FM working in EM?

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Originally Posted by EdibleEgg

You are missing my point and just taking a chance to be a smart ass. I've never claimed to be boarded in Emergency Medicine, I've never asked for grandfathered into any certification. I never even planned to work in the ED.

I really don't care what you call me. But you are being simple minded to call me the enemy and speak of what a problem it is that others like me work in the ED without offering any solutions. If things go the way you seem to want them, there will be a couple of EM residency trained guys here supervising a bunch of PA's. I don't see how that helps you, but I do see how that harms my friends and family when they need emergency care.

I'd be all for training FMs working in rural EDs to improve their emergency skills. However, you'll need to convince me that they're not going to use that training to try and practice EM in a non-rural setting.

Originally Posted by Arcan57

I'd be all for training FMs working in rural EDs to improve their emergency skills. However, you'll need to convince me that they're not going to use that training to try and practice EM in a non-rural setting.

If I ever move from my hometown, it will be to my wife's hometown in Montana. It's much more rural than I am now. I could make that promise for myself, but obviously you can never get that kind of guarantee from everyone that would be interested. I don't understand the need though. I don't claim to be in the loop, but I do get job advertisements all the time. There seem to be three loose categories of jobs.

1)>50K volume, EM only or need not apply
2a) 20-50k volume, good location, EM or need not apply
2b) 20-50K volume, bad location, EM or FP/IM with experience, but there is a usually a bonus for board certification
3) <20K volume, warm bodies needed

It seems to me that you've already won the argument that EP's are superior in the ED. In general terms, I agree. There are just not enough EM boarded docs to staff every ED, and even if there were, some of them don't have the acuity to maintain the EM skill set. I'm sure there are some administrators somewhere that use non boarded doc's to try to save some money, but that's the exception rather than the rule in my neck of the woods.

Originally Posted by ptarmigan

Edible -

I wasn't meaning to be a smart ass. I'm actually serious. Why did the family docs that I worked with in rural EDs have white coats that said emergency medicine? It's family medicine and you should be damn proud of it because it is a great specialty - especially when you practice in rural areas and get to do everything.

Fair enough, but for what its worth I only have three things that identify me. Two white coats ( I rarely wear them) that both read Dr Egg, Family Medicine, and my hospital badge, with Dr Egg, MD, Family Physician. I've never really thought about it much before, but that comment in really funny given that badges for the PA's in fast track read Roxy Noctor, PA, Emergency Physician

In my limited experience, the PAs in my practice who I supervise provide much better care than the FPs I have worked with in rural EDs. I don't like that fact, but it has been true for me. Now, I might be comparing elite PAs to bad family docs, so maybe on balance it does come out in the FPs favor. I want all EDs to be staffed by MDs, but I feel conflicted by my experience. I have only worked in 3 rural EDs, so maybe I just didn't get a good sampling. If you are getting 200 intubations, 200 central lines, and 50 chest tubes in residency, that is incredible and you are in a different category than the FPs I have worked with.

I'll agree there are some really crappy FP's out there. ( There are some really crappy EP's and internists too, but that's not the point) I hate to admit it, but a significant percentage of people who do a FP residency who never wanted it, but couldn't match otherwise. That leaves some lazy, jaded people in the mix. I wish that wasn't the case, but it is. VERY few of those people are going to end up in rural medicine. You have to love it to do what I do. You have to work like you are Amish in residency. The money is better than most FP jobs, but that's primarily because you work so much more.

I've heard this argument before. But it don't get it. On one hand you say that medical school and residency really doesn't matter. All you need is experience in the ED, and that makes you better. On the other hand, you say ALL that matters is residency. Either you need to do an emergency medicine residency or you don't. Please, don't tell me that your supervision is what makes the difference. Unless you are seeing and evaluating every patient the mid level sees, that just doesn't cut it. Most places I've seen "supervision" means signing charts and being available for questions. If you are seeing all of the patients too, then it's very understandable why they seem better. Just doesn't make sense to me.

I don't know what the solution is. I'm just colored by my experience. CT head and c spine for ay syncope but sending an 70 year old syncope with CAD home after a single set of enzymes. CT for any abdominal pain, but not doing pelvic exams on female repro age lower abdominal pain. Not working up chest pain "because he comes in for it so often." Sending 1 month olds with fevers home without a septic workup, but putting IVs in and sending CBCs/7s on kids with URIs. Letting patients wait 2 hours in treatment rooms in a 10 bed ED, letting the nurse enter the orders, and then turning them over to the next doc. It was really an eye opening experience for me.

If you want to play the name the stupid decision game, we can, both for PA's and EP's. I've seen all sides. What you describe above just sounds like a bad doctor, sometimes more lazy than stupid.

On the other hand, as I posted above - it's hard to criticize the docs who work where no one else wants to. EDs with a census <10,000 can't really support an EPs salary, and EPs don't want to commute 3 hours to work in a slow ED anyway.

Maybe my experience with FP docs practicing in EDs is unlike where you are, and I am glad of that.

Originally Posted by EdibleEgg

It seems to me that you've already won the argument that EP's are superior in the ED. In general terms, I agree. There are just not enough EM boarded docs to staff every ED, and even if there were, some of them don't have the acuity to maintain the EM skill set. I'm sure there are some administrators somewhere that use non boarded doc's to try to save some money, but that's the exception rather than the rule in my neck of the woods.

If we didn't win that argument, there would be no need for a specialty, and no need for a residency. We could go back to the days where people showed up to the ED and waited for the nurses to call their regular doctor.
I don't know why it's so hard to rationalize that we respect what you do in austere environments but at the same time don't want you to consider yourself the same as us. As before, you can scope people if you need to, but you don't call yourself a GI doctor and don't try to go to their meetings and get recognized. We have that problem because people don't feel they need specialized training to work in an ED full time.

I've heard this argument before. But it don't get it. On one hand you say that medical school and residency really doesn't matter. All you need is experience in the ED, and that makes you better. On the other hand, you say ALL that matters is residency. Either you need to do an emergency medicine residency or you don't. Please, don't tell me that your supervision is what makes the difference. Unless you are seeing and evaluating every patient the mid level sees, that just doesn't cut it. Most places I've seen "supervision" means signing charts and being available for questions. If you are seeing all of the patients too, then it's very understandable why they seem better. Just doesn't make sense to me.

When did we say residency and med school don't matter? Yes, many hospitals employ midlevels, not because they're better, but because they're cheaper. I'm sure most places would be happy to have FM docs run the fast track over a midlevel. They could bill more, etc. But docs won't work for the $70-90 an hour that most midlevels work at. It's a business decision. As far as a good PA being better than a bad anything (including EM docs), it probably comes from the fact that most PAs have had enough interaction with ABEM docs to learn at least what we want, if not how we think. Most rural guys work solo, and don't have someone to bounce ideas off of. Thus, they continue their own way, regardless of whether it's better or not. Trust me, you start taking transfer calls, and you'll start rolling your eyes at the stories you hear on the other end. GI bleeds that exsanguinate, and the only treatment is 4L NS and a bicarb gtt because they're acidotic. But no blood, because "their Hgb was 10 when we checked it".
I agree that supervision is cursory at best, and fear that we are going to suffer the same problem the anesthetists have and eat our own children. There are midlevel only EDs out there already, in places even the family docs won't work. It all comes down to volume. PPACA is going to make it worse.

For perspective I thought I would bring up the Canadian training system. There are two routes to become an emergency physician there. You can enter an emergency medicine residency directly (these tend to be people who focus on research/ academics and want to work as faculty at programs). The alternative route is an emergency medicine fellowship following a family medicine residency. The ones who choose the later route tend to do so because they want to focus more on the clinical vs academic side of EM. They both sit for the same boards and are considered identical for all intents and purposes in the clinical setting.

Originally Posted by ptarmigan

In my limited experience, the PAs in my practice who I supervise provide much better care than the FPs I have worked with in rural EDs.

Originally Posted by Dr.McNinja

I don't know why it's so hard to rationalize that we respect what you do in austere environments but at the same time don't want you to consider yourself the same as us. As before, you can scope people if you need to, but you don't call yourself a GI doctor and don't try to go to their meetings and get recognized. We have that problem because people don't feel they need specialized training to work in an ED full time.

Trust me, you start taking transfer calls, and you'll start rolling your eyes at the stories you hear on the other end.


I agree that supervision is cursory at best, and fear that we are going to suffer the same problem the anesthetists have and eat our own children. There are midlevel only EDs out there already, in places even the family docs won't work. It all comes down to volume. PPACA is going to make it worse.

It's hard for me to rationalize that you respect what I do when you've filled your replies with a bunch of dumb and lazy rural FP stories and a few attempts at direct insults. I've never said that I'm an EP. I don't want to go to ACEP and I don't need your recognition. In most situations it would be better to be an EP if you are working in the ED, but that's just not always possible. I'm sure you get a little ego boost when you think about how much better you are than all of the non boarded guys out there, but it doesn't change the fact that a large number of ED's would close and people would die if only EM trained physicians were allowed to work there. I'm not an emergency physician, but I take care of lots of emergencies. Quite a few of them don't even take place in the ED. I've intubated, placed several lines, coded, and placed a chest tube on inpatients over the last several weeks.

Regarding PA's, I work with a few good people. At least a couple here could have gone to medical school, but didn't want to put in the time. Let's compare apples to apples here. I'm talking about PA's in the main ED, not fast track. I'll bet most EM nurses with a little experience with you can usually tell what you are going to order before you leave the room. A good mockingbird is not a better physician than you or me.
I can't understand how you think half the time in school and no residency somehow improves clinical abilities.

I promise you I can raise you on your GI bleed example, but I won't go there. It's funny that you mention it though. I had a similar situation a few weeks ago. I was in the ED on a call weekend. One of the EM boarded docs asked me to see a bleeder. She recieved some fluid, but no blood. I immediately scoped her and clipped a large pumping vessel in the middle of an ulcer bed. I'm not downing the other doc. Transfusion just wasn't an option at the time. We had literally used all of the available blood in the hospital while treating multiple gunshot wounds over the last hour. Some of your dumb doc stories may just be result of a different set of resources.

Bottom line is I will be here taking care of patients. If you want to get in my way, come here and do it. It seems rather cowardly to take shots from afar, especially when no one offers any sort of viable alternative.

Originally Posted by diphenyl

For perspective I thought I would bring up the Canadian training system. There are two routes to become an emergency physician there. You can enter an emergency medicine residency directly (these tend to be people who focus on research/ academics and want to work as faculty at programs). The alternative route is an emergency medicine fellowship following a family medicine residency. The ones who choose the later route tend to do so because they want to focus more on the clinical vs academic side of EM. They both sit for the same boards and are considered identical for all intensive purposes in the clinical setting.

DISCLAIMER: I am a big Canada-phile in most respects. I love hockey, am good at geography, and think that the US has a lot to learn from many, many respects of Canadian life. I have many Canuck buddies and get upset that I can't get a Labatt at a bar down here that most of the locals look at me and say - "So, what part of Canada are you from... EHH?'

That being said... here's what I gotta say:

- FM =/= EM, and EM =/=FM.

Comparing medicine in the hinterlands between Ottawa and Toronto to medicine between Newark and Philadelphia is.... impossible.

Two different populations.
Two different demographics.
Two different mindsets.
Two different LEGAL SYSTEMS.
Two different expectations.
Two different...everything.

I challenge any Ontarian/Quebecois/Maritime doc to come down to some of my old shops in Jersey and deal with the volume, the acuity, the language barriers, the poor follow-up, the poor education, the...a;lkdfja [keyboard smash]a;ldsjf;alkj the EVERYTHING and tell me that "they can do it better".

They'd s#it their pants.

Sure, you can tube a patient, and then see 'em in the ICU, and then hug them after they're extubated, and have them bake you a pie after they get out.... but where I live.. those chest pain-ers keep coming in the front door... and those diff breathers keep coming in the back door... and there's nowhere to run to the "continuity of care" ethic... because EVERYONE NEEDS HELP, NOW ! Furthermore... there's the money that drives EM care in the states.... and THAT'S a different talk for another day. Most of Latin America knocks on my door DAILY.... and they dont' ask for.. but DEMAND their care for their emergent, urgent, non-urgent, and .. whatever... complaints. And it affects my bottom-line. My pay. My liability, My life. My everything.


I dont' ever "get to enjoy" the luxury of continuity of care. I'm too busy for that. Cuba is knocking on my front door, and Mexico is knocking on my back door. Can I send Cuba to Quebec? That'd be great ! Maybe I could catch-up on those tax-paying American citizens that have chest pain, shortness of breath, or whatever. Nevermind. EMTALA and the like make sure that I'm busy with everyone who shows up on the doorstep, or within 250 yards of the doorstep, so sayeth the law. I'd love to send Haiti to Manitoba...and see how they cope with the influx, and the legal repercussions, and the everything.

I had a surgical senior in residency. A real fuc/ing prick. Born in the Bahamas. Liked to throw around statements like "well, in the BAHAMAS.. THIS would happen, and then THAT would happen... and then TJSFLKJ [whatever]a;dsfja;" ... I said to him one day after one of his self-important tirades...."The Bahamas are so great,then ? Greeeat! I'll send all of Latin America YOUR way, then. Oh... wait.. there's a reason that they DON"T show up there... its because YOU CANT HANDLE IT. Its also because AMERICA has the BEST docs, resources, everythings.... after all... its a lot closer to the Bahamas from the Dominican/Cuba/Whatever than it is to the Gulf Coast... but yet... nobody shows up there dying of... whatever, instead, they show up to my little shop, and they KNOW that they've got the BEST care in the world.

EVERYONE WANTS TO TAKE ADVANTAGE OF AMERICA. AND WE LET THEM.

AND WE LET THEM CALL US NAMES, AND TELL US HOW BAD WE ARE AT EVERYTHING

BUT WHEN PUSH COMES TO SHOVE, IF YOU WANT LIFESAVING CARE.. WHERE DOES THE WESTERN HEMISPHERE SHOW UP ?


THE FUUUCKING USA.


DAAAMN RIGHT.

Originally Posted by RustedFox

That being said... here's what I gotta say:

- FM =/= EM, and EM =/=FM.

I'm not sure what you mean.

Originally Posted by RustedFox

THE FUUUCKING USA.


DAAAMN RIGHT.

MERICA! F YEAH!

"EM is not equal to FM, FM is not equal to EM".

And eff yeah, America. I'm tired of everyone saying "we do it better here in [insert country here]."

I'm not saying that the American health system is without its difficulties, but I don't see everyone flocking to any other nation for their advanced healthcare.

Originally Posted by EdibleEgg

It's hard for me to rationalize that you respect what I do when you've filled your replies with a bunch of dumb and lazy rural FP stories and a few attempts at direct insults. I've never said that I'm an EP. I don't want to go to ACEP and I don't need your recognition. In most situations it would be better to be an EP if you are working in the ED, but that's just not always possible. I'm sure you get a little ego boost when you think about how much better you are than all of the non boarded guys out there, but it doesn't change the fact that a large number of ED's would close and people would die if only EM trained physicians were allowed to work there. I'm not an emergency physician, but I take care of lots of emergencies. Quite a few of them don't even take place in the ED. I've intubated, placed several lines, coded, and placed a chest tube on inpatients over the last several weeks.

How many is a bunch? When did I mention that any are lazy? Show me a direct insult.

Regarding PA's, I work with a few good people. At least a couple here could have gone to medical school, but didn't want to put in the time. Let's compare apples to apples here. I'm talking about PA's in the main ED, not fast track. I'll bet most EM nurses with a little experience with you can usually tell what you are going to order before you leave the room. A good mockingbird is not a better physician than you or me.
I can't understand how you think half the time in school and no residency somehow improves clinical abilities.

Show me where I said those things improve clinical abilities. All I said was they effectively become apprentices, and thus are better able to understand our thought processes.

I promise you I can raise you on your GI bleed example, but I won't go there. It's funny that you mention it though. I had a similar situation a few weeks ago. I was in the ED on a call weekend. One of the EM boarded docs asked me to see a bleeder. She recieved some fluid, but no blood. I immediately scoped her and clipped a large pumping vessel in the middle of an ulcer bed. I'm not downing the other doc. Transfusion just wasn't an option at the time. We had literally used all of the available blood in the hospital while treating multiple gunshot wounds over the last hour. Some of your dumb doc stories may just be result of a different set of resources.

Wait, now you're confusing me. I thought your place never had ABEM docs. Also, how many GSWs do you get out there in the rurals?
And my 1 story involved a doctor who ARGUED WITH ME ON THE PHONE about why he wasn't giving blood. It wasn't because he was out of blood products, it was because he was an idiot. His literal words were "the hemoglobin is ok, so I haven't given any blood." Keep in mind that this patient coded after vomiting up blood. Thus, they lost so much blood that they died, but this guy didn't think they needed any because of a lab test. I'm not sure why this isn't sinking in. Also, when I work in one of our more rural hospitals, I'm right there taking checkout from the undertrained doctor. I'm not conjecturing their lack of expertise, I'm listening to it and challenging them about it.

Bottom line is I will be here taking care of patients. If you want to get in my way, come here and do it. It seems rather cowardly to take shots from afar, especially when no one offers any sort of viable alternative.

What viable alternative is there? As before, any fellowships usually involve the FM doc not going rural, but instead end up having them try to become more competitive for jobs in non-rural areas.
However, and I can't understand why this isn't becoming clear yet, you are only an emergency physician if you complete a residency in EM. It's a specialty, not just a job you show up to do. We lose respect as a specialty when other people pretend like they do what we do.
It's sad that nobody can advertise their role as any other specialty without actually completing residency/fellowship. The medical board in my state will actually sanction you for it. But anybody can put "EP" up, because there is this huge group of people that continue to believe that they are emergency docs just because they work in one.
Remember, ATLS was created because of the tragically substandard care someone got in a rural ED.
Finally, if you don't think you are an emergency doc, what are you doing in this thread. Or on this emergency specific forum? How did you even know this thread existed? If you're so good at rural medicine, why aren't you giving more advice in specific management threads?

How many is a bunch? When did I mention that any are lazy?

Look through the thread. It wasn't just you, but there are several, "I remember when this FP working in the ED did a stupid or lazy thing" anecdotes. Maybe it's just venting; EM is often the butt of these stories, and I guess this is your chance to throw a few out. It doesn't really serve much of a purpose. There are lots of dumb EP stories out there. It's silly, we should be on the same team.

Show me a direct insult.

Seriously? If you really don't understand what comments were insulting , or at least condescending , then it makes me sad.

Show me where I said those things improve clinical abilities. All I said was they effectively become apprentices, and thus are better able to understand our thought processes.


PA's are better because they get on the job training.

FP's are worse because they learn on the job.

Huh? I'm not comparing a PA in your hospital to an FP working in a rural ED.


Wait, now you're confusing me. I thought your place never had ABEM docs. Also, how many GSWs do you get out there in the rurals?

I never said that. We have now have one full time ABEM doc, and one that is from here who works a few shifts a month so he can write off trips home. We occasionally get ABEM locums here too. Those guys just can't cover 90 shifts a month. As for GSW's, I know of nine last month. Mostly hispanic gang related. It's highly variable. May double next month, may not see another this year.

And my 1 story involved a doctor who ARGUED WITH ME ON THE PHONE about why he wasn't giving blood. It wasn't because he was out of blood products, it was because he was an idiot. His literal words were "the hemoglobin is ok, so I haven't given any blood." Keep in mind that this patient coded after vomiting up blood. Thus, they lost so much blood that they died, but this guy didn't think they needed any because of a lab test. I'm not sure why this isn't sinking in. Also, when I work in one of our more rural hospitals, I'm right there taking checkout from the undertrained doctor. I'm not conjecturing their lack of expertise, I'm listening to it and challenging them about it.

I made that same mistake once. I was a second year medical student doing a pre-clinical rotation with the trauma surgery team. That guy sounds like an idiot, or at least he made a really stupid mistake. I don't think all EP's are arrogant. You shouldn't think all FP's are dumb.


However, and I can't understand why this isn't becoming clear yet, you are only an emergency physician if you complete a residency in EM. It's a specialty, not just a job you show up to do. We lose respect as a specialty when other people pretend like they do what we do.

I don't understand why this isn't becoming clear to you. Board certification doesn't mean you own anything. Board certification means you have certain minimum of demonstrated experience, knowledge, and competence. It doesn't mean that no one else can do any of the things you do.

It's sad that nobody can advertise their role as any other specialty without actually completing residency/fellowship. The medical board in my state will actually sanction you for it. But anybody can put "EP" up, because there is this huge group of people that continue to believe that they are emergency docs just because they work in one.
Remember, ATLS was created because of the tragically substandard care someone got in a rural ED.

Never said I'm an EP.

Finally, if you don't think you are an emergency doc, what are you doing in this thread.
Or on this emergency specific forum? How did you even know this thread existed?

Really? Are you joking? You've never posted in the family medicine forum?

Well... when you click forums, it lists the forums with the title of the most recently commented thread. When I saw the title, I knew it would be a rotting dead horse, but I couldn't help but look.

If you're so good at rural medicine, why aren't you giving more advice in specific management threads?

You've made me feel so welcome that I will as soon as I find the time.

What viable alternative is there? As before, any fellowships usually involve the FM doc not going rural, but instead end up having them try to become more competitive for jobs in non-rural areas.

So this is really about protecting turf and not about patient care. Enough said. I will stand down.