Practicing Emergency Med as an FP...

DrOctagon said:

I've decided on EM as a career and will be applying to programs in a few months, but after a recent FM conference, speaking with a FM doc opened up a few questions.

He brought up some interesting points about becoming a FM doc and practicing EM. FM docs can practice EM in the ED and when they feel as to though the career is too stressful for their age they can resort to FM which is clearly less strenuous. He had mentioned that the only drawback was that if you are an EM doc they only thing you can do to lower the stress is cut your shifts down.
Since the ED pays an hourly rate, I would be getting paid as an "EM doc" also.

He said the only catch is that you would not be able to be a director without the EM certification.. of course.

I'm still thinking about applying to EM, But based on what he says, if there is no problem in finding a spot working in the ED as a FM doc, then why wouldnt it be nice to just have that ability to fall back on practicing as a FM doc when the shift work gets too stressful? Plus.. you got a pick of the residencies and could prob end up in the location of your liking a lot easier..

I've heard EM docs say dont do it! but why..?

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Because FPs are not trained in emergency medicine adequately enough to perform as full time emergency physicians.

I wasn't going to touch this as those who know me IRL think I have an "anti-FP" bias. I do, but it comes as the result of attending a medical school where FP was "forced" on each student, and the political agenda of the AAFP ran rampant. I was often told not to go into EM but rather FP. When I started school those giving this counsel said they were certain the "practice pathway" would be reopened. When that lawsuit (finally) settled, they advised an FP EM fellowship. To quote Col. Potter - "HORSEPUCKY!"

There is no "EM Certification" for FPs that is accepted by the ABEM. While the AAFP does offer fellowships in EM, these do not lead to board certification by ABEM. There is currently no pathway, other than an EM residency, to become board certified in EM.

Does board certification matter? Yes and no. Certainly there are academic papers that suggest the residency trained EP is less likely to be sued than the non-EM residency trained EP. And this has been noticed by med-mal carriers. Many have begun refusing to cover non BE/BC EPs. But, for now, the demand for BE/BC EPs is greater than the supply. So yes, you can find work as an FP in smaller community facilities. It would be nearly unheard of now for an FP to be hired into academic or tertiary centers (but some tenured physicians might still remain).

What you should realize is that this career path (an FP practicing EM) might be severely limited. First, should you be sued and lose, or even have the appearance of liability, it is doubtful your med-mal carrier will allow to continue to practice EM (of course, for an FP the same is true of OB). Even if you don't suffer a suit, at any time, the hospital you are affiliated with can switch EM groups. These buy-outs are not infrequent, and it is unlikely FPs would be kept on. Lastly, it is not only your med-mal carrier, but that of the hospital where you work that might "squeeze" you out. For example, where I trained one of the hospitals is "home" to the FP residency. Their level-II trauma canter, 40K visit ED was staffed with a mix of FPs and EM-trained EPs. The residents also rotated through. After an unsuccessful lawsuit, the hospital's med-mal carrier threatened to drop coverage if the ED was not converted to all BE/BC EPs. An EM corporate group was in place within a month. All of the residency trained EPs were kept, and all of the FPs were let go. Some had 10+ years in the department and were quite skilled. When I left, the hospital was still negoiating to allow the FP residents to continue their EM rotations.

Basically, you should realize that EM is a specialty, just like surgery, cardiology, rheumatology, etc. And while an FP knows something of the conditions we evaluate and treat, their methodology and focus are completely different from ours. And, given the AAFP "practice pathway" lawsuit, and the sideline view of the onoing struggles between OB and FP, it is unlikely that FPs will find a wellspring of support for maintaining a presence in EM.

Lastly, if you practice EM for 20 years and want to "slow down" to an office FP practice, you will be so out of touch with the current guidelines on long term patient management that you will not be able to function well. There is a reason that FP and IM are different residencies than EM. An EP is not prepared to do EM or IM as a profession. After practicing EM for a career (certified or not) you will not be ready to resume an office practice in FP. Besides, many (if not most) EPs practice long and fufilling careers all the way to retirement.

Bottom line, if you want to do EM, do EM.

Just my $0.02 worth (actual cash value $0.005)

- H

I'll chime in as welll since I come from a school that is VERY Anti-EM and very Pro-FP and 'just work in an emergency department'...unfortunately my classmates and several current FP residents fall for it. I have caught more crap over the past two years for applying to EM, however, I am certain I will get the last laugh....


As mentioned above, if you work in the ED as an FP boarded guy, you will not remember how to address long term patient care after 20 years in the ED (EM doctors do not adjust insulin, change beta blocker doses, and talk to gramps about a new med for his erectile problems). Also (someone else correct me if I am wrong) but I understand that an EM boarded person usually cuts a higher wage than the non-EM people.

Sue rates have already been shown to be less for EM boarded people (post above mentioned there are studies on this); its just a matter of time that insurance for a non-EM boarded person becomes insanely high, thus prohibitive to working in the ED.


The EM vs FP thing is the SAME thing you saw 10-20 years ago about OB/GYN vs FP. FP has pretty much been pushed out of the baby delivery world...sure there are opportunties in super podunkville, but it would be plain ignorant to go into FP to be an OB/GYN. The EM/FP thing will be the same way in a 'matter of time'....how long, who exactly knows...but we are putting out just over 1000 new EM board certified doctors every year, so it will be sooner than you think. Flip through the back of any EM journal, any large or desirable place to live will say EM BC/BE only.



I almost fell for the FP thing and am certainly glad I saw the light. I will be better at what I want to do (I WANT to work in an ED, if I get burnt out, Id rather go fishing...not resort to clinic...yuck!) and will be much more employable. Lastly, there have also been studies that show that a boarded EM doctor has THE SAME burn out rate as comparable specialties. That old rumor that 'er doctors burn out' comes from the old IM/FP/Surgeon that burnt out of their field, instead of sacking groceries (what else can you really do with an MD degree?), were able to pick up shifts in the ED. Of course the burnout was higher when you had doctors that burned out once already...


I keep thinking of additional things to add. I had a conversation once with an FP about the FP getting beat out of OB/GYN, EM, simple Surgical procedures (chole, hernias, etc) and Gastro/Scopes. As this person mentioned to me, the FP doctor fights HARD to save these because it hurts their field where they feel it most...in the pocket! How can the FP make more money: one afternoon of clinic or one Csection/vag delivery/chole/GI Scope....and usually an FP can make more money working in the ED than in a clinic day. Obviously anyone wants to lookout for the monetary interest of their speciality....

Good luck....

DrOctagon said:

I've heard EM docs say dont do it! but why..?

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I'll be another voice saying to choose.

Imagine someone saying "Don't bother training as a cardiologist. Just open up an office and see heart patients. As long as you don't do caths and echos, it is exactly the same and you'll learn as you go." You'd laugh at them, right?

I'm about to graduate from an Urban ED residency. 70% of what I see everyday could be seen by an experienced nurse or a PA. 20% requires a doctor who has a clue. The remaining 10% require significant experience and knowledge about advanced medical and trauma management. FP trained EPs rely on that 10% being very low at their ED and having help available when that 10% arrives.

With an FP residency you aren't going to get the experience of dealing with a large volume of sick patients at their initial presentation. Yes, you can tailor your future job to your skill set. Many community EDs get very little trauma and have an ICU available to ship the sick people too. But when faced with someone who is super sick, you will likely find yourself floundering and counting the seconds until help arrives. Plus, you won't ever be able to work at a trauma center. You won't ever be able to teach. Research oppertunities are there, but far more limited. You would be hamstringing yourself.

Then there are the procedures. Intubating in the OR has very little resemblance to intubating in the ER. Putting in a chest tube in ATLS class is nothing like putting one into an actually breathing person. There is nothing more humbling than trying to put a cental line in an eldery contracted septic patient who has no venous access. I could go on.

Plus, as the supply of BC/BE EPs increases, hospitals will start to adopt EP only EDs. Our hospital system recently went EP only and there was at least one FP (that I know about) who was displaced.

Forget about an office practice. You'll be 20+ years out of date. Many EPs move into management, teaching, research, etc when they want to cut back their clinical hours, so there are options.

Basically, you have to choose. If you want to do the job of an EP, choose an EM residency. If you want to the job of an FP, then choose FP.

Many (and possibly >50%) of the EPs in Canada are family physicians who do a 3rd year fellowship in EM.

leviathan said:

Many (and possibly >50%) of the EPs in Canada are family physicians who do a 3rd year fellowship in EM.

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FM residency is only 2 years in Canada?

awdc said:

FM residency is only 2 years in Canada?

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There are two ways to EM in Canada, and FM is one of them. I forgot the other, but it's not like here, where you do EM straight through.

I read an article in Emergency Medicine News today (while I was supposed to be working) about a lawsuit between the AAPS and the NY DOH. Apparently, the AAPS (who sponsors the ABPS EM "board certification" for FPs) is suing NY DOH for not allowing it's "diplomates" to identify themselves as Board Certified in EM, even though they have not completed a residency in EM and are not, in any sense of the word, board certified or board eligible by any recognized EM governing body (ACEP, AAEM, ABEM).

Florida opened the door, and now they're fighting for rights everywhere. Makes me sick.

To the OP: If you want to do EM, complete an EM residency. If you're worried about burning out, you don't really want EM and you will burn out and probably should have chosen something different, like flipping burgers.

jd

FP's will probably be able to get jobs in rural ED's for many years to come. However, it is impossible (even today) to get jobs in ED's in urban and even surburban hospitals. Many hospitals require emergency medicine residencies and board-certification for new hires.

As EM takes hold as a specialty, and as more EM-trained physicians become ED directors, it is likely that FP will not have a chance at getting contracts as emergency physicians. EM-trained ED directors will be looking for fellow EM-trained applicants.

southerndoc said:

However, it is impossible (even today) to get jobs in ED's in urban and even surburban hospitals.

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Not true. The group I'm with is the largest private group in the south (or so they say). Of the 48 docs, about 20 are EM-trained partners, and the remaining are about 5 on partner track (like me), and the balance are FM docs that, with one exception, do intermediate or lower level (fast track) shifts, and none do single cover at the outlying hospitals. FM-trained (or, non-EM trained) cannot make partner, but the group is actively recruiting 2 FM people right now.

Here is another article from the 11/2006 issue of EM News (www.em-news.com) about ACEP and AAEM defeating another similar petition by AAPS for recognition in North Cakalacky:

http://www.em-news.com/pt/re/emmedn...KJ9JncZ5vBnkjY4!1570379021!-949856144!8091!-1

access is free to all archived issues. Link has been verified to work as of time of posting.

jd

Interesting argument given by one guy in EM news. He's not AAPS but he points out that it's hypocritical of BC ABEM docs to complain about the LLSA by saying our "ongoing clinical practice and dedication to the field" should be enough to maintain certification yet we won't recognize AAPS which is saying that practice and dedication should entitle one to certification. OK that was a horrible sentence but I'm in a hurry. I don't agree with him but it's a good point. I would argue that residency training outweighs the ongoing practice value and should still be the only path to board certification.

Apollyon said:

There are two ways to EM in Canada, and FM is one of them. I forgot the other, but it's not like here, where you do EM straight through.

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Whoa whoa whoa Let me clarify the Canadian thing.


1. FP IS two years in Canada.
2. EM is FIVE years in Canada.

However, there is such a need for EPs in Canada, that a specially designated, Family Practice-EM tract has been established. Here, the FP resident, after the 2nd year, does ONE extra year of residency in EM. Now, they are able to get a board certification in EM, but it is a certification with an asterisk: The asterisk clearly indicates that the person is NOT a full, 5 year EM residency graduate, and it restricts them to practice outside of a Level I trauma center. Most end up with a family practice in a rural community AND work 'x' number of shifts in an ED every month. It's actually a pretty good gig for those that don't want to be restricted to just family practice -- both from an interest and income supplement standpoint -- but they are not the 'go to' people in a big, thriving, academic center.

KentW said:

Sorry, but I'm flagging that play.

Here's a link to the AAFP's position statement on emergency medicine. It makes several arguments in favor of allowing qualified family physicians to continue to practice in the emergency department, but it in no way, shape, or form implies that emergency medicine isn't a "true" specialty or that family physicians should have a "back door" to board certification in EM.

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I'll repost my bit from the similar FM thread:

Imagine if the roles were reversed. Imagine if, in inner cities, owing to the lack of primary care access, groups of emergency physicians opened up small "family medicine clinics" in the back of their EDs to see patients from the community as primary care physicians. They argue that these patients will merely end up in the ED anyway and that their floor months during residency equips them to see these patients in this outpatient longitudinal setting. These physicians state that they are "close enough" to an FP to "make do" for these otherwise unserved patients. Imagine if medical students, bright and eager to enter family medicine, were being disauded from that vocation to enter EM with the promise that these clinics "were essentially the same" as "regular" FM. Then, the ABEM hobbles together a one year fellowship in outpatient medicine and a group demands that graduates of these fellowship be allowed to advertise as "board certified family practitioners".

You'd probably be a bit salty about it too...

- H

KentW said:

Don't be too sure. There's more primary care in emergency medicine than there is emergency medicine in primary care.

I'm not going to argue the point or try to convince you that you're wrong. However, if we're going to discuss the AAFP's position, we should do so accurately.

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O.K., let's do that...

KentW said:

Sorry, but I'm flagging that play.

Here's a link to the AAFP's position statement on emergency medicine. It makes several arguments in favor of allowing qualified family physicians to continue to practice in the emergency department, but it in no way, shape, or form implies that emergency medicine isn't a "true" specialty or that family physicians should have a "back door" to board certification in EM.

In a nutshell: "The AAFP is opposed to the use of specialty board certification as the sole or exclusionary criterion in determining medical staff membership."

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Hmm, what constitutes a "qualified family physician"? Now if we take the AAFP's position (in a nutshell) that "The AAFP is opposed to the use of specialty board certification as the sole or exclusionary criterion in determining medical staff membership" can we safely assume you'd advocate for full surgical privledges as well? How about cardiac cath? I mean the rural areas would be well served if they could get PCTA quickly for MIs. Face it, board certification (or board eligibility) should be an exclusionary criterion for medical staff membership. Especially in those fields of medicine where the public doesn't have the opporitunity to "shop" for their physician (e.g., emergency physicians, interventional radiology, interventional cardiology, etc.) as this is what they would likely choose for themselves if circumstances allowed them a choice. Not to mention the lower med-mal rates on BC/BE EPs in the ED.

- H

KentW said:

It's in the position statement, if you want to read it. I'm not interested in debating the AAFP's position. I was simply clarifying it.

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Yeah, it's not in the paper. What the paper does is support the AAPS position that FP EM fellowships are equivalent to BC/BE EM.

And there is nothing wrong with this quote from the paper either {dripping sarcasm}:

But it isn't just about the money right? Let's leave aside the papers that prove that BC/BE EPs have fewer lawsuits and better outcomes than other physicians practicing in the ED, the AAFP comes right out and states their motivation: "Many family physicians have faced a hiring bias in emergency departments, since access to privileges is access to potential clinical revenue." Please. If you want access to a revenue stream then train to do the work, it is that simple.

- H

I'm making popcorn. Who wants some?

Sweet Tea said:

I'm making popcorn. Who wants some?

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Sure, I'll have some. Got any Sno Caps too?

KentW said:

All turf wars are about the money. Don't kid yourself.

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Yes, but the entire position paper (except that passage) speaks to increased patient safety and serving the needs of the community.

- H

FoughtFyr said:

I'll repost my bit from the similar FM thread:

Imagine if the roles were reversed. Imagine if, in inner cities, owing to the lack of primary care access, groups of emergency physicians opened up small "family medicine clinics" in the back of their EDs to see patients from the community as primary care physicians. They argue that these patients will merely end up in the ED anyway and that their floor months during residency equips them to see these patients in this outpatient longitudinal setting. These physicians state that they are "close enough" to an FP to "make do" for these otherwise unserved patients. Imagine if medical students, bright and eager to enter family medicine, were being disauded from that vocation to enter EM with the promise that these clinics "were essentially the same" as "regular" FM. Then, the ABEM hobbles together a one year fellowship in outpatient medicine and a group demands that graduates of these fellowship be allowed to advertise as "board certified family practitioners".

You'd probably be a bit salty about it too...

- H

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Excellent point FF! couldn't have said it better myself.

Dr.McNinja said:

I'll be over in about, oh, 7 hours. Wait, which house am I coming to? May change the driving a little bit.

I like extra butter. And a little Natty Ice goes well with popcorn as well.

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I'm up in VA these days, and we've got tons of beer. We also have a brand new 40" LCD tv and a brand new Wii, so it should be a good time.

KentW said:

Sorry, but I'm flagging that play.

...but it in no way, shape, or form implies that emergency medicine isn't a "true" specialty or that family physicians should have a "back door" to board certification in EM.

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To quote the AAFP position paper:

"In lieu of ABEM certification, the American Association of Physicians Specialists offers the Board Certification of Emergency Medicine examination."

That's a backdoor Kent. Here is another one:

"For example, an emergency medicine department might promote a requirement for specialty certification in emergency medicine as a criterion for the granting of emergency department privileges. Where such criteria have been promulgated by a particular specialty, family physicians should oppose it as contrary to hospital policy and the public interest. They should remind the hospital that it is the board that sets privileging criteria and input should be sought from multiple parties."{emphasis added}

On further review the ruling on the field is overturned.

- H

KentW said:

Imagine? Dude, that's reality.

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But they aren't being told that they can do FM by going into another field. EM hopefuls are being told they can do EM by going into FM.

- H

Dr.McNinja said:

Not at my school. I have been beaten over the head with FM. Even worse, they were thoroughly trying to get me to scramble FM and stay FM. They said it would be better for me in the long run.

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Me too.

KentW said:

I can assure you that they're not hearing that from me.

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But they are hearing it from the AAFP in the position paper you posted!

- H