Crippen’s Law

EMCrit‘s Scott Weingart quoted David Crippen (Fearless Leader of the CCM-L listserv) in response to a Resus.ME post by Cliff Reid, which reviewed and expanded upon Weingart’s recent article on ED Intensivists and ED Intensive Care Units:

“Every well-intentioned dual-trained EP always comes out of training stating that they will split their time 50/50 ED and ICU and all of them by the 5 year mark will be spending all of their time in one area or the other.”

This is obviously important to all of us that have slogged through two grueling training schemes in the hope of contributing to both specialties. I’m familiar with Crippen’s Law, and still wonder if I will succumb to it. Unlike in the US where a 1-2 year fellowship can be tagged on to a 4 year residency (pretty intense years, but blissfully short!), in Australasia dual trainees generally clock up about 10 years of training after medical school. This is a huge commitment to both specialties, yet I know very few dual trained FACEM+FCICMs who still work in the ED. I hope that this can change. Or, perhaps, dual training might simply be an unnecessary extravagance in terms of training, time and resource utilisation.

What do you think?

Read more and contribute to the discussion at Upstairs vs Downstairs: an EPIC Conundrum on Resus.ME.

Also look out for the #FOAMed SMACC talks on the essence of critical care and the interface between emergency medicine and intensive care heading your way in the next couple of weeks. I’ll finish with two of Peter Safar’s Laws for the Navigation of Life that may go some way to explaining the predicament some of us find ourselves in:

2. When given a choice, take both.

12. When faced without a challenge, make one.

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  1. says

    Great topic Chris, and really at the heart of workforce planning.

    I trained in both ED and ICU, completing all training and other requirements, and made a decision to abandon my emergency practice just before fellowship. I had intended, just as you say, to split my practice. As I was studying for the exam though I felt the imposing weight of staying up to date with dual specialties and decided I only had enough RAM for one. I have never regretted my ED training though, it rounds me out as a specialist and gives me additional skills I would not have learned. I now practice in a prehospital environment too where I put these skills to good use.

    Dual trainees will continue to be an essential part of the ICU workforce, particularly in regional areas. After hours coverage of ICU, even in smaller regional hospitals, can be arduous, and you require a high number of specialist full time equivalents to support a survivable on-call roster. This then creates the problem of what you do with them during daylight hours. Clinicians capable of working in anaesthetics, ED, general medicine, prehospital care, education, administration or research are therefore worth their weight in gold.

    Additionally, the bridge-building that is generated by dual trainees practicing in more than one department is extremely useful, hopefully breaking down some of the unhelpful and arbitrary barriers so often placed between them.

    As a (reformed) department director, I hope dual training continues and should be supported, though there are numerous practical issues to consider, staying up to date just being one.

    I look forward to hearing the debate!

    • says

      Yes -- Australasian intensive care has profited greatly from snapping up ‘failed’ emergency physicians… can add LITFL’s Paul Young and ICN’s Oli Flower to that list!

  2. says

    HI Chris, thanks for this article which I came across whilst browsing for some teaching resource that may help me in an emergency shift I am working tomorrow!

    I enjoyed reading your thoughts on the topic of dual training and subsequent comment by Todd Fraser. Your article also lead me to read both Cliff Reid’s ResusMe blog post and Scott Weingart’s recent publication on the same topic ( which were quite insightful.

    Both these articles talk about some of the benefits of dual training which include shared ICU-ED protocols and a combined experience base.

    As I looked through S Weingart’s article I noticed his list of clinical scenarios of sick patients where the unique skill set of a dual (ICU/EM) trained specialist may positively affect the care of the entire ED which included the following sub-headings;- “Airway management”, “Respiratory failure”, “Shock”, “Sepsis”, “Postcardiac arrest care and therapeutic hypothermia”, “Trauma”, “Procedures”, “Palliative care”.

    It was when read this list, I thought to myself, “this is exactly the ‘hard stuff’ that I’m trying to get to grips with as an ED trainee” (and what I was looking to revise in my web-search tonight when I read your article). Also, judging by the number of people attending the recent Social Medial and Critical Care (SMACC) conference in Sydney, there are a lot of other people interested in improving their knowledge and skills in these areas too, otherwise there would be no conference and no discussion.

    I also find the above listed topics challenging to learn “in the ED”, largely because when patients like these present the focus is on ‘keeping the patient alive or getting them better’ (service), over the teaching of “how to do this” (training). Naturally this is understandable because our primary role is to our patients, even if we are working in training hospitals, but I find as an ED trainee who wants to learn “how to do” and “why to do”, rather than to just do, this subtle tension that exists between service and education plays out frequently, particularly in the domains of critical care, and when departments are under pressure.

    I for one really do hope there are more dual trained FACEM/FCICMs, because, I think this group’s activity will improve training and education for Emergency Medicine in the area’s that Scott highlight in the article. Perhaps, the recent Social Media and Critical Care (SMACC) conference, which was excellent resource by the way, is testimony to this? I wonder how many people in the organising committee were either dual trained, or dual “training”, like yourself?

    So I guess, from an education focussed perspective, it doesn’t really bother me if dual trainees succumb to “Crippen’s Law”, and move upstairs to find their main work role, as long as they remember to put at least 50% of their educational passion into downstairs “training” after the fact.

  3. Minh Le Cong says

    Bishan, Todd, great insights you make! Its an interesting educational dilemma is it not?
    Do you train for what you think interests you? Or do you train for necessity, for what you need to know and do where you intend to work?
    Australia is a good example of this melting pot concept of training. Take for example toxinology…EM and rural docs, ICU docs, we need to know about venomous injuries..its a necessity..whereas in NZ its not…mostly.
    So in other words, the more you work in Australia, remote and urban, ED, ICU, prehospital, GP medicine, the more you realise, one training skill set does not cover all of what you NEED!

    it certainly explains the predominance in post Fellowship CME of the Alphabet emergency course, APLS, EMST, ALSO, ALS, ELS..these are all made to fill a niche that most experienced doctors realise…your primary specialist training is NOT ENOUGH.
    some realise that in fact you need to train in a second specialty ! why?its not masochistic..its reality of doing a good job as a resuscitationist…no matter where you are and what resources you have at hand.

    And to me this is why FOAMEd and its real life iteration SMACC are so engaging and popular…folks realise there are other folks who get that learning is life LONG and it should be communal and open…because we all want to better patient care regardless of silos , politics and money.

    Idealistically I hope dual training physicians continue to be inspired to achieve and teach this pathway. It is however a cultural shift and personal hardship. its not easy but then again I dont think everyone needs to do it. We just need a few to inspire and motivate the rest of us in life long learning