Medical Education

ABMS Subspecialty Certification in Neurocritical Care

In June 2018, the American Board of Medical Specialties (ABMS) approved subspecialty certification in Neurocritical Care (NCC), which is co-sponsored by the American Board of Anesthesiology (ABA), the American Board of Emergency Medicine (ABEM), the American Board of Neurological Surgery (ABNS), and the American Board of Psychiatry and Neurology (ABPN).1,2 Once fully implemented, NCC will become the 10th ABMS-certified emergency medicine (EM) subspecialty, and graduates of NCC fellowships will be eligible for board certification in NCC.3

I had the opportunity to speak with an expert in neurocritical care and emergency medicine, Dr. Evie Marcolini, to learn more about the fellowship and what ABMS certification means for graduates of EM residency programs. Dr. Marcolini is an Assistant Professor at the University of Vermont Medical School, where she is also the Director of Critical Care Education in the Division of Emergency Medicine as well as the Neurocritical Care Fellowship Director in the Department of Neurology. 

What is a neurocritical care fellowship?
This is a 2-year fellowship offered to graduates of residency programs in Anesthesia, Emergency Medicine, Neurosurgery, Psychiatry, and Neurology. Board-eligible or board-certified graduates (MD/DO) may obtain fellowship certification through the traditional two-year training pathway, or those already in practice and board certified by the United Council for Neurologic Subspecialties (UCNS) may sit for a board exam to receive certification.

Is the neurocritical care fellowship new?
Board certification for NCC was established in 2005 and has been accredited by UCNS and the Society for Neurological Surgeons Committee on Advanced Subspecialty Training (SNS-CAST). There are currently 61 UCNS-accredited NCC fellowships and 22 SNS-CAST accredited fellowships in the U.S.4 

What is the benefit of an ABMS-certified NCC fellowship?
ABMS-certified fellowships are the gold standard, and bringing the NCC fellowship under the ABMS will afford the subspecialty resources to improve training. As more physicians train in NCC, fellow oversight and education will become more standardized. NCC is a relatively new subspecialty, which means Neuro ICUs are currently run by physicians boarded in neuro critical care, critical care medicine, surgical critical care, or anesthesia critical care.

What are the career options for graduates of NCC programs?
Graduates may choose to spend their clinical time completely in the emergency department (ED) or in the Neuro ICU, or may choose to split their time between the two. Many community hospitals will likely not have a dedicated Neuro ICU, so graduates may choose to work clinically in a mixed ICU caring for all patients whether they are Medical-, Surgical-, Cardiovascular-, or Neuro ICU patients.

Who would be interested in applying to NCC fellowship programs?
When choosing a critical care fellowship, emergency physicians now have all specialties to choose from: Medicine, Surgery, Anesthesia, and Neurocritical Care. Each specialty has different nuances. In the Neuro ICU, patients have complex physiology, both neurologically as well as generally. Neurocritically ill patients are also at risk for respiratory failure, sepsis, and even intraabdominal pathology. The typical Neuro ICU patient has had a sudden devastating illness and they as well as their families are dealing with the emotions and dynamics of understanding the physiology and making life decisions. A great neurointensivist will embrace the pathophysiology as well as the opportunity to help patients and families navigate the uncharted territory of a devastating disease process.

Is there anything else you think EM residents should know about this announcement?
I hope that folks are excited about this development! Please contact me if you have any questions or just want to talk about critical care fellowships in general.

As far as the NCC fellowship, here are some thoughts: Know what EM brings to the table that other specialties do not, but also recognize what EM training does not provide. We are airway experts; endotracheal intubation is essential to our job. We’re skilled at interpreting ECGs, and we’re responsible for management of everything from the neck down, as well as above. We see patients with neurologic complaints all the time, and we are solely responsible for the initial management of their acute concerns.

While EM grads have many strengths, we don’t have as much experience with the longer-term management of common diseases such as CNS based tumors, or rare entities such as NMDA receptor encephalopathy. A Neurocritical care fellowship will be a time to increase knowledge and skills in areas that EM doesn’t typically focus on, such as neuroimaging or electroencephalographic monitoring (EEG). 

What would you recommend to current EM residents who are interested in pursuing a NCC fellowship?
Above all else, show interest in NCC through scholarly activities and electives. Gain experience (to make sure you will actually like NCC) by doing a rotation in a Neuro ICU. Expand your skillset through rotations in neurology and neuroimaging.

Any recommendations for EM residents who are interested in critical care, but are still unsure which path to choose?
Think about what is important. How do you want to spend your time? What specialists do you want to work with? Know why you are pursuing a critical care fellowship. There are many EM grads that say they want to do a critical care fellowship because they think it will make them better EM physicians, but this may not be true and certainly is not a great reason to spend two years in the Neuro ICU! The ICU and the ED are very different, and each requires a specific way of thinking. The best reason to pursue a critical care fellowship is because you love it!

Additional Details
The ABMS formally approved the subspecialty certification in June of 2018, and a proposal is being sent to the Accreditation Council for Graduate Medical Education (ACGME) for accreditation recognition of the NCC subspecialty. It is anticipated that the first ABMS-recognized board certification exam will be offered in 2020 or 2021.1,2,4,5 Until details on the transition are finalized, fellowships will continue to be accredited by the UCNS and SNS-CAST, and EM graduates may apply to NCC fellowships through the San Francisco Match. 

For further information about Neurocritical Care Fellowship Programs, check out the EMRA Fellowship Guide or reach out to Dr. Marcolini at emarcolini@gmail.com.


References
1. American Board of Emergency Medicine. ABEM Co-sponsor of Neurocritical Care. Accessed September 19, 2018.
2. American Board of Psychiatry and Neurology. ABPN Announces New Subspecialty Certificate in Neurocritical Care. Accessed September 19, 2018.
3. American Board of Medical Specialties. Specialty and Subspecialty Certificates. Accessed September 19, 2018.
4. American Board of Medical Specialties. Application for Subspecialty Certificate. Accessed September 10, 2018.
5. Neurocritical Care Society. American Board of Medical Specialties Adopts New Neurocritical Care Subspecialty. Accessed September 19, 2018.

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