Internal Medicine / Emergency Medicine / Critical Care Medicine Policies
The American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM) offer triple Certification for candidates who complete a six-year (72-month) integrated, coherent program of combined training in internal medicine, emergency medicine and critical care medicine approved by both boards.
Upon successful completion and verification of the first five years of this program, candidates may apply to take the Certification examinations in internal medicine and emergency medicine. To meet eligibility for Certification in critical care medicine, the candidate must:
- Have satisfactorily completed the six-year combined program
- Be certified by ABIM
- Have met the Certification requirements of ABEM
Guidelines
In September 1999, the American Boards of Internal Medicine and Emergency Medicine announced that they would offer triple Certification for candidates (eligible for Certification by each Board) who have completed at least six years of accredited training in internal medicine, emergency medicine and critical care medicine. These guidelines are applicable to residents who entered training in July 1999 and after.
Objectives
The objectives of the combined residency training in internal medicine / emergency medicine / critical care medicine (IM/EM/CCM) include the training of physicians for practice or academic careers addressing the spectrum of illness and injury from entry into the hospital until discharge. Graduates of a combined residency would likely function as hospital-based acute care specialists in practice or academic environments.
Combined training includes components of categorical internal medicine (IM) and critical care medicine (CCM) residencies (either free-standing CCM programs or the CCM component of Pulmonary/CCM residencies) which are accredited by the Residency Review Committee for Internal Medicine (RRC-IM), and components of categorical emergency medicine residencies which are accredited by the Residency Review Committee for Emergency Medicine (RRC-EM). Both RRCs function under the auspices of the Accreditation Council for Graduate Medical Education (ACGME).
General Requirements
Combined IM/EM/CCM residency training consists of six years of integrated, coherent training in the three disciplines which meet the program requirements for accreditation by the RRC-IM for Internal Medicine and Critical Care Medicine and the RRC-EM for Emergency Medicine. While combined programs will not be independently accredited, their accreditation status is determined by that of the parent residencies. The Boards will not accept training in a newly established combined program if the accreditation status of the residency in any discipline is probationary. If the residency in any discipline receives probationary accreditation after initiation of the combined training, new residents should not be appointed to the combined training.
The participating residencies must operate under the same academic health center's graduate medical education committee. Documentation of hospital and university commitment to the program, where applicable, must be available in signed agreements. Such agreements must include institutional goals for the combined training. Participating institutions must be located close enough to facilitate cohesion among the house staff, attendance at weekly continuity clinics and integrated conferences, and faculty interaction over curriculum, evaluation, administration and related matters.
Ideally, at least two residents should be enrolled in each year of the six-year training to ensure peer interaction. The total number of residents in combined training should not exceed the number of residents in the categorical training of either specialty.
At the conclusion of 72 months of combined training in internal medicine, emergency medicine and critical care medicine, the residents must have had experience and instruction in the prevention and detection of disease; the emergent, acute, critical care and chronic treatment of disease; rehabilitation of illness; the socioeconomics of illness; the ethical care of patients; the team approach to the provision of medical care; and the administration of both an emergency department and a critical care unit.
The training of residents while on internal medicine rotations is the responsibility of the internal medicine faculty, the training of residents while on emergency medicine rotations is the responsibility of the emergency medicine faculty, and the training of residents while on critical care medicine rotations is the responsibility of the critical care medicine faculty. Prior to the completion of training, each resident must demonstrate some form of acceptable scholarly activity. Scholarly activity may include original research, comprehensive case reports, or review of assigned clinical and research topics. Any of the critical care medicine research requirement completed by the end of R-6 may fulfill this requirements of scholarly activity.
Vacations, sick leave and leave for meetings must be shared equally by the training programs. Absences from the training program (vacation, maternity or family leave, sick leave) exceeding six months in the 72 months must be made up.
Except for the following provisions, combined training must conform to the program requirements for accreditation of residencies in internal medicine, emergency medicine and critical care medicine.
The Resident
Residents should enter combined training at the R-1 level. Resident transfers must have the prospective approval of both boards. Previous training must have been satisfactorily completed and verified by the program's director.
- Residents whose first year of training was completed in an ACGME-accredited categorical EM or IM program may enter combined training at the R-2 level. (For purposes of evaluating residents transferring from an EM program, the first year of EM 1-4 programs is identified as EMO and the final three years of training in all ACGME-accredited EM residency programs are identified as EM1-2-3. The EM 0 year does not qualify as the first year of training).
- Residents who are transferring from one approved IM/EM/CCM program to another approved IM/EM/CCM program may transfer at the R-2 level. Residents whose previous training was completed in an approved IM/EM combined program may enter the IM/EM/CCM program up to the beginning of the R-4 level.
- Residents who enter combined IM/EM/CCM training as an R-2, R-3 or R-4 must be offered and complete a fully integrated curriculum. Transitional year training will provide no credit toward the combined training requirements of either Board.
- Residents transferring from combined training to a categorical internal medicine or emergency medicine program must have prospective approval from the receiving Board.
Training in each discipline must incorporate progressive responsibility. At least six months supervisory responsibility in internal medicine and six months in emergency medicine must be provided to each resident. The supervisory training may be distributed over the R-2 through R-5 years.
The Training Director(s)
The combined training must be coordinated by a designated director who can devote substantial time and effort to the education of combined training residents. The director may be appointed from internal medicine emergency medicine or critical care medicine. An associate director from the other two disciplines must be named to ensure both integration of the training and supervision from each discipline. An exception would be a single director who is certified in all three disciplines and has an academic appointment in each discipline. The director and associate directors must embrace similar values and goals for combined training.
The supervising directors from the three specialties will constitute a coordinating committee. They must document meetings with each other and the leadership of their respective departments at least twice a year to provide oversight to the program and to monitor the success and progress of the program and of each resident.
Length of Training
The training requirements for admission to the certifying examination of all three disciplines will be fulfilled after 72 months of combined training. This shortening of training, from that required for completion of three separate training programs, is possible due to the coherent, planned overlap of training requirements. The 36-month internal medicine training requirement is met by: (a) 27 months of IM training (b) six months obtained during EM supervised training (c) three months obtained during CCM supervised training. Likewise, the 36-month emergency medicine training requirement is met by: (a) 27 months of EM training (b) six months obtained during IM supervised training (c) three months obtained during CCM supervised training. Finally, the 24-month CCM training requirement is met by: (a) 18 months of CCM training (b) 3 months obtained during IM supervised training (c) three months obtained during EM supervised training.
Core Curriculum Requirements
A clearly described written curriculum for combined training must be available to residents, faculty and both RRCs. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations among the three specialties. Duplication of clinical experiences among the three specialties should be avoided. Periodic review of the program curriculum must be performed. This review must include the training directors from all three departments, as well as faculty and residents.
During the first year of training, to provide an initial acculturation to both Emergency Medicine and Internal Medicine, a minimum of five months of training should be spent under the direction of each specialty. Joint educational conferences involving residents from all three disciplines should be planned. The joint conferences should specifically include the participation of all residents in combined training.
Requirements for Internal Medicine
Each resident must obtain 27 months of training under the direction of the Internal Medicine program. Twenty months must include experience with direct responsibility for patients with illnesses in the domain of internal medicine, including geriatric medicine. Each resident must be assigned a minimum of 12 months of inpatient clinical experiences on general internal medicine or subspecialty internal medicine rotations.
At least 33 percent of the 30 months in internal medicine must involve ambulatory experiences. The ambulatory experience for each resident must include a block experience(s) without other responsibilities for at least two months. Other ambulatory experience may include work in subspecialty clinics or walk-in clinics, and brief rotations for appropriate interdisciplinary experience in areas such as dermatology, office gynecology and psychiatry. Residents are to be encouraged to follow their outpatients during the course of the patient's hospitalizations. The resident need not be scheduled in the continuity-care clinic during some emergency department and intensive care unit rotations; however, in any one year the continuity clinic should not be interrupted by more than one consecutive month excluding vacation. Health maintenance, prevention and rehabilitation should be emphasized. Residents should work in the clinics with other professionals such as social workers, nurse practitioners, physician assistants, behavioral scientists and dietitians.
The emergency medicine and critical care medicine requirements of the internal medicine training are met by rotations occurring during years one through five under the supervision of emergency medicine.
Experience with the care of patients managed by the subspecialties of internal medicine must be provided to every resident for at least four months. Some of this must include experience as a consultant. Significant exposure to inpatient cardiology, exclusive of a coronary care unit assignment, is necessary.
Residents must regularly attend morning report, medical grand rounds, work rounds, and mortality and morbidity conferences when on internal medicine rotations.
Requirements for Emergency Medicine
Unless otherwise specified, all of the ACGME Program Requirements for accredited training in Emergency Medicine must be met during combined training.
Twenty-seven months of training must be provided under the direction of Emergency Medicine faculty and must include at least 15 months of emergency department experience. The emergency department experience must provide the resident the opportunity to manage an adequate number of patients of all ages and both sexes with a wide variety of clinical problems. At least three percent of emergency department patients must present with critical illness or injury.
The requirement of at least two months of inpatient critical care rotations (during which the residents should have decision-making experience that allows them to develop the skills and judgment necessary to manage critically ill and injured patients who present to the emergency department) may be met by critical care medicine rotations occurring during years one through five under the supervision of critical care medicine.
Pediatric experience should include four months of full-time equivalent experience dedicated to the care of infants and children. Fifty percent of this time should be in an emergency setting. As this training should include the critical care of infants and children, the remaining 50 percent may be met by critical care medicine requirements by the end of the R-5 year.
Clinical experience in emergency medical systems management and major multiple trauma management must be provided.
Requirements for Critical Care Medicine
All of the ACGME Program Requirements for 24 months of accredited training in critical care medicine must be met during combined training. The critical care training must provide a balanced experience in a variety of critical care settings, and must be broad in scope. The critical care training must include a total of 14 months of direct responsibility in the care of critically ill patients. There must be three months of critical care training during the first four years of the combined program, one in year R-1 and two in years R-2, R-3 or R-4. Residents who are approved by ABEM and ABIM to enter the combined program at R-2, R-3, or R-4 level must have completed this requirement in their previous training or must complete these three months of critical care training by the end of their R-4 year.
There must be eleven months taken during R-5 and R-6 which provide critical care experience at a senior supervisory level consistent with fellowship training. In addition, there must be four months of protected time for critical care research experience in the program, preferably during R-5 or R-6, but it could be conducted throughout R-2, R-3, R-4, R-5, or R-6. CCM's training goal of assuming care for the monitoring of patients before and after admission to a critical care unit is achieved by giving CCM credit for three months on general medicine rotations supervised by IM and three months on emergency department rotations supervised by EM during years R-2 through R-5.
Evaluation
There must be adequate, ongoing evaluation of the knowledge, skills and performance of the residents. Entry evaluation assessment, interim testing and periodic reassessment, as well as other modalities of evaluation should be utilized. There must be a method of documenting the procedures that are performed by the residents. Such documentation must be maintained by the program, be available for review by the RRCs, ABEM, ABIM, and site visitors, and be used to provide documentation for future hospital privileges.
The faculty must provide a verbal and written evaluation of each resident after each rotation, and these must be available for review by the resident and site visitors. Written evaluation of each resident's knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semiannually and communicated to and discussed with the resident in a timely manner.
Residents should be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.
The training program must maintain a permanent record of evaluation for each resident and make it available to the resident and other authorized personnel. The training director of the IM, EM and CCM programs are responsible for the provision of a written final evaluation for each resident who completes the program. This evaluation must include a review of the resident's performance during the final period of training and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident's permanent record maintained by the institution.
Certification
To meet eligibility requirements for dual Certification in IM and EM, the resident must satisfactorily complete 60 months of combined training that fulfills the Boards' eligibility criteria and is verified by the program director of the IM and EM categorical programs. Lacking verification in one or both specialties, the resident must fulfill the categorical training requirements in either emergency medicine or internal medicine to meet the eligibility requirements in either specialty.
To meet eligibility for Certification in CCM, the resident must be: (1) certified in IM (2) satisfactorily complete 72 months of combined training and (3) be eligible for admission to the certifying examination in EM. Failure to meet these requirements, the candidate must complete 24 months of accredited CCM training, not including the months of CCM training taken during the incomplete IM/EM/CCM combined program.
TopPrograms
To add a program or to update program information, e-mail request@abim.org.
| State | Program |
|---|---|
| Maryland | University of Maryland Medical Center Michael E. Winters, MD (EM, IM) Nevins Todd, MD (IM, CCM, Pulmonary Medicine) Department of Medicine 110 South Paca Street Baltimore, MD 21201 410-328-8025 Fax 410-328-8028 |
| Michigan | Henry Ford Hospital Program Nikhil Goyal, MD 2799 West Grand Boulevard, CFP-258 Detroit, MI 48202-2689 (313) 916-1553 (313) 916-7437 (fax) jowensl@hfhs.org |
| New York | Long Island Jewish Medical Center Albert Einstein College of Medicine Barbara Barnett, MD (EM, IM) Alan Multz, MD (IM, CCM) 27005 76th Avenue New Hyde Park, NY 11040 718-470-7873 (telephone) 718-470-9113 (Fax) |
