Revealing the Emergency Medicine Difference: Leveraging Specialty-Specific Strengths to Optimize Critical Care Training

Introduction: Emergency physicians pursuing critical care training must enter fellowships designed for internal medicine, anesthesiology, or surgery trainees. In this study we aimed to assess how emergency medicine (EM)-trained fellows are perceived by critical care fellowship leadership compared to their peers and to identify specialty-specific strengths and gaps that may inform targeted educational approaches. Methods: We conducted a national, cross-sectional survey of program directors and associate/assistant directors of Accreditation Council of Graduate Medical Education-accredited critical care fellowships. Respondents rated the baseline competence of incoming fellows across 11 core critical care domains using a 5-point Likert scale. We compared competency ratings across residency training backgrounds using linear mixed models, accounting for clustering and adjusting for rater specialty where appropriate. Results: Of 429 distributed surveys, 118 (27.5%) were completed. Our respondents represented internal medicine-based fellowships (63, 53%), surgical fellowships (32, 27%), and anesthesia fellowships (23, 20%). On a 5-point Likert scale ranging from 1 = “Not competent” to 5 = “Very competent,” EM-trained fellows were rated significantly higher than their internal medicine-trained peers in intubation (3.93 vs 1.86, P < .01); vascular access (3.72 vs 2.52, P < .01); point-of-care ultrasound (3.80 vs 2.52, P < .01 ); surgical critical care (2.39 vs 1.99, P < .01); and neurologic emergencies (2.59 vs 2.10, P < .01). Fellows trained in internal medicine were rated higher in ventilator management (2.54 vs 2.06, P < .01); palliation (3.05 vs 2.08, P < .01); and renal physiology/acid-base disturbances (3.18 vs 2.40, P < .01). Slightly different patterns emerged when comparing EM to surgery and anesthesiology trainees, where EM-trained fellows were rated similarly or lower in procedural domains but demonstrated more robust competence in organ-specific physiology and ultrasonography. These patterns remained largely consistent in sensitivity analyses adjusting for rater specialty. Conclusion: Critical care fellows who trained in EM bring distinct strengths in diagnostics and resuscitation to critical care training, but their educational needs may differ from those of peers within specialty-specific fellowships. Tailoring curricula to address these differences can help ensure all trainees achieve proficiency across core domains.