit. However, this does not need to be achieved during residency, and many programs are apt with building in the remaining mandated time into your fellowship. 

Research requirements
All applicants are required by ACGME to have a completed scholarly project/ activity during the residency period. Research in a CCM related area is certainly helpful for your application, however it is not a requirement. Additional projects and works of high quality such as peer-reviewed publications will increase your attractiveness. Any project placed on your resume should be one in which you were intricately involved and prepared to speak about during your interviews.  Presentations at national conferences such as ATS, CORD, ACEP, SAEM and SCCM are advised and looked favorably upon. It is better to have one completed project rather than several incomplete ones. 

Completion of a QI or academic research project is also a requirement for all CCM fellowship programs. Baseline expectations are a poster or abstract presentation, case report, review article or QI project. Thus, showing that you can complete a project during residency will look favourable to a fellowship program as proof that you can execute such projects.

Suggested elective rotations to take during residency
As noted above, ABIM currently requires emergency medicine trained physicians to have 6 months of internal medicine rotations (3 of which must be MICU) before supervising internal medicine residents. It is best to complete as many of these during residency as possible. While most fellowships are flexible and do not require you have all 6 months completed prior to the onset of fellowship; some PDs have noted they will rarely consider anyone with less than 4 months. Some fellowships may allow you to fulfil this requirement by using elective time during your first few months of the program. Others have separate non-resident medical rotations where you work alongside mid-levels in the interim until the requirement is fulfilled.   

The number of medical rotations you have during residency will vary depending on if you are coming from a 3 or 4 year program. Those from 3 year programs generally have less time to obtain the required rotations and as such should plan to use their elective time to make up the difference if needed. MICU electives are of course preferable however it is important to note that surgical/trauma ICU, Cardiac ICU  (CICU) and Neuro-ICU rotations are considered helpful in making you a well-rounded resident who is prepared for fellowship. Consultation services are generally not counted towards the 6 month total as you must be part of the primary care team in order for a rotation to count. Also be aware that some programs do not count CICU rotations towards the 6 month requirement as they are sometimes regarded as surgical based rather than medicine. Other electives to consider include nephrology, cardiology, infectious disease, and pulmonary.

Suggestions on how to excel during these elective rotations
Show your dedication and commitment to the specialty especially on your ICU rotations. Be prepared to arrive early, know your patients well and stay late if necessary. Staying abreast of the current literature is key, as well as being well-versed in the fundamentals of critical care. Presentations should be polished and concise. Be respectful to your team members and regularly interact and update patients and their relatives. Show excellent communication skills and speak up when concerned. Procedural competency and resuscitation skills are paramount.   

Should I complete an away rotation?
If your home institution does not have a critical care fellowship or a faculty member who is well-known in the critical care community and/or a strong intensivist group, it is worth considering an away rotation. This is also a good avenue for you to gain a strong letter for your fellowship application and network with other physicians in the critical care field. It can be difficult to fit an away rotation into your schedule as a second-year resident. Sometimes it is easier to find an away rotation at a competing health system within your city or state than to travel far for a rotation. 

What can I do to stand out from the crowd?
The short answer is to be a well-rounded emergency physician who excels clinically as well as shows leadership capabilities. Be involved in meaningful critical care activities. If you have a critical care program at you hospital attend the lectures and introduce yourself to faculty. If you don’t have a local program, networking through conferences and getting a mentor through EMRA’s Virtual Mentor will help. Aim to be involved with the well-known critical care groups, such as EMRA and ACEP CC divisions and SCCM. Interacting with members of these groups is a good way to meet like-minded people and potentially be involved with ongoing projects they may be conducting. Being a chief resident is certainly advantageous, however the focus should be to establish yourself as a hard-working, enthusiastic and reliable resident who is academically sound. 

Should I join a hospital committee?
Consider joining a hospital CCM committee, if available at your institution, as this can serve as an excellent networking tool and resume builder. This allows for exposure to other intensivists who may serve as mentors and potential future letter writers. 

Publications other than research
Other opportunities include, but are not limited to book chapters, blog posts, magazine articles, and podcasts. 

How many recommendations should I get? Who should write these recommendations?
ERAS allows for a maximum of 4 letters of recommendation. Programs require a minimum of 3 letters, one of which must be from your program director or department chair. The others should be written by intensivists, preferably medical, who have worked with you and know you well. It is also acceptable to have letters written by surgical and anesthesia intensivists. Emergency and Internal CCM intensivists are considered of similar value. While having letters of recommendation (LOR) from well-known physicians in the field or CCM Program directors would be desirable, a strong recommendation from a lesser-known intensivist is better than an impersonal LOR from a MICU PD. Be open when asking your writers for a “strong letter of recommendation” as if they feel they cannot provide one, it is better to find another writer than to submit a luke-warm LOR. Letters should emphasize a strong work ethic, professional communication, and passion for the field. Letters from away rotations that are IM-CCM based can be very useful. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
In general, working as an attending is not a bad idea and will help your skills as a clinician, but you need to make this time after residency meaningful. Get involved in writing and/or research in critical care. Join a critical care committee at your hospital. Become involved in national critical care organizations. Make sure you have a critical care mentor that will help ensure that you make this time as productive as possible.

What if I’m a DO applicant?
The merger of AOA and ACGME for emergency accreditation will hopefully strengthen DO applicants and further support equality between DO and MDs. DOs already make up a large portion of internal medicine residents and have proven worthy of matching subspecialties. There will be added difficulty but it is possible to match. Contact individual programs to confirm they are receptive and whether all three USMLE Steps are required. 

What if I am an international applicant?
The same requirements generally exist for international applicants, inclusive of taking the USMLE and having high board scores. The biggest challenge will be whether the program is willing to sponsor your visa. It is best to contact individual programs to discuss this prior to applying.

APPLICATION PROCESS

How many applications should I submit?
 Apply only to those places where you would honestly consider working. That being said, it is better to get too many offers for fellowship than to have no offers at all. Unlike residency, there is no specific number of interviews that you need to shoot for to gain a position, but it is recommended to apply to at least 10. Be aware that the majority of these programs use ERAS, but there are a handful of programs that do not. You can find out which programs use ERAS by referring to their website as listed in section 2a. There is a bit of a loophole in that Pulmonary-CCM programs are allowed to apply for a critical care track within their program and could potentially take you as a fellow. There are only a handful of programs that will do this, and there is no current way of tracking them. If you are interested in a specific area of the country, email the Pulmonary-CCM programs to see if they would be willing to consider you under a critical care track. 

How do I pick the right program for me?
Your goal is to find a program that has a sick patient population, exposes you to different critical care environments, and has a curriculum that matches your needs/interests/goals. Remember that in some programs, the fellow is in more of a supervisory role, while in others the fellow is the worker of the team. You need to decide in which environment you learn better; if you learn by doing, then you should pick a program that allows you to do the work. During your interview, try to get a feel for the faculty, nursing staff, and other fellows to make sure you fit in. If you will be the first EM resident in a program, be aware that you are blazing a trail, and how you perform will determine if they take future EM applicants. 

Common mistakes during the application process
Submit your application as soon as it opens on ERAS, and make sure it is complete. Be truthful; do not over-inflate your accomplishments. Make sure your application demonstrates a clear critical care interest. Give your letter writers plenty of time to complete and upload your letters of recommendation so they can be sent with your application to programs in July. Pay attention to the small details, and ensure there are no spelling or grammatical errors on your application. 

Application deadlines
Applications are processed through the ERAS service, which generally opens in June. Applications are generally submitted no later than August-September. As this is ERAS, you will have to pay a fee for a token to start the application process, and another fee to send your application to a program. Interviews are usually held in August through early October, with offers made in mid-October, although each program tends to work a little differently. 

Tips for writing your personal statement  
Your personal statement should address why you are interested in critical care medicine. The best personal statements tell a story and have something unique/interesting that sets you apart from the pack. Try and keep a list of interesting ICU cases during your residency, as this can be a branch point for your personal statement. Do not regurgitate what is already listed on your CV; rather, your personal statement should be a mature reflection on what it means to be an intensivist. Let your personality show through and display yourself as thoughtful, intelligent, and insightful. This website can help you find inspiration. Remember to send your personal statement to multiple people to help edit and fine-tune your masterpiece. 

Is this a match process?
While many programs process application packets through ERAS, there is no formal match process for IM-CCM. 

What happens if I don’t obtain a fellowship position?
You will need to evaluate your application, preferably with someone in a critical care leadership position, and look for deficiencies therein. Spend the next year addressing these deficiencies and also practicing your interview skills. Do not be afraid to re-apply. 

Depending on one’s dedication to ICU-based care, advanced resuscitation fellowships may be an option. While there are only a few of these programs around the country, they may be an option to consider for critical care-minded EPs. These fellowships are not ACGME approved, and typically focus on translational research in areas such as acute resuscitation, intensive care, emergency medical services, and echocardiography.

INTERVIEW PROCESS

How do I stand out from the crowd?

As with any interview, preparation is key. Find out as much about the program and the influential people in it as possible.  Make sure you have good reasons for why you want to attend that specific program. Treat every interview as if it is your number 1 choice. Arrive early and have available printed updated copies of your CV on hand. Your goal is to show your strength as a candidate and your commitment to the field. Avoid being aggressive or coming off self-absorbed. This is your opportunity to let your personality shine and show them why you are the best candidate for the job. Highlight your strengths and accomplishments. Highlight the skills you possess as an EM trained physician compared to IM counterparts (US, Procedures, Decisiveness). If there is an opportunity to meet the current fellows either on a night before social or during lunch or a didactic session on the interview day, you should capitalise on it. These are the people who know the program best and your future potential colleagues. It is strongly recommend having a mock interview prior to the actual interviews to ensure you present your best self.

What types of questions are typically asked?
You will likely be asked about specific experiences you had during your ICU rotations or during the care of a critically ill patient. You will be expected to demonstrate that you have good clinical knowledge and understanding of the field. Some interviews will have structured pre-set questions or scenario based questions looking to elicit key things such as your task solving skills or how you deal with difficult situations. Take your time and think about your answers. Acknowledging your weaknesses and mistakes and how you have overcome them to better yourself is always looked at favorably. 

Be prepared to discuss your interest in critical care medicine and your career goals. Know some of the hot topics within the field.  Be well acquainted with everything in your application and prepared to discuss it in detail if needed. Questions about your leadership experiences, publications, research projects, are all fair game. Not knowing your research makes it seem as if you played a superficial role. Show your enthusiasm about the program at which you are applying and have pre-set questions of your own which are thoughtful and insightful and not something easily answered by the institution’s website.

How many interviews should I go on?
There is no recommended number. Given the competitiveness of the specialty, it is advised to attend as many as possible. Ideally, you should attend any interview offered at programs that you would seriously consider an acceptance offer from. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Irwin RS, et al. Irwin and Rippe's intensive care medicine. Philadelphia: Wolters Kluwer, 2018
  • Fink MP, et al. Textbook of critical care. Philadelphia, PA: Elsevier, 2017
  • Layon AJ, et al. Civetta, Taylor, & Kirby's critical care. Philadelphia: Wolters Kluwer, 2018
  • Marin, PL. Marino's the ICU book. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.
  • Tobin MJ. Principles and practice of mechanical ventilation. New York: McGraw-Hill Medical, 2013.
  • Levitov A, Mayo PH, Slonim AD. Critical care ultrasonography. New York: McGraw-Hill Education Medical, 2014
  • Winters ME. Emergency Resuscitation of the Critically Ill, 2nd Ed. S.l: ACEP, 2017
  • Brown CA, Sakles JC, Mick NW. The Walls manual of emergency airway management. Philadelphia, PA: Wolters Kluwer, 2018.
  • Awdish R. In shock: my journey from death to recovery and the redemptive power of hope. New York: St. Martin's Press, 2017

Important skills to practice while in residency to prepare for fellowship

  • Become proficient in central lines, arterial lines, intubation, thoracentesis and paracentesis. Learn to place peripheral IVs with US. Fight for chest tubes and esophageal balloon tamponade procedures.
  • Ultrasound knowledge, RUSH, ECHO, RUQ and lung exams
  • Improve your task switching ability and organization to manage multiple sick patients
  • Become comfortable running resuscitations with excellent communication and task assigning
  • Patient ventilation support devices and invasive ventilator management 

  • Become familiar with having difficult conversations and discussing goals of care

Tips on how to succeed as a fellow
Develop a well-organized work/life schedule. Fellowship will have longer hours as compared to emergency medicine residency. It is important to develop healthy habits like sleep hygiene, exercise and leisure activities early in your career to help prevent burnout even beyond fellowship. Be sure to make time for family and friends, don’t forget your support system.

CONCLUSION

Additional Resources

Journals

  • Circulation
  • NEJM
  • Chest
  • JAMA
  • Lancet
  • Journal of Trauma
  • Anesthesiology
  • Critical Care
  • Critical Care Medicine
  • Intensive Care Medicine
  • Annals of Emergency Medicine
  • Journal of Emergency and Critical Care Medicine
  • American Journal of Respiratory and Critical Care Medicine

Podcasts

Clinical Resources/Websites/Blogs

National organizations

  • The EMRA Critical Care Committee is a great resource, is resident- and fellow-based, and offers multiple opportunities for involvement – including a critical care conference travel scholarship. The ACEP Critical Care Section connects all EM physicians interested and/or trained in critical care medicine. SAEM recently created a Critical Care Interest Group as well. The Society of Critical Care Medicine connects critical care physicians regardless of their initial residency training.
  • Other organizations to consider: ACCP, ATS, EAST, and the American Heart Association 

Conferences

  • The EMRA Critical Care Division has biannual meetings in conjunction with the SAEM Annual Conference and ACEP Scientific Assembly, and the critical care sections of SAEM and ACEP have annual meetings during their respective conferences. SCCM has annual meetings in January. There are multiple other meetings, including but not limited to:
  • Social Media and Critical Care (SMACC) Conference
  • Essentials of EMCrit Conference
  • American Thoracic Society Conference
  • European Society of Intensive Medicine
  • UPENN Therapeutic Hypothermia conference
  • UMMC Critical Care Conference
  • Weil/UC San Diego Symposium on Critical Care and Emergency Medicine
  • Northern New England Critical Care Conference
  • Rocky Mountain Regional Critical Care Conference

How to find a mentor
Within your home institution, mentors to consider would be your program director and the director of your medical intensive care unit. You should establish a mentor early during residency and do your part to foster this relationship by bringing questions and scheduling regular meetings. Search out feedback from your mentor and apply it. A virtual mentorship program has been established to help guide interested residents through the decision to apply and through the application and interview process. This website is unique in that it connects you to faculty who are both EM and CCM trained.