Just finished my em fellowship!

[Lexdiamondz]

To those interested in the EM fellowship, I've been fortunate enough to pass my emergency medicine boards through ABPS, the only board available to FM's interested in certifying in EM. But before I start please understand that an FM can certainly practice EM without ABPS certification and frankly without doing the fellowship. I decided to sit for the exam to standardize my knowledge, for board certification, and for the plaque on my wall.

Now, Just a little about the process. It's both time consuming and expensive. After the fellowship you'll need to turn in ten case studies of emergency level 1 conditions, ie strokes, dka, stemis, traumas, etc. The deadline is February. The application fee is $250 bucks The exam fee is a $1000. The whole process takes 2-3 months because if the board doesn't think your cases are up to par, they will ask you to submit new case reports.

Exam prep: Your experience in the ED and in the fellowship are helpful. For example, one of the questions on my exam was about coags for a snake bite. I answered the question based on my experience in the ED. There were many questions that I answered based on my experience alone. 2nd, I used a board prep exam called rosh review. I was later informed that peer IX was a more accurate exam test bank but I found out late in the game. THat said I had a good experience with rosh. It's got like 3000 questions of which I got through approximately 1500. I recommend it highly because of the volume of questions and for its succinct and well written explanations and drawings. It also give an estimate about whether you will pass or not and your expected score. It was 400 bucks for a 1 month subscription. 3rd, I went to the National EM Board Review put on by the Center for medical education. My fellowship paid for it. It was incredibly helpful in answering questions correctly on my question bank and overall confidence. It was very professional with hilarious and incredibly smart lecturers. I attended a review in Baltimore, but I believe they are all year round in multiple cities. All in all, I studied for three weeks. Unfortunately, ABPS only organizes allows you to sit for there exam once a year in august.

The exam: I took the exam in one of the national exam centers. The exam was 400 questions and 6 hours long. I got a lot more trauma questions then I expected. A lot of questions, were peculiar to EM, ie what is the the difference between level 1 and level 5 ED? A lot of environmental questions and some toxidrome (ie dumbbels, mad as a hatter, etc) questions that weren't exactly emphasized in FM. Lots of ortho and trauma stuff. Again, between the fellowship the board review and the questions, you will be prepared. TO pass one needs a 70% according to ABPS reps.

You realise the ACGME requires us to log at least 45 medical resuscitations and 35 trauma resuscitations for graduation as a bare minimum - this fake certifying board only requires 10?


By the standards you've set forth literally every one of our current interns could be board-certified by this certifying body. I could meet these requirements in 2 weeks of moonlighting and a week of cramming.

You see a lot of insecurity for some reason from ED personnel. Not sure why.

More incredulousness at how strong the Dunning-Kruger effect is. Read the above - someone waving a credential with standards literally 1/8th as stringent stating that they're equivalent to us.

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[MedicineZ0Z]

You realise the ACGME requires us to log at least 45 medical resuscitations and 35 trauma resuscitations for graduation as a bare minimum - this fake certifying board only requires 10?


By the standards you've set forth literally every one of our current interns could be board-certified by this certifying body. I could meet these requirements in 2 weeks of moonlighting and a week of cramming.


More incredulousness at how strong the Dunning-Kruger effect is. Read the above - someone waving a credential with standards literally 1/8th as stringent stating that they're equivalent to us.

I'm not reading into credentialing or any of that because it's not something I plan to do.
I have already repeated several times that board certified em is of course the best on average. Fellowship FM is sometimes as good. And regular fm occasionally is as good.
Remember the fellowship guy already did a 3 year generalist residency.

Anyway my point was that if you felt secure about your position then you wouldnt feel the need to constantly defend it against other physicians. Dunning Kruger argument is valid with midlevels because you are comparing enormous differences in knowledge. It's not valid with EM focused FMs and board certified EM when you compare the relative difference in knowledge.

 

[SLC]

This thread went to ****...again

Yeah, thanks for that.

 

[MedicineZ0Z]

Yeah, thanks for that.

The dude is incredibly insecure. If you're confident in your position and abilities then you don't need to come defend it online against other physicians. If it was non-physicians, it would be the polar opposite as he should be defending it.

 

[Splenda88]

The dude is incredibly insecure. If you're confident in your position and abilities then you don't need to come defend it online against other physicians. If it was non-physicians, it would be the polar opposite as he should be defending it.

It's all about the benjamin...

 

[deleted109597]

I'm not a moderator for this forum specifically, but have been notified that EM members are coming to this thread and not engaging in collegial discussions. We can all moderate all areas if need be.
Bashing isn't acceptable. Stop doing it.

 

[quicksilverdo]

EM here and debating who is best, what is the best route, whose stick is longer is no better than debating liberal vs conservative politics. People dig in, don't discuss with an open mind, are not humble to accept when they are wrong.

EM like every other field is governed by economics. No more, no less.

If 90% of radiologist or anesthesiologist died tomorrow, the hospitals will not shut down. Medicine will not cease to exist. Trust me, everything will go as normal and patients would have no idea anything changed.

EM docs would start working in the OR and unlit rooms esp if they pay 2x what we make now.

I am not delusional to think that if all EM docs died tomorrow, all of the hospitals would run reasonably well with FM/IM/APCs and every other specialty that ran ERs before EM was borm.

But for anyone to think that FM with EM fellowship is as good as an EM doc, they are poorly mistaken. Is there a subset of FM+EM fellowship that will do just as well as me? Sure.
But to think that 100 FM+EM would be equivalent to 100 EM boarded doctors, then there is no reason to discuss.

I am fine with FM+Em fellowship working at places where they can't attract EM docs or afford their pay. You take the next best thing. But they also better be aware that they can finish the EM fellowship and possibly have very limited EM jobs available as the EM field moves towards saturation.

Hilarious seeing the EM docs come in here to defend their piece of the pie like it has anything to do with patient care. EM residency training in the US is unique to the rest of the world, not the other way around.

Once compensation decreases from the oversaturation of midlevels and their own EM trained docs(yay HCA!) they will be singing a different tune.

Sent from my SM-G960U1 using SDN mobile

 

[MedicineZ0Z]

Hilarious seeing the EM docs come in here to defend their piece of the pie like it has anything to do with patient care. EM residency training in the US is unique to the rest of the world, not the other way around.

Once compensation decreases from the oversaturation of midlevels and their own EM trained docs(yay HCA!) they will be singing a different tune.

Sent from my SM-G960U1 using SDN mobile

Logic dictates that on average, more training = better outcome. I really emphasized the key phrase.
But a subset of individuals will do better even with less training due to personal talent and interest. Those two factors really dominate everything else.

And yes you're right. EM and many other fields are killing themselves with midlevels. Like you guys have Midlevel "residencies" in some places and the ED attendings are training these midlevels to effectively become solo practicing personnel. Pretty crazy.

 

[Kach]

Just got started a new job at a 50k hospital level 2 in a great (and warm) city with population of half a mil. I was able to negotiate a great hourly with bonus. The em fellowship made the difference. Just wanted to encourage you fm's out there to consider the fellowship! Thanks

 

[Splenda88]

Just got started a new job at a 50k hospital level 2 in a great (and warm) city with population of half a mil. I was able to negotiate a great hourly with bonus. The em fellowship made the difference. Just wanted to encourage you fm's out there to consider the fellowship! Thanks

What's the rate?

 

[Kach]

Mid 200s

 

[Kach]

Hey all, emergency medicine jobs in desired locations are not exactly readily available to fm's even with a fellowship. What I did was I took the county that i wanted to live in, say los angeles county. I took note of all the counties surrounding la county. Then i went online and looked up all the hospitals in la county and surrounding counties and started making calls! In my search in my desired locale I made 20 calls. Of 20 calls I received 3 all expenses paid interviews and had my pick of the three jobs. So the hard work paid off and wifey can go to wholefoods whenever she wants .

 

[Splenda88]

Mid 200s

The EM people in this forum aren't going to be happy

 

[emergentmd]

Congrats Op. I don't think many EM docs have any issue with Non EM docs getting high paying jobs in places that they like. It is a job that for some reason could not be filled by an EM doc and didn't have EM specialty as a requirement.

There will always be good jobs avail for Non Boarded docs because there are not enough boarded avail.

This does not change the hierarchy and there are many jobs that only boarded EM docs will be able to get.. As OP stated, he had to look outside the desired city which means he was shut out of the city. There is nothing bad about this but if you want to be competitive everywhere, you have to be boarded.

 

[Kach]

Congrats Op. I don't think many EM docs have any issue with Non EM docs getting high paying jobs in places that they like. It is a job that for some reason could not be filled by an EM doc and didn't have EM specialty as a requirement.

There will always be good jobs avail for Non Boarded docs because there are not enough boarded avail.

This does not change the hierarchy and there are many jobs that only boarded EM docs will be able to get.. As OP stated, he had to look outside the desired city which means he was shut out of the city. There is nothing bad about this but if you want to be competitive everywhere, you have to be boarded.

I wasn't shut out of my city. I will live in my desired city.

 

[Kach]

The EM people in this forum aren't going to be happy

This forum is aimed at encouraging family docs to consider EM not upsetting anyone. All due respect to our EM and various other colleagues.

 

[MedicineZ0Z]

The EM people in this forum aren't going to be happy

I don't understand this though. ABEM people are training midlevels, who are a legitimate existential threat to their profession. Just look at the Illinois case of doctors fired and replaced by NPs.
But when it comes to (an obviously well trained) FM practicing in the ED, they flip out. Mind boggling.

 

[Kach]

Well, I'm very grateful to be in a big city working 20 mins from my house and making good money. It's not easy to jump from fm to em in a nice city. I do have a complaint to the internet world...

Why is my family member who just finished mid level training a candidate to work at a level 1 trauma in any big city in America? Should I have gone to pa school after my residency instead of doing the fellowship? I hear some of you out there. I prolly should have done em residency... Or mid levels only work in the fast track (untrue)... Or, mid levels are directly monitored by attending... But still... Wtf??

 

[MedicineZ0Z]

Well, I'm very grateful to be in a big city working 20 mins from my house and making good money. It's not easy to jump from fm to em in a nice city. I do have a complaint to the internet world...

Why is my family member who just finished mid level training a candidate to work at a level 1 trauma in any big city in America? Should I have gone to pa school after my residency instead of doing the fellowship? I hear some of you out there. I prolly should have done em residency... Or mid levels only work in the fast track (untrue)... Or, mid levels are directly monitored by attending... But still... Wtf??

Midlevels are not supervised at all.
It's pretty disgusting how the EM field allows proliferation of midlevels.

And you know there are unopposed FM residencies where midlevels handle traumas and other stuff and residents have to really push to be involved?

 

[emergentmd]

Some of it is a turf battle but I think Most ERs would be glad to take on FM docs to work in the QC (some actually do) in a big city.

But most FM docs won't work for $50-75/hr doing ML stuff. Most won't take orders from the ER doc.

How many FM docs would work for $75/hr doing QC stuff, and being told to go and suture a patient b/c Im too busy to deal with it? Or have to run complicated pts by me?

 

[Kach]

Well, I dont actually believe this to be true, but based on current thought process mid levels should not be allowed to work in the ed at all.

 

[Kach]

Some of it is a turf battle but I think Most ERs would be glad to take on FM docs to work in the QC (some actually do) in a big city.

But most FM docs won't work for $50-75/hr doing ML stuff. Most won't take orders from the ER doc.

How many FM docs would work for $75/hr doing QC stuff, and being told to go and suture a patient b/c Im too busy to deal with it? Or have to run complicated pts by me?

Well come on man, the biller is billing my license at maximum amounts. Why would one take 75 bucks an hour.

And if you are in a major ed you know and I know that mid levels see plenty of high acuity patients. Frankly, they are embarassingly underpaid.

 

[MedicineZ0Z]

Some of it is a turf battle but I think Most ERs would be glad to take on FM docs to work in the QC (some actually do) in a big city.

But most FM docs won't work for $50-75/hr doing ML stuff. Most won't take orders from the ER doc.

How many FM docs would work for $75/hr doing QC stuff, and being told to go and suture a patient b/c Im too busy to deal with it? Or have to run complicated pts by me?

They also see very complex patients, then admit them to our service (after they've been mismanaged) without any attending oversight. Then that beautiful ABEM attending signature appears on their (absurdly documented encounter) chart 2 days later as if everything is okay.

 

[Kach]

They also see very complex patients, then admit them to our service (after they've been mismanaged) without any attending oversight. Then that beautiful ABEM attending signature appears on their (absurdly documented encounter) chart 2 days later as if everything is okay.

Just for sake of conversation, I've worked with amazing Med levels who actually taught me procedures. On the flip side, how on Earth are they hiring mid-levels that recently graduated from training? That is, one year of RN experience, one year of online lectures and one year of "rotations" and suddenly someone has the authority to intubate and prescribe narcs. Wtf?

I have a question for some of y'all. Could it be possible that Physicians have TOO much training? Just a thought.

 

[deleted87716]

I have a question for some of y'all. Could it be possible that Physicians have TOO much training

So, what exactly is it that you wish you didn't know?

 

[Lexdiamondz]

Midlevels are not supervised at all. @Lexdiamondz though will come in here and go on a rant about how FM shouldn't be near an ED but if you mention midlevels to him... *crickets*
It's pretty disgusting how the EM field allows proliferation of midlevels.

And you know there are unopposed FM residencies where midlevels handle traumas and other stuff and residents have to really push to be involved?

dude don't call my name in your nonsensensical drivel. If you want to work outside of your scope of practice so bad, intern then go ahead and get your @ss sued, IDGAF.

 

[VA Hopeful Dr]

So, what exactly is it that you wish you didn't know?

Almost everything I've read in this thread after the OP?

 

[MedicineZ0Z]

dude don't call my name in your nonsensensical drivel. If you want to work outside of your scope of practice so bad, intern then go ahead and get your @ss sued, IDGAF.

lol'd at scope of practice, you clearly have no clue what mine is.
And your last reply was literally on this very page of this thread, it's not a random call out. The point is continuous deflection of the real problem.

 

[Kach]

So, what exactly is it that you wish you didn't know?

Right

 

[rokshana]

Its interesting to see the contrast between how the FM Emergency medicine fellowship is perceived vs the Pediatrics emergency medicine fellowship. Right or wrong Peds EM docs have convinced the majority of children's hospitals that their fellowship trained pediatricians are the best option and that someone with just an EM residency is a 2nd best option. On the other hand it seems like even FPs buy into the idea that their fellowship is a second best option behind an EM residency.

Isn’t peds EM a 3 yr fellowship after 3 yrs of peds? That’s the length of an EM residency on top of a peds residency...it’s seems like that would be justified to say a peds EM person that is peds fellowship trained would be the better option for a pediatric ED...after all how much time is spent In the peds ED in the avg EM residency.

 

[Lexdiamondz]

Isn’t peds EM a 3 yr fellowship after 3 yrs of peds? That’s the length of an EM residency on top of a peds residency...it’s seems like that would be justified to say a peds EM person that is peds fellowship trained would be the better option for a pediatric ED...after all how much time is spent In the peds ED in the avg EM residency.

The arguments about EM v PEM from the perspective of people who trained primarily in EM revolve less around the exposure to kids and more about the management of acute illness. Peds-->PEM give you a considerable advantage in managing kids with complex PMHx, austere congenital disorders as well as atypical presentations of bread and butter peds issues. That being said, on balance EM training gives you a several-fold greater experience in resuscitation and management of the critically ill, even when compared to fellowship trained PEM docs.

My institution has both an EM residency and PEM fellowship and the majority of our PGY-2s (and virtually all of our PGY-3s) are more competent in airway management than the average PEM PGY-5

 

[Reboa]

The arguments about EM v PEM from the perspective of people who trained primarily in EM revolve less around the exposure to kids and more about the management of acute illness. Peds-->PEM give you a considerable advantage in managing kids with complex PMHx, austere congenital disorders as well as atypical presentations of bread and butter peds issues. That being said, on balance EM training gives you a several-fold greater experience in resuscitation and management of the critically ill, even when compared to fellowship trained PEM docs.

My institution has both an EM residency and PEM fellowship and the majority of our PGY-2s (and virtually all of our PGY-3s) are more competent in airway management than the average PEM PGY-5

So you’re saying EM has better training than PEM in acutely I’ll pediatric patients? Are you an attending? Just curious to where you’re coming from aside from your anecdotal experience and what’s the point of your argument?
Pretty sure anesthesia is more competent than EM and everyone else in airway management. EM is a generalist field just like FM. There is a specialist that can do everyone of the procedures you do better, but that in no way downplays the importance of EM or FM or any specialty. This turf protection bologna is getting old dude. You stated earlier you could do the 10 resuscitations that abps required in two weeks and a week of cramming. So I guess the 75 cases you need could be pumped out in 22.5 weeks at your institution. Maybe I should spend a few
aways at your institution instead of a year long fellowship. I sure hope you’re from shock trauma or one of the other amazing high volume EDs in the nation to be talking they way you have on this forum.

 

[rokshana]

Just for sake of conversation, I've worked with amazing Med levels who actually taught me procedures. On the flip side, how on Earth are they hiring mid-levels that recently graduated from training? That is, one year of RN experience, one year of online lectures and one year of "rotations" and suddenly someone has the authority to intubate and prescribe narcs. Wtf?

I have a question for some of y'all. Could it be possible that Physicians have TOO much training? Just a thought.

No...simply no...being a physician is about lifelong long learning...I am always training...

 

[rokshana]

The arguments about EM v PEM from the perspective of people who trained primarily in EM revolve less around the exposure to kids and more about the management of acute illness. Peds-->PEM give you a considerable advantage in managing kids with complex PMHx, austere congenital disorders as well as atypical presentations of bread and butter peds issues. That being said, on balance EM training gives you a several-fold greater experience in resuscitation and management of the critically ill, even when compared to fellowship trained PEM docs.

My institution has both an EM residency and PEM fellowship and the majority of our PGY-2s (and virtually all of our PGY-3s) are more competent in airway management than the average PEM PGY-5

Yeah but a 1st year nicu or picu fellow will be better at taking care of critically ill kids as well as better at doing procedures including intubations on children than any ED doctor, peds or adult...that’s not necessarily the point...it’s not that an EM trained physician can’t take care of kids, but that 3rd year fellow is going to have far more experience with kids AND have the equivalent number of years in EM training...focused on kids... the EM trained person that decides to do peds EM has spent a great deal of time learning about adults and now has to go away from that training...and learn about kids....who are totally different from adults.

 

[Splenda88]

The whole EM vs FM/EM fellowship is about turf protection...


Same thing with IM vs FM hospitalist... They might not start on the same ground on average, but after FM doc do it for a few months(6-12 months), I believe they should be as good as an IM doc... and I am saying that as an IM resident.

 

[Kach]

The whole EM vs FM/EM fellowship is about turf protection...


Same thing with IM vs FM hospitalist... They might not start on the same ground on average, but after FM doc do it for a few months(6-12 months), I believe they should be as good as an IM doc... and I am saying that as an IM resident.

Experience is key but there's also something to be said about standardization of knowledge. There are plenty of doctors out there who have plenty of practice doing the wrong thing. This is the argument for fellowship and residency training. But if one does not have that training I think these annual board reviews are an awesome source of info and updates.

 

[Lexdiamondz]

Yeah but a 1st year nicu or picu fellow will be better at taking care of critically ill kids as well as better at doing procedures including intubations on children than any ED doctor, peds or adult...that’s not necessarily the point...it’s not that an EM trained physician can’t take care of kids, but that 3rd year fellow is going to have far more experience with kids AND have the equivalent number of years in EM training...focused on kids... the EM trained person that decides to do peds EM has spent a great deal of time learning about adults and now has to go away from that training...and learn about kids....who are totally different from adults.

The issue is that kids (thankfully) don't get sick nearly as often as adults do, and undifferentiated sick kids are far rarer than undifferentiated sick adults.

The fact that EM trained docs in general are more comfortable and proficient at resuscitation that PEM docs is mostly a numbers game - we have a bigger pool of sick patients to work with so we have the opportunity to get more hands on training. ABEM requires 45 medical resuscitations for graduation whereas I know peds PGY3s who have never seen a code despite doing 6 months of PICU and NICU in residency. Doesn't mean they are bad docs by any means - just that the pathology often isn't there to make one truly comfortable managing a crashing patient.

So you’re saying EM has better training than PEM in acutely I’ll pediatric patients? Are you an attending? Just curious to where you’re coming from aside from your anecdotal experience and what’s the point of your argument?
Pretty sure anesthesia is more competent than EM and everyone else in airway management. EM is a generalist field just like FM. There is a specialist that can do everyone of the procedures you do better, but that in no way downplays the importance of EM or FM or any specialty. This turf protection bologna is getting old dude. You stated earlier you could do the 10 resuscitations that abps required in two weeks and a week of cramming. So I guess the 75 cases you need could be pumped out in 22.5 weeks at your institution. Maybe I should spend a few
aways at your institution instead of a year long fellowship. I sure hope you’re from shock trauma or one of the other amazing high volume EDs in the nation to be talking they way you have on this forum.

I'm not sure what to make of this word salad here. Literally nothing you just wrote made any sense.

 

[MedicineZ0Z]

So you’re saying EM has better training than PEM in acutely I’ll pediatric patients? Are you an attending? Just curious to where you’re coming from aside from your anecdotal experience and what’s the point of your argument?
Pretty sure anesthesia is more competent than EM and everyone else in airway management. EM is a generalist field just like FM. There is a specialist that can do everyone of the procedures you do better, but that in no way downplays the importance of EM or FM or any specialty. This turf protection bologna is getting old dude. You stated earlier you could do the 10 resuscitations that abps required in two weeks and a week of cramming. So I guess the 75 cases you need could be pumped out in 22.5 weeks at your institution. Maybe I should spend a few
aways at your institution instead of a year long fellowship. I sure hope you’re from shock trauma or one of the other amazing high volume EDs in the nation to be talking they way you have on this forum.

He thinks he's better at everything than anyone. Just a case of severe insecurity and major projection.
The whole turf battle thing gets annoying. FM + fellowship is very easily equipped for EM work and the minimal deficiencies they have vs a 3 year ABEM is compensated by having more general outpatient/inpatient knowledge. Then after some time, it balances out.

The arguments about EM v PEM from the perspective of people who trained primarily in EM revolve less around the exposure to kids and more about the management of acute illness. Peds-->PEM give you a considerable advantage in managing kids with complex PMHx, austere congenital disorders as well as atypical presentations of bread and butter peds issues. That being said, on balance EM training gives you a several-fold greater experience in resuscitation and management of the critically ill, even when compared to fellowship trained PEM docs.

My institution has both an EM residency and PEM fellowship and the majority of our PGY-2s (and virtually all of our PGY-3s) are more competent in airway management than the average PEM PGY-5

I'm curious, how did you come to this conclusion? A PEM fellowship has like 2 peds anesthesia blocks (of which most EM residencies do none of) and far more time in the PICU and Peds simlab. How exactly is your PGY2 in the month of December better equipped to intubate a 3 year old than someone who has had dedicated practice at it? And if there are PEM fellows, how many peds airways do the EM folks even get? Realistically, very little.

 

[MedicineZ0Z]

The whole EM vs FM/EM fellowship is about turf protection...


Same thing with IM vs FM hospitalist... They might not start on the same ground on average, but after FM doc do it for a few months(6-12 months), I believe they should be as good as an IM doc... and I am saying that as an IM resident.

Vast majority of FM doing hospitalist generally self-select and come from residencies with excellent inpatient training. There really shouldn't be any difference compared to an average IM grad. Mainly because we're comparing great to average. Basically, if you have really good exposure (as an FM) to high acuity pathology and complexity - that compensates for the less time spent on inpatient vs a community grad IM who mostly managed bread and butter chf/copd/pneumonia.

 

[emergentmd]

Well come on man, the biller is billing my license at maximum amounts. Why would one take 75 bucks an hour.

And if you are in a major ed you know and I know that mid levels see plenty of high acuity patients. Frankly, they are embarassingly underpaid.

This is such a liberal thing to say. I will never agree when someone says "They are underpaid" or "They are overpaid"

You are worth what someone is willing to pay you. No more, No less. There are people who have PHDs in language that gets paid 40K. There are high school drop outs working in the oil fields making 150K. There are actors who gets paid $30mil a film. There are CEOs making 50 mil/yr. There are athletes making 40 mil/yr.

They all make what they are worth, what the market bears regardless of how hard they work.

In the ER, its a business and we all try to make money. If I have an shift that can be staffed by a Midlevel, then my choices are

1. Midlevel for 100K/yr
2. ER doc for 400K/yr

Everyone would want an ER doc and make our lives easier with less supervision and better care. But no matter what we want, the laws of economics and supply/demand always wins out.

Why would a FM doc take 75/hr? Of course they won't and that is why they will never work in most urban ERs and this will become extinct when more boarded EM docs get minted.

Why in the world would I want to hire a FM doc to work in the ER, pay them 400K? I might as well hire a boarded ER doc.

 

[Lexdiamondz]

I'm curious, how did you come to this conclusion? A PEM fellowship has like 2 peds anesthesia blocks (of which most EM residencies do none of) and far more time in the PICU and Peds simlab. How exactly is your PGY2 in the month of December better equipped to intubate a 3 year old than someone who has had dedicated practice at it? And if there are PEM fellows, how many peds airways do the EM folks even get? Realistically, very little.

Our PGY2s primarily work alone overnight with an attending directly so they don't really compete with fellows for procedures since they rarely work with them. Furthermore our institution has a "your patient your procedure" policy for EM residents - a fellow cant take your airway from you. Additionally, peds anesthesia is built into our anesthesia block.

Tubing in the OR is not the same as in the ER. On the adult side our residents tube upper GI bleeders, post-traumatic arrests with head and facial trauma, ARDS patients in septic shock and obese no-neck butterballs with relative frequency - they know their drugs and their airway adjuncts when **** hits the fan. Even if you don't intubate kids that frequently (and truthfully really don't want to) your familiarity with the anatomy in question, the tools and the drugs mean you have more useful translatable skills.

 

[emergentmd]

I don't understand this though. ABEM people are training midlevels, who are a legitimate existential threat to their profession. Just look at the Illinois case of doctors fired and replaced by NPs.
But when it comes to (an obviously well trained) FM practicing in the ED, they flip out. Mind boggling.

Just look at the money. That is all anyone cares about, quality of care being a distant 2nd.

Why would any ER doc want to have a FM doc taking their high paying jobs? We deal with Midlevels because we can pay them 100K/yr and then pocket the 300K in profit. If a FM doc would work for 150K/yr, I am sure most ERs would love to pay the extra 50K for less supervision and increased quality but this would be impossible to find.

 

[Kach]

Just look at the money. That is all anyone cares about, quality of care being a distant 2nd.

Why would any ER doc want to have a FM doc taking their high paying jobs? We deal with Midlevels because we can pay them 100K/yr and then pocket the 300K in profit. If a FM doc would work for 150K/yr, I am sure most ERs would love to pay the extra 50K for less supervision and increased quality but this would be impossible to find.

Sounds like you hit it on the head.

 

[emergentmd]

There are two hurdles that non Boarded EM docs will always have with both being increasing higher and will get to the point where nonboarded EM docs will be completely shut out of most if not all ERs

1. Economics and supply - More EM docs are coming out and the increased volume will just be staffed with Midlevels. Even those BFE sites will eventually get staffed by the increased supply of EM docs.

2. Liability - No one cares if a FM doc is clinically as good or even better than the avg EM doc. I have been in MEC long enough to say that most docs are already Prejudge depending on their Board status. If you are boarded in EM (Or any speciality), you get the ultimate leeway. Bad outcome for EM doc= "That was just a hard intubation, pt was 300 lbs". "He's a good doc and discharging the pt is something many of us would do"
Bad outcome for FM doc (assuming they did the same evaluation = "Why is an FM doc intubating? Show me his procedure log. Why didn't he call anesthesiology?". "Why didn't he admit he pt? Look at Lab A/B/C - that is a no brainer"


I know it is hard to hear, but if you want full access to EM jobs, do a residency regardless of how good you clinically are. Its like a dating App, no one is going to give you a chance unless you look good on paper.

 

[MedicineZ0Z]

Just look at the money. That is all anyone cares about, quality of care being a distant 2nd.

Why would any ER doc want to have a FM doc taking their high paying jobs? We deal with Midlevels because we can pay them 100K/yr and then pocket the 300K in profit. If a FM doc would work for 150K/yr, I am sure most ERs would love to pay the extra 50K for less supervision and increased quality but this would be impossible to find.

It's a self destructing trajectory though. You're ultimately training midlevels to replace you. Especially with these midlevel "residencies" that are slowly popping up. Short term financial gain for long term destruction.

There are two hurdles that non Boarded EM docs will always have with both being increasing higher and will get to the point where nonboarded EM docs will be completely shut out of most if not all ERs

1. Economics and supply - More EM docs are coming out and the increased volume will just be staffed with Midlevels. Even those BFE sites will eventually get staffed by the increased supply of EM docs.

2. Liability - No one cares if a FM doc is clinically as good or even better than the avg EM doc. I have been in MEC long enough to say that most docs are already Prejudge depending on their Board status. If you are boarded in EM (Or any speciality), you get the ultimate leeway. Bad outcome for EM doc= "That was just a hard intubation, pt was 300 lbs". "He's a good doc and discharging the pt is something many of us would do"
Bad outcome for FM doc (assuming they did the same evaluation = "Why is an FM doc intubating? Show me his procedure log. Why didn't he call anesthesiology?". "Why didn't he admit he pt? Look at Lab A/B/C - that is a no brainer"


I know it is hard to hear, but if you want full access to EM jobs, do a residency regardless of how good you clinically are. Its like a dating App, no one is going to give you a chance unless you look good on paper.

Your first point is true.
Your second point, sort of. At least from a medmal standpoint. You won't simply lose a lawsuit because someone thinks you weren't qualified to do something that ended up being extremely challenging. It all comes down to what a reasonable physician would have done in that scenario. To your point though, how does a flight nurse stand in court then given that their only airway experience is maybe a few OR human intubations? Or the midlevel doing it in the ICU? Or RTs doing it? Or paramedics?
And same thing for the poor medical decision making. The midlevel sends home someone who dies. Who is responsible? Oh right, I forgot there's a thread in the EM forum with attendings who are in current lawsuits over their midlevels malpractice because they signed the charts. Oops.

 

[emergentmd]

It's a self destructing trajectory though. You're ultimately training midlevels to replace you. Especially with these midlevel "residencies" that are slowly popping up. Short term financial gain for long term destruction.


Your first point is true.
Your second point, sort of. At least from a medmal standpoint. You won't simply lose a lawsuit because someone thinks you weren't qualified to do something that ended up being extremely challenging. It all comes down to what a reasonable physician would have done in that scenario. To your point though, how does a flight nurse stand in court then given that their only airway experience is maybe a few OR human intubations? Or the midlevel doing it in the ICU? Or RTs doing it? Or paramedics?
And same thing for the poor medical decision making. The midlevel sends home someone who dies. Who is responsible? Oh right, I forgot there's a thread in the EM forum with attendings who are in current lawsuits over their midlevels malpractice because they signed the charts. Oops.

Where did I say anything about lawsuits? I can care less if an FM doc gets sued in the ER. If they screwed up and get sued b/c they didn't have knowledge then they bear the brunt.

I am just telling you what realistically happens in MEC and QA. We review bad outcomes all the time. If you are board certified, even if you just got out of residency, they rubber stamp outcomes that are gray. If you are not Board certified, someone in the room will bring this up and your case will be reviewed with a fine tooth comb. Thats life.

I send a PE home with good justification, it gets rubber stamped.

Its all about money and everyone knows it. FM/IM wants to work in the ER b/c it pays more per hour. If FM paid $400/hr, I would probably open up an FM practice somewhere and take increased risk/liability. If EM paid $125/hr, this thread would not exist.

FM sends a PE home with good justification, chart gets thoroughly reviewed by me and you now officially have a target on your back.

That is one of the perils of working outside of your field.

 

[SLC]

I send a PE home with good justification, it gets rubber stamped...

FM sends a PE home with good justification, chart gets thoroughly reviewed by me and you now officially have a target on your back.

That is one of the perils of working outside of your field.

And this hypocrisy doesn’t bother you?

 

[MedicineZ0Z]

And this hypocrisy doesn’t bother you?

I have to actually see a legitimate source for the claim made in that post. Haven't heard of this from medmal friends so I'm very skeptical.

 

[SLC]

I have to actually see a legitimate source for the claim made in that post. Haven't heard of this from medmal friends so I'm very skeptical.

I think he’s talking about internal review, not malpractice. Though to be fair, at my institution, no one doctor gets something “rubber-stamped“ just because they have a board certification in a field, while another doctor gets a “target” placed on his/her back for doing the exact same thing.

 

[Lexdiamondz]

And this hypocrisy doesn’t bother you?

Not really. We face the same hypocrisy in relation to management of things on the periphery of our scope of practice as well. Even if you're a good doctor, if you do something that you were not explicitly trained for and a bad outcome comes of it there will always be a question of whether that bad outcome is a result of lack of training. This is true for all fields, not just FM docs in the ED.


Bottom line, if you've gotten the training (residency) and passed the test (board certification) it's much harder for people to argue that you straight up didn't know what you were doing, especially if the data isn't 100% clear what happened.