Fellowships, Critical Care

Pathways to Critical Care Fellowship Training (Panel Discussion, ACEP14)

The Fellows' Perspective

Ann Tsung, MD. Ann is from the University of Florida and has matched at Washington University in St. Louis for an anesthesia critical care (ACCM) fellowship beginning July 2015.

Cindy Hsu, MD. Cindy is a first year at University of Maryland/Shock Trauma Center (STC) in a two-year surgical critical care (SCCM) fellowship.

John Greenwood, MD. John is in his final year of a two-year medical critical care (IM-CCM) fellowship at the University of Maryland.

The following is taken from our critical care fellow panel discussion at ACEP 2014.
See Virtual ACEP14 at https://bookstore.acep.org/en/virtual-acep14-314014.

Full text transcription can be found on the EMRA Critical Care Division website at

Q. Each of the fellowship tracks have particular quirks associated with them. Can you all discuss the application timeline, prerequisites, and fellowship structure as it pertains to your specific track?

Ann: For ACCM, you need to determine your career path pretty early on. My year was the first year that anesthesia filled their spots though a match, the SF match. I didn't find out until March that the match list was due in May. I was pretty late to the process. At that time there were 13 approved programs (now there are 16) and that's how I narrowed my search.

John: For the IM-CCM track, there are prerequisites of six months of internal medicine rotations. Three have to be done in the medical ICU and three others outside the MICU setting. Coming from a three-year program, I had to be efficient with my elective time. I spent one month with the infectious disease team in the ICU. When I started fellowship, I only had five months of prerequisites out of the six. If you are able to knock them out during residency, it is helpful.

Cindy: The inherent hesitancy many people have applying to an SCCM pathway rests in the first year. People are afraid that they may get dumped on with scut instead of learning what you need to know to work in the ICU. When I went to Shock Trauma, I knew it was a group of surgeons who were dedicated to teaching EM candidates. Three months of the first year are in the ICU and we have two months of trauma surgery, acting as the fellow. The rest are surgical rotations where you act as an intermediate trainee. Every other day you operate and the other days you hold the pager and manage the service. In cardiac surgery, you help cannulate for V-V ECMO, and you get to learn from the perfusionists.

 Q. What are some tips for making yourself a successful critical care fellowship applicant?

Ann: I got the advice in my intern year to ask for letters right after my rotations. I obtained one from my MICU attending and the SICU director after each of my rotations.

John: I got a letter from our ED Medical Director who is active in critical care, our EM program director, and one letter from an attending I had on a trauma ICU rotation. Even though it was a trauma ICU letter for an IM-CCM program, I felt like getting it from someone who can write you a strong letter and has a relationship with you will benefit you.

Lilian Emlet (Program Director, University of Pittsburgh IM-CCM Program): I'm glad you brought up this point. When asking for letters, it probably won't matter if Judy Tintinalli wrote your letter. The letters should come from intensivists. It doesn't matter greatly if it is Pulm/CCM, Anesthesia CCM, or Surgery CCM. If I get three EM letters, I won't interview that candidate.

Brian Wessman (Program Director, Washington University ACCM Program): A program director letter is necessary because they know you in a longitudinal fashion. If I get a letter from someone I know, that goes a long way. I agree it is important to get letters from intensivisits.

Cindy: My advice is to do a senior level ICU rotation. Go back to whatever unit you enjoyed. Advocate for yourself if there is flexibility within your residency program to do a senior rotation, even if it is not set up within the standard curriculum.

John: That's an awesome point. If the ability to do senior level rotations in various ICUs isn't built into your curriculum it can be challenging. My colleague wanted to act as a senior resident in the medical ICU and met some initial resistance. But she was smart and persistent, and she had developed some relationships that helped her ultimately obtain that rotation.

Q. How are the curriculums of the different fellowship tracks different?

John: In IM-CCM, you need 12 months of critical care to meet ABIM requirements. We get much of that done in our first year. In our second year, we do six months critical care and six month elective. It gives you flexibility to do more research or to create your own track with elective time. I've created a cardiology and cardiac surgery track for myself with that time.

Brian Wessman: In our ACCM program's curriculum, we have 18 months of ICU time. Six months in a medical ICU, nine months in a surgical ICU, one month in the Neuro ICU, and one month of CCU. We also have elective time for things like nutrition and bronchoscopy. There is also room for research or other electives like renal and infectious disease. Medicine programs, the way they are set up, may give you more time to do research. The way the surgical and anesthesia programs are set up emphasize clinical electives over research elective.

Cindy: The first year for SCCM I spoke about earlier. The second year is more traditional surgical critical care, where you can do months in the medical ICU, and in a critical care resuscitation unit, which acts like an ED ICU/receiving ICU. It is a clinically heavy training program. The downside of this pathway is the lack of elective time if you were really interested in something like research.