This study was not without limitations, as it required current residents to make a prediction of their future practice patterns. Thus, any comparison of current residents to graduates evaluates actual practice by attending physicians versus anticipated future practice by residents. In 1 survey of 2,638 internal medicine residents, of the 86% PGY-3 residents with specific career plans, 62% had changed their career plans at least once during residency.11
Secondly, this study includes data from 71% current EM/IM residents and makes comparisons with 78% of physicians who graduated from EM/IM training programs during the previous decade. It remains unknown if the results mirror those of the complete EM/IM certified workforce, including physicians who certified in both specialties through either independent residencies or examination (without completing an EM residency). Nonetheless, the data in this study are useful if only to provide a benchmark by which to compare the actual practice patterns of the current PGY-1–4 cohort once they become established attending physicians.
One key finding of this study is that the overwhelming majority of EM/IM residents intend on practicing in an academic setting. However, further examination is required to determine if EM/IM residents are receiving the administrative support (such as dedicated research time, funding, faculty mentorship) to prepare them for careers in academia. In 1 article on academic career development for EM residents, it was noted that fellowships are “increasingly viewed as a key component to a successful academic career and clearly significantly enhances the competitiveness of the applicant seeking an academic post.”12
While we found that more than 90% of EM/IM residents believed combined training will advance their career relative to categorical training, there is not yet any empirical data from a head-to-head comparison to substantiate this ideation.
Given that combined EM/IM residencies have only existed since the early 1990s, it would be valuable to survey dually board-certified attending physicians who went through separate residencies as a point of comparison to those who went through combined training. Such research may help to elicit methods of optimizing the integration of the 2 specialties during training.
With regard to EM/IM graduates seemingly developing a predilection for EM-only practice once they leave residency, a future study could further evaluate the etiology of this phenomenon. The central question could address if it is discordance between resident ideals versus practice realities, or rather lifestyle and financial remuneration, that leads EM/IM residents to engage in EM-only practice. In addition, a follow-up study could be designed to survey the responding residents later in their careers to compare their expectations as residents with how they chose in reality to pursue clinical practice.
Selection bias and response bias were also factors that manifested themselves in the study. The selection bias arose from the need to include the graduating fifth-year resident class in the EM/IM graduate cohort rather than the resident cohort owing to the lag in response time, causing these individuals to be already in clinical practice. Since a fourth-year resident responder is still a resident, they may be counted as a fourth-year resident even with the lag in response time. The authors concede that this issue was not foreseen at the studies inception. Though unintended, it may have had an effect on the study results. The response bias could have affected the study, as the nonresponding residents may have had vastly different opinions and, had they responded, interyear comparisons could have been more effectively done with the boost in power. Also, no adjustments for multiple hypotheses were made during this study owing to concern about decreasing the power of the study.
Finally, given that a significant percentage of EM/IM residents are interested in critical care, it may be helpful to determine how such combined residencies will be affected by the October 2009 agreement between the ABIM and ABEM, allowing EM-trained physicians to become certified in IM critical care.13
It is unknown if under these conditions this sizable minority of EM/IM residents (39%) would choose the shorter categorical EM route rather than longer combined training. As the first group of EM-only critical care trainees will not sit for the certification examination until 2012, the impact of this change on EM/IM residencies remains to be seen.14