IM/EM/CC -question about EM side of things

[cbrons]

I am interested in the combined IM/EM/CC programs (only a small handful in the country). I understand its 6 years total, and you of course start out as a PGY-1 IM/EM resident. I was curious if anyone had any tips about how to be most competitive for these programs and also how to be the most competitive applicant for the EM side of things to a combined program. For instance, I have heard away rotations are more important in EM compared to IM.

Also curious if you think the EM training would give you anything special/unique for CC that you wont get from just IM alone. I understand there are not that many EM trained intensivists.

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[MattyBee]

I was curious if anyone had any tips about how to be most competitive for these programs and also how to be the most competitive applicant for the EM side of things to a combined program. For instance, I have heard away rotations are more important in EM compared to IM.

If you are competitive for the corresponding EM or IM program (EM more so) then you are competitive for the EM/IM program. It is that simple.

As JDH said in one of your previous threads...

These programs are not "competitive" in the traditional sense that dermatology is "competitive". These programs simply want solid, serious candidates. Be able to articulate why you want to do a mixed program.

There are no tips or tricks that are different for EM/IM applicants when compared to the categorical applicants. I do think it is beneficial to write a separate personal statement for the EM/IM programs and have a clear understanding of why you want to do it. But really beyond that much of what it takes to apply and get into a categorical EM program is what it takes to get into an EM/IM program (Good SLOEs/letters, good boards scores, good grades, good ECs, etc.).

From your post history it sounds like you have a particular interest in one specific program. Yes, doing a rotation there will help increase your competitiveness as an applicant as long as you preform well and people don't hate you by the end of the month. I think that pretty much holds true for almost every specialty.

If you are interested in EM/IM I would strongly advocate doing an EM rotation over the IM rotation. In general most EM/IM programs lean EM. Also you will probably need the SLOE regardless. Even if you are applying IM as backup, most (if not all) of the EM/IM programs still require you to have at least 1 SLOE if not 2.

Also curious if you think the EM training would give you anything special/unique for CC that you wont get from just IM alone. I understand there are not that many EM trained intensivists.

Yes I think EM training gives you something special/unique for CC that you won't get from just IM alone. Likewise I think IM training gives you something special/unique for CC that you won't get from just EM alone.

I know you know the answer to this question. Basically all the threads I was looking to hopefully grab a useful quote from you have already posted in.

Needless to say the consensus is that whether you do EM/CC, IM/CC, or EM/IM/CC you have equal opportunity to be a great critical care doctor. EM/IM/CC training is just the lengthier and more "well rounded" approach in terms of training.

 

[Hair Police]

Have some coherent plan as to how you will use the combined training. What specific career niche do you want to fulfill, and how does the combined training get you there? You shouldn't say "I want to able to work anywhere in the hospital", because you won't be in the OR or Peds or psych. Spend some time with current EM/IM combineds and get their thoughts. If you don't have a program at your school, rotate at one, as suggested. Of the applicants that I saw that became our combined residents (EM/IM, EM/Peds), they had CVs that would have got them in at -you name it- any competitive EM program across the country.

 

[engineeredout]

So I am going to direct you to a post I made on this subject previously: Osteopathic EM programs

To restate what was mentioned above, yes in the EM/IM programs we tend to be more EM-minded people, when it comes to love of procedures, ability to multitask and handle multiple sick patient simultaneously, short attention spans, etc... (note these are generalities, does not apply to all IM residents). Just about everyone who finishes from our combined program does EM primarily, although people definitely find ways to do both.

Admittedly I am biased being in a combined residency myself, but I definitely see the differences in what we learn and how we may approach problems differently then our colleges. Not to say that any of them are doing things wrong, just different. I might care more about electrolytes and what types of fluids that we are resuscitating a patient with (IE don't give a DKA patient whose uncorrected sodium is 135 with glucose of 1200 8000cc of NS and not expect their sodium to be 155 tomorrow). A few weeks ago in the ED when I was making an argument for using Bumex over lasix in a patient I was told to stop thinking like an internist. Because I spend time on the inpatient side, I have a better idea of what services are like in the various levels of care at my hospitals, where is best to dispo the patient, what an inpatient team will actually do for the patient and what can I initiate from the ED as far as diagnostic pathways (maybe I'll send off the iron studies in the anemic patient before transfusing them and ****ing it all up).

Just random examples, but I think the combination serves me well and is definitely a good fit for myself. Like I said though, I still believe we still have the EM mentality where it counts.

 

[dotcb]

Just know that EM/IM may be more competitive than EM, so you need to focus on the essentials - board scores, course grades, leadership, research, etc. Doing 1 or 2 away rotations in EM may be useful. Have a back up plan because the number of slots in the country is small.

Compared to IM- trained intensivists, I think EM trained intensivists may have better procedural and airway skills, and be more comfortable with uncertainty.

 

[DrDrummer]

If you're interested in aways to evaluate the IM/EM curriculum, I know that at least Christiana Care has an IM/EM-specific away rotation (not IM/EM/CCM, though I'd imagine you could easily match into a CCM fellowship out of there, perhaps even at CC).

The ABIM pathway for CCM fellowship training is now open to EM grads though, so for me the incentive that once existed for EM/IM training was sort of eroded-- that said, the smartest doctors I know in EM are dual/triple-boarded. If you go to a place like Hennepin for IM/EM or UCLA or Christiana Care, then somewhere else (or stay) for fellowship, you'll be a boss by the end of it all.

 

[BJJVP]

(IE don't give a DKA patient whose uncorrected sodium is 135 with glucose of 1200 8000cc of NS and not expect their sodium to be 155 tomorrow). A few weeks ago in the ED when I was making an argument for using Bumex over lasix in a patient I was told to stop thinking like an internist.

What would be your IVF of choice in this situation?
Why did you consider bumex a better choice in this pt?

 

[engineeredout]

What would be your IVF of choice in this situation?
Why did you consider bumex a better choice in this pt?

The most easily acceptable alternate resuscitation fluid would be LR, and the advantage that it provides is that there is less (although still a decent amount) of sodium (~130meq as opposed to the 154meq of NS) but also of importance, the chloride of LR is only about 110, as opposed to 154meq of NS. When a patient receives high volume crystalloid resuscitation with NS, whether for dehydration, DKA, sepsis whatever, not only do they become hypernatremic, but they become hyperchloremic and actually develop a non anion gap metabolic acidosis as a result, which may make a preexisting acidosis (IE due to sepsis or DKA) worse. One liter of NS is not going to mess up anything by itself, but when these patients receive multiple liters of fluid, sometimes we may want to consider switching up the fluid so as not to cause further metabolic derangement.

And in hypoalbuminemic patients, lasix may not be as effective as bumex because the lasix does not get secreted into the tubules as well without albumin. Granted, I'm not aware of any RCTs that show a clinical difference, but I have been tending to go with bumex over lasix in these patients

 

[Hair Police]

While there is much todo about non-gap hyperchloremic metabolic acidoses, I have never seen a publication that shows having one changes outcomes. I will say that adding a pretty acidic solution (pH=5.5 for NS) to an acidic pt (e.g. DKA) is kinda silly when you have access to cheap balanced solutions (Plasmalyte or LR).

 

[BJJVP]

The most easily acceptable alternate resuscitation fluid would be LR, and the advantage that it provides is that there is less (although still a decent amount) of sodium (~130meq as opposed to the 154meq of NS) but also of importance, the chloride of LR is only about 110, as opposed to 154meq of NS. When a patient receives high volume crystalloid resuscitation with NS, whether for dehydration, DKA, sepsis whatever, not only do they become hypernatremic, but they become hyperchloremic and actually develop a non anion gap metabolic acidosis as a result, which may make a preexisting acidosis (IE due to sepsis or DKA) worse. One liter of NS is not going to mess up anything by itself, but when these patients receive multiple liters of fluid, sometimes we may want to consider switching up the fluid so as not to cause further metabolic derangement.

And in hypoalbuminemic patients, lasix may not be as effective as bumex because the lasix does not get secreted into the tubules as well without albumin. Granted, I'm not aware of any RCTs that show a clinical difference, but I have been tending to go with bumex over lasix in these patients

Holy Cow. You need to stop thinking like an internist. j/k.
Thanks for the answer. Sometimes, I wish I had more exposure to this kind of perspective during my EM training.

 

[TooMuchResearch]

I don't encounter many emergent Lasix/Bumex deficiencies.

 

[DrDrummer]

While there is much todo about non-gap hyperchloremic metabolic acidoses, I have never seen a publication that shows having one changes outcomes.

http://www.ncbi.nlm.nih.gov/m/pubmed/22470070/

Not the best evidence in the world, but it's something.

 

[Hair Police]

An observational study (no controls) describing lower mortality in the plasmalyte arm when the rate of emergency surgery was twice as high in the NS arm. The point I made above was fitting the fluid to the clinical scenario, but by this study's design, we can't know why the clinicians chose the particular crystalloid.

 

[Groove]

I'm just going to say it like I see it... but I've never thought much of these combined EM/X programs and certainly think no differently about an EM/IM program. Combination programs, by and large (not all) are for residents who simply don't know what they want to do when they grow up. I can remember having these discussions with the med/peds guys and gals and heard all these glorious answers about how useful their dual board certification was going to be. What did they all end up doing? Hospitalist or full time peds. Literally, every one. I'm sure some exceptions will pop on here and scream foul but seriously... why would you want to do IM/EM? Thinking like an internist in the ED would make me the absolutely least productive member of our group. I'd probably only see 0.5pt/hr and I'd MRI everyone with CT guided biopsies on their way to the floor and have an average of at least 3 consultants called for each pt admitted and 4 called for each pt discharged. Now, if you want to do full time IM, just know that you're going to be mighty tempted to do full time EM once you roll around to graduation and are comparing apples to oranges in the salary fruit bowl while Uncle Sam hovers in the background licking his chops and counting his "IOU's".

Could you practice in the ED and work part time as a hospitalist? Sure. But....why would you want to?

Now, if you want to do CC, why torture yourself with an EM residency? Just do the IM route and do pulm/cc. It's a no brainer. I'm convinced the proliferance of these EM/IM/FM/Peds/<pick one> training spots is just a glorified way for GME to get the absolute maximum CME funding from all the "sucker!" residents who want to stay in the nest for as many years as possible. But hey...that's just me.

 

[deleted547339]

I'm just going to say it like I see it... but I've never thought much of these combined EM/X programs and certainly think no differently about an EM/IM program. Combination programs, by and large (not all) are for residents who simply don't know what they want to do when they grow up. I can remember having these discussions with the med/peds guys and gals and heard all these glorious answers about how useful their dual board certification was going to be. What did they all end up doing? Hospitalist or full time peds. Literally, every one. I'm sure some exceptions will pop on here and scream foul but seriously... why would you want to do IM/EM? Thinking like an internist in the ED would make me the absolutely least productive member of our group. I'd probably only see 0.5pt/hr and I'd MRI everyone with CT guided biopsies on their way to the floor and have an average of at least 3 consultants called for each pt admitted and 4 called for each pt discharged. Now, if you want to do full time IM, just know that you're going to be mighty tempted to do full time EM once you roll around to graduation and are comparing apples to oranges in the salary fruit bowl while Uncle Sam hovers in the background licking his chops and counting his "IOU's".

Could you practice in the ED and work part time as a hospitalist? Sure. But....why would you want to?

Now, if you want to do CC, why torture yourself with an EM residency? Just do the IM route and do pulm/cc. It's a no brainer. I'm convinced the proliferance of these EM/IM/FM/Peds/<pick one> training spots is just a glorified way for GME to get the absolute maximum CME funding from all the "sucker!" residents who want to stay in the nest for as many years as possible. But hey...that's just me.

Eh, I mostly agree. We have a Med/Peds program here. The residents tend to be VERY strong. Several plan on doing outpatient gen med, in which case they are essentially just doing an extra long family medicine residency. A couple plan on doing either IM or Peds subspecialties, in which case it was a wasted year. I do know of one who wants to do adult congenital heart patients. Med/Peds seems like and excellent training course for this person.

I think you're wrong about CC. I want to do CC and I'm doing EM. What do you mean, why torture yourself within an EM residency? I love being in the ED. If I had to round on floor patients I would lose my mind, but I love the sick patients. Both CC and EM have schedules conducive to doing both. EM is a great training foundation for CC. I'll certainly have some deficiencies relative to my IM colleagues, but I think I'll be ready. And I have no interest in doing outpatient clinic with pulm.

 

[cbrons]

I'm just going to say it like I see it... but I've never thought much of these combined EM/X programs and certainly think no differently about an EM/IM program. Combination programs, by and large (not all) are for residents who simply don't know what they want to do when they grow up. I can remember having these discussions with the med/peds guys and gals and heard all these glorious answers about how useful their dual board certification was going to be. What did they all end up doing? Hospitalist or full time peds. Literally, every one. I'm sure some exceptions will pop on here and scream foul but seriously... why would you want to do IM/EM? Thinking like an internist in the ED would make me the absolutely least productive member of our group. I'd probably only see 0.5pt/hr and I'd MRI everyone with CT guided biopsies on their way to the floor and have an average of at least 3 consultants called for each pt admitted and 4 called for each pt discharged. Now, if you want to do full time IM, just know that you're going to be mighty tempted to do full time EM once you roll around to graduation and are comparing apples to oranges in the salary fruit bowl while Uncle Sam hovers in the background licking his chops and counting his "IOU's".

Could you practice in the ED and work part time as a hospitalist? Sure. But....why would you want to?

Now, if you want to do CC, why torture yourself with an EM residency? Just do the IM route and do pulm/cc. It's a no brainer. I'm convinced the proliferance of these EM/IM/FM/Peds/<pick one> training spots is just a glorified way for GME to get the absolute maximum CME funding from all the "sucker!" residents who want to stay in the nest for as many years as possible. But hey...that's just me.

The reason I'm interested in the 3x program is that I've been told that EM training is a great foundation for CC. It's also 6 years (so the same length as IM/Pulm/CC). Lastly, I figure that the first 4-5 years of IM/EM will help mix things up so it's not the same thing everyday.

I freely admit that my reasoning could be completely illogical though

 

[deleted547339]

The reason I'm interested in the 3x program is that I've been told that EM training is a great foundation for CC. It's also 6 years (so the same length as IM/Pulm/CC). Lastly, I figure that the first 4-5 years of IM/EM will help mix things up so it's not the same thing everyday.

I freely admit that my reasoning could be completely illogical though

Yes, but you're trading EM for pulm. At the end of the day, CC and EM are probably much more similar to CC and pulm. CC and EM are hospital-based, shift work that is fast paced and high stress. Pulm is usually outpatient clinic work. If you're worried about not mixing things up, I think CC/Pulm makes for better variety than EM/CC.

Mind you, I'm going into CC from EM. I'm not saying this isn't an awesome blend of careers, just saying that I don't necessarily agree with your reasoning.

 

[Groove]

Having your MICU staffed with Pulmonary/CC docs has much greater value for the hospital. They have a "whole 'nother" bag of tricks that we don't have... they can do consults, bronch's, BAL's, stents, biopsies, read pfts in the pulm lab on the way to the ICU, are better equipped for pulmonary rehab, and possess a myriad of other skills outside vanilla ICU management. The hospital sees them as a more valuable commodity and a "CC only" trained doc brings less to the table. It doesn't mean there aren't plenty of jobs out there, but they are fewer. There are more jobs in SICU environments.

It's like having your eyes set on EM and deciding to do FM with a 1yr EM fellowship instead of an EM residency. It just doesn't make sense. I'm all for more EM docs sitting for the CC boards but it will honestly prob take awhile to convince the establishment of our value in a field long dominated by gas/pulm/surgery. There's just not a lot of us out there yet and there is still a palpable degree of bias within most of the fellowship programs that will take time to dissipate.

 

[MattyBee]

I'm just going to say it like I see it... but I've never thought much of these combined EM/X programs and certainly think no differently about an EM/IM program. Combination programs, by and large (not all) are for residents who simply don't know what they want to do when they grow up. I can remember having these discussions with the med/peds guys and gals and heard all these glorious answers about how useful their dual board certification was going to be. What did they all end up doing? Hospitalist or full time peds. Literally, every one. I'm sure some exceptions will pop on here and scream foul but seriously... why would you want to do IM/EM? Thinking like an internist in the ED would make me the absolutely least productive member of our group. I'd probably only see 0.5pt/hr and I'd MRI everyone with CT guided biopsies on their way to the floor and have an average of at least 3 consultants called for each pt admitted and 4 called for each pt discharged. Now, if you want to do full time IM, just know that you're going to be mighty tempted to do full time EM once you roll around to graduation and are comparing apples to oranges in the salary fruit bowl while Uncle Sam hovers in the background licking his chops and counting his "IOU's".

Could you practice in the ED and work part time as a hospitalist? Sure. But....why would you want to?

Now, if you want to do CC, why torture yourself with an EM residency? Just do the IM route and do pulm/cc. It's a no brainer. I'm convinced the proliferance of these EM/IM/FM/Peds/<pick one> training spots is just a glorified way for GME to get the absolute maximum CME funding from all the "sucker!" residents who want to stay in the nest for as many years as possible. But hey...that's just me.

At one of my EM/IM interviews the first thing the PD asked was for everyone who has been told not to peruse an EM/IM residency by a faculty member and/or advisor to raise their hand. There were 12 of us there and we all raised our hands.

This is nothing new. Some people get it some people don't. That is the reality of perusing a combined specialty.

Most EM docs did not do internal medicine for a reason. So the thought of doing a combined specialty is a nightmare. Hearing perspectives like Groove's are important especially for the 'residents who simply don't know what they want to do when they grow up'.

I would encourage those who are still interested to talk to an EM/IM trained physician. They will be the first to tell you if your reasoning for perusing an EM/IM residency isn't a good one. In all honesty if you make it to interviews you will get weeded out if you are there for the wrong reasons. Most programs only have 2 EM/IM spots. Losing a combined resident means losing half of the entire class for that particular year. So the programs are very careful with who they choose.

The last thing I wanted to touch on was the funding issue that Groove brought up. I am not going to argue. I am not even going to really discuses the issue that Groove was trying to talk about. It just reminded me of something that I wanted to say.

My understanding of the combined specialties, specifically for EM/IM, is that the last two years go unfunded by the government (DGME/IME funding?). The institutions that have combined specialties find ways to fund the final two years (i.e. affiliation with the VA, hospital group/system contributions, etc.)

The only reason I really know this is because you hear about it when you are applying. Maryland even has a section in the EM/IM FAQ that says 'Are there any financial issues that may affect the stability of the EM/IM program?'. The thought is that if a particular institution needs to make GME cuts to reduce cost the combined specialty will be the first to go if the funding for the extra time isn't well established.

Is this important for applicants? Maybe. On my interviews I did not a feel like there were any particular programs that were financially unstable. Then again it is pretty hard to get a gauge for financial stability on an interview. I doubt any one would be openly honest with you about a hospital financially collapsing if they invited you there for an interview.

Again I am not sure how important this is but it is something to think about and consider. It is also quite a bit off topic but I figured I'd bring it up. If someone has a better understanding of things feel free to comment. I am by no means anywhere close to an expert on the topic.

 

[ryuuzaki]

I'm just going to say it like I see it... but I've never thought much of these combined EM/X programs and certainly think no differently about an EM/IM program. Combination programs, by and large (not all) are for residents who simply don't know what they want to do when they grow up. I can remember having these discussions with the med/peds guys and gals and heard all these glorious answers about how useful their dual board certification was going to be. What did they all end up doing? Hospitalist or full time peds. Literally, every one. I'm sure some exceptions will pop on here and scream foul but seriously... why would you want to do IM/EM? Thinking like an internist in the ED would make me the absolutely least productive member of our group. I'd probably only see 0.5pt/hr and I'd MRI everyone with CT guided biopsies on their way to the floor and have an average of at least 3 consultants called for each pt admitted and 4 called for each pt discharged. Now, if you want to do full time IM, just know that you're going to be mighty tempted to do full time EM once you roll around to graduation and are comparing apples to oranges in the salary fruit bowl while Uncle Sam hovers in the background licking his chops and counting his "IOU's".

Could you practice in the ED and work part time as a hospitalist? Sure. But....why would you want to?

Now, if you want to do CC, why torture yourself with an EM residency? Just do the IM route and do pulm/cc. It's a no brainer. I'm convinced the proliferance of these EM/IM/FM/Peds/<pick one> training spots is just a glorified way for GME to get the absolute maximum CME funding from all the "sucker!" residents who want to stay in the nest for as many years as possible. But hey...that's just me.

From a pragmatic perspective someone who wants to practice straight emergency medicine would agree with Groove and say it's totally a waste of time. But there are people who go to medical school and want to go into academia and realize that extra training will benefit them into carving a niche into the field that they love. There are a multitude of opportunities for EM/IM trained graduates that do not exist for EM only grads, and I would argue that EM/IM trained graduates are more academic oriented physicians than those who are not.

People go for the extra training not because they can't decide. If you can't decide, you pick one. If you do the combined program, it's because your pursuit of the training is driven by the complimentary nature of the two fields coming together and how that translates into your practice of medicine. That knowledge base and experience which pull from a multitude of facets from the ED and the wards can lead you down the road into academic EM, administration, combined ED-Obs, ED-Hospitalist, ED-Intensivist, ED-IMSubspecialty, or ED-International Medicine (I am sure I missed something).

Why you may choose to do EM/IM is your own choice. If you know for a fact that you have a goal in mind, or that you will make use of the training, go do it. Who cares what other people say. The reflection of others is based on their own perception of their personal choice and what they've observed. That will not translate into your own practice unless you make it that choice. If you are okay with one or two extra years, and you would be more than happy to have that additional training and go into fellowship or administration or combined ED-Hospitalist practice/Academic EM, then that is your personal pursuit alone.

You just have to have the right reasons and why the extra one or two years is important to you and how you'll use it.

 

[The White Coat Investor]

While evaluating your reasons for getting that extra training, be sure to consider the financial implications. If an emergency doc makes $300K, and an EM/IM/CC resident/fellow/whatever he is makes $50K for those last 3 years of training, the cost there is something north of $750K. Now, life isn't all about money or anything, but to pretend $750K isn't significant (not to mention 3 extra years of residency) seems foolhardy. That's a heckuva price for someone who can't decide what they want to do when they grow up.

 

[quickfeet]

At one of my EM/IM interviews the first thing the PD asked was for everyone who has been told not to peruse an EM/IM residency by a faculty member and/or advisor to raise their hand. There were 12 of us there and we all raised our hands.

This is nothing new. Some people get it some people don't. That is the reality of perusing a combined specialty.

Most EM docs did not do internal medicine for a reason. So the thought of doing a combined specialty is a nightmare. Hearing perspectives like Groove's are important especially for the 'residents who simply don't know what they want to do when they grow up'.

I would encourage those who are still interested to talk to an EM/IM trained physician. They will be the first to tell you if your reasoning for perusing an EM/IM residency isn't a good one. In all honesty if you make it to interviews you will get weeded out if you are there for the wrong reasons. Most programs only have 2 EM/IM spots. Losing a combined resident means losing half of the entire class for that particular year. So the programs are very careful with who they choose.

The last thing I wanted to touch on was the funding issue that Groove brought up. I am not going to argue. I am not even going to really discuses the issue that Groove was trying to talk about. It just reminded me of something that I wanted to say.

My understanding of the combined specialties, specifically for EM/IM, is that the last two years go unfunded by the government (DGME/IME funding?). The institutions that have combined specialties find ways to fund the final two years (i.e. affiliation with the VA, hospital group/system contributions, etc.)

The only reason I really know this is because you hear about it when you are applying. Maryland even has a section in the EM/IM FAQ that says 'Are there any financial issues that may affect the stability of the EM/IM program?'. The thought is that if a particular institution needs to make GME cuts to reduce cost the combined specialty will be the first to go if the funding for the extra time isn't well established.

Is this important for applicants? Maybe. On my interviews I did not a feel like there were any particular programs that were financially unstable. Then again it is pretty hard to get a gauge for financial stability on an interview. I doubt any one would be openly honest with you about a hospital financially collapsing if they invited you there for an interview.

Again I am not sure how important this is but it is something to think about and consider. It is also quite a bit off topic but I figured I'd bring it up. If someone has a better understanding of things feel free to comment. I am by no means anywhere close to an expert on the topic.

From a pragmatic perspective someone who wants to practice straight emergency medicine would agree with Groove and say it's totally a waste of time. But there are people who go to medical school and want to go into academia and realize that extra training will benefit them into carving a niche into the field that they love. There are a multitude of opportunities for EM/IM trained graduates that do not exist for EM only grads, and I would argue that EM/IM trained graduates are more academic oriented physicians than those who are not.

People go for the extra training not because they can't decide. If you can't decide, you pick one. If you do the combined program, it's because your pursuit of the training is driven by the complimentary nature of the two fields coming together and how that translates into your practice of medicine. That knowledge base and experience which pull from a multitude of facets from the ED and the wards can lead you down the road into academic EM, administration, combined ED-Obs, ED-Hospitalist, ED-Intensivist, ED-IMSubspecialty, or ED-International Medicine (I am sure I missed something).

Why you may choose to do EM/IM is your own choice. If you know for a fact that you have a goal in mind, or that you will make use of the training, go do it. Who cares what other people say. The reflection of others is based on their own perception of their personal choice and what they've observed. That will not translate into your own practice unless you make it that choice. If you are okay with one or two extra years, and you would be more than happy to have that additional training and go into fellowship or administration or combined ED-Hospitalist practice/Academic EM, then that is your personal pursuit alone.

You just have to have the right reasons and why the extra one or two years is important to you and how you'll use it.

So what is an acceptable answer when they ask you why you want to do the combined EM/IM program? Is it acceptable to say something along the lines of "I want a good foundation to practice critical care medicine?" (Talking about those programs where you can add the 1 year for CCM)

 

[sylvanthus]

So what is an acceptable answer when they ask you why you want to do the combined EM/IM program? Is it acceptable to say something along the lines of "I want a good foundation to practice critical care medicine?" (Talking about those programs where you can add the 1 year for CCM)

The above is perfectly acceptable and was my response when asked.

 

[sylvanthus]

While evaluating your reasons for getting that extra training, be sure to consider the financial implications. If an emergency doc makes $300K, and an EM/IM/CC resident/fellow/whatever he is makes $50K for those last 3 years of training, the cost there is something north of $750K. Now, life isn't all about money or anything, but to pretend $750K isn't significant (not to mention 3 extra years of residency) seems foolhardy. That's a heckuva price for someone who can't decide what they want to do when they grow up.

Not entirely accurate, 750k with taxes taken out is much less, plus at least at my program we can moonlight quite a bit our last few years, easily clearing 100k a year at least for the last two. The 6th year is essentially 40 hours a week no weekends and moonlighting as an attending is entirely possible. I agree if a person does EM/IM/CC because they do not know what they want to do, it is a waste of time. If you have clear reasons why you want do combined training, however, it can be totally worth it.

 

[pulmoblast]

Most hospitals prefer pulm/cc trained physicians. They hire a few EM/cc guys for doing nights/holiday shift work while the pulm guys happily bill for vent management/BAL and CCtime and the EM/cc guy deals with all the other **** but bills for only CCtime. Not to mention cover SICUs and be the surgeons bitch. As a result, the RVUs and salaries are lower with ****ty work hours/night/holiday shifts for pure intensivists. ED pays much better $/hr. You really gotta decide what you want to do in life. One could make a great doctor if you did EM/IM/Peds/gen surg. But that's not practical and doesn't make sense in terms of time/money/effort

It's just my opinion.

 

[sylvanthus]

Most hospitals prefer pulm/cc trained physicians. They hire a few EM/cc guys for doing nights/holiday shift work while the pulm guys happily bill for vent management/BAL and CCtime and the EM/cc guy deals with all the other **** but bills for only CCtime. Not to mention cover SICUs and be the surgeons bitch. As a result, the RVUs and salaries are lower with ****ty work hours/night/holiday shifts for pure intensivists. ED pays much better $/hr. You really gotta decide what you want to do in life. One could make a great doctor if you did EM/IM/Peds/gen surg. But that's not practical and doesn't make sense in terms of time/money/effort

It's just my opinion.

Nope, most hospitals don't even have an intensivist on staff, let alone pulm/cc. If you want to work at a large tertiary, teaching hospital, well ya pulm/cc is pretty much preferred. It all depends on what you want to do.

 

[Brigade4Radiant]

Not entirely accurate, 750k with taxes taken out is much less, plus at least at my program we can moonlight quite a bit our last few years, easily clearing 100k a year at least for the last two. The 6th year is essentially 40 hours a week no weekends and moonlighting as an attending is entirely possible. I agree if a person does EM/IM/CC because they do not know what they want to do, it is a waste of time. If you have clear reasons why you want do combined training, however, it can be totally worth it.

That's not the point we are trying to make. You also get taxed on the 50k you make as a resident so you really make 36k. You have to moonlight on top of your fellowship or resident duties so you are working 50-60 hours a week. You can moonlight as an attending and make 450k+ working the same hours as a resident. If CC is your goal you are best off doing IM/CC/Pulm. If you are like me and didn't know what to do EM and then do CC is fine. Also with the EM/IM/CC you only get 1 year as a CC fellow sure your base is strong but the EM/CC has a lengthier fellowship. Though if money is your sole motivator it makes no sense to do CC at all since EM makes more than CC.

 

[The White Coat Investor]

That's not the point we are trying to make. You also get taxed on the 50k you make as a resident so you really make 36k. You have to moonlight on top of your fellowship or resident duties so you are working 50-60 hours a week. You can moonlight as an attending and make 450k+ working the same hours as a resident. If CC is your goal you are best off doing IM/CC/Pulm. If you are like me and didn't know what to do EM and then do CC is fine. Also with the EM/IM/CC you only get 1 year as a CC fellow sure your base is strong but the EM/CC has a lengthier fellowship. Though if money is your sole motivator it makes no sense to do CC at all since EM makes more than CC.

Right. So whatever the difference is, whether it's $750K or $500K or $300K or whatever, there is a cost there.

 

[sylvanthus]

That's not the point we are trying to make. You also get taxed on the 50k you make as a resident so you really make 36k. You have to moonlight on top of your fellowship or resident duties so you are working 50-60 hours a week. You can moonlight as an attending and make 450k+ working the same hours as a resident. If CC is your goal you are best off doing IM/CC/Pulm. If you are like me and didn't know what to do EM and then do CC is fine. Also with the EM/IM/CC you only get 1 year as a CC fellow sure your base is strong but the EM/CC has a lengthier fellowship. Though if money is your sole motivator it makes no sense to do CC at all since EM makes more than CC.

It depends on your goal, I have no interest whatsoever in working in a pulm clinic. However, I do plan on doing 1/2 EM and 1/2 CC. So doing pulm makes no sense to me.

 

[sylvanthus]

Right. So whatever the difference is, whether it's $750K or $500K or $300K or whatever, there is a cost there.

The point is, what is your plan? If you have none, than the additional training is a waste. If you have a legitimate plan, than the additional training may or may not be worth it. Why I don't see as much bashing of 4 year versus 3 year programs on here is beyond me.

 

[sylvanthus]

That's not the point we are trying to make. You also get taxed on the 50k you make as a resident so you really make 36k. You have to moonlight on top of your fellowship or resident duties so you are working 50-60 hours a week. You can moonlight as an attending and make 450k+ working the same hours as a resident. If CC is your goal you are best off doing IM/CC/Pulm. If you are like me and didn't know what to do EM and then do CC is fine. Also with the EM/IM/CC you only get 1 year as a CC fellow sure your base is strong but the EM/CC has a lengthier fellowship. Though if money is your sole motivator it makes no sense to do CC at all since EM makes more than CC.

So, you only get one year as a fellow? Who cares? We do multiple extra months in SICU and MICU where we are essentially considered a fellow even before that 6th year during our combined residency. I as a 2nd year am already the go to person for peripheral lines, central lines, paracentesis, lumbar punctures, etc. I know procedures are not the end all and be all, but my training is well suited to do both EM and CC, moreso than doing a EM residency followed by a CC fellowship. Critical care is an up and coming specialty for EM, feel free to bash the extra yeas of training, but in the end, I will be capable of working essentially anywhere in the hospital save for surgery and can demand quite a bit of money from locum tenems positions.

 

[cbrons]

So, you only get one year as a fellow? Who cares? We do multiple extra months in SICU and MICU where we are essentially considered a fellow even before that 6th year during our combined residency. I as a 2nd year am already the go to person for peripheral lines, central lines, paracentesis, lumbar punctures, etc. I know procedures are not the end all and be all, but my training is well suited to do both EM and CC, moreso than doing a EM residency followed by a CC fellowship. Critical care is an up and coming specialty for EM, feel free to bash the extra yeas of training, but in the end, I will be capable of working essentially anywhere in the hospital save for surgery and can demand quite a bit of money from locum tenems positions.

Anything you can do with the IM training alone if you wanted a break from the hospital in general?

 

[Dr.CCM]

Most hospitals prefer pulm/cc trained physicians. They hire a few EM/cc guys for doing nights/holiday shift work while the pulm guys happily bill for vent management/BAL and CCtime and the EM/cc guy deals with all the other **** but bills for only CCtime. Not to mention cover SICUs and be the surgeons bitch. As a result, the RVUs and salaries are lower with ****ty work hours/night/holiday shifts for pure intensivists. ED pays much better $/hr. You really gotta decide what you want to do in life. One could make a great doctor if you did EM/IM/Peds/gen surg. But that's not practical and doesn't make sense in terms of time/money/effort

It's just my opinion.

This simply isn't true.

 

[Hamhock]

Most hospitals prefer pulm/cc trained physicians. They hire a few EM/cc guys for doing nights/holiday shift work while the pulm guys happily bill for vent management/BAL and CCtime and the EM/cc guy deals with all the other **** but bills for only CCtime. Not to mention cover SICUs and be the surgeons bitch. As a result, the RVUs and salaries are lower with ****ty work hours/night/holiday shifts for pure intensivists. ED pays much better $/hr. You really gotta decide what you want to do in life. One could make a great doctor if you did EM/IM/Peds/gen surg. But that's not practical and doesn't make sense in terms of time/money/effort

It's just my opinion.

As just mentioned above, this is not one bit true. I can personally attest to offers in both the community and academics where EM/CCM is treated exactly the same and works exactly the same hours/shifts/has same clinical responsibility as the Pulm folks when in the ICU.

"pulm guys happily bill for vent management/BAL"...I assume you mean billing vent mgt as part of CC time, in which that is exactly what the EM-CCM guys do. And we bill for BAL just like the pulm guys...pulm fellowship is certainly not required for bronch billing.

Thanks for visiting, pulmoblast.

HH

 

[The White Coat Investor]

The point is, what is your plan? If you have none, than the additional training is a waste. If you have a legitimate plan, than the additional training may or may not be worth it. Why I don't see as much bashing of 4 year versus 3 year programs on here is beyond me.

I feel the same way about 4 year programs. I mean, do what you want. If you want more training, get it. Just realize there is a cost to it. It won't matter much if you spend 30 years doing what you love. But have a darn good reason to "spend" that money.

 

[Hair Police]

I feel the same way about 4 year programs. I mean, do what you want. If you want more training, get it. Just realize there is a cost to it. It won't matter much if you spend 30 years doing what you love. But have a darn good reason to "spend" that money.

I felt the same way when I was applying to residency programs. If I was going to spend an extra twelve months somewhere, they better give me more than 6 months electives.

 

[namethatsmell]

The best option here is to do what you think will make you happiest and eff the rest. You wanna do wards and work in an ED? Great, do it. You wanna work in the unit and the ED? More power to you. You wanna get boarded in 5 things? I think that's crazy but good for you it doesn't matter what I think.

At present the economics make EM a better deal than CC (in terms of $/hr). As all things in life this may change, and it may change quickly. Or it may not. The only guarantee in medicine is that in the future docs will still be whipping their **** out to measure and compare.

OP, if you know what you want out of your career/life than don't be afraid to take the path to get yourself there, even if it's the hard road or not conventional.

 

[The White Coat Investor]

The only guarantee in medicine is that in the future docs will still be whipping their **** out to measure and compare.

Dude! Check out this turd. It's like the statue of liberty!

 

[namethatsmell]

Dude! Check out this turd. It's like the statue of liberty!

Heh, I guess I did leave the door open for that. Well played.

 

[MattyBee]

So what is an acceptable answer when they ask you why you want to do the combined EM/IM program? Is it acceptable to say something along the lines of "I want a good foundation to practice critical care medicine?" (Talking about those programs where you can add the 1 year for CCM)

In a general sense that is an acceptable answer (for all EM/IM programs not just the ones with the 6 year CCM option). In reality, you will need to be able to articulate why you think EM/IM training "will provide you with a good foundation to practice critical care medicine". You will need to be able to explain why it makes more sense for you go through an EM/IM program over just doing EM/CCM, IM/CCM, or IM/PCCM.

It sounds like you understand this but I just wanted to emphasize that saying 'I want a good foundation to practice critical care medicine' is only acceptable in a general sense. As you can tell from the posts on this thread there is a level of sacrifice you must be willing to take on if you are considering a combined specialty. It is not something that should be considered lightly and interviewers will expect your explanations to reflect that.

Anything you can do with the IM training alone if you wanted a break from the hospital in general?

I do not think I am understanding what exactly you are asking. Do you mind explaining?