Introduction
The field of critical care medicine (CCM) is vital in modern healthcare, with Internal Medicine (IM) serving as the foundational specialty for a significant portion of intensivists. The Accreditation Council for Graduate Medical Education (ACGME) outlines several pathways for IM physicians seeking CCM certification through the American Board of Internal Medicine (ABIM). These pathways, while all including a year of clinical fellowship in CCM, exhibit notable variations in their training requirements. Recognizing these discrepancies, the Critical Care Societies Collaborative (CCSC) assembled a task force of experts to evaluate these IM-based CCM pathways and propose recommendations for more consistent and unified training standards. This article delves into the task force’s findings, highlighting the disparities in current Acgme Critical Care Program Requirements and advocating for a more harmonized, competency-based approach to CCM fellowship training for internists.
Understanding the ACGME Critical Care Pathways for Internal Medicine
For IM physicians aiming to specialize in critical care, the ACGME recognizes distinct routes to achieve board certification in CCM via the ABIM. These pathways are designed to accommodate different prior training experiences within internal medicine subspecialties. Pathway A is tailored for those completing two years of fellowship in an IM subspecialty (three years for cardiology and gastroenterology), incorporating critical care unit experience, followed by a year of dedicated CCM fellowship. Pathway B involves a more direct route with two years of CCM fellowship, including a substantial clinical training component. Pathway C, though currently without ACGME-accredited fellowships, describes a path through advanced general IM fellowship with significant critical care exposure, followed by a year of CCM fellowship. These pathways, detailed in Table 1, aim to equip fellows with the necessary competencies to excel as intensivists, whether in a primary or consultative role.
Alt text: Table outlining the three ACGME pathways (A, B, C) for internal medicine physicians to achieve critical care certification, detailing the fellowship training requirements for each pathway including subspecialty fellowship duration and critical care medicine fellowship duration.
Despite shared objectives, significant differences exist in the specific requirements for IM-CCM training programs compared to other specialties and even within IM-related CCM fields like Pulmonary-CCM. These variations, as summarized in Table 2, span across site requirements, key clinical faculty (KCF) qualifications and ratios, procedural requirements like bronchoscopy, emergency medicine (EM) trainee considerations, and clinical time allocations within intensive care units (ICUs). While some variation might be justified by differing trainee backgrounds, the task force questioned whether all current distinctions are necessary for optimal CCM education.
Alt text: Table comparing key training requirements for critical care medicine fellowships across different specialties in the United States, including Internal Medicine-Critical Care Medicine (IM-CCM), Pulmonary-Critical Care Medicine (Pulmonary-CCM), Anesthesiology-Critical Care Medicine, and Surgery-Critical Care Medicine, highlighting differences in site requirements, key clinical faculty, bronchoscopy, EM trainee requirements and clinical time and ICU requirements.
Task Force Formation and Objectives
In response to the need for standardization, the CCSC, comprising representatives from leading societies such as the American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), established a task force in 2012. This task force was charged with developing consensus-based recommendations to harmonize and coordinate IM intensivist training pathways, ensuring they effectively address the evolving demands of critical care in the US. The task force aimed to create a unified set of recommendations for standardizing the educational journey for IM-trained physicians to become intensivists.
The task force comprised CCM professionals with certifications in Pulmonary-CCM and/or IM-CCM, all from ACGME-accredited programs. These individuals brought diverse expertise in education, administration, research, and clinical practice, offering a comprehensive perspective on the challenges and opportunities within CCM training. Their mandate was to evaluate the CCM physician workforce landscape, analyze current training processes and requirements for IM-based CCM certification, identify obstacles in creating uniform training pathways, and ultimately propose recommendations for accrediting bodies to consider.
Methodology and Guiding Principles
The task force adopted a rigorous approach, grounded in specific principles, to formulate its recommendations. Recognizing the limited direct evidence for defining optimal CCM training requirements for IM specialists, they prioritized:
- Principle-Based Recommendations: Basing recommendations on established educational principles, international standards, and the collective experience and consensus of the task force members.
- Competency-Based Training: Emphasizing competency acquisition in critical care for internists, aligning with broader ACGME training standards.
- Workforce Considerations: Acknowledging workforce projections for estimating training positions but not letting these dictate training content or duration needed for clinical competence.
- Justification for Variation: Advocating for explicit rationales for any differences in requirements across IM-based critical care training programs.
To inform their deliberations, the task force conducted a thorough review of relevant literature via MEDLINE searches and examined materials from ACGME, ABIM, and other specialty organizations. Consensus was achieved through a series of roundtable meetings, email exchanges, and conference calls, ensuring a collaborative and iterative process.
Key Findings: Disparities in IM-CCM Program Requirements
The task force’s analysis revealed significant disparities in program requirements, particularly when comparing IM-CCM fellowships with Pulmonary-CCM and CCM fellowships in other specialties like anesthesiology and surgery. These differences, outlined in Table 3, appear to create unnecessary hurdles for IM-CCM programs without clear justification based on trainee preparation or curriculum needs.
Alt text: Table listing five key training barriers specific to Internal Medicine-Critical Care Medicine (IM-CCM) programs, including requirements for ACGME-accredited IM subspecialty programs at the primary site, exclusion of non-ABIM critical care board-certified faculty from key faculty status, higher key clinical faculty to fellow ratio, restrictions on fellows from non-IM ACGME programs and therapeutic bronchoscopy procedure requirements.
One notable barrier is the requirement for IM-CCM programs to have a higher number of co-located ACGME-accredited IM subspecialty fellowships compared to Pulmonary-CCM. Specifically, IM-CCM requires three out of five IM subspecialties (cardiovascular disease, gastroenterology, infectious diseases, nephrology, or pulmonary disease), while Pulmonary-CCM requires two out of four. This site requirement may unnecessarily prevent otherwise qualified institutions, particularly those without extensive medical school affiliations, from establishing IM-CCM fellowships. The task force found no empirical evidence to support the necessity of this extensive on-site subspecialty program requirement for effective CCM fellowship training.
Another key difference lies in the requirement for IM-CCM fellows to perform a minimum of 50 therapeutic bronchoscopies. This procedural volume mandate is unique to IM-CCM among core critical care procedures and contrasts with Pulmonary-CCM’s requirement of 100 total bronchoscopies (including diagnostic and therapeutic). The task force questioned the evidence base for a specific number of therapeutic bronchoscopies for IM-CCM trainees, especially when compared to other essential critical care procedures like intubation and chest tube placement, which do not have prescribed volume requirements. They emphasized that competency should be assessed through formal evaluation, potentially incorporating simulation, rather than relying on arbitrary procedural numbers.
Furthermore, IM-CCM programs face restrictions regarding key clinical faculty and fellow ratios. Only ABIM-certified intensivists can serve as KCF for IM-CCM and Pulmonary-CCM, limiting the role of otherwise qualified intensivists certified by other boards, such as anesthesiology or surgery, even when they are integral to the educational programs. Additionally, IM-CCM programs face a more stringent KCF-to-fellow ratio (1:1 for programs with more than 3 fellows) compared to Pulmonary-CCM (1:1.5 for programs with more than 9 fellows) and other IM fellowships. These stricter faculty requirements may hinder program growth and expansion without clear justification.
The Imperative for Competency-Based Training
The ACGME and ABIM emphasize competency-based education, requiring demonstration of competence in patient care, medical knowledge, practice-based learning, interpersonal skills, professionalism, and systems-based practice. The task force strongly endorsed this competency-based approach for CCM training. They advocated that all IM-based CCM programs should aim to produce graduates with a uniform and high level of skill and expertise. Competency assessment, beyond traditional knowledge-based exams, should incorporate methods to evaluate performance in the core competency domains, potentially utilizing tools like simulation and direct observation. The ACGME’s Next Accreditation System, with its focus on educational milestones, is anticipated to further enhance competency assessment and documentation in IM-based CCM training.
Recommendations for Harmonizing ACGME Critical Care Program Requirements
Based on their comprehensive analysis, the task force proposed several key recommendations to the ACGME:
- Harmonize Training Requirements: Standardize ACGME training requirements across all IM-based CCM fellowship programs to eliminate unjustified variations.
- Eliminate Redundant Subspecialty Fellowship Requirement: Remove the requirement for IM-CCM and Pulmonary-CCM programs to offer a minimum number of specific IM subspecialty fellowships at the primary site, as there is no evidence to support its necessity for effective CCM training.
- Broaden Key Clinical Faculty Eligibility: Allow board-certified intensivists from anesthesiology and surgery to serve as KCF in IM-based CCM programs and supervise fellows in MICUs, suggesting a proportional limit on non-IM-trained KCF and MICU teaching time.
- Standardize KCF-to-Fellow Ratio: Establish a uniform KCF-to-fellow ratio of 1:1.5 for all IM-based CCM fellowships to facilitate program growth and resource allocation.
- Re-evaluate Bronchoscopy Requirement: Eliminate the mandatory 50 therapeutic bronchoscopy requirement for IM-CCM trainees, advocating for competency assessment through alternative methods that better reflect procedural skill and clinical need.
- Modify IM Graduate Ratio: Adjust the requirement that 75% of IM-CCM and Pulmonary-CCM fellows be IM program graduates, proposing a 50% limit to allow programs to recruit top candidates from other ACGME-approved specialties like emergency medicine.
Conclusion
The task force concluded that the existing variations in ACGME critical care program requirements between IM-CCM and Pulmonary-CCM fellowships, particularly concerning KCF ratios and bronchoscopy requirements, are not justified and may impede optimal training. They strongly recommend a shift towards competency-based training and the harmonization of requirements across IM-based CCM pathways. Implementing these recommendations would streamline CCM fellowship programs, enhance training effectiveness for both programs and trainees, and ensure that IM-trained intensivists are well-prepared to meet the complex demands of critical care medicine. These proposed changes aim to maintain the strong IM foundation of these programs while embracing the multidisciplinary nature of critical care and fostering a more unified and effective educational framework.
