By: Dr. Travis Manasco and Dr. Matthew Tyler

Over the past 5-10 years, critical care has become a popular fellowship choice after emergency medicine (EM) residency training.  Many EM physicians enjoy performing procedures and taking care of critically ill patients. In critical care, you have the ability to care for these patients throughout the course of their critical illness. You form meaningful relationships with patients and their families. In addition, critical care practice exposes you to health disciplines that are unfamiliar to most EM providers, such as long-term disease management,  advanced mechanical ventilation and weaning, extubation criteria, nutrition and palliative care.

 

Should you go into critical care?

While many EM physicians love procedures and caring for critically ill patients, few pursue a critical care fellowship.  If you are considering a fellowship in critical care, you should ask yourself these questions.

  1. Do I enjoy my SICU, MICU, CCU, etc. time as much or more than my ED time?
  2. Do I want to pursue 2 more years of additional training?
  3. Am I willing to defer an attending salary for two years?
  4. What is my ideal practice environment?
  5. What is my ideal split between ED and ICU time?

 Training

 There are various avenues to achieve board certification in critical care medicine after completion of your EM residency.

 

  1. Anesthesia

Since 2013, emergency medicine residency graduates are eligible to apply for a position in a two-year American Board of Anesthesiology (ABA) critical care fellowship. Individual program curriculums vary in their content.          Some programs are multidisciplinary, where you spend equal amounts of time in  various ICUs (Medical ICU (MICU), Surgical ICU (SICU), Cardiothoracic ICU (CTICU), and Neuro ICU). Other programs prioritize time and education in the  surgical critical care units.  It is important to consider where you would like to work after fellowship when evaluating programs. If you want to work in a MICU, then your fellowship training program should offer more time in that setting.

If you are interested in an Anesthesia-Critical Care fellowship, it is best to plan early in residency! Fellowship applications are accepted in the fall/winter of your PGY3 year (if in a PGY4 program).  The Society of Critical Care Anesthesiologists (SOCCA) give fellowship spots through the San Francisco Match, which is usually in late May of your PGY3 year.

My suggestion is to let your ICU attendings know you are considering a career in critical care  early on during your rotations. If you have a good relationship with that person, ask for a letter of recommendation.  Prefacing the question with “Do you think you know me (or we have worked together) enough to write a             strong letter on my behalf” will ensure that the letter indeed strengthens your application.  Try to obtain the letter shortly after the rotation so you are still fresh in their mind.

Accredited programs are found here: http://www.theaba.org/TRAINING-PROGRAMS/Resident-Options/ACCM-Fellowships

 

  1. Internal Medicine

This fellowship is ideal for EM providers that would like to work in the Medical ICU, though some programs are truly multidisciplinary and spend equal time across ICU specialties. This 2-year pathway requires 12 months of clinical time (at least 6 months of caring for critically ill medical patients) and 12 months for academic development and/or clinical experiences.  Of note, you must complete 6 months of inpatient internal medicine, with 3 months being in a MICU, before you are allowed to supervise residents. It is ideal to have this done before completing your residency, though programs allow you to complete missing months during your first year of fellowship.

Applications are usually accepted through ERAS and are due July 1 at the start of your final residency year.  There is no match. Fellowship offers are made on a rolling basis.

 

  1. Surgery

 EM residents may apply to approved surgical critical care (SCC) fellowships. These two-year fellowships are broken down into an initial “preparatory” surgical year, followed by a traditional one-year SCC fellowship. An example of the preparatory year (from Maryland – Shock Trauma) is below:

  • Acute Care Surgery (UMMC) – 2 months
  • Trauma Surgery (STC) – 2 months
  • Vascular Surgery (UMMC) – 1 month
  • Cardiac Surgery (UMMC) – 1 month
  • Soft Tissue Service (STC) – 1 month
  • Trauma Orthopedics (STC) – 1 month
  • Trauma ICU – 3 months
  • Elective – 1 month

The surgical critical care programs are through the NRMP match website (http://www.nrmp.org/fellowships/surgical-critical-care-match).  Match day is in early October of your final year of residency.

 

  1. Neurology

EM residents can apply for board certification in neurocritical care.  These programs are two years in duration, with the majority of time spent in the Neuro ICU.  As an example, The University of Cincinnati has a neurocritical care program that includes 12 months of critical care time, and 12 months “designed to focus on critical care subspecialties, vascular neurology, critical care EEG, clinical or basic science            research or pediatric neurocritical care.”

For a list of programs, please visit: https://www.ucns.org/apps/directory/

 

What can you do after residency?

There are many possibilities for your future practice. The options range from 100% of your time in the ED (being the “critical care expert”) to fully devoting your time to the ICU. Many fellowship graduates settle somewhere in the middle, splitting their time between ED and ICU shifts. Applicants should be aware that EM-Critical Care is a relatively new specialty and that many ICUs have traditionally been managed by Pulmonary & Critical Care physicians, Anesthesiologists, or Surgeons. Some hospitals will be more open to your training background while others will be hesitant to hire an EM physician. This will certainly change over time as the specialty grows and more EM physicians prove themselves as indispensable resources to any ICU program.

Helpful links:

EMRA Critical Care Division – https://www.emra.org/committees-divisions/Critical-Care-Division/

  • NOTE: You can register for mentorship through EMRA. This is very helpful since we do not have any EM-CCM trained attendings at BMC!

ACEP Critical Care Medicine Section – https://www.acep.org/criticalcaresection/

EMcrit –www.emcrit.org

PulmCCM – www.pulmccm.org

Mastering Intensive Care – http://masteringintensivecare.libsyn.com/
Critical Care Fellow Authors:
Travis Manasco, MD 

Matthew Tyler, MD 

Faculty Reviewers:
Alex Sheng, MD
Jordan Spector, MD