Critical care is an integral part of emergency medicine (EM) practice, and critical care fellowship training is becoming an increasingly common training pathway for graduating emergency medicine residents (Gaeta et al, 2024). Many pursue critical care with the hope of maintaining a career in both EM and critical care, only to find that this dream job rarely exists.
A 2016 survey of emergency physicians (EP’s) who were completing or had completed critical care fellowship showed that 90% desired a dual practice; however, only 63% of dual-trained EPs were successfully practicing both EM and critical care (Strickler et al, 2019). As workforce forecasts are predicting a surplus of approximately 10,000 emergency physicians by 2030, finding a dual appointment will only become more challenging (Marco et al, 2021).
Furthermore, when EM intensivists are forced to choose between the ED and the ICU, they overwhelmingly choose to leave emergency medicine behind. But why do physicians with a specialized skillset that is valuable in both the ICU and ED find themselves leaving their initial specialty of choice?
The acute resuscitation of sick patients is what many EPs love most about their jobs, and EM intensivists bring an added level of expertise to these situations. The ability to initiate treatment and smooth out the clinical transition from the ED to the ICU is of particular value. Yet the practice environment and paradigm in the ED create frustration for both EPs and EM intensivists alike, nudging EM intensivists towards an oftentimes more rewarding work environment in the ICU. The pressure to move patients through the ED as quickly as possible often limits the time that EP’s can devote to caring for their critically ill patients.
At the same time, the focused practice of EM is often at odds with the more “maximalist” approach of critical care, where time and resources allow for the workup of an expanded differential and meaningful connections with patients and families. Although the “ED ICU” model is a potential solution to this internal tension, it is not a widely adopted practice model, for various reasons: the ED ICU model is limited in its ability to function as a true ICU due to issues maintaining 24/7 EM intensivist staffing, appropriate nursing staffing, the realities of ED and ICU bed scarcity, and the competing priorities of other critical care spaces throughout healthcare systems.
Another challenge EM intensivists face is finding a hospital where both ED and ICU leadership support a fruitful split practice. Stickler et al found that the most common barriers to a dual practice, cited by EM intensivists, were difficulty finding a balance in practice between EM and critical care along with the administrative logistics of employment (2019). EM intensivists looking for a dual appointment have little bargaining power when negotiating for their clinical time with two separate departments. An anesthesiologist practicing critical care and anesthesiology is usually hired under a single organizational umbrella in a Department of Anesthesia, allowing for a flourishing split practice.
Pulmonary critical care physicians bill for services for the same cost center, whether they are acting as a pulmonology consultant or an intensivist. Because EM and critical care are administratively separate practices, split full time equivalents (FTEs) often result in the EM intensivist filling in as a “line doc” within each department, with less opportunity to occupy leadership positions or demonstrate his or her translational value to the larger organization. Additionally, the varied definitions of what constitutes a 1.0 FTE clinical load can increase the administrative burden on dual-practice EM intensivists, who can find themselves working more clinical shifts and fulfilling more administrative and clinical responsibilities to meet the requirements of two departments.
Financial incentives also compel many EM intensivists to work exclusively in the ICU. EM intensivists working in surgical critical care, for example, benefit from the competitive anesthesia market, and a sole (surgical) ICU practice often becomes more lucrative than an exclusively EM or dual practice. A known shortage of intensivists, coupled with the predicted surplus of EP’s, will likely make these financial disparities more pronounced in the coming years (Pastores et al, 2019).
With significant barriers to a dual practice, additional administrative headaches, and financial losses, one might ask why an EM intensivist would want to continue practicing EM. Yet most EM intensivists still desire a dual practice. There are a few institutions throughout the country that have been able to create an environment welcoming to EM intensivists and these typically require careful negotiation and much collaboration between departments. Unfortunately, for most EM trainees graduating from critical care fellowship, this will not be their experience.
As the EM practice environment continues to grapple with the challenges inherent to our fractured healthcare and public health systems, more exit strategies will be pursued by an increasingly burned-out EP workforce. Nonetheless, we believe that EM intensivists can be drawn back to the ED and function as a valuable resource.
EM intensivists’ expertise in hemodynamics, mechanical ventilation, and advanced procedures can be leveraged across roles in education and clinical and operations leadership. Their ability to interface with both the ED and the ICU makes them valuable as administrators, with ideal training and perspective to open communication lines within the hospital for the purposes of shared protocol development and optimizing admissions throughput processes and hospital quality metrics.
Utilizing EM intensivists in these ways will require collaborative partnerships with department leadership and the flexibility to move beyond typical hospital silos. Until then, many EM intensivists who reluctantly left EM for critical care look forward to a time when their “first love” is once again a gratifying place to practice and contribute.
Citations
Gaeta, T.J. et al. American Board of Emergency Medicine Report on Residency and fellowship Training Information (2023-2024). Ann Emerg Med. 2024;84:1,65-81.
Strickler, S. S. Emergency physicians in critical care: where are we now?. JACEP Open. 2020;1:1062-1070.
Marco, C.A. et al. The Emergency Medicine Physician Workforce: Projections for 2030. Ann Emerg Med. 2021;78:6,726-737
Pastores, S. M. et al. Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Critical Care Medicine. 2019;47:4,550-557.