Question about getting a fellowship

[jacksparrow82]

Hi, I'm just trying to get an idea of how competitive the CC fellowships are in comparison to other IM specialties.
What does one need to do throughout residency to help them get a spot in a CC fellowship?
Thanks!

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[nilla_wafer]

Is an IM residency better than EM to get to CCM? (given that some programs accept EM grads into CCM).

 

[KGUNNER1]

Is an IM residency better than EM to get to CCM? (given that some programs accept EM grads into CCM).

Nilla,
With the current RRC and ACGME guidelines, the IM route is a much easier road to take. That doesn't mean you can't do EM/CCM. There are about 100 EM/CCM grads practicing EM, CCM, or both. We are seeing about 10 new EM/CCM fellows each year, so this number is growing.

Nilla, you basically have to ask yourself what you like better, IM or EM. You need to be the best resident you can be in either specialty if you want to excel in your cc fellowship.

Good luck,
Kyle

 

[rogerthat]

kgunner,
do you have any ideas on whether IM and EM will agree upon critical care training in the near future? I mean on a broad scale, with all fellowships being open to applicants from either background (not just a smattering of programs here and there that accept EM applicants)?

 

[KGUNNER1]

kgunner,
do you have any ideas on whether IM and EM will agree upon critical care training in the near future? I mean on a broad scale, with all fellowships being open to applicants from either background (not just a smattering of programs here and there that accept EM applicants)?

If you look back in history, ABIM and ABEM never played well together.

I think the climate is slowly changing. Some of the "old guard" is gradually leaving and we should have a productive dialogue soon addressing critical care. The EM side has laid some of the ground work (white paper published in CCM and Annals EM, recent EM/CCM workforce survey presented at SCCM).

I truly believe things will start changing in the next few years.

Stay tuned!!!
kg

 

[EMCC]

If you look back in history, ABIM and ABEM never played well together.

I think the climate is slowly changing. Some of the "old guard" is gradually leaving and we should have a productive dialogue soon addressing critical care. The EM side has laid some of the ground work (white paper published in CCM and Annals EM, recent EM/CCM workforce survey presented at SCCM).

I truly believe things will start changing in the next few years.

Stay tuned!!!
kg

I certainly hope so! I am starting the fellowship in July, and it would be great to be "grandfathered" in to critical care within a few years. Although, if you listen to the doom and gloom stock analysts, it may not be a bad idea to run off to Europe and set up a practice there...

I already have job offers to work here in the US, so even if people go the EM route to critical care (I am actually doing trauma and critical care), they shouldn't have a problem getting intensivist jobs...

 

[dd4w2000]

hi guys

There is trouble in europe at the moment with the job market and the market forces within the eeu.CC is still a great career but you need to select your destination with care

good luck

regards

dave

 

[BMW19]

Correct me if I'm wrong but to my knowledge Surgery, IM and Anesth were the only legal, "true" routes to critical care. Yes I know you can do trauma/CC thru EM but to LEGALLY work in an ICU and not just do "critical care stuff" in the ER you would have to do a fellowship in the above 3 specialties I mentioned. Have things changed?

BMW-

hi guys

There is trouble in europe at the moment with the job market and the market forces within the eeu.CC is still a great career but you need to select your destination with care

good luck

regards

dave

 

[EMCC]

Correct me if I'm wrong but to my knowledge Surgery, IM and Anesth were the only legal, "true" routes to critical care. Yes I know you can do trauma/CC thru EM but to LEGALLY work in an ICU and not just do "critical care stuff" in the ER you would have to do a fellowship in the above 3 specialties I mentioned. Have things changed?

BMW-

Anyone can work in an ICU--many "rural" places have primary care doctors taking care of their own patients in ICUs. There is no "legal" standard to work in an ICU.

Whilst it is true that the ONLY ways to board certification in Critical care is through the three you mentioned, there is a movement underfoot to get ER docs back to the unit. [Quick history lesson:] When EM formed as a specialty, it was as EM/Critical care. In order to be recognized as a full specialty (with certification), however, IM demanded that EM docs not be allowed to admit their own patients to the hospital. The big fear was that EM docs would take business away from IM docs... Thus, EM agreed to give up admitting priveledges in order to get recognized as a specialty.

There is a huge shortage of critical care docs in this country. That is why the move for EM to work as ICU docs (or watch critical patients in the ED while boarded) is occuring.

Do I know whether EM will be fully recognized in the US? No, and no one else does either. At the current time, however, EM docs can sit for the European boards and be certified as critical care doctors. The European boards are recognized by the US (read--you don't have to do a fellowship), and that is how EM/critical care docs are getting jobs as ICU docs...

Hopefully that helps clear things up.

 

[KGUNNER1]

The European boards are recognized by the US (read--you don't have to do a fellowship), and that is how EM/critical care docs are getting jobs as ICU docs...

Hopefully that helps clear things up.

I agree with what EMCC wrote except this last line. An EM grad cannot sit for the first part of the EDIC (European Diploma of Intensive Care) without at least 1 year of CC fellowship training. Part 1 is a written test. Part 2 of the EDIC is an oral exam and a bedside "exam" with a real ICU patient.

In order to sit for part 2, one has to pass part 1, AND either successfully complete a 2 year CC fellowship OR "practice" critical care medicine as their full time job.

http://www.esicm.org/Data/upload/images/file/EDIC guidelines 2008.pdf

So the only way get any formal recognition of critical care training, for EM only grads, is by doing a fellowship.

KG

 

[EMCC]

I agree with what EMCC wrote except this last line. An EM grad cannot sit for the first part of the EDIC (European Diploma of Intensive Care) without at least 1 year of CC fellowship training. Part 1 is a written test. Part 2 of the EDIC is an oral exam and a bedside "exam" with a real ICU patient.

In order to sit for part 2, one has to pass part 1, AND either successfully complete a 2 year CC fellowship OR "practice" critical care medicine as their full time job.

http://www.esicm.org/Data/upload/images/file/EDIC%20guidelines%202008.pdf

So the only way get any formal recognition of critical care training, for EM only grads, is by doing a fellowship.

KG

Sorry, i typed that in wrong. I meant to say that an EM grad does not have to redo a fellowship after getting boarded in Europe (after having done a fellowship in the US). My apologies for the confusion...

 

[BMW19]

Yes of course I did not mean to say that it was illegal for anyone to practice medicine in the ICU. I should not have phrased it that way. What I meant to say was to claim that you were a board certified intensivist. Thanks for clearing that up.

Anyone can work in an ICU--many "rural" places have primary care doctors taking care of their own patients in ICUs. There is no "legal" standard to work in an ICU.

Whilst it is true that the ONLY ways to board certification in Critical care is through the three you mentioned, there is a movement underfoot to get ER docs back to the unit. [Quick history lesson:] When EM formed as a specialty, it was as EM/Critical care. In order to be recognized as a full specialty (with certification), however, IM demanded that EM docs not be allowed to admit their own patients to the hospital. The big fear was that EM docs would take business away from IM docs... Thus, EM agreed to give up admitting priveledges in order to get recognized as a specialty.

There is a huge shortage of critical care docs in this country. That is why the move for EM to work as ICU docs (or watch critical patients in the ED while boarded) is occuring.

Do I know whether EM will be fully recognized in the US? No, and no one else does either. At the current time, however, EM docs can sit for the European boards and be certified as critical care doctors. The European boards are recognized by the US (read--you don't have to do a fellowship), and that is how EM/critical care docs are getting jobs as ICU docs...

Hopefully that helps clear things up.

 

[RxnMan]

I agree with what EMCC wrote except this last line. An EM grad cannot sit for the first part of the EDIC (European Diploma of Intensive Care) without at least 1 year of CC fellowship training. Part 1 is a written test. Part 2 of the EDIC is an oral exam and a bedside "exam" with a real ICU patient.

In order to sit for part 2, one has to pass part 1, AND either successfully complete a 2 year CC fellowship OR "practice" critical care medicine as their full time job.

http://www.esicm.org/Data/upload/images/file/EDIC guidelines 2008.pdf

So the only way get any formal recognition of critical care training, for EM only grads, is by doing a fellowship.

KG

This makes total sense to me with a 3 year EM residency + 2 year fellowship in CC. But what about if you did a 4 year EM residency + 1 year CC fellowship? Are you able to sit for the EDIC then? Or do you need to do 4 + 2 years?

 

[EMCC]

This makes total sense to me with a 3 year EM residency + 2 year fellowship in CC. But what about if you did a 4 year EM residency + 1 year CC fellowship? Are you able to sit for the EDIC then? Or do you need to do 4 + 2 years?

I am in a 3 year program and will then do a 1 year Trauma and Critical Care fellowship. Once I finish my training, I will go and sit for the EDIC... I know this is "kosher" because I will be the fourth year fellows from my hospital will be going to Europe for the boards... It doesn't matter whether you are in a 3 year or a 4 year program--as long as you do at least one year of fellowship.

 

[RxnMan]

I am in a 3 year program and will then do a 1 year Trauma and Critical Care fellowship. Once I finish my training, I will go and sit for the EDIC... I know this is "kosher" because I will be the fourth year fellows from my hospital will be going to Europe for the boards... It doesn't matter whether you are in a 3 year or a 4 year program--as long as you do at least one year of fellowship.

This actually confuses me more - I was under the impression that EM/CC took 5 years, one way or the other (3+2 or 4+1).

Also, I browsed the document KGUNNER posted, and it requires 24 months of acute care before you can do the oral exam (the 2nd part). How does this fit in with the 3+1 track? When you go to Europe, are you going to do EDIC part one, two, or both? You need both to be considered "board certified" in the States, correct?

 

[KGUNNER1]

This actually confuses me more - I was under the impression that EM/CC took 5 years, one way or the other (3+2 or 4+1).

Also, I browsed the document KGUNNER posted, and it requires 24 months of acute care before you can do the oral exam (the 2nd part). How does this fit in with the 3+1 track? When you go to Europe, are you going to do EDIC part one, two, or both? You need both to be considered "board certified" in the States, correct?

The oral part requires 24 months of acute care training (i.e. 2 year fellowship) or if you go the practice route (read the 2 asterisks) then this could mean 1 year fellowship + 1 year practice.

The written exam is given only once a year, and the oral is given only once a year. So you take the written one year, orals the next. Similar to EM.

The "board certified" stamp ONLY holds weight in those hospitals that will recognize this. Some won't, they'll only recognize ABMS certification.

There is no universal standard in the US as who can practice CC and what you have to do to become "boarded" or certified. This is the problem.

Yes, some grads are doing a 3 + 1 route, but I think this is becoming frowned upon more. Ultimately it will probably be a 3+2 route (maybe 4+1). I know a few academic places that will not hire a 3+1 EM/CC grad, but will consider a 3+2 or a 4+1.

This is what happens when there is no consensus and no ABMS recognized formal pathway for EM/CCM. We don't have to like it, it is what it is, pure politics. This is the game and if you want a chance at playing, then you need to follow the rules. Right now, several previous EM/CCM grads have excelled and have set a high bar, they have opened up many doors for future generations to have a chance at doing the same.

However, equity (real or perceived) will ultimately prevail, and ABMS will probably not stand for a shortened course of CCM training. Medicine, surgery, peds will not support the EM 4 yr plan to CC certification when each of their specialty requires 5-6 years.

Right now there are no "rules", only guidelines. If one does less, then be prepared to face some real challenges.

kg

 

[EMCC]

As KGunner puts it (or quoted best in Pirates), "...the code is more what you'd call "guidelines" than actual rules..."

True, I am only doing 4 years total (as opposed to 5). The main thrust (uh-oh) of the trauma and critical care fellowships is to prepare you to work in a SICU and/or Trauma.

If you read the most recent EM (and possibly trauma) lit, there seems to be a move to NOT have a trauma surgeon present at every trauma. Personally, I think this is where a fellowship trained EM doc comes in. My goal is to be part time EM and part time ICU (and trauma) work... Frees up the trauma surgeons to round on the floors/go to the OR; and allows me to take care of sick patients in the trauma bay/SICU.

Supposedly, some trauma foundations (can't remember all of them right now) are quite happy with 1 year trauma and critical care trained EM docs... So, while MICU jobs may be not as plentiful if and when RULES are finally setdown, I really do believe there will always be jobs in SICUs for 1 year fellows...

Does this mean I think my fellowship is better? No. I think it is accelerated and prepares you for yet a further niche within the vast world of critical care. Besides which, I am seriously considering yet further specialization in neurocritical care. My wife hates when I say that...

 

[KGUNNER1]

So, while MICU jobs may be not as plentiful if and when RULES are finally setdown, I really do believe there will always be jobs in SICUs for 1 year fellows...

EMCC, when (not if) the ABMS gets their act together and accepts EM as a legitimate pathway towards CC training and certification, the "boards" (or certification) will most likely NOT be unit specific (ie no separate pathway for trauma). You will be certified to practice critical care, period.

In order to open this avenue, all the specialties have to agree to this. I truly don't see the ABIM, ABS, and especially ABP (pediatrics) agreeing to certifying a 3+1 pathway. I may be wrong, but the impression I'm getting from their leadership right now does not support a 3+1 pathway.

Will this affect you or others that did a 3+1, I don't know, but I highly doubt it. The big programs will follow the pathway that the ABMS and RRC lay out. Shock Trauma and Pitt won't thumb their noses at these guys and allow a non-board eligible pathway exist in their program along side the acceptable routes.

Right now, all you have to do is go to a reputable program and fulfill the requirements for the EDIC. Then cross your fingers that the health system you want to practice in is open minded and progressive in their cc understanding.

kg

 

[RxnMan]

...My goal is to be part time EM and part time ICU (and trauma) work... Frees up the trauma surgeons to round on the floors/go to the OR; and allows me to take care of sick patients in the trauma bay/SICU...

This is the sort of practice I am thinking about - I'd get change of pace/approach between the two, and it's a combination that would make me an overall better clinician.

But I reserve all judgement until 4th year when I'll actually experience EM and ICU as a student!

...Right now, several previous EM/CCM grads have excelled and have set a high bar, they have opened up many doors for future generations to have a chance at doing the same...

I wonder who you could be talking about?

Seriously, thank you both for your answers. It gives me a lot to think about.

 

[docdaname]

Anyone have any advice as to whether its best to get to the critical care route via medicine or anesthesia? I want to work in a MICU or a mixed unit. Is there an advantage to doing one over the other?

 

[bulgethetwine]

The main thrust (uh-oh) of the trauma and critical care fellowships is to prepare you to work in a SICU and/or Trauma.

Disagree here. The main thrust of a "trauma critical care" fellowship (i.e. shock trauma, etc.) might be to work in a SICU and/or trauma, but there are several other critical care fellowships which are NOT restricted to just SICU.

Those critical care fellowships that are more evenly split between medical and surgical units can enable you to work in a mixed unit setting (or potentially in separate MICU and SICU settings in the same hospital) provided the hospital is willing to employ you as a non-boarded intensivist (due to the above mentioned inability of ER docs to get certified).

Also, I might add that I have a much more pessimistic view than the (by me) respected KGunner with regard to EM docs getting certified in CC. In the interest of fairness and a balanced opinion, I submit that the fact that the IOM report, despite recommending that intensivist credentialing be expanded to include EM, had absolutely NO tangible benefit in advancing the aim of EM docs getting credentialed/certified is a very poor prognostic sign. The general lack of political inertia to make it happen from the leaders in our specialty (save for a never ending round of meetings and teleconferences) and the protectionist nature of the other ICU credentialing bodies does not bode well for any real progress on this front for at least another decade.

But, that there are plenty of jobs is undeniable. Just that without the boards you will always be vulnerable to practice limitations and geographic restrictions.

Just my .02

 

[jacksparrow82]

Wow, this thread went off on a complete tangent. Not a single person paid any attention to the original post.

 

[Henle]

Wow, this thread went off on a complete tangent. Not a single person paid any attention to the original post.

here is your answer:

pure CCM = 2 years fellowship is not really competitive

pulm/ccm: more competitive, 3 years

reason: most jobs (>90 %) are advertised by pulm/ccm groups. it is not THAT easy to find a decent job in pure CCM in a desirable location or desirable/prestigious hospital if you have an IM background, despite many people repeating the mantra of "there are plenty of jobs in critical care". look at job postings in www.sccm.org, www.chestnet.org, www.nejm.org to see the picture for yourself.

 

[KGUNNER1]

here is your answer:

pure CCM = 2 years fellowship is not really competitive

pulm/ccm: more competitive, 3 years

reason: most jobs (>90 %) are advertised by pulm/ccm groups. it is not THAT easy to find a decent job in pure CCM in a desirable location or desirable/prestigious hospital if you have an IM background, despite many people repeating the mantra of "there are plenty of jobs in critical care". look at job postings in www.sccm.org, www.chestnet.org, www.nejm.org to see the picture for yourself.

I agree with most everything Henle has posted. I would have to say that most Pulm/CC and pure IM/CC are not really that competitive outside the traditionally "big" programs (Duke, etc...) in the whole scheme of things. Just go to this year's USMLE specialty match results.

Critical care as a whole is rather flat as a specialty.

The vast majority of jobs is pulm/cc because that is where the need is. Most pulm practices do both, and there are a lot of pulm practices. Almost all pure cc practices are hospital based (some are groups) and they tend not to advertise as much in journals or society websites henle quoted. So there is a little selection bias there.

I get about 10 offers a week in the mail and 60% are from pulm/ccm, 40% pure ccm.

I don't think the job market influences the competitiveness of the programs as much as their individual reputation.

kg

 

[jacksparrow82]

Thank you KGUNNER1 and Henle for your replies. That was exactly the kind of information I was curious about.