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ABIM and ABEM approved the development of a proposal for the co-sponsorship of the ABIM subspecialty of Critical Care Medicine

The following summary has been endorsed by the American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM) and describes the background to the proposed ABEM co-sponsorship of the ABIM subspecialty of Critical Care Medicine (CCM).

Current Status:

ABIM and ABEM have approved the development of a proposal for the co-sponsorship of the ABIM subspecialty of Critical Care Medicine. This proposal is in the process of being developed by ABEM. When completed, the proposal will be reviewed by ABIM and ABEM, and if agreeable to both Boards, will be forwarded to ABMS for review and ultimate approval. Once approved by ABMS, the IM RRC has agreed to modify existing program requirements for critical care medicine fellowship to allow this training pathway to be completed in ACGME-accredited CCM programs.

Background:

On March 20, 2009, a multi-stakeholder group of thought leaders in internal medicine and emergency medicine met to continue discussions initially begun in 2006 and revisited in 2008 regarding the feasibility of this pathway.

ABIM representation on this taskforce included:

Sue Ravenscraft, MD, Chair, ABIM Subspecialty Board on Critical Care Medicine;
Gregory Kane, MD, Internal Medicine Program Director and Vice-Chairman Department of Medicine, Jefferson Medical College;
John Kellum, MD, Professor, Critical Care Medicine, University of Pittsburg;
Robert Kotloff, MD, Chair, ABIM Subspecialty Board on Pulmonary Disease; and
Eric Scher, MD, DIO and Vice President of Medical Education, Henry Ford Health System.

ABEM representation included:

Debra Perina, MD, Secretary-Treasurer, ABEM and Fellowship Director, EMS Fellowship, University of Virginia;
James Jones, MD, Indiana University School of Medicine;
Jo Ellen Linder, MD, Associate Professor, Department of Surgery, University of Maine;
Francis Counselman, MD, Program Director, Emergency Medicine Residency, Eastern Virginia Medical School;
Samuel Keim, MD, Residency Director, Emergency Medicine Residency, University of Arizona College of Medicine; and
Emanuel Rivers, MD, Vice Chairman and Director of Research, Department of Emergency Medicine, Henry Ford Hospital.

At the conclusion of this meeting:

The task force unanimously recommends that the American Board of Internal Medicine (ABIM) and American Board of Emergency Medicine (ABEM) submit a proposal to the American Board of Medical Specialties (ABMS) for ABEM co-sponsorship of ABIM Critical Care Medicine (CCM) subspecialty certification. The program would require three years of EM training and two years of CCM training.

Recommendation:

This recommendation was taken to the American Board of Internal Medicine Subspecialty Board on Critical Care Medicine. The following recommendation was offered:

The ABIM Subspecialty Board on Critical Care Medicine concurs with the above recommendation of the ABIM/ABEM task force on Critical Care Medicine, which we hereby submit to the ABIM Board of Directors for recommended approval. We unanimously endorse allowing ABEM diplomates who have successfully completed three years of training in an accredited EM program and two years of CCM training in an accredited IM/CCM program to enter the ABIM process leading to certification in Critical Care Medicine.

In June 2009 the Board of Directors (ABIM BOD) of the American Board of Internal Medicine (ABIM) approved the recommendation from the joint ABIM/ABEM task force and the ABIM Subspecialty Board on Critical Care Medicine to petition the American Board of Medical Specialties (ABMS) for ABEM co-sponsorship of the ABIM subspecialty of Critical Care Medicine. While the ABIM BOD was in full support of pursuing this co-sponsorship, ABIM requested the opportunity to review the proposal before the application is finalized and forwarded to ABMS.

In addition, ABEM representatives presented the proposal and suggested training requirements for EM residents applying for CCM fellowship to the ACGME IM RRC to insure that this potential training pathway complies with existing training regulations. The IM RRC has agreed to modify CCM program requirements to allow trainees in this pathway to complete training in ACGM accredited programs once the proposal is approved by ABMS.

In July 2009 the ABEM Board of Directors (ABEM BOD) approved the recommendation made by the ABIM/ABEM task force. It was agreed that ABEM would develop the application and that it would go to ABIM and the ABEM BOD for approval prior to sending it to ABMS.

ABEM Co-sponsorship of IM CCM Subspecialty Frequently Asked Questions:

ABIM and ABEM have anticipated that key stakeholders will have important questions about this proposed co-sponsorship. As a result, the following questions and answers have been developed:

  1. What is the purpose of creating this pathway for Critical Care Medicine (CCM) certification of diplomates of the American Board of Emergency Medicine (ABEM)?

    Emergency physicians are already being accepted and trained in CCM fellowships (such as in the University of Pittsburgh's program, which has trained emergency physicians since 1976) – but these trainees have no American Board of Medical Specialties (ABMS) CCM certification option available to them. The CCM training of emergency physicians is occurring already; offering a certification process to them would merely provide an indicator to the public and to the physicians themselves that certain standards are being met.

  2. Can a two-year CCM fellowship program accommodate the different training backgrounds of emergency physicians and internists?

    The ABEM/ABIM joint task force that negotiated the agreement between both boards came to the unanimous conclusion that this is a reasonable accommodation that can be made within the framework of a two-year CCM fellowship. As evidence, approximately 100 emergency physicians have already successfully completed accredited critical care fellowships (through programs such as the University of Pittsburgh's), and many have chosen to take (and have successfully passed) the exam offered by the European Society of Intensive Care Medicine. In addition, EM residents who choose to pursue CCM fellowships are a self-selecting group who has often chosen to focus their residency electives on aspects that may be helpful in CCM training. The task force believes that in some areas (such as procedures), EM residents would be better prepared for CCM than IM residents, and that two-year CCM fellowships provide enough flexibility to accommodate potential training deficiencies for EM residents (e.g., nutrition, rehabilitation and longitudinal care).

  3. Are there other differences in philosophy to care that need to be addressed? Particularly, does the different cognitive orientation to patient care inherent in emergency medicine versus internal medicine make it difficult for emergency physicians to train and practice in medical intensive care units?

    The task force discussed this issue at length and came to the conclusion that CCM blends the diagnostic paradigm of internal medicine with the therapeutic imperative of emergency medicine, so that IM-trained intensivists also need to adjust their orientation to be able to manage the melding of medical and surgical patients in the ICU. Surgery shares a therapeutic imperative with emergency medicine, and many IM-trained intensivists work in surgical ICUs. Intensivists need the full range of diagnostic/cognitive skills and therapeutic skills, so IM and EM residents both need somewhat of a philosophy shift in CCM. As further evidence, a task force member with experience with the Pittsburgh program noted that all the Pittsburgh CCM fellows emerge with the same knowledge, skills and philosophy to care; once they finish the program, it is impossible to differentiate which ones were EM-trained and which were IM-trained.

  4. What if a CCM fellowship program believes that it cannot reasonably accommodate emergency physicians' training differences?

    Each individual fellowship program will decide whether it wants to admit emergency physicians. Some CCM fellowship programs (notably, the program at the University of Pittsburgh) already accept emergency physicians. Even at Pittsburgh, only a select number of fellows are accepted into the program, from any specialty, and the judgment is made on the individual level whether the resident should be admitted to the program. No fellowship program will be required to accept emergency physicians.

  5. How can we ensure that emergency physicians receive the necessary CCM training to practice?

    Ultimately, it is the program director's responsibility to ensure that fellows (of any background) are adequately trained for practice. The task force noted that accommodations are already often required for IM-trained fellows in any subspecialty, due to the heterogeneity of IM residency training. In fellowship programs of all disciplines, accommodations typically are made on an individual level, not necessarily based on primary specialty. The burden rests on the program director to ensure that all trainees acquire proficiency in all necessary competencies.

  6. Would the CCM certification/MOC process for ABEM diplomates differ from the process for ABIM diplomates?

    No. ABEM diplomates would be participating in the same Critical Care Medicine certification/Maintenance of Certification process and would be held to the same standard as ABIM diplomates. Emergency physicians must be ABEM diplomates, complete accredited CCM training, and pass the same Critical Care Medicine examination administered to ABIM diplomates.

  7. Why does creating this pathway require that ABEM “co-sponsor” ABIM's Critical Care Medicine subspecialty?

    “Co-sponsorship” is the process established by the American Board of Medical Specialties (ABMS) for diplomates to be certified through a subspecialty developed by another Board. For example, ABIM is technically a “co-sponsor” of Adolescent Medicine, which is administered to ABIM diplomates by the American Board of Pediatrics. Likewise, ABEM co-sponsors Pediatric Emergency Medicine, which is administered to ABEM diplomates by the American Board of Pediatrics.

  8. Does this require approval from the American Board of Medical Specialties (ABMS)?

    Yes. If the leadership of ABIM and ABEM decide to move forward with this proposal, ABEM will need to develop a formal application for co-sponsorship to submit to ABMS for approval. This draft proposal will be reviewed and approved by both the ABIM and ABEM Boards of Directors before submission to ABMS.

  9. Who would issue the Critical Care Medicine certificate to ABEM diplomates: ABIM or ABEM?

    As with other co-sponsored subspecialties, ABEM would issue the Critical Care Medicine certificate to its diplomates, but the certificate would indicate that the standards are the same as those of ABIM. This is the model all ABMS Boards use when a subspecialty is co-sponsored.

  10. Would the composition of the ABIM Critical Care Medicine Subspecialty Board change if ABMS approves ABEM as a co-sponsor of Critical Care Medicine?

    Probably. ABIM would likely add one ABEM representative to the Subspecialty Board on Critical Care Medicine, as has been the case with other co-sponsored subspecialties. The task force, including the Chair and a member of the ABIM Subspecialty Board on Critical Care Medicine, believes that emergency medicine expertise would be a valuable perspective to add to the subspecialty board.

  11. If this proposal is approved, would EM residents be eligible for combined Pulmonary/Critical Care fellowships or certification?

    This proposal provides a pathway for certification in Critical Care Medicine only, not Pulmonary Disease. Only Pulmonary/Critical Care fellowships with an embedded Critical Care Medicine only track would be able to accept EM residents as fellows.

  12. How many ABEM diplomates are expected to participate in this program?

    ABEM estimates 20-25 EM fellows per year would pursue CCM certification if a pathway were developed. Surveys have indicated that the lack of an ABMS certification pathway has deterred some emergency physicians from pursuing critical care fellowships, so this estimate may be slightly higher but is still expected to be a small number.

  13. If the proposal is approved, would there be a “grandfathering” period for emergency physicians who have already completed Critical Care fellowships?

    Yes. ABIM and ABEM would work out the details of a “grandfathering” period, which would be specified in the formal application to ABMS. This would be similar to the “grandfather” pathway of other ABIM subspecialty certification programs, which is typically available as an option to physicians for only the first five years of a certification program. We expect that some of the approximately 100 emergency physicians in current practice in the United States who have completed accredited fellowship training in critical care would apply to take the CCM certifying examination. ABIM and ABEM would determine the eligibility criteria required and deadline for participation through this pathway (e.g., within five years after CCM certification is first offered to ABEM diplomates).