Surgical Critical Care is a board-certified subspecialty of the American Board of Surgery. Although often combined with trauma, this is by no means required. Fellowship training positions are governed by a match process.

To begin a fellowship in Surgical Critical Care, residents must have completed at least three years of a General Surgery residency and have a guaranteed categorical surgical spot to complete their last years of General Surgical training. The majority of fellows, however, choose to complete their entire General Surgical residency before beginning this fellowship. This order of training is recommended, as the success rate in passing the certifying examination in Surgical Critical Care is much higher for those having completed their general surgery residency program prior to entering fellowship. This may change with the recent ruling that the examination may be taken after the fellowship year even if the fellow has not completed training in general surgery.

There are 84 accredited programs in Surgical Critical Care, with 136 positions filled for the 2005-2006 academic year. There are a few programs that focus primarily on critically ill pediatric patients; the majority have some exposure to pediatric surgical patients but fellows spend the majority of time caring for adult patients. Fellows are able to sit for the certifying examination if they complete an accredited fellowship regardless of which age group they had the greatest exposure to, although the exam is weighted much more heavily to adult clinical practice.

A match was begun in 2004, with the majority of programs participating in the match. More fellowship positions are available than are interested applicants, so the likelihood of finding a position is good. Surgical Critical Care is a specialty match conducted by the NRMP, in which candidates apply directly to the residency program that interests them rather than centrally through NRMP. Registration through the match begins in August, and match day is the end of November.

Research experience is not required, although many applying for competitive
fellowships have done at least one year of research. A commitment to care of the critically injured patient and letters of recommendation are very important. There are many who have successful careers in surgical critical care; some have combined this with vascular surgery, some with pediatric surgery, some with general surgery, and some with trauma surgery.

A list of fellowships is on the Eastern Association for the Surgery of Trauma (EAST) Website and the American Association for the Surgery of Trauma (AAST) Website. The AAST is the sponsoring organization for the Surgical Critical Care match. The list of programs participating in the match is available at www.nrmp.org.  

Fellowship Requirements

Programs vary from one to two years. The second year is often a research year, and can be either clinical or basic research. Other programs have an optional trauma fellowship that can be combined with the critical-care fellowship. No Board Certification is available for trauma, nor is there likely to be in the future. Potential employers are more interested in the critical-care fellowship than in the trauma fellowship, if your residency has provided you with a reasonable exposure to trauma.

For the fellowship to be accredited, the year focused on critical care must be at least 80% nonoperative. Many residents are concerned that they will “forget” how to operate, particularly as they will be leaving the fellowship to become attending staff. This is a common worry, but an extremely uncommon problem. Some of the trauma fellowships become extended Chief residencies with little opportunity for a junior staff role. Therefore, be careful you are not signing up for another year of -call without real exposure to trauma systems, research, and staff opportunity, unless that is what you want.

Surgical Critical Care is at least 50% political; it can be tricky convincing other surgeons to let you take care of their patients, particularly when you are advocating something with which they are unfamiliar. The political role varies depending on whether the unit is open (critical-care team functions as a consultant) or closed (critical-care team becomes the primary service while the patient is in the Intensive Care Unit ICU). Knowing in which type of unit you will be practicing, as well as your personal strengths and weaknesses, can avoid problems in the future.

Board Certification - Added Qualifications in Surgical Critical Care

One must pass the American Board of Surgery Certifying Examination in Surgery and complete an approved surgical critical-care training program to qualify. The surgeon will be eligible to take the Certifying Examination in Surgical Critical Care (written examination) in the Fall after completing their training. This requirement was recently revised for fellows completing a surgical critical care fellowship after 3 years of general surgery residency. Fellows are required to complete a case-log to document all patients cared for as a Fellow. The individual is not required to recertify in Surgery to re-certify in Surgical Critical Care (every ten years).

Clinical Practice 

A minority of those who complete Surgical Critical Care fellowships practice critical care exclusively. Most find the opportunity to combine it with a practice of General Surgery, Trauma Surgery, Vascular Surgery, or Pediatric Surgery. In many places, job opportunities in critical care are linked to trauma. In some places, certification in critical care is required to take care of patients in an ICU. This trend is likely to continue, as data show improved outcome in many patient subsets with care supervised by an intensivist, which affords an opportunity to receive salary and other support from hospital administration in addition to departmental support.

Administrative duties, including ICU directorates, are reserved for those with critical-care certification. Billing for critical-care services is slightly different than for many operative specialties, and is focused on time, direct patient care, and documentation. Learning the nuances of billing is important, and exposure to the business aspects of critical care during fellowship is invaluable.

Grant Funding and Research Fellowships

Although a number of awards are available through other surgical societies, certain programs specific to the discipline of trauma/critical care are available. In general, trauma research is underfunded. Many more funding opportunities are available for basic critical-care research. Much of this funding comes from the National Institutes of Health (NIH) and is not specific to any of the societies listed. Within the NIH, the National Institute for General Medical Sciences and the National Heart, Lung, and Blood Institute are the usual institutes that fund critical-care research. The descriptions of qualifications listed herein are not complete.

Medical Students

The AAST¹ has a scholarship that funds medical students to attend the annual meeting. Students must be nominated by a member of the AAST. A special lunch program is provided for the students during the meeting, and they are able to participate in all aspects of the annual meeting except the business meeting.

Residents

The Surgical Infection Society (SIS) Fellowship Awards are $35,000/year.² The purpose of these awards is to provide the opportunity for a Resident or Fellow to spend one to two years in full-time research in the laboratory of a member of the SIS. Residents or Fellows who have completed at least two years of post-graduate training in a surgical discipline are eligible to apply. The award is to be used only for salary support or direct-cost expenditures of the funded research project conducted in the laboratory of the SIS member.

Faculty

An AAST scholarship of $35,000 is available for junior faculty who have a major commitment to a career in trauma surgery. Membership in the AAST is not a requirement. This fellowship covers direct costs only and does not provide salary support.

The SIS Junior Faculty Fellowship is $40,000. The award can be renewed for an additional year, contingent upon a report to the Foundation that demonstrates satisfactory progress in the project. Funds can only be used for salary support and direct expenses of this research project, and cannot be used for overhead expenses. Candidates for this award must have an M.D. or equivalent degree and have completed a residency in a surgical discipline. The applicant must be a member of the SIS and have a full-time faculty appointment at a United States or Canadian Medical School. The applicant must have an appointment at the Instructor or Assistant Professor level and be within five years of his/her initial faculty appointment at the time of the award.

Membership in Trauma/Critical Care Societies

Three societies combine the specialties of trauma and critical care, and one focuses on infectious disease but includes a large number of physicians who specialize in critical care. The only specialty society devoted exclusively to critical care includes physicians and allied health professionals from all disciplines of critical care. A brief description of each society, along with membership requirements, is provided below. Many of the other local, regional, and national societies have critical-care sections. This is important, particularly when choosing where to submit research and which general societies you might be interested in joining.

American Association for the Surgery of Trauma (AAST)¹

The AAST was formed to further the study and practice of trauma surgery in its various departments in the United States and Canada. Its purpose is to furnish leadership and foster advances in the surgery of trauma, including research, practice, and training.

Membership in the AAST is intended to afford recognition to those who have contributed to the surgery of trauma, as well as the investigation, care, and rehabilitation of injured patients. Members must be practicing physicians who are Initiates or Fellows of the American College of Surgeons or an equivalent international society, and are active in the field of trauma, burns, surgical-critical care, or related surgical specialties.

Eastern Association for the Surgery of Trauma (EAST)³ 

Society for Critical-Care Medicine (SCCM)⁵