J Shiber, E Fontane
critical care education, emergency medicine – critical care medicine, post-graduate training
J Shiber, E Fontane. Post-Graduate Training of Faculty at National Emergency Medicine - CCM Conferences. The Internet Journal of Emergency and Intensive Care Medicine. 2015 Volume 15 Number 1.
Emergency medicine (EM) encompasses the care of diverse patient presentations of disease and injury. As such, EM incudes the practice of virtually all specialties to some extent but primarily deals with resuscitation and stabilization, which is generally considered to be the first 20-60 minutes of care in the Emergency Department (ED).(1) Although only approximately 5% of ED patients are critically ill, Emergency Physicians (EPs) may spend up to one third of their total time doing critical care since these patients may remain in the ED for extended times awaiting an ICU bed.(1,2,3) EPs are tasked with having a very wide breadth of knowledge in order to recognize, diagnose and initiate treatments before handing over the patient to another medical or surgical specialty provider for ongoing and definitive care. Therefore EM is a specialty that although distinct in its approach and goals for patient care, includes aspects of all of the specialties such as Internal Medicine, Surgery, Pediatrics, Ob/GYN, Psychiatry, etc.
Since EM focuses on the resuscitation and stabilization of the most ill and injured patients, there are certainly aspects of critical care medicine involved with EM.(1,4) Indeed, critical care has been defined as the triad of resuscitation, emergency care and intensive care that spans the continuum from pre-hospital to the ED and into the ICU.(3,5) However, the continued assessment and care after their acute resuscitation is not a focus of EM training as there are no specific critical care topics in the EM model curriculum.(2,4,6) There are some specialties with formal fellowship training available to EM physicians; Pediatric EM, Sports Medicine, Toxicology, Hyperbaric and Undersea Medicine, Hospice and Palliative Medicine, Emergency Medical Services (EMS), and Critical Care Medicine (offered through ABIM, ABA, or ABS programs) are the current ACGME approved fellowships for EM program graduates; there are also other non-accredited training programs available such as emergency ultrasonography, ED administration, international EM, and more. There are numerous conferences advertised as some combination of Emergency Medicine and Critical Care Medicine (EM-CCM) but the background and qualifications of the speakers at these conferences is not well known. We were to review the post-graduate training of the speakers at seven prominent EM-CCM educational conferences to determine if they have training in both EM and CCM as compared to training only in EM.
We reviewed the course programs for the training and background of the faculty speakers at seven prominent national EM-CCM conferences from 2008 -2012: America College of Emergency Physicians (ACEP) Scientific Assembly – Critical Care Medicine Tract, Critical Points: Emergency Critical Care, The Weil Symposium on Critical Care and Emergency Medicine, Emergency and Critical Care Medicine –“The Cutting Edge”, Florida Emergency Physicians Symposium on Critical Care in the Emergency Department, University of Maryland EM – The Crashing Patient, and Resuscitation. Confirmation of post-graduate training was performed by on-line research of the speaker’s academic department bioprofile. As a reference, we compared the percentage of speakers trained in both EM and CCM with the post-graduate training of the speakers at the ACEP Pediatric Emergency Medicine Assembly from 2010-2012 who have training in both Pediatrics and Emergency Medicine as compared to Emergency Medicine or Pediatrics alone.
There were a total of 221 speakers at the seven studied EM-CCM conferences from 2008-2012: faculty trained in EM-CCM 42 (19.1%) and trained in EM alone 179 (80.9%).[see figure 1] There were 58 speakers at the ACEP Pediatric Emergency Medicine Assembly from 2010-2012: faculty trained in Peds-EM 29 (50.0%), Pediatrics plus subspecialty [critical care, cardiology, dermatology, etc.] 23 (39.6%), EM plus subspecialty [ultrasound, toxicology, etc.] 4 (6.9%), Pediatrics alone 1 (1.7%), and EM alone 1 (1.7%).[see figure 2]
We suggest that although general EM physicians have adequate training and knowledge in all of the requisite specialties, it would seem logical that EM trained physicians who have completed formal training in critical care would have additional knowledge and experience in the care of critically ill and injured patients. We would therefore suggest that these physicians with fellowship training should take the lead in the education and research efforts in EM-CCM just as the majority of academic leaders of Pediatric Emergency Medicine (PEM) are dually trained (residency training in EM and Pediatrics, or Pediatrics residency plus fellowship in PEM) and are not simply general emergency physicians or general pediatricians. The recognition that additional training in CCM is needed to be combined with EM residency training to achieve additional expertise in resuscitation and critical care has been known for over 30 years.(7) A similar argument has been common within the EM leadership that other non-EM physicians would need significant formal training in EM to safely and adequately care for ED patients.(8)
Although not ACGME-approved, structured EM ultrasound (EM-US) fellowships are now widely available and have produced more than a decade of EM physicians with additional expertise in bedside ultrasound. It would be quite a surprise to attend a current EM-US conference or skills workshop and discover that none (or only a few) of the faculty had completed an ED-US fellowship. In the nineties, prior to formalized EM-US training, it would have been considered sufficient to simply be interested in EM-US in order to become a leader in the academics of that field, but we would suggest that is no longer so. We could give similar analogies with any of the fellowships available to EM graduates as the publications, research, and CME presentations in clinical toxicology, hyperbaric medicine, or EMS are typically represented by emergency physicians with additional fellowship training in their respective fields instead of general emergency physicians.
In the included EM-CCM conferences, less than 1/5 of speakers were trained in both EM and CCM with the overwhelming majority trained in only EM. Using the ACEP Pediatric EM Assembly as a comparison model, there were a much larger percentage of dually trained speakers in either Pediatrics-EM or Pediatrics Subspecialty, with only a very small percentage (approximately 2%) of speakers trained in EM alone or Pediatrics alone. We believe that conference directors should be encouraged to invite speakers who have the appropriate training (additional residency or fellowship) in the area of the specific conference so that the audience can benefit from those presenters with the most formal education and expertise in their respective specialty.