Can EM physicians open a private outpatient office?

Discussion in 'Emergency Medicine' started by PossibleEMapplicant, Feb 10, 2019.

  1. PossibleEMapplicant

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    Serious question per title. Can EM docs open their own private outpatient office (like IM physicians who do outpatient medicine out of a private office)? And in doing so, manage chronic conditions like diabetes, HTN etc?
     
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  2. John Red

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    Sure. A licensed Dr could open a cash clinic in whatever the heck s/he felt like it. That is until the first lawsuit comes your way.

    For a more nuanced discussion I will let the more experienced chime in
     
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  3. Apollyon

    Apollyon Screw the GST
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    EM is expressly not primary care. Even if patients come in for it, we are not trained in vaccine schedules (except to update tetanus, or give rabies vax), chronic DM management, chronic hypertension, or preventative care. If you want longitudinal care, do IM or FM. However, you would be at quite a disadvantage, and lord help you if you missed something.
     
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  4. e30ftw

    e30ftw peace
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    Can they?

    Yes.

    Should they?

    No.

    Twice the hours plus all the PITA business expenses/stress/etc for none of the fun parts of EM and 1/2 the pay.. plus the malpractice issues listed above.
     
  5. The Knife & Gun Club

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    I’ve heard of people who get around this by having an urgent care, and some of the UC pts become “regulars”. Obviously would defer to the real attendings on here as to if that’s wise or not.

    Not quite primary care; but close. Sounds mind numbingly boring to me, but I’m still in my 20s with no kids. May change my tune when I’m older and have a family.
     
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  6. Apollyon

    Apollyon Screw the GST
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    No, if you are EM, your tune will not change into wanting to do primary care. Honest!
     
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  7. OP
    OP
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    So any malpractice insurance one has for coverage in the ED, won't transfer to an outpatient IM setting? Damn, the things they don't teach in med school.
     
  8. RoyBasch

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    If these are your clinical interests why would you do a residency in emergency medicine and become an emergency physician instead of training in internal medicine or family practice? These specialities' residencies are dedicated to learning how to manage outpatient problems such as chronic diabetes, hypertension, etc.

    Most ER physicians do not have the interest or adequate training to practice in the setting you are discussing.
     
  9. OP
    OP
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    Just trying to keep my options open so when (not if) burnout hits I have something to fall back on. Hearing about all the midlevels and CMG's taking over, its only a matter of time to hit burnout. EM/IM is an option for a residency but the duration kinda sucks,
     
  10. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Malpractice is specialty (and even to a degree scope) specific. This seems common sense, otherwise why do you hear about OBs having such expensive policies while say FM/IM do not?
     
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  11. RoyBasch

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    mid level and corporate encroachment are not unique to emergency medicine, it has been a feature of many other specialties as well such as anesthesia and internal medicine. The specialities most resistant to these issues tend to be surgical.

    There are other ways to adjust your clinical or non clinical practice as an ER physician if you are getting burned out by high acuity/high volume ER shifts (as detailed extensively on this board). Practicing outpatient primary care is NOT one of them.

    I am not a PCP, but I would argue that primary care medicine is not very relaxed in the modern era as many primaries are contending with a huge volume of patients (30 patient visits per day, 10-15 min visits, 4 patients per hour). Even if each patient is there for a specific issue compared to undifferentiated ER patients, there is still time pressure to address problems in a very hasty fashion on a regular basis, which could result in misses and errors as well. I think that would be fairly stressful.
     
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  12. GeneralVeers

    GeneralVeers Globus Hystericus
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    Opening a primary care clinic sounds like a special kind of hell. I'd rather quit medicine altogether.
     
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  13. OP
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    Haha got a good laugh out of that. But to some extend, yes EM docs aren't trained to manage chronic issues over time, but in the ED it does seem like a lot of primary care stuff rolls through (at least where I rotated).
     
  14. thegenius

    thegenius Senior Wharf Rat
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    That's true! We see a lot (the majority) of non-emergency stuff. The Emergency Room should be called something else, and Emergency Medicine should be called something else if we want it to reflect what we actually see on a daily basis.

    Or, hospitals need to back us up when we summarily discharge patients without doing a workup. but patients who come to the ER for free will complain about that.
     
  15. RoyBasch

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    Do not confuse the fact that these patient's show up ("roll through") with the idea that they are being comprehensively treated. Just because a medical screening exam is performed, the patient is determined to be stable for discharge and then discharged is not the same thing as real primary care.

    Example: If I determine at patient with DM is not in DKA and refill his 500mg of metformin BID for 2 weeks till the patient can see a PCP. This may be appropriate from an ER point of view; however, it is not adequate comprehensive care for a patient with diabetes. Why does the patient have DM? What modifiable risk factors are there? How can those be treated? What is their HgbA1c? Does this patient need to start insulin? What other non-insulin therapies can be tried? What end organ dysfunction from DM do they have and does that need to be screened for?

    Understand where ERs and ER physicians fit into the house of medicine. Yes we do help patients get through the gaps and holes in the current system, but the idea is always that these patients will eventually follow up with somebody. The patient's who never do followup--which I understand they are many--ultimately receive much worse care and over time probably have decreased life expectancy.

    Do not be fooled by the name; "Primary Care" is a complicated specialized skill set. For example: Age appropriate cancer screening and risk factor management, which I am only dimly aware of how to manage, definitely saves lives when executed appropriately. There are constantly shifting guidelines based on new research and statistics, and many modifiers based on patient's individual family histories and other risk factors, etc. There is a reason these types of decisions should be left to people who are specialized in primary care.

    If your goal is to disposition these patient's quickly then you may be more of an ER physician. If you want to get at more those second order questions, why do they have a chronic disease, what are the risk factors, how to manage it optimally long term, then you may be more primary care minded.

    I think as you are finding out in this thread even though there is significant overlap between ER and Primary Care in terms of the pathologies treated; the approach and mindsets are drastically different. For that reason training to do one does not really adequately prepare you to do the other. The opposite question has been asked many times on this board: "Can a primary/family/internist practice in an ER?" and the answer is always unequivocally: "It's not a good idea."
     
  16. OP
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    Excellent points, thank you for that well articulated response.
     
  17. gro2001

    gro2001 SOCMOB
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    Very well written post. Should probably be stickied.
     
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  18. alpinism

    alpinism Give Em' the Jet Fuel
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    Keep in mind though that while this is true for patients with chronic diseases those with acute illnesses basically get identical care.

    URIs, coughs, sore throats, rashes, cellulitis, abscesses, muscle spasms, cuts and scrapes, etc all get the same level of care.

    EM in the United States is essentially 90% primary care.
     
  19. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Hence why a fair number of EPs slow down into urgent care without any issue
     
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  20. throckmortonDO

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    While some of the things we deal with in the ED could be construed as things that we deal with that people should probably visit a PCP for care for, we do NOT equivocally practice primary care. Our specialty is designed to stabilize, resuscitate, diagnose and address acute issues, rule out life-threatening conditions and provide short term critical, trauma or acute care.

    As an ACGME ABEM boarded physician with a fellowship in a subspecialty of EM I have no business performing cancer screening, complex DM long term management, primary pediatrics, vaccination protocols or antenatal obstetrical care. I wasn't formally trained in that. A residency trained FM physician is trained in that.

    You would be doing yourself and your patients a disservice to try to practice as a PCP if you are formally trained in EM.

    What you can do - with some additional training, fellowship, etc - is something like sports medicine clinic/concussion clinic, non-interventional or interventional pain management clinic.

    You can take the road less traveled and open a ketamine infusion clinic for off label use, medical aesthetics, medical weight loss, or something similar, but as someone above astutely pointed out, this is a malpractice risk and you take your license and career in your own hands.

    If you want to work less or have less stress you can cut down your hours in a regular ED, practice in a rural low volume ED, transition to urgent care or freestanding ED practice, or variations of the above. All of these options involve taking a significant pay cut.

    If you have an impressive CV and willing to travel some, you can find a non-clinical career in pharma - a topic for another thread.
     
    #20 throckmortonDO, Feb 13, 2019
    Last edited: Feb 13, 2019
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  21. OP
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    What if one took out malpractice insurance to cover those types of ventures? Or would insurance companies not offer malpractice insurance for those things since one isn't formally trained in it (especially as an EM doc)? Sorry if this is common sense to others... my medical school really did a poor job of explaining things like this.
     
  22. TooMuchResearch

    TooMuchResearch i'm goin' to Kathmandu...
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    What exactly is a ketamine infusion clinic? Or I guess, WHY exactly?
     
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  23. Apollyon

    Apollyon Screw the GST
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    One definition of EM is "the rapid recognition of sickness and health, and the resuscitation of the critically ill and injured". Literally nothing of that is chronic management of medical problems.

    I'll say it clearly - if you want to do EM and have an office practice, do EM/IM, or, realize that you can only do one of them well, especially if you are trained in one, but not the other.

    And, just knowing the basics of malpractice insurance, were I the insurer, boy howdy, would I charge you through the nose, if I was even to insure you at all, for indemnifying you for treatment and procedures in which you have not been trained. I think that that is a non-starter.
     
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  24. NicMouse64

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    If a NP/PA can do it in 25 states I don't see why not..........



    /s
     
  25. Vandalia

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    This brings back memories from decades ago of my mother saying, "I don't know if you can walk down the block to see your friend, the question is may you." In this case, the answer is twisted from back then: you certainly may open an outpatient clinic, the question is if you can.

    Now, an EM physician is probably the best prepared of anyone outside of FM to do primary care (adults and kids.) In the same way, FM is probably the best prepared of any other specialty to do EM. But that is not saying much. That is like saying a row-boat is next best to a jet for crossing the Atlantic: certainly true, but not exactly comforting.

    If I decided to do primary care, I am fairly confident I could make sure a patient would not die in the next 72 hours. But I am also sure I would end up costing as many days of life, long term, as a non-EM physician would in the ED. Sure, I may not cause someone to immediately die, but I would probably do something that would take 3 years off their life.

    Now, for the mid-level issue: Sure, as a physician you would probably be better qualified than an NP/PA, but there are two complications. First, an independent NP would be judged for "standard of care" with respect to another NP (depending on the state, and malpractice lawyers are rumbling about this), you will be judged with respect to FM/IM. Second, as we all know, these places (mid-level run) send everything questionable to the ED. Now, when a 70 year old with early-stage dementia comes in with the extended family to decide what to do long term (what does insurance cover? how much will it cost? what level of care?) are you going to be comfortable referring that to an FM or someone board-certified in geriatrics? It is one thing to send a patient to the ED, or to consult cardiology... but will your ego handle sending something to FM/IM that you can't handle? Assuming you have that option.
     
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  26. gro2001

    gro2001 SOCMOB
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    Just because most of the cases we see are not true emergencies, does not mean that we practice primary care though.
     
  27. Lexdiamondz

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    I think you're mistaking urgent care for primary care.

    Dealing with URIs, coughs, sore throats and abscesses are all urgent care.

    Managing someone's BP meds, DM meds, CHF meds, antidepressants, thyroid meds and coordinating their PT are emphatically NOT skills emphasised in an EM residency
     
    #27 Lexdiamondz, Feb 14, 2019 at 5:48 AM
    Last edited: Feb 14, 2019 at 6:15 AM
  28. Birdstrike

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    Yes, you can open your own outpatient clinic. But it's a lot of work, equal to a second full time job, at least. And it's getting harder and harder to be a solo doc starting up, with increasing complexities of regulations such as EHRs, Obamacare, MIPPS, Macra, meaningless use, etc. So, it might not be worth it. You have to ask yourself, why?

    For most people, the large increase in workload and startup costs outweigh the potential gains. This is why you don't see much of this anymore. And yes, you can see whatever type of patients you want to see and can handle.
     
  29. alpinism

    alpinism Give Em' the Jet Fuel
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    Urgent care is primary care.

    Go to any other developed country in the world and those are all things managed in the clinic by primary care doctors.
     
  30. gro2001

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    No, it's not.

    Primary care is continuous care, usually for chronic conditions. Urgent care is one time care for arising problems that do not constitute life threatening emergencies. Emergency care is one time care for arising problems that are life threats.

    Primary care physicians are trained to provide primary and urgent care. Emergency physicians are trained to provide urgent and emergent care. Urgent care is where both specialties overlap, which is why you commonly see folks from both specialties working at urgent care centers. The examples you gave in your first post ("URIs, coughs, sore throats, rashes, cellulitis, abscesses, muscle spasms, cuts and scrapes") are examples of urgent care issues. Everyone here agrees that EM trained folks would be able to handle those just fine. But that is not the point of contention. The point that all the other posters are making is that typical examples of primary care issues (as listed by Lex: "Managing someone's BP meds, DM meds, CHF meds, antidepressants, thyroid meds and coordinating their PT") are not urgent care issues and are not typically dealt with (at least comprehensively) at urgent care centers. EM physicians just don't have the training to do that well. This is not a knock on emergency physicians. I myself am an emergency physician. My training is fairly typical for an EP in the US. I feel very comfortable working in any ER or urgent care center. I do not at all feel comfortable running a primary care service. I would do a terrible disservice to my patients if I tried.
     
  31. BoardingDoc

    BoardingDoc Don't worry. I've got my towel.
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    I assume @alpinism was saying that what comes through UC can be managed by primary care and in most other countries it is. I don't know that they were saying that all primary care issues should be managed in a UC though. I certainly don't think they should. I work UC sometimes. If someone comes in with poorly controlled HTN but there is no acute emergency, I have them see their PCP. I don't start them on a new antihypertensive or do whatever else PCPs do in that scenario.
     
  32. Lexdiamondz

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    You're missing the point. Urgent care presentations do not encompass the full scope of what primary care is.
     
  33. alpinism

    alpinism Give Em' the Jet Fuel
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    The above is simply not true.

    Here's the definition of primary care straight from the AAFP website:

    Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.).
     
  34. dpmd

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    I really don't think outpatient medicine is going to be desirable to the burned out doc
     
  35. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Emphasis mine.

    Urgent care lacks that continuing care part. We often all see the same problems, doesn't mean its one in the same.
     
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  36. alpinism

    alpinism Give Em' the Jet Fuel
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    My point is that EM docs provide primary care on a daily basis and its disingenuous to suggest otherwise.

    Regardless I'm not arguing that all primary care is urgent care but rather that all urgent care is primary care.
     
  37. dpmd

    dpmd Relaxing
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    That is sort of like saying that since surgery is figuring out who needs an operation and then doing it that you so surgery daily because you find appys and choles that need to come out.
     
  38. Groove

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    Primary care sounds like being waterboarded all while being electrocuted like Rambo from that first blood torture scene. Man, I’m sick of some of these people after an hour, I can’t imagine dealing with them long term...

    Urgent care doesn’t sound much better.

    I thought the EP elephant graveyard these days was either academics or FSED?
     
  39. Groove

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    No offense to the academic and FSED peeps! ;):D
     
  40. VA Hopeful Dr

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    I enjoy what I do, but it couldn't be more different on a day to day basis than what y'all do.
     
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  41. Groove

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    I certainly respect what you do. That being said I wouldn’t know the first thing about outpatient medicine. It sounds like a plausible bridge but the gap in training is probably much greater than what people realize.
     
  42. Apollyon

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    EM - acute generalists.
    FM - chronic generalists.
     
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  43. Dr.McNinja

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    They have more "same day" visits, and don't have the 4 double booked 15 minute slots per hour.
    Yes, a facile PCP should be able to handle the majority of acute things. They just don't have the time.
    However, we cannot handle the chronic well. I promise.
     
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