Editorials
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Critical Care Medicine Certification and Pulmonary Disease Trainees
Over the past decade, there has been an intense debate about certification for critical care medicine. One of the most pressing questions was whether or not the training offered in our pulmonary training programs provided appropriate experience to qualify physician trainees to manage patients in critical care units. While arguments have often been heated, they have been difficult to resolve because data were nonexistent. A view held by many of the pulmonary program directors was that the training in pulmonary medicine programs that were heavily involved in critical care qualified trainees to carry out the care of critically ill patients in intensive care units. The results of the Critical Care Medicine Certification examination given in 1987and 1989shed some light on the issue of pulmonary/critical care medicine training. The relevant information was obtained with the cooperation of Dr. John Norcini of the American Board of Internal Medicine (ABIM) and was presented to the Association of Pulmonary Program Directors at the recent annual meeting of the American Thoracic Society. After the presentation, a large number of program directors asked that this information be published so that it would be available to all members of the pulmonary/critical care community who have a long-standing commitment to critical care training. It is hoped that presentation ofthis material will give a snapshot of the performance of previous trainees on the certification test and will help training directors anticipate how future trainees will perform. In addition, it is hoped that all pulmonary/critical care certified individuals will find the information useful. Thus far, there have been two exams, one in 1987 and the second in 1989. The next examination, in the fall of 1991, will be the last exam to come under the current guidelines with Pathways E and F. Unless the Board changes its policy,after the 1991 exam only graduates with acceptable critical care mediAM REV RESPIR DIS 1990; 142:495-496
cine training will be eligible to sit for the critical care certification examination. As can be seen in table 1, 2,712 individuals sat for the initial examination in 1987 and 2,046 of them came through Pathway E, which is two years of practice plus a subspecialty in internal medicine. It is the belief of most pulmonary training program directors that the majority of their trainees entered the examination through this pathway rather than test the ''validity'' of their critical care training, which is required for Pathways A, B, and D. The data in table 2 clearly supports the entry of pulmonary specialists through Pathway E. In 1989, a total of 1,819 individuals took the test. If one subtracts the 415retakers, a total of 4,116 individuals took the examination for the first time. Also, in table 1, one can see that Pathway A has basically remained stable with 38 and 40 individuals entering through that pathway. Pathway B, a three-year combined program that represents the majority of pulmonary/critical care programs, has increased from 96 applicants in 1987 to 158in 1989. In Pathway D, two years of critical care medicine training, the number of applicants has decreased from 115 in 1987 to 76 in 1989. Whether the increase in Pathway B and the decrease in Pathway D are indicative of a trend must await confirmation in the 1991 and future exams. Pathway E has also decreased from 2,046 in 1987 to 1,292 in 1989; Pathway F decreased from 358 to 247. It is understood that "undefined" represents individuals who did not specifically fit into any of the above categories but who werejudged by the ABIM to be eligible for the examination. Becausethe pathways did not truly give an indication of the number of pulmonary specialists who took and passed the examination, a request was made to examine the statistics with respect to subspecialty training of the applicants who took and passed the Boards. Data on those who passed the exami-
nation according to sub specialties are broken down in table 2. The majority of individuals passing the examination were pulmonary specialists, representing 71070 of the total who were certified in both examinations. In fact, if one looks at all the subspecialties, 84% of those who passed the Boards have a subspecialty of internal medicine. Only 16% of the individuals passing the test are general internists without a subspecialty. Of this group, 160 (or 5% of the total passing) had two years of critical care medicine training. Eleven percent of those passing had no formal critical care training according to their applications. Also in table 2, one can see that the pulmonary specialists did very well. Although they only represented 63% of the individuals taking the test, they accounted for 71% of those who passed the test. In this table, we have assumed that all three-year combined trainees are pulmonary/critical care trainees (Pathway B). One can see that the pass rate for this group is similar to that for two-year critical care medicine trained physicians (i.e., 87 and 84%). If one examines the "no formal critical care" trainee, a euphemism used for physiciansentering through Pathway E or F, it is evident that pulmonary specialists are the largest number of physicians passing the examination (i.e., 1,779 or 63% of total passing the exam) with a pass rate of 69%. Likewise notable is that the pass rate of this group exceeds the mean pass rate for all those who took the examination (69 versus 63%). So what do these tables indicate? Although it is too early to come to any concrete conclusions, it certainly seems that the previous pulmonary trainees weregiven adequate training to pass the certification examination. They indeed do represent the vast majority of internal medicine specialists who have been certified in critical care medicine. One conclusion that was drawn by the Association of Pulmonary Program Directors (now the Association of Pulmonary and Critical Care 495
496
EDllORIAL
TABLE 1 CRITICAL CARE MEDICINE EXAMINATION: TOTAL NUMBER TAKING THE EXAMINATION BY EACH PATHWAY 1987 (n)
Pathway
Pass Rate
(%)
A: CCM/1 yr + subspecialty B: 3-yr combined program D: CCM/2 yr + 1M E: 2 yr of practice + subspecialty in 1M F: 4 yr practice + Boards in 1M Undefined
38
82
96 115 2,046 358 59
86
Total
2,712
64
82 64
46
1989 (n)
Pass Rate
40 158 76 1,272 247 26
83 87
(%)
86 59
45
1,819
61
Definition of abbreviations: CCM = cr~ical care madicine; 1M = internal madicine.
TABLE 2 TOTAL NUMBER OF EACH SUBSPECIALTY IN 1987/1989
Subspecialty Area
Number Taking Test
General internal medicine 2 yr CCM training No formal CCM training" Cardiology Pulmonary 3 yr combined training No formal CCM trainingt Infectious Disease Nephrology
618 2,830 254 2,576 27 196
Total
4,510:1:
839 191
648
0Al of Total Taking Test 4 14 14 6 57 1 4
Those Passing Test (n) 463 160 303 248 1,999 220 1,779 19 103 2,832
(%)
% of Total Passing Test
55
84 47 40 71 87 69 70 51
5 11 9 8
63 1 4
Acknowledgment The writers wish to thank Drs. John Benson and John Norcini of the ABIM, the members of the ACGME Residency ReviewCommittee, and the staff of the ACGME for their help in compiling the data contained in this editorial.
63
Definition of abbreviation: CCM = critical care madlcine . • Pathway F. t Pathway E. Excludes 21 candidates certifiad in other sUbspecialties; seven were certified in CCM.
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Program Directors) was that the previous training in pulmonary medicine offered an adequate knowledge base to pass the certifying examination and that program directors in pulmonary medicine should continue to have a voice in the ABIM in establishing policy and critical care medicine examination material. Accreditation of critical care medicine training programs is given by the Accreditation Council for Graduate Medical Education (ACGME). Accreditation was carried out in the last year or so, and the results were discussed at the Association of Pulmonary Program Directors' meeting by a representative of the ACGME. Seventy-five of 106 programs, reviewed by the Residency Review Committee of
certification, it is important that they continue to have very strong input in the ABIM and the ACGME. Over the next several years, the full impact of the critical care certification and the accreditation of training programs will begin to be known. Both of these activities are carried out by separate entities, namely, the ABIM and the ACGME. If the number of three-year combined program graduates continues to rise, as suggested by the data in table 1, and the number of graduates of the two-year critical care program declines or stabilizes, it should be clear that the majority of physicians trained to care for patients in critical care medical units will be pulmonary/critical care trainees and that the pulmonary/critical care training directors should continue to have a major voice in determining policy in regard to training, patient care, and certification.
the ACGME, were accredited for critical care medicine training. In examining the list, it is difficult to be absolutely certain how many of these are combined pulmonary and critical care programs versus two- year critical care programs. A rough estimate obtained by examining the programs listed in the AMERICAN REVIEW OF RESPIRATORY DISEASE and in CRITICAL CARE MEDICINE would suggest that more than 60 of the 7S programs are combined pulmonarylcritical care medicine programs. It has been suggested by the program directors at the meeting that, although the pulmonary/critical care training programs should not be the only voice ill establishing the criteria for training and
ROBERT M. ROGERS, M.D.
Division of Pulmonary and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, PA ThOMAS L. PETTY, M.D.
University of Colorado Health Sciences Center Presbyterian-St. Luke's Center for Health Sciences Education Denver, CO LEONARD D. HUDSON, M.D.
Division of Pulmonary and Critical Care Medicine University of Washington Seattle, WA DICK D. BRIGGS, JR., M.D.
Division of Pulmonary and Critical Care Medicine University of Alabama School of Medicine Birmingham, AL
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Critical Care Medicine Certification and Pulmonary Disease Trainees
Over the past decade, there has been an intense debate about certification for critical care medicine. One of the most pressing questions was whether or not the training offered in our pulmonary training programs provided appropriate experience to qualify physician trainees to manage patients in critical care units. While arguments have often been heated, they have been difficult to resolve because data were nonexistent. A view held by many of the pulmonary program directors was that the training in pulmonary medicine programs that were heavily involved in critical care qualified trainees to carry out the care of critically ill patients in intensive care units. The results of the Critical Care Medicine Certification examination given in 1987and 1989shed some light on the issue of pulmonary/critical care medicine training. The relevant information was obtained with the cooperation of Dr. John Norcini of the American Board of Internal Medicine (ABIM) and was presented to the Association of Pulmonary Program Directors at the recent annual meeting of the American Thoracic Society. After the presentation, a large number of program directors asked that this information be published so that it would be available to all members of the pulmonary/critical care community who have a long-standing commitment to critical care training. It is hoped that presentation ofthis material will give a snapshot of the performance of previous trainees on the certification test and will help training directors anticipate how future trainees will perform. In addition, it is hoped that all pulmonary/critical care certified individuals will find the information useful. Thus far, there have been two exams, one in 1987 and the second in 1989. The next examination, in the fall of 1991, will be the last exam to come under the current guidelines with Pathways E and F. Unless the Board changes its policy,after the 1991 exam only graduates with acceptable critical care mediAM REV RESPIR DIS 1990; 142:495-496
cine training will be eligible to sit for the critical care certification examination. As can be seen in table 1, 2,712 individuals sat for the initial examination in 1987 and 2,046 of them came through Pathway E, which is two years of practice plus a subspecialty in internal medicine. It is the belief of most pulmonary training program directors that the majority of their trainees entered the examination through this pathway rather than test the ''validity'' of their critical care training, which is required for Pathways A, B, and D. The data in table 2 clearly supports the entry of pulmonary specialists through Pathway E. In 1989, a total of 1,819 individuals took the test. If one subtracts the 415retakers, a total of 4,116 individuals took the examination for the first time. Also, in table 1, one can see that Pathway A has basically remained stable with 38 and 40 individuals entering through that pathway. Pathway B, a three-year combined program that represents the majority of pulmonary/critical care programs, has increased from 96 applicants in 1987 to 158in 1989. In Pathway D, two years of critical care medicine training, the number of applicants has decreased from 115 in 1987 to 76 in 1989. Whether the increase in Pathway B and the decrease in Pathway D are indicative of a trend must await confirmation in the 1991 and future exams. Pathway E has also decreased from 2,046 in 1987 to 1,292 in 1989; Pathway F decreased from 358 to 247. It is understood that "undefined" represents individuals who did not specifically fit into any of the above categories but who werejudged by the ABIM to be eligible for the examination. Becausethe pathways did not truly give an indication of the number of pulmonary specialists who took and passed the examination, a request was made to examine the statistics with respect to subspecialty training of the applicants who took and passed the Boards. Data on those who passed the exami-
nation according to sub specialties are broken down in table 2. The majority of individuals passing the examination were pulmonary specialists, representing 71070 of the total who were certified in both examinations. In fact, if one looks at all the subspecialties, 84% of those who passed the Boards have a subspecialty of internal medicine. Only 16% of the individuals passing the test are general internists without a subspecialty. Of this group, 160 (or 5% of the total passing) had two years of critical care medicine training. Eleven percent of those passing had no formal critical care training according to their applications. Also in table 2, one can see that the pulmonary specialists did very well. Although they only represented 63% of the individuals taking the test, they accounted for 71% of those who passed the test. In this table, we have assumed that all three-year combined trainees are pulmonary/critical care trainees (Pathway B). One can see that the pass rate for this group is similar to that for two-year critical care medicine trained physicians (i.e., 87 and 84%). If one examines the "no formal critical care" trainee, a euphemism used for physiciansentering through Pathway E or F, it is evident that pulmonary specialists are the largest number of physicians passing the examination (i.e., 1,779 or 63% of total passing the exam) with a pass rate of 69%. Likewise notable is that the pass rate of this group exceeds the mean pass rate for all those who took the examination (69 versus 63%). So what do these tables indicate? Although it is too early to come to any concrete conclusions, it certainly seems that the previous pulmonary trainees weregiven adequate training to pass the certification examination. They indeed do represent the vast majority of internal medicine specialists who have been certified in critical care medicine. One conclusion that was drawn by the Association of Pulmonary Program Directors (now the Association of Pulmonary and Critical Care 495
496
EDllORIAL
TABLE 1 CRITICAL CARE MEDICINE EXAMINATION: TOTAL NUMBER TAKING THE EXAMINATION BY EACH PATHWAY 1987 (n)
Pathway
Pass Rate
(%)
A: CCM/1 yr + subspecialty B: 3-yr combined program D: CCM/2 yr + 1M E: 2 yr of practice + subspecialty in 1M F: 4 yr practice + Boards in 1M Undefined
38
82
96 115 2,046 358 59
86
Total
2,712
64
82 64
46
1989 (n)
Pass Rate
40 158 76 1,272 247 26
83 87
(%)
86 59
45
1,819
61
Definition of abbreviations: CCM = cr~ical care madicine; 1M = internal madicine.
TABLE 2 TOTAL NUMBER OF EACH SUBSPECIALTY IN 1987/1989
Subspecialty Area
Number Taking Test
General internal medicine 2 yr CCM training No formal CCM training" Cardiology Pulmonary 3 yr combined training No formal CCM trainingt Infectious Disease Nephrology
618 2,830 254 2,576 27 196
Total
4,510:1:
839 191
648
0Al of Total Taking Test 4 14 14 6 57 1 4
Those Passing Test (n) 463 160 303 248 1,999 220 1,779 19 103 2,832
(%)
% of Total Passing Test
55
84 47 40 71 87 69 70 51
5 11 9 8
63 1 4
Acknowledgment The writers wish to thank Drs. John Benson and John Norcini of the ABIM, the members of the ACGME Residency ReviewCommittee, and the staff of the ACGME for their help in compiling the data contained in this editorial.
63
Definition of abbreviation: CCM = critical care madlcine . • Pathway F. t Pathway E. Excludes 21 candidates certifiad in other sUbspecialties; seven were certified in CCM.
*
Program Directors) was that the previous training in pulmonary medicine offered an adequate knowledge base to pass the certifying examination and that program directors in pulmonary medicine should continue to have a voice in the ABIM in establishing policy and critical care medicine examination material. Accreditation of critical care medicine training programs is given by the Accreditation Council for Graduate Medical Education (ACGME). Accreditation was carried out in the last year or so, and the results were discussed at the Association of Pulmonary Program Directors' meeting by a representative of the ACGME. Seventy-five of 106 programs, reviewed by the Residency Review Committee of
certification, it is important that they continue to have very strong input in the ABIM and the ACGME. Over the next several years, the full impact of the critical care certification and the accreditation of training programs will begin to be known. Both of these activities are carried out by separate entities, namely, the ABIM and the ACGME. If the number of three-year combined program graduates continues to rise, as suggested by the data in table 1, and the number of graduates of the two-year critical care program declines or stabilizes, it should be clear that the majority of physicians trained to care for patients in critical care medical units will be pulmonary/critical care trainees and that the pulmonary/critical care training directors should continue to have a major voice in determining policy in regard to training, patient care, and certification.
the ACGME, were accredited for critical care medicine training. In examining the list, it is difficult to be absolutely certain how many of these are combined pulmonary and critical care programs versus two- year critical care programs. A rough estimate obtained by examining the programs listed in the AMERICAN REVIEW OF RESPIRATORY DISEASE and in CRITICAL CARE MEDICINE would suggest that more than 60 of the 7S programs are combined pulmonarylcritical care medicine programs. It has been suggested by the program directors at the meeting that, although the pulmonary/critical care training programs should not be the only voice ill establishing the criteria for training and
ROBERT M. ROGERS, M.D.
Division of Pulmonary and Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, PA ThOMAS L. PETTY, M.D.
University of Colorado Health Sciences Center Presbyterian-St. Luke's Center for Health Sciences Education Denver, CO LEONARD D. HUDSON, M.D.
Division of Pulmonary and Critical Care Medicine University of Washington Seattle, WA DICK D. BRIGGS, JR., M.D.
Division of Pulmonary and Critical Care Medicine University of Alabama School of Medicine Birmingham, AL
