Why Emergency Medicine Residents Rarely Choose Surgical Critical Care — A Nationwide Survey and a Roadmap to Increase EM-SCC Matriculation

Highlights

– Limited exposure to surgical intensivists and EM-designed SCC fellowships during residency is common and correlates with low matriculation into surgical critical care (SCC).
– Trainees prioritize intellectual appeal of critical care and specific fellowship components (core CC knowledge, institutional respect for EM-CC, ECMO experience) over board-certification ease.
– Geography, specialty unit exposure, and multidisciplinary team interactions are modifiable determinants of pathway choice; multifaceted interventions at society, institutional, and program levels are indicated.

Background

Emergency medicine (EM)-trained intensivists bring distinct strengths to the intensive care unit (ICU): broad resuscitation skills, rapid diagnostic decision-making, and comfort with undifferentiated critical presentations. Surgical critical care (SCC) fellowships historically attract surgeons but have increasingly become sites of multidisciplinary practice. Given workforce needs in trauma and surgical ICUs, attracting EM physicians to SCC could expand staffing models, enhance resuscitation-driven care, and improve handoffs across the acute care continuum. However, EM trainees electing other critical care pathways (medical or anesthesiology critical care) outnumber those choosing SCC. Understanding trainee preferences and barriers is essential to design practical interventions to increase EM representation in SCC.

Study design

This cross-sectional survey study (Hynes et al., Crit Care Med. 2025) sampled 111 emergency medicine trainees (69 residents, 42 fellows) across four national EM societies. Respondent median age was 32 years (IQR 30–35). The primary outcome was the top factors influencing pathway selection into different critical care fellowships. Secondary outcomes included influential motivations for entering critical care and specific fellowship components that interested trainees. Respondents reported intended critical care fields and whether they had exposure to SCC training environments and surgical intensivists during residency.

Key findings

Demographics and intended pathways

– Of 111 respondents, 67 were matched into fellowship positions (combining fellows and matched residents). Intended practice fields reported were: 49 anesthesiology critical care (26 matched), 58 medicine critical care (29 matched), two neurology CC (1 matched), six resuscitation (one matched), 15 surgical critical care (8 matched), and five non-critical care (2 matched).

Exposure and experiences

– Only 28% of trainees had exposure to EM-specific SCC fellowships at their residency institution.
– Only 42% had exposure to surgical intensivists during training.
– Before the application season, 8.2% of applicants reported no exposure to a surgical ICU/trauma ICU/trauma service that managed their ICU patients, compared with 3.2% who reported no exposure to a medical ICU.
– Notably, 41% of respondents envisioned practicing in a surgical ICU despite limited exposure, indicating interest that is not being systematically translated into matriculation.

Drivers of pathway choice

– Top factors associated with choosing a pathway were exposure to specialty units, geographic considerations, and experience with multidisciplinary specialty teams (p < 0.05).
– Ease of board certification did not significantly influence pathway choice.
– The highest-ranking motivation for entering critical care overall was intellectual appeal, which outranked job opportunities and lifestyle considerations (p < 0.05).

Fellowship features valued by EM trainees

– Core critical care knowledge ranked highly as a fellowship priority.
– Institutional valuation of EM/critical care medicine (perceived respect and support for EM-trained intensivists) was an important program-level factor.
– Exposure to extracorporeal membrane oxygenation (ECMO) was a highly desirable training component.

Interpretation and implications

This survey illuminates a gap between trainee interest in practicing in surgical ICUs and the actual rates of EM matriculation into SCC fellowships. Several observations from the study carry operational significance:

– Exposure is pivotal. Trainees with hands-on or observational experiences in SCC, surgical ICUs, or multidisciplinary trauma services were more likely to choose SCC. Low institutional exposure rates (28% for EM-SCC fellowships; 42% to surgical intensivists) indicate an opportunity: increasing structured rotations, early clinical exposure, and faculty interaction could raise SCC uptake.

– Institutional culture matters. The perceived value of EM in the critical care ecosystem influences trainee decisions. Programs that visibly integrate EM-trained intensivists, support cross-disciplinary mentorship, and highlight successful EM-SCC career paths will likely be more attractive.

– Training content drives selection more than credentialing logistics. Trainees prioritized intellectual engagement and specific procedural/technical exposures (e.g., ECMO) over board-certification pathways. Therefore, emphasizing robust procedural training, breadth and complexity of clinical exposure, and academic opportunities may recruit more EM applicants than focusing on administrative or credentialing simplifications.

– Geography and team-based practice are pragmatic determinants. Fellowship location, proximity to family, lifestyle and local job markets remain key. Programs seeking to recruit nationally should develop remote mentorship, virtual electives, and regional recruitment strategies.

Recommendations to increase EM matriculation into SCC

A multifaceted, tiered approach is warranted, addressing professional society, institutional, and program-level levers.

Professional societies and national-level actions

– Create and disseminate EM-specific SCC curricula and elective frameworks endorsed by EM and surgical critical care professional societies to standardize exposure.
– Develop national mentorship networks pairing EM trainees with EM-SCC faculty and recent graduates to provide career guidance, mock interviews, and research project opportunities.
– Sponsor visiting rotations or mini-fellowships that lower geographic barriers and give trainees concentrated SCC exposure.

Institutional and residency program strategies

– Integrate mandatory or elective rotations in surgical ICUs, trauma services, and with surgical intensivists into EM residency training where feasible.
– Invite surgical intensivists for joint didactics and simulation sessions to showcase SCC practice patterns and highlight interdisciplinary collaboration.
– Track trainee interest longitudinally and provide individualized mentorship and research support for those considering SCC pathways.

Fellowship program-level interventions

– Publicize multidisciplinary team exposure and ECMO training opportunities prominently during recruitment cycles.
– Offer early career development assets relevant to EM applicants (e.g., transition-to-practice modules, dual-appointment pathways, EM-specific faculty mentorship).
– Consider hybrid or flexible fellowship structures that accommodate EM applicants coming from diverse credentialing backgrounds and optimize clinical continuity with acute care responsibilities.

Limitations

Interpreting these results requires consideration of study limitations. The cross-sectional survey design is susceptible to selection and response bias; respondents were members of four national EM societies and may not represent all EM trainees. Sample size is modest (n=111), and self-reported intentions may not always predict eventual career outcomes. The survey provides associations rather than causation, and factors like local job markets or personal life circumstances that affect career choice may be incompletely captured. Finally, regional differences and evolving fellowship structures may limit generalizability over time.

Areas for future research

To translate these insights into measurable change, prospective evaluations should be pursued:
– Pilot interventions (e.g., structured SCC rotations, national mentorship programs) with pre-post measurement of application and matriculation rates from EM to SCC.
– Qualitative studies (interviews, focus groups) to characterize nuanced barriers (cultural, procedural, financial) experienced by EM trainees considering SCC.
– Workforce modeling to quantify how increased EM matriculation would affect ICU staffing, outcomes, and trauma system resilience.

Conclusion

Hynes et al.’s nationwide survey identifies limited exposure to SCC environments, institutional valuation of EM in critical care, and fellowship content such as ECMO as principal, potentially modifiable determinants of whether EM trainees choose surgical critical care. Because the drivers are multifactorial, a coordinated response spanning professional societies, residency programs, and fellowship programs is necessary. Practical, evidence-informed steps—enhanced clinical exposure, visible mentorship, and programmatic emphasis on procedural and multidisciplinary experiences—could increase the number of EM-trained SCC physicians and strengthen the surgical ICU workforce.

Funding and clinicaltrials.gov

Funding: Not reported in the referenced article.
ClinicalTrials.gov: Not applicable.

Reference

Hynes AM, Carver TW, Owodunni OP, Murali S, Gmora FL, Tisherman SA, Martin ND. Attracting Emergency Medicine-Trained Residents to Surgical Critical Care: The Implications From a Nationwide Survey of Emergency Medicine Trainees Interested in Critical Care. Crit Care Med. 2025 Oct 31. doi: 10.1097/CCM.0000000000006935. Epub ahead of print. PMID: 41171038.