Em/im

From what I've read and heard people pursue EM/IM programs for several different reasons:

1. Shift splitting: You could in theory work 3 days/wk in an ED and say 2 as a hospitalist on the medical floor - you know break up the routine; These guys often say the like EM but elso enjoy the continuity of care/long term management offered in IM; Some feel that as they get older and want "slower" schedules they may just phase out of EM and go into IM

2. Critical Care: There's a move in EM to support further trianing in Critical Care - it seems like a natural transition. Although a few places offer critical care fellowships to EM trained MD's, you can't become boarded unless you're IM boarded.

3. ****s and Giggles: By this I mean, some people just like the idea of learning more IM.

4. Academics?: With the advent of 4 year EM programs, why not do 5 and be dual boarded? My quesiton however is: If a carreer in academic EM is desired, would it be better to go to a 4 year EM program or a combined EM/IM program? It may be that combined programs tend to be in academicly oriented programs as a default.

There's a good review of combined programs and other topics in EMRA's Medical Student's Guide to EM

Hope this helped

Vince,
I finished a combined EM/IM program at Henry Ford a couple of years ago and now I'm finishing up a 2 year fellowship in critical care at Pitt. I agreee with everything O had to say but I may have a little better perspective since I've been through it and judging by O's response, they haven't.

I just signed a great contract where I'll be working in the ED, ICU and research in shock with about 50% protected time. All these years have finally started to pay off and I believe I have the best job in the world. But...... it was an extremely long road. Just as long as some surgical subspecialists. You really have to have convictions as why you'd want to do this. As to O's categories:

1) Practice both..... I have several friends who do practice IM (as hospitalists) and EM. They love it and are great teachers. But you have to enjoy IM or it will be a chore. If you don't like IM, forget about it.

2) Critical Care..... If you absolutely hate IM, but want to practice critical care and EM, don't fret. There are MANY fellowships who are drooling over the chance to get an EM trained fellow. We just put together a list on the ACEP's CCM website. Don't worry about boards, I know two directors of ICU's who are recently trained EM and CCM (no IM at all). You can always take the European boards, even though they aren't recognized in the US. It will not be a problem getting a job!

3)Academics.....It is one route. It will help. Don't do it just for this unless you like IM. You can do a research fellowship, Tox, Hyperbarics, EMS etc...

Here are a few critical care links if you are interested. Please drop me an email if you want to talk more.

http://www.anes.upmc.edu/mcctp/epemcur.html
http://www.anes.upmc.edu/mcctp/emfaqs.html

Good luck,
Kyle

I'm glad you posted your response. I'm wondering, is the idea of Critical Care training following EM to allow continuity of care from the ED to the MICU Unit? Do you typically continue to provide care to the patients you admitted during your ED shift?

The continuity is nice, but really not the big attraction. My attraction to both is an interest in really sick patients and shock research. Where I trained it was not uncommon to have sick patients on a ventilator for 6-10 hours waiting for an ICU bed. The ICU team did not manage these patients until they went to the unit, so the ED had to. Work force projections estimate longer waits and increased overcrowding in the ED's....so....this means longer ICU waits as well. I was part of a study (Early Goal Directed Therapy in Sepsis) by Manny Rivers (NEJM 2001), we made more of a difference in 6 hours than the entire hospital stay. Mortality was reduced by 16% (twice that of Xigris). There has been a paucity of good research in ED critical care/shock issues and this is a brand new frontier, the EM/CCM trained doc will be positioned to lead this wave. This is another good website as to what some motivated EM docs can do with the help of CCM, surgery and anesth. www.vcures.com

So rather than the continuity, which is a bonus, I think the understanding of the complexity of a critically ill patient, polishing your critical care skills, multiple research opportunities and just having fun caring for all these sick patients are the reason EM/CCM are a good mix. Most CCM programs are now going to shift work, just like EM.

Hope this helps and if anyone out there is interested in this option, please contact me anytime.

Good luck,
Kyle

Dr. Gunnerson,
I am starting at Pitt next year and really want to get involved with EM research. Do you need help or can you give me any advice re. research at Pitt. cheers

Dear India,
Pitt's EM program has many research projects. The president of SAEM, Don Yealy is the Vice Chair. The big interest down there is mostly pre-hospital care. Some resident's have worked in the Safar shock center, which is mostly basic science on therapeutic hypothermia. I guess it really depends on what your interests are. If you know what you really want to do (it took me 4 years) now, then you can search some people out. If you don't, then just open your eyes and you'll be bombarded with opportunities. This part of Pitt is very amazing, if you have an idea, you'll probably find a lab that would love to have you join the team. Check out the Safar center, McGowan center, our website if you are interested in critical care to start. If you have specific questions, please drop me a line anytime. Good luck and enjoy your residency.

Remember to Keep CCM in mind as a fellowship option

Kyle

Just posted this to keep the thread alive since I have repeated my same response about 4 times in other threads and this discussion may answer some questions. If anybody has any other questions about Critical care and EM, or IM/EM at all,
please let me know.

Kyle

KGUNNER1 said:

Just posted this to keep the thread alive since I have repeated my same response about 4 times in other threads and this discussion may answer some questions. If anybody has any other questions about Critical care and EM, or IM/EM at all,
please let me know.

Kyle

Click to expand...

I think I'll take you up on your offer (or anyone else for that matter)....

For straight EM residents I understand that moonlight can begin somewhere around the beginning of the third year, does this hold true for the EM/IM residents as well? I would imagine that it doesn't because those guys have completed less time in either EM or IM by the third year than a categorical third year resident in EM or IM alone. So, I guess my question is, what are the moonlighting opportunities like for EM/IM people? After all, if I'm going to do the two extra years I think I'd like to somewhat offset the PGY IV and V salaries!

Thanks

MS05' said:

I think I'll take you up on your offer (or anyone else for that matter)....

For straight EM residents I understand that moonlight can begin somewhere around the beginning of the third year, does this hold true for the EM/IM residents as well? I would imagine that it doesn't because those guys have completed less time in either EM or IM by the third year than a categorical third year resident in EM or IM alone. So, I guess my question is, what are the moonlighting opportunities like for EM/IM people? After all, if I'm going to do the two extra years I think I'd like to somewhat offset the PGY IV and V salaries!

Thanks

Click to expand...

I moonlit occasionally during my 4th and 5th years.

KG

it seemed liked a lot of em/im residents on met on the interview trial did it. Mostly 4/5 year but some 3rd and even 2nd. Most of the time it was an urgent care setting

At my program we can moonlight as 1st years in the internal medicine dept.

To KGUNNER and anyone else in the know, are critical care fellowships switching to shift work like EM or jobs post fellowship making this change? I know that jobs in peds CC are changing to shift work but I haven't heard this for adult CC. I'm also curious if you know of people doing IM and straight CC fellowships then getting jobs outside of academia. If so, what are their hours like? Full time CC seems pretty intense but a hospitalist like schedule, 2 weeks on, week off would be great. I don't know yet if I like pulm enough to spend another year poor but I know that is currently the best way to get a job. Thanks for any info.

augmel said:

To KGUNNER and anyone else in the know, are critical care fellowships switching to shift work like EM or jobs post fellowship making this change? I know that jobs in peds CC are changing to shift work but I haven't heard this for adult CC. I'm also curious if you know of people doing IM and straight CC fellowships then getting jobs outside of academia. If so, what are their hours like? Full time CC seems pretty intense but a hospitalist like schedule, 2 weeks on, week off would be great. I don't know yet if I like pulm enough to spend another year poor but I know that is currently the best way to get a job. Thanks for any info.

Click to expand...

The answer is Yes, maybe. It depends where you go. There is such a shortage of intensivists, that every hospital can't find enough to staff 24/7. Those places obviously can't have shift work. Other hospitals are going to shift work. I think many of us practicing like the shift work model, for nothing else than one of our partners are physicially in house during the night if something starts to go south.

I know about 3 or 4 EM/CCM grads in private practice groups. One is actually a unit director. I think most of us gravitate to academia.

Pulm/CCM is a pretty safe bet. But you have to like outpatient medicine. I didn't like outpatient medicine enough to do it.

KG

KGUNNER1 said:

Just posted this to keep the thread alive since I have repeated my same response about 4 times in other threads and this discussion may answer some questions. If anybody has any other questions about Critical care and EM, or IM/EM at all,
please let me know.

Kyle

Click to expand...

Dr Gunnerson,
I posted this in another thread and got one response. Someone said that there was an expert on CCM in the SDM forums. After looking at some of your post, I think they meant you. Would you be able to answer my questions?

I apologize in advance for my naïveté or if my questions seem foolish.


------------------------------------------------------
Hello folks,
I have been doing quite a bit of research and I think I almost have it all sorted out. I would like to ask a few more questions just to make sure I have it all right.

Internist – can do a fellowship in Critical care medicine.
1. Does this mean they are considered an Intensivist?
2. Does that Critical care fellowship entitle them to work in EM?

Hospitalist
3. Are most of these folks Internist?
4. Does this require any specialty training?

EM
5. If they do an EM/IM residency they are double boarded, right?
6. Since EM does critical care, can they work as Intensivist?

Anesthesia
7. I read that these folks also practice critical care. Does that make also them intensivist?
8. If they practice Critical care can they practice EM?


I get that all specialties are called to work on patients in an ED. I understand that EM is a relatively new specialty. I also understand that in many rural areas there’s lots of overlap. I would just appreciate some help clearing away the fog.

Agape

sunnyjohn said:

Dr Gunnerson,
I posted this in another thread and got one response. Someone said that there was an expert on CCM in the SDM forums. After looking at some of your post, I think they meant you. Would you be able to answer my questions?

I apologize in advance for my naïveté or if my questions seem foolish.


------------------------------------------------------
Hello folks,
I have been doing quite a bit of research and I think I almost have it all sorted out. I would like to ask a few more questions just to make sure I have it all right.

Internist – can do a fellowship in Critical care medicine.
1. Does this mean they are considered an Intensivist?
2. Does that Critical care fellowship entitle them to work in EM?

Hospitalist
3. Are most of these folks Internist?
4. Does this require any specialty training?

EM
5. If they do an EM/IM residency they are double boarded, right?
6. Since EM does critical care, can they work as Intensivist?

Anesthesia
7. I read that these folks also practice critical care. Does that make also them intensivist?
8. If they practice Critical care can they practice EM?


I get that all specialties are called to work on patients in an ED. I understand that EM is a relatively new specialty. I also understand that in many rural areas there’s lots of overlap. I would just appreciate some help clearing away the fog.

Agape

Click to expand...

1. An "intensivist" is one that practices critical care medicine as a profession, not a "dabbler” This also has come to mean one that is officially "trained" in critical care medicine, especially the newer generation. You'll still see some of the "old-timers" who have done critical care before there was a specialty.

2. No. You can work anywhere if the hospital will grant you privileges. If a hospital will hire someone not trained or boarded in EM to work in the ED, then yes, anyone can work there. But critical care training does NOT equal ED training or certification.

3. Yes

4. Really no. Anybody that is boarded in IM can work as a hospitalist. No special boards or other tests.

5. Yes, if they pass both boards.

6. Just like number 2, EM training does NOT equal critical care training. You can still take care of the critical care patient in the ED, but you can't round in the unit.

7. Official Critical Care fellowships are available for IM, Surgery, Peds, Anesth, and OB (don't ask). If an Anesthesiologist does a critical care fellowship, and practices critical care, they are an intensivist. You have to do the training. ER grads and neurology grads can do fellowships at various places, but there are no formal US boards or certifications. You have to go to Europe and take those critical care boards. This usually doesn't pose a problem.

8. Again, anybody can work in an ER if the hospital/ER will hire you. If you want to risk it, and you can find an ER willing to hire you, you can practice EM as a psychiatrist. EM is a recognized ABMS specialty, and has been for many years, so the standard is set. The only really way to practice EM well is by doing an EM residency.

Hope this helps.

KG

Dr Gunnerson,

Thank you very much for your response. It was very helpful.