It is a great time to be an emergency medicine resident interested in pursuing Critical Care Medicine fellowship training and subspecialty certification. For more than 30 years, there existed no straightforward pathway for emergency medicine graduates to obtain American Board of Medical Specialties (ABMS) Critical Care Medicine certification. Today, however, three pathways have been fully realized and are available to emergency medicine residency graduates. All share the requirement of an additional 24 months of training following emergency medicine residency graduation (whether the emergency medicine residency is three or four years in duration). To choose the most appropriate route to Critical Care Medicine certification, it’s important to know the current state of Critical Care Medicine fellowship training for emergency medicine residency graduates.

American Board of Internal Medicine (ABIM) Critical Care Medicine Fellowship

In September 2011 the ABMS approved the American Board of Emergency Medicine (ABEM) and ABIM application to co-sponsor subspecialty certification in Internal Medicine-Critical Care Medicine. The IM-CCM fellowship is 24 months, of which 12 months are explicitly defined by program requirements. The remainder can be elective clinical experience or scholarly activity.

For emergency medicine residency graduates to be eligible for this fellowship, they must have completed at least six months of direct patient care experience in Internal Medicine–type rotations (such as ward medicine or cardiology), three months of which must be in the medical intensive care unit (MICU).

Time spent in other intensive care environments, such as surgical, neonatal, or pediatric intensive care units do not count toward this requirement.

If emergency medicine residency graduates have not meet this “3/6” requirement described above, they can complete the necessary prerequisites during their first year of fellowship training.

However, while fulfilling these prerequisites, they are not permitted to supervise Internal Medicine residents. Once these requirements are met, they are then allowed to supervise any resident. The good news is that even if emergency medicine residency graduates did not meet any of the prerequisites, which is highly unlikely, they would still be able to graduate from the fellowship on time. One caveat to be cognizant of: a minimum of 75% of the fellows in the IM-CCM training program must be IM residency graduates.

Finally, the emergency medicine physician must be an ABEM diplomate meeting the requirements of ABEM’s Maintenance of Certification program when applying to take the IM-CCM certification examination.

The first IM-CCM certification examination that emergency medicine residency graduates could take was in November 2012. All 25 emergency medicine candidates passed the examination. Because this is a cosponsorship agreement, ABEM issues the subspecialty certificate.

A “grandfather” pathway does exist; this will be reviewed in a subsequent article.

American Board of Surgery (ABS) – Surgical Critical Care (SCC) Fellowship

In April 2012, the ABMS approved emergency medicine residency graduates to enter SCC fellowships. This is quite different from the cosponsorship relationship with ABIM. In this case, the ABS merely broadened the entrance criteria for SCC fellowships to include emergency medicine residency graduates.

The ABS will issue the subspecialty certificate. In this pathway, a residency graduate is required to complete a modified, advanced preliminary year at the same institution as the SCC fellowship. During the preliminary year, the residency graduate will be treated as a more senior surgery resident, gaining experience in managing recent postoperative patients and gaining advanced surgical clinical experiences.

Following completion of this advanced preliminary year, the graduate will immediately enter the 12-month SCC fellowship. Upon successful completion, the graduate is permitted to sit for the SCC certification examination. Again, the emergency medicine physician must be an ABEM diplomate meeting the requirements of the ABEM MOC program when applying to take this subspecialty examination.

Emergency medicine residency graduates can begin the modified, advanced preliminary year July 2013. There is no “grandfather” pathway available for SCC.

American Board of Anesthesiology (ABA) – Critical Care Medicine

The ABA and ABEM have agreed to cosponsor subspecialty certification in Anesthesiology Critical Care Medicine (ACCM). The ABMS Board of Directors unanimously approved this cosponsorship on June 26, 2013. According to the agreement, emergency medicine residency graduates must have at least four months of CCM experience (such as in a MICU or SICU) during their residency training prior to enrollment in the ACCM fellowship.

The graduate must then complete a total of 24 months of additional training. The first 12 months must be under the auspices of the ACCM Fellowship. During the first six months, there will be three rotations that have a focused surgical emphasis (such as acute care surgery or trauma surgery). The second 12 months will consist of the ACGME-accredited ACCM fellowship.

Of the total 24 months of experience, these must be 12 months aggregate exposure to surgical conditions. This includes time in the surgical critical care unit, surgical rotations (i.e., acute care surgery, etc.) or clinical rotations with a significant surgical component. Finally, there will be a minimum of nine months of CCM rotations.

The emergency medicine physician must be an ABEM diplomate meeting the requirements of the ABEM MOC program when applying to take the ACCM certification examination.

A “grandfather” pathway for ACCM does exist; this will be reviewed in a subsequent article.

Additional information regarding these various pathways can be found by going to the ABEM website at www.abem.org.

Dr. Counselman is an emergency physician at Norfolk General Hospital and Secretary-Treasurer of the American Board of Emergency Medicine.