Can I practice EM after IM residency?

[MedicineZ0Z]

I’d say the right amount of training intubating, central lines, ortho reductions, thoracostomies, paracentesis, thoracentesis, lumbar puncture, I&D, FB removal in cornea, pericardiocentesis, lateral canthotomy, conscious sedation, deep sedation, transvenous pacing, CPR, and about 20 other procedures is well defined in the EM RRC requirements.

Not just “doing about 10.”

If you want to do ER, one should be formally trained in ER. You can’t do ER if you can only do 1/4 or even 1/2 of the things needed to be an ER doc.

Requirements for traning = / = competency. Lots of attendings suck at something despite meeting all requirements.

This isn't true in the least.

I know IM trained guys who grandfathered into EM 30 years ago in continuous practice who cannot tubed and aren't credentialed to supervise residents because of it.

You're an intern in September - how would you possibly know what most non-BCEM docs are comfortable with? The reality of what actually goes down out there would probably terrify you.

Idk dude, maybe cause I rotated with both (2 large groups) and got a good sense of the contrasts. You very likely have not unless you have specific examples you want to share?
I did ED tubes under their supervision and got some great pointers. It's silly to think that non-EM boarded docs can't intubate in the ED. Once again as an example, most ED docs in Canada are non-EM boarded and the concept of anesthesia back up does not even exist in most hospitals.

And you know there are places where RTs or midlevels routinely intubate, right? Where do you think they get their training? Same with medics etc. Until you can address non-physicians doing EM procedures, you have no business criticizing physicians.

---

Members don't see this ad.

 

[GonnaBeADoc2222]

Feel free to correct me. We have residents placing unsupervised lines after doing 5(sometimes less). And there's literature behind # of tubes.

EM training's value is in the breadth of exposure and mentality training. The notion that non-EM boarded guys routinely sit around waiting for a CRNA is nonsense.

I would never let a resident place an unsupervised line after 5....or 10...or 20.

Guess what...that's malpractice.

 

[TooMuchResearch]

My "most non-EM docs" experience is as posted above.
You need more procedures than that for proficiency.
Ortho does reductions? (I'm kidding, but only slightly. I saw one of ours try to reduce an open trimal. I couldn't figure out why since all signs pointed to OR anyway.)

That's very unusual. Most non-EM docs working in an ED are comfortable with the vast majority of airways. Same with putting in lines etc. You need like 70-80 tubes + a good airway course to become proficient with airways. Lines? Like 10. Chest tubes? A couple tops. Reductions, sure... but they're all auto-ortho consults anyway in academic centers so its not like EM guys are doing it in those places.

 

[thegenius]

Requirements for traning = / = competency. Lots of attendings suck at something despite meeting all requirements.

That is a non-argument. It suggests that licenses and certifications could be basically useless.
No point being a licensed architect.
A certified real estate agent.
A certified insurance agent.
Passing the bar for being a lawyer.
Being a certified or licensed plane pilot, or whatever it's called for them.

Because there are bad architects, real-estate and insurance agents, and even lawyers out there. So what's the point of being certified?

Would I rather have a certified, licensed, plane pilot flying the 737 I'm taking or someone who has flown several thousand of hours because he's done it as a hobby or as a side job?

Answer is easy

 

[Lexdiamondz]

And you know there are places where RTs or midlevels routinely intubate, right? Where do you think they get their training? Same with medics etc. Until you can address non-physicians doing EM procedures, you have no business criticizing physicians.

This argument doesn't make sense. Medics and RTs intubate as a core competency of their clinical practice and a central focus of their training - I criticise physicians who intubate without training precisely because they're doing something they aren't trained to do.

Absolutely I would be skeptical of an FM doc who intubates unsupervised - there are no ACGME requirements that establish a baseline competency in airway management for FM docs. You can't say that about RTs and Medics.

 

[VA Hopeful Dr]

This argument doesn't make sense. Medics and RTs intubate as a core competency of their clinical practice and a central focus of their training - I criticise physicians who intubate without training precisely because they're doing something they aren't trained to do.

Absolutely I would be skeptical of an FM doc who intubates unsupervised - there are no ACGME requirements that establish a baseline competency in airway management for FM docs. You can't say that about RTs and Medics.

Its why the handful of FPs I know that want to be able to intubate in the hospital keep a updated case log showing significant experience.

 

[MedicineZ0Z]

I would never let a resident place an unsupervised line after 5....or 10...or 20.

Guess what...that's malpractice.

Seniors supervise juniors all the time for procedures. This isn't anything new. And that supervision turns to unsupervised once you show competence after a few.

That is a non-argument. It suggests that licenses and certifications could be basically useless.
No point being a licensed architect.
A certified real estate agent.
A certified insurance agent.
Passing the bar for being a lawyer.
Being a certified or licensed plane pilot, or whatever it's called for them.

Because there are bad architects, real-estate and insurance agents, and even lawyers out there. So what's the point of being certified?

Would I rather have a certified, licensed, plane pilot flying the 737 I'm taking or someone who has flown several thousand of hours because he's done it as a hobby or as a side job?

Answer is easy

Your analogies don't even come close to how real life medicine works in the context of different specialties. The gap between a hobby and profession is enormous, the gap between certain specialties is relatively small. This should be an easy concept to understand.

This argument doesn't make sense. Medics and RTs intubate as a core competency of their clinical practice and a central focus of their training - I criticise physicians who intubate without training precisely because they're doing something they aren't trained to do.

Absolutely I would be skeptical of an FM doc who intubates unsupervised - there are no ACGME requirements that establish a baseline competency in airway management for FM docs. You can't say that about RTs and Medics.

Dude, they do like 10 (cherry picked) tubes in the OR. Just cause you have a magic "RT" title which includes "airway management" as a competency doesn't mean you're actually competent. Very few programs truly train RTs/Medics to be even remotely skilled at tubing in 2019.

How many tubes does the ACGME need for ED residents? And trick question, how many of those end up being VLs The real # to become proficient is much higher. Also, there are FMs on SDN who tube in the ED or open-ICU settings. It's not some obscure thing. We have NPs doing it for god sakes because some intensivist let them try a few times.

 

[namethatsmell]

That's very unusual. Most non-EM docs working in an ED are comfortable with the vast majority of airways. Same with putting in lines etc. You need like 70-80 tubes + a good airway course to become proficient with airways. Lines? Like 10. Chest tubes? A couple tops. Reductions, sure... but they're all auto-ortho consults anyway in academic centers so its not like EM guys are doing it in those places.

In terms of academic EDs, I've worked in maybe 8 of them in 5 states. At approximately 0/8 of these places are reductions "auto-ortho consults" -- but maybe that's what you've come to expect after your rotations with the non-EM boarded docs you're promoting?

Idk dude, maybe cause I rotated with both (2 large groups) and got a good sense of the contrasts. You very likely have not unless you have specific examples you want to share?

On the one-hand I appreciate you generalizing how EDs work based on your experience in 2 of maybe the 8000 EDs in the country.

On the other hand I appreciate you saying in one of your other posts that having placed 5 central lines in residency makes somebody good enough to place central lines in general, yet in another post you state "Requirements for traning = / = competency" which, Idk dude, sounds almost like a contradiction.

 

[deleted109597]

Seniors supervise juniors all the time for procedures. This isn't anything new. And that supervision turns to unsupervised once you show competence after a few.

See, that's the funny thing about every residency except EM.
100% of our patients have the attending available 24/7. The EM residents are seeing patients and doing things over night with no attending oversight (or by phone).
It's simply not the same. Yes, seniors supervise juniors. But I had to teach the ICU fellow how to suture central lines because they sheepishly admitted one night that nobody had ever showed them.
As we've mentioned now multiple times, teaching yourself something does not teach you the best way, just the way you figure it should be done. We have EM M&M conferences, so we learn from others mistakes. You don't. End of discussion.

 

[InternistDO]

This argument doesn't make sense. Medics and RTs intubate as a core competency of their clinical practice and a central focus of their training - I criticise physicians who intubate without training precisely because they're doing something they aren't trained to do.

Absolutely I would be skeptical of an FM doc who intubates unsupervised - there are no ACGME requirements that establish a baseline competency in airway management for FM docs. You can't say that about RTs and Medics.

These arguments are ridiculous every time they happen, but I want to point out that while medics intubate as part of their core training, the standards are extremely low--in Florida, for example, it was 5 supervised tubes before you were cleared to intubate independently. While yes, if you **** up the tube in the truck you are theoretically taking the patient to an ED where a more experienced physician can intubate, that can still be up to thirty minutes without a definitive airway in urban areas, and even longer out in the sticks. Where I worked we were lucky to get 6 tubes a year, and we were a pretty busy service. I wouldn't use paramedic standards as a yardstick to determine airway competency.

 

[MedicineZ0Z]

In terms of academic EDs, I've worked in maybe 8 of them in 5 states. At approximately 0/8 of these places are reductions "auto-ortho consults" -- but maybe that's what you've come to expect after your rotations with the non-EM boarded docs you're promoting?

The only reductions I ever did were in places staffed by non-em docs. Are you really surprised places with an ortho residency consult ortho to come to the ED? cmon.

On the one-hand I appreciate you generalizing how EDs work based on your experience in 2 of maybe the 8000 EDs in the country.

On the other hand I appreciate you saying in one of your other posts that having placed 5 central lines in residency makes somebody good enough to place central lines in general, yet in another post you state "Requirements for traning = / = competency" which, Idk dude, sounds almost like a contradiction.

What? I said after doing that many you are have the technical skill to perform one without someone guiding you. The rest comes with experience over time. It's not like seniors who have done 12 will have someone watching their every move on their 13th line. And in many hospitals a lot of those lines are done with 0 supervision once they show competency after 5 or so.

These arguments are ridiculous every time they happen, but I want to point out that while medics intubate as part of their core training, the standards are extremely low--in Florida, for example, it was 5 supervised tubes before you were cleared to intubate independently. While yes, if you **** up the tube in the truck you are theoretically taking the patient to an ED where a more experienced physician can intubate, that can still be up to thirty minutes without a definitive airway in urban areas, and even longer out in the sticks. Where I worked we were lucky to get 6 tubes a year, and we were a pretty busy service. I wouldn't use paramedic standards as a yardstick to determine airway competency.

His agenda is about opposing non-EM docs intubating in emergent settings rather than actually making a logical argument. In most western countries, non-EM docs in EDs are intubating and the idea of a CRNA or anyone similar driving in to do it is laughable.

 

[TooMuchResearch]

We had Ortho residents where I trained. We did not routinely call them to reduce fractures. When we did, they wanted to do stupid **** like procedural sedation to reduce the open trimal immediately before going to the OR to fix it.

The only reductions I ever did were in places staffed by non-em docs. Are you really surprised places with an ortho residency consult ortho to come to the ED? cmon.

What? I said after doing that many you are have the technical skill to perform one without someone guiding you. The rest comes with experience over time. It's not like seniors who have done 12 will have someone watching their every move on their 13th line. And in many hospitals a lot of those lines are done with 0 supervision once they show competency after 5 or so.


His agenda is about opposing non-EM docs intubating in emergent settings rather than actually making a logical argument. In most western countries, non-EM docs in EDs are intubating and the idea of a CRNA or anyone similar driving in to do it is laughable.

 

[Splenda88]

The truth is EM docs make too much money. You have a target on your back... I admittedly will try to moonlight at a VA ED once I am done with my training in IM. You can't beat $200/hr for seeing decompensated HF, COPD exacerbation, EtOH intoxication etc... They don't pay us that much to take care of these people on the floor.

 

[GonnaBeADoc2222]

We don't make too much. You make too little

The truth is EM docs make too much money. You have a target on your back... I admittedly will try to moonlight at a VA ED once I am done with my training in IM. You can't beat $200/hr for seeing decompensated HF, COPD exacerbation, EtOH intoxication etc... They don't pay us that much to take care of these people on the floor.

 

[Lexdiamondz]

The truth is EM docs make too much money. You have a target on your back... I admittedly will try to moonlight at a VA ED once I am done with my training in IM. You can't beat $200/hr for seeing decompensated HF, COPD exacerbation, EtOH intoxication etc... They don't pay us that much to take care of these people on the floor.

Really? Because we're expected to efficiently manage a wide range of complaints (literally from "stubbed toe" to crashing ARDS), perform a wide range of procedures, expose ourselves to workplace violence on a regular basis and operate in a highly litigious environment 24h a day, 7 days a week.

 

[BoardingDoc]

Really? Because we're expected to efficiently manage a wide range of complaints (literally from "stubbed toe" to crashing ARDS), perform a wide range of procedures, expose ourselves to workplace violence on a regular basis and operate in a highly litigious environment 24h a day, 7 days a week.

No, no, you see EM is basically IM and IM gets paid less than that, ergo EM is obviously overpaid.

 

[VA Hopeful Dr]

Really? Because we're expected to efficiently manage a wide range of complaints (literally from "stubbed toe" to crashing ARDS), perform a wide range of procedures, expose ourselves to workplace violence on a regular basis and operate in a highly litigious environment 24h a day, 7 days a week.

Yeah there's a good reason y'all are the highest paid of the 3 year residency fields.

 

[Splenda88]

Really? Because we're expected to efficiently manage a wide range of complaints (literally from "stubbed toe" to crashing ARDS), perform a wide range of procedures, expose ourselves to workplace violence on a regular basis and operate in a highly litigious environment 24h a day, 7 days a week.

I should have said you guys are well compensated... My apology!

 

[deleted109597]

Regardless, I will go ahead and directly email ABPS and ask them "If i were board certified by ABPS in EM today, would i be able to advertise myself as Board Certified in EM in Texas?" and once i hear back i'll return here with a definitive response.

So what came of this?

 

[Amazingmuzmo]

The truth is EM docs make too much money. You have a target on your back... I admittedly will try to moonlight at a VA ED once I am done with my training in IM. You can't beat $200/hr for seeing decompensated HF, COPD exacerbation, EtOH intoxication etc... They don't pay us that much to take care of these people on the floor.

Jealousy is not a good look. Nobody hid the salaries of all the specialties when you were applying, if you're dissatisfied then perhaps you weren't honest with yourself when applying with what you valued.

 

[Splenda88]

Jealousy is not a good look. Nobody hid the salaries of all the specialties when you were applying, if you're dissatisfied then perhaps you weren't honest with yourself when applying with what you valued.

I can only tolerate EM for 1 day/wk at $200-250/hr...

 

[GonnaBeADoc2222]

Jealousy is not a good look. Nobody hid the salaries of all the specialties when you were applying, if you're dissatisfied then perhaps you weren't honest with yourself when applying with what you valued.

He obvi didn't have the scores

Sent from my Pixel 3 using SDN mobile

 

[Splenda88]

He obvi didn't have the scores

Sent from my Pixel 3 using SDN mobile

Yeah, I am not smart enough to be an EM doc...

 

[SpacemanSpifff]

He obvi didn't have the scores

Sent from my Pixel 3 using SDN mobile

EM hasn’t exactly been the most competitive specialty historically.

 

[Splenda88]

EM hasn’t exactly been the most competitive specialty historically.

Apparently EM is the new derm...