Forget Paris: Emergency Physicians Can Soon Sit for US Critical Care Boards

Abstract

Paris. Berlin. Barcelona. All lovely destinations for a vacation, a conference, maybe a honeymoon. But not necessarily for board certification examinations. For the past decade or so, a growing number of emergency physicians have sought and completed fellowships in critical care medicine (CCM). But the only way they can get board certification is through the European Society of Intensive Care; hence, the transatlantic testing jaunts. Change may be coming. The American Board of Emergency Medicine (ABEM) and the American Board of Internal Medicine (ABIM) have reached a framework agreement to allow internal medicine CCM fellowship-trained emergency physicians to take the American Board of Internal Medicine CCM boards. Some aspects—including grandfathering status—need to be worked out, according to Mark T. Steele, MD, president of the ABEM. The agreement must still be approved by American Board of Medical Specialties, which will take time. Nor does the internal medicine accord address the status of emergency physicians who complete critical care fellowships in surgery or anesthesiology, although some overtures have been made on their behalf as well. “There have been discussions intermittently over the years with both boards, but to date we don't have any firm agreement,” Dr. Steele said. Dr. Steele cited estimates that about 150 emergency physicians have finished or are now completing critical care fellowships, most in the last decade. To those melding emergency and critical care training and practice, it's welcome progress, said Dr. Julie Mayglothling, MD, Department of Emergency Medicine Department of Surgery, Division of Trauma/Critical Care Virginia Commonwealth University. Dr. Mayglothling, who took her own boards in Berlin, has documented the growth of the combined field. Dual certification wasn't on Dr. Mayglothling's radar until a trauma surgeon at Bellevue, where she was a resident, observed her affinity for trauma patients and encouraged her to look into a fellowship at the University of Maryland R. Adams Cowley Shock Trauma Center, one of the main training sites for emergency physicians pursuing critical care. She did just that and has managed to combine her 2 fields, splitting her time at Virginia Commonwealth University between the emergency department (ED) and the ICU—and developing a niche in academic medicine. The growing interest in the dual track corresponds with a deepening need. The Institute of Medicine and the Leapfrog group have both observed a shortage of intensivists and no shortage of patients needing intensive care. As far back as 2004, the Society for Critical Care Medicine and 3 other critical care societies included expanding subspecialty training to emergency physicians as one means of filling the gap. One goal now is to address the practical, as well as the political, aspects of certification while working with a consortium of fellowship directors to ensure that training is “uniform and standard” and evolving in ways that meets anticipated needs of hospitals—and patients, said Lillian L. Emlet, MD, MS, chair of the Critical Care Medicine Section of the American College of Emergency Physicians, a practicing emergency medicine–CCM physician, and the program director of the EM-CCM Fellowship of the Multidisciplinary Critical Care Training Program at the University of Pittsburgh. That multidisciplinary program trains physicians from internal medicine, anesthesiology, surgery, and emergency medicine, and part of its underlying philosophy is to see critical care as a continuum, from out-of-hospital to the ED to the ICU. Emergency physicians with critical care training blend the fields in a variety of ways: full-time ED, full-time ICU, or a mix. Several of the physicians interviewed said one reason they were drawn to critical medicine was the chance to provide care that was less episodic than in the ED, caring for the patient for a few days, not a few hours. Some said they just love taking care of the sickest of the sick. Right now, most of the emergency physicians who pursue critical care fellowships end up in academic medical centers; the US certification challenges still appear to be more of a stumbling block in community hospitals, Dr. Emlet and other physicians interviewed said. But in the coming years, as the certification issues get sorted out, these physicians may be even more in demand in smaller hospitals, which may find the “2-fers” physicians attractive, especially because they can cover both the ICU and the sickest ED patients. The fields are a natural fit. Emergency medicine residents learn a lot of the life-sustaining procedures that are the staple of ICU practice: resuscitation, intubation, central venous access, treating trauma victims, and managing hemodynamically unstable patients. Dually trained physicians can help improve coordination between the 2 departments. Upstairs, meet downstairs. And vice versa. Ruth Lamm, MD, who teaches emergency medicine at Emory and splits her time between emergency and critical medicine at 3 Atlanta hospitals (Grady, Emory, and Emory Midtown), sees how the 2 specialties enhance each other in her own practice. In the ICU, she draws on her ED expertise, particularly the ability to make rapid and efficient decisions, even before all the tests and scans are completed, or when there is no time to consult a legion of specialist colleagues. In the ED, she brings the deeper understanding of really sick patients she honed in her time in the ICU. “In the ICU, I've learned more about physiology. We see low blood pressure a lot in the ICU, and we try to figure it out. You learn a little more about the processes and the medications and why I like this one [medication] over that one. It made me a better doctor for patients who are really sick. And it gave me some insight into the patients who have had surgery, and who were discharged, and who then came to the ED with surgical complaints.” Yet Dr. Lamm doesn't have that certification, that piece of paper, and because she completed an anesthesiology critical care fellowship, the internal medicine agreement may not change that. Will it make a difference to her career? So far it hasn't, but she's leaning toward sitting for the European boards once she's clocked the requisite postfellowship experience. At the University of New Mexico Health Sciences Center, Jonathan L. Marinaro, MD, said the lack of a US certification was a large obstacle both for himself and for critical care more broadly at his hospital. He managed to win over some of the skeptics; he's now the section chief of surgical critical care and codirector of the Trauma Surgical ICU in the state's only Level I trauma center. He's doing what he wants: taking his emergency medicine background and applying it to full-time surgical, neurosurgical, and trauma critical care. He doesn't miss the ED; his heart wasn't in the primary care aspects of the ED. “I like taking care of really sick people and I wanted to do that full time.” Dr. Marinaro completed his boards in Europe, with trips to Cambridge and Barcelona (oral and written sections). And it does bother him, knowing that the lack of US board certification is a hindrance. “We're thought of as a fringe area. Although we're growing, we are still somewhat held back from certain positions and we have to fight substantially more for acceptance.” He believes the hassles and prejudices deter other emergency medicine residents from entering critical care, even though the field is “sorely short of qualified physicians.” Despite the ongoing difficulties, he has made strides in opening doors at his own hospital. He's brought 3 other physicians with emergency backgrounds and critical care fellowships to UNM and encouraged 4 emergency medicine residents to pursue critical care fellowships. He sees how the combined skills enrich patient care, creating a more seamless continuum for the critically ill and injured no matter whether they are in an ambulance, an ED, or an ICU. That nexus—critical care in an emergency setting—has been the heart of Scott Weingart's career. Dr. Weingart, MD, RDMS, loves both specialties, but his focus has been to entwine them in a crowded urban ED, where he often finds himself taking care of patients who, in an ideal world and less crowded hospital, would move far more swiftly to the ICU. Dr. Weingart knew early on that he wanted to practice critical care; he chose emergency medicine because he thought it would give him the best foundation. After residency at the Mount Sinai School of Medicine, he, too, found his way to the Shock Trauma Center in Baltimore for a fellowship. Now he's the director of ED Critical Care at the Mount Sinai School of Medicine and an attending physician at the Mt. Sinai–affiliated Elmhurst Medical Center in Queens. “With the current shortage of ICU beds in almost every hospital I come across, patients are spending 8 or 10 or 24 hours in the ED before going upstairs. On the West Coast, sometimes it's 2 days,” Dr. Weingart said. His mission: “No barriers to getting identical care downstairs instead of upstairs.” In his ED, he has 7 designated critical beds and the same respirators and monitors that patients would have upstairs. And he created protocols so that all the attending emergency physicians can treat these patients confidently and competently. “When I'm there, I'm doing ED intensive care. When I'm not there, my ED attending colleagues are there. There's no barrier for them to provide the same level of care as long as all the pieces are in place, and we've sat down and talked about the ways things are done,” he said. Dr. Weingart also received European certification, but he strikes an ambivalent note about whether a US certification would really mean that much. “If there's a piece of paper, I'm going to go for it. That's what we do: we collect pieces of paper.” But the controversy is “of only theoretical concern to most of us.” He has the job he wants now, and like his other dual-trained colleagues, he sees growing acceptance of emergency physicians in critical medicine, upstairs or down. The obstacles to certification were initially a disincentive for Evie Marcolini, MD, Emergency Medicine and Critical Care at Yale University School of Medicine. While Dr. Marcolini was completing her emergency residency in Portland, ME, the chief of surgery noticed her aptitude for critical care and helped her spend an “away” rotation at shock trauma. She wasn't initially inclined to pursue another year of training as a fellow without a certification glide path. But Dr. Marcolini defines obstacles differently than most people; she's a wilderness medicine specialist, a mountaineer, ice climber, and former firefighter. She finished the fellowship and now juggles several roles at Yale, half of the time in the ED and half split between surgical and neurocritical ICUs. In the ED, her critical care experience subtly shapes the care she gives. For instance, she is more likely to push hard for propofol for certain patients needing a neurologic evaluation or to follow ICU protocols when inserting a central line. She has gained what she calls “fluency” ordering ventilator treatment for patients or weaning them off ventilator treatment and thinks about whether a septic, comatose 95-year-old nursing home resident beginning to receive ventilator treatment will ever be weaned from it. “I'm likely to say, ‘Somebody, call the family. What would she want?'” She's gotten better at knowing which patients can be “turned around” in the ED and then admitted to a regular floor and which will in fact need the full-court press of the ICU. Dr. Marcolini still thinks about the boards, but it hasn't been an impediment so far; “My attendings, when I was a resident, would ask, ‘Why would you pursue a fellowship in something that you can’t get a board certification in, you can't use it?' That's a valid question in some respects. But I really wanted to do it. All I needed was someone to say, ‘You‘ll never regret it.'” She's had no problem in finding a job. And no regrets. How much an individual physician really needs or wants the certification varies widely, said Dr. Mayglothling, who has surveyed and tracked her emergency medicine–CCM colleagues. Sometimes the physicians want that piece of paper, either for a specific job or just because they want the personal satisfaction. Sometimes the hospital demands it. Dr. Mayglothling has found through her survey that half of those who completed fellowship did take the European boards; it's probably safe to assume even more would take recognized US ones. ABEM president Dr. Steele believes more young emergency physicians will explore the intersection of emergency and critical medicine once the certification challenges are resolved. In the meantime, they'll always have Paris.