Board Certification for Family Physicians in Emergency Medicine

[MedicineZ0Z]

Then I think the answer is a combined FM/EM residency. And maybe the answer is pushing more combined programs to open up, not claiming that 1 year of an ER fellowship, with a lot of EM-heavy electives, makes you "just as good."

They did a study, and I can find it in probably 2 mins, comparing FM to EM fellowship docs in Canada to 5 year EM residency trained. I think 3 or 5 years post practice, the outcomes were identical between the two.

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[VA Hopeful Dr]

They did a study, and I can find it in probably 2 mins, comparing FM to EM fellowship docs in Canada to 5 year EM residency trained. I think 3 or 5 years post practice, the outcomes were identical between the two.

Please do then

 

[Lexdiamondz]

And the US has way more ERs with infinitely more resources & residencies etc.
Try managing an over-packed ER with a 7 hour wait time as the only physician with no CT scanner and access to a fraction of the labs/tests. Can't get an airway? Tough luck, you have to. Outside of the veryyy few academic urban centers, most ED docs are seeing and doing a lot more solo, even in large community settings. The equivalent setting in USA would have an EM residency among other residencies in the hospital. Basically an army backs you up 24/7.

So either FM residents/med students are far better trained from day 1 over there, or... FM has the capability to handle ER work. But I do agree that MOST family med residents are not trained nor equipped to handle it at all. We're talking about ones who have had an interest in it from med school and developed skills over time for it, then later improve into early attending years.

You're literally describing every emergency room in NYC. That is literally my daily experience.

 

[MedicineZ0Z]

You're literally describing every emergency room in NYC. That is literally my daily experience.

You don't have a CT? You don't have resources in theory? And NYC is a very unique location given the whole nursing union thing among other unions/staff issues.

 

[Lexdiamondz]

You don't have a CT? You don't have resources in theory? And NYC is a very unique location given the whole nursing union thing among other unions/staff issues.

Machines break, dude.

Well basic criteria is prior ED experience.

There's also significant interest in ER and gearing all of your electives towards it. Occasionally some FM residents will do so, even longitudinally (working ER shifts all 3 years, going to the OR to intubate some mornings, etc.).

The reason we get this crossover is that there's major overlap with FM and EM, and lot of people like the idea of doing both and/or not full time ER forever. With outpatient to fall back on later.

You yourself pointed out that not all ED experience is the same. You can work in a VA as an IM trained physician in the ED for years and never see trauma, rarely intubate and never see women and supposedly meet your basic criteria.

Furthermore, a massive part of training and arguably the biggest benefit to doing an EM residency over just having EM "experience" is the structure and mentorship that comes with formal residency training. Having someone actually track your progress, given you constructive feedback and ensure you're meeting milestones is an integral part of learning to practice medicine and for the most part, you aren't going to get that level of involvement in EM-specific education outside of an EM residency.

Also, please stop implying going to the OR some mornings is an adequate substitute for actual difficult airway training. It's not.

 

[MedicineZ0Z]

Machines break, dude.




You yourself pointed out that not all ED experience is the same. You can work in a VA as an IM trained physician in the ED for years and never see trauma, rarely intubate and never see women and supposedly meet your basic criteria.

Furthermore, a massive part of training and arguably the biggest benefit to doing an EM residency over just having EM "experience" is the structure and mentorship that comes with formal residency training. Having someone actually track your progress, given you constructive feedback and ensure you're meeting milestones is an integral part of learning to practice medicine and for the most part, you aren't going to get that level of involvement in EM-specific education outside of an EM residency.

Also, please stop implying going to the OR some mornings is an adequate substitute for actual difficult airway training. It's not.

I don't disagree. Just saying it varies from case by case.

And the point was that if you record 100+ intubations, you'll become proficient at the airway. Time spent in the ED and ICU also exposes you to difficult airways.

 

[InternistDO]

And the point was that if you record 100+ intubations, you'll become proficient at the airway. Time spent in the ED and ICU also exposes you to difficult airways.

Being proficient at the technical skill of intubating is not the same as being good at emergent airway management.

 

[MedicineZ0Z]

Being proficient at the technical skill of intubating is not the same as being good at emergent airway management.

Depending on your hospital, you can be an FM resident who gets exposure to difficult airways or you can be an EM resident who doesn't get adequate exposure (ex. some new programs that have popped up). Your experience prior to residency counts too. I've intubated a lot in the OR but have had a bunch of (mostly, but not all) successful attempts at difficult airways in the icu and ed. I've also seen ED pgy1s in November who are terrible at it and never did it prior to residency.

I'm not arguing for a second that anything other than an EM residency is ideal. But rather saying you can obtain reasonable proficiency as an FM in an unopposed program.

 

[BoardingDoc]

They did a study, and I can find it in probably 2 mins, comparing FM to EM fellowship docs in Canada to 5 year EM residency trained. I think 3 or 5 years post practice, the outcomes were identical between the two.

Still waiting on that 2 min lookup....

 

[SpacemanSpifff]

Depending on your hospital, you can be an FM resident who gets exposure to difficult airways or you can be an EM resident who doesn't get adequate exposure (ex. some new programs that have popped up). Your experience prior to residency counts too. I've intubated a lot in the OR but have had a bunch of (mostly, but not all) successful attempts at difficult airways in the icu and ed. I've also seen ED pgy1s in November who are terrible at it and never did it prior to residency.

I'm not arguing for a second that anything other than an EM residency is ideal. But rather saying you can obtain reasonable proficiency as an FM in an unopposed program.

FPs work in EDs across the US. It's happening every day and they probably do fine. Or maybe they don't. I don't have any large data to suggest one over the other. Can they reach reasonable proficiency? Probably, depending on how you define that.

The source of frustration, from my perspective, for EP's in this discussion is the fact that the you're operating on the margins of experience. Are there some FM grads who get exposure to difficult airways, resuscitation of toxic patients, and higher level management of an emergency department? Probably. Are these core components of the FM curriculum, a part of their every day life? No. There are incredibly smart FM docs, and incredibly dumb EM docs out there. But the baseline skill and intelligence of individuals is not the question. The experience, or possibility of experience, in a select few programs is not the question. The mission of the residency and specialty as a whole is the question. And the average experiences of an FM-trained doc are not the average experiences of an EM-trained doc at the end of their training, which is the point of specialties in general.

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?

The short answer to your question is no, the opportunities are not the same. EM boarded physicians own EDs in the level I and academic settings. You cannot apply for EM fellowships without completing an EM residency. You can likely serve as an EMS director without the FP to EM fellowship, depending on your setting.

 

[Lexdiamondz]

Depending on your hospital, you can be an FM resident who gets exposure to difficult airways or you can be an EM resident who doesn't get adequate exposure (ex. some new programs that have popped up). Your experience prior to residency counts too. I've intubated a lot in the OR but have had a bunch of (mostly, but not all) successful attempts at difficult airways in the icu and ed. I've also seen ED pgy1s in November who are terrible at it and never did it prior to residency.

I'm not arguing for a second that anything other than an EM residency is ideal. But rather saying you can obtain reasonable proficiency as an FM in an unopposed program.

This is totally irrelevant and I don't know why you would even mention this.

Nobody cares if you've intubated prior to starting residency - whether or not their are EM interns who can't tube isn't the point. The point is what your level of skill is at the end of your training. An EM residency guarantees you at least a baseline level of proficiency in airway management. FM residency does not, and just because you think you know how to tube after doing a dozen or so "difficult" airways does not give you even close to the experience necessary to accurately appraise what skills you can realistically acquire from a training programme that isn't actually dedicated to teaching you how to manage an airway. Sit down.

 

[Matthew9Thirtyfive]

Which would be why no other specialty has them to begin with.

Sorry for the ignorance, but I’m trying to educate myself. Aren’t peds EM fellowships open to docs who have completed or are completing a peds residency? Are there studies showing that peds trained docs with a PEM fellowship aren't as good as EM docs, or that they don't do as well after a PEM fellowship as an EM trained doc doing the same fellowship?

 

[smq123]

Sorry for the ignorance, but I’m trying to educate myself. Aren’t peds EM fellowships open to docs who have completed or are completing a peds residency? Are there studies showing that peds trained docs with a PEM fellowship aren't as good as EM docs, or that they don't do as well after a PEM fellowship as an EM trained doc doing the same fellowship?

Peds EM fellowships are, I think, 3 years long. Not just 1 year, as they are in FM.

 

[Matthew9Thirtyfive]

Peds EM fellowships are, I think, 3 years long. Not just 1 year, as they are in FM.

Ah, that's probably the difference then. Thanks for clarifying.

 

[Hamhock]

Sorry for the ignorance, but I’m trying to educate myself. Aren’t peds EM fellowships open to docs who have completed or are completing a peds residency? Are there studies showing that peds trained docs with a PEM fellowship aren't as good as EM docs, or that they don't do as well after a PEM fellowship as an EM trained doc doing the same fellowship?

And to add more to smq123's post, there is some good evidence and an overwhelming sense that peds to pedsEM docs are far less procedure and resuscitation proficient relative to EM to pedsEM.

Furthermore, after doing three years of training, a peds to pedsEM doc still has a much healthier population. Most pedsEM jobs are in huge academic centers with ready access to the PICU and pediatric cardiologists.

It's just different.

HH

 

[Matthew9Thirtyfive]

And to add more to smq123's post, there is some good evidence and an overwhelming sense that peds to pedsEM docs are far less procedure and resuscitation proficient relative to EM to pedsEM.

Furthermore, after doing three years of training, a peds to pedsEM doc still has a much healthier population. Most pedsEM jobs are in huge academic centers with ready access to the PICU and pediatric cardiologists.

It's just different.

HH

I saw something on the peds forum actually that said something similar—that peds to pem docs have much less procedural experience. That’s kind of depressing.

 

[GonnaBeADoc2222]

Yah we should totz study this. Would make a great resident scholarly research project! Whoever is advocating for FM crossover should have them and their families "randomized" to "rural" where there are FM docs to intubate and run the show. It's not like I routinely have to bail out my non em trained colleagues on airway management and vascular access literally all the time.

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[MedicineZ0Z]

Yah we should totz study this. Would make a great resident scholarly research project! Whoever is advocating for FM crossover should have them and their families "randomized" to "rural" where there are FM docs to intubate and run the show. It's not like I routinely have to bail out my non em trained colleagues on airway management and vascular access literally all the time.

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Did you see the thread about midlevels getting some "fellowship" to work independently in the ER?? I feel like 99.9% of your outrage should be focused on that issue.
I'm not even going into FM but have rotated with FMs (half a dozen who worked there) in a rural ER who were excellent and actually taught me way more than I ever lived in an urban ER setting from boarded ER docs. I performed my first chest tube there and intubated as well and everything was a well run machine.

 

[Lexdiamondz]

Did you see the thread about midlevels getting some "fellowship" to work independently in the ER?? I feel like 99.9% of your outrage should be focused on that issue.
I'm not even going into FM but have rotated with FMs (half a dozen who worked there) in a rural ER who were excellent and actually taught me way more than I ever lived in an urban ER setting from boarded ER docs. I performed my first chest tube there and intubated as well and everything was a well run machine.

Mhmm.

 

[cbrons]

A lot of ERs are staffed by mid-levels only. Ponder that for a bit.

 

[Lexdiamondz]

A lot of ERs are staffed by mid-levels only. Ponder that for a bit.

I don't think anyone is arguing that this is ideal either. But many people in this thread are using NP-logic to argue why they should be doing jobs they haven't trained for.

 

[MedicineZ0Z]

I don't think anyone is arguing that this is ideal either. But many people in this thread are using NP-logic to argue why they should be doing jobs they haven't trained for.

Because someone with 1/10th of the knowledge & skills doing X job shows that it must be doable by someone who has 10x the knowledge & skills. Get rid of the truly untrained folks first.

 

[Lexdiamondz]

Because someone with 1/10th of the knowledge & skills doing X job shows that it must be doable by someone who has 10x the knowledge & skills. Get rid of the truly untrained folks first.

Except neither does the job adequately, which is the point that you all seem to be missing.

 

[MedicineZ0Z]

Except neither does the job adequately, which is the point that you all seem to be missing.

Yet the FM guys manage patients in rural EDs every single day. You still have 4 years of med school and 3 years of generalist training. The NP has 2 years of online courses.

 

[Lexdiamondz]

Yet the FM guys manage patients in rural EDs every single day. You still have 4 years of med school and 3 years of generalist training. The NP has 2 years of online courses.

Many of them, poorly.

I don't doubt that they can handle the 80% of presentations that are really urgent-care level stuff, and that gives most a false sense of competency and security. But the other 20% that they may either not handle well or may straight up not even recognise is where the difference in training really matters.

Furthermore can we stop talking about damn midlevels? If FM training is truly sufficient and non-inferior to EM training in the ED then it should be able to stand on its own merits in a head to head competition and shouldn't be held up as an alternative to a worst case scenario. If the best one can say is "at least we aren't NPs" then you still aren't good enough.

 

[MedicineZ0Z]

Many of them, poorly.

I don't doubt that they can handle the 80% of presentations that are really urgent-care level stuff, and that gives most a false sense of competency and security. But the other 20% that they may either not handle well or may straight up not even recognise is where the difference in training really matters.

Furthermore can we stop talking about damn midlevels? If FM training is truly sufficient and non-inferior to EM training in the ED then it should be able to stand on its own merits in a head to head competition and shouldn't be held up as an alternative to a worst case scenario. If the best one can say is "at least we aren't NPs" then you still aren't good enough.

Where's the evidence for them managing it poorly? Are FM docs failing airways all the time? Are they doing surgical airways at a significantly higher rate? Are they grossly mismanaging the transfers you get? Your training prepares you for a busy ED full of sick people. Lower volume EDs where the FM can focus on the occasional sick person at hand is definitely manageable if they've had the exposure during training.
Also, lets not ignore the help (or take over in reality) you get from trauma surgeons in the trauma bay. And quick consults for anything complicated.

 

[Lexdiamondz]

Where's the evidence for them managing it poorly? Are FM docs failing airways all the time? Are they doing surgical airways at a significantly higher rate? Are they grossly mismanaging the transfers you get? Your training prepares you for a busy ED full of sick people. Lower volume EDs where the FM can focus on the occasional sick person at hand is definitely manageable if they've had the exposure during training.
Also, lets not ignore the help (or take over in reality) you get from trauma surgeons in the trauma bay. And quick consults for anything complicated.

Bruh.

I moonlight at one of our community affiliates w an in-house FM residency. Their residents are good at ESI 3-4 stuff but anything actually acute? Fugheddaboutit. Yesterday I walked past a FM PGY-3 staring at his phone while his pt was in SVT with a BP of 85/50. This is someone who will be an attending in 5 mos. Bonkers.

Again, I'm sure there are plenty of FM trained docs who are decent in the ED. ****, I've met a few outstanding ones. But the FM training curriculum in general is not geared towards actually making an EM doctor and going rural - where there is even less backup and where your training arguably matters far more - is potentially putting your career at risk and patients lives in question.

 

[MedicineZ0Z]

Bruh.

I moonlight at one of our community affiliates w an in-house FM residency. Their residents are good at ESI 3-4 stuff but anything actually acute? Fugheddaboutit. Yesterday I walked past a FM PGY-3 staring at his phone while his pt was in SVT with a BP of 85/50. This is someone who will be an attending in 5 mos. Bonkers.

Again, I'm sure there are plenty of FM trained docs who are decent in the ED. ****, I've met a few outstanding ones. But the FM training curriculum in general is not geared towards actually making an EM doctor and going rural - where there is even less backup and where your training arguably matters far more - is potentially putting your career at risk and patients lives in question.

But those aren't people going into ED practice.They're doing the bare minimum to get by and will go into a 9-5 outpatient practice.

And who do you want covering rural ERs then?

 

[Lexdiamondz]

But those aren't people going into ED practice.They're doing the bare minimum to get by and will go into a 9-5 outpatient practice.

And who do you want covering rural ERs then?

Ideally they would properly incentivise people trained to do the job they need to come over.

Look, 6 mos of EM electives and 1 mo of MICU does not make an ED physician. I had more ED and ICU time as an intern than most FPs get in their entire residency - if you want to take a job you’re untrained for then go ahead but there’s a reason EM has been its own specialty for nearly 4 decades now.

 

[Hamhock]

https://residency.christianacare.org/em-fm

HH

 

[LeroyJenkinsMD]

I would just like to remind everyone of the obvious. The argument “I spent x more months in the ED than soandso” is pretty weak. The are experiences elsewhere in the clinic and hospital that are beneficial to practice in the ED setting.

 

[Sardonix]

We were doing so well before this thread got brought back.

 

[Lexdiamondz]

I would just like to remind everyone of the obvious. The argument “I spent x more months in the ED than soandso” is pretty weak. The are experiences elsewhere in the clinic and hospital that are beneficial to practice in the ED setting.

Not as weak as the argument that you spent x amount of time doing things tangentially related to practicing EM. There's no substitute for learning how to do something effectively besides actually doing it.




With that said, this thread has loooooooong outlived it's usefulness. You wanna be board certified in EM? Do an EM residency.

 

[smq123]

I agree with others that this thread has outlived its usefulness.

Closing.