Board Certification for Family Physicians in Emergency Medicine

[DoctahB]

Good evening, all. After having read several of the threads here in this forum regarding EM vs. FM + EM fellowship, I would like to take a different angle on this question that I have not yet seen addressed.

FP's who become boarded in EM.

From what I saw on the website link below, FPs may either do a select fellowship and become board certified or work full time in an ED x5y and become board certified.

Family Physicians in Emergency Medicine | ABPS | AAPS

With this, my question: are EM-boarded FPs allotted the same opportunities both in where one can work (eg: level I trauma center, EMS medical director, EM fellowship opportunities) and income opportunity as EM-residency-trained physicians?

My target response audience: courteous, respectful FPs with either direct or indirect experience/knowledge of the above.

Thank you, and please be nice.

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[smq123]

This has been discussed before.

Be very wary of anything that the ABPS tries to sell you. They are a minority group, and their certification is not universally recognized at this time.

 

[DoctahB]

What certification is universally recognized?

 

[smq123]

What certification is universally recognized?

ABMS.

 

[DoctahB]

So, doing some more digging, it looks like ABPS is accepted by at least 50 of the 70 state medical boards - would this not have the final say then?

 

[smq123]

So, doing some more digging, it looks like ABPS is accepted by at least 50 of the 70 state medical boards - would this not have the final say then?

No.

What really matters is whether or not the hospital accepts it. You’re saying that less than 75% of state medical boards accept ABPS certification, which makes it VERY likely that the hospital/emergency department you’re applying for won’t accept it at all.

If you want to guarantee that you can work in a Level 1 trauma center, do EM. Don’t backdoor it.

 

[DoctahB]

Personally I'm not sold on the glory of lvl 1 trauma. I'm more interested in local EMS Med Directorship, which I've heard of FPs doing even without fellowship training. So, I guess that makes the discussion up to this point unnecessary.

 

[smq123]

Personally I'm not sold on the glory of lvl 1 trauma. I'm more interested in local EMS Med Directorship, which I've heard of FPs doing even without fellowship training. So, I guess that makes the discussion up to this point unnecessary.

If you’re not that interested in level 1 trauma, why did you ask about it?

Also, I don’t know if it is common for FM physicians to become EMS directors, but make sure that they’re the norm, and not just exceptions. Common things being common, MOST FM physicians will follow the typical FM path - i.e. outpatient primary care.

 

[LeroyJenkinsMD]

Obtaining ABPS certification in EM is a rigorous process and will likely leave you feeling qualified to work in emergency departments where you will be offered jobs, level two and below. Whether or not a FM with EM fellowship is equivalent to an EM residency trained graduate is up for endless debate. There is of course wide variation in quality among individuals that depends on more than where one spent 3-4 years.

 

[Make Or Break]

No they are not afforded the same privileges. Working level 1 is mostly an EM’s turf nowadays. Income wise, I know multiple level 4 fm docs who solely do em making 260-280k for 11 12 hour shifts. Not exactly em money but it is a level 4. They also do telemedicine and pick up shifts in other ER’s for both experience and extra money so I’m sure they are clearing 300k but they are also working more than 11 shifts to get there.

I’ve talked to a few FM grads who are working in level 2’s but I didn’t ask their salary so not sure how it compares to EM’s. I also know of a FM grad who is now the director of an ED in a smaller city. Lots of opportunity out there. Just have to go to a residency that will give you the opportunity to hone in on EM skills which is becoming a rarity these days.

 

[BigSib]

I work about 60% outpatient, 20% inpatient, 5% emergency, 10% nursing home, 5% other in a rural setting. Everyone working in the ER makes the same hourly wage here. The majority of ED attendings for the day are not board certified in ER. They're so hard up for doctors taking shifts I'm sure they would take someone who was not board certified in anything.

 

[LeroyJenkinsMD]

EM jobs around here pay FM residents 180-220/hr. Which would be 463k per year for 14 12 hr shifts per month. You would of course have to spend your life in the ER full time which is back breaking circadian rhythm chaos. Weekend coverage supplementing a four day clinic work week is great occasional cash however.

 

[Sardonix]

I work about 60% outpatient, 20% inpatient, 5% emergency, 10% nursing home, 5% other in a rural setting. Everyone working in the ER makes the same hourly wage here.

How common would you say that balance is? Because a spread like that sounds really appealing.

 

[Lexdiamondz]

If you want to be board certified in EM, do an EM residency. Why anyone would want to not train for the job they want is beyond my understanding

 

[LeroyJenkinsMD]

If you want to be board certified in EM, do an EM residency. Why anyone would want to not train for the job they want is beyond my understanding

People don’t want to do an EM residency if they only plan to practice in the ED part time and are already comfortable in the ED they chose to work in due to prior training.

 

[Lexdiamondz]

People don’t want to do an EM residency if they only plan to practice in the ED part time and are already comfortable in the ED they chose to work in due to prior training.

But just because you don't want to do something full time, doesn't mean you can shirk the training necessary to do that job. I can tube, sedate, block and manage a vent but that wouldn't necessarily make me qualified to be a part time-anaesthesiologist regardless of how comfortable I think I am in the OR.

Idk, maybe I'm missing something but I don't really understand how someone could be comfortable not seeking training in a job they weren't actually trained for, and why they would want to be board certified in a job they didn't train for and don't have plans on practicing full time.

 

[Sardonix]

But just because you don't want to do something full time, doesn't mean you can shirk the training necessary to do that job. I can tube, sedate, block and manage a vent but that wouldn't necessarily make me qualified to be a part time-anaesthesiologist regardless of how comfortable I think I am in the OR.

Idk, maybe I'm missing something but I don't really understand how someone could be comfortable not seeking training in a job they weren't actually trained for, and why they would want to be board certified in a job they didn't train for and don't have plans on practicing full time.

This is why I've stopped offhandedly mentioning to ER docs that I like the idea of moonlighting as an FM. As much as I like the idea of having what I want from both worlds I would be scared to handle a code that I wasn't full trained on.

 

[LeroyJenkinsMD]

But just because you don't want to do something full time, doesn't mean you can shirk the training necessary to do that job. I can tube, sedate, block and manage a vent but that wouldn't necessarily make me qualified to be a part time-anaesthesiologist regardless of how comfortable I think I am in the OR.

Idk, maybe I'm missing something but I don't really understand how someone could be comfortable not seeking training in a job they weren't actually trained for, and why they would want to be board certified in a job they didn't train for and don't have plans on practicing full time.

I’ve heard the arguments. Just answering your question. The eventual board certification in trauma bay medicine won’t make your EM residency skills obsolete. Medicine is addicted to specializing in order to win turf battles. Doesn’t mean the certification is necessary for every job. Hospitals decide who is qualified, not the academic overlords, despite their attempts.

 

[Lexdiamondz]

I’ve heard the arguments. Just answering your question. The eventual board certification in trauma bay medicine won’t make your EM residency skills obsolete. Medicine is addicted to specializing in order to win turf battles. Doesn’t mean the certification is necessary for every job. Hospitals decide who is qualified, not the academic overlords, despite their attempts.

Not needing certification and not having the training are two completely different things. But let's agree to disagree.

 

[shepardsun]

I can tube, sedate, block and manage a vent but that wouldn't necessarily make me qualified to be a part time-anaesthesiologist regardless of how comfortable I think I am in the OR.

It's weird to me how competency in some areas of an overlapping specialty make some people feel they are entitled to practice the full spectrum of it, and be exposed to the rare, complex situations the formal training programs are designed to prepare you for. It comes across as borderline disrespectful to me- before anesthesia I did peds, and as such had decent outpatient exposure. Now I know a little more about adult disease processes and physiology- but I would never claim to be able to combine the two and do family medicine clinic in place of a board certified family medicine physician.

Similarly- I know a lot of great family medicine physicians who do inpatient hospital medicine, but exposure to higher acuity patients and some procedural training doesn't mean they are then qualified to go down to the ED and do thoracotomies and run traumas.

 

[LeroyJenkinsMD]

Ok, so we agree the certification doesn’t matter then. It’s the training. Can you be more specific about the training FM is lacking?

 

[LeroyJenkinsMD]

It's weird to me how competency in some areas of an overlapping specialty make some people feel they are entitled to practice the full spectrum of it, and be exposed to the rare, complex situations the formal training programs are designed to prepare you for. It comes across as borderline disrespectful to me- before anesthesia I did peds, and as such had decent outpatient exposure. Now I know a little more about adult disease processes and physiology- but I would never claim to be able to combine the two and do family medicine clinic in place of a board certified family medicine physician.

Similarly- I know a lot of great family medicine physicians who do inpatient hospital medicine, but exposure to higher acuity patients and some procedural training doesn't mean they are then qualified to go down to the ED and do thoracotomies and run traumas.

Most hospitals would agree that managing 5,000 more chest pains in EM residency is marginally better when you are pan scanning people head to toe, trending ekgs/troponins, and consulting cardiology/CT surgery. Because you have limited your training to win a turf battle, does not mean you can project your weaknesses onto other specialties.

 

[VA Hopeful Dr]

Ok, so we agree the certification doesn’t matter then. It’s the training. Can you be more specific about the training FM is lacking?

Well in my FM program we had 6 weeks of time in the ED.

The closest EM program geographically had 36 weeks in the ED intern year alone.

 

[Lexdiamondz]

Ok, so we agree the certification doesn’t matter then. It’s the training. Can you be more specific about the training FM is lacking?

Actually we don't agree on that at all.

As for what is lacking in FM training in regards to working in the ED, it's a few things. While the difference in exposure to trauma, critical care and resuscitation is an obvious difference, the amount of exposure to undifferentiated sick patients with the potential to decompensate is probably the most significant deficit in FM training as far as working in the ED is concerned. Medical and trauma resuscitation are core skills that are essential for a competent ED physician, but being able to sniff out the patient with stable vitals that is going to crump in the next 12 hours is essential for a good ED physician and that comes with exposure - exposure you simply don't get if you haven't spent enough time in the ED being mentored by experienced ED physicians.

Most hospitals would agree that managing 5,000 more chest pains in EM residency is marginally better when you are pan scanning people head to toe, trending ekgs/troponins, and consulting cardiology/CT surgery. Because you have limited your training to win a turf battle, does not mean you can project your weaknesses onto other specialties.

I've said this before, but the fact that you think this is what constitutes EM practice illuminates quite clearly how little you actually know about the field.

 

[LeroyJenkinsMD]

Alright, let’s all stay calm, focused and on task since those are good EM skills. Just trying to follow your logic here. So the certification (piece of paper) matters, and you have also personally evaluated all FM programs. During your survey of all FM programs you have determined there are no FM residencies that have significant “exposure” to ED cases. There are no FM residencies where the FM residents run trauma, codes, work in the ED for several months during residency and also obtain thousands of hours moonlighting. This never occurs. There is also no such thing as a one year fellowship where FM residents are directly mentored by boarded EM physicians for an additional full year. If that’s your honest assessment, I think we’re all done here. I can’t constructively converse with that kind of rationale.

 

[smq123]

Alright, let’s all stay calm, focused and on task since those are good EM skills. Just trying to follow your logic here. So the certification (piece of paper) matters, and you have also personally evaluated all FM programs. During your survey of all FM programs you have determined there are no FM residencies that have significant “exposure” to ED cases. There are no FM residencies where the FM residents run trauma, codes, work in the ED for several months during residency and also obtain thousands of hours moonlighting. This never occurs. There is also no such thing as a one year fellowship where FM residents are directly mentored by boarded EM physicians for an additional full year. If that’s your honest assessment, I think we’re all done here. I can’t constructively converse with that kind of rationale.

If an EM-heavy FM residency + a 1 year EM fellowship afterwards makes you competent to be an EM physician, then why even do an EM residency? Why do they exist? In what instance would you recommend someone actually do an EM residency?

 

[VA Hopeful Dr]

If an EM-heavy FM residency + a 1 year EM fellowship afterwards makes you competent to be an EM physician, then why even do an EM residency? Why do they exist? In what instance would you recommend someone actually do an EM residency?

Its almost like there was a time at some point where FPs and others did run EDs. Its also almost like the outcomes sucked and so it was decided that we needed dedicated doctors in the ED with training directed specifically at emergency medicine.

 

[deleted859535]

Its almost like there was a time at some point where FPs and others did run EDs. Its also almost like the outcomes sucked and so it was decided that we needed dedicated doctors in the ED with training directed specifically at emergency medicine.

Weird. So what you're saying is that EM is its own specialty, with its own board, with its own specific training and core abilities? And that if I decide to show up to an ED and am critically ill, I should see someone who actually has trained on emergencies specifically for years?

 

[smq123]

Weird. So what you're saying is that EM is its own specialty, with its own board, with its own specific training and core abilities? And that if I decide to show up to an ED and am critically ill, I should see someone who actually has trained on emergencies specifically for years?

Psh, get out of here with that kind of crazy talk!

 

[VA Hopeful Dr]

Weird. So what you're saying is that EM is its own specialty, with its own board, with its own specific training and core abilities? And that if I decide to show up to an ED and am critically ill, I should see someone who actually has trained on emergencies specifically for years?

It's bizarre. Especially since apparently any FP can do your job just as well anyway.

 

[Lexdiamondz]

Its almost like there was a time at some point where FPs and others did run EDs. Its also almost like the outcomes sucked and so it was decided that we needed dedicated doctors in the ED with training directed specifically at emergency medicine.

Please don't kill em with your common sense.

Alright, let’s all stay calm, focused and on task since those are good EM skills. Just trying to follow your logic here. So the certification (piece of paper) matters, and you have also personally evaluated all FM programs. During your survey of all FM programs you have determined there are no FM residencies that have significant “exposure” to ED cases. There are no FM residencies where the FM residents run trauma, codes, work in the ED for several months during residency and also obtain thousands of hours moonlighting. This never occurs. There is also no such thing as a one year fellowship where FM residents are directly mentored by boarded EM physicians for an additional full year. If that’s your honest assessment, I think we’re all done here. I can’t constructively converse with that kind of rationale.

If you've obtained "thousands" of hours moonlighting in the ED while a full-time FM resident you're either A) a liar or B) flagrantly violating ACGME duty hours - so which is it?

Look, the people who founded EM were for the most part, IM and FM trained GPs w a few general surgeons who recognised that the training in IM, FM and GS was insufficient to consistently produce physicians who could safely practice in the emergency department. Literally people with (arguably more) training in your own specialty were the ones who decided that your training wasn't adequate to optimally practice emergency medicine. You're not arguing with my rationale - this was something that was recognised as a need more than three decades ago.

 

[LeroyJenkinsMD]

“Ooooo-rah! Goooo emergency medicine! Rah rah rah!!!! That guy is an idiot! Yea, he certainly is! I agree!”

Alright, now that that is out of the way. Back to facts.

1) >40% of EDs in the US are staffed with non EM boarded physicians. These facilities are not burning to the ground.

2) The specialty of EM was not created because patients were being slaughtered by FM physicians. EM was created because busy physicians of all specialties no longer felt like taking ER call on their own patients at all hours of the day. See the current hospital medicine movement as an example. Hospitalists were not created because IM and FM physicians suck at inpatient medicine. It’s a specialty created out of necessity to do the crap no one else wants to do anymore.

3) I did not say FM > EM at EM. I made the argument that FM physicians are capable of knowing which EM jobs they are qualified for based on the quality of their prior training. Hospitals agree with this. See fact #1.

 

[VA Hopeful Dr]

“Ooooo-rah! Goooo emergency medicine! Rah rah rah!!!! That guy is an idiot! Yea, he certainly is! I agree!”

Alright, now that that is out of the way. Back to facts.

1) >40% of EDs in the US are staffed with non EM boarded physicians. These facilities are not burning to the ground.

2) The specialty of EM was not created because patients were being slaughtered by FM physicians. EM was created because busy physicians of all specialties no longer felt like taking ER call on their own patients at all hours of the day. See the current hospital medicine movement as an example. Hospitalists were not created because IM and FM physicians suck at inpatient medicine. It’s a specialty created out of necessity to do the crap no one else wants to do anymore.

3) I did not say FM > EM at EM. I made the argument that FM physicians are capable of knowing which EM jobs they are qualified for based on the quality of their prior training. Hospitals agree with this. See fact #1.

Hospitals hire family physicians because they can't get for afford emergency physicians. There's nothing more to it.

 

[Make Or Break]

Hospitals hire family physicians because they can't get for afford emergency physicians. There's nothing more to it.

his point if you’re referring to number 1 is that these facilities are still running just fine even if they are staffed by fm

 

[Make Or Break]

I’ve talked to a few applicants on the trail and it’s scary the number of people who think 3-4 months of em electives in residency is enough to get by to work in the ED safely.

 

[VA Hopeful Dr]

his point if you’re referring to number 1 is that these facilities are still running just fine even if they are staffed by fm

But are they though? For all we know they could have 3X the mortality rate - we don't know.

 

[LeroyJenkinsMD]

But are they though? For all we know they could have 3X the mortality rate - we don't know.

This is a fair point. We should study it. The mortality rate could be way worse, could be the same, could be better. We don’t know. It would be hard to study however. Did rural sites do worse because of crappy FM doctors? Do rural sites do better because they ship sick people? Do referral centers do worse because of crappy EM physicians that just click order sets and rely on consultants? Do referral centers do better because of all the additional resources, specialties, etc? In the meantime we have to assume, the quality of care of places staffed with FM physicians at least meets a standard that is acceptable to society or these places would be closed.

 

[Vandalia]

This is a fair point. We should study it. The mortality rate could be way worse, could be the same, could be better. We don’t know. It would be hard to study however. Did rural sites do worse because of crappy FM doctors? Do rural sites do better because they ship sick people? Do referral centers do worse because of crappy EM physicians that just click order sets and rely on consultants? Do referral centers do better because of all the additional resources, specialties, etc? In the meantime we have to assume, the quality of care of places staffed with FM physicians at least meets a standard that is acceptable to society or these places would be closed.

Replace "emergency medicine" with "family medicine" and "family medicine" with either doc's who didn't complete a residency or NP/PA. One can argue that the fact they haven't shut down the "family care" practice with a NP whose only training was a 12 month internship with her sister means they are doing an acceptable job.,, and thus should have equal status in a family medicine practice.

 

[LeroyJenkinsMD]

Replace "emergency medicine" with "family medicine" and "family medicine" with either doc's who didn't complete a residency or NP/PA. One can argue that the fact they haven't shut down the "family care" practice with a NP whose only training was a 12 month internship with her sister means they are doing an acceptable job.,, and thus should have equal status in a family medicine practice.

You could argue that, and I could argue that it’s much easier to hide doing a crappy job in an outpatient clinic than it is in an emergency department.

And just to be clear, I could care less about status. I’m not making any claims that have anything to do with status. Take your status to the bank and let me know what you get for it.

 

[VA Hopeful Dr]

You could argue that, and I could argue that it’s much easier to hide doing a crappy job in an outpatient clinic than it is in an emergency department.

And just to be clear, I could care less about status. I’m not making any claims that have anything to do with status. Take your status to the bank and let me know what you get for it.

I believe status in his post refers to legal status which is actually amazing important in a regulated profession.

But I'm not surprised you didn't get that.

 

[LeroyJenkinsMD]

I believe status in his post refers to legal status which is actually amazing important in a regulated profession.

But I'm not surprised you didn't get that.

I believe status in his post was referring to magical unicorns, but I guess we’ll never know since he didn’t specify. I’m not surprised that you made an assumption.

 

[Lexdiamondz]

“Ooooo-rah! Goooo emergency medicine! Rah rah rah!!!! That guy is an idiot! Yea, he certainly is! I agree!”

Alright, now that that is out of the way. Back to facts.

1) >40% of EDs in the US are staffed with non EM boarded physicians. These facilities are not burning to the ground.

2) The specialty of EM was not created because patients were being slaughtered by FM physicians. EM was created because busy physicians of all specialties no longer felt like taking ER call on their own patients at all hours of the day. See the current hospital medicine movement as an example. Hospitalists were not created because IM and FM physicians suck at inpatient medicine. It’s a specialty created out of necessity to do the crap no one else wants to do anymore.

3) I did not say FM > EM at EM. I made the argument that FM physicians are capable of knowing which EM jobs they are qualified for based on the quality of their prior training. Hospitals agree with this. See fact #1.

Out of the above, literally only one of the things you said is a fact.

You're thoughts on EM are literally Dunning-Kruger put into words. Let's just agree to disagree and hope you don't kill anyone your first EM job out of residency.

 

[Vandalia]

I believe status in his post was referring to magical unicorns, but I guess we’ll never know since he didn’t specify. I’m not surprised that you made an assumption.

Status means being treated exactly the same in all respects - law, regulation, and employment situation. Should the guy who did two outpatient rotations during his only year of GME and then worked for 4 years in an urgent care clinic be able to have that partner position in a family medicine practice? A couple of years of practice is equal to a residency, right? Should NP/PA be able to prescribe C-II's the same as a physician? Should they have the same unrestricted license that physicians do? They claim to have statistics that their outcomes are as good as physicians. If they weren't as good as physicians, North Dakota wouldn't have given them independent practice rights, right? Should they be hired as partners rather than employees? Have the same membership on the hospital medical staff?

You are heading down a road I really don't think you want to go down. I knew a number of the founders of Family Medicine, they would be horrified by the idea that residency and the specialty were equivalent to someone else who could do basically sort of the same things without the residency.

 

[NITRAS]

.... In the meantime we have to assume, the quality of care of places staffed with FM physicians at least meets a standard that is acceptable to society or these places would be closed.

I just wanted to point out that I've taken calls from outside facilities, and continue to be astonished at the lack of basic medical knowledge of some physicians. Granted, I didn't ask them if they were trained as FM, EM or children's cereal maker. . . . the lines are recorded after all.

 

[Hamhock]

nevermind.

 

[VA Hopeful Dr]

I believe status in his post was referring to magical unicorns, but I guess we’ll never know since he didn’t specify. I’m not surprised that you made an assumption.

You have a funny way of saying "I was wrong", but to each his own I suppose.

 

[Sardonix]

I feel like this is the 5th FM-EM thread in a short period where the OP has a legitimate question and sincere desire for discussion... but then the LeroyJenkinsMD comes along starts a BS argument that eventually results in it getting locked.

 

[LeroyJenkinsMD]

Let’s see, first post.

“Obtaining ABPS certification in EM is a rigorous process and will likely leave you feeling qualified to work in emergency departments where you will be offered jobs, level two and below. Whether or not a FM with EM fellowship is equivalent to an EM residency trained graduate is up for endless debate. There is of course wide variation in quality among individuals that depends on more than where one spent 3-4 years.”

I don’t think that post is inflammatory at all. I think there are a lot of EM physicians that have a problem with my perspective, attack me, and then get their feelings hurt when I’m simply stating facts. I’m allowed to defend my perspective, and so is anyone else. Readers can make up their own minds. I hope everyone has a great day. No hard feelings about the additional unprofessional insults.

 

[Lexdiamondz]

Let’s see, first post.

“Obtaining ABPS certification in EM is a rigorous process and will likely leave you feeling qualified to work in emergency departments where you will be offered jobs, level two and below. Whether or not a FM with EM fellowship is equivalent to an EM residency trained graduate is up for endless debate. There is of course wide variation in quality among individuals that depends on more than where one spent 3-4 years.”

I don’t think that post is inflammatory at all. I think there are a lot of EM physicians that have a problem with my perspective, attack me, and then get their feelings hurt when I’m simply stating facts. I’m allowed to defend my perspective, and so is anyone else. Readers can make up their own minds. I hope everyone has a great day. No hard feelings about the additional unprofessional insults.

The only fact you ever state is that a significant number of EDs nationwide are staffed by non-EM trained physicians. The rest is more or less your (dubiously) informed opinions

 

[Make Or Break]

So what are the take home messages here? Should FM not practice in the ED? Or what are we trying to get at here? We are all attacking Leroy’s comments but I’m curious what EM thinks should be the solution to shortages in the ED’s.