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ACEP and the leaders of other medical specialties representing emergency medicine, have taken issue with a recent survey of emergency medicine residency programs, by US News & World Report and Doximity. Below is a letter from Dr. Rosenau to US News & World Report.
September 12, 2014
Mr. Ben Harder
Managing Editor and Director
Health Care Analysis
US News & World Report
105 Thomas Jefferson Street, NW
Washington, DC 20007
Dear Mr. Harder:
As leaders of the top organizations representing emergency medicine, we have been contacted by scores of emergency physicians from around the country about a survey being conducted by U.S. News & World Report and Doximity. We appreciate your recognition of emergency medicine as an academic medical specialty with a unique core of knowledge and robust research agenda.
However, we are concerned about the sampling method chosen for this survey, because we believe it will fail to achieve your objective for this survey — to identify America’s top emergency medicine training programs. Asking only physicians enrolled in a social media website to nominate their five most preferred residencies will result in egregious sample bias and is not capable of resulting in a scientifically valid result. The results will be based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended themselves.
While not a formal ranking of residency programs, the results would convey that some programs provide better training than others. However, given the limitations, this would not be an accurate portrayal — to medical students or to the public. It also would not be useful to many medical students, because research shows that more than 75 percent of emergency physician residents report the number one reason for selecting a residency program is geography.
More concerning, the results could send a dangerous public health message to people with medical emergencies. It implies they should consider bypassing hospital emergency departments with residency programs that fared poorly in the survey. In a medical emergency, people should seek emergency care at the nearest emergency department, not one that scored better on a highly subjective opinion survey.
Patients need confidence in their physicians in times of crisis, especially since comparison shopping among doctors is not an option when someone is having a medical emergency. Emergency medicine residency programs train physicians in the emergent and acute conditions of just about every medical specialty in health care. As a result, emergency physicians are uniquely qualified to handle a full range of adult and pediatric emergencies. In addition, they see every kind of human drama imaginable, often treating multiple patients at a time.
The overall quality of medical care delivered in emergency departments in the United States is excellent, thanks to the uniformly high standards that govern the accreditation of residency programs in emergency medicine. Emergency medicine residencies collaborate openly with shared curricular tools built around a core model of clinical practice, an approach that is fairly unique in medical education. Ranking training programs above others is contrary to the principles of our specialty, although we recognize that certain programs are best suited for certain trainees.
Many factors contribute to a successful residency program, not all of which can be measured or compared. If your target audience is medical students contemplating a career in our field, we would be happy to work with you to identify objective, measurable factors to help students find the best program for their individual needs.
Unfortunately, our organizations, which represent more than 40,000 emergency physicians, could not recommend or encourage participation in the current survey by emergency physicians. We would, however, be happy to meet with you and help to identify the parameters that might better accomplish that purpose. If you are interested, please contact Marjorie Geist at 800-798-1822, ext. 3290.
Alex M. Rosenau, DO, CPE, FACEP
President, American College of
Meaghan Mercer, MD
President, American Academy of Emergency
Medicine Resident and Student Association
Mark Mitchell, DO, FACOEP
President, American College of Osteopathic
Jeffrey N. Love, MD, MSc
President, Council of Emergency Medicine
Jordan Celeste, MD
President, Emergency Medicine Residents’
cc: Avery Comarow, Health Rankings Editor
By Andrew E. Sama, MD, FACEP
With nearly two-thirds of all admitted septic patients presenting to the ED, and with the clear time sensitivity that exists between recognition, treatment, and outcomes, our members are on the front lines to save lives from this frequently fatal disease. In the CY 2015 IPPS rule, in which CMS cited the fact that “that patients admitted through the ED had a 17% lower likelihood of dying from sepsis than when directly admitted,” CMS finalized NQF #0500: Early Management Bundle for Severe Sepsis and Septic Shock, which mandated the invasive monitoring of CVP and ScVO2 via the placement of a central line in the ED. However, late on Friday, CMS notified hospitals, that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice.
Emanuel Rivers, MD, MPH, and his team improved mortality and raised the awareness of the EM community about sepsis through their Early Gold Directed Therapy (EGDT) study in the early 2000s. A few years later, the measure was initially endorsed by the NQF in 2008 without the requirement for a central line for the emergency department. While it is certain that early intervention does reduce mortality, not all elements of the sepsis composite bundle were equally evidence-based. Many studies over the years have demonstrated dramatic improvements in sepsis-related mortality after the implementation of early interventions for septic patients, which included early antibiotic administration, source control, and aggressive fluid resuscitation without invasive monitoring of CVP and ScVO2. One study addressing this, authored by Dr. Alan Jones and colleagues, was conducted at three EDs in the US, and compared two protocols that both included central venous pressure measurement; however, one used lactate clearance and the other used central venous oxygenation monitoring as a way to guide resuscitation. Dr. Jones’ 2010 study found no differences in mortality, suggesting that using central venous oxygenation to guide resuscitation may not be necessary.
In 2012 the measure underwent routine NQF maintenance review for re-endorsement in 2012-2013. During those proceedings, under the leadership of David Seaberg, MD, FACEP and myself ACEP commented that central venous pressure (CVP) was not the only reliable measure of intravascular volume. Several members of ACEP’s Quality and Performance Committee (QPC) including chair Jeremiah D. Schuur, MD, MHS, FACEP, Michael Phelan, MD, RDMS, FACEP, Todd Slessinger, MD, FACEP, FCCM, FCCP, Christopher Fee, MD, FACEP, and others testified on conference calls and at in-person meetings, that there were equally effective and less invasive methods for monitoring septic patients. Nonetheless, the NQF endorsed the requirement for the central line, noting that they would re-consider if additional evidence warranted it.
Within a few months the Protocolized Care for Early Septic Shock (ProCESS) trial was published on March 18, 2014 and under Dr. Alexander Rosenau’s leadership ACEP immediately requested that NQF #0500 undergo an ad hoc review given the impact that this new data would have on this quality measure. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review, one of the PIs, Donald Yealy, MD, FACEP engaged in a scientific debate noting that the ProCESS trial enrolled 1,341 patients, with a power to detect a 6-7 percent absolute difference, yet demonstrated no difference in mortality 60-day mortality 90-day mortality, one year mortality, or the need for organ support. The ProCESS also noted no benefit in any outcome when using CVC- guided care and the simpler approaches that stressed early and ongoing care produced the same good outcomes.
CMS, NQF, and others are now also convinced that honing the sepsis bundle is a move forward for our septic patients, with or without invasive monitoring depending on the progression of their disease, their unique circumstances, and the resources available at the ED where they are being treated. As it is ACEP’s mission, we will continue to advocate on behalf of our patients presenting with a diagnosis of sepsis to ensure that they receive the highest quality of emergency care. We look forward to continuing to work with the measure developer to ensure that all septic patients receive the timely, effective care they need, and to continue to save lives from this deadly disease.
Dr. Sama is ACEP’s Immediate Past President and Chair of the Board of Directors
In a recent newsletter, the American Hospital Association informed its members of a change by CMS as it relates to data collection for severe sepsis and sepsis shock. Below is the CMS announcement.
The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice. This measure was adopted for the FY 2017 payment determination in the CY 2015 IPPS final rule.
CMS continues to believe that this is an important area for measurement given mortality rates that range from 16-49% and that sepsis is one of the top 10 most common principle causes for hospitalizations. Further, through surveillance of early effective treatment of severe sepsis or septic shock, hospitals will not only know where in the sequence of steps to treat severe sepsis and septic shock patients, but also begin to decrease mortality related to sepsis and the costs associated with inefficient care of severe sepsis and septic shock patients. With this measure CMS will gauge if care of severe sepsis and septic shock patients is improving.
This measure was initially endorsed by the NQF in 2008 for the hospital/acute care facility setting and underwent routine NQF maintenance review for re-endorsement in 2013. During the 2013 NQF endorsement proceedings it was noted that should new data be published related to the measure, that the measure would undergo an ad hoc review. With publication of the Protocolized Care for Early Septic Shock (ProCESS) trial in early 2014, NQF #0500 underwent an ad hoc review to discern if the new data would impact the measure as currently designed. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review two other trials were identified that might also impact NQF #0500, those trials are the Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE) and The Protocolised Management in Sepsis Trial (ProMISe). After much discussion of the results of the ProCESS trial, the potential impact the ARISE and ProMISe trials may have on the measure, and the recommendations to remove item ‘F’ from the measure, NQF recommended that measure stewards collaborate with other stakeholders to reach a compromise on NQF #0500’s item F. NQF recommended that measure developers collaborate with other stakeholders to reach a compromise on this specific element of NQF #0500 measure.
Given forthcoming research and NQF’s recommendations, with potential changes to the measure, CMS will delay data collection for the measure until further notice. The duration of this suspension pending further information from the measure developer has not yet been determined. This delay does not affect the data collection period for any other Hospital IQR Program measures.
July’s audio/podcast for Annals of EM is now posted here. Highlights:
-Early vs late rhythm analysis in OOHCA
-Ground based EMS transports and complications
-When do sepsis patients become septic? Usually NOT on arrival. Time to change the metric?
-Diethylene glycol outbreak
-Much, much more!
By Justin McNamee, DO; Nilesh Patel, DO; and Joseph Affortunato, DO
Department of Emergency Medicine
St. Joseph’s Regional Medical Center, Paterson, New Jersey
A 26-year-old woman presented to the emergency department, complaining of a 3-day history of lower abdominal pain and vaginal bleeding. She reported positive home pregnancy test results and that her last menstrual period was 17 weeks ago. On examination, the patient appeared comfortable and was afebrile, with a blood pressure of 131/67 mm Hg, pulse rate of 100 beats/min, and respiratory rate of 16 breaths/min.
Clinical Policy: Critical Issues in the Evaluation and Management
of Adult Patients Presenting to the Emergency Department With Seizures
By J. Stephen Huff, MD, FACEP
In the April 2014 issue of the Annals of Emergency Medicine, the American College of Emergency Physicians (ACEP) published a clinical policy focusing on seizures. This is a revision of a 2004 clinical policy with the same name.
This clinical policy can also be found on ACEP’s website www.acep.
This clinical policy takes an evidence-based approach to answering four frequently encountered questions with regards to decision making associated with seizures in the emergency department. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:
Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; Level C recommendations represent other patient management strategies based on Class III studies, or in the absence of any adequate published literature, based on consensus of the members of the Clinical Policies Committee.
During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, neurologists, and individual members of the American Epilepsy Society, the American Academy of Neurology, the Epilepsy Foundation of America, the National Association of Epilepsy Centers, and ACEP’s Quality and Performance Committee. The draft was also open to further comments through various ACEP communication pieces. All responses were used to further refine and enhance this policy; however, their responses did not imply endorsement of this clinical policy.
This revision of the clinical policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department focused on selected critical questions. Key to this policy revision was employing updated nomenclature for classification of seizures. Seizures can be thought of as provoked or unprovoked. Provoked seizures are secondary to electrolyte disturbances, toxins, infections, central nervous system mass lesions, withdrawal syndromes, or other etiologies. These provoked seizures, also known as acute symptomatic seizures, by definition occur at the time of or within seven days of acute neurologic, systemic, metabolic, or toxic processes. Unprovoked seizures occur in the absence of acute precipitating factors. Seizures from such processes as stroke, brain injury, and other CNS insults that occurred more than seven days in the past are also classified as unprovoked seizures. Epilepsy is defined by recurrent unprovoked seizures.
The question of initiating treatment with antiepileptic drugs for the adult patient presenting to the ED following a first generalized seizure who has returned to baseline clinical status was one critical question. The short-term recurrence risk of this group of patients is unknown but thought to be low. After literature review and grading the evidence, level C recommendations were developed for subgroups of patients. Appropriate clinical assessment by emergency physicians of patients is important since presumptive assignment of the seizure as provoked or unprovoked drives the treatment recommendation. However, it is unclear if seizures can be precisely identified as provoked or unprovoked using information available during an emergency department evaluation. Additionally, patient safety should remain a paramount concern for the practicing physician. Though the evidence supports discharging an adult patient who has returned to baseline status following a first unprovoked seizure, supporting articles assumed a safe support system for the discharged patient. Consideration of social issues or other factors may prompt consideration for admission.
Another critical question addressed treatment of ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine. There are remarkably few randomized prospective studies on this problem and none that consider the causes of status epilepticus. Large prospective studies are in the planning stages. Until these studies are completed, recommendations for specific drugs must reflect current lower levels of evidence. Many different medications are recommended and no medication or class of medications is clearly superior.
Designation of a seizure as provoked or unprovoked at some level is arbitrary and may change with the clinical course or as additional studies are performed. Emergency physicians play a critical role in determining whether a seizure is provoked or unprovoked. If there is an underlying medical condition, identification and treatment of that process is the primary consideration. It is hoped that future studies will focus on seizure recurrence of patients presenting to the ED with seizures, and study outcomes over days or another time frame relevant to emergency medicine.
Critical Questions and Recommendations
Question 1: In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?
Level C recommendations.
(1) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
(2) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
(3) Emergency physicians may initiate antiepileptic medication* in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.
* Antiepileptic medication in this document refers to medications prescribed for seizure prevention.
Question 2: In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events
Level C recommendations. Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.
Question 3: In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.
Question 4: In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Dr. Huff is Professor of Emergency Medicine and Neurology, University of Virginia, Charlottesville, Virginia
Nearly half of emergency physicians responding to a poll are already seeing a rise in emergency visits since January 1 when expanded coverage under the Affordable Care Act (ACA) began to take effect. In an online poll conducted by the American College of Emergency Physicians (ACEP), 86 percent expect emergency visits to increase over the next three years. More than three-fourths (77 percent) say their ERs are not adequately prepared for significant increases.
“Emergency visits will increase in large part because more people will have health insurance and therefore will be seeking medical care,” said Alex Rosenau, DO, FACEP, president of ACEP. “But America has severe primary care physician shortages, and many physicians do not accept Medicaid patients, because Medicaid pays so low. When people can’t get appointments with physicians, they will seek care in emergency departments. In addition, the population is aging, and older people are more likely to have chronic medical conditions that require emergency care.”
The data suggest that states that expanded Medicaid are more likely to see increases in the volume of Medicaid emergency patients. Dr. Rosenau said that policymakers need to make sure there are adequate resources to care for growing numbers of emergency patients.
What other jobs allow you to stay up all night long, party with crazy people, and get paid for it?
That’s what I like to say every New Year’s Eve. New Year’s Eve is my favorite shift, and it’s because of the people.
They are what keep me going in this career: the people, the crazy people, and I don’t mean just the patients.
Docs, nurses and techs all have to be a little bit loony to enjoy this job as well. It is the best job in the world! I come to work not knowing exactly what I will be doing, and even while working we never know what’s going to happen next.
Time-bombs are lurking in the humdrum of the daily routine. Our job is to identify them and defuse them. This keeps us on our toes, and this keeps me intrigued. When I can solve a medical puzzle, I am intellectually rewarded. When I can help someone I am gratified. When I can make a child smile I am happy. I can’t figure everything out or everybody out but I can sure have fun trying! This is why I continue my career of emergency medicine.
Why did I make it my career in the first place?
It looked exciting, isn’t that why we all chose it?
By: Seth R. Gemme, MD
The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations for the education, recognition, and management of concussions, published by the American Academy of Neurology in June, 2013.
Concussions have become a popular topic of concern in the media and with the public over the last several years as many amateur and professional athletes have had career ending head injuries. According to the Centers for Disease Control and Prevention, concussion visits to the emergency department have increased, likely as a result of the increased awareness. Thus there is a need for a better understanding of the neurocognitive pathology and risks associated with a concussion.
In June of 2013, the American Academy of Neurology (AAN) published a guideline focusing on the risk factors of concussion, clinical features associated with worse outcome, and management. They graded the literature since 1955 using a modified version of the GRADE working group process and made recommendations using a modified Delphi process.
Various risk factors were investigated. There was not enough evidence that age made a difference in risk of concussion. With regards to gender, men make up the majority of concussions, likely due to more men playing contact sports, with the greatest risk in American football and Australian rugby. Females were found to be at higher risk if participating in soccer or basketball versus other sports. There is no evidence that mouth guards protect athletes from concussion in any sport. In American football, there is no evidence regarding superiority of one type of football helmet in preventing concussion. Other factors associated with greater risk include a BMI of greater than 27 or training for less than three hours per week. In addition, it is likely that there is an increased risk for repeat concussion within 10 days of the initial concussion.
Clinical features associated with severe or prolonged early postconcussion impairments include a history of prior concussion, early post-traumatic headache, fatigue or fogginess at the time of diagnosis, early amnesia, altered mental status or disorientation, or younger age. Increasing concussion exposure is a risk factor for chronic neurobehavioral impairment in a broad range of professional contact sports but evidence is insufficient in amateur sports of whether or not prior concussion exposure increases chronic cognitive impairment.
The AAN recommends that school-based professionals, athletes, and parents be educated by a designated licensed health care provider (LHCP) about concussions in general and associated risks. A LHCP is one who has acquired skills and knowledge relevant to the evaluation and management of sport concussions and is practicing within his or her scope of practice. This can be either a sideline or clinical LHCP. AAN also recommends that assessment tools be used by the sideline LHCP and those results be made available to the clinical LHCP. One sideline tool discussed is the Standardized Assessment of Concussion which can be administered in 6-minutes and assesses orientation, immediate memory, concentration and delayed recall. Other sideline tools discussed include the Post-Concussion Symptom Scale and the Graded Symptom Checklist which also may be administered in a short time interval and identify concussion.
Two important grade B recommendations are that team personnel should immediately remove any athlete from play with a suspected concussion and that the athlete not be allowed to return until evaluated by the LHCP. It is also recommended that no player should return to play until a LHCP has deemed the concussion to be resolved after being off all medications. A graded process for return of play is recommended with consideration given for formal neurocognitive testing. This makes it essential that patients with a concussion who are discharged from the ED follow up with a LHCP in the outpatient setting.
Per this guideline, in the diagnosis of a concussion, head CT scan is not indicated unless other more serious complications are possible. Factors they deemed as risks in their recommendation include loss of consciousness, post-traumatic amnesia, persistence of a GCS<15, focal neurologic deficit, clinical skull fracture, or clinical deterioration. The guideline does not go into any more detail with regards to imaging.
As an athlete gets older and enters more competitive sports, there is a high level of pressure to get back to play. With continued awareness programs and through this guideline, physicians, parents, coaches, and athletes may be able to reduce risk of recurrent concussions and help prevent long-term neurobehavioral impairment.
Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology. June 11, 2013;80(24):2250-2257.
Dr. Gemme is a resident in emergency medicine at Alpert Medical School of Brown University, and is the 2013-2014 EMRA Representative to the ACEP Clinical Policies Committee.
By Francis L. Counselman, M.D., CPE, FACEP
In the August 2013 issue of ACEP News, the various pathways available to current and future emergency medicine residency graduates to achieve Critical Care Medicine (CCM) certification through fellowship training were reviewed. In this issue, the options available to ABEM diplomates who completed a Critical Care Medicine fellowship prior to the establishment of the current pathways will be discussed.
First, there is no “practice only” pathway for Critical Care Medicine. All CCM certification requires successful completion of ACGME-accredited CCM fellowship training, and practice of Critical Care Medicine. Secondly, there is no “grandfather” pathway available through the American Board of Surgery (ABS) for Surgical Critical Care. This decision by ABS was made for internal policy consistency, and there are no exceptions. Finally, like all “grandfather” pathways, there is a time-limited window during which one can apply for certification. Please make yourself aware of these dates.
American Board of Internal
Medicine (ABIM) Critical Care Medicine
For Internal Medicine-Critical Care Medicine (IM-CCM), the “grandfather” pathway requires both the completion of a 24-month CCM fellowship and the practice of Critical Care Medicine. This pathway is scheduled to close on June 30, 2016. For the 24-month CCM fellowship to count, it must meet one of the following criteria: a) an ACGME-accredited IM-CCM fellowship completed prior to September 21, 2011; b) an unaccredited IM-CCM fellowship that subsequently became ACGME-accredited on or before December 31, 1992; or c) an ACGME-accredited fellowship in another critical care specialty (i.e., Surgical CCM, Anesthesiology CCM).
The second component, the practice portion, is a little more complicated. The EM applicant must have met the practice criteria as of the date on which the application is submitted to ABEM. For at least three years, not necessarily contiguous, of the five years prior to submitting the application (including the 12 months immediately prior to submission), the applicant must have met one of the following criteria: a) 40% of post-training clinical practice time in the practice of CCM; or b) 25% of total post-training professional time in the practice of CCM.
Finally, for those ABEM diplomates who completed an ACGME-accredited IM-CCM fellowship in the recent past (i.e., between September 21, 2008, and September 20, 2011) criteria can be met if, during 60% of the time between completing fellowship training and applying for certification, the applicant completed one of the following: a) 40% of post-training clinical practice in the practice of CCM or; b) 25% of total post-training professional time in the practice of CCM. For example, if an applicant completed fellowship training on June 30, 2011, and applied for certification on July 1, 2013, 60% of the time (i.e., 24 months) would be 14.4 months. So, during that 14.4-month period between completion of fellowship training and application submission, the applicant must meet either the 40% or 25% criterion, as described above.
Physicians whose total practice exceeds 40 hours per week may use 40 hours as the denominator for the “40%” or “25%” calculations for either of the above scenarios.
American Board of Anesthesiology (ABA)
Critical Care Medicine (ACCM)
ABEM diplomates seeking certification through the “grandfather” pathway must have completed both an ACGME-accredited ACCM fellowship program (one or two years in length) and the CCM practice component by the time of application submission, and no later than June 30, 2018; this is the final date of the last application period within the grandfather pathway. The ACCM fellowship training must have been started prior to July 1, 2013. In order for the fellowship program to count, it must have been ACGME-accredited at the time of the applicant’s training; it does not count if the fellowship subsequently became accredited.
For the practice component, during the two years immediately preceding the application submission, the applicant must have completed one of the following: a) 40% of post-training clinical practice time in the practice of CCM, or; b) 25% of total post-training professional time in the practice of CCM. For either calculation, if total practice time exceeds 40 hours per week, 40 hours may be used as the denominator for the “40%” or “25%” calculation.
For both the IM-CCM and ACCM eligibility criteria, the “practice of CCM” is strictly defined. An acceptable practice must occur in a designated critical care unit. Caring for critically ill patients in the ED does not count toward the practice component. For more detail on what constitutes the practice of CCM, please visit the ABEM website at www.abem.org
For all CCM subspecialty pathways, the ABEM diplomate must: meet the requirements of the ABEM Maintenance of Certifications (MOC) program at the time of application and throughout the certification process; be in compliance with the ABEM Policy on Medical Licensure; and provide information about someone who can independently verify the physician’s clinical competence in CCM, successful completion of ACGME-accredited CCM fellowship training, and the physician’s practice of CCM. No opportunities for CCM certification existed just two years ago for emergency physicians, but we now have three pathways going forward, including two grandfather pathways. It is a very exciting time for emergency physicians interested in Critical Care Medicine. The opportunities that now exist are the direct result of the hard work, persistence, and energy of many of our colleagues. To all involved, “Thank you!”
Dr. Counselman is Chairman of the Department of Emergency Medicine at Eastern Virginia Medical School, and President-elect of ABEM.
Here’s a link to the first article in this two-part series