Compensation of an FP in an ED

[VA Hopeful Dr]

I can't think of any patient a FP couldn't handle after a couple of months in the ER. Some rural EDs are staffed by solo FPs or worse.

Uhh, what?

I have literally never intubated a patient (I intubated a cat during PALS though, is that good enough?). My last central line was 3rd year medical school. No chest tubes, no cardioversions (electric or medical), no joint dislocations, no fracture reductions. And those are just the procedures that should be routine for anyone doing EM.

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[GonnaBeADoc2222]

What's the point of hiring an attending physician if they require "reasonable backup" to do their job? That requires two attendings now - when you can get a PA or NP to do the same thing for much cheaper. You're railing against the use of midlevels in the ED and yet you're asking why an attending physician can't fill the role of midlevel in the ED. Use your brain.

"Reasonable backup" for an attending in the ED? lulz. I can only hope you are referring to consultant support? Like having a surgeon around maybe? You're probably not going to have much of that in a rural ED where an FP is allowed to practice.

I can't think of any patient a FP couldn't handle after a couple of months in the ER. Some rural EDs are staffed by solo FPs or worse.

Thanks for your input PA d2305. Seriously is this just trolling for the f*** of it? The level of ignorance is egregious.

Ya, EDs are staffed by solo FPs, or even solo PAs with FP "supervision" (from home). And guess what? People die left and right. When I was in training we got a call from one of these places begging for someone to drive over to intubate a patient cause no one knew how.

 

[Lexdiamondz]

I can't think of any patient a FP couldn't handle after a couple of months in the ER. Some rural EDs are staffed by solo FPs or worse.

You're missing the point -the question isn't simply "can you handle a single sick patient" - although the vast majority of FM residencies are primarily outpatient-oriented. The question is can you handle potentially receiving multiple sick patients in a rapid succession while continuing to see new patients, performing procedures and maintaining throughput? The vast majority of FPs have never had to run two simultaneous codes, never had to manage a difficult airway or manage a vented ARDS patient w a systolic of 70/40 while simultaneously seeing a full pod of >15 patients. I haven't come across a single IM grad or even ICU attending capable of doing this, never mind an FM grad who spent >50% of the residency outpatient.

Rural EDs are often staffed by solo FPs but those EDs generally have issues attracting EM trained physicians for various reasons, and few people will argue that they're equivalent to EM trained physicians in the ED. In many cases it's literally a case of "better them than nobody".

 

[W19]

I think FM ----> 1 yr ED fellowship should be allowed to be boarded.

That is a reasonable compromise.

 

[W19]

"Reasonable backup" for an attending in the ED? lulz. I can only hope you are referring to consultant support? Like having a surgeon around maybe? You're probably not going to have much of that in a rural ED where an FP is allowed to practice.



Thanks for your input PA d2305. Seriously is this just trolling for the f*** of it? The level of ignorance is egregious.

Ya, EDs are staffed by solo FPs, or even solo PAs with FP "supervision" (from home). And guess what? People die left and right. When I was in training we got a call from one of these places begging for someone to drive over to intubate a patient cause no one knew how.

These are just anecdotes...

 

[RustedFox]

I think FM ----> 1 yr ED fellowship should be allowed to be boarded.

That is a reasonable compromise.

 

[VA Hopeful Dr]

I think FM ----> 1 yr ED fellowship should be allowed to be boarded.

That is a reasonable compromise.

As an FP, I think that's stupid. I had 6 weeks of EM in my residency. The EM program where I went to med school did 112 weeks of EM.

Even if we add on another 52 weeks, I would still be 54 weeks shy. That's over 1 year of less EM time.

How does that make any sense?

 

[MedicineZ0Z]

These are just anecdotes...

They do that in Canada. I think the majority of ED docs there are family med + 1 year fellowship trained. There is no difference in outcomes there than USA.... everything is very much on par.

 

[W19]

As an FP, I think that's stupid. I had 6 weeks of EM in my residency. The EM program where I went to med school did 112 weeks of EM.

Even if we add on another 52 weeks, I would still be 54 weeks shy. That's over 1 year of less EM time.

How does that make any sense?

They are not in the ED for 112 taking care of truly emergency...

 

[VA Hopeful Dr]

They are not in the ED for 112 taking care of truly emergency...

I can promise you that they get at least one critical patient/shift in an academic ED.

And even if we cut that down to 2 critical patients for every 3 shifts, it still takes more than a year after FP training to catch up.

Plus, they get way more CC time than we do on top of their ED time. Most FP programs are either 4 weeks of ICU time or longitudinal, so we'll use the 4 weeks. The EM program I'm most familiar with has 16 weeks of CC time.

You just need to understand that there is a reason you can't fellowship your way into other specialties. Its not random or malicious.

 

[deleted859535]

I think I should be allowed to do a one year fellowship and be a family physician. Or a radiologist. Or an anesthesiologist. I mean, why not, right? Surely outcomes will be similar. Most of the time.

 

[W19]

I think I should be allowed to do a one year fellowship and be a family physician. Or a radiologist. Or an anesthesiologist. I mean, why not, right? Surely outcomes will be similar. Most of the time.

Rad and gas are not the same with EM... Most things that come to the ED are not emergency... @MedicineZ0Z talked about Canada that has FM--->ED and outcome is no different. Maybe it's something they can try here instead of opening EM residency in every 100/200 beds hospital (FL is an example) where EM training is subpar.

Are people really saying that a FM doc wont be able to manage ED patients after doing 1 yr fellowship at a good ED trauma hospital?

 

[CCM-MD]

Canada also has FM + 1 year in anesthesia and obstetrics. I know physicians with FM + 1 year ER training practice in trauma centers alongside EM residency trained physicians in at least one major Canadian city. Keep in mind a true accredited EM residency in Canada is 5 years in duration.

 

[GonnaBeADoc2222]

Dude what is your mental block? You have both EM and FM attendings telling you that this notion is dead wrong. EM isn't any better than FM or vice versa, it's just a different skill set. The issue isn't that "most things that coming to the ED aren't emergencies." It's that EM docs are trained to take those seemingly non emergent vague complaints and risk stratify them. Our mental approach is just completely different.

 

[W19]

Dude what is your mental block? You have both EM and FM attendings telling you that this notion is dead wrong. EM isn't any better than FM or vice versa, it's just a different skill set. The issue isn't that "most things that coming to the ED aren't emergencies." It's that EM docs are trained to take those seemingly non emergent vague complaints and risk stratify them. Our mental approach is just completely different.

Mental approach is learned in residency and fellowship... Gas/PM&R/Neuro/Psych----> Pain fellowship..... EM/IM/Gas---->CCM fellowship.

The arbitrary nature of med school education has to be challenged. You guys dont have a convincing argument as to why FM---> EM fellowship is a bad idea. Your argument is that you think it will be. Why are FM doc not allowed to do AI, ID, endo and rheum fellowship? By the way, I am not a FM resident... I dont think we should accept things as they are just because it's how it has been done.

 

[VA Hopeful Dr]

Mental approach is learned in residency and fellowship... Gas/PM&R/Neuro/Psych----> Pain fellowship..... EM/IM/Gas---->CCM fellowship.

The arbitrary nature of med school education has to be challenged. You guys dont have a convincing argument as to why FM---> EM fellowship is a bad idea. Your argument is that you think it will be. Why are FM doc not allowed to do AI, ID, endo and rheum fellowship? By the way, I am not a FM resident... I dont think we should accept things as they are just because it's how it has been done.

And you don't see that FM and EM have very different mindsets, while elements of those other specialties are similar enough that its not a huge difference?

 

[W19]

And you don't see that FM and EM have very different mindsets, while elements of those other specialties are similar enough that its not a huge difference?

Read the 1st paragraph of the post you quoted...

 

[Apollyon]

EM docs are acute generalists. FM docs are chronic generalists. We are brothers in a large family. Just like brothers, we share a lot of genetics. However, I am NOT my brother. I tell the patients that I am NOT a primary care doctor.

There IS a lot of overlap, but, it is the differences that, well, differentiate us. I work rural. There are three FM trained docs that work probably 50% +/- of the shifts per month. They are less efficient, generate more complaints, and make less money for the hospital.

If you do FM, and want to do EM, the very reason I am there, you don't have. What do you do when you get a precipitated delivery? A blue baby? A pneumothorax? Septic shock? STEMI? 5 patients in 10 minutes?

If you want EM, do EM.

 

[VA Hopeful Dr]

Read the 1st paragraph of the post you quoted...

I addressed that directly, you just didn't get it.

Neuro, psych, EM, anesthesia, PM&R all have similarities that lend them to doing pain.

The main difference between FM and EM is the EM mindset. FM training just doesn't do what needs doing for EM. Same way EM doesn't prepare one for work as a FP.

 

[W19]

EM docs are acute generalists. FM docs are chronic generalists. We are brothers in a large family. Just like brothers, we share a lot of genetics. However, I am NOT my brother. I tell the patients that I am NOT a primary care doctor.

There IS a lot of overlap, but, it is the differences that, well, differentiate us. I work rural. There are three FM trained docs that work probably 50% +/- of the shifts per month. They are less efficient, generate more complaints, and make less money for the hospital.

If you do FM, and want to do EM, the very reason I am there, you don't have. What do you do when you get a precipitated delivery? A blue baby? A pneumothorax? Septic shock? STEMI? 5 patients in 10 minutes?

If you want EM, do EM.

That's why I have been saying FM---->EM fellowship. I can't believe that you guys are seeing it as a turf war. Why dont we have a few FM---->EM fellowships at some trauma centers and see how they do when they are out practicing instead of voicing our 'feelings'.

 

[W19]

I addressed that directly, you just didn't get it.

Neuro, psych, EM, anesthesia, PM&R all have similarities that lend them to doing pain.

The main difference between FM and EM is the EM mindset. FM training just doesn't do what needs doing for EM. Same way EM doesn't prepare one for work as a FP.

You think psych has more similarity with EM than IM/FM....

Any reason why a FM doc should not be allowed to do an endo fellowship?

 

[VA Hopeful Dr]

That's why I have been saying FM---->EM fellowship. I can't believe that you guys are seeing it as a turf war. Why dont we have a few FM---->EM fellowships at some trauma centers and see how they do when they are out practicing instead of voicing our 'feelings'.

Its not a turf war (otherwise why would I be opposing it?). Its that one year on top of an FM residency doesn't equal someone who has done an EM residency. Just based on pure numbers, it can't.

 

[VA Hopeful Dr]

You think psych has more similarity with EM than IM/FM....

Any reason why a FM doc should not be allowed to do an endo fellowship?

Couple of reasons. We don't get as much adult training as IM. There's no need for it (I'm not seeing endocrine spots going unfilled) nor do I hear of FPs wanting to go into it.

That said, I wouldn't strongly oppose the idea. I just don't see the need for it.

 

[W19]

Its not a turf war (otherwise why would I be opposing it?). Its that one year on top of an FM residency doesn't equal someone who has done an EM residency. Just based on pure numbers, it can't.

3 yr EM vs 4 year EM... We can also argue about that just based on pure #...

It's not fair to say the door should be closed to all FM docs because YOU dont see the need for it.

 

[VA Hopeful Dr]

3 yr EM vs 4 year EM... We can also argue about that just based on pure #...

It's not fair to say the door should be closed to all FM docs because YOU dont see the need for it.

Except its not just me. The ABFM isn't fighting for it so they obviously don't see the need either. Nor is the AAFP.

If the 2 main FM groups aren't trying to accomplish something, maybe there's a reason for that.

 

[W19]

~80% of what comes to the ED can be handled by FM/IM doc... But you guys think the remaining 20% can't be learned in 1 yr fellowship.

 

[W19]

Except its not just me. The ABFM isn't fighting for it so they obviously don't see the need either. Nor is the AAFP.

If the 2 main FM groups aren't trying to accomplish something, maybe there's a reason for that.

Again, you guys accept things as they are... I argued with you before and I can see you are part of the establishment and you dont think that there is anything that should be changed in US med education--even CS. I know you and I won't get anywhere in that discussion.

 

[Apollyon]

Why are you perseverating so hard? You say you're not FM, fine, but, you sound like you have skin in this game.

But, then again, you refuse to see reality. 1 year of fellowship does not equal the residency. That's irrefutable (except to you - pro tip - the sky is blue, and the Earth is an oblate spheroid).

If you want to do EM, do an EM residency.

Or, how about this appeal to emotion? What if it is your kid with the obstructed airway? Do you want the doc who can have the best opportunity to save your kid, or someone who (figuratively, or, maybe literally) throws their hands up in the air?

Residency is to develop core skills. Fellowship is to refine them. FM core skills are not the same as EM (ere they WOULD be the same). Again, if you want to do EM, do an EM residency.

 

[VA Hopeful Dr]

Again, you guys accept things as they are... I argued with you before and I can see you are part of the establishment and you dont think that there is anything that should be changed in US med education--even CS. I know you and I won't get anywhere in that discussion.

You mean like when I said this:

But the point wasn't about Step 1. It was about Step 2 CS which even for me in 2009 was like $1200 not including travel/lodgings. That's a decent chunk of change for a fairly worthless test.

Yeah, I obviously think CS is a good thing.

As for accepting things as they are? Horse****. Would I have done DPC if I loved the status quo?

Here's the thing. Family medicine is a field for generalists. That's our purpose. I would argue that full-scope FM is the broadest field in medicine. That's what we're designed for. Babies, women (pregnant and not), teenagers, young adults, elderly, pretty much anything can walk into my office and I'll have a general idea of what needs doing. That is what makes FM a unique specialty. Why would we try and change that?

If you want to do endocrine, there's a pathway for that. You want to do EM? That's a path for that. I'm sorry you don't like it, but there is not a single good reason to change it other than "I don't like my original specialty and want a shortcut into another one".

 

[VA Hopeful Dr]

Why are you perseverating so hard? You say you're not FM, fine, but, you sound like you have skin in this game.

But, then again, you refuse to see reality. 1 year of fellowship does not equal the residency. That's irrefutable (except to you - pro tip - the sky is blue, and the Earth is an oblate spheroid).

If you want to do EM, do an EM residency.

Or, how about this appeal to emotion? What if it is your kid with the obstructed airway? Do you want the doc who can have the best opportunity to save your kid, or someone who (figuratively, or, maybe literally) throws their hands up in the air?

Residency is to develop core skills. Fellowship is to refine them. FM core skills are not the same as EM (ere they WOULD be the same). Again, if you want to do EM, do an EM residency.

That's the main reason I care, as a matter of fact.

 

[W19]

Done arguing since I see it's a turf war mindset... No data/stuidies to support anything.

 

[VA Hopeful Dr]

Done arguing since I see it's a turf war mindset... No data to support anything.

Do you actually know what a turf war is? I mean this honestly because I really don't think you do. If that's all it was, why would I, an FP, be against it since it would benefit me?

 

[W19]

Do you actually know what a turf war is? I mean this honestly because I really don't think you do. If that's all it was, why would I, an FP, be against it since it would benefit me?

I know what it means even if English is my 4th language... You are an establishment figure as I said before... Talking about ED docs here that are arguing against it.

 

[GonnaBeADoc2222]

So design the prospective trial to refute us. The burden of proof is on you as patients stand to be hurt.

Only reason I can think that this guy keeps hammering away at this is that they couldn't get into an EM residency.

 

[VA Hopeful Dr]

I know what it means even if English is my 4th language... You are an establishment figure as I said before... Talking about ED docs here that are arguing against it.

No, I'm really not. As I've proven several times. I'm conservative, which is quite different. If you want to change the status quo, you have to prove its benefit. As the post above my points out, if you are wrong then patients will be harmed.

 

[W19]

So design the prospective trial to refute us. The burden of proof is on you as patients stand to be hurt.

Only reason I can think that this guy keeps hammering away at this is that they couldn't get into an EM residency.

Fair...

Never considered it. And I respect what you do guys because I would not be able to do it even for $1000/hr...

 

[deleted859535]

Again, you guys accept things as they are... I argued with you before and I can see you are part of the establishment and you dont think that there is anything that should be changed in US med education--even CS. I know you and I won't get anywhere in that discussion.

That's the thing, though. It has nothing to do with being part of "the establishment" nor a turf war.

Our point is that a family physician will never, ever, ever be able to function to the capacity of an emergency physician when it really counts just as well as I'd be doing a disservice to a family practice or an internist's office.

Yes, an FP could handle some of what comes in just as well as our PAs do. FM management isn't EM management, though. Meanwhile, our experienced PAs have other benefits. Practicing in an ED is a learned skill. In the end, the critical folks, the critical folks plus other volume, and various other workings of how to run an ED in day-to-day practice are best left for someone who trained in how to do that and do it well.

As was mentioned above: if I'm ever in extremis, I want one of my EM-trained partners to take care of me. If my choices are EM-trained x3 years with or without a year's experience versus FM-trained x3 years plus a "fellowship" year, I'll take the former. Similarly, a well-honed FP will be my first pick when it comes to primary care and long-term management.

You don't need data for that. It's not rhetoric, not traditionalism, not blind faith. It's common sense which yet again proves to be not common, like the medical student mouthing off about airway management to people who have intubated more patients than he has seen.

 

[MedicineZ0Z]

So design the prospective trial to refute us. The burden of proof is on you as patients stand to be hurt.

Only reason I can think that this guy keeps hammering away at this is that they couldn't get into an EM residency.

We have "studies" that show a NP with 0 work exp and some online courses provides "better care" than a board certified doctor. Heck, there was a post on reddit showing a study that shows RNs can provide better care. Soon we'll have MAs providing better care in some study.

 

[Lexdiamondz]

They do that in Canada. I think the majority of ED docs there are family med + 1 year fellowship trained. There is no difference in outcomes there than USA.... everything is very much on par.

Canada also has FM + 1 year in anesthesia and obstetrics. I know physicians with FM + 1 year ER training practice in trauma centers alongside EM residency trained physicians in at least one major Canadian city. Keep in mind a true accredited EM residency in Canada is 5 years in duration.

If you're going to bring up Canada, please remember that

1) FM/EM combined programmes are 5 years in duration, not four

2) Despite Canada being the USs neighbour, Canada has a fairly different demographic profile and as a result, their patient demographics also look quite different, leading to differences in how their training is structured.

Canada is not analogous to the US. An FM attending already told you that even if he did a fellowship in EM, he still would have < half of the training an EM attending has in EM.

This isn't a turf war...we already know what happens when people who aren't trained to do EM decide to do EM - the reason why a licensing board for EM even exists is because prior to that the outcomes were utterly abysmal.

 

[Lexdiamondz]

Rad and gas are not the same with EM... Most things that come to the ED are not emergency... @MedicineZ0Z talked about Canada that has FM--->ED and outcome is no different. Maybe it's something they can try here instead of opening EM residency in every 100/200 beds hospital (FL is an example) where EM training is subpar.

Are people really saying that a FM doc wont be able to manage ED patients after doing 1 yr fellowship at a good ED trauma hospital?

I mean why aren't Rad and Gas the same? Even though we have in-house radiology, I read my own head CTs, CXRs and extremity XRs all the time! Even though we have in house-anaesthesia, I've already done >100 intubations, and I perform conscious sedation for procedures literally every other day! Why shouldn't I have a year-long fellowship and be allowed to perform the same job as a board-certified anaesthesiologist or radiologist with double the training? What's the worst that could happen?


Do you see how utterly stupid you sound?

 

[Brigade4Radiant]

These are just anecdotes...

No ther's a lot of data. You can't just create a new field of medicine with multiple painful requirements unless there is data that supports it. This is the history of EM there is a reason why the emergency department predated Emergency medicine as a field. I get it ER is cool and sure be a FM that works in the ER. I could also work as a primary care physician in a rural place. You can do that after 1 year of residency in surgery. It doesn't mean it's a good idea.

By that logic FM should be OBGYN boarded after 1 year fellowship

 

[NITRAS]

I think I'm dumber for reading this thread.

 

[It's lupus!]

This has become the most entertaining example of the dunning kruger curve in action I've seen since the DNP=MD debate. Haha

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[CCM-MD]

If you're going to bring up Canada, please remember that

1) FM/EM combined programmes are 5 years in duration, not four

2) Despite Canada being the USs neighbour, Canada has a fairly different demographic profile and as a result, their patient demographics also look quite different, leading to differences in how their training is structured.

Canada is not analogous to the US. An FM attending already told you that even if he did a fellowship in EM, he still would have < half of the training an EM attending has in EM.

This isn't a turf war...we already know what happens when people who aren't trained to do EM decide to do EM - the reason why a licensing board for EM even exists is because prior to that the outcomes were utterly abysmal.

The demographics of New York and Kentucky differ more than Ontario and New York. Give me a break. The training is analogous and most American boards allow reciprocal certification for almost all of the specialties with some caveats.

Canadian FM training is 2 years in duration and their “ER fellowship” is 1 year in length. To be an emergency medicine “specialist” in Canada requires a 5 year EM residency. There’s plenty of 2+1 attendings practicing even even in large hospitals. There is no data on whether the 5 year EM specialists provide better care.

I have no bias in this discussion - I am neither FM nor EM.

 

[deleted109597]

Yep. This has outlived its usefulness.