EM/IM Combined Residency: What up with that?

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Authors: Kyla Rakoczy

MS-3, University of Miami Miller School of Medicine

Kasha Bornstein, MD, MPH
PGY-1, LSU New Orleans Internal Medicine/Emergency Medicine

Choosing a specialty is one of the most daunting tasks of medical school. Pursuing an emergency medicine residency affords a fast-paced, often unpredictable environment with a diversity of patients unique to the specialty, while the life of an internist involves rounding, longitudinal patient care, and long contemplative sessions pertaining to pathophysiology and diagnosis. A combined Emergency Medicine (EM)/Internal Medicine (IM) residency program may allow for the best of both worlds. There are currently eleven, and soon to be twelve, programs that offer a combined five-year program. Required exposures in EM include experience performing invasive procedures, critical care experience, pediatric exposure, and emergency preparedness, while the IM aspect requires completion of rotations through IM subspecialties including oncology, cardiology, and infectious disease, with clinic opportunities in neurology, rheumatology, and endocrinology, as well as an additional four months dedicated specifically to pediatrics.[1] Graduates of the combined degree may choose to work solely in either field, enter a subspecialty, pursue additional fellowship experience in critical care, or engage in research.[2] The most popular fellowship pursued by combined training candidates is critical care (CC), and there are five all-inclusive combined EM/IM/CC programs in the United States. This path involves seventy-two months split between emergency medicine and internal medicine with additional experience in the critical care setting.[3] Upon completion of this challenging six-year period, residents are eligible for triple-board certification. Many triple-certified physicians choose to divide their time between the emergency department (ED) and intensive care unit (ICU) for extra variability in their careers, staying sharp in both the high acuity and physiological management of the most ill and complex patients.

Board certification in EM and IM allows for the confidence to handle the high acuity of the ED while also developing sophisticated understanding of the pathophysiology of chronic conditions. In the United States, nearly half (45 percent) of all Americans suffer from at least one chronic disease, making the utility of a combined board certification easily apparent.[4] EM/IM doctors are well suited to manage “observation units” where patients whose conditions fall in between warranting inpatient care and outpatient follow-up are monitored for select intervals of time in a controlled setting just outside the ED. Veterans are a particularly needy population who frequently present with acute exacerbations of chronic disease. Working in rural and international settings offer the opportunity to gain unique cultural experiences and practice in providing high quality care in more austere environments.

A fourth-year medical student rotation at a combined degree program is highly encouraged to bolster applications as spots are selective and highly competitive. Students pursuing a combined degree should be eager to apply both fields in their future career with a keen interest in research, scholarly endeavors at academic institutions, and a strong commitment to keeping up with changes in medical literature to manage both acute and chronic conditions. It is a common misconception that combined programs are preferred for learners desiring a slower paced emergency medicine education. Many who have completed the dual program themselves report that the training is far from slow-paced, however the challenge and clinical advantages of increased training and diversity of exposures is more than worth the extra time invested.[5] Dual-trained physicians are strong candidates for leadership positions including international clinic directors, program directors, and fellowship directors. Combined EM/IM doctors are lauded for their breadth of knowledge, commitment to upholding a high level of personal standard and patient care, and distinctive training to think like an internist and act with the speed and precision of an EM physician.

1. Martinez J. Emergency Medicine The Medical Student Survival Guide . https://www.emra.org/globalassets/emra/publications/books/emra-mssgonline-final.pdf.
2. ABEM. Guidelines for Combined Residency Training in Emergency Medicine and Internal Medicine.
3. Marcus D. Welcome to LIJ EM/IM and EM/IM+CC. EM Pulse
4. Raghupathi W, Raghupathi V. An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health. International Journal of Environmental Research and Public Health. 2018; 15(3):431. https://doi.org/10.3390/ijerph15030431
5. Winters M. Combined Residency Programs in Emergency Medicine. The Journal of Emergency Medicine . Published online August 31, 2019.