Considering getting out of EM

[Nocturnist]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people.

All of Medicine is a dumpster.

To manage an ICU patient's chronic medical problems, or to do something that would closely resemble what you specialize in doing in the first 15 minutes in the ED?

Anyway, I'm not an intensivist and 2 wrongs don't make a right. All I know if I didnt start feeling remotely comfortable with outpatient internal medicine until the last couple months of residency, and I have enough experience to know when to stay in my lane.

---

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[Siggy]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people. You can’t preach about how good your are when you hand off an entire icu census to someone who go their degree online.

All of Medicine is a dumpster.

Every hospital I've worked at as an intensivist has had 24 hour in house intensivist coverage.

 

[Rekt]

Every hospital I've worked at as an intensivist has had 24 hour in house intensivist coverage.

Neat. A majority of the country does not. Your specialty is fine with it as a whole.

 

[Siggy]

Neat. A majority of the country does not. Your specialty is fine with it as a whole.

I agree it's a problem.

...but if we want to go down this route the frequency of that the PLPs from the ED are calling in consults to the ICU is certainly above rare. So we're to the point that the field of EM doesn't even think that critically ill patients in the ED need to be seen or managed by an EM physician.

Broad brushes are fun to paint with.

 

[RustedFox]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people. You can’t preach about how good your are when you hand off an entire icu census to someone who go their degree online.

All of Medicine is a dumpster.

Jeeeezus.... same here!
The FIRST thing I do when I get to the hospital for a nightshift (I'm a nocturnist) is look at that call sheet to see which ICU pretender it is that night...

They're fine with PLPs managing the ICU overnight, as long as Ol' Fox is there to come up for every little thing.

 

[RustedFox]

Every hospital I've worked at as an intensivist has had 24 hour in house intensivist coverage.

HA HA HA HA HA

 

[Brigade4Radiant]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people. You can’t preach about how good your are when you hand off an entire icu census to someone who go their degree online.

All of Medicine is a dumpster.

With no training at that and they see patients independently I never see any corrections on any outpatient clinic chart that the doc sees in retrospect 15 days later

Also the same argument can be had about a hospitalist vs clinical if they can just do outpatient 15 years after not doing it the same as a clinical doctor decides to up and do hospitalist work

 

[Prehealth1011]

I’ve wondered if someone wanted to do a second residency in IM or FM after completing an EM residency would it still be 3 years or would they count an intern year making it two?

I’m IM and I honestly don’t know how a typical EM residency is structured. Isn’t ICU the only common rotation between EM vs FM/IM? We have so much floors/clinic/ICU that I imagine it would take more than 2 years. Advanced specialties like anesthesia/neurology/pmr also have specific rotation requirements you had to have done in your pgy1 year, including floors.

 

[GonnaBeADoc2222]

LOL I remember when they refused to hire more intensivists, and our ED PLPs wanted "more critical care experience" so they thought it was a good idea to have them do ICU shifts after a couple sessions of minimal training.

This lasted about a month.

Notice to PLPs: if you want to do a job, go to school for it.

 

[RustedFox]

LOL I remember when they refused to hire more intensivists, and our ED PLPs wanted "more critical care experience" so they thought it was a good idea to have them do ICU shifts after a couple sessions of minimal training.

This lasted about a month.

Notice to PLPs: if you want to do a job, go to school for it.

Yep.
I have a side gig that also employs PLPs.
They really can't do even the simplest of tasks correctly.
I'm tasked with quarterly reviews and such.
This quarter, the boom fell. People are getting fired for their nonsense.
The message is: "Look, do your job correctly. Its not something you can do while you're busy MommyBossing. Pay attention and knock it off."
People are gonna get fired, and I'm gonna be happy to do it.

 

[The Knife & Gun Club]

“You guys can’t manage even beyond the first couple hours!”

“But I’m fine with my zero experience mid levels taking care of 30 vented patients and teetering NIPPV pts overnight so I can sleep soundly”.

I can’t even count the amount of times I’ve had to go to the icu at all the places I’ve worked so far to save your own patients from your PLPs killing people. You can’t preach about how good your are when you hand off an entire icu census to someone who go their degree online.

All of Medicine is a dumpster.

There’s definitely a pretty real problem with having PLPs green out of fake school working nights in the unit.

And every unit and model is a bit different so there’s a ton of ways to do it wrong.

But just to be devils advocate at bit - in the ICU the PLPs aren’t making plans or doing intricate management on their own. In the ED they’re seeing the patient and determining the workup which has huge implications for diagnostic momentum. In the unit they’re just maintaining the course set during the day and putting out fires.

At least the community model of my current place they see an admit, present to me (or the attending if I’m not on call) at home who reviews the labs and imaging. Sometimes I call the EM doc to chat about the case for a sec to understand their thought process.

If their plan is reasonable I say go for it and if not I tell them what to change. And for the admitted already people I just tell them my plan and goals and they execute it. Not much in the way of them making high level clinical decisions on their own - just trying a bit of fluids here. Maybe a few hours on levo there, just to get them through to the morning when the usual team is back.

Again obviously depends on the shop and the volume and acuity the unit is seeing during nighttime hours

 

[TrailRun]

My feeling is that if a motivated, board certified attending PHYSICIAN wants to switch from EM to PCP, have at it. Increasingly NPs and PAs are practicing more autonomously, so there's no reason why a doctor can't learn those skills. If there's a super complicated patient on 12 anti-hypertensives then know your limits and refer out. And similarly, if a FM-trained Physician wants to do ER, they can do a course or something to learn about those less than a dozen procedures that we do that they don't. I mean, listen to the EM:RAP rural medicine tales of those docs 10 hours away from the nearest tertiary care places in Canada. They get the job done. We are way too siloed in medicine. Just like the other threads here, there is absolutely no reason an EM doc can't learn to do sleep. Or cardiology. Or hospitalist. Or whatever. I feel that more career mobility would be helpful, as you'd have people in fields they are interested in as opposed to remaining in fields they are stuck

 

[Nocturnist]

My feeling is that if a motivated, board certified attending PHYSICIAN wants to switch from EM to PCP, have at it. Increasingly NPs and PAs are practicing more autonomously, so there's no reason why a doctor can't learn those skills. If there's a super complicated patient on 12 anti-hypertensives then know your limits and refer out. And similarly, if a FM-trained Physician wants to do ER, they can do a course or something to learn about those less than a dozen procedures that we do that they don't. I mean, listen to the EM:RAP rural medicine tales of those docs 10 hours away from the nearest tertiary care places in Canada. They get the job done. We are way too siloed in medicine. Just like the other threads here, there is absolutely no reason an EM doc can't learn to do sleep. Or cardiology. Or hospitalist. Or whatever. I feel that more career mobility would be helpful, as you'd have people in fields they are interested in as opposed to remaining in fields they are stuck

Sure, buddy. Let's have ourselves a race to the bottom. 12 antihypertensives? I generally can't trust an ER doc to start even one antihypertensive (from experience every time they do it's over 50% the wrong one). Again, love all you guys, but ya'll out there like anything other than IV labetalol is coming out of your paychecks.

Forget never having stepped foot in a ward or a clinic before. Forget the 15k hours of experience. Let's start with at least having an EM doc pass the IM boards, then we'll talk.

 

[Rekt]

Sure, buddy. Let's have ourselves a race to the bottom. 12 antihypertensives? I generally can't trust an ER doc to start even one antihypertensive (from experience every time they do it's over 50% the wrong one). Again, love all you guys, but ya'll out there like anything other than IV labetalol is coming out of your paychecks.

Forget never having stepped foot in a ward or a clinic before. Forget the 15k hours of experience. Let's start with at least having an EM doc pass the IM boards, then we'll talk.

Such an absurd statement. Probably one of the dumbest things I’ve read on here. Not even worth debating. You just have a hard on for putting down EM docs. Go back to consulting every specialist to do your work for you on the floors.

 

[Nocturnist]

Such an absurd statement. Probably one of the dumbest things I’ve read on here. Not even worth debating. You just have a hard on for putting down EM docs. Go back to consulting every specialist to do your work for you on the floors.

Not one bit, but i respect your opinion! What I *might* have a hard on for is putting down docs who think they can do my job after watching some "course or something." If that ain't the dumbest thing I've heard on here, I don't know what is.

Btw if you support docs doing your job without going through residency or board certification, and aren't a fan of mid levels encroaching- wait til you hear about the millions of foreign docs with actual training and expertise in your field that would be thrilled to take your job for pennies on the dollar. The slippery slope has never been more slippery..

 

[Drrrrrr. Celty]

Is there something about December that makes everyone hate each other or something?
How many threads are we hate x specialty right now on SDN lol.

Sure, buddy. Let's have ourselves a race to the bottom. 12 antihypertensives? I generally can't trust an ER doc to start even one antihypertensive (from experience every time they do it's over 50% the wrong one). Again, love all you guys, but ya'll out there like anything other than IV labetalol is coming out of your paychecks.

Forget never having stepped foot in a ward or a clinic before. Forget the 15k hours of experience. Let's start with at least having an EM doc pass the IM boards, then we'll talk.

I think like all specialties there are good and bad specialists in each field.

I've had to explain a an ER doc that their patient is in DKA or that an a1c of 14 is not going to get better on Metformin 500 bid until they are seen by their PCP when they're symptomatically hyperglycemic.

Alternatively I've had an ER doctor call me for a thyrotoxicosis patient, had already started appropriately dosed propranolol, a moderate dose of methimazole, and ask me to just have them set up follow up.

It's not like admitting nocturnists are all great either. During residency I used to fight the nocturnists during rapids or push back on admits that needed ICU or watch them do random medicine out of their ass like decide to do stress dose steroids for clearly cardiogenic shock to stay on the floor until day team gets here, giving adenosine to 5x to a visibly agitated person in 'svt' who was in DT, and give 20 of haldol to a patient and then call me to tube them when they stopped protecting their airway.

 

[Drrrrrr. Celty]

Not one bit, but i respect your opinion! What I *might* have a hard on for is putting down docs who think they can do my job after watching some "course or something." If that ain't the dumbest thing I've heard on here, I don't know what is.

Btw if you support docs doing your job without going through residency or board certification, and aren't a fan of mid levels encroaching- wait til you hear about the millions of foreign docs with actual training and expertise in your field that would be thrilled to take your job for pennies on the dollar. The slippery slope has never been more slippery..

I agree, here though with this premise. Most ER doctors aren't prepared to do primary care.

Experience is not derived from a book or a CME event.

You can understand physiology or guidelines. And I'll argue that in the ER is one of the fields most following strict guidelines. However outpatient medicine is guideline... inspired. It's very experience driven and driven by expectations. When you're doing a lot of acute medicine, you don't get a good grasp for natural progression of slow moving things. And that can be very jarring for almost anyone coming from a hospital based field into an outpatient one. That jarringness makes you make mistakes.

 

[TrailRun]

Sure, buddy. Let's have ourselves a race to the bottom. 12 antihypertensives? I generally can't trust an ER doc to start even one antihypertensive (from experience every time they do it's over 50% the wrong one). Again, love all you guys, but ya'll out there like anything other than IV labetalol is coming out of your paychecks.

Forget never having stepped foot in a ward or a clinic before. Forget the 15k hours of experience. Let's start with at least having an EM doc pass the IM boards, then we'll talk.

If primary care is so complicated, how come every time I try to schedule an appointment for myself or family they schedule us with a nurse practitioner or PA?

My opinion is that you could do about 90% of my job and I could do about 90% of yours. We all did step1/2/3, boards, rotations in IM, family, etc in med school. Doesn’t seem like the system cares about the other 10%. Most of my patients don’t know the difference between a PA and MD. Like it or not, this is the direction medicine is heading. I have no doubt a residency trained IM doc could be a better PCP than me, but I truly feel if a boarded EM doc is motivated to learn primary they can. Again your post illustrates the point - docs can keep fighting amongst themselves to try to hold onto territory, but the truth is it’s already gone

 

[greatnt249]

If primary care is so complicated, how come every time I try to schedule an appointment for myself or family they schedule us with a nurse practitioner or PA?

Because administrators think we (including emergency physicians) are interchangeable; that doesn't mean we actually are. It has nothing to do with complexity and everything to do with "needing a body to see more bodies=profit." The tune would change if administrators were actually liable for the medical outcomes that come with the downstream effects of their "policies," but as it stands they get to coast on the coattails of our liability insurance without needing to have a care in the world about it.

 

[The kitchen sink]

LOL I remember when they refused to hire more intensivists, and our ED PLPs wanted "more critical care experience" so they thought it was a good idea to have them do ICU shifts after a couple sessions of minimal training.

This lasted about a month.

Notice to PLPs: if you want to do a job, go to school for it.

What does PLP stand for?

 

[RustedFox]

What does PLP stand for?

Pretend-level-provider.

A pejorative that plays on the term mid-level provider.

Generally, a PA/NP who loves to clamor that they have equivalent education/skills, but can't manage even the simplest of physician cognitive tasking.

 

[Drrrrrr. Celty]

If primary care is so complicated, how come every time I try to schedule an appointment for myself or family they schedule us with a nurse practitioner or PA?

My opinion is that you could do about 90% of my job and I could do about 90% of yours. We all did step1/2/3, boards, rotations in IM, family, etc in med school. Doesn’t seem like the system cares about the other 10%. Most of my patients don’t know the difference between a PA and MD. Like it or not, this is the direction medicine is heading. I have no doubt a residency trained IM doc could be a better PCP than me, but I truly feel if a boarded EM doc is motivated to learn primary they can. Again your post illustrates the point - docs can keep fighting amongst themselves to try to hold onto territory, but the truth is it’s already gone

The answer is that they really shouldn't be.

And again it depends on a the FNP/PA. Some have practiced for enough time and read and are good with managing a lot of stuff and know their limits. Others really are mostly great for a non complicated patient with something very simple. Ex. a 40 year old who needs metformin, a 50 year old who has basic hypertension, etc or inbetween appointments to make sure that the MD/DO's orders are conveyed and well followed.

Regarding 90% of the job. You're getting paid for the 10% that everyone can't do well.

How many ER doctors think of hyperaldosteronism? What about indications to do a full work up for hypertension in a young patient? How about interpretation of lab results. Can you tell me what you'd do about a prolactin of 30? What about what would you do with a LDL of 180 in a 22 year old who is there for a physical to play a college sport? What about the difference between when a patient is a good candidate for an SSRI v.s Wellbutrin? Or how to interpret neuropathy as being vitamin b deficiency? Can you tell me what the A1c goal is for someone who is 50 with T2Dm v.s someone who is 80? What about the A1c goal of a T2DM who is blind and has CKD4?

Yes, you can look up on up to date. But I purposefully chose some very intermediate numbers that don't read as truly high or things that need you to dig a bit and order labs to further elaborate or numbers that aren't that easy to google explicitly.

Like I think as an Endocrinologist I can tell you right now that everyone thinks they can do my job. But when they are asked a basic question almost everyone fails to get it right because they have limited experience in the field. And I think this analogies it completely saying that an ER doc can go happily do PCP.

You think that because you've got this set of experience you think you're ready to do it. When really you're not and you're walking into something thinking that the superficial is adequate because it on the surface works.

And the reality is that we are missing obvious things. Even those who are trained in FM and IM. And it's contributing to a lot of heart attacks, broken bones, etc.

 

[The kitchen sink]

The answer is that they really shouldn't be.

And again it depends on a the FNP/PA. Some have practiced for enough time and read and are good with managing a lot of stuff and know their limits. Others really are mostly great for a non complicated patient with something very simple. Ex. a 40 year old who needs metformin, a 50 year old who has basic hypertension, etc or inbetween appointments to make sure that the MD/DO's orders are conveyed and well followed.

Regarding 90% of the job. You're getting paid for the 10% that everyone can't do well.

How many ER doctors think of hyperaldosteronism? What about indications to do a full work up for hypertension in a young patient? How about interpretation of lab results. Can you tell me what you'd do about a prolactin of 30? What about what would you do with a LDL of 180 in a 22 year old who is there for a physical to play a college sport? What about the difference between when a patient is a good candidate for an SSRI v.s Wellbutrin? Or how to interpret neuropathy as being vitamin b deficiency? Can you tell me what the A1c goal is for someone who is 50 with T2Dm v.s someone who is 80? What about the A1c goal of a T2DM who is blind and has CKD4?

Yes, you can look up on up to date. But I purposefully chose some very intermediate numbers that don't read as truly high or things that need you to dig a bit and order labs to further elaborate or numbers that aren't that easy to google explicitly.

Like I think as an Endocrinologist I can tell you right now that everyone thinks they can do my job. But when they are asked a basic question almost everyone fails to get it right because they have limited experience in the field. And I think this analogies it completely saying that an ER doc can go happily do PCP.

You think that because you've got this set of experience you think you're ready to do it. When really you're not and you're walking into something thinking that the superficial is adequate because it on the surface works.

And the reality is that we are missing obvious things. Even those who are trained in FM and IM. And it's contributing to a lot of heart attacks, broken bones, etc.

EM docs can’t just walk into a primary care clinic and do the job…. Even PMDs don’t have enough time to do what they have to do

Revisiting the Time Needed to Provide Adult Primary Care

Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.To quantify the time needed to provide 2020 preventive care, ...

www.ncbi.nlm.nih.gov

 

[Drrrrrr. Celty]

EM docs can’t just walk into a primary care clinic and do the job…. Even PMDs don’t have enough time to do what they have to do

Revisiting the Time Needed to Provide Adult Primary Care

Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.To quantify the time needed to provide 2020 preventive care, ...

www.ncbi.nlm.nih.gov

I think the only thing that will save PC is AI. We are going to look at primary care before and after Artificial intelligence integration. AI is going to chart review vitals and labs and decide globally if someone needs something like a Sleep Study or Echo or vaccinations. And It'll likely result in more of these tests done likely 5 years earlier than they're being done currently.

AI is going to be to us, what PCN/Sulfa antibiotics were to medicine in the 20-30s.

 

[Splenda88]

In my opinion, It will take an EM doc about 1 year to become a good outpatient PCP and about 6-8 months to become a good hospitalist.

Conversely, it might take a FM doc 1 year to become a good EM doc.

IM docs might need a little bit more than 12 months to become a good EM doc given that they know nothing about peds and obgyn.

 

[Drrrrrr. Celty]

In my opinion, It will take an EM doc about 1 year to become a good outpatient PCP and about 6-8 months to become a good hospitalist.

Conversely, it might take a FM doc 1 year to become a good EM doc.

IM docs might need a little bit more than 12 months to become a good EM doc given that they know nothing about peds and obgyn.

I think it'd take longer than all of that to truly be good. Again, a lot of medicine is experience keeping your head on your shoulders and not making a mistake because you wanted to rush a process or thinking that doing something Herculean when it's not warranted will help. I don't think people who graduate from residency or fellowship have the right to think they're good level either. They're passable, that's all.

 

[Brigade4Radiant]

Of course with more experience the better you are but Primary care is very broad as in Peds, FM, IM, can all do primary care not to mention in the real world most patients just have one doctor like a cardiologist then there is insurance which dictates what people can do.

Many EM docs when they say clinic mean urgent care or a very narrow clinic not full on full scope primary care

8-5 M-F no weekends and make 250k being an employee

You can just open an urgent care and make about 300k and employ an NP no labs or rads in a well insured area and think about it there are places that you need a two year fellowship for urgent care.

 

[VA Hopeful Dr]

If primary care is so complicated, how come every time I try to schedule an appointment for myself or family they schedule us with a nurse practitioner or PA?

Because there aren't enough of us.

 

[Lexdiamondz]

Mainly because there aren't real fellowships (ABMS) that train anyone to practice in another specialty that has its own separate residency pathway already set up.

But there also hasn't been any demand for this until pretty recently. 10 years ago EM was still super competitive and I don't remember hearing much discontent about the specialty overall.

In terms of logistics, to do it right it would need to be a 2 year program. Picking up the new information wouldn't take that long, but if you're going to learn to manage chronic diseases you need to follow patients for more than 1 year.

Basically this. There is a reason why EM/FM and EM/IM are combined 5yrs in the US. 1 year isn't enough to get the resus experience to do EM, nor is it enough to get the longitudinal care experience to do FM.

 

[Splenda88]

Basically this. There is a reason why EM/FM and EM/IM are combined 5yrs in the US. 1 year isn't enough to get the resus experience to do EM, nor is it enough to get the longitudinal care experience to do FM.

Lol.

A lot of things they do in medicine are just... arbitrary

3-yr vs. 4-yr EM

3-yr med school vs. 4-yr med school

Baccalaureate degree not really needed to become a doc

Don't swallow what people in these ivory towers are jamming down our throat.

Let's be real here: 80%+ of what EM do, FM can just do it as well.

 

[Apollyon]

Let's be real here: 80%+ of what EM do, FM can just do it as well.

You are generous. I would give it more to 90%. But, therein lies the rub. We in EM were sold a bill of goods - that that 10% where we are really needed will be more than 10% of the time. However, in residency, the bottom out of sight cases are in Fast Track, or, barring that, are unnecessarily worked up "just in case". So, go into the community, 90, maybe 95% of cases are straight primary care. And we weren't trained into that, directly. We tell ourselves we are there for the 5% that need our special skills, and our "superpower" is going through the chaff of PC cases to find the wheat. It's when two things look alike, and one is really bad, and the other is really not. However, to give away the ending, there's a LOT of chaff.

It was said by an FM doc here on SDN many years ago, and it holds up well: FM - chronic generalists. EM - acute generalists. In the family of medicine, FM and EM are the closest siblings. Might even call them "Irish twins".

 

[Splenda88]

You are generous. I would give it more to 90%. But, therein lies the rub. We in EM were sold a bill of goods - that that 10% where we are really needed will be more than 10% of the time. However, in residency, the bottom out of sight cases are in Fast Track, or, barring that, are unnecessarily worked up "just in case". So, go into the community, 90, maybe 95% of cases are straight primary care. And we weren't trained into that, directly. We tell ourselves we are there for the 5% that need our special skills, and our "superpower" is going through the chaff of PC cases to find the wheat. It's when two things look alike, and one is really bad, and the other is really not. However, to give away the ending, there's a LOT of chaff.

It was said by an FM doc here on SDN many years ago, and it holds up well: FM - chronic generalists. EM - acute generalists. In the family of medicine, FM and EM are the closest siblings. Might even call them "Irish twins".

I just don't get why people in medicine keep lying to themselves.

FM + procedures = EM

Just like

IM + procedures = CCM

 

[VA Hopeful Dr]

I just don't get why people in medicine keep lying to themselves.

FM + procedures = EM

Just like

IM + procedures = CCM

I can't speak to the IM part but that's not at all accurate for FM.

 

[VA Hopeful Dr]

Lol.

A lot of things they do in medicine are just... arbitrary

3-yr vs. 4-yr EM

3-yr med school vs. 4-yr med school

Baccalaureate degree not really needed to become a doc

Don't swallow what people in these ivory towers are jamming down our throat.

Let's be real here: 80%+ of what EM do, FM can just do it as well.

I have never been anywhere that even approached an Ivory tower. Small not-super-special liberal arts school in Virginia. USC, the South Carolina one. Community FM program in upstate SC. I'm as far from Ivory tower as you can get.

I could not have done a 3 year MD program. Cramming 2 years of preclinical work into 1 would have been beyond me. Its good to have the option, but let's not pretend that everyone can make that work.

I thought the general consensus was that 4 year EM programs were overkill.

A goodly number of attendings I've known (both here and in real life) have said that the 6 year BS/MD programs often produce graduates who just aren't ready to be doctors yet. Yes, some people are which is why its nice that those programs exist but many people aren't.

 

[Franzd'Epinay]

A goodly number of attendings I've known (both here and in real life) have said that the 6 year BS/MD programs often produce graduates who just aren't ready to be doctors yet. Yes, some people are which is why its nice that those programs exist but many people aren't.

I have a suspicion these people's opinions are strongly colored by what they see as the normal way of training doctors in the US.

The vast majority of physicians in the world begin their training right after high school. I have a hard time believing that the rest of the world's doctors are less ready/capable than us, or that Americans are less mature than their foreign counterparts.

 

[VA Hopeful Dr]

I have a suspicion these people's opinions are strongly colored by what they see as the normal way of training doctors in the US.

The vast majority of physicians in the world begin their training right after high school. I have a hard time believing that the rest of the world's doctors are less ready/capable than us, or that Americans are less mature than their foreign counterparts.

Really? I have no problem believing that if for no other reason than that many countries' high school equivalents are much more specialized/intense that what we typically do here and so you self-select better before college.

 

[Splenda88]

I have a suspicion these people's opinions are strongly colored by what they see as the normal way of training doctors in the US.

The vast majority of physicians in the world begin their training right after high school. I have a hard time believing that the rest of the world's doctors are less ready/capable than us, or that Americans are less mature than their foreign counterparts.

I have lived in 4 countries so far, and there is nothing different form kids here than the rest of the world.

Med school is a pre-seclection thing probably almost everywhere.

2 of these countries are in latin America and these kids finish HS at the age of 16.

One of my co-residency (also friend) finished residency at the age of 25 and she is doing more than ok as a hospitalist.

I have many friends who are FMG and the one thing all of them will tell you our med school here go more more in depth in basic science than most other countries. Debatable how useful that is.

 

[Splenda88]

Really? I have no problem believing that if for no other reason than that many countries' high school equivalents are much more specialized/intense that what we typically do here and so you self-select better before college.

Not more intense TBH. I did all my grade school outside of the US, and what my daughter is doing now in 8 grade is what I did in at the beginning of HS. She is doing a lot freaking more homework than I ever did.

 

[emergentmd]

FM docs can do an avg job with 90% of EM pts.
EM docs can do an avg job with 90% of FM pts.

How do I know? Because APCs can see prob 90% of EM pts and can essentially do 100% of FM pts in rural places.

The difference is if I mess up on FM pts, then they decompensate and most likely do well going to ER. If an FM messes up in the ER, a pt can die. I have seen FM docs who can't even read an obvious STEMI.

So If I as an experience EM doc who sees 10% emergencies, 50% urgent care, 40% PCP stuff should clearly be better than an FM resident starting as an attending overall. I dont think I am wrong.

Give me 1 year and I would be able a good FM doc.

 

[larpleston]

You are generous. I would give it more to 90%. But, therein lies the rub. We in EM were sold a bill of goods - that that 10% where we are really needed will be more than 10% of the time. However, in residency, the bottom out of sight cases are in Fast Track, or, barring that, are unnecessarily worked up "just in case". So, go into the community, 90, maybe 95% of cases are straight primary care. And we weren't trained into that, directly. We tell ourselves we are there for the 5% that need our special skills, and our "superpower" is going through the chaff of PC cases to find the wheat. It's when two things look alike, and one is really bad, and the other is really not. However, to give away the ending, there's a LOT of chaff.

It was said by an FM doc here on SDN many years ago, and it holds up well: FM - chronic generalists. EM - acute generalists. In the family of medicine, FM and EM are the closest siblings. Might even call them "Irish twinsFM docs can do an avg job with 90% of EM pts.

EM docs can do an avg job with 90% of FM pts.

How do I know? Because APCs can see prob 90% of EM pts and can essentially do 100% of FM pts in rural places.

The difference is if I mess up on FM pts, then they decompensate and most likely do well going to ER. If an FM messes up in the ER, a pt can die. I have seen FM docs who can't even read an obvious STEMI.

So If I as an experience EM doc who sees 10% emergencies, 50% urgent care, 40% PCP stuff should clearly be better than an FM resident starting as an attending overall. I dont think I am wrong.

Give me 1 year and I would be able a good FM doc.

Really depends on the shop. I work one low acuity place with good specialty support where I think a really good PA could do 99% of what I do and FM could work there no problem. I work another site that’s super high volume where I get critically ill patients almost every shift and have almost no resources. I do not see how your average FM doc would work there without the department crumbling around them.

 

[emergentmd]

Really depends on the shop. I work one low acuity place with good specialty support where I think a really good PA could do 99% of what I do and FM could work there no problem. I work another site that’s super high volume where I get critically ill patients almost every shift and have almost no resources. I do not see how your average FM doc would work there without the department crumbling around them.

I agree. Just like if I started out as a FM doc, I would not work in a place without support but a place where a NP can run. No one will ever be able to tell me that I could not do what an Avg NP can do. My medical knowledge is much more vast and what I don't know would take me an hour to learn.

 

[Splenda88]

I could not have done a 3 year MD program.

Even 18 months + 18 months?

 

[Birdstrike]

Bad stuff is going to happen to you. One of those things may be that you were lied to about EM, either by others or by yourself and now you feel trapped on an unsustainable pathway. What you do about the situation you are in, is another matter. You can let it destroy you by slowly eating away at you, causing stress, depression, bitterness, substance abuse or PTSD. Or you can use it as a springboard, or with creative inspiration to climb to a better place in your life. The choice is yours.

 

[EMhawkeye]

Bad stuff is going to happen to you. One of those things may be that you were lied to about EM, either by others or by yourself and now you feel trapped on an unsustainable pathway. What you do about the situation you are in, is another matter. You can let it destroy you by slowly eating away at you, causing stress, depression, bitterness, substance abuse or PTSD. Or you can use it as a springboard, or with creative inspiration to climb to a better place in your life. The choice is yours.

Wise.

 

[VA Hopeful Dr]

Even 18 months + 18 months?

Maybe? More likely now with Step 1 being pass/fail than before.

 

[VA Hopeful Dr]

I have lived in 4 countries so far, and there is nothing different form kids here than the rest of the world.

Med school is a pre-seclection thing probably almost everywhere.

2 of these countries are in latin America and these kids finish HS at the age of 16.

One of my co-residency (also friend) finished residency at the age of 25 and she is doing more than ok as a hospitalist.

I have many friends who are FMG and the one thing all of them will tell you our med school here go more more in depth in basic science than most other countries. Debatable how useful that is.

MD school at least is still geared towards making physician scientists so the in-depth basic sciences are emphasized more. Can't speak to DO schools as I didn't go to one.

Not more intense TBH. I did all my grade school outside of the US, and what my daughter is doing now in 8 grade is what I did in at the beginning of HS. She is doing a lot freaking more homework than I ever did.

And maybe that's changing. My kids are also learning more and earlier than I did. But I also have friends who are college professors and the stories they tell me are horrifying for "adult" students in terms of maturity level.

 

[VA Hopeful Dr]

I agree. Just like if I started out as a FM doc, I would not work in a place without support but a place where a NP can run. No one will ever be able to tell me that I could not do what an Avg NP can do. My medical knowledge is much more vast and what I don't know would take me an hour to learn.

I love the utter disdain for another specialty you're exhibiting. Sure, FM resident is 3 years but you can make up the difference between that and the ED in an hour.

FM docs can do an avg job with 90% of EM pts.
EM docs can do an avg job with 90% of FM pts.

How do I know? Because APCs can see prob 90% of EM pts and can essentially do 100% of FM pts in rural places.

The difference is if I mess up on FM pts, then they decompensate and most likely do well going to ER. If an FM messes up in the ER, a pt can die. I have seen FM docs who can't even read an obvious STEMI.

So If I as an experience EM doc who sees 10% emergencies, 50% urgent care, 40% PCP stuff should clearly be better than an FM resident starting as an attending overall. I dont think I am wrong.

Give me 1 year and I would be able a good FM doc.

The bold just shows your intense ignorance. If you screw up and a primary care patient ends up in the ED than you have probably been screwing up for months/years. If I do a **** job with a patients diabetes then by the time they have a foot ulcer that I'm sending to the ED their neuropathy is going to be severe and will almost certainly lead to amputations in the future since nothing I can do will reverse that. If I ignore high cholesterol and someone has a stroke, even if they get great stroke care, their risk of future strokes is now very high. And again, that's assuming they pull through with no deficits. If I ignore someone's high calcium and don't find their hyperparathyroidism, its very difficult to completely replace the bone loss. Same with HTN leading to CKD.

Most poorly done primary care complications don't end up in the ED because its not an emergency or isn't one until the disease process hits end-stage and there's nothing we can do to reverse it. But the guy who's half-blind from his retinopathy isn't any less bad off for that.

 

[TooMuchResearch]

Wouldn’t this be essentially selling snake oil since there are no peer reviewed studies demonstrating the efficacy of OMM

How many of our medicines and treatments don't work and at what cost? People come for the show. Give them the show.

 

[TooMuchResearch]

Sure... 2 year fellowship and you can be a PCP.

However in this thread people aren't even talking about formal training. It's 10 years of EM and a few CME videos... and suddenly the EM doc is the same as a residency trained IM or FM doc.

...meanwhile 10 years ago on here it was, "EM is the master of the undifferentiated patient and resuscitation" and now it's, "We don't have time to resuscitate or properly work up patients, so we'll just admit them and let other teams do our jobs."

...and if you think I'm wrong... please explain why last week I was consulted for a postpartum preeclampsia patient without a UA (no proteinuremia when we got it back) and on a cardene GTT instead of a mag GTT. 2 Months ago it was the emergency department trying to pawn off a facial burn/possible airway burn patient (patient tried lighting a candle while on BiPAP) without even talking to the burn center (burn center immediately accepted the patient).

So the thoughts of modern EPs going, "With 10 years experience and a few CMEs we can do FM's or IM's jobs... but you have to do an EM residency to be a proper emergency physician" is... interesting.

Because you work somewhere ****ty? None of that would fly in any of our hospitals.

 

[GonnaBeADoc2222]

I love the utter disdain for another specialty you're exhibiting. Sure, FM resident is 3 years but you can make up the difference between that and the ED in an hour.


The bold just shows your intense ignorance. If you screw up and a primary care patient ends up in the ED than you have probably been screwing up for months/years. If I do a **** job with a patients diabetes then by the time they have a foot ulcer that I'm sending to the ED their neuropathy is going to be severe and will almost certainly lead to amputations in the future since nothing I can do will reverse that. If I ignore high cholesterol and someone has a stroke, even if they get great stroke care, their risk of future strokes is now very high. And again, that's assuming they pull through with no deficits. If I ignore someone's high calcium and don't find their hyperparathyroidism, its very difficult to completely replace the bone loss. Same with HTN leading to CKD.

Most poorly done primary care complications don't end up in the ED because its not an emergency or isn't one until the disease process hits end-stage and there's nothing we can do to reverse it. But the guy who's half-blind from his retinopathy isn't any less bad off for that.

I hate when I hear other EM docs complain that we do primary care. We don't do primary care at all.