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Communications to the Editor |

Missed Opportunity To Address the Critical Care Medicine Crisis FREE TO VIEW

Carey D. Chisholm, MD; Donald M. Yealy, MD; on behalf of the Board of Directors Society for Academic Emergency Medicine
Author and Funding Information

Lansing, MI

Correspondence to: Carey D. Chisholm, MD, Society for Academic Emergency Medicine, 901 N Washington Ave, Lansing, MI 48906



Chest. 2005;127(5):1863-1864. doi:10.1378/chest.127.5.1863-a
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Published online

To the Editor:

The recent white paper from the Critical Care Professional Societies1 notes “an unprecedented, and largely unrecognized, shortage of physician intensivists in the near future” that “will deny standard critical care services for large populations of patients with serious illnesses.” To avert this crisis, the Critical Care Professional Societies offer a variety of recommendations, including steps to increase the number of fellowship-trained providers. We strongly support the need for the quality training of skilled physicians in critical care medicine.

One recommendation was to change immigration laws to permit international medical graduates increased access to critical care fellowship training. Ironically, the American Board of Internal Medicine (ABIM) recently closed access to critical care specialty training fellowships to US emergency medicine (EM) residency graduates. This decision was unrelated to any objective data suggesting suboptimal performance by EM residency graduates in critical care training programs or practice. While formal certification pathways have remained blocked to EM residency graduates by various members of the American Board of Medical Specialties (ABMS), EM residency graduates have successfully completed critical care fellowships across the country for 2 decades, performing at levels equal to their internal medicine (IM) and other colleagues.

Graduates of EM residencies are mandated to participate in more critical care training opportunities than their counterparts in categorical IM or pediatrics. In addition, EM residents deliver and teach care from the home or site of illness/injury—prehospital—through to the hospital. They offer a unique ability to understand a broad part of the continuum of care, a natural addition to a training program, complementing other graduates.

EM residents also participate in a large number of critical care activities in their daily work. Hospital crowding and the increased demand for intensive care services equate to prolonged emergency department stays for gravely ill patients (or those in jeopardy of becoming more ill), who usually remain under the care of the EM physician. In many community hospitals, the EM provider is often the sole on-site physician, and responds to all critical status changes for patients in the ICUs. Ultimately, it is obvious that we do care for the same patients.

Thus, one component to solving the impending patient care crisis in critical care medicine would be to reverse the recent ABIM ban on training EM residents. EM residents have not “usurped” critical care training positions from IM residency graduates, but rather allowed creation of broad, diverse training programs. EM residency graduates constitute a ready pool of high-quality fellowship candidates (note the National Resident Matching Program results for the last decade placing EM residencies as one of the top three most competitive to access for US medical school graduates). Since expanding the pool of candidates from within IM programs has limits, restoring the access to training of the highly skilled EM residency graduates would be a better step than seeking solutions elsewhere (including foreign-trained graduates). Separately, we encourage the ABMS to consider allowing EM graduates who have successfully completed a critical care fellowship to be eligible for certification after training. This would increase the pool of interested EM graduates and would assist in reaching the goal of expanding both the pool and number of critical care fellowship positions and trained intensivists. Ultimately, it is in the best interests of our patients.

Ewart, GW, Marcus, L, Gaba, MM, et al (2004) The critical care medicine crisis: a call for federal action.Chest125,1518-1521
 

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Ewart, GW, Marcus, L, Gaba, MM, et al (2004) The critical care medicine crisis: a call for federal action.Chest125,1518-1521
 
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