Emergency Medicine/Internal Medicine Combined Residency Graduates Have High Career Satisfaction and Commonly Practice in Both Specialties

Abstract

Objectives

The first combined emergency medicine/internal medicine (EM/IM) residency was established in 1991. As the 30th anniversary of this unique dual‐training opportunity approaches, multiple changes to the practice and educational landscape have occurred. Previous surveys examining this topic are now more than 10 years old and occurred prior to the establishment of the EM/IM/critical care medicine (EM/IM/CCM) pathway. We conducted a survey to investigate career trajectories, satisfaction, and opportunities available to EM/IM graduates.

Methods

Survey questions were developed to both allow for comparison with previously published data and examine new topics not previously investigated. A group of EM/IM and EM/IM/CCM program directors validated the survey questions. Eligible respondents were identified and contacted through their previous residency program leadership.

Results

Fifty‐two percent (152/290) of graduates completed the survey. Thirty‐seven percent of respondents practice both EM and IM, 51% practice EM only, and the remainder practice IM only. Thirty‐one percent of total respondents completed a fellowship, with critical care being the most popular choice. Seventy‐one percent of graduates practice in an academic center, and many hold leadership positions within education, research, and hospital administration. Eighty‐seven percent of graduates were “extremely satisfied” with their choice to pursue EM/IM or EM/IM/CCM and 95% reported that they would choose this path again.

Conclusions

Most respondents are satisfied with their residency choice and would choose to pursue this training again, despite the additional years of training. The proportion of graduates pursuing fellowship is higher than previously published data. Most continue to work in academics, and many are leaders within their institutions. The changing health care landscape offers multiple opportunities to dually trained graduates.

Over 30 years ago, Dr. Robert Dailey submitted a letter to Annals of Emergency Medicine advocating for the creation of combined residency training programs in emergency medicine and internal medicine (EM/IM). ¹ Dr. Dailey's letter preceded the achievement of independent primary board status for EM, triggering concerns about prematurity in considering the establishment of dual‐training programs. ² , ³ EM achieved primary board status in 1989, and 2 years later the American Board of Internal Medicine (ABIM) and the American Board of Emergency Medicine (ABEM) published EM/IM residency training program guidelines, marking the beginning of combined EM/IM residency programs in their current format. ⁴

Subsequent analysis of the career outcomes of EM/IM graduates has occurred infrequently and with narrow focus, with the most recent data published in 2009. ⁵ Notable changes to the practice landscape in EM and IM have occurred since that time, including the rise of hospital and observation medicine and the availability of board certification in critical care medicine (CCM) following emergency medicine training. Furthermore, outcomes of EM/IM/CCM graduates, a 6‐year pathway leading to board eligibility in all three specialties that was developed in 1999, have never been described. ⁶

As the 30th anniversary of the establishment of EM/IM training programs approaches, this study seeks to provide an updated and detailed description of the career outcomes of EM/IM and EM/IM/CCM graduates.

Methods

This study was a survey of graduates of combined EM/IM and EM/IM/CCM residency programs. Graduates of programs in which the component categorical programs in EM, IM, and CCM were not accredited by the Accreditation Council for Graduate Medical Education (ACGME) were excluded. This study was reviewed by the institutional review board at Hennepin Healthcare in Minneapolis, Minnesota, and found to be exempt.

Survey Development

Selected survey questions were adapted from previous studies to allow for comparisons to previously published results. ⁵ , ⁷ Additional survey questions were developed by the study authors. Content validity evidence was established by expert review consisting of residency program directors for EM/IM and EM/IM/CCM programs. Response process validity was established by a group of pilot participants composed of graduates of EM/IM and EM/IM/CCM programs.

Study Protocol

Emergency medicine/internal medicine and EM/IM/CCM residency training programs were identified using the Fellowship and Residency Electronic Interactive Database (FREIDA). American College of Emergency Physician listservs were utilized to find additional programs that had previously closed. Eligible study participants were identified through correspondence with residency program coordinators and program directors. Participants were e‐mailed a link by the study authors to complete the survey anonymously using a Web‐based platform (Qualtrics, Provo, UT). Responses were confidential. Eligible participants were first contacted in July 2017 and reminders were sent to maximize responses.

Data Analysis

Descriptive statistics were calculated using Microsoft Excel.

Results

We identified 316 graduates from 11 EM/IM and five EM/IM/CCM training programs. E‐mail addresses were available for 92% (290/316) of identified graduates, and 52% (152/290) completed the survey.

Outcomes for fellowship training, practice patterns, and practice characteristics for EM/IM and EM/IM/CCM graduates are described in Table 1. Frequency of practice in both specialties is similar for graduates of different years, with the exception of 2016 to 2017, for whom 62% report practicing both EM and IM (Data Supplement S1, Table S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10493/full).

Table 1.

Fellowship Training and Practice Patterns for EM/IM and EM/IM/CCM Graduates

	EM/IM	EM/IM/CCM
Fellowship
Pulm/CCM	4%	n/a
CC (1 or 2 year)	12%	n/a
Other	15%	5%
No additional fellowship	69%	95%
Practice setting
EM only	69%	23%
IM only	5%	18%
EM and IM	26%	59%
IM: Outpatient	9%	0%
IM: Inpatient	14%	5%
IM: ICU	2%	55%
Geographic location
Urban	66%	68%
Suburban	28%	27%
Rural	6%	0%
Military	0%	5%
Academic practice	30%	23%
Leadership position noted	29%	18%

CC = critical care; EM/IM = emergency medicine/internal medicine Pulm/CCM = combined pulmonary and critical care medicine fellowship.

Fellowship were entered by 31% of EM/IM graduates, with 16% choosing critical care training of some type. Specific fellowships included critical care (inclusive of CCM and surgical critical care; 17), pulmonary/critical care (5), infectious disease (ID)/critical care (1), ultrasound (3), pediatric EM (1), emergency medical services/disaster (1), administration (2), health policy research (1), toxicology (1), ID (4), geriatrics (1), renal (1), simulation (1), and sports medicine (1).

All graduates obtained initial board certification in EM. All EM/IM/CCM and 96% of EM/IM graduates obtained initial board certification in IM. Ninety‐five percent of all graduates are planning to recertify in EM, while 86% of EM/IM graduates and 100% of EM/IM/CCM graduates are planning to recertify in IM.

A leadership role was listed by 29% of EM/IM and 19% of EM/IM/CCM graduates as part of their current position. Combined training may increase competitiveness for positions with 75% responding that their training was “extremely important” or “very important” to obtaining their current position. Specific leadership roles cited included ED chair, assistant dean of medical education, vice chair of research, multiple NIH‐funded investigators, associate editor for a leading EM journal, chief medical officer, EMS medical director, program director, and assistant program director.

Graduates report high rates of satisfaction with their training. Of 87% report being “extremely satisfied” and 12% reporting being “somewhat satisfied.” No graduates expressed dissatisfaction with their training. Ninety‐five percent reported that they would pursue combined training again. Reasons cited for high satisfaction included well‐roundedness, opportunities to work in academics, increased intensive care unit experience, wider breadth of knowledge, understanding systems, and preparation for international practice. Comments included, “It not only served me … to get me an academic position in a top hospital, but it led to my current position that I never could have imagined in residency” and “I don't think there is any question that an EM/IM training program produces outstanding physicians and the combined program is perfect for those going into critical care medicine.”

When asked how practical it is to work both in EM and IM, there was a wide distribution in answers, with most respondents noting that it is “moderately practical.” Of 90% feel that obtaining a position with both IM and EM clinical practice required “somewhat” or “much more” effort than a position with either one alone. Factors contributing to difficulties finding an EM/IM position include scheduling, splitting salary between two departments, and staying up to date with two specialties, with one graduate noting “Every place that I discussed working in both settings were very supportive, but we kind of have to start from scratch in determining the logistics.”

Discussion

This study reflects a contemporary analysis of the career outcomes of EM/IM and EM/IM/CCM graduates and utilized best practices to strengthen its validity argument. These findings are relevant for medical students considering EM/IM and EM/IM/CCM, current residents, program leadership, employers, and entities involved in the supervision of these programs.

Anecdotally, medical students frequently receive advice to not choose combined programs, with a primary reason cited being the assertion that graduates from combined programs only practice in one specialty. Approximately one‐quarter of EM/IM graduates in this study practice in both EM and IM, while the majority of EM/IM/CCM graduates practice in both specialties. As a whole, the percent practicing in both specialties is similar to previous descriptions, including 30 and 37% in studies published in 2002 and 2009, respectively. ⁵ , ⁷ This indicates some stability over time, however, the high rate of dual practice in graduates from recent years (Data Supplement S1, Table S1) may suggest increasing popularity of dual practice. Furthermore, the proportion practicing in internal medicine has increased, likely reflecting increased practice in critical care. ⁵ , ⁷

The frequency of academic practice for combined graduates is much higher than is reported in previous descriptions of EM residency graduates. ⁸ In 1987, Dr. Dailey wrote that “physicians so ‘double boarded’ have been quietly making a contribution to our specialty, especially in the academic sphere.” Each of the studies examining outcomes of EM/IM graduates has found overrepresentation in academics and administrative leadership positions. ⁵ , ⁷ , ⁹

Despite a longer residency, fellowship training is common. The 31% cited in this study represents an increase from the 24% reported in 2009 and the 4% cited in 2002. ⁵ , ⁷ A possible explanation for the higher percentage of graduates entering fellowship is the need for advanced training to secure academic and/or leadership positions.

The challenges of practicing in multiple specialties were noted in this study. Historically these may have been greater in private practice and may account in part for the high percentage of graduates in academic practice.

Changes in the practice landscape may influence the career choices of EM/IM and EM/IM/CCM graduates. The rise of hospital medicine and observation medicine offer additional practice opportunities well suited for graduates. The growth of large groups that increasingly manage both EM and hospital medicine practices may create more opportunities for dual practice outside of academics. Eligibility of categorical EM graduates for CCM board certification may decrease the number of EM/IM graduates choosing CCM over time.

Limitations

Limitations to this survey include a lower‐than‐desired response rate, although the total sample is larger than in previous studies. ⁵ , ⁷ Contact information was not available for a substantial number of graduates, and privacy considerations limited the ability of large national organizations to assist with filling these gaps. Graduates from 2000 onward completed the majority of the responses, indicating a possible bias toward more recent graduates. Given that participants were identified through their residency training program, this may have contributed to an overrepresentation of graduates in academic practice. Representative quotes from study respondents were chosen without utilization of formal qualitative methodology; therefore, conclusions from these responses are limited.

Conclusions

Emergency medicine/internal medicine and emergency medicine/internal medicine/critical care medicine graduates report high rates of satisfaction with their training, and most graduates reported that their combined training was integral to obtaining their current positions. Fellowship training and academic practice are frequently chosen. For graduates who do not pursue fellowship, emergency medicine only, and practice in both emergency medicine and internal medicine is common.

Supporting information

Data Supplement S1. Practice Pattern by Graduation Year.

AEM Education and Training 2021;5:1–4