New EM fellowship program in Denver suburbs

[alpinism]

Guess which CMG decided to start a EM fellowship program to help solve their staffing problems.

Emergency Medicine Fellowship | CommonSpirit Health

www.centura.org

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[JacobMcCandles]

I hope the fellowship is 365 days of one lecture a day telling the FM fellow that if they want to practice EM then they should have gone into an EM residency.

 

[bravotwozero]

I think most FM docs would be less inclined to work EM these days

 

[Birdstrike]

EM always should have been a fellowship of IM, FM and Peds. That way you could work EM for a few years, a rational few years, then retreat back to the sanity of a normal life and a normal schedule. It never should have been, “Born for EM. EM for life.”

They made it a residency by design. The intent was for the practitioners of EM to be trapped, with a tremendously high barrier to exit.

Burnout is rampant. They have the best people, trapped in the worst system.

Their plan worked as designed.

 

[GonnaBeADoc2222]

EM always should have been a fellowship of IM, FM and Peds. That way you could work EM for a few years, a rational few years, then retreat back to the sanity of a normal life and a normal schedule. It never should have been, “Born for EM. EM for life.”

They made it a residency by design. The intent was for the practitioners of EM to be trapped, with a tremendously high barrier to exit.

They now have a generation of burned out, disillusioned and emotionally exhausted soldiers feeling they need to leave, but don’t see a pathway, or have the energy if they did. They have the best people, trapped in the worst system.

Their plan worked as designed.

Sounds pretty conspiratorial.

There's nothing wrong with EM training as is, except for existence of 4 yr programs.

Ask your avg general pediatrician how they like making 150k/yr.

This forum not only selects for the most burnt out, but also the biggest positive skew in compensation .

 

[Birdstrike]

Sounds pretty conspiratorial.

There's nothing wrong with EM training as is, except for existence of 4 yr programs.

Ask your avg general pediatrician how they like making 150k/yr.

This forum not only selects for the most burnt out, but also the biggest positive skew in compensation .

 

[EctopicFetus]

Guess which CMG decided to start a EM fellowship program to help solve their staffing problems.

Emergency Medicine Fellowship | CommonSpirit Health

www.centura.org

USUCS For the win..

 

[Lexdiamondz]

- No actual published curriculum
- 32 hour weeks (I worked 60 as an intern)
- No confirmed trauma experience
- No confirmed ICU experience
- Rural rotation "if the schedule allows" despite this "fellowship" being advertised as giving FM docs the ability to provide care to rural communities

WTF is this farce.

 

[JacobMcCandles]

Any training for rural EM should have a “how to transfer a patient when every hospital within 200 miles has no staffed open beds” rotation.

 

[EctopicFetus]

- No actual published curriculum
- 32 hour weeks (I worked 60 as an intern)
- No confirmed trauma experience
- No confirmed ICU experience
- Rural rotation "if the schedule allows" despite this "fellowship" being advertised as giving FM docs the ability to provide care to rural communities

WTF is this farce.

USUCS trying to get some free labor.. pay the fellow crap money, profit off of them, stick them out in the sticks of Colorado.

 

[Fox800]

"We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities enabling our system to provide lower-quality patient care by hiring unqualified physicians to work in our emergency departments so we can increase profits."

 

[Birdstrike]

EM always should have been a fellowship of IM, FM and Peds. That way you could work EM for a few years, a rational few years, then retreat back to the sanity of a normal life and a normal schedule. It never should have been, “Born for EM. EM for life.”

They made it a residency by design. The intent was for the practitioners of EM to be trapped, with a tremendously high barrier to exit.

Burnout is rampant. They have the best people, trapped in the worst system.

Their plan worked as designed.

To those that "disliked" this post, I'm curious as the what you dislike about it, specifically. Explain what about it you disagree with.

 

[Mount Asclepius]

To those that "disliked" this post, I'm curious as the what you dislike about it, specifically. Explain what about it you disagree with.

I didn’t dislike your post, and am intrigued by your first part even if I’m not sure if I agree.

I do think though that perhaps you slightly forget the history of the founding of the specialty. EM had to fight to exist as a specialty by convincing other specialties that it took special training to be able to handle emergencies from every other specialty. It wasn’t that other specialties tried to trap us in EM. That was an unforeseen side effect.

 

[Birdstrike]

I didn’t dislike your post, and am intrigued by your first part even if I’m not sure if I agree.

I do think though that perhaps you slightly forget the history of the founding of the specialty. EM had to fight to exist as a specialty by convincing other specialties that it took special training to be able to handle emergencies from every other specialty. It wasn’t that other specialties tried to trap us in EM. That was an unforeseen side effect.

I haven't forgotten that history of the founding of the specialty. That's what we're all taught about the founding of EM. I believe that "founding story" to be true. But I think that's only part of the story, and there's part if the origin story of EM, that they didn't teach you, or me. I don't think other specialties tried to "trap us into EM." I think EM tried to trap us in EM. The founders of EM, knew that an easy entry/easy exit EM, wouldn't achieve the stated goal.

Imagine if one could easily joint the military, and could just as easily get out. As soon as the first bombs go off, the first bullet whizzes by your head and you realize what you've gotten yourself into, you can just as easy sign out, as you can sign in. Imagine that. But they didn't design it that way. They design it, so soldiers were trapped. Stay and fight, risk getting shot or blown up, or get courtmartialed and go to jail for desertion.

Much like an easy entry/easy exit military doesn't work. Neither does an easy entry/easy exit, EM.

65% of Emergency Physicians report burnout.

Now again, envision two alternate EM universes, one where those 65% can easily leave to a parallel career and specialty, and one where they can't. Which one would you design?

 

[GonnaBeADoc2222]

I haven't forgotten that history of the founding of the specialty. That's what we're all taught about the founding of EM. I believe that "founding story" to be true. But I think that's only part of the story, and there's part if the origin story of EM, that they didn't teach you, or me. I don't think other specialties tried to "trap us into EM." I think EM tried to trap us in EM. The founders of EM, knew that an easy entry/easy exit EM, wouldn't achieve the stated goal.

Imagine if one could easily joint the military, and could just as easily get out. As soon as the first bombs go off, the first bullet whizzes by your head and you realize what you've gotten yourself into, you can just as easy sign out, as you can sign in. Imagine that. But they didn't design it that way. They design it, so soldiers were trapped. Stay and fight, risk getting shot or blown up, or get courtmartialed and go to jail for desertion.

Much like an easy entry/easy exit military doesn't work. Neither does an easy entry/easy exit, EM.

65% of Emergency Physicians report burnout.

Now again, envision two alternate EM universes, one where those 65% can easily leave to a parallel career and specialty, and one where they can't. Which one would you design?

Yah judy tintinalli and peter rosen conspired to trap a bunch of ms4s in the ER....forever!!!!

 

[Birdstrike]

Yah judy tintinalli and peter rosen conspired to trap a bunch of ms4s in the ER....forever!!!!

They either conspired to trap of bunch of MS4s into the ER forever, or they did a fabulous job of doing it by accident (in my opinion). Take your pick. I'll give credit, for either answer.

By the way, do you know what Rosen did to ER docs for a living, his last few years?

 

[Siggy]

I didn’t dislike your post, and am intrigued by your first part even if I’m not sure if I agree.

I do think though that perhaps you slightly forget the history of the founding of the specialty. EM had to fight to exist as a specialty by convincing other specialties that it took special training to be able to handle emergencies from every other specialty. It wasn’t that other specialties tried to trap us in EM. That was an unforeseen side effect.

The fellowship idea is intriguing though. I think the problem is the peds aspect for non-FM fellowships. That extra knowledge requiring special training from every other specialty is exactly what a fellowship should accomplish. Non-tertiary centers, for example, are going to have an intensivist handle all of critical care. I'm the CV intensivist, OB intensivist, neuro intensivist, medical intensivist, and surgical intensivist at my hospital since we don't have the patient volume for a specific intensivist for each specialty. It doesn't matter whether your IM-CCM, surgical CCM, EM-CCM, or anesthesiology-CCM, you're getting the 22 bed ICU with what ever mix of patients is there.

 

[TooMuchResearch]

Yah judy tintinalli and peter rosen conspired to trap a bunch of ms4s in the ER....forever!!!!

Classic Judy and Pete.

 

[Make Or Break]

The issue is rural ERs are understaffed and always needing help. I don’t know how else to put it but that’s the issue. Non boarded EM can’t work at a level 1. Until you all start moving into the rural ERs and out of the bigger cities this problem will exist. And if it’s not a physician staffing then it’s an unsupervised midlevel.

 

[deuist]

In EM's infancy, IM was trying to create its own EM subspecialty. EM only became a separaye specialty when Tintinalli agreed to drop EM's pursuit of CCM. IM then agreed to recognize EM as a separate field. As someone mentioned in another thread, I do think that EM should be a fellowship after IM or FM. We already require pediatricians to go through fellowship to become pediatric emergency physicians.

 

[EctopicFetus]

The issue is rural ERs are understaffed and always needing help. I don’t know how else to put it but that’s the issue. Non boarded EM can’t work at a level 1. Until you all start moving into the rural ERs and out of the bigger cities this problem will exist. And if it’s not a physician staffing then it’s an unsupervised midlevel.

Maybe im a mean person. who cares. Without a cardiologist they cant do caths. Open an urgent care. reality is these crappy little worthless places cant take care of much, the quality of docs is often atrocious and this is done for $$. There are lots of greta things living in rural places. But they dont "deserve" a real EM doc and they dont "deserve" an ED unless they are willing to pay real rates plus some to get people to go out there.

They dont have cards, ortho, hem onc etc. Thats a CHOICE thats made. I have literally 0 pity. And before people go crazy, I have worked rural. Some of that very recent. I have worked at places where they see 9 patients per day, I have worked at rural places seeing 20-30 a day.

The one seeing 9 a day was a legit 90 mins from a real hospital. There were some other similarly useless EDs about 30-45 mins away.

 

[Arcan57]

I guess I'm kinda confused at this new groupthink that EM should be a fellowship (especially having worked with docs that have done FM->EM fellowship) off of another specialty. This is the forum that pretty unanimously agrees that a 4th yr of EM is a completely unacceptable loss of income and now the argument is to make EM 5 yrs of training? Are we pretending that it's not the need to maintain our income that keeps us working jobs that have become increasingly suboptimal? Are we imagining that training 8-10 years ago which hasn't been used since makes us a viable alternative for the "good" hospitalist/clinic jobs? Or is the fantasy that the high paying procedural specialties (GI, interventional cards, etc) will start snapping us up for a 2nd fellowship after we've burned out?

EM has escape hatches, including going back and training in another specialty. The reason they're not utilized more has a lot less to do the structure of our initial training and a lot more to do with not being willing to take the paycut or to increase the number of hours we work.

 

[GonnaBeADoc2222]

I guess I'm kinda confused at this new groupthink that EM should be a fellowship (especially having worked with docs that have done FM->EM fellowship) off of another specialty. This is the forum that pretty unanimously agrees that a 4th yr of EM is a completely unacceptable loss of income and now the argument is to make EM 5 yrs of training? Are we pretending that it's not the need to maintain our income that keeps us working jobs that have become increasingly suboptimal? Are we imagining that training 8-10 years ago which hasn't been used since makes us a viable alternative for the "good" hospitalist/clinic jobs? Or is the fantasy that the high paying procedural specialties (GI, interventional cards, etc) will start snapping us up for a 2nd fellowship after we've burned out?

EM has escape hatches, including going back and training in another specialty. The reason they're not utilized more has a lot less to do the structure of our initial training and a lot more to do with not being willing to take the paycut or to increase the number of hours we work.

It's a result of the pervasive victim mindset here of "EM terrible, everything else great, I was tricked blah blah" instead of just getting in, getting out and getting paid.

 

[JacobMcCandles]

If anything, maybe internal medicine and family medicine should be a fellowship of EM so people get good emergency training and can actually see what does/does not need to be referred to the ED.

 

[EctopicFetus]

Fwiw I don’t support the idea of an em fellowship. I will say that the crappier the main em training sites are the more feasible a fellowship would be.

 

[Brigade4Radiant]

4 years ago when IM or FM was asking to work in The ED was only through a residency now the tables have turned

If I was another specialty I don’t see why I would open my doors to EM

 

[TooMuchResearch]

Maybe im a mean person. who cares. Without a cardiologist they cant do caths. Open an urgent care. reality is these crappy little worthless places cant take care of much, the quality of docs is often atrocious and this is done for $$. There are lots of greta things living in rural places. But they dont "deserve" a real EM doc and they dont "deserve" an ED unless they are willing to pay real rates plus some to get people to go out there.

They dont have cards, ortho, hem onc etc. Thats a CHOICE thats made. I have literally 0 pity. And before people go crazy, I have worked rural. Some of that very recent. I have worked at places where they see 9 patients per day, I have worked at rural places seeing 20-30 a day.

The one seeing 9 a day was a legit 90 mins from a real hospital. There were some other similarly useless EDs about 30-45 mins away.

I work at rural hospitals that have ortho and heme/onc. They have cardiology or telecardiology but don't do caths (but I know places in the suburbs that don't have interventional cards or radiology).

Maybe what I've seen/worked in terms of rural is not what you've seen/worked.

 

[Make Or Break]

Maybe im a mean person. who cares. Without a cardiologist they cant do caths. Open an urgent care. reality is these crappy little worthless places cant take care of much, the quality of docs is often atrocious and this is done for $$. There are lots of greta things living in rural places. But they dont "deserve" a real EM doc and they dont "deserve" an ED unless they are willing to pay real rates plus some to get people to go out there.

They dont have cards, ortho, hem onc etc. Thats a CHOICE thats made. I have literally 0 pity. And before people go crazy, I have worked rural. Some of that very recent. I have worked at places where they see 9 patients per day, I have worked at rural places seeing 20-30 a day.

The one seeing 9 a day was a legit 90 mins from a real hospital. There were some other similarly useless EDs about 30-45 mins away.

I think there’s a clear lack of understanding on your part regarding the economics of rural care. I don’t say this because I do EM too. Honestly if more EM came to rural America I would happily leave. You can’t just hire a cardiologist on staff to do 2-3 caths a week or hire an ortho to do 1-2 hips a week. That economically doesn’t make any sense for the hospital to keep up with supplies, medications, paying the physician. You don’t have the volume to support an endeavor like that. I also don’t think any Dr. Should get big city EM pay seeing 10-20 pts in a 24 hour period. Is that what you are suggesting? What these places serve to do is stabilize those who are too sick to come and keep those who can get care managed at these smaller places in the area to avoid overwhelming the cities. Your post has a handful of counter points I can make but it’s just too long to spell out. I think it’s heartless for you to say they don’t “deserve” an ED. The drive for an hr and a half to a bigger city isn’t feasible for some to just show up. No ambulance is able to drive that distance for every patient either to take them to a bigger city hospital. Again I can go on and on about the logistics and economy of rural medicine and your suggestions will kill people.

 

[EctopicFetus]

I work at rural hospitals that have ortho and heme/onc. They have cardiology or telecardiology but don't do caths (but I know places in the suburbs that don't have interventional cards or radiology).

Maybe what I've seen/worked in terms of rural is not what you've seen/worked.

Seen a mix. I’m talking low resource rural.

 

[EctopicFetus]

I think there’s a clear lack of understanding on your part regarding the economics of rural care. I don’t say this because I do EM too. Honestly if more EM came to rural America I would happily leave. You can’t just hire a cardiologist on staff to do 2-3 caths a week or hire an ortho to do 1-2 hips a week. That economically doesn’t make any sense for the hospital to keep up with supplies, medications, paying the physician. You don’t have the volume to support an endeavor like that. I also don’t think any Dr. Should get big city EM pay seeing 10-20 pts in a 24 hour period. Is that what you are suggesting? What these places serve to do is stabilize those who are too sick to come and keep those who can get care managed at these smaller places in the area to avoid overwhelming the cities. Your post has a handful of counter points I can make but it’s just too long to spell out. I think it’s heartless for you to say they don’t “deserve” an ED. The drive for an hr and a half to a bigger city isn’t feasible for some to just show up. No ambulance is able to drive that distance for every patient either to take them to a bigger city hospital. Again I can go on and on about the logistics and economy of rural medicine and your suggestions will kill people.

The care people receive is killing them also.

My point is have a 24 hour urgent care. They mislabel their departments. If it’s staffed by a non em doc in my world it’s not an Ed. You can’t financially run an 8 visit a day rural Ed profitably either. Yet here we are with a bunch of low value sites.

A counter to you. We don’t have enough physicians in America. Does it make sense to waste 1-2 docs a day to see 10 patients in 24 hours?

This is a complete waste of resources and money.

Yes there may be a hospital that exists somewhere that you mentioned as a semi extreme example. Many of these low volume Ed’s (not fseds) are within 45 mins of another hospital. It’s a waste of physician, nursing and tech labor to staff them to do almost nothing every day.

I know my opinion is not popular. It’s ok. I stand by it.

I think many of the rural places needs to close. I also think hospitals shouldn’t be able to bill ED visits if there isn’t an em trained doc there.

My 2 cents. Happy to dive deeper.

People have worse outcomes when they don’t get a cath quickly. Plenty of locations in America can’t make that happen. People again have the benefits of living rural, it comes with a cost as well.

 

[JacobMcCandles]

People again have the benefits of living rural, it comes with a cost as well.

I think that’s the big takeaway. There are always trade offs. There are trade offs moving to an urban location and trade offs living in a rural location. There are trade offs going to space and trade offs going to Antarctica. It seems like rural EDs getting closed for a day or two at a time is a common thing in Canada and then you see the docs and nurses making tweets with all kinds of hashtags and whatnot. The bottom line is that rural healthcare at a high level just isn’t feasible. It isn’t feasible from a human capital or financial standpoint. That’s the trade off with living in a rural area.

 

[EctopicFetus]

I think that’s the big takeaway. There are always trade offs. There are trade offs moving to an urban location and trade offs living in a rural location. There are trade offs going to space and trade offs going to Antarctica. It seems like rural EDs getting closed for a day or two at a time is a common thing in Canada and then you see the docs and nurses making tweets with all kinds of hashtags and whatnot. The bottom line is that rural healthcare at a high level just isn’t feasible. It isn’t feasible from a human capital or financial standpoint. That’s the trade off with living in a rural area.

Agreed. I have and still do work rural. Politically it’s super unpopular to close rural hospitals. From a public health perspective and financially these things are crazy to have in many locations. From experience many of these sites are Medicaid (terrible payer mix), medicare (moderate) and self pay make up an insanely high percentage of the ED volume and the population as a whole.

Thats reality. In general getting your “ED“ care from an IM doc or an FP doc is substandard. For most patients sure, it doesnt matter, but the IM doc cant do peds and generally are terrible at ortho. Many IM residents do very little ob/gyn. The FP doc (for the most part) is ill equipped in managing critically ill patients, also many dont do much in the way of ortho. Many are weak with basic critical procedures. Intubations? neither of these specialties learn much in the way of airway management. I could go on….

On top of that throw in “rust” these patients generally dont present with any frequency at these sites so they lack any experience to go on top of their lack of knowledge in managing these patients. Those are but the few examples that come to the top of my mind.

 

[alpinism]

Agreed. I have and still do work rural. Politically it’s super unpopular to close rural hospitals. From a public health perspective and financially these things are crazy to have in many locations. From experience many of these sites are Medicaid (terrible payer mix), medicare (moderate) and self pay make up an insanely high percentage of the ED volume and the population as a whole.

Thats reality. In general getting your “ED“ care from an IM doc or an FP doc is substandard. For most patients sure, it doesnt matter, but the IM doc cant do peds and generally are terrible at ortho. Many IM residents do very little ob/gyn. The FP doc (for the most part) is ill equipped in managing critically ill patients, also many dont do much in the way of ortho. Many are weak with basic critical procedures. Intubations? neither of these specialties learn much in the way of airway management. I could go on….

On top of that throw in “rust” these patients generally dont present with any frequency at these sites so they lack any experience to go on top of their lack of knowledge in managing these patients. Those are but the few examples that come to the top of my mind.

Completely agree.

I know its an unpopular opinion but more I work at rural sites the more I've come to realize that most are a giant waste of money.

There's plenty of research papers that show that on average your typical hospital with 5K visits has 10% admits and 1% ICU admits.

Do the math and thats about 50-100 actual life threatening emergencies per year at most and realistically speaking most of these cases would survive the car ride to be seen at the closest regional hospital. So in reality maybe 5-10 of these per year at most are benefiting from the hospital choosing to operate an "emergency department." It's completely insane to spend millions a month on a 24/7 ED with ED trained RNs and MDs that will on average benefit about one patient a month with actual life threatening emergencies.

Let's be honest the reason CAHs have EDs is due to current government regulations.

 

[EctopicFetus]

Completely agree.

I know its an unpopular opinion but more I work at rural sites the more I've come to realize that most are a giant waste of money.

There's plenty of research papers that show that on average your typical hospital with 5K visits has 10% admits and 1% ICU admits.

Do the math and thats about 50-100 actual life threatening emergencies per year at most and realistically speaking most of these cases would survive the car ride to be seen at the closest regional hospital. So in reality maybe 5-10 of these per year at most are benefiting from the hospital choosing to operate an "emergency department." It's completely insane to spend millions a month on a 24/7 ED with ED trained RNs and MDs that will on average benefit about one patient a month with actual life threatening emergencies.

Let's be honest the reason CAHs have EDs is due to current government regulations.

On top of that imagine all the prevention that could occur if those FP/IM docs instead of their 60 -12s (I know many are working 24s) shifts saw 20 patients in a clinic instead. 1200 outpt visits, how much prevention can be done? how many of those patients might not have needed to come to the ED at all?

Its completely insane that we WASTE such limited resources on such a stupid idea. i would suggest if there isnt an ED within 90 -120 mins driving then maybe it makes sense. Many of these CAHs arent that. It would be cheaper and better to pay for HEMS (which I also hate BTW) and they can fly people around to a real hospital in lieu of an actual physician. Yes weather.. i know.. such is life..

 

[TooMuchResearch]

Seen a mix. I’m talking low resource rural.

Oh, I've not worked one of those and likely wouldn't.

 

[EctopicFetus]

Oh, I've not worked one of those and likely wouldn't.

I’m about that $$. Want to pay me good $$$ to do nothing im in.. i aint doing squat for free… f alll that