Combined Training FAQs

Welcome to the frequently asked questions page for combined residency training. Here you will find an overview of several of the combined training paths, as well as some general information regarding the application process. Understand that these paths are all quite unique and, that for specific questions, it will often be more helpful to reach out to a representative of that specific program for specific details. This information is more to give a general idea of where to start and get a sense of each program. Make sure to come to the virtual residency fair and ask plenty of questions to get a good vibe!

Application process

Strong combined applicants are generally those who also tend to be strong applicants for categorical programs. True interest in both specialties, eagerness to learn, and teachability are important. It is very important that you consider which path will best help you achieve your career goals. While plans change, having an idea of what you hope to do with your training will help both you and the programs you are applying to evaluate where you will have the best fit. All programs use ERAS, and most interview days will include the opportunity to meet the faculty from both halves of your training and get a taste of what residency at each location will look like. Below are some helpful do’s and don’ts:

Do’s

• Do reach out to someone who has been through one of these residencies to get their perspective.
• Do try to rotate at a location that has the combined program you are interested in, if possible.
• Do make sure to have an idea of where you want to take a career following combined training (this is important when considering where to train, as well).
• Do ask plenty of questions, as these programs are not as standardized as many categorical programs.
• Do find a program you love and go for it!

Don’ts

• Don’t only apply to combined programs. Usually, applicants apply to the combined programs of their choice and also to one or the other of their categorical programs, as well, to ensure that they have enough opportunities to interview and successfully match.
• Don’t choose a combined program simply because you can’t decide between the two. An extra one-two years of training is a serious commitment and should be made with a goal in mind. This can certainly evolve over time, but keeping your eyes on the prize will make the years go by much more smoothly.
• Don’t sell yourself short. We love unique individuals in combined training, so be yourself in interviews, and everything will go well!

Required letters

While all applications are reviewed, it is recommended that at least one letter is an emergency medicine (EM) SLOE, and a second letter is in the combined specialty (whether internal medicine (IM), family medicine (FM), pediatrics (Peds), aerospace medicine, or anesthesia). Many programs often will prefer an away EM rotation; however, please refer to individual programs when seeking direction in applications requirements. This is an area of ongoing coordination between programs.

Residency schedules

Schedules will vary based on type of combined residency and specific locations. EM/IM programs are required by the ACGME to switch specialties every three-six months. It is more important than for categorical programs to go to each combined program’s website to see how their curriculum is structured. These are very different between programs and reflect the strengths and style of each program.

Work-life balance for a long residency

Fundamental in the pursuit of residency is the importance of maintaining one’s own health and wellness.  To that end, the selection of a site at which to train will need to include an investigation of the resources and support offered to help with that maintenance. For many medical students transitioning into residency, this is a period of their lives where advancements in the personal and growth spaces are accelerating. The notion that one should put that growth on hold to shoulder the burden of residency is a fallacy unto itself and should be put to rest. Take the time to examine programs from all angles, with a mind toward how they present their priorities for resident wellness. The transition from medical school to residency is a challenge within itself and the transition out of residency to fellowship or clinical work is absolutely no easier an endeavor. Make sure that the program offers room for you to evolve as a person as well as a physician. Part of the training should include development of strategies to preserve a sense of self, independent from the identity of physician. The longer the residency, the greater the imperative to learn those strategies, as they will fundamentally serve the physician across all stages of their career. 

International students/applicants

Due to sponsorship requirements, this will be very residency dependent. Please reach out individually to each residency program.

Information Regarding Specific Tracks 

Overview of EM/IM

The American Boards of Emergency Medicine and Internal Medicine (ABEM & ABIM respectively) approved the concept of combined EM/IM training in 1989. Currently, there are twelve EM/IM programs in the country. Each of these programs has a five-year curriculum, through which residents become eligible for board certification in both EM and IM. Additionally, seven EM/IM programs offer an optional EM/IM/critical care medicine (CCM) training. This adds one year to the training (six years total) and board eligibility in CCM on completion.

Although about half of dual training graduates are working primarily in an emergency department (ED), more than one-third of recent EM/IM graduates practice both in EM and IM and more than two-thirds practice in an academic setting. About 10% work in IM or a medical subspecialty only and about one out of four graduates has pursued formal fellowship training after residency. 

Benefits

Dually trained EM/IM residents are able to confidently face acute illness and injury as well as chronic disease in the ED, the intensive care unit (ICU), on the wards, and in the clinic. EM/IM residents have the unique opportunity to integrate the knowledge base and skill sets of both specialties into their daily practice. Many “combined” residents feel that their IM exposure helps them to better understand the pathophysiology of medical patients seen in the ED. EM/IM physicians can confidently manage emergency situations in IM settings and are able to take care of the minor surgical problems of their patients as they would in an acute setting like the ED. 

CCM is a popular field for EM/IM physicians and is the most common IM fellowship pursued by EM/IM residents. The high acuity care provided in the ED and ICU is complementary, and a career working in both settings can provide many challenges and rewards. Additionally, EM/IM trained physicians with board certification in both IM and EM are ideal candidates for leadership roles in the growing field of observation medicine, where efficiency and continuity of care must be balanced.

Dually trained physicians are uniquely equipped to be systemic problem solvers and leaders in managing administrative issues, because they have trained in almost every hospital setting and have worked with nearly every specialty. Dual board certification allows graduates to understand the needs of various service lines and instills a commitment to seeing various perspectives invaluable in administration. Additionally, collaborating with residents in different programs and learning how to share the knowledge of both specialties are important experiences which help one to become a successful educator and mediator.

Dually trained physicians are also well suited for work in international or rural medicine. In areas with few resources, the ability to manage both acute and chronic problems is essential. The adaptive and innovative skills enhanced by five-years of combined training are particularly useful in the often difficult or make-shift conditions faced in rural, international, and disaster medicine. 

Applicants

Applicants to combined EM/IM residency training programs, like categorical EM applicants, are often some of the best in their class. EM/IM applicants often have a diverse and distinct personal background with a wide variety of experiences. Many of them express a great interest in academic careers, in international health, or research opportunities. Others are interested in combining work in the ED with work as a hospitalist or in pursuing subspecialty training in fields such as critical care medicine. Whatever their career aspirations or personal background, applicants to EM/IM programs should certainly love both EM and IM and be willing to spend five years training in both. Applicants should be prepared for a demanding five-year training program that integrates the large volume of knowledge and skills required of both specialties. Additionally, applicants should have a vision for incorporating both components of dual training into their career. Dual training is probably not the best choice for applicants who simply cannot decide between EM and IM training or who only see themselves practicing in one field in the future.

How can I learn more?

A fourth-year rotation at an institution with an EM/IM program is highly recommended. Such a rotation provides the opportunity to interact directly with EM/IM residents. This first-hand experience can lend credibility to your EM/IM residency application and personal statement. Additionally, it enables both the applicant and the program leadership to see if there is a good fit.

We would encourage students who are interested in this path, but do not have easy access to a guide, to reach out to the American College of Emergency Physicians Dual Training Section to get their questions answered and to develop a sense for what opportunities exist in this area.

Programs

• Christiana Care
• East Carolina University
• Hennepin Healthcare
• Henry Ford Health
• Jefferson Health Northeast
• Long Island Jewish Health/Northwell
• Louisiana State University
• State University of New York (SUNY) Downstate
• The Ohio State University
• University of Illinois: Chicago
• University of Maryland
• Virginia Commonwealth University

Overview of EM/IM/CCM

In September of 1999, both ABEM and ABIM approved a six-year integrated curriculum in EM, IM, and CCM (EM/IM/CCM). The primary goal of this integrated curriculum is to prepare physicians for practice and academic careers addressing the spectrum of critical illness from entry into the hospital until discharge. At the completion of training, residents are eligible for board certification in all three specialties.

Programs

• East Carolina University
• Hennepin Healthcare
• Henry Ford Health
• Jefferson Health Northeast
• Long Island Jewish Health/Northwell
• State University of New York (SUNY) Downstate
• University of Maryland

This program is ideal for prospective residents who have a strong desire to pursue CCM and want to integrate EM training into their path. This may include those who desire to start or work in an ED ICU or walk between the worlds of ED and critical care. See above for the links to the respective programs that offer this option.

Overview of EM/FM

EM/FM provides the opportunity to emphasize continuity of care and understand the life of a patient as completely as possible. EM/FM graduates have the potential to be truly outstanding primary physicians, work in rural medicine, or move into academia and bring their unique perspective to the wards and ED. Training with EM and FM allows a resident to have a full spectrum approach to clinical care. Not only do you provide critical care medicine to the sickest patients, but you continue to follow and manage their chronic issues in the clinic. With this combination of training, residents rise to the challenge for patient care and hospital leadership. This translates to a large breadth of employment opportunities for future attendings since they have valuable training, which extends to multiple areas of a health system.

Programs

• Christiana Care
• Jefferson Health Northeast
• Louisiana State University

Overview of EM/Peds

EM/Peds training looks to provide comprehensive training in the emergency evaluation of patients of all ages, with a special focus on the illness of illnesses in children spanning emergency, preventative and chronic issues. Video of overview of EM/Peds https://vimeo.com/731598911 or https://www.emra.org/be-involved/committees/pediatric-em-committee/#_

Programs

• Arizona
• Indiana University
• Louisiana State University
• University of Maryland

Overview of EM/Anesthesiology

Joint anesthesiology and EM training offers an exclusive opportunity for trainees to obtain dual board certification in two highly complementary fields, with high-yield training in procedural skills and critical care management. When merged together, they offer trainees the ability to practice in any setting, from the ED to the operating room (OR) to the ICU, with the ability to work across departments and encourage interprofessional education and collaboration, as well as scholarly work. EM-Anesthesiology graduates represent an exceptional commodity as dual- or triple-boarded physicians in either an academic or community setting, and they bring a broad skill set to rural or low-resource settings.

Programs

• John Hopkins Medicine

Overview of EM/Aerospace Medicine

A new training program starting in 2024. This program aims to meld the skills of EM with those required for practicing in extreme environments including hyper/hypobaric, high g injuries, radiation exposure, and more. This is ideal for those medical students interested in pursuing a career with NASA or anywhere else in the aerospace industry.

Programs

• University of Texas Medical Branch

Other questions? Please feel free to reach out to us!