Internal Medicine / Emergency Medicine / Critical Care Medicine Guidelines

In September 1999, the American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM) announced that they will offer triple certification for candidates (eligible for certification by each Board) who have completed at least six years of accredited training in internal medicine, emergency medicine, and critical care medicine.

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Objectives

The objectives of the combined training in emergency medicine/internal medicine/critical care medicine (IM/EM/CCM) include the training of physicians for practice or academic careers, which address the spectrum of illness and injury from the emergent through the chronic. Graduates of the combined training may function as hospital-based, acute care specialists in practice of academic environments. Within an institution, their perspective spanning two specialties has the potential to increase communications and understanding.

Combined programs include components of categorical emergency medicine, internal medicine, and critical care medicine (CCM) residencies (either freestanding CCM programs or the CCM component of pulmonary/CCM residencies), which are accredited respectively by the Residency Review Committee for Emergency Medicine (RRC-EM) and by the Residency Review Committee for Internal Medicine (RRC-IM), both of which function under the auspices of the Accreditation Council for Graduate Medical Education (ACGME). While combined programs will not be independently accredited, their accreditation status is determined by that of the parent residencies.

Every program that wishes to offer this combined training must be approved by both ABEM and ABIM before residents are recruited. In addition, both Boards, and RRCs when applicable, will review these training requirements periodically. Both Boards must adhere to these guidelines in the administration of combined programs and may not alter the guidelines without the written consent of both Boards.

To be eligible for certification, the resident must satisfactorily complete 72 months of integrated, coherent training in the three disciplines, which must be verified by the Program Director, and Associate Program Director, if applicable, of both programs. Proposals for combined residency training programs must be submitted to, and approved by, ABEM and ABIM before a candidate can be accepted into this joint training.

General Requirements

A combined IM/EM/CCM residency consists of six years of balanced training in the three disciplines, which meet the program requirements for accreditation by the RRC-EM for emergency medicine, and the RRC-IM for internal medicine and critical care medicine. The EM and IM residencies must be ACGME accredited and in good standing when the application for a combined residency program is submitted.

It is strongly recommended that the participating residencies be in the same academic health center, and documentation of hospital and university commitment, where applicable, to the program must be available in signed agreements. Such agreements must include institutional goals for the combined program. Participating institutions must be located close enough to facilitate cohesion among the program's house staff, attendance at weekly continuity clinics and integrated conferences and faculty exchanges over curriculum, evaluations, administration, and related matters. At the conclusion of 72 months of training in emergency medicine, internal medicine and critical care medicine, the residents must have had experience and instruction in the prevention, detection, and treatment of illness and injury; the emergent, acute, critical care and chronic treatment of disease; rehabilitation of illness; the socioeconomics of illness; the ethical care of patients; the team approach to the provision of medical care; and the administration of both and emergency department and a critical care unit.

The training of residents while on emergency medicine rotations is the responsibility of the faculty of emergency medicine. Likewise, the training of residents while on internal medicine rotations is the responsibility of the internal medicine faculty. Prior to the completion of training, each resident must demonstrate some form of acceptable scholarly activity. Scholarly activity may include original research, comprehensive case reports, or review of assigned clinical and research topics. Any of the critical care medicine research requirement completed by the end of the R-6 year may fulfill this requirement of scholarly activity.

Vacations, sick leave, and leave for meetings must be shared equally by both training programs. Absences from the training program (vacation, maternity/paternity leave, sick leave) exceeding five months in the 72 months must be made up.

Combined residencies must conform to the program requirements for accreditation of residencies in emergency medicine, internal medicine, and critical care medicine. If the residency in either discipline receives probationary accreditation after initiation of the combined training, new residents should not be appointed to the combined training program. For training that occurs during a period of probationary accreditation, the eligibility criteria that ABEM and ABIM have in place for residents in categorical residency training will likewise apply to residents in the combined program.

The Resident

Residents should enter a combined program at the R-1 level. A resident may enter a combined program at the R-2 level only if the first residency year was served in an accredited, categorical residency in either emergency medicine or internal medicine.

Residents may not enter combined training beyond the R-1 level or transfer between combined training programs in different institutions unless prospectively approved by both Boards.

• Residents may transfer from one approved IM/EM/CCM program to another approved IM/EM/CCM program at the R-2 level.
• Residents whose previous training was completed in an approved EM/IM combined program may enter the EM/IM/CCM program up to the beginning of the R-5 level.
• A transitional year of training will provide no credit toward the requirements of either Board.

Residents who enter combined IM/EM/CCM training programs as an R-2, R-3 or R-4, must be offered, and complete a fully-integrated curriculum.

Residents transferring from a combined training program to a categorical emergency medicine or internal medicine program must have prior approval from the specialty Board whose categorical training program would accept the resident.

Training in each discipline must incorporate graded responsibility throughout the training period. Each resident must have six months of supervisory responsibility in internal medicine and six months in emergency medicine. The supervisory training may be distributed over the R-2 through R-5 years.

The Training Director(s)

The combined training must be coordinated by a designated director or co-directors who can devote substantial time and effort to the educational program. An overall Program Director may be appointed from either specialty, or co-directors may be appointed from internal medicine, emergency medicine, or critical care medicine. If a single Program Director is appointed, an Associate Program Director from the other two specialties must be named to ensure both integration of the program and supervision of each discipline. An exception to the above requirements would be a single director who is board certified in each discipline and has an academic appointment in each department. The director and associate directors should embrace similar values and goals for combined training.

Length of Training

The training requirements for credentialing for the certifying examination of each Board will be fulfilled in 72 months of the combined training. This shortening of training, from that required for completion of three separate training programs, is possible due to coherent, and planned appropriate overlap of training requirements.

Core Curriculum Requirements

A clearly described, written curriculum must be available for residents, faculty, ABEM, ABIM, and both Residency Review Committees.

The 36-month internal medicine training requirement is met by:

1. 27 months of IM training;
2. Six months obtained during EM supervised training; and
3. Three months obtained during CCM supervised training.

Likewise, the 36-month emergency medicine training requirement is met by:

1. 27 months of EM training;
2. Six months obtained during IM supervised training; and
3. Three months obtained during CCM supervised training.

Finally, the 24-month CCM training requirement is met by:

1. 18 months of CCM training;
2. Three months obtained during IM supervised training; and
3. Three months obtained during EM supervised training.

The curriculum must assure a cohesive, planned, educational experience, and not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the three specialties should be avoided. The curricular components must conform to the program requirements for accreditation in emergency medicine, internal medicine, and critical care medicine. This should include both the common and specialty-specific program requirements, addressing the six ACGME general competencies, incorporation of the ACGME Milestones for each specialty, discipline specific procedure requirements, and the duty hour and supervision standards. Periodic review of the program curriculum must be performed. This review must include the Program Directors from each department, as well as faculty and residents.

During the first year of training, to provide an initial acculturation to both emergency medicine and internal medicine, a minimum of five months of training must be spent under the direction of each specialty. During the final 48 months, continuous assignments to one specialty or the other should be not less than three, nor more than six months in duration.

Joint educational conferences involving residents from all three disciplines should be planned. The joint conference should specifically include the participation of all residents in the combined training program.

Requirements for Internal Medicine

Each resident must obtain 27 months of training under the direction of the internal medicine program. Twenty months must include experience with direct responsibility for patients with illnesses in the domain of internal medicine, including geriatric medicine. Each resident must be assigned a minimum of 12 months of inpatient clinical experiences on general internal medicine or subspecialty internal medicine rotations.

At least 33% of the 30 months in internal medicine must involve ambulatory experiences. The ambulatory experience for each resident must include a block experience(s) without other responsibilities for at least two months. Other ambulatory experience may include subspecialty clinics, walk-in clinics and brief rotations for appropriate interdisciplinary experience in areas such as dermatology, office gynecology and psychiatry. Residents are to be encouraged to follow their outpatients during the course of the patient's hospitalizations. The resident need not be scheduled in the continuity-care clinic during some emergency department and intensive care unit rotations; however, in any one year, the continuity clinic should not be interrupted by more than one consecutive month excluding vacation. Health maintenance, prevention, and rehabilitation should be emphasized. Residents should work in the clinics with other professionals such as social workers, nurse practitioners, physician assistants, behavioral scientists and dietitians.

The emergency medicine and critical care medicine requirements of the internal medicine training are met by rotations occurring during years 1–5 under the supervision of emergency medicine.

Experiences with the care of patients managed by the subspecialties of internal medicine must be provided to every resident for at least four months. Some of this must include experience as a consultant. Significant exposure to inpatient cardiology exclusive of coronary care unit assignment is necessary.

Residents must regularly attend morning report, medical grand rounds, work rounds and mortality and morbidity conferences when on internal medicine rotations.

Requirements for Emergency Medicine

Unless otherwise specified, all program and curricular requirements as described in the ACGME Program Requirements for Graduate Medical Education in Emergency Medicine must be met, including those related to the education and evaluation of residents under the ACGME Milestones for Emergency Medicine. The emergency department experience must provide the resident the opportunity to manage an adequate number of patients of all ages, and both sexes, with a wide variety of clinical problems. Twenty-seven months of training must be provided under the direction of emergency medicine faculty.

Training in emergency medicine must include the following experiences:

1. At least three percent of the patient population must present with critical illness or injury. The curriculum must include four months of dedicated critical care experiences, including critical care of infants and children. At least two months of these experiences must be at the PGY-2 level or above.
2. A pediatric experience, defined as care of patients less than 18 years of age, should be provided, consisting of five full-time equivalent months, or 20 percent of all emergency department encounters. At least 50 percent of the five months should be in an emergency setting. This experience should include the critical care of infants and children.
3. Experience in performing invasive procedures, monitoring unstable patients and directing major resuscitations of all types, in all age groups, must be provided. Each resident must maintain, in an accurate and timely manner, a record of all major resuscitations and procedures performed throughout the entire educational program.
4. Residents must have experience in Emergency Medical Services (EMS), emergency preparedness and disaster management. EMS experiences must include ground unit runs and direct medical command. This should also include participation in multi-casualty incident drills. Residents should have experience teaching out-of-hospital emergency personnel.
5. Each resident must obtain 27 months of training under the direction of the emergency medicine program.

Requirements for Critical Care Medicine

All of the ACGME program requirements for 24 months of accredited training in critical care medicine must be met during combined training. The critical care training must provide a balanced experience in a variety of critical care settings, and must be broad in scope. The critical care training must include a total of 14 months of direct responsibility in the care of critically ill patients. There must be three months of critical care training during the first four years of the combined program, one in year R-1 and two in years R-2, R-3 or R-4. Residents who are approved by ABEM and ABIM to enter the combined program at the R-2, R-3 or R-4 level must have completed this requirement in their previous training or must complete these three months of critical care training by the end of their R-4 year.

There must be eleven months taken during years R-5 and R-6 which provide critical care experience at a senior supervisory level consistent with fellowship training.

All procedural requirements for certification eligibility in CCM by ABIM must be satisfactorily completed. View CCM Training and Procedural Requirements.

CCM's training goal of assuming care for monitoring of patients before and after admission to a critical care unit is achieved by giving CCM credit for three months on general medicine rotations supervised by IM and three months on emergency department rotations supervised by EM during years R-2 through R-5.

Evaluation

The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment. The evaluations must be accessible for review by the resident, as well as the RRC site visitors. Written evaluation of each resident's knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semi-annually, and must be communicated to, and discussed with, the resident in a timely manner.

Both ABEM and ABIM require documentation that candidates for certification are competent in:

1. patient care and procedural skills,
2. medical knowledge,
3. practice-based learning and improvement,
4. interpersonal and communication skills,
5. professionalism, and
6. systems-based practice.

The Program Director must ensure the reporting of Milestones’ evaluations of each resident semi-annually to the ACGME.

There must be a method of documenting the procedures that are performed by the residents. Such documentation must be maintained by the Program Director and/or Associate Program Director, be available for review by the RRCs in emergency medicine and internal medicine, ABEM, ABIM and site visitors, and may be used to provide documentation for application for hospital privileges by graduates of these training programs.

Residents should be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.

The training program must maintain a permanent record of evaluation for each resident and have it accessible to the resident and other authorized personnel. The training director of the EM/IM program is responsible for provision of a written, final evaluation for each resident who completes the program. This evaluation must include specialty-specific milestones as one of the tools to ensure that residents are able to practice core professional activities without supervision upon completion of the program, and that they are prepared to apply for the certification processes of both ABEM and ABIM. This final evaluation must be part of the resident’s permanent record maintained by the institution.

Certification

To meet eligibility requirements for dual certification in IM and EM, the resident must satisfactorily complete 60 months of combined training that fulfills the Boards’ eligibility criteria and is verified by the program director of the IM and EM categorical programs. Lacking verification in one or both specialties, the resident must fulfill the categorical training requirements in either emergency medicine or internal medicine to meet the eligibility requirements in either specialty.

To meet eligibility for certification in CCM, the resident must be:

1. certified in IM or EM;
2. satisfactorily complete 72 months of combined training.

Failing to meet these requirements, the candidate must complete 24 months of accredited CCM training. Successful graduates may sit for the CCM examination through either the ABIM or the ABEM.

Approval and Effective February 10, 2017