FM/EM

[TedStark]

Apparently the main reason to get boarded in EM is to work at a level one trauma center. However, someone doing both FM and EM would be doing part time EM. I'm imagining there aren't many part time EM physicians at level one trauma centers. They're probably all full time.

So if someone really wants to do both, wouldn't it make more sense to do family medicine and work part time in a rural ER?

I've heard these jobs are never going away if you're willing to commute to the ED. Is that true?

I just don't want to do an extra two years of training and find that I can't do half FM and half level one trauma center ER. But if I go family med only, I also don't want to use all of my electives for ER and later find out that I can't work in an ER.

Thanks!

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[KP2AZ]

Apparently the main reason to get boarded in EM is to work at a level one trauma center. However, someone doing both FM and EM would be doing part time EM. I'm imagining there aren't many part time EM physicians at level one trauma centers. They're probably all full time.

So if someone really wants to do both, wouldn't it make more sense to do family medicine and work part time in a rural ER?

I've heard these jobs are never going away if you're willing to commute to the ED. Is that true?

I just don't want to do an extra two years of training and find that I can't do half FM and half level one trauma center ER. But if I go family med only, I also don't want to use all of my electives for ER and later find out that I can't work in an ER.

Thanks!

On FM rotation right now and asked my preceptor this today. You can work in an ER with FM only, but a level 1 would be very difficult to find a job for...unless that specific part of the country has a history of this ( I think I read this about OKC?). It also has a lot to do with your comfort level and experience/# of hours(and procedures) logged. FWIW I wonder this all the time. PM me if you find out anything.


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[cabinbuilder]

Just like urgent care, ER is shift work. Lots of ER locums work too. However, If you are planning to do full time FM you may decide that you are too tired to add more shifts to your life. Many larger ERs (and rural ER's) are now expecting EM board certification to be on staff in an ER. If you do expect to work in a large ER then I would suggest that you max out your electives in residency in trauma centers and get a much exposure as you can in the ER setting. Be sure you keep track of every procedure you do in the ER as you will have to present those to show proficiency.

I am FM and have worked mostly rural ER but did work in a very large ER in Midland, TX for 4 months. I did not work on the "Big Side" as they called it where the EM boarded docs "lived". I worked on the step down side to take care of the "busy" patients who generally could be taken care of in urgent care or those medical patients who would be admitted for pneumonia, heart failure, sepsis, etc.

 

[TedStark]

Just like urgent care, ER is shift work. Lots of ER locums work too. However, If you are planning to do full time FM you may decide that you are too tired to add more shifts to your life. Many larger ERs (and rural ER's) are now expecting EM board certification to be on staff in an ER. If you do expect to work in a large ER then I would suggest that you max out your electives in residency in trauma centers and get a much exposure as you can in the ER setting. Be sure you keep track of every procedure you do in the ER as you will have to present those to show proficiency.

I am FM and have worked mostly rural ER but did work in a very large ER in Midland, TX for 4 months. I did not work on the "Big Side" as they called it where the EM boarded docs "lived". I worked on the step down side to take care of the "busy" patients who generally could be taken care of in urgent care or those medical patients who would be admitted for pneumonia, heart failure, sepsis, etc.

Are rural ER's expecting boarded ER guys or hiring them? I was under the impression that EM residency spots are under a tight lid to keep demand high... Resulting in rural jobs always being available for FM guys. I realize EM residency spots are increasing but last I checked I think they are pacing with population growth? Curious if anyone knows updated numbers.

 

[Natividad Resident]

EM BC/BE requirements are set by each individual institution/overlord, and they change all the time in response to a bunch of factors...including...malpractice rates going up/down based on BC/BE, insurer reimbursement hinging on BC/BE, hiring/retention easiness/difficulty leading to more/less stringent BC/BE, start/end of contract with EM provider agency, etc.

I suggest having a much more regional focus - national numbers are useless unless you're literally willing to live/work anywhere. In your shoes (I think you're an M3?) I'd pick a region or two (such as "middle 1/3 of Oregon" or "upstate Michigan, on the hand") and just identify all the hospitals and all the EM agencies serving that region. Generally a hospital that contracts with an EM agency that has no FMs listed isn't a FM-friendly ED. Go through hospital physician directories for hints on whether there are FM people staffing the ED. Google stalk the ED providers to see what residencies they did, how long ago. When you find FM docs who apparently staff EDs, reach out. Try to get some mentorship that is highly relevant to you.

For example:
1. oh hey I've gotta ski to be happy let's see what's in the PNW Cascades - that one time I broke my arm where did I go? Oh yeah Leavenworth.
2. so I google "leavenworth hospital" and then to get rid of Kansas hits I google "Leavenworth washington hospital"
3. I dig into the website and find physician lists - at the Leavenworth hospital I have to go to the ED page. I assume these lists are completely out of date and leave out a lot of docs, and I don't let this derail me because I'm sherlock effing holmes.
4. I grab those doctor names and google them, doximity them, find the FMs. also I find more hospitals this way - oh hey Leavenworth Doctor B is listed at other hospitals...and now I have a Lake Chelan hospital...bet they know a lot about burns now, fires were so bad last year...
5. ok so what trauma levels are these hospitals - I can probably get that on Wikipedia. And I'll google maps it looking for a helipad if I feel like it.
6. I start looking/guessing at regional trauma catchment - a Leavenworth doc would maybe refer to Wenatchee, a Wenatchee doc would probably refer to Harborview
7. OK now I found an FM doc who is ED medical director at one hospital and ED staff at another...and he doesn't look too old...bingo
8. now I start sending polite emails, make some polite phone calls, snail mail some letters, expect no response for weeks-months, expect maybe 10% return on investment
9. and I go for the gold: get that shadow gig, use holiday/vacation if necessary, get in there, interrogate management, interrogate providers, take copious notes. if I don't touch a single patient who cares, that's not what this is for.

Good luck!

 

[TedStark]

EM BC/BE requirements are set by each individual institution/overlord, and they change all the time in response to a bunch of factors...including...malpractice rates going up/down based on BC/BE, insurer reimbursement hinging on BC/BE, hiring/retention easiness/difficulty leading to more/less stringent BC/BE, start/end of contract with EM provider agency, etc.

I suggest having a much more regional focus - national numbers are useless unless you're literally willing to live/work anywhere. In your shoes (I think you're an M3?) I'd pick a region or two (such as "middle 1/3 of Oregon" or "upstate Michigan, on the hand") and just identify all the hospitals and all the EM agencies serving that region. Generally a hospital that contracts with an EM agency that has no FMs listed isn't a FM-friendly ED. Go through hospital physician directories for hints on whether there are FM people staffing the ED. Google stalk the ED providers to see what residencies they did, how long ago. When you find FM docs who apparently staff EDs, reach out. Try to get some mentorship that is highly relevant to you.

For example:
1. oh hey I've gotta ski to be happy let's see what's in the PNW Cascades - that one time I broke my arm where did I go? Oh yeah Leavenworth.
2. so I google "leavenworth hospital" and then to get rid of Kansas hits I google "Leavenworth washington hospital"
3. I dig into the website and find physician lists - at the Leavenworth hospital I have to go to the ED page. I assume these lists are completely out of date and leave out a lot of docs, and I don't let this derail me because I'm sherlock effing holmes.
4. I grab those doctor names and google them, doximity them, find the FMs. also I find more hospitals this way - oh hey Leavenworth Doctor B is listed at other hospitals...and now I have a Lake Chelan hospital...bet they know a lot about burns now, fires were so bad last year...
5. ok so what trauma levels are these hospitals - I can probably get that on Wikipedia. And I'll google maps it looking for a helipad if I feel like it.
6. I start looking/guessing at regional trauma catchment - a Leavenworth doc would maybe refer to Wenatchee, a Wenatchee doc would probably refer to Harborview
7. OK now I found an FM doc who is ED medical director at one hospital and ED staff at another...and he doesn't look too old...bingo
8. now I start sending polite emails, make some polite phone calls, snail mail some letters, expect no response for weeks-months, expect maybe 10% return on investment
9. and I go for the gold: get that shadow gig, use holiday/vacation if necessary, get in there, interrogate management, interrogate providers, take copious notes. if I don't touch a single patient who cares, that's not what this is for.

Good luck!

Wow, that's awesome. Thank you. Maybe that's where my confusion stems from. In my region FM's do it all, but on SDN... Very different picture ED wise.

 

[cabinbuilder]

Are rural ER's expecting boarded ER guys or hiring them? I was under the impression that EM residency spots are under a tight lid to keep demand high... Resulting in rural jobs always being available for FM guys. I realize EM residency spots are increasing but last I checked I think they are pacing with population growth? Curious if anyone knows updated numbers.

All I know is I was going to be hired for a job in Mesquite, Nevada in working in the ER. I was officially "hired" and was working on the credentialling when there was a change in policies during that time and they were no longer hiring FM doctors to cover their ER. Only EM boarded docs were going to be hired and I was politely unhired.

Now as locums I covered ER (by myself) in Conrad, MT (2 beds); Wrangell, AK (2 beds); Tonopah, NV (2 beds). All depends on the size of the ER and the location.

 

[TedStark]

What about all of these unopposed family medicine residencies with ER's. There are tons in my state. Is moonlighting for FM residents ever going away at these places?

 

[Natividad Resident]

FM residents do EM rotations. But generally a training hospital ED isn't a moonlighting site, any more than L&D is a moonlighting site, because as a resident you don't have enough experience for that kind of responsibility. Moonlighting during residency means doc-in-a-box or similar, where all that's required is a license. US grads get that license after about 18 months, IMGs after 30. Also moonlighting happens only at the discretion of your PD, within the 80 hour work week limit. There are training-site-specific gigs such as covering psych admissions or covering overnight c-sections that tend to be piece work, where you only get paid if you get paged. (No "real" doctor would take that gig because the time carrying the non-buzzing pager isn't paid.)

With an EM focus, you wouldn't generally want to train at a site that has FM docs regularly staffing the ED. You should train at a site that has the craziest, highest trauma level ED you can find, where you can get in on anything. (Ventura has a heavy trauma curriculum, for example.) Get your EM training from docs who only do EM/trauma/CC. (I'm sure there are sites where you can find an experienced FM doc who only does EM...which would be good training...which is the point.)

If you look back through CB's posts about how she gets her locum tenens gigs, you'll see how much work she does on her procedure logs. She can get a gig in an ED because she's got details on how many lines, tubes etc she's done. I think she has a whole lot more than the average EM-interested FM doc. Would you say that's true @cabinbuilder ?

 

[cabinbuilder]

If you look back through CB's posts about how she gets her locum tenens gigs, you'll see how much work she does on her procedure logs. She can get a gig in an ED because she's got details on how many lines, tubes etc she's done. I think she has a whole lot more than the average EM-interested FM doc. Would you say that's true @cabinbuilder ?

Yes, I would generally say this is true. I ended up in a residency that was very ER heavy AND we helped the ER for 6 hours every time we were on call. That was part of our call shift. However, we never go trauma in the ER where I trained. We didn't get many children either since there was a children's hospital. I ended up doing locums just 4 months out of residency when my job fell through. I have kept patient logs during residency (which is required) and after that whenever I was going to be in an ER setting. With the exception of Midland, TX, all the ER jobs I manned where in the middle of nowhere and basically was stabilize the MI or acute abdomen or back fracture and put them on the plane to the "big ER". I haven't done a line or intubated someone since residency. I personally am not comfortable anymore in a large ER and yes it does take a huge amount of work to prove your worthiness in a large ER setting as an FM doc. Anymore I think it is better to choose your profession and be proficient instead of being half-ass in both. That's why I do urgent care now. Too many "oh ****" moments for me that I didn't feel qualified for so I have the face pace, unknown that I like without people dying in front of me. ER is super stressful and I"m glad to be out of it.

 

[NurWollen]

All I know is I was going to be hired for a job in Mesquite, Nevada in working in the ER. I was officially "hired" and was working on the credentialling when there was a change in policies during that time and they were no longer hiring FM doctors to cover their ER. Only EM boarded docs were going to be hired and I was politely unhired.

Now as locums I covered ER (by myself) in Conrad, MT (2 beds); Wrangell, AK (2 beds); Tonopah, NV (2 beds). All depends on the size of the ER and the location.

How does a small town like Mesquite, Nevada plan to staff only EM-boarded physicians?

 

[KP2AZ]

How does a small town like Mesquite, Nevada plan to staff only EM-boarded physicians?

They can plan all they want...but doesn't mean it's going to happen.


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[teacherman84]

How does a small town like Mesquite, Nevada plan to staff only EM-boarded physicians?

It's an hour from Vegas and less than that from St George. You pay enough and docs commute out.

 

[TedStark]

So not your typical rural ED

 

[cabinbuilder]

How does a small town like Mesquite, Nevada plan to staff only EM-boarded physicians?

Mesquite is only 1 hour from vegas. They have doctors who commute. Lots of locums. They are only taking EM boarded physicians. Generally they do 3 day shifts.

 

[cabinbuilder]

They can plan all they want...but doesn't mean it's going to happen.


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It is happening. Most of the docs who work the ER don't necessarily live there. Just looked on their website. There are no ER openings at this time.

 

[styphon]

Apparently the main reason to get boarded in EM is to work at a level one trauma center. However, someone doing both FM and EM would be doing part time EM. I'm imagining there aren't many part time EM physicians at level one trauma centers. They're probably all full time.

So if someone really wants to do both, wouldn't it make more sense to do family medicine and work part time in a rural ER?

I've heard these jobs are never going away if you're willing to commute to the ED. Is that true?

I live outside of a mid-sized city (around 500k population), EVERY hospital in the city AND suburbs require EM boards to be in the ER. This includes the level I trauma center, plus the tertiary hospitals, plus the suburban hospitals who funnel patients to the fore-mentioned places.

The area I actually live in is rural, we have 3 hospitals in the surrounding community, and one requires EM boards. The other two are usually staffed by FM/IM/midlevels.