Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States Julie A. Mayglothling, MD, Kyle J. Gunnerson, MD, and David T. Huang, MD, MPH
Abstract Objectives: Critical care medicine (CCM) is of growing interest among emergency physicians (EPs), but the number of CCM-trained EPs and their postfellowship practice is unknown. This study’s purpose was to conduct a descriptive census survey of EPs who have completed or are currently in a CCM fellowship. Methods: The authors created a Web-based survey, and requests to participate were sent to EPs who have completed or are currently in a CCM fellowship. Responses were collected over a 12-month period. Physicians were located via multiple whom electronic mailing lists, including the Emergency Medicine Section of the Society of Critical Care Medicine, Critical Care Section of the American College of Emergency Physicians, and the Emergency Medicine Residents’ Association. The authors also contacted CCM fellowship coordinators and used informal networking. Data were collected on emergency medicine (EM) and other residency training; discipline, duration, and year of CCM fellowship; current practice setting; and board certification status, including the European Diploma in Intensive Care (EDIC). Results: A total of 104 physicians completed the survey (97% response rate), of whom 73 had completed fellowship at the time of participation, and 31 of whom were in fellowship training. Of those who completed fellowship, 36 ⁄ 73 (49%) practice both EM and CCM, and 45 ⁄ 73 (62%) practice in academic institutions. Multiple disciplines of fellowship were represented: multidisciplinary (39), surgical (28), internal medicine (16), anesthesia (14), and other (4). Together, the CCM fellowships at the University of Maryland R Adams Cowley Shock Trauma Center and the University of Pittsburgh have trained 42% of all EM-CCM physicians, with 38 other institutions training from one to four fellows each. The number of EPs completing CCM fellowships has risen: from 1974 to 1989, 12 EPs; from 1990 to 1999, 15 EPs; and from 2000 to 2007, 43 EPs. Conclusions: Emergency physicians are entering CCM fellowships in increasing numbers. Almost half of these EPs practice both EM and CCM. ACADAEMIC EMERGENCY MEDICINE 2010; 17:325–329 ª 2010 by the Society for Academic Emergency Medicine Keywords: emergency medicine, critical care, fellowship, board certification
From the Department of Emergency Medicine (JAM, KJG), the Department of Surgery, Division of Trauma ⁄ Critical Care (JAM), Virginia Commonwealth University Reanimation, Engineering and Shock Center (JAM, KJG), and the Department of Anesthesiology (KJG), Virginia Commonwealth University, Richmond, VA; and the Department of Critical Care Medicine, CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), and the Department of Emergency Medicine, University of Pittsburgh (DTH), Pittsburgh, PA. Received July 8, 2009; revision received September 2, 2009; accepted October 2, 2009. The work was performed at Virginia Commonwealth University. Editor’s Note: Subsequent to the submission of this manuscript, the American Board of Emergency Medicine (ABEM) reached an agreement with the American Board of Internal Medicine to develop an application to the American Board of Medical Specialties (ABMS) to become a co-sponsor in IM Critical Care Medicine. Upon ABMS approval of the application, emergency medicine residents will have access to training in 2-year internal medicine critical care fellowship programs upon completion of their emergency medicine residencies. Following successful completion of the fellowship, they will be able to become certified in Internal Medicine Critical Care Medicine through ABEM. Additional information will be provided on the ABEM Web site (http://www.abem.org) as it becomes available. Address for correspondence and reprints: Julie A. Mayglothling, MD; e-mail:
[email protected].
ª 2010 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2010.00683.x
ISSN 1069-6563 PII ISSN 1069-6563583
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emand for critical care services is increasing even as a shortage of intensivists exists,1 and interest in critical care fellowship training among trainees is low.2–4 In 2005, a consensus paper endorsed by the Society of Critical Care Medicine (SCCM) and multiple emergency medicine (EM) societies called for establishing access to formal critical care medicine (CCM) training and certification for emergency physicians (EPs) and noted that dual-trained EM-CCM physicians would not only help address the intensivist shortage, but also strengthen critical care delivery in the emergency department (ED) and facilitate coordination between EDs and intensive care units (ICUs).5 However, as a nontraditional training pathway, the demographics of EM-CCM physicians are not tracked by the main graduate medical education or board certification bodies and are therefore unknown. We sought to determine the number of CCM fellowship-trained EPs, describe their fellowship training and current clinical practice, and examine the growth of the specialty over the past three decades. In addition, we sought to evaluate the participation in the European Diploma in Intensive Care (EDIC) among EM-trained intensivists. METHODS Study Design and Population Between May 1, 2007, and May 1, 2008, we conducted a self-administered, Web-based survey of investigatoridentified EM-CCM physicians. We identified our survey population using multiple methods. Our target population was all physicians, board eligible or board certified by the American Board of Emergency Medicine (ABEM) or the American Board of Osteopathic Emergency Medicine, who have completed or were currently enrolled in a CCM fellowship during survey administration. The Virginia Commonwealth University Institutional Review Board approved the study. Consent was implied by voluntarily completing the questionnaire We sent e-mail survey invitations to multiple physician group electronic mailing lists, including those of the critical care section of the American College of Emergency Physicians (ACEP), the Emergency Medicine Residents’ Association (EMRA), and the Emergency Medicine Section of the SCCM. Survey respondents were compared to the membership lists of each of these groups, and e-mail survey invitations were sent to nonresponders. We also contacted the program directors of all CCM fellowships that have been known to accept EPs.6 The investigators then sent personal survey invitations to those individuals. Informal networking was performed by the investigators with numerous e-mail and phone call solicitations to find other EM-CCM physicians not identified by the above search strategies. Survey Content and Administration We created a Web-based survey using Remark Web Survey Professional V3.0 (Gravic, Inc., Malvern, PA). This survey consisted of 25 primary questions, with follow-up questions when applicable, and used both descriptive questions (e.g., Where did you do EM residency?) and explanatory questions (e.g., How do you
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feel EM residency prepared you for a CCM fellowship?). Data collected included institution of residency training; location, date, length, and discipline of CCM fellowship; demographics of current employment including type of hospital, leadership, or academic titles, EM practice, and CCM practice; and board certification eligibility in both EM and CCM. We piloted the survey to 10 eligible survey participants and subsequently refined the survey based on participant feedback. To complete the survey, subjects were given a URL to a Web site (http://www.emccm.org) that explained the goals and objectives of the survey. By clicking the icon to enter the survey questionnaire, respondents agreed to have their survey answers stored in a confidential database. Those participants who were currently enrolled in a fellowship were instructed to complete as much of the survey as they thought applicable to their current practice. Data Analysis We downloaded data from the Web survey and housed it in a password-protected database. We tallied descriptive data and calculated means and standard deviations (SD) when appropriate using easycalculation.com (HIOX, India). For three free-text survey responses that did not precisely follow survey instructions, we minimally interpreted the responses to allow complete data capture and analysis (e.g., interpretation of ‘‘2 weeks’’ as 14 days). RESULTS A total of 110 physicians filled out the survey, of whom six were excluded for either not completing a CCM fellowship or not training and practicing medicine in the United States. Despite multiple requests, three physicians who were identified as eligible for study participation declined to participate, leaving 104 as the study population (97% response rate). Thirty-one of the 104 respondents were fellows at the time of study participation and 73 had completed fellowship. Fellows’ responses were included for fellowship training analysis only and were not included in data pertaining to current practice. Current Practice Of the respondents who had completed fellowship prior to 2008, 70% (51 ⁄ 73) practice EM, 74% (54 ⁄ 73) practice inpatient CCM, and half practice both EM and CCM. EPs who practice only EM worked more ED shifts per month than those who practice both EM and CCM. However, the mean number of days per month worked in total was higher for those physicians who practice both EM and CCM than for physicians who practice only EM or only CCM (Figure 1). Almost two-thirds (63%) reported working in academic institutions, with the remainder spread among academically affiliated institutions (17%) and community hospitals (18%). One respondent reported working at a Veterans Affairs hospital. Many reported working in more than one discipline of CCM; however, surgical and surgical ⁄ trauma was the most common, followed
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completed CCM fellowships, all of whom completed EM residency training, four of whom were residency trained in both EM and IM. Finally, the 31 EPs who were enrolled in CCM fellowships at the time of participation in the survey are all EM residency trained, four of whom have been trained in both EM and IM. There are multiple disciplines of fellowship represented. Thirty-nine respondents described the primary discipline of their CCM fellowship as multidisciplinary, followed by surgery (28), medicine (16), anesthesia (14) and other (4). All four of the ‘‘other’’ disciplines were further described as neuro critical care. Three respondents did not answer. The CCM fellowships at the University of Maryland R Adams Cowley Shock Trauma Center and the University of Pittsburgh Medical Center have trained more than 42% of all EM-CCM physicians. Survey respondents also reported CCM training at 38 other institutions and in many instances were the first accepted EPs in these fellowships (Table 1).
Figure 1. Current practice. Of the 73 EPs who have completed fellowship training, 49% practice both EM and critical care medicine. CCM = critical care medicine; ICU = intensive care unit; IQR = interquartile range.
by combined medical ⁄ surgical, medical, neurology and neurosurgical, cardiothoracic surgery, transplant, and other (Figure 2). Other was classified as pediatric ICU and electronic ICU (‘‘e-ICU’’). Surgical and surgical subspecialty ICUs accounted for 58% of the reported ICU type.
Board Certification One of the alternative pathways to critical care certification in the United States is through the EDIC sponsored by the European Society of Intensive Care Medicine. At the time of participation of the study, 51% of EPs stated that they have taken or plan to take the EDIC exam (Table 2). Sixteen respondents stated they do not plan to take the EDIC exam, as they are eligible for CCM certification through other residency training. In total, there were 21 individuals who reported residency training other than EM (19 IM, one anesthesiology, and one general surgery) who are eligible for CCM certification in the United States. DISCUSSION
Fellowship Training Increasing numbers of EPs are entering CCM fellowships. From 1974 to 1979, only two physicians reported completing CCM fellowships, both of whom were trained in internal medicine (IM) as a base specialty and grandfathered into EM certification. From 1980 to 1989, the number of EPs who completed CCM fellowships increased to 10, six of whom were first IM trained and were grandfathered into EM certification. From 1990 to 1999, 15 EPs completed CCM fellowships, only four of whom were trained in a specialty other than EM (three IM, one anesthesiology), and from 2000 to 2007, 43 EPs
Figure 2. Discipline of ICU where EPs work. Many EPs work in more than one type of ICU; however, surgery ⁄ trauma and surgical subspecialty ICUs make up 58%. n = 73. ICU = intensive care unit.
The data from this survey demonstrate that EPs who have completed CCM fellowships are a diverse group. Many of these physicians practice in both the ED and the ICU, linking the care of critically ill patients between these two locations. The number of EPs entering critical
Table 1 Institutions That Have Trained EPs in Critical Care
CCM Fellowship Program University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore MD University of Pittsburgh Medical Center, Pittsburgh, PA Brigham and Women’s Hospital, Boston, MA University of Cincinnati, Cincinnati, OH Henry Ford Hospital, Detroit, MI Northshore ⁄ Long Island Jewish, Manhasset, NY St. Luke’s Hospital, Bethlehem, PA University of Florida, Shands Hospital, Gainesville, FL All other institutions training one to two fellows CCM = critical care medicine.
Number of Fellows 26 18 4 4 3 3 3 3 32
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Table 2 Plans to Take the EDIC
Response I plan to take the EDIC exam I do not plan to take the EDIC exam I took the EDIC exam I do not plan to take the EDIC exam as I am board eligible in CCM in the United States by other specialty training No answer
Completed Fellowship
Current Fellows
Total
19 22
16 2
35 24
18 12
0 4
18 16
2
9
11
CCM = critical care medicine; EDIC = European Diploma in Intensive Care.
care has increased dramatically over the past 30 years and this trend appears to be continuing. Indeed, more than 50% of all EM-CCM physicians have graduated from their fellowships in the past 8 years. Three-fourths of EPs who have trained in critical care now work in the inpatient ICU setting. Historically, EM and inpatient medicine were separate entities with little overlap in practice. However, critical care fellowships are training EPs in ICU-based inpatient medicine. Results of this unique mix are encouraging. The survey has shown that many hospitals are willing to credential these physicians as intensivists, despite not being board eligible in CCM. This likely reflects the needs and opportunities of jobs available, as well as market forces of supply and demand for critical care specialists as hospitals try to meet Leapfrog standards for intensivist staffing7 and create inpatient rapid response teams.8 In addition, departments of surgery, anesthesiology, IM, and neurosurgery who run the ICUs are willing to employ these physicians, which may indicate a growing acceptance of emergency intensivists among other specialties.9 Over 50% of EM-trained intensivists practice critical care in a surgical or surgical subspecialty ICU. However, all unit types were reported in the survey as practice environments. The diversity of ICU practice environments is encouraging, demonstrating multiple opportunities to practice CCM without base specialty limitations. Surgeons and anesthesiologists, those who historically have practiced in surgical and subspecialty surgical settings, are entering critical care in fewer numbers in the past several years, leaving open the opportunity for EPs to occupy these positions. In addition, a high percentage of critical care trained EPs have trained at surgical and multidisciplinary fellowship programs, mainly the University of Maryland R Adams Cowley Shock Trauma Center and the Multidisciplinary Critical Care Training Program at the University of Pittsburgh Medical Center. These fellowships tend to have more rotations in surgical critical care than medical critical care, so graduates may feel more suited to surgical and surgical subspecialty ICU care after fellowship completion. While interest in critical care is decreasing in many specialties, the interest among EPs is growing. There
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are more EPs currently enrolled in CCM fellowships than have graduated in the first three decades of the specialty. EPs are responsible for caring for life-threatening acute illness in the early hours of disease. Many see the more prolonged ICU management of these conditions in CCM as a logical extension of EM. Perhaps as EM continues to evolve as a specialty, more EPs are pursuing fellowship opportunities to develop their professional careers.10,11 CCM training offers an intellectually challenging, exciting experience with a continuity of care and long-term perspective not offered by traditional EM practice. The increase in numbers may also simply be due to EM residents and their mentors becoming aware that CCM is a viable option. Many EM physician groups, including ACEP, EMRA, and the Society for Academic Emergency Medicine, now have critical care sections, and given that many EM-CCM physicians practice in academic medical centers, many EM residents have been exposed to these physicians. One survey administered by EMRA showed that more EM residents would consider entering critical care fellowship if there was a pathway to certification.12 The EDIC is currently the only pathway to certification for U.S. EM-based intensivists.13 This exam is sponsored by the European Society of Intensive Care Medicine and is open to physicians who have completed a residency in anesthesiology, IM, surgery, pediatrics, or EM, plus completion of 24 months training and experience in CCM.14 Without access to U.S. certification, some hospitals or departments accept this certification for credentialing purposes for EM intensivists. Approximately half of EM-CCM physicians choose not to take the EDIC exam, possibly due to the expense and time commitment of going to Europe to take an exam with uncertain impact on their employment options. LIMITATIONS Documenting the number and demographics that EPs contribute to the critical care workforce was challenging. There is no formal U.S. certification pathway for EPs who complete a CCM fellowship and no training accreditation organization that tracks EM-CCM fellows or diplomates. Despite an exhaustive search of multiple professional organization electronic mailing lists, personal e-mail solicitations, and CCM fellowship inquiries, it is likely there are more CCM trained EPs who were unable to be located. According to our survey data, there are greater numbers of CCM fellowships that are giving opportunities to EM-trained residents in the past several years, which makes it harder to keep track of these graduates. However, we performed a thorough search over a 1-year period and believe that we identified most of the target population. We relied on respondent self-reporting and did not confirm the accuracy of the provided data. This may limit the validity of the data. However, we piloted our survey instrument to improve clarity and reduce respondent burden, and survey questions were straightforward and objective. In the future, it will be important to see if the trends observed in this paper continue. It is unclear if the interest in critical care among EPs would increase even
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more if there was a pathway to certification, but if this were to happen, we now have a baseline from which to compare future data. CONCLUSIONS Emergency physicians who complete critical care medicine fellowships currently work in a wide range of clinical practices. Half practice both EM and critical care medicine, and most practice in academic institutions. This is the first effort to attempt to quantify how many dual-trained EM-critical care medicine physicians exist, and it gives a baseline on which to compare the future growth of the specialty. The authors acknowledge Douglas Dompkowski, Department of Emergency Medicine, Virginia Commonwealth University.
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