Best way to do primary care and EM

[deleted1074007]

Hey! I've looked all over the forum and can't find any recent good answers for this.

I've been thinking about this for all three years I've been in school so far. So while some may judge me for this post, I feel my desire to pursue this is significant to me. I'd like to practice in primary care and in the ED.
I am familiar with some of the pathway options to do this (in no particular order):
1. FM residency and practice ED shifts in a rural setting.
2. FM residency and EM fellowship.
3. Same thing as above but IM residency.
4. Dual residency programs (FM/EM, IM/EM)
5. EM residency with a focused primary care practice following a relevant fellowship (like primary care sports med or addiction med).

Was wondering if anyone has any input on which choice would be the most straight forward and give the best chance of achieving this career.

Specifics to my situation:
I'm interested in small town/rural practice and eventually some global medicine.
I am not convinced that option 1 is a guarantee to work out. Seems more like something that just has to fall into place with the community you move to and the skills you obtain along the way. Actively modifying my day to day training to obtain a completely new skill set (IE: being a family med resident who spends a lot of extra time in the ED because they know they want to do both) seems like a big challenge. I would like a more solid pathway option if possible. I'd also like the option to work at level 2 or level 1 trauma centers if my life leads me to a less rural setting. Everyone I've talked to says it doesn't happen for Fam Med docs doing EM.

The option I'm most interested in is option 5. I like sports med and am considering that even if I pursued other residencies.

I wish there was Fellowships for EM docs to do primary care. Seeing as the reverse option is there (FM to EM fellowship), and with the apparent saturation of the EM field, I don't really understand why we haven't created a primary care fellowship for EM docs.

If I was to pursue option 4 (dual residency), they seem to be competitive. I am a decent residency candidate but not a rock star. Decent US med school. Decent step 1 score. Slightly above average numbers and decent evals. Would rather not spend five years in residency though. But may be up for it, if the career I want is there. Does anyone have any input on those?

Are there any other options I haven't thought of? Thanks for the help!

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[Crayola227]

I would say it's probably an unreasonable career plan if you're not willing to do the training. There's a reason that the separate residencies exist and are as long as they are. Neither residency alone really fully prepares you to give SOC to patients (edited to add: to patients in a field for which yiu did not do residency).

Many FM docs would admit it's somewhat marginal that they provide EM care in the ED, and there's a reason they are not preferred for say staffing a Level 1 trauma center.

So putting aside the fact that for most people it's only really practical to pursue one or the other, is to say that it's certainly unreasonable to want to pursue both but not extend the length of training.

 

[VA Hopeful Dr]

Hey! I've looked all over the forum and can't find any recent good answers for this.

I've been thinking about this for all three years I've been in school so far. So while some may judge me for this post, I feel my desire to pursue this is significant to me. I'd like to practice in primary care and in the ED.
I am familiar with some of the pathway options to do this (in no particular order):
1. FM residency and practice ED shifts in a rural setting.
2. FM residency and EM fellowship.
3. Same thing as above but IM residency.
4. Dual residency programs (FM/EM, IM/EM)
5. EM residency with a focused primary care practice following a relevant fellowship (like primary care sports med or addiction med).

Was wondering if anyone has any input on which choice would be the most straight forward and give the best chance of achieving this career.

Specifics to my situation:
I'm interested in small town/rural practice and eventually some global medicine.
I am not convinced that option 1 is a guarantee to work out. Seems more like something that just has to fall into place with the community you move to and the skills you obtain along the way. Actively modifying my day to day training to obtain a completely new skill set (IE: being a family med resident who spends a lot of extra time in the ED because they know they want to do both) seems like a big challenge. I would like a more solid pathway option if possible. I'd also like the option to work at level 2 or level 1 trauma centers if my life leads me to a less rural setting. Everyone I've talked to says it doesn't happen for Fam Med docs doing EM.

The option I'm most interested in is option 5. I like sports med and am considering that even if I pursued other residencies.

I wish there was Fellowships for EM docs to do primary care. Seeing as the reverse option is there (FM to EM fellowship), and with the apparent saturation of the EM field, I don't really understand why we haven't created a primary care fellowship for EM docs.

If I was to pursue option 4 (dual residency), they seem to be competitive. I am a decent residency candidate but not a rock star. Decent US med school. Decent step 1 score. Slightly above average numbers and decent evals. Would rather not spend five years in residency though. But may be up for it, if the career I want is there. Does anyone have any input on those?

Are there any other options I haven't thought of? Thanks for the help!

EM physicians don't think that fellowship really does any good (nor is it a true ABMS fellowship) so why would you think us PCP types would feel any different if there was an EM Primary Care Fellowship?

If you want to provide the best care, do a dual residency.

That said, you CAN do both with just an FM or EM residency. Lots of rural FPs work in the ED and I suspect rural EPs could do some primary care without too much trouble. You just won't be a well trained PCP or EP (depending on which residency you did).

 

[deleted1074007]

I would say it's probably an unreasonable career plan if you're not willing to do the training. There's a reason that the separate residencies exist and are as long as they are. Neither residency alone really fully prepares you to give SOC to patients.

Many FM docs would admit it's somewhat marginal that they provide EM care in the ED, and there's a reason they are not preferred for say staffing a Level 1 trauma center.

So putting aside the fact that for most people it's only really practical to pursue one or the other, is to say that it's certainly unreasonable to want to pursue both but not extend the length of training.

I appreciate the sobering feedback. Seeing as there are only two or three FM/EM residencies in existence, I felt less inclined to put this high on my priority list. I am of course willing to do the training. Thanks.

 

[Crayola227]

The closer I was to med school, the more I was focused on not wanting to "give things up."

The further I get, the more I realize that the goals of employment, and certainly not in a field medicine, is not for employees to avoid boredom or do lots of things so they feel really cool and accomplished.

It's about patient safety. And any one of the specialized fields and their subspecialties and fellowships, contain enough breadth to make it challenging to make sure you're fully trained, stay abreast, and do things with enough repetition to be really, really good at it.

We're not talking about not getting bored with softwarw coding or creating art. The emphasis on providing the closest thing there can be to perfect patient care, every single encounter, makes it a bit unrealistic to want to double specialize.

And I frequently defend combined programs. But keep in mind, if you do a pediatric neurology residency, the goals isn't exactly to make you the best general pediatrician AND general neurologist on the block. In fact the argument can be made you become less well trained in either, an expense made to be an expert specifically in neurological issues in the pediatric population.

I myself grappled with the exact issue between general practice and EM, and I could not convince myself that it made sense to combine both or do both. I did EM rotations as settled for wanting to be especially competent in recognizing and initiating management of emergencies, within the realm of general practice. And I think it's fine if you want to find acceptable ways to provide competent care in certain settings where appropriate (rural EM). I don't really know how it works the other way (EM interfacing with general practice) except I could see that as primary care makes up a great deal of one's EM practice in practice even if it's not supposed to in theory, than being better at that management might have value.

The person who finds themselves in general practice and bored just isn't challenging themselves appropriately. You can always pick up skills, like cosmetic stuff or opioid replacement management, or focus more on obstetrics, plenty of ways to challenge yourself. Or in urgent care or even rural. Manage your own inpatients (this has arguments against it, but apparently patient outcomes or mortality is the same compared to dedicated hospitalist). But don't be a cowboy with any of the technically accepted things you can do.

As for the boredom in EM, that is real, I don't know the best way they address this.

 

[deleted1074007]

The closer I was to med school, the more I was focused on not wanting to "give things up."

The further I get, the more I realize that the goals of employment, and certainly not in a field medicine, is not for employees to avoid boredom or do lots of things so they feel really cool and accomplished.

It's about patient safety. And any one of the specialized fields and their subspecialties and fellowships, contain enough breadth to make it challenging to make sure you're fully trained, stay abreast, and do things with enough repetition to be really, really good at it.

We're not talking about not getting bored with softwarw coding or creating art. The emphasis on providing the closest thing there can be to perfect patient care, every single encounter, makes it a bit unrealistic to want to double specialize.

And I frequently defend combined programs. But keep in mind, if you do a pediatric neurology residency, the goals isn't exactly to make you the best general pediatrician AND general neurologist on the block. In fact the argument can be made you become less well trained in either, an expense made to be an expert specifically in neurological issues in the pediatric population.

I myself grappled with the exact issue between general practice and EM, and I could not convince myself that it made sense to combine both or do both. I did EM rotations as settled for wanting to be especially competent in recognizing and initiating management of emergencies, within the realm of general practice. And I think it's fine if you want to find acceptable ways to provide competent care in certain settings where appropriate (rural EM). I don't really know how it works the other way (EM interfacing with general practice) except I could see that as primary care makes up a great deal of one's EM practice in practice even if it's not supposed to in theory, than being better at that management might have value.

The person who finds themselves in general practice and bored just isn't challenging themselves appropriately. You can always pick up skills, like cosmetic stuff or opioid replacement management, or focus more on obstetrics, plenty of ways to challenge yourself. Or in urgent care or even rural. Manage your own inpatients (this has arguments against it, but apparently patient outcomes or mortality is the same compared to dedicated hospitalist). But don't be a cowboy with any of the technically accepted things you can do.

As for the boredom in EM, that is real, I don't know the best way they address this.

I hear you and I will remember your advice but... these specialities are not the natural order. They didn't exist from before and then we joined into them. They are man-made artificial boundaries. And the specialties we are referring to are relatively modern specialities. So I don't understand the objection to wanting to blur these lines as a way to help patients.
I am not trying to be a cowboy. Yes of course there is some selfishness. I am trying to do something I feel would be interesting.
But more importantly, I have observed the limitations that these two pathways offer and feel that primary care and EM in the rural setting is a very promising way to help improve the outcomes of marginalized rural communities or communities that have zero health literacy and horrible access to both primary and emergency services.

In the science communities, the most exciting advances come from the intersectionality of diverse fields. Genomics and computer science, organic chemistry and molecular biology, engineering and biochemistry. And the leaders in scientific innovation are not people who exist within their defined boundaries, innovators actively seek out ways to cross boundary lines. I am young in medicine, and probably very stupid in terms of medicine. But I believe the future is for those who bring divergent fields together, not separate them.

 

[Crayola227]

I hear you and I will remember your advice but... these specialities are not the natural order. They didn't exist from before and then we joined into them. They are man-made artificial boundaries. And the specialties we are referring to are relatively modern specialities. So I don't understand the objection to wanting to blur these lines as a way to help patients.
I am not trying to be a cowboy. Yes of course there is some selfishness. I am trying to do something I feel would be interesting.
But more importantly, I have observed the limitations that these two pathways offer and feel that primary care and EM in the rural setting is a very promising way to help improve the outcomes of marginalized rural communities or communities that have zero health literacy and horrible access to both primary and emergency services.

In the science communities, the most exciting advances come from the intersectionality of diverse fields. Genomics and computer science, organic chemistry and molecular biology, engineering and biochemistry. And the leaders in scientific innovation are not people who exist within their defined boundaries, innovators actively seek out ways to cross boundary lines. I am young in medicine, and probably very stupid in terms of medicine. But I believe the future is for those who bring divergent fields together, not separate them.

The argument for why many of the specialties split has to do with how they knowledge base has broadened, is what I'm saying. Being a PCP and doing EM and inpt work 50 years ago is not the same as the reality of it now.

 

[mvenus929]

I hear you and I will remember your advice but... these specialities are not the natural order. They didn't exist from before and then we joined into them. They are man-made artificial boundaries. And the specialties we are referring to are relatively modern specialities. So I don't understand the objection to wanting to blur these lines as a way to help patients.
I am not trying to be a cowboy. Yes of course there is some selfishness. I am trying to do something I feel would be interesting.
But more importantly, I have observed the limitations that these two pathways offer and feel that primary care and EM in the rural setting is a very promising way to help improve the outcomes of marginalized rural communities or communities that have zero health literacy and horrible access to both primary and emergency services.

In the science communities, the most exciting advances come from the intersectionality of diverse fields. Genomics and computer science, organic chemistry and molecular biology, engineering and biochemistry. And the leaders in scientific innovation are not people who exist within their defined boundaries, innovators actively seek out ways to cross boundary lines. I am young in medicine, and probably very stupid in terms of medicine. But I believe the future is for those who bring divergent fields together, not separate them.

1. As Crayon said, the knowledge base required to take good care of patients has significantly increased in the past 50 years. It would be challenging to keep up in both all things family medicine and all things EM. Besides that, you're only one person. Do you envision working in a primary care office 4 days per week and the ED another two shifts per week? Is that enough to keep up your EM skills? Or maybe you envision a triage to an urgent care/primary care clinic from the ED--which you could do quite easily from a FM/IM standpoint if you had a good ED triage system in place (and I'm sure the ED docs would love for you to take on the patients who come in for refills of meds, etc).

2. In rural communities, good primary care is going to go a lot further than mediocre primary care and mediocre EM. If you can keep them well enough, they won't need the ED as often. And a lot of the limitations in the ED setting are due to access issues that aren't within the patient's control--no access to a cath lab at that hospital, for instance, because there's not enough volume to support one. Same for strokes.

3. I don't think FM and ED are different enough to have 'innovations' from bringing them together. They're both still medicine (with entirely different focuses, but many similar pathologies). The diverse fields that will probably go places are things like genomics and obesity medicine, informatics and diabetes care, engineering and cardiology--fields that are separate from medicine but have a lot to bring to the medical table.

 

[Ganon]

I know of fresh midlevels who are flying solo in rural EDs.
I know a few seasoned family practice docs who moonlight in ED.

I know which I'd prefer to see if I had an emergency in a rural setting.

Obviously ED trained docs are the gold standard, but when you're comparing the REALITY (online trained FNPs vs. residency-trained FM docs) I don't think too many people will fight that hard. Same conversation with FM doing OB care. I don't think it's ideal, but if these rural communities can't attract an OB and the patients are unwilling to travel, I believe a properly-trained family med doc is a no-brainer.

I personally would be uncomfortable practicing in either of the above situation, but everyone is different!

 

[Tenk]

This doesn’t really work due to circadian rhythm. So unless you don’t require sleep and absolutely hate doing anything but work, pick one or the other.

Also, with the large expansion of EM residencies, there will be virtually zero non ABEM board certified doctors working in EDs in 10 years. When I first started at my critical access site 6 years ago we had ~4-5 FM trained docs. We have zero currently.

 

[Rekt]

FM with EM fellowship is rapidly approaching being a thing of the past. They are not adequately trained to staff EDs. But mainly, with a predicted oversupply of 7,000-10,000 EM (ABEM) docs in the next 7-10 years, the gap in rural EM is rapidly closing. Many hospital systems are currently taking over small rural hospitals and firing the FM docs and replacing them with ABEM docs because there's plenty of supply.

Save yourself the anguish and do FM.

 

[deleted1074007]

Thanks everyone.
I’ll be planning to apply to one of the 7 FM/EM residency spots.
Lmao.

 

[TelemarketingEnigma]

Something worth considering is what do you actually want your day-to-day practice to look like? How often would you be in clinic vs. the ED - are you trying to do both every week? How would you schedule that? If you just want to pick up shifts in the ED occasionally - will you stay sharp enough to feel confident in your skills? or is the goal to start in one (say, ED) and then transition to the other later in your career as you get older/more burnt out? Depending on which of these appeals to you, there may be a different best approach.

Edit: also, would something like urgent care satisfy your primary care desires or are you seeking more longitudinal relationships?

 

[deleted1074007]

Something worth considering is what do you actually want your day-to-day practice to look like? How often would you be in clinic vs. the ED - are you trying to do both every week? How would you schedule that? If you just want to pick up shifts in the ED occasionally - will you stay sharp enough to feel confident in your skills? or is the goal to start in one (say, ED) and then transition to the other later in your career as you get older/more burnt out? Depending on which of these appeals to you, there may be a different best approach.

Edit: also, would something like urgent care satisfy your primary care desires or are you seeking more longitudinal relationships?

Thanks for this.

I had mainly considered the combined skill sets in a rural setting to be more valuable rather than how I will spend my time. But I have of course thought of that. And will consider it much more.

I’d like to spend most of my time doing primary care. Maybe 60-70% of my time. If I got very specific with things (which I’ve never seriously thought about) I think a good schedule would be something like 4 days a week in clinic and 1 or 2 days a week in the ED. Then have a stretch at the end of the month or every other month where I’ll do just ED shifts for a week straight. Part time in both.

I know the hate will continue to flow from this idea. I know almost everyone is going to tell me to choose one. And I understand people’s concerns and recommendations to just pursue one career. But I disagree with the opinion that this is a completely bad idea. I disagree with the opinion that there is no room for someone to do both.

I was raised in a small town and I am in my thirties now, medicine is my second career. I’m not trying to pony up and show off how cool I am. I’ve thought about this for the better half of a decade. I have seen fam docs with 4 or 5 clinic days a month in my hometown sometimes. And they were great doctors, well respected and loved by their patients. Will it be world class health care if I split my time, no! But there are more than enough poor quality health care provider who only practice one specialty to go around. Also I will be a happier, more productive doctor if I can lead the career I want.

Being in the middle of no where changes the game IMO. the greater skill set you have, the more prepared you are for many different challenges, and the better leader you can be in diverse situations, the better things will end up for patients IMO.

I’ve been in contact with EM/IM docs who pursued this career path for the same reasons I’ve listed.

K. Off my soap box.

 

[Crayola227]

Thanks for this.

I had mainly considered the combined skill sets in a rural setting to be more valuable rather than how I will spend my time. But I have of course thought of that. And will consider it much more.

I’d like to spend most of my time doing primary care. Maybe 60-70% of my time. If I got very specific with things (which I’ve never seriously thought about) I think a good schedule would be something like 4 days a week in clinic and 1 or 2 days a week in the ED. Then have a stretch at the end of the month or every other month where I’ll do just ED shifts for a week straight. Part time in both.

I know the hate will continue to flow from this idea. I know almost everyone is going to tell me to choose one. And I understand people’s concerns and recommendations to just pursue one career. But I disagree with the opinion that this is a completely bad idea. I disagree with the opinion that there is no room for someone to do both.

I was raised in a small town and I am in my thirties now, medicine is my second career. I’m not trying to pony up and show off how cool I am. I’ve thought about this for the better half of a decade. I have seen fam docs with 4 or 5 clinic days a month in my hometown sometimes. And they were great doctors, well respected and loved by their patients. Will it be world class health care if I split my time, no! But there are more than enough poor quality health care provider who only practice one specialty to go around. Also I will be a happier, more productive doctor if I can lead the career I want.

Being in the middle of no where changes the game IMO. the greater skill set you have, the more prepared you are for many different challenges, and the better leader you can be in diverse situations, the better things will end up for patients IMO.

I’ve been in contact with EM/IM docs who pursued this career path for the same reasons I’ve listed.

K. Off my soap box.

The first issue is getting adequate training. FM theoretically lets you do rural EM. EM lets you do urgent care.

But you do address this with a combined program, at least.

Primary care 60-70% of the time is challenging, trying to do part time primary care AND EM, while staying sharp enough in both...

The schedule you outline that is 6 days a week or even 5, doing both, is unsustainable long term. I too know EM docs that work part time. Part time is a big enough handful for most. And your proposed schedule also doesn't make sense circadian rhythm-wise, let alone just having free any time at all.

How many of the FM docs only doing 5 or 6 days a month rural, started that schedule out of residency, and how many have years of full time work experience under their belt before transitioning to that? How do they have continuity of care? Lack of that is a real challenge and PITA for doing primary care work. It's not just hard on patients, it's hard on providers.

Keep in mind that any schedule you have as a PCP or EM doc that isn't traditional, often only works if you are in a group situation where other workers' schedules are part of accommodating your own.

So trying to have a week every other month away from primary care practice and in the ED? Good luck.

Also, most of the EM people I know who are able to work part time or cherry pick what dates to work, frequently have to do so by working holidays and less desirable shifts, ie swing and nights.

Working clinic 4 days a week and then 1 or 2 shifts odd timed ED shifts on the weekend? When will you recover? The schedule you propose sounds as difficult or even moreso than residency for crying out loud. Doing that for a whole career, while simultaneously likely never practicing enough or having time enough to stay current, without supervision, the stress of that?

And nothing you have said has addressed the point about a glut of EM providers. Most of the challenges I've pointed out with trying to have the EM schedule you propose, is only made worse with a glut.

You absolutely need to be careful when you consider people who currently have careers doing things outside the norm, to consider if the job market or practice environment has changed in any way making it more difficult to follow in their footsteps. People have pointed this out to you in this thread.

It's ridiculous for you to even act like you have a soapbox about this, like as a medical student you can get up there and lecture to practicing physicians and physician educators "what it's like" out in the world of practice.

Lastly, what people forget, is what it is like transitioning from training to attending where NO ONE is there to help you, train you, look over your shoulder. So I wouldn't be dimissive of what it's like to not be providing "world class healthcare" and be closer to "poor quality health care providers" in a post-training practice on your own, 6 days a week. It's easier to conceive of having less training, AND then practicing part time in two challenging broad fields in an unforgiving grueling schedule right out of training, when you have never experienced practice without training wheels.

Keep in mind that a lot of what has people seemingly comfortable with being half-assed midlevels over their head providing poor quality care, is often ignorance. Most of them don't actually know how bad a job they're doing. What makes a residency-trained physician is exactly the opposite of that: you definitely know enough to know what is acceptable and what is not. You have had several practicing physicians come in here and tell you your proposed practice model is concerning for multiple reasons.

I hope you find your niche. I hope it isn't overwhelming. I hope you don't find yourself in over your head as an attending. I hope the job market doesn't corner you.

At least if you go to a combined program, or do FM, there's a chance you'll have the training to pursue a reasonable practice and schedule. But I doubt it will look like what you've proposed here.

Not many people do anything like you propose, and it's not for lack of interest. It's because there are lots of practical issues that make it not very feasible.

This has nothing to do with "hate," and is just physicians trying to tell you what the job market ends up looking like and what people actually find reasonable to do post-residency.

Are the number of slots in the combined programs not a clue to you at all of the difficulties and the niche need for primary care/EM? This isn't exactly like proposing being an ENT AND an ob/gyn, but c'mon.

Good luck.

 

[Crayola227]

Also people forget that in many fields, practicing "part time" still often amounts to full time hours or effort. FM that work 3-4 days a week, can have banker hours during the week, and the time they spend on "catch up", admin duties, emails, CMS, staying current with literature, instead of making their work days longer can fall to another day.

Many part time physicians just find it easier to keep current within their own field with respect to reading, or put more time to more challenging cases or research or specialty administrarion or leadership activities, not part time a second specialty.

You do gen IM and nephro, for example. I know someone that does IM/psych. Some of these things lend themselves well to a blended practice.

Primary care doesn't even belong in the ED. That so much makes it in there, is just from our broken system. It isn't the right practice environment for a lot of FM specialty skills.

 

[ortnakas]

OP: what do you guys think about X
Responses: well, it’ll be hard to make that work because A, B, and C
OP: nope, you all think wrong
-an SDN tale as old as time

OP, I hope you find a career that fulfills you. I like your dedication to rural medicine even if your goal to provide just over “poor quality care” sounds a little off-putting (I choose to believe you just worded that poorly). I think it’s going to be hard to feel qualified in both without doing a combination residency, and I also think it’s going to be hard to maintain competence in both and to find a job schedule that works doing both.

 

[deleted1074007]

Lol. I appreciate the replies but it’s kind of classic physician isn’t it? Someone says this is what I want to do with my life/health choices, and physician says “no that’s dumb. You can’t. Do this instead. I have no other advice for you except that this idea is dumb.”
Yea. I guess I don’t really vibe with this forum either. I’ll stop posting.

Thanks for the advice that my dream is idiotic. 🤘🏽

 

[deleted1074007]

Maybe I will do just fm. Maybe just EM.
Maybe I’ll have a completely different schedule than what I shared. I came up with it on the fly.
All I was posting about was a logistical question on how people have done it in the past. Not ideas on why it won’t work.

I hope you all have fulfilling careers and lives as wel. Bye!

 

[ortnakas]

Maybe I will do just fm. Maybe just EM.
Maybe I’ll have a completely different schedule than what I shared. I came up with it on the fly.
All I was posting about was a logistical question on how people have done it in the past. Not ideas on why it won’t work.

I hope you all have fulfilling careers and lives as wel. Bye

What you’re being told is that it hasn’t been done in the (recent) past because it unfortunately logistically won’t work in today’s world. It isn’t abad dream just not a very realistic one.

Best of luck.

 

[Candidate2017]

The closer I was to med school, the more I was focused on not wanting to "give things up."

The further I get, the more I realize that the goals of employment, and certainly not in a field medicine, is not for employees to avoid boredom or do lots of things so they feel really cool and accomplished.

Exactly.

The point of being a physician is to become an expert in the common 7-10 medical conditions in one's field to best help patients. It helps personal satisfaction to treat conditions and patient populations in which you are interested, but the primary purpose is to serve patients, rather than patients serving our needs to do "cool" stuff. Being able to do cool stuff is sort of the purpose of an attending paycheck.

But med student gonna med student. It's understandable though, because med school is set up in month to month classes and rotations, which creates a voyeuristic effect and conditions med students to constantly need to see new things without actually being mired in the actual daily work and process of obtaining expert competence.

 

[mvenus929]

Lol. I appreciate the replies but it’s kind of classic physician isn’t it? Someone says this is what I want to do with my life/health choices, and physician says “no that’s dumb. You can’t. Do this instead. I have no other advice for you except that this idea is dumb.”
Yea. I guess I don’t really vibe with this forum either. I’ll stop posting.

Thanks for the advice that my dream is idiotic. 🤘🏽

Yes, as physicians we are saying 'I don't think what you want to do is in your best interest long term, this is what I would recommend based on my knowledge and experience as an expert in this field.' A person with hypothyroidism comes in demanding Armor thyroid or to be taken off levothyroxine. They want to feel better, don't want the fatigue that they associate with their thyroid condition (rather than, say, life), but doing what they want isn't going to meet their goals. That's what we're trying to get from you--what is it, exactly, that you're hoping to gain from doing both FM and EM? Because chances are, you'll end up mediocre at both. It sounds like you want to be a good physician--we also want that for you. People here have brought up concerns related to burnout (a very real problem), skill atrophy, training duration, and real considerations related to the job market. If you make a powerful enough argument, those concerns may be moot.

But, as you don't care for the collective SDN wisdom, we wish you the best and hope that you're able to figure out what you want out of your career.

 

[Dral]

Op, this is the sort of thread that I predict you'll look back on (or think of) 10 years down the road and maybe cringe a little...maybe not...hopefully not...but...

I remember thinking back in med school that I wanted to do a field but make changes to it to get more patient care (without going into specifics). Other people in the thread rolled their eyes at me and told me how it just didn't make sense. I look back on that thread/discussion and just cringe so hard I can barely stand it. I thought as a medical student with little experience that I could make it work and be good at one thing and apply it to another and really change things. I was just clueless. I'm not accusing you of that per se, but I'm just relating my experience.

I currently practice in two different but related fields. I can tell you that knowledge decay is a real thing. I practice more in one field and just over the course of a few years I perceive that I'm just not as knowledgeable in the other field any longer. As others have asserted, this translates into care that is not as optimal as if the patient was seeing one of my colleagues who practices in that aspect of the field more often than I. In fact, I have since pretty much stopped practicing in that realm because of that very concept.

I know of some people in my field who are superstars who can do both. They are remarkable people though. We all go through the phase where we feel we will be able to do it all...then reality hits.

We're not here to say you are not one of those people who can do both or multiple things well. They exist. We are here to give you our experiences so you think long and hard before you move forward with putting your eggs in more than one basket. We are trying to save you time and lost capital by telling you it is extremely difficult (though not theoretically impossible) to practice the way you envision in today's medical environment.

 

[Ali23]

Hey! I've looked all over the forum and can't find any recent good answers for this.

I've been thinking about this for all three years I've been in school so far. So while some may judge me for this post, I feel my desire to pursue this is significant to me. I'd like to practice in primary care and in the ED.
I am familiar with some of the pathway options to do this (in no particular order):
1. FM residency and practice ED shifts in a rural setting.
2. FM residency and EM fellowship.
3. Same thing as above but IM residency.
4. Dual residency programs (FM/EM, IM/EM)
5. EM residency with a focused primary care practice following a relevant fellowship (like primary care sports med or addiction med).

Was wondering if anyone has any input on which choice would be the most straight forward and give the best chance of achieving this career.

Specifics to my situation:
I'm interested in small town/rural practice and eventually some global medicine.
I am not convinced that option 1 is a guarantee to work out. Seems more like something that just has to fall into place with the community you move to and the skills you obtain along the way. Actively modifying my day to day training to obtain a completely new skill set (IE: being a family med resident who spends a lot of extra time in the ED because they know they want to do both) seems like a big challenge. I would like a more solid pathway option if possible. I'd also like the option to work at level 2 or level 1 trauma centers if my life leads me to a less rural setting. Everyone I've talked to says it doesn't happen for Fam Med docs doing EM.

The option I'm most interested in is option 5. I like sports med and am considering that even if I pursued other residencies.

I wish there was Fellowships for EM docs to do primary care. Seeing as the reverse option is there (FM to EM fellowship), and with the apparent saturation of the EM field, I don't really understand why we haven't created a primary care fellowship for EM docs.

If I was to pursue option 4 (dual residency), they seem to be competitive. I am a decent residency candidate but not a rock star. Decent US med school. Decent step 1 score. Slightly above average numbers and decent evals. Would rather not spend five years in residency though. But may be up for it, if the career I want is there. Does anyone have any input on those?

Are there any other options I haven't thought of? Thanks for the help!

I listened to a podcast about a pediatrician in a rural setting and she did a lot of EM . She was the only pediatrician for 75,000 square miles. She basically did it all and if someone was too sick she stabilized them to transfer them. So I feel like if you are in a rural setting you will get to do more EM than you think.

 

[deleted1074007]

Again. I appreciate the feedback.
But I feel negativity towards someone’s goals is one of the worst things about our field.
My previous career was in the military.
The attrition rate for someone in certain Spec Ops training groups is >95%.
But if someone voiced a desire to try out, and was willing to work hard- the individual was given enough respect to pursue it and try. And I NEVER heard of someone being told their ideas were unrealistic, even though for most men trying out for these spots, they almost always were. And most dropped out.

If I keep hanging around here it’s just going to go in circles.
I qualified the unrealistic possibilities in my initial post by saying I’m interested in diverse options to do this pathway. One of the most interesting to me is sports med after an EM residency.
Which has a very large number of people also pursuing.
And the EM/FM or EM/IM pathways exist. The very fact that these residency positions exist speaks contrary to every negative voice here.
So ya. I’m an immature, cringe worthy med student. And I don’t know any of you and if you want to tell me I’m an idiot, cool!
I simply don’t care. And will be pursuing what my heart is telling me to do (because contrary to what you say, it is possible) regardless of your expertise and world-class clinic acumen.
And if I don’t make it, I will do that on my terms. Having tried. And having sought encouragement and direction. And I will find a career that fulfills me regardless.
I came just to ask if anyone knew about this pathway. Instead of putting it down, if you didn’t think it was possible, you could just simply… not say anything???

 

[Crayola227]

Again. I appreciate the feedback.
But I feel negativity towards someone’s goals is one of the worst things about our field.
My previous career was in the military.
The attrition rate for someone in certain Spec Ops training groups is >95%.
But if someone voiced a desire to try out, and was willing to work hard- the individual was given enough respect to pursue it and try. And I NEVER heard of someone being told their ideas were unrealistic, even though for most men trying out for these spots, they almost always were. And most dropped out.

If I keep hanging around here it’s just going to go in circles.
I qualified the unrealistic possibilities in my initial post by saying I’m interested in diverse options to do this pathway. One of the most interesting to me is sports med after an EM residency.
Which has a very large number of people also pursuing.
And the EM/FM or EM/IM pathways exist. The very fact that these residency positions exist speaks contrary to every negative voice here.
So ya. I’m an immature, cringe worthy med student. And I don’t know any of you and if you want to tell me I’m an idiot, cool!
I simply don’t care. And will be pursuing what my heart is telling me to do (because contrary to what you say, it is possible) regardless of your expertise and world-class clinic acumen.
And if I don’t make it, I will do that on my terms. Having tried. And having sought encouragement and direction. And I will find a career that fulfills me regardless.
I came just to ask if anyone knew about this pathway. Instead of putting it down, if you didn’t think it was possible, you could just simply… not say anything???

But we do know about the pathway. We've discussed combined programs and also rural primary care.

And the fact there are so few combined spots speaks nothing to you? How does that not support what people here have told you?

You need to talk to recent grads of these combined programs. The programs themselves may even help put you in contact. They will be the best sources of why their program exists and what grads can expect to be able to do after.

I don't think EM trained physicians are doing sports med fellowships in order to hang out a shingle and open up their own primary care practice. Most EM people I know doing most fellowships are doing it to augment skills they use while working in their primary practice environment - the ED. I can see sports medicine be useful in the ED. I can't see a sports medicine fellowship allowing an EM-trained physician to become someone's PCP.

I don't know what is involved in training for special ops. Is that an additional 1-2 years of training that leads nowhere?

Plus no one is going to argue there isn't a need for people to do Special Ops. So the analogy with combined EM/IM Or FM/EM pathways is extremely flawed.

Would you ever suggest to someone that dropped out of Special Ops training that there was another pathway to Special Ops if there wasn't one?

We have already told you the best ways to practice primary care and to include some emergency medicine into your practice, you just don't like what those pathways are. This is akin to someone wishing there was some way to be Special Ops despite washing out of a training group.

Also, newsflash. Medicine only has a few parallels to the military. Medicine is not the military.

 

[deleted1074007]

But we do know about the pathway. We've discussed combined programs and also rural primary care.

And the fact there are so few combined spots speaks nothing to you? How does that not support what people here have told you?

You need to talk to recent grads of these combined programs. The programs themselves may even help put you in contact. They will be the best sources of why their program exists and what grads can expect to be able to do after.

I don't think EM trained physicians are doing sports med fellowships in order to hang out a shingle and open up their own primary care practice. Most EM people I know doing most fellowships are doing it to augment skills they use while working in their primary practice environment - the ED. I can see sports medicine be useful in the ED. I can't see a sports medicine fellowship allowing an EM-trained physician to become someone's PCP.

I don't know what is involved in training for special ops. Is that an additional 1-2 years of training that leads nowhere?

Plus no one is going to argue there isn't a need for people to do Special Ops. So the analogy with combined EM/IM Or FM/EM pathways is extremely flawed.

Would you ever suggest to someone that dropped out of Special Ops training that there was another pathway to Special Ops if there wasn't one?

We have already told you the best ways to practice primary care and to include some emergency medicine into your practice, you just don't like what those pathways are. This is akin to someone wishing there was some way to be Special Ops despite washing out of a training group.

Also, newsflash. Medicine only has a few parallels to the military. Medicine is not the military.

Glad your not my doc broooooo

 

[Crayola227]

Glad your not my doc broooooo

Lol is that supposed to hurt me? I'm not talking to you in that capacity, anyway.

 

[TulaneUnderdog]

I’m IM PGY so definitely have biases here but I’m also being blunt and honest.

EM is a field encroached at multiple fronts. PAs/NPs on one and PCPs on the other. Our program even allows us to moonlight in rural EDs for $120/h and were not even ER docs nor attendings; businesses I guess realises if NPs can do it, then any doctor can. Our third years do two shifts a month to double the salary.

The truth is now that doors are open, we no longer care for ED. It’s a fun thrill while you’re young but just like strip-poker, beer pong, tinder dating, and crypto mining — the fun stops and never regains appeal. I’d rather PCP, or fellow into a sub clinical specialty even at less $/h just for the job stability and geographic preference. And the truth is: ED opportunity will always be there . Type any Locums ED hiring keyword and it’ll say “recruiting ABEM ABFM or ABIM” with … “ACLS” “ER hours”. it’s the lowest hanging fruit , why not shoot higher

 

[LadyDustyBlue]

I listened to a podcast about a pediatrician in a rural setting and she did a lot of EM . She was the only pediatrician for 75,000 square miles. She basically did it all and if someone was too sick she stabilized them to transfer them. So I feel like if you are in a rural setting you will get to do more EM than you think.

Yeah, okay. But how long can she keep that up and what’s her lifestyle like? Is she single? If she’s on this podcast, it’s not just to showcase her, it’s likely that she’s advocating for more hired doctors who can come her way, perhaps more hospitals, etc. since she knows that her job is restrictive on her life & the quality goes down when the ones treating you aren’t able to get to you in time.

Even the greatest at what they do, get tired, and make mistakes.

I don’t think people on SDN are saying that it’s impossible, they just want to emphasize where they feel the system as it is may present bumps in the road or walls that may impede on OP’s chosen path. Like it’s fine if he wants to do a double residency and eventually do rural medicine. But I’m not sure it’s necessary, given that EM isn’t looking too great right now.

I’m IM PGY so definitely have biases here but I’m also being blunt and honest.

EM is a field encroached at multiple fronts. PAs/NPs on one and PCPs on the other. Our program even allows us to moonlight in rural EDs for $120/h and were not even ER docs nor attendings; businesses I guess realises if NPs can do it, then any doctor can. Our third years do two shifts a month to double the salary.

The truth is now that doors are open, we no longer care for ED. It’s a fun thrill while you’re young but just like strip-poker, beer pong, tinder dating, and crypto mining — the fun stops and never regains appeal. I’d rather PCP, or fellow into a sub clinical specialty even at less $/h just for the job stability and geographic preference. And the truth is: ED opportunity will always be there . Type any Locums ED hiring keyword and it’ll say “recruiting ABEM ABFM or ABIM” with … “ACLS” “ER hours”. it’s the lowest hanging fruit , why not shoot higher

^ That last paragraph is something I hear often off AND on SDN. So I’m not really surprised by anyone who has responded to OP by trying to give rationales as to why choosing one over the other may very well be the outcome… even after sacrificing years to do a “double residency”.

Personally, I’d feel better if my interests were yours but doing FM or IM first and then seeing what the market/economy does in a few years after that.

Be flexible because regardless what residency you choose, you gotta think about what the community/population you want to serve needs prior to ED. The fact is, it’s likely their needs that are everyday and preventative via being able to see a doctor.

Whatever your decision, OP. There won’t be a perfect schedule but you can make certain that you’re good at the things people need that happen to match your interests. That’s all & no one here is bullying you, just advising you.

No need for backlash. It’s just tough love from people who’ve been there & back again & see the signs before you do (as it is now). Do what you will with it.

Perhaps you’re only responding in such a way because you’re scared to make the wrong decision & no one else has accomplished the things you want. There aren’t enough examples.

No one here knows you or your goals entirely, so you don’t have to prove anything. It’s SDN. You came here for advice to scope it out farther than you had already. Now you know, but time w/ your choices will test what you actually understand from this system you’re about to work in.

Rural medicine is awesome and I hope you do it, seriously.

I can only imagine what my grandmother’s province in the Philippines would be like, if they had more than 1 doctor in town. It’s still like that even now.

If that’s what you’re passionate about (but in the U.S.), go be that physician.

 

[Rekt]

I’m IM PGY so definitely have biases here but I’m also being blunt and honest.

EM is a field encroached at multiple fronts. PAs/NPs on one and PCPs on the other. Our program even allows us to moonlight in rural EDs for $120/h and were not even ER docs nor attendings; businesses I guess realises if NPs can do it, then any doctor can. Our third years do two shifts a month to double the salary.

The truth is now that doors are open, we no longer care for ED. It’s a fun thrill while you’re young but just like strip-poker, beer pong, tinder dating, and crypto mining — the fun stops and never regains appeal. I’d rather PCP, or fellow into a sub clinical specialty even at less $/h just for the job stability and geographic preference. And the truth is: ED opportunity will always be there . Type any Locums ED hiring keyword and it’ll say “recruiting ABEM ABFM or ABIM” with … “ACLS” “ER hours”. it’s the lowest hanging fruit , why not shoot higher

This is just floridly wrong on so many levels. The only people that do more harm in the ED than IM trained docs is mid levels. I also moonlight in 5-6 rural shops in my state. I spend several hours per shift cleaning up IM messes or seeing their bounce backs. And see my post above about availability of jobs coming to an end. You have no idea what you're talking about.

 

[Splenda88]

Do a combine program (FM/EM) and spit your time 60/40. (3 days FM and 2 day EM)

The idea that people say you won't be good at both is BS. There is a significant overlap between the two. 2 days/wk working EM is close to a FT employment.

The question is: will you be able to keep that up for >5 yrs? EM work is no joke... and you will see that once you rotate in the ED as a resident (not as a med student). You will be seeing 10-12 patients as a resident and you will get tired. Imagine that a BC EM doc has to see twice of that! That is no freaking joke.

 

[mvenus929]

I listened to a podcast about a pediatrician in a rural setting and she did a lot of EM . She was the only pediatrician for 75,000 square miles. She basically did it all and if someone was too sick she stabilized them to transfer them. So I feel like if you are in a rural setting you will get to do more EM than you think.

Probably more reflective of her being a pediatrician than anything else. Family medicine doctors are great, but they don't get as much training in kids as pediatricians do and often don't see as much pathology. EM docs also don't see a super high volume of pediatrics, because they tend not to get sick as much. The transfers I get from rural hospitals for my patients (mostly diabetes) aren't usually managed appropriately because they go by adult care guidelines and there are nuances to pediatric care that people forget.

So, it does not surprise me that a rural pediatrician can easily have this set-up, but I agree with the poster above--there's still lots of potential for burnout there.

 

[Dral]

Again. I appreciate the feedback.
But I feel negativity towards someone’s goals is one of the worst things about our field.
My previous career was in the military.
The attrition rate for someone in certain Spec Ops training groups is >95%.
But if someone voiced a desire to try out, and was willing to work hard- the individual was given enough respect to pursue it and try. And I NEVER heard of someone being told their ideas were unrealistic, even though for most men trying out for these spots, they almost always were. And most dropped out.

If I keep hanging around here it’s just going to go in circles.
I qualified the unrealistic possibilities in my initial post by saying I’m interested in diverse options to do this pathway. One of the most interesting to me is sports med after an EM residency.
Which has a very large number of people also pursuing.
And the EM/FM or EM/IM pathways exist. The very fact that these residency positions exist speaks contrary to every negative voice here.
So ya. I’m an immature, cringe worthy med student. And I don’t know any of you and if you want to tell me I’m an idiot, cool!
I simply don’t care. And will be pursuing what my heart is telling me to do (because contrary to what you say, it is possible) regardless of your expertise and world-class clinic acumen.
And if I don’t make it, I will do that on my terms. Having tried. And having sought encouragement and direction. And I will find a career that fulfills me regardless.
I came just to ask if anyone knew about this pathway. Instead of putting it down, if you didn’t think it was possible, you could just simply… not say anything???

I never said you were cringeworthy (as you alluded to in your above post). I said you may cringe when you look back on it later (but hopefully not). Please don't twist my words.

Anyway, good luck. Try not to take the things we are saying personally. I'm sure there are many rural areas where you can make what you want to do work. We are just trying to give some insight and experiences (at least I was) that could help you make decisions along the way. If you haven't already, maybe try going to the EM or FM forums. You may get more information on the specifics/outlook of your career plans. There is also a combined residency forum, but I don't think it gets much movement.

This forum may be of particular help to you. Though again, it seems it doesn't get much movement:

Rural & Underserved Communities

A forum for discussion of medicine in rural and underserved communities.

forums.studentdoctor.net

 

[CyrilFiggis]

OP what year are you? In May SAEM holds a residency fair at their annual meeting. All the FM/EM programs are there. Or if you can’t make that, email the programs and ask what their grads are doing and where they are working. They are receptive to hearing from you. You can imagine what that career holds, or just get the data straight from the horse’s mouth.

As for all the other noise, you’re hearing from a lot of voices who aren’t EM trained docs. This obviously wasn’t their career choice so of course they aren’t going to speak emphatically about the field. But I’ll say this, if anyone in my family had to go to an ED, I’d be scared to let an IM moonlighter just there to “double their salary” try to intubate, put in a chest tube, reduce an ischemic limb or deliver a baby.

 

[Lawpy]

I'm shocked EM is even being considered given the disastrous state of the job market

 

[Dral]

Is it that bad that even rural areas are significantly affected? I ask mainly just out of curiosity.

 

[CyrilFiggis]

Is it that bad that even rural areas are significantly affected? I ask mainly just out of curiosity.

Rural areas aren’t as affected

 

[Lawpy]

Rural areas aren’t as affected

I thought there were more EM physicians than all of EM jobs from that report iirc a while ago?

 

[Crayola227]

OP what year are you? In May SAEM holds a residency fair at their annual meeting. All the FM/EM programs are there. Or if you can’t make that, email the programs and ask what their grads are doing and where they are working. They are receptive to hearing from you. You can imagine what that career holds, or just get the data straight from the horse’s mouth.

As for all the other noise, you’re hearing from a lot of voices who aren’t EM trained docs. This obviously wasn’t their career choice so of course they aren’t going to speak emphatically about the field. But I’ll say this, if anyone in my family had to go to an ED, I’d be scared to let an IM moonlighter just there to “double their salary” try to intubate, put in a chest tube, reduce an ischemic limb or deliver a baby.

To be fair, the point where OP told me to eat a Richard was also when I told OP to actually contact the combined programs and see if they had any recent grads to talk to.

And a few EM trained people such as yourself also chimed in here. Many others such as myself are primary care trained. I think primary care trained people certainly have a valid viewpoint on what schedules are like and how much primary care trains you for practicing EM (hint, not enough).

I am not EM trained, but I was EM or primary care bound as an MS4, did rotations to apply to both, and also did the leg work on researching both career paths and with interest in combining them. I was also advised by a close family member that did BOTH an IM AND an EM residency in succession. Went to a 4 year program even. So that person can most definitely speak to what training in both fields is like more than most.

So I wouldn't say that OP hasn't been advised by people that aren't qualified to offer the advice that they offered. One IM resident that moonlights made a comment, but they're not necessarily wrong that it is possible to pick up shifts in some settings. That said, the bulk of people have questioned the wisdom of that for various reasons.