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, 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, 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 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 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.
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!
- Katz ED, Katz JT. Careers of graduates of combined emergency medicine/internal medicine programs. Acad Emerg Med. 2002;9(12):1457-9.
- 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.
- 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.
Christiana Care has been a top-rated academic medical center for more than a century. Our residents and fellows experience a rigorous and rewarding combination of academic training and hands-on experience.
The Internal Medicine Residency Program attracts candidates from around the country who value our challenging university-affiliated academic curriculum within a community-based setting.
Our diverse patient mix offers residents exceptional opportunities to diagnose and treat a broad spectrum of primary-care diseases, as well as tertiary-care medical conditions not routinely encountered in smaller hospital settings.
Christiana Care appoints 12 residents to the categorical internal medicine program each year. Additionally, Christiana Care appoints 4 internal Medicine/Pediatrics and 3 Internal Medicine/Emergency Medicine interns each year.
Innovative training blocks
The Christiana Care Internal Medicine Residency was the first program in the country to develop an innovative 4+2 ambulatory block schedule. In this schedule, rather than typical half-day clinics added to all inpatient and outpatient rotations, our curriculum splits the residents’ experiences into inpatient and outpatient blocks of time. The residents’ experience consists of a four-week inpatient-medicine experience alternating with a two-week ambulatory-medicine experience. This design allows residents to completely focus on the rotation. If you are on an inpatient rotation, you will not need to leave in the middle of the day to go to clinic. Similarly, in the outpatient setting, you will not need to run back to the hospital.
The inpatient-medicine experiences will consist of general inpatient medicine at Christiana Hospital and Wilmington Hospital, as well as rotations in the MICU and CICU. Additionally, the inpatient based specialty rotations will occur during the 4 week blocks of time (e.g. cardiology, pulmonary, nephrology, hematology, infectious diseases and neurology).
During each 2 week ambulatory block, residents will spend 2 full days per week in their outpatient continuity practice at Wilmington Hospital. Each resident will also have a half day per week of administrative time to work on research, performance improvement, or other patient care needs, and a half day per week of academic during our protected academic half day (see didactic curriculum). The remaining four days over the two-week block will be spent on subspecialty experiences . Time is available in the schedule that will allow residents to tailor the curriculum to their individual learning needs and career goals.
The inpatient medicine experience has adopted a “Teacher-Manager-Learner” model. As “Learners”, PGY-1 residents do just that- learn. Under the supervision of a PGY-3 resident and an attending physician they broadly build their knowledge in patient care, medical knowledge, communication skills, and professionalism. Our “Manager” teams allow PGY-2 residents to work side by side with an attending physician which provides greater autonomy. In addition to building on the knowledge they developed as “Learners”, “Managers” develop skills and knowledge in evidence based medicine, cost effective care, transitions of care, and working in a multidisciplinary team. Finally, we consider our PGY-3 residents “Teachers” and we provide them the autonomy to lead the team in making medical decisions. Perhaps more importantly we expect them to educate PGY-1 “Learners” (as well as 3rd and 4th year medical students), and role model the skills, knowledge, and attitudes they have developed during their first two years of residency training. We believe this graduated learning experience builds competency and confidence in our residents to become excellent physicians.
Christiana Care offers outstanding ancillary support 24/7 so that you are supported by an excellent group of nurses, therapists, patient-care techs, phlebotomists and social workers.
We strictly adhere to the ACGME work-hour guidelines so that you are assured adequate rest.
Some highlights of the program:
- Largest teaching affiliate of Sidney Kimmel Medical College at Thomas Jefferson University of Thomas Jefferson University, Philadelphia.
- Two-day, off-site retreats each year in beautiful locations to focus on team-building, leadership, teaching and feedback skills.
- Resident night float on all inpatient services ensuring compliance with duty hours.
- A strong academic program and nationally recognized faculty in a friendly, collegial setting.
- Rotations designed to work with diverse populations in urban and suburban hospital settings.
- Extensive research and fellowship opportunities, including fellowships at Christiana Care in cardiology, nephrology, sports medicine, patient quality and safety and hospice and palliative medicine.
- Enhanced patient care due to fewer handoffs.
- Residencies in Categorical Internal Medicine, Combined Medicine/Pediatrics and Combined Emergency Medicine/Internal Medicine.
Sample PGY-1 block schedule
Sample block schedule for Christiana Care Internal Medicine Residency Program
Sample ambulatory schedule
|Thursday||Academic Half Day/Continuity|
Innovative call structure
We have a fully integrated night float system on every inpatient rotation. Interns do an average of four weeks of inpatient floor night float and two weeks of ICU night float during the first year. Intern night float is an approximately 13 hour shift nightly six nights per week. Interns are not scheduled for shifts longer than this. Interns on inpatient rotations share “short call” (until 7 p.m.) responsibilities and on average have one of these shifts every three to four days.
Upper-year residents take four to eight weeks of night float on the floors and ICUs in each year. In the MICU and CICU, the upper year residents work a staggered shift schedule without overnight call only on Friday night in the CICU.
A resident’s typical day
|Inpatient Floor Services|
|0600 – 0630||“Start time.” Obtain sign in from on-call team. Critical patients are to be seen immediately.|
|0700 – 0900||Interns evaluate patients and write progress notes.|
|0800 – 0900||Medical Morning Report. Attendance is mandatory for PGY 2 and PGY 3 floor residents (optional for interns.)|
|0900 – Noon||Team Work Rounds|
|Noon – 1300||Core Lecture/Board Review (Mon, Wed, Fri)|
|1400 – 1630||Admission, chart reviews, etc.|
|1700 – 1800||Sign-Out. New admissions are reviewed and potential problems are identified.|
|Intensive Care Units|
|0600 – 0630||“Start time.” Obtain sign in from on-call team.|
|0730 – 0930||Work Rounds. Interns and residents evaluate patients, write notes, order tests.|
|0930 – 1100||Teaching Attending Rounds|
|Noon – 1300||Core Lecture/Board Review|
|1300 – 1600||Admissions, chart reviews, etc.|
|1600 – 1700||Sign-Out. All patients are reviewed.|