Training & Education

Typically, the physician has completed an ACGME emergency medicine residency (either 3 or 4 years) and are board-eligible/certified in emergency medicine. The physician has then completed additional training (2 years) in critical care medicine (CCM) and is board-eligible/certified in critical care medicine. This CCM training can be completed through internal medicine, anesthesiology, or surgery.

Most EM/CCM physicians have broad based multidisciplinary CCM training (fellowship training time in medical and surgical based units) and can provide appropriate care for all intensive care unit (ICU) patients. Some EM/CCM physicians also have experience and training in neurocritical care and are board-eligible/certified in neurocritical care.

EM/CCM physicians are looking for opportunities that allow them in-patient ICU clinical time and emergency department (ED) clinical time. They work in both the academic and community settings and can be found working in all types of ICU settings: medical, surgical, mixed, multidisciplinary, subspecialty (neurocritical, cardiothoracic, transplant).

This varies considerably. About 1/3 of physicians want a 100% intensivist positions (with or without EM moonlighting additional), 1/3 want mostly critical care medicine with a smaller percentage of EM clinical time (example: 75%/25% split), and the remaining want work exclusively in an ED setting (with or without ED-based critical care practice).

Some EM/CCM physicians prefer critical care medicine and emergency medicine practices at the same health care system or hospital, while others are willing to practice at two different hospitals/health care systems.

Emergency medicine physicians can complete critical care medicine subspecialty fellowship training in critical care medicine (IM-CCM), anesthesia critical care medicine (ACCM), or surgical critical care (SCC).  Agreements and pathways for board certification through ABMS member boards have been in existence since 2011. EM physicians can also complete neurocritical care fellowship training that is board certified by the United Council for Neurologic Subspecialties.

• Hospital-based employers - major academic centers, community academic centers, community hospitals, managed health care systems.
• Private practice groups contracting with multiple hospitals or health care systems - multispecialty critical care medicine, pulmonary critical care medicine, surgical critical care medicine, and anesthesiology critical care medicine.
• Emergency medicine groups.

It usually depends on the employment group and the staffing model:

• Weeks of ICU coverage: days/nights/mixed models.
• Averaging around 14-18 shifts per month (usually for 1.0 CCM FTE) with a mixture of day, overnight, and swing shifts.
• Clinical shifts are often varied between day and night shifts.
• Schedules can vary for EM/CCM physicians who combine ICU and EM time (ie, week of ICU coverage followed by intermittent ED shifts)

Some groups have decided to follow hospitalist and EM groups that hire dedicated night-time intensivists, and a variety of staffing options are available to be considered.

Consideration of health and long-term wellbeing of shift-working needs to be considered when advising groups on staffing models, as most intensivist groups do not have the experience of EM shift-staffing models of compensation or schedule design.

EM/CCM physicians can be interested in both hospital-based and pre-hospital-based quality improvement, administrative leadership, and education/teaching opportunities.

Some EM/CCM physicians decide to focus on a disease entity (ex: cardiac arrest spanning presentation to long term outcome), or a process of care (ex: trauma regionalization), or clinical content delivery (ex: point of care ultrasound).

Other EM/CCM physicians dedicate their time to hospital-based or system-based committees or initiatives (ex: regionalization of critical care air transport or ED-based critical care delivery) for the purposes of quality improvement or clinical research.

EM/CCM physicians may focus on opportunities related to education and training of medical students, advanced practice providers (NP/PA), trainees (residents/ fellows), and faculty development.

EM/CCM physicians are generally flexible and interested in a wide variety of opportunities. They are often interested in being go-between physician liaisons between different specialties and departments. EM/CCM physicians naturally want to collaborate and improve care for a wide range of medical-surgical diseases and groups. They can serve as a great liaison between your ED and your ICU.

EM/CCM physicians are usually good communicators with specific expertise in patient hand-over and interactions with consultants.

EM/CCM physicians are usually good at multi-tasking and managing multiple sick patients concurrently. They also have expertise at triaging acute illness.

Emergency medicine (like critical care medicine) is a “team sport” with close interactions between physicians, nurses, respiratory therapists, patient care techs, etc., with the goal of providing excellent patient care. EM/CCM physicians are great at this role of team player/communicator.

EM/CCM physicians are accustomed to shift work including days, nights, weekends, holidays. Both the ED and the ICU need to be available to provide clinical care 24/7.

EM/CCM physicians usually have expertise in CCM ultrasound applications. They are also facile with all of the other typical Intensivist procedures: arterial and venous vascular access, airway management, bronchoscopy, cardioversion, lumbar puncture, para/thoracentesis, thoracotomy, etc.

EM/CCM physicians are usually well versed in medical charting/documentation, computerized medical records, and billing practices.

Many major academic centers serve as training centers for EM/CCM (with corresponding EM/CCM faculty). Training programs/curriculums exist at more than 50+ academic centers, including University of Pittsburgh, Washington University in St. Louis, Stanford, Emory, University of Washington, Shock-Trauma in Maryland, among others. Large health care managed systems, such as Kaiser and Intermountain Health, have also hired EM/CCM physicians.

In smaller community hospitals, bylaws which haven’t been updated for many years might not reflect the last decade of increased board certification pathways and practice opportunities for many specialties (anesthesiology critical care medicine, surgical critical care, EM/CCM). Review of specific wording of these bylaws or credentialing forms early in the hiring process is necessary to prevent unwanted delays. There might also be medical prejudices held by practicing physicians in health care systems.