Anesthesiology and Emergency Medicine Combined Training Guidelines

INTRODUCTION

The ABA and the American Board of Emergency Medicine (ABEM) offer dual certification in emergency medicine and anesthesiology. A combined residency consists of five years of balanced education in the two disciplines, not seven years, as would be necessary if these two residency programs were completed separately or sequentially. Upon completing this combined program, physicians will have met the training criteria for initial certification in anesthesiology and emergency medicine.

Combined training includes the components of independent emergency medicine and anesthesiology residencies, which are accredited respectively by the Residency Review Committee (RRC) for each specialty, both of which function under the auspices of the Accreditation Council for Graduate Medical Education (ACGME).

Every program that wishes to offer this combined training must be approved by both ABEM and ABA 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 administering combined programs and may not alter the guidelines without the written consent of both boards.

To be eligible for dual certification, the resident must satisfactorily complete 60 months of combined education, which must be verified by both programs’ program director and associate program director, if applicable. Physicians cannot take final certifying exams in emergency medicine or anesthesiology until they have successfully completed all five years of the program.

OBJECTIVES

Combined training in emergency medicine and anesthesiology should promote the development of physicians who are fully qualified in both specialties. Physicians completing this training should be competent emergency physicians and anesthesiologists, capable of professional activity in either discipline. The strengths of the residencies in emergency medicine and anesthesiology should complement each other to provide an optimal educational experience to trainees.

Combined training includes components of emergency medicine programs that are independently accredited, respectively by each specialty’s RRC. While combined training will not be independently accredited by the RRCs and the ACGME, the continued approved accreditation status of the parent emergency medicine and anesthesiology programs is essential for the stability and continued approval of the combined training program. Thus, residents for combined training must not be recruited if the accreditation status of either core program is probationary or provisional. Proposals for combined residency training programs must be submitted to and approved by ABEM and ABA before a candidate can be accepted into joint training.

Both boards encourage residents to extend their training for an additional sixth year, or more, in subspecialty training in emergency medicine or anesthesiology, and/or investigative, administrative, or academic pursuits. This helps prepare graduates of this combined training program for careers in research, teaching, or departmental administration, and encourages them to become leaders in their fields.

GENERAL REQUIREMENTS

Combined training in anesthesiology and emergency medicine must include at least five years of cohesive training, integral to residencies in the two disciplines, that meets the program requirements for accreditation by each specialty’s RRC.

Combined training must be conducted under the umbrella of the Committee on Graduate Medical Education within a single institution and its affiliated hospitals. Documentation of hospital, university, and faculty commitment to the program must be available in signed agreements. Affiliated institutions must be located close enough to facilitate cohesion among the house staff, attendance at continuity clinics and integrated conferences, and faculty exchanges of curriculum, evaluation, administration, and related matters.

Ideally, at least one resident should be enrolled in combined training each year. A combined training program with no trainees for a period of five years will no longer be approved. ABA and ABEM will only approve a combined training program intended to be offered to residents annually and will not approve a training track for a single resident.

Characteristics of Eligible Combined Residencies

The two participating core residency programs must be accredited by ACGME and in good standing. Both programs must be located within the same academic medical center. Proximity between rotation locations must be close enough to facilitate cohesion among the residents, attendance at conferences when scheduled, and faculty exchanges of curriculum, evaluation, administration, and related matters. The same ACGME sponsoring institution should sponsor them both.

RESIDENTS

Residents should enter a combined program at the PGY-1 level. A resident may enter a combined program at the PGY-2 level only if the first residency year was served in an accredited residency in emergency medicine in the same institution. Residents may not enter combined training beyond the PGY-1 level or transfer between combined training programs in different institutions unless prospectively approved by both boards. If they transfer between combined training programs, residents must be offered and complete a fully-integrated curriculum. A transitional year of training will provide no credit toward the requirements of either board.

A resident transferring from a combined training program to an anesthesiology or emergency medicine program must have prior approval from board whose training program would accept the resident.

TRAINING PROGRAM DIRECTOR(S)

The combined residency must have one designated program director who will be responsible for all administrative aspects of the program and who can devote substantial time and effort to the educational program. This individual can be the director of either specialty’s residency program; the program director of the other categorical residency program will be designated the associate program director of the combined program. An exception to this requirement would be a single director who is certified in both specialties and has an academic appointment in each department.

The program director is responsible for ensuring that all aspects of the program requirements are met. This individual, along with the associate program director, should submit the application for the program to both ABEM and ABA. Once the combined program is approved, these individuals should notify both boards if any significant changes occur in either of the associated residency programs. The program director and associate program director are responsible for completing evaluation forms for all trainees in the combined program as required by their respective boards, and both must verify satisfactory completion of the training program on the resident’s final evaluation form.

The training of residents in emergency medicine is the responsibility of the emergency medicine faculty, and the training of residents in anesthesiology is the responsibility of the anesthesiology faculty. There should be an adequate number of faculty members who devote sufficient time to provide leadership to the combined residency program and supervision of the residents. It is recommended that some faculty members have completed training in these two specialties. Since each component of the residency must be accredited by its respective discipline, the faculty must meet the requirements for their specialty.

Emergency medicine faculty must be certified by ABEM or have equivalent educational qualifications in emergency medicine. Anesthesiology faculty must be certified by ABA or have equivalent educational qualifications in anesthesiology.

TRAINING    

The training requirements for eligibility for the certification process of each board can be fulfilled by the satisfactory completion of 60 months of approved combined training. A reduction of 24 months over that required for the two separate residencies is possible due to the overlap of curriculum and experience inherent in the training of each discipline. The requirement of 48 months of training in anesthesiology is met by the 12 months of the first year of residency in emergency medicine, 30 months of training in the anesthesiology component of the combined residency, and additional overlap between anesthesiology and emergency medicine.  This ensures an adequate distribution of the emergency medicine rotations. The working relationships developed among categorical and combined residency trainees will facilitate communication between the two specialties and increase the exposure of categorical residents to the other discipline. Training in each discipline must incorporate graded responsibility throughout the training period.

• During PGY-1, surgery, obstetrics-gynecology, neurology, pediatric emergency medicine and three other elective rotations will qualify for meeting both the anesthesiology and emergency medicine requirement.
• During PGY-2-5, residents will have six months of training in emergency medicine and six months of training in anesthesiology. Rotations of shorter duration, but not less than three months in each specialty, are also acceptable. The critical care medicine rotation will qualify for both the anesthesiology and emergency medicine requirements.
• During the PGY-5 year, in addition to the critical care medicine rotation, the resident may select one elective rotation for credit for both anesthesiology and emergency medicine.  The ABA and ABEM will review the program’s proposed block diagram to determine whether there is sufficient exposure to each specialty throughout each academic level as well as the totality of the combined training program.
• It is important that program directors make certain that in PGY 3-5, PGY-4, and PGY-5, each resident will have 18 months of training in each specialty.

CURRICULAR REQUIREMENTS

A clearly described, written curriculum must be available for residents, faculty, ABEM, ABA and each specialty’s RRC. The curricular components must conform to the program requirements for accreditation in emergency medicine and anesthesiology. 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 and the duty hour and supervision standards. The curriculum must ensure a cohesive, planned, educational experience and continuum of training, rather than providing an uncoordinated series of rotations in each specialty’s program requirements.

Duplication of clinical experiences between the two specialties should be avoided. Periodic review of the residency curriculum must be performed by the program director and associate program director in consultation with residents and faculty from both departments. Combined training must not interfere with or compromise the training of the categorical residents in either field.

Joint educational conferences involving residents from emergency medicine and anesthesiology are desirable and should specifically include the participation of all residents in the combined program whenever possible.

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. 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.

Training in emergency medicine must include the following experiences:

• 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.
• 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.
• 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.
• 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.
• The resident must complete a minimum of six months of emergency medicine in the final year of training. The other five months may be emergency medicine rotations or electives, including possible anesthesiology rotations, as determined by the combined program and approved by both the ABA and ABEM.

REQUIREMENTS FOR ANESTHESIOLOGY

The development of the resident’s anesthesiology skills will be fostered by rotations in anesthesiology and its subspecialties, caring for adults and pediatric patients. The training should be the same as described in the ACGME Program Requirements for Graduate Medical Education in anesthesiology with the following exceptions.

The requirement of 48 months of training in anesthesiology is met by the 12 months of the first year of residency in emergency medicine (to satisfy clinical base year training requirements for anesthesiology), 30 months of training in the anesthesiology component of the combined residency, and six months of credit for training, appropriate to anesthesiology obtained during the remaining 18 months of residency in emergency medicine.

Training in anesthesiology must include the following experiences:

• Two identifiable, one-month rotations in obstetric anesthesia, pediatric anesthesia, neuroanesthesia, and cardiothoracic anesthesia, with graded levels of responsibility and complexity of the patient populations
• At least four months of critical care medicine experience during the 60 months of combined training
• Three months of pain medicine; this may include one month in an acute perioperative pain management rotation, one month in the assessment and treatment of inpatients and outpatients with chronic pain problems, and one month of regional analgesia experience
• One-half month in a preoperative evaluation clinic
• One-half month in a post-anesthesia care unit
• Advanced experiences can be in additional, focused anesthesiology subspecialties, related areas, or research
• Rotations in a single anesthesiology subspecialty must not exceed six months total
• Minimum clinical experiences as defined by the program requirements for anesthesiology must be met

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 ABA require documentation that candidates for certification are competent in (a) patient care and procedural skills, (b) medical knowledge, (c) practice-based learning and improvement, (d) interpersonal and communication skills, (e) professionalism and (f) systems-based practice.

The program director must appoint the Clinical Competency Committee (CCC). At a minimum, the CCC must be composed of three members of the program faculty from each core program. There must be a written description of the responsibilities of the CCC. Each CCC should (a) review all resident evaluations semi-annually, (b) prepare and ensure the reporting of milestones evaluations of each resident semi-annually to ACGME and (c) advise the program director regarding resident progress, including promotion, remediation and dismissal.

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 each specialty’s RRC, ABEM, ABA 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 program director and associate program director are responsible for the maintenance of a permanent record of each resident and must enable accessibility to the record by the resident and other authorized personnel. The program director, associate program director, and faculty are 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 ABA. This final evaluation should be part of the resident’s permanent record and should be maintained by the institution.

ELIGIBILITY FOR CERTIFICATION

Residents in a combined emergency medicine and anesthesiology training program must satisfactorily complete the specific requirements of both ABEM and ABA to be eligible for each board’s exam.

Clinical competency must be verified by both the program director and associate program director of the combined program. Lacking this verification, the resident must satisfactorily complete a fully- ACGME–accredited residency program in emergency medicine or anesthesiology, as well as 12 months of education in fundamental clinical skills of medicine during a PGY-1 year, to qualify specifically for the anesthesiology exams.

Residents who wish to be certified by ABA will be required to take the BASIC Exam, offered to residents at the end of their CA-1 year. It focuses on the scientific basis of clinical anesthetic practice and is offered twice per year. A resident who fails the BASIC Exam for the first time may take it again at the next opportunity. A resident who fails the BASIC Exam a second time will automatically receive an “unsatisfactory” for the reporting period during which the exam was taken. After a third failed attempt, a resident will be required to complete six months of additional training under the guidance of the anesthesiology training program. After a fourth failed attempt, a resident will be required to complete an additional 12 months of residency training also under the direction of the anesthesiology training program. Continuation of residency training is at the discretion of the individual training program. A resident cannot graduate from anesthesiology residency training without passing the BASIC Exam. The Board strongly encourages residents to register and take the BASIC Exam as soon as they meet the requirements.

Upon successful completion of all requirements of the combined training program, a resident meets the training criteria for initial certification of both ABEM and ABA. Residents may apply for the emergency medicine certifying examination and the anesthesiology ADVANCED Exam during their fifth year of training. However, applicants may not take either of these exams until all of the combined residency training requirements have been successfully completed. The ABA’s APPLIED Exam can occur the following year at the earliest. Each board will certify the candidate, upon successful completion of its certifying requirements. Certification in one specialty will not be contingent upon certification in the other. It is the candidate’s responsibility to complete the certification process in each specialty.