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Emergency medicine and critical care

Despite the fact that emergency physicians specialize in identifying and caring for critically ill patients in the emergency department, they do not have access to certification in critical care medicine (CCM). For the benefit of patients, this should change. A few recent articles give me hope that it will.

Huang et. al., in an article published in both Annals of Emergency Medicine (46(3): 217-23) and Critical Care Medicine (33(9): 2104-9) lays out the argument. Recent studies have found that ICU patients do better (for less money) when they're cared for by a trained intensivist. The problem is that there are too few trained intensivists available. Internists, surgeons, anesthesiologists, and pediatricians, if they complete a CCM fellowship, are eligible to obtain certification in critical care, and have been for some time. But there is evidence that interest in CCM fellowships among residents in these specialties is low. At the same time, there are many emergency medicine residents who are chomping at the bit to specialize in critical care and would pursue fellowship training if they had a reasonable expectation that they'd be able to practice in the ICU. Without the ability to obtain certification in CCM, their prospects for finding such opportunities are highly uncertain.

In an editorial published in the same issue of Annals, Dr. David T. Overton writes:

There seems to be little logical rationale to limit critical care fellowship training and board certification only to graduates of internal medicine, anesthesia, general surgery, and pediatric residencies. Unlike some other subspecialties, critical care medicine has always been a multidisciplinary field. Indeed, critical care medicine has as much or more in common with emergency medicine as with these other specialties. As Huang et al point out, emergency medicine residency curricula are Residency Review Committee program requirements–mandated to include at least 2 months of critical care. In fact, they often contain considerably more (mine contains 6 months).

Drs. Somand and Zink point out in their article in Academic Emergency Medicine (12(9): 879-883) that turf wars over CCM between the new specialty of EM and other established specialties played a large part in the struggle to achieve primary board status for emergency medicine. Basically, the American Board of Internal Medicine agreed to support the American Board of Emergency Medicine's petition for primary board status only after ABEM had agreed not to pursue authorization to issue certification in critical care. The history of these turf wars are fascinating, but it reveals that there isn't much patient-care justification for excluding EM physicians from CCM certification.

As I read Somand and Zink's history, these turf wars arose because of the fear that emergency medicine physicians would start to horn in on in-hospital continuous care at the expense of internists. Well, now that we have several decades of experience with emergency medicine as a recognized specialty, I think we can put that fear to bed. EM residents go into EM because, among other things, they want to care for critically-ill patients in the ED. (If they wanted to do what most internists do, they'd have become internists.) The ICU is a quintessentially interdisciplinary place, so it's no surprise that some significant subset of EM residents would want to extend their practice to that arena. At a time when too few internists, surgeons, and anesthesiologists are specializing in ICU care, it's absurd not to welcome the emergency physicians aboard.


Carey, as an aside to this post, you might be interested in visiting www.carolinasmed-1.org. I work for this healthcare system, and we're proud of the capabilities of our trauma/critical care teams.

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