Authors: Matthew Huang, MD, Brian Levine, MD, Pawan Suri, MD, Caitlin Schrepel, MD, Alexis Pelletier-Bui, MD on behalf of the CORD Advising Students Committee in Emergency Medicine (ASC-EM)

This applying guide is intended for both students and their advisors to provide insight into the dual accredited emergency medicine specialties and the associated application process.

General Overview

The American Board of Emergency Medicine (ABEM), in cooperation with other American Board of Medical Specialties (ABMS) Members, has approved 5 combined training tracks within emergency medicine (EM). These include: Emergency Medicine/Anesthesiology (EM/Anes), Emergency Medicine/Family Medicine (EM/FM), Emergency Medicine/Internal Medicine (EM/IM), Emergency Medicine/Internal Medicine/Critical Care Medicine (EM/IM/CC), and Emergency Medicine/Pediatrics (EM/Peds).  These training models allow for integrated training in each specialty with an overall reduction in total training time by 1 to 2 years depending on the combined pathway. Choosing these specialties 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 and their advisors should know before applying.

What are the options for dual accredited specialties within emergency medicine?

There are currently 5 approved combined EM training tracks. These are detailed individually below.

Emergency Medicine/Anesthesiology

EM/Anes is the newest combined emergency specialty. As of 2018, there is one Accreditation Council for Graduate Medical Education (ACGME) EM/Anes program accepting applicants. This training pathway allows for candidates to complete a six-year curriculum through which they are eligible for board certification in both emergency medicine and anesthesiology.

EM/Anes Programs:

• Johns Hopkins University School of Medicine

Emergency Medicine/Family Medicine

EM/FM is a training pathway that allows for candidates to complete a five-year curriculum, through which they are eligible for board certification in both emergency medicine and family medicine. As of 2018, there are two ACGME EM/FM programs accepting applicants.

EM/FM Programs:

• Christiana Care Health Services
• Louisiana State University (Shreveport)
• Jefferson Health – Northeast / Aria Health (Philadelphia)

Emergency Medicine/Internal Medicine

EM/IM is a training pathway that allows for candidates to complete a five-year curriculum, through which they are eligible for board certification in both emergency medicine and internal medicine. As of 2018, there are 11 ACGME EM/IM programs accepting applicants.

EM/IM Programs

• Christiana Care Health Services
• University of Illinois College of Medicine at Chicago
• Louisiana State University
• University of Maryland
• Henry Ford Hospital/Wayne State University
• Hennepin County Medical Center
• Vidant Medical Center/East Carolina University
• SUNY Health Science Center at Brooklyn
• Zucker School of Medicine at Hofstra/Northwell
• Ohio State University Hospital
• Virginia Commonwealth University Health System
• Jefferson Health – Northeast / Aria Health (Philadelphia)

Emergency Medicine/Internal Medicine/Critical Care Medicine

EM/IM/CC training pathway allows for triple board certification in emergency medicine, internal medicine, and critical care medicine for those who complete a 6-year accredited EM/IM/CCM residency. As of 2018 there are 6 approved EM/IM/CCM programs. There is no direct application for these programs. Prospective applicants apply to the EM/IM program at one of these 6 residencies. If accepted they have the option of enrolling in the EM/IM/CCM program at some point during their residency (commonly by the end of PGY3).

EM/IM/CC Programs:

• University of Maryland
• Henry Ford Hospital/Wayne State University
• Hennepin County Medical Center
• Vidant Medical Center/East Carolina University
• Zucker School of Medicine at Hofstra/Northwell
• SUNY Health Science Center at Brooklyn

Emergency Medicine/Pediatrics

EM/Peds is a training pathway that allows for candidates to complete a five-year curriculum, through which they are eligible for board certification in both emergency medicine and pediatrics. As of 2018, there are 4 ACGME EM/Peds programs accepting applicants.

EM/Peds Programs:

• University of Arizona
• Indiana University School of Medicine/Methodist Hospital
• Louisiana State University School of Medicine
• University of Maryland

Why would someone choose to apply to a dual accredited specialty?

The reason to pursue a combined residency varies from person to person. For most, the decision revolves around their long-term goals. These goals may include a career in academics, administration, a medical subspecialty or international medicine. Applicants see the utility of both specialties in enhancing their future career goals. Given the length of training, most programs will offer leadership roles and extracurricular opportunities that may not be available in a categorical program. Choosing a combined specialty requires careful thought.  In general, being undecided between the two specialties or desire to just “become a better physician” are not good reasons to apply to a combined residency.

How do I apply to dual accredited programs?

Applications for the dual accredited programs, with the exception of EM/IM/CC, are handled through the Electronic Residency Application System (ERAS) and the National Residency Match Program (NRMP). Each combined program is ranked as a single program.  An applicant who also wishes to apply to one of the categorical programs  will need to complete a separate ERAS application. There is no direct application to enroll into an EM/IM/CC program. Prospective applicants apply to the EM/IM program at one of the 6 residencies that have this pathway. If accepted they have the opportunity of applying to the EM/IM/CCM program during their residency.

How competitive are the dual accredited programs?

In general, most combined residencies are as competitive as the corresponding categorical residencies at the same institution. Although the number of positions is substantially smaller for the dual accredited specialties, the applicant pool is also much smaller. There are many applicants who go through the application cycle and realize that a combined residency is not for them and may decide not to rank a combined program. Review of the NRMP data going back to 2015 reveals successful candidate matches from U.S Grads, Osteopathic schools, U.S IMGs and Non-U.S IMGs into  EM/IM, EM/FM, EM/Peds programs (see below). EM/Anes has been through one match process to date and there is limited data on this specialty. Please note this is composite data collected from all existing programs and does not reflect the recruitment patterns of individual residency programs.

Senior student of U.S. Allopathic Medical School (U.S. Senior): A fourth-year medical student in a U.S. allopathic school of medicine accredited by the Liaison Committee on Medical Education (LCME) with a graduation date after July 1 in the year before the Match.

Previous Graduate of U.S. Allopathic Medical School (U.S. Grad): A graduate of a U.S. allopathic school of medicine accredited by the LCME with a graduation date before July 1 in the year before the Match.

Student/Graduate of Osteopathic Medical School (Osteo): A senior student or graduate of a medical school accredited by the Commission on Osteopathic College Accreditation (COCA).

U.S. Citizen Student/Graduate of International Medical School (U.S. IMG): A U.S. citizen who attended an international medical school.

Non-U.S. Citizen Student/Graduate of International Medical School (Non-U.S. IMG): A non-U.S. citizen who attended an international medical school

Do I need to write a separate personal statement? What does my personal statement need to include?

Yes. It is recommended you write a personal statement that is specific to the combined program.  The personal statement should address why you wish to pursue an combined residency and how it would benefit you and your future career goals. Programs are looking for candidates who can articulate a passion for both specialties. The personal statement carries more weight for combined applicants as it is athe chance to show motivation and interest in the specialty.

Should I apply to a categorical specialty as “back up”?

Yes. Applying to a categorical specialty is recommended. If you have applied to the corresponding categorical program or programs, most combined residencies will grant a categorical interview as well.  In fact, in a recent survey of dual accreditation EM residency program leadership (n=13), 100% reported considering applicants for both their joint and categorical EM programs.1  Applying for a combined position and a categorical position requires separate ERAS submissions. Keep in mind that no residency program likes to hear the word “backup.” Also, in a recent survey of EM only residency program leadership (not dual accreditation), 17.6% (95% CI 9.8-25.4; n=101) stated that they would be less likely to rank an applicant if it is known that they are also applying for dual accreditation programs. (1)  During the interview process, you may find that a categorical program suits you better than a combined one. So it is important to keep an open mind when applying and interviewing and you may want to consider not bringing up your dual accreditation applications on EM categorical program interviews.

What letters of recommendation are needed?

Most combined programs require 1-2 Standardized Letter of Evaluation(s) (SLOE(s)) specific for Emergency Medicine. In a recent survey of dual accreditation EM residency program leadership (n=13), 69% (CI 44-94%) wanted 1 SLOE to offer an interview (vs 31% who wanted 2) and 54% (27-81%) still only wanted 1 SLOE to rank (vs 46% who wanted 2). No one required 3 SLOEs for interview offer or ranking.1 Two SLOEs are often preferred by EM residency leadership to rank applicants for a categorical EM position, and this is often cited as one of the most valuable factors in determining which applicants to interview and rank. Therefore, if you are also applying to categorical EM programs, you should strongly consider obtaining 2 EM SLOEs from institutions with a residency program to place yourself in the best position to match. You should request 1-2 letters in the complementary specialty as well. Letters that specifically address your wish to pursue a combined specialty are a bonus but not essential. Most applicants use letters that can be used for both their combined and categorical applications. Below is a list of recommended letters that can be used to apply to each combined specialty. These sets of letters are geared towards combined applicants who are applying to EM as their alternative categorical program. This is a generic list. Please visit each program’s website or contact them directly for institution specific requirements in addition to those listed below.

EM/Anes

(2) EM SLOE

(1) Letter from an Anesthesia physician (anesthesia or ICU rotation acceptable)

EM/IM

(2) EM SLOE

(1) Letter from the Chair of the Department of Internal Medicine

(1) Letter from an Internal Medicine or Internal Medicine subspecialty physician.

EM/FM

(2) EM SLOE

(1) Letter from a Family Medicine physician

EM/Peds

(2) EM SLOE

(1) Letter from a Pediatric Medicine or Pediatric Subspecialty Medicine physician

What away rotations are needed to apply?

The most important away rotation(s) to have completed early in 4th year is EM because one of the required letters of recommendation needed to apply to a combined EM program is a SLOE. This is especially important if your alternative categorical program to which you will apply is EM.  It is in your best interest to perform a home and an away EM rotation early in your fourth year so that you have SLOEs ready for your application. Away rotations for IM, Peds, and Anesthesia may be helpful but are not necessary.

Is there a difference between the combined program and categorical EM interview day?  Can I apply to both programs at the same institution?

Yes. You can apply to both categorical and combined residencies at the same institution. Applicants will generally be scheduled to interview with both departments  in one day. The time spent with each program may be less when compared to a typical categorical interview day. Come prepared with questions to make the most of your interview day. Staying with a current resident, if possible, can be very helpful. Some programs count the combined residency interviews towards the categorical interviews if you applied to both.

What fellowship opportunities are available after completing a combined residency?

A number of combined residents pursue fellowship after graduation. Completing two residencies opens fellowship opportunities in both fields. Critical care and ultrasound  fellowships are popular among combined residents. Graduates of combined residencies are competitive fellowship candidates when compared to their categorical counterparts because of their extra training and unique skill set.

How do I know if applying to a dual accredited program is the right for me?

Considering a 5 or 6-year residency is a big decision. If your career goal is to solely practice either EM or another specialty, then a combined program would not be a valuable investment. There is an advantage to dual training if you want to pursue rural medicine, international medicine, observational medicine, critical care, or an administrative career path. Dual training applicants are encouraged to discuss their desire to apply to a combined program with their categorical mentors and faculty members. Ideally applicants should also discuss their thoughts with a combined trained physician. If you do not have dual trained faculty at your institution, consider contacting combined programs directly as residency leadership in the combined fields tend to be very accommodating and willing to help guide interested applicants.

Key Points:

1. There are 5 approved combined training tracks within emergency medicine: EM/Anes, EM/FM, EM/IM, EM/IM/CC, EM/Peds.
2. Applicants should be able to articulate why and how both specialties will enhance their future career goals.
3. Being undecided between the two specialties or the desire to “become a better physician” are not good reasons to apply to a combined residency.
4. Most combined residencies are as competitive as the corresponding categorical programs at the same institution.
5. It is recommended that applicants write a personal statement that is specific to combined programs.
6. Applying to a categorical program in addition is recommended for all combined applicants.
7. Most programs require 1-2 EM SLOEs and 1-2 letters in the complementary specialty.
8. EM is the most important away rotation(s) to have completed early in 4th year.
9. You can apply to both categorical and combined residencies at the same institution.
10. A number of combined residents pursue fellowship after graduation and are competitive applicants due to the length of residency and unique skill set.
11. Prospective applicants are encouraged to discuss their desire to apply to a combined program with a combined trained physician in the specialty.

References:

1. Council of Emergency Medicine Residency Directors Advising Students Committee in Emergency Medicine. (2018). [CORD ASC-EM Advising Addenda Study].  Unpublished raw data.
2. National Resident Matching Program, Results and Data: 2018 Main Residency Match. National Resident Matching Program, Washington, DC. 2018.
3. National Resident Matching Program, Results and Data: 2017 Main Residency Match. National Resident Matching Program, Washington, DC. 2017.
4. National Resident Matching Program, Results and Data: 2016 Main Residency Match. National Resident Matching Program, Washington, DC. 2016.
5. National Resident Matching Program, Results and Data: 2015 Main Residency Match. National Resident Matching Program, Washington, DC. 2015.