- Email: [email protected]
Emergency medicine career paths less traveled: cruise ship medicine, indian health, and critical care medicine
E D U C AT I O N / R E S I D E N T S ’ P E R S P E C T I V E
Residents’ Perspective Michael Cawdery, MD Michael D. Burg, MD From the Emergency Medicine Residency Program (Cawdery, Burg), and the Department of Emergency Medicine (Burg), University of California San Francisco-Fresno, Fresno, CA; and the Department of Emergency Medicine, Onze Lieve Vrouwe Gasthuis (Hospital), Amsterdam, The Netherlands (Burg). Section Editor Clare Atzema, MD University of Toronto, Royal College Emergency Medicine Residency Training Program Toronto, Ontario, Canada
Emergency Medicine Career Paths Less Traveled: Cruise Ship Medicine, Indian Health, and Critical Care Medicine [Ann Emerg Med. 2004;44:79-83.]
INTRODUCTION
Over the past several decades, the field of emergency medicine has grown substantially.1-3 Growth in new, related areas of medicine is often closely followed by the development of career opportunities in the area, resulting in the expansion of career path options for emergency physicians. The increase in fellowship training opportunities4 has contributed to the establishment of many emergency physicians in unique niche areas in academia. The development of specialized section memberships in the American College of Emergency Physicians (ACEP)5 and the Society for Academic Emergency Medicine (SAEM)6 has further enhanced the careers of many emergency physicians by promoting projects ranging from international volunteer work to medical education.
0196-0644/$30.00 Copyright Ó 2004 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2004.03.034
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
Entry into many specialized areas of emergency medicine requires extensive postresidency training, which may place a significant financial and/or time constraint on debtladen residents who are eager to begin the next phase of their careers. However, the conventional career path, consisting of entry into a traditional, community-based practice after residency, may fail to capture the imagination of all future emergency physicians. Fortunately, alternative career paths do exist. This article outlines 3 of many alternative career conduits for graduates of an emergency medicine residency program: cruise ship medicine, the Indian Health Service, and critical care medicine. For emergency medicine residents who are investigating their career options, these alternatives each serve a different patient population, and each offers a different form of emergency medicine practice. Physicians in both cruise ship medicine and the Indian Health Service will treat primarily healthy populations in a clinic-based practice, with limited access to specialty care, but whereas the former will care for vacationers, the latter will attend to the needs of the underserved. By comparison, critical care practitioners will treat all-comers in a controlled, high-tech environment where specialists are often forthcoming. The choice depends on the personality, the interests, and the goals of the resident. Full-time employment is available in each of these career paths; part-time or intermittent full-time work may be available as well. In a large emergency medicine practice group, one could arrange to depart for a month or two at a time to work as a cruise ship physician. Likewise, a string of locum tenens postings could be interspersed with time cruising. A permanent full-time job as a cruise ship physician is possible as well. A part-time position would not be an option in the Indian Health Service if the physician had arranged to take advantage of the Loan Repayment Program, which requires a commitment of 2 years of full-time clinical practice at an Indian Health Service facility or approved Indian health program. If one is not in the Loan Repayment Program, then it is possible to work part-time or full-time, and intermittent full-time work—which allows time for military service or other commitments—is also possible. Once trained in critical care, emergency physicians can divide their time between
7 9
RESIDENTS’ PERSPECTIVE
the emergency department (ED) and the ICU. Although working part-time in the critical care unit is a possibility for physicians who share a call schedule with a large group of intensivists, this type of position is likely only possible in a center with a large staff roster or resident call coverage. CRUISE SHIP MEDICINE
For emergency medicine residency graduates intrigued by the prospect of coupling their desire to travel with their interest in emergency medicine, cruise ship medicine may be a good option. Of note, entry into the field requires little beyond the completion of an emergency medicine residency and a sense of adventure. Numerous cruise lines employ health care professionals from the United States, Canada, and Europe for vacation cruises throughout the world. Physicians and nurses provide health care for passengers and crew in a full-service health care facility. Workplace safety, infectious disease monitoring, and the coordination of the evacuation of the critically ill are some of the vital roles of the cruise ship physician. A detailed cruise line directory can be found on the ACEP Section on Cruise Ship and Maritime Medicine Web site.7 The site provides brief descriptions of many cruise lines, contact information, and application instructions. A universal application form can be downloaded from the Web site; the application is used by most cruise lines. Employers may also request that their own application be completed and submitted with documentation of credentials. In addition, it is recommended that physicians attracted to a particular cruise line send a letter of interest along with their curriculum vitae. Most cruise lines require 3 years of postgraduate training in emergency medicine, family practice, or internal medicine. Preference is given to those physicians who are board prepared or board certified in emergency medicine or a critical care specialty. Advanced cardiac life support and advanced trauma life support certification are usually required. Great variability exists between individual cruise lines regarding health care services and delivery, employment contracts, salaries, benefits, and other employment details. Contracts can range anywhere from 2 weeks to 8 months. As an example, Norwegian Cruise Lines employs physicians for 14 weeks of cruising followed by 7 weeks of vacation.7 The daily experiences of each cruise ship physician are variable depending on the cruise line and the particular cruise. A typical day consists of a scheduled 1-hour morning and evening clinic. Times vary based on the port or sea status of the cruise ship. As in the ED, emergencies
8 0
are not scheduled, therefore the physician is always on call by pager. Larger cruise ships with multiple physicians will develop a call schedule. The nursing staff can usually handle most of the calls during the day, allowing the physician to participate in some port excursions. Sleep during the night is usually uninterrupted. The amount of free time varies and is hard to predict. Arrangements can be made for family to accompany the physician on the cruise (J. Jacobson, personal communication, February 14, 2004). Elderly patients with chronic medical problems are common passengers on cruises, and they may develop significant medical conditions. In such cases, the cruise ship physician is responsible for the stabilization and transfer of the patient to a land-based medical facility. This takes coordination with port authorities, health care providers in a variety of health care systems (who may not speak English), medical evacuation organizations, and travel insurance companies. At times, the nearest landbased medical facility may provide little benefit over the cruise ship; in this situation, the cruise ship physician must work toward an aeromedical evacuation. Patients and family members may not understand the seriousness of a condition and resist an evacuation. Termination of the cruise and admission to an unknown port hospital can also be very stressful for the patient and family, making medical evacuation one of the most challenging aspects of cruise ship medicine (J. Jacobson, personal communication, February 14, 2004). Interested residents may consider a cruise medicine elective during their fourth year, offered in cooperation with the Disney Cruise Line and Yale University. The resident receives an expense-paid trip on a Caribbean cruise while providing medical care to passengers and crew under the supervision of the cruise physician. The interested individual must plan this elective as a secondyear resident, because demand is high and slots fill early. More information regarding this 4-week elective, including an application, can be found at http://www.vanterventures. com.8 A textbook of cruise medicine is available for further study.9 It is published by Maritime Health Systems, Ltd., and is the only textbook and reference written for cruise medical personnel. Maritime Health Systems is a consulting firm established by 6 emergency physicians with cruise medicine experience. They provide the cruise line industry with many health care services, including infirmary design, computerized documentation, and medicolegal services. Further information on this organization and their textbook can be found at http://www.marimed.com.10
ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4
RESIDENTS’ PERSPECTIVE
INDIAN HEALTH SERVICE
The Indian Health Service, a part of the United States Department of Health and Human Services, is responsible for providing health care services to Native Americans in the continental United States and Alaska. Employment is available for emergency physicians and a variety of other specialists to staff their clinics and hospitals. Opportunities are available in tribal hospitals, private hospitals that care for a significant number of Native Americans, and Indian Health Service referral centers. The referral centers include the Phoenix Indian Medical Center in Arizona, Gallup Indian Medical Center in New Mexico, and the Anchorage Indian Medical Center in Alaska. Information about long- or short-term careers with the Indian Health Service is available on their Web site at http://www. ihs.gov.11 One can work for the Indian Health Service directly after residency; no fellowship training is required. Emergency physician salaries at the Indian Health Service are typically at the low to moderate end of the earnings range for community practice. Benefits are provided, and indebted physicians willing to make a 2-year commitment to the Indian Health Service are eligible for the Loan Repayment Program. Only physicians who are employed full-time in direct patient care are eligible for the Loan Repayment Program, and the 2 years must be carried out at one time. One may apply for the Loan Repayment Program by working at any Indian Health Service location, but the highest likelihood of being accepted into the program is by working at a site the Indian Health Service identifies as ‘‘high-need.’’ Physicians may apply for extensions beyond the original 2 years if they still have student loans to repay. From the Indian Health Service Web site, ‘‘the [Loan Repayment Program] will repay all or a portion of the applicant’s eligible health professionals educational loans (undergraduate and graduate) for tuition expenses. Applicants are eligible to have their educational loans repaid in amounts up to $20,000 per year for each year of service. In addition, the [Loan Repayment Program] will pay up to 20% of Federal taxes directly to the Internal Revenue Service (IRS)—incurred as a result of payments made on behalf of recipients. Note: Loan repayments are deemed taxable income.’’12 The quality of one’s life as an emergency physician with the Indian Health Service is dependent on many of the same factors that influence one’s personal and professional life in any job. Some Indian Health Service facilities are in or near large population centers; others are rural. Some are resource and personnel poor, while others are
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
rich in both. Benefits and drawbacks of employment with the Indian Health Service are therefore likely to be facility dependent. Some of the disadvantages may include the following: relatively low frequency of critically ill patients, with a resultant decline in certain skill sets; limited local subspecialty care, resulting in decreased support and long transport times; working with non–emergency medicine residency–trained physicians; relatively modest pay; a rural living situation; being constantly confronted with the problems associated with extreme poverty; difficulties resulting from cultural differences; and the limited availability of medical technology. The advantages of working for the Indian Health Service are less tangible but may include: the opportunity to care for an underserved patient population; the chance to expand one’s cultural horizons; working with colleagues who are intensely committed to the patient population they serve; and a high level of job satisfaction and autonomy, working in a challenging environment (I. Benavides, personal communication, February 18, 2004). Finally, some physicians may be attracted by the chance to work in—and learn from—such an environment for a defined time period before moving on to another practice setting. When approaching the Indian Health Service for a job, as with any other contract negotiation, several employment conditions are open to discussion. Salary, benefits, interview and moving expenses, a job for one’s spouse, contract length, and other issues of personal concern should be part of the dialogue with the Indian Health Service if you are considering taking a position with them.
CRITICAL CARE MEDICINE
Critical care begins at the onset of critical illness or at the scene of a life-threatening trauma.13 It continues during transport, resuscitation, and life support. Stabilization, the pursuit of a diagnosis, and initial treatment are the fundamental precepts of effective emergency medicine and critical care.14 Demand for critical care services in the ED has increased over the past decade and continues to rise; in California the volume of critically ill patients presenting to the ED increased by 57% from 1990 to 1999.15 Nationally, ED visits have increased from 89.8 million to 110.2 million from 1992 to 2002 while the number of hospitals has decreased by 15%, and in 2002, 22% of patients were triaged as ‘‘emergent’’ and 919,000 required ‘‘immediate medical attention.’’16 As more patients with life-threatening disease processes present to the ED, critical care has become a natural extension of emergency medicine.17
8 1
RESIDENTS’ PERSPECTIVE
Table 1.
Critical care fellowships accepting emergency medicine residents.19 Specialty
Institution (Location)
Anesthesiology* University of California–San Francisco (San Francisco, CA) University of Florida–Gainesville (Gainesville, FL) University of South Florida (St. Petersburg, FL) University of Iowa (Iowa City, IA) The Johns Hopkins University (Baltimore, MD) Brigham and Women’s Hospital (Boston, MA) University of Massachusetts (Amherst, MA) University of Michigan (Ann Arbor, MI) Mayo Clinic (Rochester, MN) Dartmouth-Hitchcock (Lebanon, NH) University of Rochester (Rochester, NY) Wake Forest University (Winston-Salem, NC) Cleveland Clinic (Cleveland, OH) University of Pittsburgh (Pittsburgh, PA) Vanderbilt University (Nashville, TN) University of Texas–Houston (Houston, TX) San Antonio Uniformed Services Health Education Consortium (San Antonio, TX) George Washington University (Washington, DC) Internal Finch University of Health Sciences/Chicago Medical mediciney School (Chicago, IL) Louisiana State University (Shreveport, LA) Walter Reed (Washington, DC) St. Louis University (St. Louis, MO) Dartmouth-Hitchcock (Lebanon, NH) University of Medicine and Dentistry of New Jersey (Camden, NJ) University of New Mexico (Albuquerque, NM) Albert Einstein College of Medicine (New York, NY) Memorial Sloan-Kettering/New York Presbyterian Hospital (Cornell Campus) Program (New York, NY) Wake Forest University (Winston-Salem, NC) University of Pittsburgh (Pittsburgh, PA) Brown University (Providence, RI) University of Washington (Seattle, WA) University of Alabama at Birmingham (Birmingham, AL) Surgeryz Boston University (Boston, MA) University of Hawaii (Honolulu, HI) Jackson Memorial Hospital/Jackson Health System (Miami, FL) The Johns Hopkins University (Baltimore, MD) University of Maryland-Shock Trauma (Baltimore, MD) Massachusetts General Hospital (Boston, MA) University of Massachusetts–Worchester (Worchester, MA) Henry Ford Hospital (Detroit, MI) University of Minnesota (Minneapolis, MN) University of Missouri–Columbia (Columbia, MO) St. Louis University (St. Louis, MO) MCP Hanneman (Philadelphia, PA) University of Pittsburgh (Pittsburgh, PA) University of Texas–Houston (Houston, TX) Washington University/BJH/SLCH Consortium Program (St. Louis, MO) Medical College of Wisconsin (Milwaukee, WI) Vanderbilt University (Nashville, TN) *72.5% of programs responded; 46% of respondents accept emergency medicine residents. y 78.25% of programs responded; 58.3% of respondents accept emergency medicine residents z 83% of programs responded; 30% of responders accept emergency medicine residents
8 2
Critical care medicine requires fellowship training, but currently it is not a board-certified subspecialty in the United States; it is considered a ‘‘certificate of added qualification.’’ An American Board of Emergency Medicine (ABEM) certifying examination in critical care medicine does not exist presently. An alternative route to certification exists through the European Society of Intensive Care Medicine (http://www.esicm.org). On completion of 2 years of critical care fellowship training, emergency medicine– trained physicians from the United States may sit for the European Diploma in Intensive Care examination. The European Society of Intensive Care Medicine has a reciprocal relationship with the US-based Society for Critical Care Medicine (http://www.sccm.org), and its examination provides the only means possible for an emergency physician to demonstrate a compatible knowledge base of critical care medicine.18 Acceptance of the European Diploma in Intensive Care for credentialing purposes is hospital dependent. As the number of emergency physicians trained in critical care medicine continues to grow, ABEM will likely develop a certifying examination (E. Kimball, personal communication, February 21, 2004). Multiple critical care fellowships throughout the United States accept emergency physicians. A list of critical care fellowships that accept emergency physicians is provided on the ACEP Section of Critical Care Medicine Web site (Table 1).19 Traditional programs based in surgery, anesthesiology, and internal medicine are represented. Critical care fellowships vary in length from 1 to 2 years, although most programs are 2 years in duration, providing training that is equal to that of other intensivists and allowing trainees to sit the European board examination. Emergency physicians are currently employed as intensivists in both private and academic university hospi-
Table 2.
Information resources. Web Address
Organization
www.acep.org/index.cfm?id=4254 www.vanterventures.com www.marimed.com www.ihs.gov www.esicm.org www.sccm.org www.acep.org/index.cfm?id=4252
ACEP Section on Cruise Ship and Maritime Medicine Vanter Ventures Maritime Health Systems Indian Health Services European Society of Intensive Care Medicine Society for Critical Care Medicine ACEP Section of Critical Care Medicine
ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4
RESIDENTS’ PERSPECTIVE
tals. As the US population ages, the demand for more intensivists is likely to increase, suggesting a promising job market for critical care specialists in the future.18 Critical care medicine training and certification can enhance the career of the emergency physician by providing more research and administrative opportunities, and may also afford professional diversity by allowing the emergency physician to work in both the fast-paced ED and the more controlled ICU. We hypothesize that the challenges and tempos of these two different environments may help to prevent career stagnation and burnout. Finally, critical care training may allow emergency physicians to develop and coordinate the expanding role of emergency medicine in the care of the critically ill. A significant drawback may be that, as a relatively new role for the emergency physician in the United States, collegial acceptance and recognition may be difficult, depending on the particular setting (E. Kimball, personal communication, February 21, 2004). CONCLUSION
We have provided a brief overview of 3 nontraditional career alternatives available to emergency physicians. These somewhat less traveled career paths are not for everyone. Before choosing one of these career alternatives, one must carefully consider the effect that choice will have on one’s personal and professional life, whether it be at sea or on land, in a rural or an urban environment. Opportunity within, and information about, these alternative careers tends to change rapidly. Personal exploration of any of the resources (Table 2) or careers discussed here is likely to uncover still more prospects and possibilities.
6. Society for Academic Emergency Medicine Web site. Available at: http:// www.saem.org/inform/intgrps.htm. Accessed March 1, 2004. 7. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=4254. Accessed February 21, 2004. 8. Vanter Cruise Health Services Web site. Available at: http://www.vanterventures.com. Accessed February 21, 2004. 9. TE Harrison, ed. Cruise Medicine. 2nd ed. Nassau, Bahamas: Maritime Health Systems, Ltd.; 1999. 10. Maritime Health Systems, Ltd., Web site. Available at: http://www.marimed.com. Accessed February 21, 2004. 11. US Department of Health and Human Services, Indian Health Service Web site. Available at: http://www.ihs.gov. Accessed February 21, 2004. 12. US Department of Health and Human Services, Indian Health Service Web site. Available at: http://www.ihs.gov/JobsCareerDevelop/DHPS/LRP/LRP_index.asp. Accessed February 21, 2004. 13. Safer P. The critical care medicine continuum from scene to outcome. In: Parillo JE, Ayres SM, eds. Major Issues in Critical Care Medicine. 2003;41Baltimore, MD: Williams and Wilkins; 1984:714-732. 14. Gunn S, Grenvik A. Emergency medicine and critical care certification. Acad Emerg Med. 2002;9:322-323. 15. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency departments, 1990-1999. Ann Emerg Med. 2002;39:389-396. 16. McCaig LF, Burk CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Advance data from vital and health statistics. No 340.2002;39 Hyattsville, MD: National Center for Health Statistics; 2004:389-396. 17. Osborn TM. A call for critical care training of emergency physicians. Ann Emerg Med. 2002;39:562-563. 18. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=5411. Accessed February 21, 2004. 19. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=5412. Accessed February 21, 2004.
The authors report this study did not receive any outside funding or support. Reprints not available from the authors. Address for correspondence: Michael Cawdery, MD, University Medical Center, 445 South Cedar Avenue, Fresno, CA 93702-2907; 559459-5105, fax 559-459-3844; E-mail [email protected].
REFERENCES 1. Krome R. Twenty-five years of evolution and revolution: how the specialty has changed. Ann Emerg Med. 1997;30:689-691. 2. van de Leuv JH, Gold SR, Krome RL. Twenty-five years of Annals of Emergency Medicine: a history. Ann Emerg Med. 1997;30:97-98. 3. Wiegenstein J. What, another milestone? The first steps in the founding of a specialty. Ann Emerg Med. 1997;30:329-333. 4. Hoffman GL, Bock BF, Gallagher EJ, et al. Report of the task force on residency training information (2002-2003), American Board of Emergency Medicine. Ann Emerg Med. 2003;41:714-732. 5. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/1,38,0.html. Accessed March 1, 2004.
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
8 3
Residents’ Perspective Michael Cawdery, MD Michael D. Burg, MD From the Emergency Medicine Residency Program (Cawdery, Burg), and the Department of Emergency Medicine (Burg), University of California San Francisco-Fresno, Fresno, CA; and the Department of Emergency Medicine, Onze Lieve Vrouwe Gasthuis (Hospital), Amsterdam, The Netherlands (Burg). Section Editor Clare Atzema, MD University of Toronto, Royal College Emergency Medicine Residency Training Program Toronto, Ontario, Canada
Emergency Medicine Career Paths Less Traveled: Cruise Ship Medicine, Indian Health, and Critical Care Medicine [Ann Emerg Med. 2004;44:79-83.]
INTRODUCTION
Over the past several decades, the field of emergency medicine has grown substantially.1-3 Growth in new, related areas of medicine is often closely followed by the development of career opportunities in the area, resulting in the expansion of career path options for emergency physicians. The increase in fellowship training opportunities4 has contributed to the establishment of many emergency physicians in unique niche areas in academia. The development of specialized section memberships in the American College of Emergency Physicians (ACEP)5 and the Society for Academic Emergency Medicine (SAEM)6 has further enhanced the careers of many emergency physicians by promoting projects ranging from international volunteer work to medical education.
0196-0644/$30.00 Copyright Ó 2004 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2004.03.034
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
Entry into many specialized areas of emergency medicine requires extensive postresidency training, which may place a significant financial and/or time constraint on debtladen residents who are eager to begin the next phase of their careers. However, the conventional career path, consisting of entry into a traditional, community-based practice after residency, may fail to capture the imagination of all future emergency physicians. Fortunately, alternative career paths do exist. This article outlines 3 of many alternative career conduits for graduates of an emergency medicine residency program: cruise ship medicine, the Indian Health Service, and critical care medicine. For emergency medicine residents who are investigating their career options, these alternatives each serve a different patient population, and each offers a different form of emergency medicine practice. Physicians in both cruise ship medicine and the Indian Health Service will treat primarily healthy populations in a clinic-based practice, with limited access to specialty care, but whereas the former will care for vacationers, the latter will attend to the needs of the underserved. By comparison, critical care practitioners will treat all-comers in a controlled, high-tech environment where specialists are often forthcoming. The choice depends on the personality, the interests, and the goals of the resident. Full-time employment is available in each of these career paths; part-time or intermittent full-time work may be available as well. In a large emergency medicine practice group, one could arrange to depart for a month or two at a time to work as a cruise ship physician. Likewise, a string of locum tenens postings could be interspersed with time cruising. A permanent full-time job as a cruise ship physician is possible as well. A part-time position would not be an option in the Indian Health Service if the physician had arranged to take advantage of the Loan Repayment Program, which requires a commitment of 2 years of full-time clinical practice at an Indian Health Service facility or approved Indian health program. If one is not in the Loan Repayment Program, then it is possible to work part-time or full-time, and intermittent full-time work—which allows time for military service or other commitments—is also possible. Once trained in critical care, emergency physicians can divide their time between
7 9
RESIDENTS’ PERSPECTIVE
the emergency department (ED) and the ICU. Although working part-time in the critical care unit is a possibility for physicians who share a call schedule with a large group of intensivists, this type of position is likely only possible in a center with a large staff roster or resident call coverage. CRUISE SHIP MEDICINE
For emergency medicine residency graduates intrigued by the prospect of coupling their desire to travel with their interest in emergency medicine, cruise ship medicine may be a good option. Of note, entry into the field requires little beyond the completion of an emergency medicine residency and a sense of adventure. Numerous cruise lines employ health care professionals from the United States, Canada, and Europe for vacation cruises throughout the world. Physicians and nurses provide health care for passengers and crew in a full-service health care facility. Workplace safety, infectious disease monitoring, and the coordination of the evacuation of the critically ill are some of the vital roles of the cruise ship physician. A detailed cruise line directory can be found on the ACEP Section on Cruise Ship and Maritime Medicine Web site.7 The site provides brief descriptions of many cruise lines, contact information, and application instructions. A universal application form can be downloaded from the Web site; the application is used by most cruise lines. Employers may also request that their own application be completed and submitted with documentation of credentials. In addition, it is recommended that physicians attracted to a particular cruise line send a letter of interest along with their curriculum vitae. Most cruise lines require 3 years of postgraduate training in emergency medicine, family practice, or internal medicine. Preference is given to those physicians who are board prepared or board certified in emergency medicine or a critical care specialty. Advanced cardiac life support and advanced trauma life support certification are usually required. Great variability exists between individual cruise lines regarding health care services and delivery, employment contracts, salaries, benefits, and other employment details. Contracts can range anywhere from 2 weeks to 8 months. As an example, Norwegian Cruise Lines employs physicians for 14 weeks of cruising followed by 7 weeks of vacation.7 The daily experiences of each cruise ship physician are variable depending on the cruise line and the particular cruise. A typical day consists of a scheduled 1-hour morning and evening clinic. Times vary based on the port or sea status of the cruise ship. As in the ED, emergencies
8 0
are not scheduled, therefore the physician is always on call by pager. Larger cruise ships with multiple physicians will develop a call schedule. The nursing staff can usually handle most of the calls during the day, allowing the physician to participate in some port excursions. Sleep during the night is usually uninterrupted. The amount of free time varies and is hard to predict. Arrangements can be made for family to accompany the physician on the cruise (J. Jacobson, personal communication, February 14, 2004). Elderly patients with chronic medical problems are common passengers on cruises, and they may develop significant medical conditions. In such cases, the cruise ship physician is responsible for the stabilization and transfer of the patient to a land-based medical facility. This takes coordination with port authorities, health care providers in a variety of health care systems (who may not speak English), medical evacuation organizations, and travel insurance companies. At times, the nearest landbased medical facility may provide little benefit over the cruise ship; in this situation, the cruise ship physician must work toward an aeromedical evacuation. Patients and family members may not understand the seriousness of a condition and resist an evacuation. Termination of the cruise and admission to an unknown port hospital can also be very stressful for the patient and family, making medical evacuation one of the most challenging aspects of cruise ship medicine (J. Jacobson, personal communication, February 14, 2004). Interested residents may consider a cruise medicine elective during their fourth year, offered in cooperation with the Disney Cruise Line and Yale University. The resident receives an expense-paid trip on a Caribbean cruise while providing medical care to passengers and crew under the supervision of the cruise physician. The interested individual must plan this elective as a secondyear resident, because demand is high and slots fill early. More information regarding this 4-week elective, including an application, can be found at http://www.vanterventures. com.8 A textbook of cruise medicine is available for further study.9 It is published by Maritime Health Systems, Ltd., and is the only textbook and reference written for cruise medical personnel. Maritime Health Systems is a consulting firm established by 6 emergency physicians with cruise medicine experience. They provide the cruise line industry with many health care services, including infirmary design, computerized documentation, and medicolegal services. Further information on this organization and their textbook can be found at http://www.marimed.com.10
ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4
RESIDENTS’ PERSPECTIVE
INDIAN HEALTH SERVICE
The Indian Health Service, a part of the United States Department of Health and Human Services, is responsible for providing health care services to Native Americans in the continental United States and Alaska. Employment is available for emergency physicians and a variety of other specialists to staff their clinics and hospitals. Opportunities are available in tribal hospitals, private hospitals that care for a significant number of Native Americans, and Indian Health Service referral centers. The referral centers include the Phoenix Indian Medical Center in Arizona, Gallup Indian Medical Center in New Mexico, and the Anchorage Indian Medical Center in Alaska. Information about long- or short-term careers with the Indian Health Service is available on their Web site at http://www. ihs.gov.11 One can work for the Indian Health Service directly after residency; no fellowship training is required. Emergency physician salaries at the Indian Health Service are typically at the low to moderate end of the earnings range for community practice. Benefits are provided, and indebted physicians willing to make a 2-year commitment to the Indian Health Service are eligible for the Loan Repayment Program. Only physicians who are employed full-time in direct patient care are eligible for the Loan Repayment Program, and the 2 years must be carried out at one time. One may apply for the Loan Repayment Program by working at any Indian Health Service location, but the highest likelihood of being accepted into the program is by working at a site the Indian Health Service identifies as ‘‘high-need.’’ Physicians may apply for extensions beyond the original 2 years if they still have student loans to repay. From the Indian Health Service Web site, ‘‘the [Loan Repayment Program] will repay all or a portion of the applicant’s eligible health professionals educational loans (undergraduate and graduate) for tuition expenses. Applicants are eligible to have their educational loans repaid in amounts up to $20,000 per year for each year of service. In addition, the [Loan Repayment Program] will pay up to 20% of Federal taxes directly to the Internal Revenue Service (IRS)—incurred as a result of payments made on behalf of recipients. Note: Loan repayments are deemed taxable income.’’12 The quality of one’s life as an emergency physician with the Indian Health Service is dependent on many of the same factors that influence one’s personal and professional life in any job. Some Indian Health Service facilities are in or near large population centers; others are rural. Some are resource and personnel poor, while others are
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
rich in both. Benefits and drawbacks of employment with the Indian Health Service are therefore likely to be facility dependent. Some of the disadvantages may include the following: relatively low frequency of critically ill patients, with a resultant decline in certain skill sets; limited local subspecialty care, resulting in decreased support and long transport times; working with non–emergency medicine residency–trained physicians; relatively modest pay; a rural living situation; being constantly confronted with the problems associated with extreme poverty; difficulties resulting from cultural differences; and the limited availability of medical technology. The advantages of working for the Indian Health Service are less tangible but may include: the opportunity to care for an underserved patient population; the chance to expand one’s cultural horizons; working with colleagues who are intensely committed to the patient population they serve; and a high level of job satisfaction and autonomy, working in a challenging environment (I. Benavides, personal communication, February 18, 2004). Finally, some physicians may be attracted by the chance to work in—and learn from—such an environment for a defined time period before moving on to another practice setting. When approaching the Indian Health Service for a job, as with any other contract negotiation, several employment conditions are open to discussion. Salary, benefits, interview and moving expenses, a job for one’s spouse, contract length, and other issues of personal concern should be part of the dialogue with the Indian Health Service if you are considering taking a position with them.
CRITICAL CARE MEDICINE
Critical care begins at the onset of critical illness or at the scene of a life-threatening trauma.13 It continues during transport, resuscitation, and life support. Stabilization, the pursuit of a diagnosis, and initial treatment are the fundamental precepts of effective emergency medicine and critical care.14 Demand for critical care services in the ED has increased over the past decade and continues to rise; in California the volume of critically ill patients presenting to the ED increased by 57% from 1990 to 1999.15 Nationally, ED visits have increased from 89.8 million to 110.2 million from 1992 to 2002 while the number of hospitals has decreased by 15%, and in 2002, 22% of patients were triaged as ‘‘emergent’’ and 919,000 required ‘‘immediate medical attention.’’16 As more patients with life-threatening disease processes present to the ED, critical care has become a natural extension of emergency medicine.17
8 1
RESIDENTS’ PERSPECTIVE
Table 1.
Critical care fellowships accepting emergency medicine residents.19 Specialty
Institution (Location)
Anesthesiology* University of California–San Francisco (San Francisco, CA) University of Florida–Gainesville (Gainesville, FL) University of South Florida (St. Petersburg, FL) University of Iowa (Iowa City, IA) The Johns Hopkins University (Baltimore, MD) Brigham and Women’s Hospital (Boston, MA) University of Massachusetts (Amherst, MA) University of Michigan (Ann Arbor, MI) Mayo Clinic (Rochester, MN) Dartmouth-Hitchcock (Lebanon, NH) University of Rochester (Rochester, NY) Wake Forest University (Winston-Salem, NC) Cleveland Clinic (Cleveland, OH) University of Pittsburgh (Pittsburgh, PA) Vanderbilt University (Nashville, TN) University of Texas–Houston (Houston, TX) San Antonio Uniformed Services Health Education Consortium (San Antonio, TX) George Washington University (Washington, DC) Internal Finch University of Health Sciences/Chicago Medical mediciney School (Chicago, IL) Louisiana State University (Shreveport, LA) Walter Reed (Washington, DC) St. Louis University (St. Louis, MO) Dartmouth-Hitchcock (Lebanon, NH) University of Medicine and Dentistry of New Jersey (Camden, NJ) University of New Mexico (Albuquerque, NM) Albert Einstein College of Medicine (New York, NY) Memorial Sloan-Kettering/New York Presbyterian Hospital (Cornell Campus) Program (New York, NY) Wake Forest University (Winston-Salem, NC) University of Pittsburgh (Pittsburgh, PA) Brown University (Providence, RI) University of Washington (Seattle, WA) University of Alabama at Birmingham (Birmingham, AL) Surgeryz Boston University (Boston, MA) University of Hawaii (Honolulu, HI) Jackson Memorial Hospital/Jackson Health System (Miami, FL) The Johns Hopkins University (Baltimore, MD) University of Maryland-Shock Trauma (Baltimore, MD) Massachusetts General Hospital (Boston, MA) University of Massachusetts–Worchester (Worchester, MA) Henry Ford Hospital (Detroit, MI) University of Minnesota (Minneapolis, MN) University of Missouri–Columbia (Columbia, MO) St. Louis University (St. Louis, MO) MCP Hanneman (Philadelphia, PA) University of Pittsburgh (Pittsburgh, PA) University of Texas–Houston (Houston, TX) Washington University/BJH/SLCH Consortium Program (St. Louis, MO) Medical College of Wisconsin (Milwaukee, WI) Vanderbilt University (Nashville, TN) *72.5% of programs responded; 46% of respondents accept emergency medicine residents. y 78.25% of programs responded; 58.3% of respondents accept emergency medicine residents z 83% of programs responded; 30% of responders accept emergency medicine residents
8 2
Critical care medicine requires fellowship training, but currently it is not a board-certified subspecialty in the United States; it is considered a ‘‘certificate of added qualification.’’ An American Board of Emergency Medicine (ABEM) certifying examination in critical care medicine does not exist presently. An alternative route to certification exists through the European Society of Intensive Care Medicine (http://www.esicm.org). On completion of 2 years of critical care fellowship training, emergency medicine– trained physicians from the United States may sit for the European Diploma in Intensive Care examination. The European Society of Intensive Care Medicine has a reciprocal relationship with the US-based Society for Critical Care Medicine (http://www.sccm.org), and its examination provides the only means possible for an emergency physician to demonstrate a compatible knowledge base of critical care medicine.18 Acceptance of the European Diploma in Intensive Care for credentialing purposes is hospital dependent. As the number of emergency physicians trained in critical care medicine continues to grow, ABEM will likely develop a certifying examination (E. Kimball, personal communication, February 21, 2004). Multiple critical care fellowships throughout the United States accept emergency physicians. A list of critical care fellowships that accept emergency physicians is provided on the ACEP Section of Critical Care Medicine Web site (Table 1).19 Traditional programs based in surgery, anesthesiology, and internal medicine are represented. Critical care fellowships vary in length from 1 to 2 years, although most programs are 2 years in duration, providing training that is equal to that of other intensivists and allowing trainees to sit the European board examination. Emergency physicians are currently employed as intensivists in both private and academic university hospi-
Table 2.
Information resources. Web Address
Organization
www.acep.org/index.cfm?id=4254 www.vanterventures.com www.marimed.com www.ihs.gov www.esicm.org www.sccm.org www.acep.org/index.cfm?id=4252
ACEP Section on Cruise Ship and Maritime Medicine Vanter Ventures Maritime Health Systems Indian Health Services European Society of Intensive Care Medicine Society for Critical Care Medicine ACEP Section of Critical Care Medicine
ANNALS OF EMERGENCY MEDICINE
44:1
J U LY 2 0 0 4
RESIDENTS’ PERSPECTIVE
tals. As the US population ages, the demand for more intensivists is likely to increase, suggesting a promising job market for critical care specialists in the future.18 Critical care medicine training and certification can enhance the career of the emergency physician by providing more research and administrative opportunities, and may also afford professional diversity by allowing the emergency physician to work in both the fast-paced ED and the more controlled ICU. We hypothesize that the challenges and tempos of these two different environments may help to prevent career stagnation and burnout. Finally, critical care training may allow emergency physicians to develop and coordinate the expanding role of emergency medicine in the care of the critically ill. A significant drawback may be that, as a relatively new role for the emergency physician in the United States, collegial acceptance and recognition may be difficult, depending on the particular setting (E. Kimball, personal communication, February 21, 2004). CONCLUSION
We have provided a brief overview of 3 nontraditional career alternatives available to emergency physicians. These somewhat less traveled career paths are not for everyone. Before choosing one of these career alternatives, one must carefully consider the effect that choice will have on one’s personal and professional life, whether it be at sea or on land, in a rural or an urban environment. Opportunity within, and information about, these alternative careers tends to change rapidly. Personal exploration of any of the resources (Table 2) or careers discussed here is likely to uncover still more prospects and possibilities.
6. Society for Academic Emergency Medicine Web site. Available at: http:// www.saem.org/inform/intgrps.htm. Accessed March 1, 2004. 7. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=4254. Accessed February 21, 2004. 8. Vanter Cruise Health Services Web site. Available at: http://www.vanterventures.com. Accessed February 21, 2004. 9. TE Harrison, ed. Cruise Medicine. 2nd ed. Nassau, Bahamas: Maritime Health Systems, Ltd.; 1999. 10. Maritime Health Systems, Ltd., Web site. Available at: http://www.marimed.com. Accessed February 21, 2004. 11. US Department of Health and Human Services, Indian Health Service Web site. Available at: http://www.ihs.gov. Accessed February 21, 2004. 12. US Department of Health and Human Services, Indian Health Service Web site. Available at: http://www.ihs.gov/JobsCareerDevelop/DHPS/LRP/LRP_index.asp. Accessed February 21, 2004. 13. Safer P. The critical care medicine continuum from scene to outcome. In: Parillo JE, Ayres SM, eds. Major Issues in Critical Care Medicine. 2003;41Baltimore, MD: Williams and Wilkins; 1984:714-732. 14. Gunn S, Grenvik A. Emergency medicine and critical care certification. Acad Emerg Med. 2002;9:322-323. 15. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California’s emergency departments, 1990-1999. Ann Emerg Med. 2002;39:389-396. 16. McCaig LF, Burk CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Advance data from vital and health statistics. No 340.2002;39 Hyattsville, MD: National Center for Health Statistics; 2004:389-396. 17. Osborn TM. A call for critical care training of emergency physicians. Ann Emerg Med. 2002;39:562-563. 18. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=5411. Accessed February 21, 2004. 19. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/index.cfm?id=5412. Accessed February 21, 2004.
The authors report this study did not receive any outside funding or support. Reprints not available from the authors. Address for correspondence: Michael Cawdery, MD, University Medical Center, 445 South Cedar Avenue, Fresno, CA 93702-2907; 559459-5105, fax 559-459-3844; E-mail [email protected].
REFERENCES 1. Krome R. Twenty-five years of evolution and revolution: how the specialty has changed. Ann Emerg Med. 1997;30:689-691. 2. van de Leuv JH, Gold SR, Krome RL. Twenty-five years of Annals of Emergency Medicine: a history. Ann Emerg Med. 1997;30:97-98. 3. Wiegenstein J. What, another milestone? The first steps in the founding of a specialty. Ann Emerg Med. 1997;30:329-333. 4. Hoffman GL, Bock BF, Gallagher EJ, et al. Report of the task force on residency training information (2002-2003), American Board of Emergency Medicine. Ann Emerg Med. 2003;41:714-732. 5. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/1,38,0.html. Accessed March 1, 2004.
J U LY 2 0 0 4
44:1
ANNALS OF EMERGENCY MEDICINE
8 3