EM-CCM FELLOWSHIPS

Medical Students

Becoming an excellent EM physician first

While a few medical students enter into EM knowing that they will eventually pursue CCM training, the majority of EM residents and physicians come to realize this after some variable amount of time in training and practice. The key to a good becoming a good intensivist is to first become a good emergency physician. Qualities sought after in physicians are universal: excellent clinical performance, communication skills, procedural competence, team leadership, and medical knowledge. Concentrate in becoming a thoughtful, well-rounded, emergency physician first.

Resources to assist in finding your way to Emergency Medicine include:
EMRA
SAEM
AAEM

Residents

Choosing the right CCM fellowship

So you think you have an interest in critical care medicine? How do you know if you need to do a fellowship in critical care medicine?

Fellowship training in critical care medicine is designed to refine your clinical skills and teach you how to become an intensivist. Emergency Medicine physicians choose to do CCM fellowship for 2 reasons:

  1. Desire to practice as an intensivist.
  2. Desire to refine academic or community EM practice with special interest in critically ill patients.

EM physicians who pursue fellowship training in CCM have a variety of practice patterns:

  1. 100% time spent in practice as an intensivist
  2. 100% time spent in practice as an emergency physician (EP)
  3. Split of time spent in practice as an intensivist & as EP (i.e. 50:50 or 80:20 or 90:10)

The majority of EM physicians that have pursued fellowship training in CCM currently practice in academic or teaching institutions. While it is still possible to practice in community medical settings, it may be currently be less prevalent due to either individual career desires or regional hospital physician needs and politics.

Fellowship training in CCM is designed to make you into an intensivist, and is 2 years in length.

While some EPs have been able to make critical care their academic interest within EM, we anticipate due to the rapid growth in EP pursuing CCM fellowship training that eventually EPs who desire to practice CCM within EM will need fellowship training.

What are the differences between Internal Medicine, Anesthesia, and Surgical Critical Care fellowship training programs?

IM-CCM fellowships are focused on comprehensive care of the critically ill medical patient, while Anesthesia and Surgical Critical Care fellowships primarily are focused on comprehensive care of the critically ill surgical patient. IM-CCM fellowships can include exposure to surgical patients in mixed medical-surgical ICUs or in dedicated elective surgical ICU rotations. Anesthesia and Surgical CCM fellowships can include exposure to medical ICU patients through electives as well. Exposure to TEE is primarily included through the Anesthesia Critical Care fellowships.

IM-CCM fellowships are designed for 12 months of clinical ICU time and total 24 months of training.
Anes-CCM fellowships are designed for 9 months of clinical ICU time and 3 months of electives.
Surgical CCM fellowships are designed for 9 months of clinical ICU time and 3 months of electives.

Newer non-accredited training programs created by graduates of traditional (Anes, IM, or Surg CC) fellowships are often multidisciplinary in nature, with broad exposure in both medical & surgical ICUs.

What is needed for application to CCM fellowship? How do I improve the strength of my application?

Aside from excellent USMLE Step scores, the most important component of application are usually the letters of recommendation. Letters should be obtained from a variety of sources, but only 1 from EM (usually Residency Program Director of Department Chair). The remaining letters should come from intensivists that have worked with you, and can come from a variety of other disciplines from EM. Personal statements can help reflect your personality, personal story for how you came to EM and CCM, and provide greater depth to you application, if requested. Research experience in topics of interest to intensivists may be helpful.

How do I know if EM-CCM is the right career path for me?

For some, practice as an intensivist is the ultimate career goal in medicine, which makes the decision easy. For others, the desire to split practice between the ED and ICU and improve clinical care provided in both arenas is usually welcomed by hospitals and Departmental Chairs. However, technically splitting the time between the 2 Departments is sometimes hard to achieve, as you will be part-time in both Departments. EM-CCM is the right career path for you if you enjoy the continuity of care of the most critically ill patients beyond the first 2 hours, and enjoy seeing patients and their families through post-resuscitative care.

How do I improve my performance on ICU rotations & electives?

The practice of critical care medicine requires comprehensive attention to detail and speed in deciding resuscitative interventions. Fortunately, the practice of EM already includes the recognition of physiologic collapse and resuscitative interventions necessary to stabilize the patient. Further care of the patient requires systematic, detailed, planned maneuvers of cardio-pulmonary, nutritional, endocrine, and preventative interventions over time. Aside from ability to synthesize and integrate multiple points of data and understand the physiology underlying care, some review of clinical guidelines and best practices may be helpful. Some resources to identify basic critical care practices include SCCM and ACCP/ Chest websites. Complete & thorough presentation and ability to strategically plan patient’s care for a variety of medical problems is the desired competency. Asking questions, providing family updates, coordinating care amongst consulted sub-specialists, and prompt skillful performance of procedures are important performance at the resident and fellow levels.

Does certification pathway affect what type of CCM fellowship to consider?

Possibly. Individual need for mobility throughout the country and desire to practice CCM for a particular population of patients (i.e. surgical, medical, neuro) might affect what type of CCM fellowship to consider. In 2011, the only current pathway for US board certification being offered to EM physicians is the IM-CCM examination via co-sponsorship between ABEM and ABIM. This may change in the future years. The requirement for the certification exam requires the ABEM diplomate to complete a 2 year IM-CCM fellowship. When considering fellowship training, residents are encouraged to look specifically at the types of ICUs they will be rotating in, the number of electives possible, the breadth of clinical exposure (i.e. types of patient problems, numbers of procedures), and the involvement in research or scholarly projects. Residents may also want to consider whether any attention or flexibility to practice the primary specialty of EM is incorporated in the fellowship training time. Anesthesia and Surgical Critical Care training may have additional exposure to surgical patients and TEE. Most EM physicians prefer the breadth of all medical and surgical patients in critical care training and practice.

What is Neurocritical Care?

Neurocritical care is a sub-specialty critical care specifically focused on the care and outcomes of patients with life-threatening neurological illnesses. Neurocritical care fellowships are accredited by the United Council for Neurocritical Subspecialties. For more information, please see:

UCNS
Nuerocritical Care Society

Virtual Mentorship Program
http://www.emccmfellowship.org/mentorship.php