Fellowships

alison_in_oh said:

I am the non-medical spouse of a 4th year, and as such I'm pretty far from being in touch with the politics and nitty gritty of EM. I'm embarrassed to ask but could y'all help me to straighten some things out about the field my husband is going into?

I'm fuzzy about post-residency fellowship training for EM. I know that there are four accredited/board-eligible subspecialties, and it seems like a truckload of non-accredited fellowships. For the latter, how does such training affect one's employability if they don't get board certified in that field? Also, where can one find a comprehensive list of programs?

For example, my husband really enjoys critical care/ICU. He's mentioned that he'd really be interested in a fellowship if it became board-eligible. A search here reveals that accreditation for CC from EM is at least 5 years off (is this still true?). For non-accredited fellowships, SAEM lists two in EM&CC and 5 in Trauma/CC. But in a recent thread FoughtFyr mentioned that his Mayo-trained colleagues are doing CC fellowships at Harvard and Mayo, neither of which is on the SAEM lists. What's the scoop? Can you do a fellowship just anywhere? Can an EM resident match into an IM program?

Last question. Is fellowship training usually an academically-oriented pursuit, or can it help with employment in a smaller, private community hospital?

Thanks!

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In EM fellowship=less money. You do it for love and/or academics.

Our value to society and hospitals is that we'll see anyone around the clock. If we specialize and try to actually limit our practice, we make less money. Wilderness medicine, who's gonna pay? The squirrels?

You can take a EM/IM/CC program, but it's a long time and the board eligibility comes through the IM board.

Hi Allison, remember, even cardiology, gastroenterology, and other IM subspecialty certifications were once non-accredited by the ACGME.

To my knowledge, the only ACGME accredited fellowships for emergency medicine are medical toxicology, pediatric emergency medicine, hyperbaric medicine, and sports medicine.

Non-accredited fellowships include ultrasound, research, administration/assistant chief of service, pre-hospital/disaster medicine, wilderness medicine, cardiovascular and neurologic research fellowships, international medicine, and a few others.

Critical care fellowships are usually not directly offered through a Department of Emergency Medicine. Therefore, the SAEM list is not even remotely accurate. There are tons of critical care fellowship training sites that will accept EM-trained individuals, and a very few select that actively recruit EM trained individuals (Pitt, UF, UMB). A more accurate list can be obtained from the ACEP Critical Care Section website: http://www.acep.org/webportal/membercenter/sections/ccmed/prog/default.htm (this may require you to be a member to view).

Not all programs listed on that website will accept EM-trained individuals, and some that are noted to not accept EM-trained applicants actually will accept them. (My program is listed as not accepting EM-trained applicants, but have, in fact accepted one EM-trained individual and another resident in our program will be doing a CC surgery fellowship here.)

As was mentioned previously, obtaining certification in critical care as an EM-trained individual is going to be a long process that will likely take 5-10 years to achieve. I'm not even sure it will be obtainable in 10 years, but hopefully with the works of great advocates and a lot of EM-trained people who go into CC fellowships this will be overcome. A lot of the fellowship directors feel that EM-trained applicants are better than their medicine counterparts because of our experience in stabilizing patients. Each primary specialty brings with it its own unique advantages and disadvantages. Whichever is best is probably a moot point. We should all just realize that we're all unique and recognize each other for our unique advantages we bring to a program. Hopefully with due time we will be able to obtain CC subspecialty certification either through the boards of anesthesiology, medicine, surgery, or perhaps our own board. This will only happen if we make our voices known and have enough numbers to make subspecialty certification in demand.

alison_in_oh said:

You guys are great. Southerndoc, I'm indebted for a great, informative post! That list is *perfect*, exactly what I was looking for. From what little I'm picking up about "politics of EM", it does seem that a boarded subspecialty in CC would be valuable and that it would require some grassroots effort to bring about. Hopefully that day will come soon.

BKN, I think my husband was actually thinking more of *expanding* his repertoire rather than limiting his scope. Having the versatility to comfortably cover both the ICU and a low-volume ED on nights (when perhaps only the EM physician is on site) seemed like a reason to pursue further training. However, I guess another option is to get residency training that emphasizes ICU time during the EM curriculum, and he's looking hard at several of these.

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There are several residencies that have great ICU exposure. Most 3-year programs have only 3 months of ICU time, but several 4-year programs have more (4-6 months, one program even has 7 months).

A boarded CCM subspecialty through EM would be valuable to those that have done or are contemplating a CC fellowship. However, ABEM does not believe it's valuable enough to warrant subspecialty certification. It will come with due time though.

southerndoc said:

There are several residencies that have great ICU exposure. Most 3-year programs have only 3 months of ICU time, but several 4-year programs have more (4-6 months, one program even has 7 months).

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Because we feel that you can get more resuscitations and procedures and learn about followup, we have 5-6 months in a 3 year curriculum. It does crowd the rest of the curriculum.

A boarded CCM subspecialty through EM would be valuable to those that have done or are contemplating a CC fellowship. However, ABEM does not believe it's valuable enough to warrant subspecialty certification. It will come with due time though.

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I wouldn't characterize ABEM's position that way. As I remember it, there were repeated negotiations over several years and IM blocked us. Their justification was that we had to promise not to do inpatient work to get the specialty approved in the first place. They saw us as threatening their income. Eventually ABEM gave up to pursue it much later if ever.

BKN said:

Because we feel that you can get more resuscitations and procedures and learn about followup, we have 5-6 months in a 3 year curriculum. It does crowd the rest of the curriculum.

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I think 6 months of critical care should be mandatory in all residencies. I didn't get much out of my inpatient internal medicine and pediatric months, and perhaps these could be eliminated. There might be resistance to do this though. Many may feel that inpatient wards are a prerequisite to critical care time.

I wouldn't characterize ABEM's position that way. As I remember it, there were repeated negotiations over several years and IM blocked us. Their justification was that we had to promise not to do inpatient work to get the specialty approved in the first place. They saw us as threatening their income. Eventually ABEM gave up to pursue it much later if ever.

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I do think that EM-trained individuals will be allowed to become certified in critical care in the distant future. There isn't enough interest in critical care among our medicine colleagues, and there is a growing need for intensivists.

southerndoc said:

I think 6 months of critical care should be mandatory in all residencies. I didn't get much out of my inpatient internal medicine and pediatric months, and perhaps these could be eliminated. There might be resistance to do this though. Many may feel that inpatient wards are a prerequisite to critical care time.

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Actually, our program has eliminated inpatient internal medicine and inpatient peds. We do 2 ICU months in the first year (one medical ICU and one surgical) and 3 ICU months in the second year (one CCU, one PICU, and a second SICU month). About half of our residents do an optional 3rd year medical ICU elective. And two of last year's graduates went into Critical Care fellowships. So, for those of you looking, there is at least one 3 year program with heavy ICU experiences and I would suspect that there are more (I am not familiar with all of the programs in the US).

- H

FoughtFyr said:

Actually, our program has eliminated inpatient internal medicine and inpatient peds. We do 2 ICU months in the first year (one medical ICU and one surgical) and 3 ICU months in the second year (one CCU, one PICU, and a second SICU month). About half of our residents do an optional 3rd year medical ICU elective. And two of last year's graduates went into Critical Care fellowships. So, for those of you looking, there is at least one 3 year program with heavy ICU experiences and I would suspect that there are more (I am not familiar with all of the programs in the US).

- H

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We are about to make a push to our PD to eliminate one of our inpatient months for either an additional elective or an additional ICU month.

southerndoc said:

We are about to make a push to our PD to eliminate one of our inpatient months for either an additional elective or an additional ICU month.

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PM me if you need more personal correspondence to "back up" what our program has gone to. (If it would help).

- H

I know this is kind of a different tilt to this fellowship thing but roughly speaking... Are you basically a PGY4(or5) (50K) or are paid like a cheap junior attending (120K). Thanks in advance!

EctopicFetus said:

I know this is kind of a different tilt to this fellowship thing but roughly speaking... Are you basically a PGY4(or5) (50K) or are paid like a cheap junior attending (120K). Thanks in advance!

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Most programs pay you for whatever level of training you have obtained. If you graduated from a 3-year residency and started a fellowship, you would be paid at the PGY-4 level. If you graduated from a 4-year residency, then you would start at the PGY-5 level.

However, there are some programs that will pay you at the PGY-4 level regardless of prior experience. You could have completed two fellowships and they would only pay you at the PGY-4 level.

So most EM fellowships just pay like a fellow.. Interesting.. Can you "pick up" some shifts (kind of like moonlighting) for extra $$ or is that frowned upon..Obviously things are dependent on the PD and Chair..

southerndoc said:

There are several residencies that have great ICU exposure. Most 3-year programs have only 3 months of ICU time, but several 4-year programs have more (4-6 months, one program even has 7 months).

A boarded CCM subspecialty through EM would be valuable to those that have done or are contemplating a CC fellowship. However, ABEM does not believe it's valuable enough to warrant subspecialty certification. It will come with due time though.

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There are some 3 year programs that are very ICU intensive. My program has two ICU months the first year MICU and a pseudoCCU/Cards month. 2nd year we do 2 PICU months, a CCU month, and a combined MICU/SICU month, in addition on trauma you occasionally cover the Trauma ICU.

EctopicFetus said:

So most EM fellowships just pay like a fellow.. Interesting.. Can you "pick up" some shifts (kind of like moonlighting) for extra $$ or is that frowned upon..Obviously things are dependent on the PD and Chair..

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Yes, you can pick up shifts. It's much easier to do it as an EM fellow than any other fellow. Most of our fellows pick up an extra shift or two each week. Most EM moonlighting shifts pay $100/hr.

EctopicFetus said:

So most EM fellowships just pay like a fellow.. Interesting.. Can you "pick up" some shifts (kind of like moonlighting) for extra $$ or is that frowned upon..Obviously things are dependent on the PD and Chair..

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Actually you have to in order to maintain board eligibility if your fellowship program doesn't include EM shifts.

- H

FoughtFyr said:

Actually you have to in order to maintain board eligibility if your fellowship program doesn't include EM shifts.

- H

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Are you serious? This is the first I've heard of this. (Doesn't mean you aren't correct though.)

Can you provide a link?

southerndoc said:

Are you serious? This is the first I've heard of this. (Doesn't mean you aren't correct though.)

Can you provide a link?

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I'll find one. I was told this by a faculty member who is fellowship trained and it was brought up when discussing fellowship with a fellowship director (but that director was at the program the faculty graduated from). They both quoted a minimum of "four EM shifts per month"...

I'll see what I can find in writing.

- H

FoughtFyr said:

I'll find one. I was told this by a faculty member who is fellowship trained and it was brought up when discussing fellowship with a fellowship director (but that director was at the program the faculty graduated from). They both quoted a minimum of "four EM shifts per month"...

I'll see what I can find in writing.

- H

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We have fellows who do not do 4 EM shifts per month. In fact, one of our RWJ fellows only does 1 shift/month.

Where I am considering for my tox fellowship, they offer full stipend without any ED shifts at all. There have been a few that haven't moonlighted during this.

Perhaps they were saying that 4 shifts/month is necessary to maintain your skills?

southerndoc said:

We have fellows who do not do 4 EM shifts per month. In fact, one of our RWJ fellows only does 1 shift/month.

Where I am considering for my tox fellowship, they offer full stipend without any ED shifts at all. There have been a few that haven't moonlighted during this.

Perhaps they were saying that 4 shifts/month is necessary to maintain your skills?

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I don't know about rules, but I thought the 1 shift/week/4 shift/month was about what it cost to "pay your own way" as an EM fellow.

Apollyon said:

I don't know about rules, but I thought the 1 shift/week/4 shift/month was about what it cost to "pay your own way" as an EM fellow.

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It varies by institution.

southerndoc said:

Where I am considering for my tox fellowship, they offer full stipend without any ED shifts at all. There have been a few that haven't moonlighted during this.

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Where and when are you looking? It looks like we have similar goals...

- H

Tox=Job Security