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• W4386585427 abstract "Combined EM-ICU programs will create higher demand, more job openings, and better salaries for emergency physiciansFigureEmergency medicine and critical care may have once seemed worlds apart, but they have become nearly indistinguishable over just the past few decades. Despite being several floors apart in nearly every hospital, even a physician should be forgiven for walking into an ED and thinking he stumbled into the ICU by mistake. Patients and pathologies managed in both departments are now intrinsically shared. Our research and technological developments are practically the same. We even perform the same bedside procedures and peruse the same journals. Physicians and nurses trained in emergency medicine are often called upon to provide ICU-level care for their critically ill and ICU-bound boarding patients, so much so that combined ED-ICU units are beginning to pop up across the country and more and more EM-trained residents are entering and graduating from intensive care fellowships. Because emergency medicine and critical care are separated more by geography than stark differences in training and medical knowledge, it means these two specialties should lock arms and take those final steps toward forming a more perfect union. How the convergence might take shape remains to be seen. Should emergency medicine continue to encourage a strong focus on ICU training for residents and make it easier for them to enter critical care fellowships? Peter Safar, MD, a leading figure of critical care, agreed with this idea quite early on. He praised the early bonds between his peers and the nascent American College of Emergency Physicians in his 1974 presidential address by emphasizing his goals “to remove traditional interdisciplinary boundaries” and foster “imaginative and flexible...career opportunities in [critical care medicine] for physicians.” Emergency medicine did not become a specialty until 1979, but Dr. Safar and others recognized that critical care and resuscitative medicine do not depend on geographic location but education, resources, and timely delivery of care. Countless advocates of an EM-CC merger have surfaced since that speech, such as EMCrit blogger and podcast host Scott Weingart, MD, who said the mission is “bringing upstairs care downstairs. That is bringing ICU care down to the ED where it needs to be.” Not a New Idea Emergency medicine residents have been able to sit for their critical care boards through the American Board of Internal Medicine since 2011. This pathway was expanded to include the American Board of Surgery the following year, the American Board of Anesthesiology in 2013, and the American Board of Psychiatry and Neurology in 2021. (J Am Coll Emerg Physicians Open. 2020;1[5]:1062; https://bit.ly/3Xk1czk.) This rapid, sequential acceptance of emergency physicians by four different specialties underscores the natural transition for EM residents to move upstairs to ICU fellowships. Approximately 517 emergency physicians are board certified in critical care (117 in anesthesiology-CC, 303 in internal medicine-CC, 40 in neurocritical care, and 57 in surgical CC), which accounts for 15.5 percent of fellowship-trained EM attendings and 1.25 percent of all 41,483 board-certified EM attendings practicing in the United States today. (American Board of Emergency Medicine Annual Report. 2021-2022; https://bit.ly/3vR50fT.) The latter number may seem small, but this represents 171 new EM-CC trained physicians since the previous year, roughly a 149 percent increase. Internal medicine-CC may soon overtake medical toxicology as the second most popular fellowship for emergency medicine subspecialty training. Additional changes should be considered to expand the options for EM residents considering a career in critical care. EM-trained applicants are not generally accepted to all established critical care fellowships, and often require an extended training period of two years as opposed to one for their surgical and anesthesia counterparts. There are currently five combined emergency, internal medicine, critical care medicine residency-fellowship programs (Northwell Health, Henry Ford Hospital, East Carolina University, Hennepin Healthcare, University of Maryland). (University of Maryland School of Medicine. 2022. https://bit.ly/3XfPdTC.) Unfortunately, this is just a fraction of the critical care programs, but hopefully this becomes more mainstream for those applying after EM residency or medical school. Combined programs should consider omitting the internal medicine component to create more dedicated five- or six-year EM-CC curricula with focus on emergent, critical, and resuscitative care. A New Generation The most critical step, however, would be the independent certification of critical care physicians through the American Board of Emergency Medicine. Rather than continue to rely solely on other specialties, ACEP, ABEM, and affiliated EM organizations should push dedicated EM-CC programs and accepting those physicians in ICUs. Emergency medicine residents spend an average of 16.4 weeks vs. 18.1 weeks in critical care rotations over three vs. four years and a range in the medical (45.1% vs. 47.7%), surgical (15.0% vs. 12.9%), cardiac (11.0% vs. 14.6%), and other intensive care units. (AEM Educ Train. 2018;2(4):288; https://bit.ly/3X54Ux9.) Graduation requirements from ACGME-accredited critical care fellowships seem more of a continuance and refinement of emergency medicine residencies than a shift requiring board certification through different specialties. EM residents must, for example, manage critical patients by “prioritizing critical initial stabilization action” and demonstrate competency in “performing invasive procedures, monitoring unstable patients, and directing major resuscitations.” (ACGME. June 13, 2020; https://bit.ly/3W1WsNU.) ICU fellows also manage patients with pathologies seen by their EM counterparts, including acute lung injury, metabolic disturbances, cardiovascular disease, hypertensive emergencies, respiratory failure, and sepsis. (ACGME. Feb. 7, 2022; https://bit.ly/3ivXxzD.) The procedural requirements of ICU fellows almost perfectly match those of EM residents and exceed those of other specialties, including airway management and intubation, paracentesis, tube thoracostomy, and point-of-care ultrasound (which is a skill highly specific to emergency medicine). The integration of these fields seems obvious and inevitable. EDs continue to be inundated with patients of every acuity level and often exceed capacity, leading to prolonged waits and delayed care, sometimes at the expense of more critically ill patients. Nearly 33 percent of ICU admissions now have increased lengths of stay in the ED prior to transfer (more than six hours), and patients boarding in the ED have become the new norm, exacerbated by a nursing shortage that cripples functionality across every discipline. (J Am Coll Emerg Phys. 2022;3[1]:e12684; https://bit.ly/3GVVZYZ.) This makes ED and ICU beds even more scarce, ultimately placing the burden on emergency physicians and nurses to provide ICU-level care beyond stabilization. The educational barriers between EM and CC have already begun to break down to begin the years-long process of training a new generation of ICU fellows and intensivists. The geographic separation of the ED and ICU has started to become obsolete as well: Michigan Medicine opened a combined ED-ICU adjacent to the ED in 2015, which has already treated 11,000 patients. (University of Michigan. 2022. https://bit.ly/3CHElWx.) More Job Openings It has also helped streamline transfer for inpatient care, improve 30-day patient mortality, and reduce the need for ICU admissions from the ED. (JAMA. 2019;2[7]:e197584; https://bit.ly/3kcABWQ.) This has not been implemented widely, but this model could prove promising as medical care becomes more complex and the volume of critically ill patients in overwhelmed EDs and ICUs continues to strain our health care system. This approach will also encourage if not require training more EM-CC physicians, in turn creating higher demand, more job openings, and better salaries for emergency physicians. This last point is particularly crucial for my generation of emergency physicians. The future job market for EPs will not be as plentiful as that of our predecessors, although the initial projection of a 7845-physician surplus by 2030 remains controversial and might be overstated. (Ann Emerg Med. 2021;78[6]:726; https://bit.ly/3lVrGYu; HealthLeaders. Aug. 22, 2022; https://bit.ly/3WbsmaQ.) Major metropolitan areas remain highly saturated with physicians in an increasingly competitive market, creating obstacles for those who hope to practice there. Nearly every ICU in the country meanwhile is starving for intensivists. One model says there was a deficit of nearly 7900 intensivists during the peak of the COVID-19 pandemic, which will continue to have damaging consequences. (Pan Afr Med J. 2022;41:210; https://bit.ly/3CEQb3R.) This will only strengthen the call to create more spots for EM residents in ICU fellowships, the creation of more dedicated EM-CC tracks, and perhaps experiment with combined ED-ICU layouts and employment structures. As a critical care-bound emergency medicine resident, I must confess some bias perhaps not shared by peers who are less enthusiastic about ICU rotations, but I cannot overemphasize the importance of supporting this merger as we become the next generation of emergency physicians who may practice in a world where the ICU will be our second home. Our specialty is still young, and our ability to deal with everything from broken toes to resuscitations is our most valuable asset. One does not need a critical care fellowship to provide basic ICU care for our sickest patients in the ED, and that may be enough for some. But I encourage my fellow EM residents to consider an ICU fellowship. Even if you're not the biggest fan of the ICU, the care you provide, the knowledge you employ, and the intense work you do every single shift downstairs means you're really sort of upstairs too. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected]." @default.
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