Authors:  Matthew Huang, MD, Jason Nace, MD, and Brian Levine, MD, Christiana Care Health System, on behalf of the CORD Medical Student Advising Task Force

In June 1989, the American Board of Emergency Medicine (ABEM) and American Board of Internal Medicine (ABIM) approved a training pathway that would allow for candidates to complete a five-year curriculum, through which they could be eligible for board certification in both emergency medicine (EM) and internal medicine (IM).  As of 2017, there are currently 11 Accreditation Council for Graduate Medical Education (ACGME) EM/IM programs accepting applicants. Choosing this specialty and applying to these programs is similar in many ways to the application process for categorical EM. There are, however, some nuances and details that prospective applicants should know. Below is a list of frequently asked questions that may help to guide and direct those who are interested.

 

Why would someone choose to apply to an EM/IM residency?

 

The reasons as to why one pursues a combined residency varies from person to person. For most combined residents the decision typically revolves around their long-term goals. These goals include careers in critical care, academics, administration, and international medicine to name a few. They see the utility of both specialties and how each may enhance their future career goals. Given the 5-year length of training, most programs also incorporate leadership roles and other extracurricular opportunities. This adds another layer of training that may not be as easily accomplished in a 3 or 4-year residency. In 2002, Katz and Katz[1], a study surveying recent EM/IM graduates found that the most common reasons that these graduates choose an EM/IM residency was to (1) be a better physician (2) practice in both fields and (3) become better prepared for an academic career. A later study in 2011[3], which surveyed a group of then current EM/IM residents, showed that 47% intended to pursue fellowships, 81% indicated intent to practice academic medicine, and 96% planned to allocate at least 10% of their future time toward an university/academic setting.

 

What do most EM/IM graduates end up doing after residency? Are they happy with their residency choice?

 

A majority of EM/IM graduates practice emergency medicine only. Several of the reasons for this include pay, lifestyle, and availability of combined EM and IM job opportunities. Katz and Katz[1] found that 65.2% of their surveyed graduates practiced EM only, 30.4% practiced EM and IM, 4.3% practiced IM only. A later survey study in 2009[2] reflected similar results showing 55% of graduates practiced EM only, 37% practiced both EM and IM, and 7% practiced IM or an IM subspecialty only. All studies evaluating satisfaction found a majority of EM/IM residents and graduates to have high satisfaction with their career and residency choice.[1,2,3] One study found 94% of  those surveyed to be (1) satisfied with their residency choice, (2) believed that a combined residency will advance their career, and (3) would repeat a combined residency if given the opportunity.[3]

 

What are EM/IM/CCM programs?

 

In 1999, ABEM and ABIM announced they would offer triple board certification in emergency medicine, internal medicine, and critical care medicine (CCM) for those who complete a 6-year accredited EM/IM/CCM residency. As of 2017 there are currently 5 ACGME accredited EM/IM/CCM programs. There is no direct application for these programs. Prospective students apply to the traditional EM/IM program at one of these 5 residencies. If accepted they have the option of enrolling in the EM/IM/CCM program. Residents in both the EM/IM and the EM/IM/CCM programs have nearly identical rotations and responsibilities during their first 4 years. The difference comes during the 5th and 6th year of residency where residents in the EM/IM/CCM track complete eleven months of critical care rotations at a senior supervisory level. At completion, residents are eligible to sit for all three board exams.

 

How do I apply to EM/IM programs?

 

Applications are handled through the Electronic Residency Application System (ERAS) and the National Residency Match Program (NRMP). EM/IM programs are ranked as a single program. If an applicant also wants to apply separately to a categorical EM or IM program, then a separate ERAS application would be required. For more information on the general application process please see the CORD Emergency Medicine Applying Guide and FAQ (https://cordemblog.wordpress.com/2016/07/07/student-advising-a-comprehensive-guide-and-faq/).

 

How competitive is it to apply to EM/IM programs?

 

As a general rule of thumb EM/IM residencies are as competitive as the corresponding categorical EM residency at the same institution. Although the number of positions is substantially smaller the applicant pool is also much smaller. Keep in mind too that not every EM/IM applicant may rank an EM/IM program highly or at all. There are many applicants who go through the application cycle and realize that a combined residency is not for them.

 

What kind of letters of recommendation (LOR) do I need?

 

From reviewing the LOR requirements that are publically available on the websites of each program, the recommended letters for applying to any EM/IM program would be: (2) emergency medicine Standardized Letters of Evaluation (SLOE), (1) letter from the Chair of the Department of Internal Medicine, and (1) letter from an Internal Medicine or Internal Medicine Subspecialty physician. The LOR requirements vary for each program. If there are questions about the LOR requirements for one particular program please refer to the residency’s website or contact them directly.

 

What away rotations should I do if I am planning to apply to EM/IM programs?

 

The only required away rotations are in EM. These are a necessity because one of the required letters of recommendation to apply to most EM/IM programs is a SLOE. A dedicated EM/IM away or dedicated IM away elective may be helpful to feel out the specialty and possibly show interest in a particular program but are by no means necessary. For more information on the details of SLOEs and arranging EM away rotations please see the CORD Emergency Medicine Applying Guide and FAQ (https://cordemblog.wordpress.com/2016/07/07/student-advising-a-comprehensive-guide-and-faq/).

 

Should I apply to “back up” programs?

 

Yes. Applying to a categorical specialty is recommended for all EM/IM applicants. As long as the applicant has applied to the corresponding categorical program, most residencies will automatically grant a categorical EM and/or IM interview once a combined interview has been offered. Most EM/IM applicants apply to EM. There are, however, a growing number of applicants that apply to IM or both EM and IM. Keep in mind that no residency program likes to hear the words “back up”. Over the application cycle there are many EM/IM applicants that find particular categorical programs suit them better than EM/IM programs. So it is important to keep an open mind when applying and interviewing.

 

Do I need to write a separate personal statement specific for EM/IM programs? What does my personal statement need to include?

 

Yes. It is recommended that applicants write a personal statement that is specific to combined programs. Parts of the personal statement may overlap with a personal statement addressed toward a categorical program. At a minimum an EM/IM personal statement should address why the applicants wishes to pursue an EM/IM residency and how it would benefit them and their future career goals.

 

How do EM/IM interview days differ from categorical EM interview days?

 

Most EM/IM interviews start in the early morning and last until the late afternoon. Applicants typically interview separately with each department. Most programs will count the EM/IM interviews as categorical interviews if they applied to the EM and/or IM categorical programs. The interviews themselves are similar in many ways to any categorical interviews. The exception being that applicants should expect and be able to answer EM/IM specific questions such as why they wish to pursue a combined residency.

 

How do I know if applying EM/IM is the right for me?

 

Considering a 5-year residency is a big decision. As a general rule, being undecided between the two specialties is not a good reason to apply to a combined residency. Ideally applicants who have questions should discuss their thoughts with an EM/IM trained physician. Unfortunately the EM/IM community is relatively small and not every medical school has EM/IM faculty. It is still important and encouraged for prospective applicants to discuss their desire to apply to EM/IM programs with their EM and/or IM trained mentors and faculty members.  Consider contacting EM/IM programs directly as most residency leadership in the specialty tend to be very accommodating to questions.  Best of luck!

**For the most up to date advice on applying to EM/IM (and other EM dual accreditation programs), please visit this newer post.**

References

1. Katz ED, Katz JT. Careers of graduates of combined emergency medicine/internal medicine programs. Acad Emerg Med. 2002;9(12):1457-9.

 

2. Kessler CS, Stallings LA, Gonzalez AA, Templeman TA. Combined residency training in emergency medicine and internal medicine: an update on career outcomes and job satisfaction. Acad Emerg Med. 2009;16(9):894-9.

 

3. Kessler CS, Gonzalez AA, Stallings LA, Templeman TA. In-training practice patterns of combined emergency medicine/internal medicine residents, 2003-2007. West J Emerg Med. 2011;12(4):530-6.