Critical Care Fellowship after Emergency Medicine

[Roy7]

Hey everyone,

I was just wondering if there is any way for a person board certified in EM can get a surgical critical care fellowship?

The only reason I'm asking, is because I'm currently on my surgical rotation, and as an EM physician I'd really like to be able to do so more surgery (appendectomies, cholecystectomies, minor internal fixations, etc). Things that would decrease the amount of referring out and help me be more versatile in a rural environment.

I could be totally wrong 'bout the critical care fellowship part... i'm just curious how I can learn the basic emergency surgeries in case I work somewhere without a surgical team on hand.

If this is a residency issue in that I'd be better served going to a rural residency program - anywhere in the MD/DC/VA area that fits those needs?

Thanks!

---

Members don't see this ad.

 

[GeneralVeers]

Surgical critical care does not mean you do surgeries. A critical care fellowship would qualify you to take care of ICU patients, not to cut them open.

If you really want to do appys, there is no way except to do the whole surgery residency (5-6 years)

 

[bulgethetwine]

Hey everyone,

I was just wondering if there is any way for a person board certified in EM can get a surgical critical care fellowship?

The only reason I'm asking, is because I'm currently on my surgical rotation, and as an EM physician I'd really like to be able to do so more surgery (appendectomies, cholecystectomies, minor internal fixations, etc). Things that would decrease the amount of referring out and help me be more versatile in a rural environment.

I could be totally wrong 'bout the critical care fellowship part... i'm just curious how I can learn the basic emergency surgeries in case I work somewhere without a surgical team on hand.

If this is a residency issue in that I'd be better served going to a rural residency program - anywhere in the MD/DC/VA area that fits those needs?

Thanks!

I'm assuming you are doing your surgical rotation as a medical student. I echo General Veers comments... if you're really into the surgery procedures you describe, then you might have self selected for a General Surgery residency. That's ok -- we won't begrudge you! That's what rotations are for.... to find your best fit.

 

[Roy7]

I'm assuming you are doing your surgical rotation as a medical student. I echo General Veers comments... if you're really into the surgery procedures you describe, then you might have self selected for a General Surgery residency. That's ok -- we won't begrudge you! That's what rotations are for.... to find your best fit.

Thanks for the responses. Honestly, I'm not a big fan of being in the OR, I'm not all that into surgeries.

I was just seeing if there was a way to get to the point where I could genuinely handle most major emergencies that come through the door w/out doing an additional trauma surgery residency. I dont want to learn how to do an elective colectomy or do a breast mass excision, just major emergencies that from what the surgeons say are relatively "simple" procedures.

That being said, I can definitely live a great life w/out ever doing one. =)

 

[USCDiver]

A couple of points based on your post:

There isn't such thing as a 'trauma surgery residency'. There is General Surgery residency (5-6 years) followed by a Trauma/Critical Care fellowship.

Also, I'm unclear how you could even come close to incorporating OR time as a part of practicing EM. Suppose you get a patient that comes in with RLQ abdominal pain and you think they need an appendectomy; you just drop what you're doing and go scrub in to take it out?

This of course assumes you are able to get privileges at your hospital for both EM and Gen Surg, which would NEVER happen.

 

[howelljolly]

In general (if not always),a Surgical Critical Care fellowship requires a General Surgery residency (as per the FREIDA listing for SCC). SCC consists of Trauma Surgery and Surgical ICU management. Theres also Critical Care which requires an Internl Medicine residency, where you deal with the CCU/ICU.

If you watch Trauma: Life in the ER on TV, you'll see that they always shadow a surgery resident or trauma fellow... not usually the EM resident or attending.

Anyway, if you want to handle critical patients as an EP, you can probably do so by choosing where you are employed. You'll need to work in an Emergency Dept. that attracts higher acuity critical patients. That is, a hospital with a level 1 or 2 Trauma service, emergent cardiac cath lab, Burn unit. PICU, or whatever service that said critical patient would be admitted to. Paramedics bring patients to the nearest APPROPRIATE facility. Its up to you to work in that appropriate facility.

As an EP you'll be able to "handle" any major emergency that comes thru your door....though it depends on what you mean by "handle"

 

[EctopicFetus]

they are considering a critical care/EM fellowship here. There are issues but I think this could be a very interesting option. the issue of course would be getting priviledges to practice this brand of medicine which is another issue.

 

[howelljolly]

they are considering a critical care/EM fellowship here. There are issues but I think this could be a very interesting option. the issue of course would be getting priviledges to practice this brand of medicine which is another issue.

I would suspect that they are considering combining with Critical Care Medicine, not Surgery.... as only three other programs have done. (LIJ, Maryland, and Pitt... off the top of my head) What program are you in?

From what Ive read on other posts on the SDN, some of the major issues of the Fellowship after EM revolve around the point that the existing fellowships... Cards, GI, ... including Critical Care Med. are reserved for IM residents. EM has its own fellowships, such as Tox, and Sports, and never the twain shall meet. It seems that it was part of an agreement that earned EM its official status on the ABMS.

But the point is, that CCM is ICU, not Trauma.

 

[davbrucas]

UF Gainesville is opening slots for EM/Critical Care medicine fellowships...

 

[AmoryBlaine]

I would suspect that they are considering combining with Critical Care Medicine, not Surgery.... as only three other programs have done. (LIJ, Maryland, and Pitt... off the top of my head) What program are you in?

From what Ive read on other posts on the SDN, some of the major issues of the Fellowship after EM revolve around the point that the existing fellowships... Cards, GI, ... including Critical Care Med. are reserved for IM residents. EM has its own fellowships, such as Tox, and Sports, and never the twain shall meet. It seems that it was part of an agreement that earned EM its official status on the ABMS.

But the point is, that CCM is ICU, not Trauma.

I doubt this, the shortage of intensivists is going to be as bad as anything else in the future.

 

[EctopicFetus]

I would suspect that they are considering combining with Critical Care Medicine, not Surgery.... as only three other programs have done. (LIJ, Maryland, and Pitt... off the top of my head) What program are you in?

From what Ive read on other posts on the SDN, some of the major issues of the Fellowship after EM revolve around the point that the existing fellowships... Cards, GI, ... including Critical Care Med. are reserved for IM residents. EM has its own fellowships, such as Tox, and Sports, and never the twain shall meet. It seems that it was part of an agreement that earned EM its official status on the ABMS.

But the point is, that CCM is ICU, not Trauma.

Critical Care is also only reserved for surgeons. Hence in the Surgical ICU you dont see the medical intensivists roaming around.

When EM split apparently there was an agreement to "not work on the wards" while that has somewhat gone away (tox for example) it is still there. our chair was the prez of ABMS and I talked to him about this personally and he agrees that it weill change but the question is when.

The bigger questions is credentialing. Doing these fellowships wont let you sit for the critical care fellowships and as such you probably will have a hard time getting credentialed to work in any hospital other than those who offer these options to EM docs (which is not many right now). This is a question I think anyone interested in this should consider since in essence you may be doing a fellowship and not be able to get a job in it afterwards which in my mind is a waste of time.

 

[pseudoknot]

You may want to do a search for the posts of Kyle Gunnerson (KGUNNER1 I think) who is EM/IM/CCM and has posted extensively on this issue. I don't think the perspectives expressed so far on this thread represent the whole range very well, but I can't comment from personal knowledge either.

See, for example:
http://forums.studentdoctor.net/showpost.php?p=2129532&postcount=13
http://forums.studentdoctor.net/showthread.php?t=267115

Also if you go to the ACEP's Critical Care section they have a list of CCM fellowships that take or will consider EM trained applicants. link. There is also a good FAQ.

Actually, on reading the OP's post again I don't think this is particularly relevant, since CCM fellowships aren't about becoming a "mini-surgeon." But the the information above is pertinent to the issue of EPs working in CCM.

 

[TysonCook]

Talk with you CCM colleagues as we have EM/CCM intensivists that did EM residency, then are attending intensivists after their CCM fellowship.

You can sit for boards, just not the US boards (European boards), and from the intensivists I've spoken to, they've stated that they could care less from their standpoint about WhICH board you sit for, as long as you are boarded.

At Carolinas we just hired on a EM/CCM European boarded MD who is fantastic, and he moonlights in the ED at the same time. From those that I've spoken with, CCM is going into a crunch as there are more patients then MD's a this point, and getting MD's hired on is more important that political BS about EM MD's sitting for US boards.

If you have more ?'s go to the CCM section of SDN.

For the OP, no you will not be doing Lap Appy's anytime soon, you need to do a surgery residency if that is your gig.

 

[kungfufishing]

what will become of the rest of the ED while you are performing these surgeries?

 

[Seaglass]

Regarding Surgical CCM fellowships - there certainly are some that take EM trained docs - one of my classmates will be starting one this July. So take that!

 

[howelljolly]

Regarding Surgical CCM fellowships - there certainly are some that take EM trained docs - one of my classmates will be starting one this July. So take that!

How will that work? Wouldnt you need to know general surgery before they teach you to repair lacerations to solid organs, trace bleeders, resect destroyed tissue, and all that other jazz I see them do on Trauma: life in the ER?

 

[pseudoknot]

How will that work? Wouldnt you need to know general surgery before they teach you to repair lacerations to solid organs, trace bleeders, resect destroyed tissue, and all that other jazz I see them do on Trauma: life in the ER?

I can't tell if you are being sarcastic, but I think you probably aren't. Forgive me if I'm wrong! Anyway, critical care fellowships are not focused on operative management but rather [medical] care of patients in ICU settings. It is true that many surgical critical care programs are combined with trauma training for surgeons, but presumably this would not be included in the fellowship pursued by an EP.

 

[Seaglass]

what he said

 

[howelljolly]

I can't tell if you are being sarcastic, but I think you probably aren't. Forgive me if I'm wrong! Anyway, critical care fellowships are not focused on operative management but rather [medical] care of patients in ICU settings. It is true that many surgical critical care programs are combined with trauma training for surgeons, but presumably this would not be included in the fellowship pursued by an EP.

Just a misunderstanding really. My (mis)interpretation of the statement was absurd, so I was being sarcastic. Seaglass mentioned that some "Surgical CCM" fellowships take EM grads. I decided to read that as "Surgical CC", and not "CCM".
I know that there are some CCM programs that take EM grads (I want to do this myself actually), but I doubted that a SCC program would take an EM grad. It seems that the OP is looking for a SCC program post EM, so....

I also assumed that all Surgical critical care programs include trauma surgery. I thought that's the only way to become a trauma surgeon (besides orthopedic trauma).

 

[ambiguous]

Sorry to bump this old thread but I was wondering if there were any progress in promoting CCM fellowships in more EM programs. I'm still struggling between the two specialties and it would make life much easier if I could get the best of both worlds.

 

[Hallm_7]

http://www.acep.org/ACEPmembership.aspx?id=24910

Here's a website that discusses EM critical care options. Summary: 21 surgical critical care programs consider EM applicants, 10 IM critical care programs consider EM applicants, 22 anesthesia critical care programs consider EM applicants, 5 neuro critical care programs consider EM applicants, and there are 10 Emergency Medicine run critical care fellowships. Also important: Those numbers only include programs that have been studied. There several other programs whose stance is unknown when it comes to EM applicants applying for critical care.


I know it's an old topic, but the OP was wanting to know about EM guys doing surgery. Legally, there is nothing stopping an EM doc (or any MD or DO that is licensed for that matter) from doing any type of surgery. The only barrier to this is gaining hospital privileges which requires some sort of training. I seriously doubt any large hospital would give privileges unless you finished a surgery residency. However, there are some small hospitals that might consider giving privileges for some minor surgical procedures if you had some training.

I think everyone would agree that appys aren't that difficult, and a couple months of training would probably be enough for any physician to safely perform the operation. Cholecystectomies are considerably more difficult because of the tight anatomy in the region, but you could still probably safely perform them after a couple months as well. The problem with getting training just for a couple procedures is finding a surgeon to train you for those couple months and then arguing for privileges at the hospital. Atul Gawande in Complications writes about a group of Family Docs in Canada that does Appys/Gallbladders. They never graduated from a surgical residency, but they have the lowest complication rate in the entire country because their volume is so high.

Personally, it's probably more trouble than its worth. Plus, if you do get privileges at a small hospital then you become responsible for caring for every patient with that condition (assuming no other surgeons).

 

[SoCuteMD]

http://www.acep.org/ACEPmembership.aspx?id=24910

Here's a website that discusses EM critical care options. Summary: 21 surgical critical care programs consider EM applicants, 10 IM critical care programs consider EM applicants, 22 anesthesia critical care programs consider EM applicants, 5 neuro critical care programs consider EM applicants, and there are 10 Emergency Medicine run critical care fellowships. Also important: Those numbers only include programs that have been studied. There several other programs whose stance is unknown when it comes to EM applicants applying for critical care.


I know it's an old topic, but the OP was wanting to know about EM guys doing surgery. Legally, there is nothing stopping an EM doc (or any MD or DO that is licensed for that matter) from doing any type of surgery. The only barrier to this is gaining hospital privileges which requires some sort of training. I seriously doubt any large hospital would give privileges unless you finished a surgery residency. However, there are some small hospitals that might consider giving privileges for some minor surgical procedures if you had some training.

I think everyone would agree that appys aren't that difficult, and a couple months of training would probably be enough for any physician to safely perform the operation. Cholecystectomies are considerably more difficult because of the tight anatomy in the region, but you could still probably safely perform them after a couple months as well. The problem with getting training just for a couple procedures is finding a surgeon to train you for those couple months and then arguing for privileges at the hospital. Atul Gawande in Complications writes about a group of Family Docs in Canada that does Appys/Gallbladders. They never graduated from a surgical residency, but they have the lowest complication rate in the entire country because their volume is so high.

Personally, it's probably more trouble than its worth. Plus, if you do get privileges at a small hospital then you become responsible for caring for every patient with that condition (assuming no other surgeons).

a) They don't do appys, they do hernias. And they've been specifically trained to do hernias. And they only do ELECTIVE hernias on people and have extremely stringent weight requirements. In short, it's hard to generalize their results to even other hernia repairs because they have such a selected population.
b) Please don't go there. Really, we're not surgeons. We aren't qualified to be. I doubt a malpractice insurance company would provide coverage for "Dr. Family medicine trained who moonlights as a surgeon." Please don't go speculating on this stuff unless you have data to back it up.

 

[Hallm_7]

It is hernias. I misspoke. But there is no speculation here. A family doc could just as legally and adequately perform appys instead of hernias. In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill.

The scenario I presented was an EM doc graduating residency and then receiving adequate training to perform whatever procedure you want to be credentialed in. There's nothing speculative about that at all. If someone wants to go for it then I say do it. For example, a physician graduating from a psychiatry residency that wants to go back and do hernias or gall bladders for a few months with a community doc doing a couple of these a day will have far, far larger numbers than any general surgery resident graduating from a typical university program. While they wouldn't be qualified to do a colectomy or repair a liver laceration, they would be adequately trained in hernias. There's nothing magical about graduating from any type of residency program. Residency programs just serve as a vehicle to get enough volume and supervision for a variety of procedures. The same could be said for a surgery resident that decides to quit the residency after 3 years. While they wouldn't be a residency graduate, they would be adequately trained for certain procedures.

You're correct that medical malpractice would be an issue because it would be expensive, but I believe you could get coverage. Family docs still routinely get coverage for Ob despite their rather paltry Ob experience. Of course, there's much more liability with Ob than there is with hernia repair.

People have said very similar things with interventional cardiology. Vascular and CT surgeons threw (and are still throwing in many places) a fit when cardiologists started stenting coronaries, and then started stenting carotids, and then started stenting femorals and popliteals, and then started doing endovascular AAA repair. Cries of inadequate training were everywhere. Yet it is becoming so mainstream that I think anyone without a monetary interest acknowledges that interventionists can perform these procedures equally, if not better than, their surgical colleagues.

Lastly, if you look at my post I made it clear that at the vast majority of hospitals this would not even be a possibility. However, I would bet money there are hospitals in some parts of the country that would grant privileges given adequate training by the physician.

 

[SoCuteMD]

FM docs can be credentialed for obstetrics because it is part of their residency requirements. Drawing parallels between FM credentials for uncomplicated deliveries and EM credentials for surgery is absurd.

I'd challenge you to find ONE hospital in the US that will grant credentials to someone who is not surgery trained to performs appys or cholecystectomies. You won't find it.

Also, malpractice insurance might be expensive? Do you have ANY idea what surgeons pay for malpractice? One general surgeon I know pays 200K a year. I doubt you'd ever find a company to insure someone who hadn't trained in surgery to...well...perform surgery.

Really, just stop with the whole, "EM docs can be surgeons too!" We're not surgeons. Most of us don't want to be surgeons. And talking like that just gets the surgeons mad, and frankly, I like it when the surgeons are at least a little less cranky.

I bet if the surgery forum caught wind of this thread they would have lots to contribute.

 

[deleted109597]

It is hernias. I misspoke. But there is no speculation here. A family doc could just as legally and adequately perform appys instead of hernias.

No doubt. However, they wouldn't get privileges. I've seen scrub nurses that could probably perform surgeries, but they aren't allowed by the hospital either.

In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill.

Some hernias are more difficult than most appys. However, there are some appys that are more difficult than anything. I've seen people end up with right colectomies after an appy. How would the FM doc handle that situation?
Also, the 5 year residency isn't just so you can perform an appy. It is so you can operate on anything. If it was different, you would have a 1 year residency on how to cut, and then have a million fellowships on each system. As it is, you just do them all at the same time.

I wouldn't hold my breath. If you can find a hospital somewhere that will let you live out your fantasy, then by all means go for it. However, I find it highly more likely that they would allow a BC/BE surgeon run their ED than a BC/BE EP run their OR.
Also, I'm curious as to what you mean in the OP about "minor internal fixations". Does this mean ortho stuff too?

 

[annie5644]

It is hernias. I misspoke. But there is no speculation here. A family doc could just as legally and adequately perform appys instead of hernias. In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill.

The scenario I presented was an EM doc graduating residency and then receiving adequate training to perform whatever procedure you want to be credentialed in. There's nothing speculative about that at all. If someone wants to go for it then I say do it. For example, a physician graduating from a psychiatry residency that wants to go back and do hernias or gall bladders for a few months with a community doc doing a couple of these a day will have far, far larger numbers than any general surgery resident graduating from a typical university program. While they wouldn't be qualified to do a colectomy or repair a liver laceration, they would be adequately trained in hernias. There's nothing magical about graduating from any type of residency program. Residency programs just serve as a vehicle to get enough volume and supervision for a variety of procedures. The same could be said for a surgery resident that decides to quit the residency after 3 years. While they wouldn't be a residency graduate, they would be adequately trained for certain procedures.

You're correct that medical malpractice would be an issue because it would be expensive, but I believe you could get coverage. Family docs still routinely get coverage for Ob despite their rather paltry Ob experience. Of course, there's much more liability with Ob than there is with hernia repair.

People have said very similar things with interventional cardiology. Vascular and CT surgeons threw (and are still throwing in many places) a fit when cardiologists started stenting coronaries, and then started stenting carotids, and then started stenting femorals and popliteals, and then started doing endovascular AAA repair. Cries of inadequate training were everywhere. Yet it is becoming so mainstream that I think anyone without a monetary interest acknowledges that interventionists can perform these procedures equally, if not better than, their surgical colleagues.

Lastly, if you look at my post I made it clear that at the vast majority of hospitals this would not even be a possibility. However, I would bet money there are hospitals in some parts of the country that would grant privileges given adequate training by the physician.

this is one of the absolute dumbest things i've seen on here. no EM doc in their right mind and no hospital in it's right mind would let an EM doc in the OR, taking out appys and doing lap choles. while "dabbling" with some ORIFs. i'm an EM doc and there is NO WAY i would feel comfortable taking someone's mother to the OR! it's called a residency. you do it so you can safely treat patients. and yes, it IS important to do one. anyone who is a resident or has been through residency will surely vouch for that.

 

[BADMD]

In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill....

This is the technician theory of surgery. It works great as long as everything goes swimmingly well. Too bad people on the inside rarely look like a Netter drawing.

Surgery is more than cut and sew. Good surgery often seems as simple as "Tab B into slot C" because you are watching a highly trained, highly experienced person who has had their share of F-ups, problem fixes, tough calls and changes of plan.

Given a laproscope and the right tools, I could probably do 75-80% of most cholecystectomies...and the other 20-25% would die from a complication. I couldn't fix my problems. I couldn't change my approach. I wouldn't know when the ship was sinking. I'll stop listing things I wouldn't know, as it would be a lot. Learning cut by following the book is a recipe for disaster.

It takes far more than a few months doing the same procedure to be a master of it. It takes actually understanding it. I once talked to a chief surgery resident who told me that she didn't "get" hernia repairs until her 4th year of residency. Up until that point, she could do technically perfect repairs, but it really took doing some of the other big procedures to finally get it to all to mesh and actually "understand" some subtle aspects. She said that suddenly some of the stranger hernia repairs failures she had seen, all of a sudden made sense. A good surgeon is more than technician who cuts.

 

[howelljolly]

This has turned into silly-talk.

An EM doc has no business doing appys, choleys, hernias, or anything else in surgery. Besides all the aforementioned points, what about pre-op and post-op management? What about the surgical admission? What if something un-expected happens? What if there is intra-abdominal pathology that the ER doc doesnt notice? Theres a huge list of things that you might find on laparotomy... cancer, intestinal malrotations, or hyper-mobile intestines that are at risk for any number of things, adhesions. Are you going to say: "Oh, I skipped that in my surgical residency... oh wait, I didnt do a surgical residency...."?

Do your rotations, and decide what you can see yourself doing.
Personally, when I did my first few laparotomies, I thought it was great, but then I realized that closing the laparatomy, layer by layer, was about as interesting as watching paint dry. Why woulda thunk?

 

[BADMD]

How apres peau to this discussion: http://ohiosurgery.blogspot.com/2008/09/vasculitis-and-acute-cecal-infarct.html

Let your appi tech deal with this one...

 

[Apollyon]

apres peau

"After skin"? I think you're looking for "àpropos".

 

[BADMD]

"After skin"? I think you're looking for "àpropos".

I never was very good at spelling, let alone in french. But if you think about it, it kind of works my way too, if you think about surgery....

 

[Apollyon]

But if you think about it, it kind of works my way too, if you think about surgery....

Truthfully, I did think just that.

 

[AmoryBlaine]

It is hernias. I misspoke. But there is no speculation here. A family doc could just as legally and adequately perform appys instead of hernias. In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill.

The scenario I presented was an EM doc graduating residency and then receiving adequate training to perform whatever procedure you want to be credentialed in. There's nothing speculative about that at all. If someone wants to go for it then I say do it. For example, a physician graduating from a psychiatry residency that wants to go back and do hernias or gall bladders for a few months with a community doc doing a couple of these a day will have far, far larger numbers than any general surgery resident graduating from a typical university program. While they wouldn't be qualified to do a colectomy or repair a liver laceration, they would be adequately trained in hernias. There's nothing magical about graduating from any type of residency program. Residency programs just serve as a vehicle to get enough volume and supervision for a variety of procedures. The same could be said for a surgery resident that decides to quit the residency after 3 years. While they wouldn't be a residency graduate, they would be adequately trained for certain procedures.

You're correct that medical malpractice would be an issue because it would be expensive, but I believe you could get coverage. Family docs still routinely get coverage for Ob despite their rather paltry Ob experience. Of course, there's much more liability with Ob than there is with hernia repair.

People have said very similar things with interventional cardiology. Vascular and CT surgeons threw (and are still throwing in many places) a fit when cardiologists started stenting coronaries, and then started stenting carotids, and then started stenting femorals and popliteals, and then started doing endovascular AAA repair. Cries of inadequate training were everywhere. Yet it is becoming so mainstream that I think anyone without a monetary interest acknowledges that interventionists can perform these procedures equally, if not better than, their surgical colleagues.

Lastly, if you look at my post I made it clear that at the vast majority of hospitals this would not even be a possibility. However, I would bet money there are hospitals in some parts of the country that would grant privileges given adequate training by the physician.

Go into Emergency Medicine because you want to practice Emergency Medicine. The whole idea of procedural emergency medicine is that the trained clinician is able to a) do procedures that are vital to collect data (i.e. LP, femoral stick), b) do procedures that are vital to rescusitation (i.e. central lines, airway management), and c) do procedures on the moribund patient when the risk/benefit ratio is appropriate (i.e. thoracotomy, c-section).

An ED thoracotomy is a perfect example of the procedural limit of EM. The indications for EDT are basically a patient that could die in seconds (and has already lost vitals). There is no benefit to the patient to waiting for general or CT surg and substantial risk. No one would suggest that an EP is as good at EDT as a trauma surgeon or CT surgeon but the patient has nothing to lose!

Appys, hernias, even incarcerated hernias do not fall within this model.

 

[deleted52758]

ridiculous. a psychiatrist performing surgery? ridiculous, horrifying, and everything in between.

It is hernias. I misspoke. But there is no speculation here. A family doc could just as legally and adequately perform appys instead of hernias. In fact, I dare say hernias are a little more difficult than appys to perform well. I mentioned that anyone performing surgery would need to receive the adequate training, but the idea that you need a 5 year residency to perform an appy is overkill.

The scenario I presented was an EM doc graduating residency and then receiving adequate training to perform whatever procedure you want to be credentialed in. There's nothing speculative about that at all. If someone wants to go for it then I say do it. For example, a physician graduating from a psychiatry residency that wants to go back and do hernias or gall bladders for a few months with a community doc doing a couple of these a day will have far, far larger numbers than any general surgery resident graduating from a typical university program. While they wouldn't be qualified to do a colectomy or repair a liver laceration, they would be adequately trained in hernias. There's nothing magical about graduating from any type of residency program. Residency programs just serve as a vehicle to get enough volume and supervision for a variety of procedures. The same could be said for a surgery resident that decides to quit the residency after 3 years. While they wouldn't be a residency graduate, they would be adequately trained for certain procedures.

You're correct that medical malpractice would be an issue because it would be expensive, but I believe you could get coverage. Family docs still routinely get coverage for Ob despite their rather paltry Ob experience. Of course, there's much more liability with Ob than there is with hernia repair.

People have said very similar things with interventional cardiology. Vascular and CT surgeons threw (and are still throwing in many places) a fit when cardiologists started stenting coronaries, and then started stenting carotids, and then started stenting femorals and popliteals, and then started doing endovascular AAA repair. Cries of inadequate training were everywhere. Yet it is becoming so mainstream that I think anyone without a monetary interest acknowledges that interventionists can perform these procedures equally, if not better than, their surgical colleagues.

Lastly, if you look at my post I made it clear that at the vast majority of hospitals this would not even be a possibility. However, I would bet money there are hospitals in some parts of the country that would grant privileges given adequate training by the physician.

 

[Hallm_7]

I think everyone is taking my comments a little out of the context that I meant them. I was also likely less clear than I needed. Several people seem to think I want to do this. I do not. I have no desire whatsoever to go into the OR, and if I did I would do surgery. I'm also not saying this just applies to EM physicians. The OP was, but I am not.

The point I'm making is this:
Given the right training any MD or DO can perform any area of medicine. Everyone agrees with that since any MD or DO can go into any specialty. You all seem to be forgetting that I repeatedly said anyone would have to receive training to perform any procedure in medicine, whether it's a central line, a chest tube, an appy, or a CABG. I don't know what the adequate training would be in terms of length or content, but there is some level of training that would qualify anyone to peform said procedure.

There's an underlying theme I'm seeing among many of the posters that I do disagree with. That's the idea that just because something has always been done means it's the right thing to do always. I stand by my statement that someone wouldn't have to complete a full residency to perform a piece of that specialty's procedures or management of patients. For example, completing an emergency medicine residency is probably overkill if your ultimate goal is to work in an urgent care center. Will the residency-trained physician be able to handle more of the patients in an appropriate way? Yes, I think they would. But is that a reason to mandate 100% of urgent care physicians be EM trained? I hope not because we'd have urgent care centers around the country close overnight. Heck, we've got urgent care centers that are de facto run by PAs.

The same thing goes for surgery in my opinion. Reading through the posts it appears many are saying that to perform any surgery at all a complete 5 or 6 year residency in Gen Surg is needed. True, that's the traditional way of approaching surgical training. However, I contend that this isn't the most efficient system, and isn't without fault. And others agree as well seeing as we now have categorical vascular surgery and plastics programs. Many people now reject the idea that you have to be a residency-trained general surgeon before you can train to perform a AAA repair or breast reconstruction. Do they receive appropriate training? Yes, they do. Do they do it in the traditional 5+2 format? No. Are there circumstances where a 5+2 trained vascular surgeon might be better equipped to deal with a situation? Possibly, but I don't believe it warrants a mandate that 5+2 is the only way to be a vascular surgeon. You can make very similar arguments for urologists in regards to open operations or renal transplant. The same can be said for gynecologists performing surgery.

Many people here mentioned that surgical qualifications are more than the technicalities of the operation. I couldn't agree more, and I think this actually stregthens my stance. There are SICUs around the country that are staffed by anesthesiology-trained or EM-trained intensivists (moreso anesthesia, but EM is a burgeoning field for this) with absolutely no techinical surgical training. However, they still manage the post-op patient, and they do a superb job. So is it really that much of a stretch to say that some of the people could go back and receive abbreviated training to do operations? Are you all saying that someone who completed an anesthesia residency and then went on to do a surgical critical care fellowship (managing the sickest of sick post-op patients) couldn't complete an additional "1/2/3/whatever" year period of training to perform an operation? In most traditional, "old-school" surgical training programs the first couple years there is very little time spent on learning the technical aspects of surgery. That's typically reserved for years 3-5.

I realize this is somewhat out-of-the-box, but there's nothing wrong with that I my opinion. Afterall, Emergency Medicine was way, way outside the box at one time too.

And what's with all the animosity on here about this? Everyone needs to chill out a little. We are just discussing this. It's not like any of us have the power to change anything or grant hospital privileges or determine malpractice rates.

 

[Hallm_7]

ridiculous. a psychiatrist performing surgery? ridiculous, horrifying, and everything in between.

The whole reference to the psychiatrist was a little hyperbole and was intended to be over the top a little. I don't think any psychiatrist is going to be doing this any time soon.

But is it really so horrifying to think about a shrink being a surgeon after receiving years of training to do so? After all, this year there will be thousands of former med students training to be surgeons.

 

[howelljolly]

Without picking at the details of what you wrote...
The basic counterpoint is this (and you actually hit this point yourself): A surgical procedeure is not a procedeure in the same sense that starting an IV or inserting a Foley is.
Surgical residency curriculum (or any curriculum for that matter) is the way it is because it's primarily designed to get you to think like a surgeon. Like all of medicine, its not somthing that can be learned in a linear fashion, but since we dont have timewarps, it must be. Like the begining of any rotation you have in med school. you learn many data points, in isolation, and then the points start connecting to each other. then hopefully someday, you have enough points and connections that things fall into place, and you "know" something.
Once you think like a surgeon, and have memorized and done the textbook procedeures, you can, and are expected to be able to do some crafty engeneering when needed. Sure, there are "routine" lap-choleys, but no surgery is routine. On the upper extreme, there are the complex facial reconstructions and conjoined twin separations, and such, but every surgery falls somewhere on the continuum of the unexpected.

So, when you do an appy, the easy part is locating the appendix, and clipping it. The hard part is deciding if you need to do anything else in there, looking around for other pathologies, running the bowel, deciding if you need to run the bowel, etc etc. And this is can only be done (with any usefulness) if youve youve also done surgery for cancer, and know what that looks and feels like.... done surgery for diverticula, and know what they look and feel like... have done surgery for bowel infarct, and know what that looks and feels like.... have done surgery for intussuseption, and know what that looks and feels like...... have done a cecopexy, and know what a hypermobile bowel looks and moves like.... etc etc.
So sure, you can get trained do do a surgical procedeure, but by the time you have trained at a minimum level of competency for that procedeure, you'll have done a 5 year surgery residency.

 

[ambiguous]

While I am currently battling between EM vs CCM, I was wondering... what would be some reasons to NOT go into CCM through EM and rather, the IM to pulm/CCM route. I am still trying to analyze all the options I have available. Thanks.

 

[howelljolly]

Im guessing on this, but I think that one point against the EM/CCM route has to do with why/how EM was barred from fellowships in the first place. If you do EM/CCM you are likely to be confined to the ER and the ICU because having trained in EM, you can not admit your own patients, like an internist would. You would also not be able to have patients admitted to your service on a medical floor. As a PCCM doc, you'd be able to follow a patient on a medical floor that is really sick, but doesnt need to take up and ICU bed.

I think

 

[deleted109597]

While I am currently battling between EM vs CCM, I was wondering... what would be some reasons to NOT go into CCM through EM and rather, the IM to pulm/CCM route. I am still trying to analyze all the options I have available. Thanks.

Some hospitals will not recognize the European board. One was a hospital that I was at last year. The director explicitly told me "it is not reciprocal here, you won't get a job here". The EM director was trying to change that, but it is unlikely until a few people retire.
Granted, these people are usually fighting old turf battles, but still. I'm sure you could find work lots of places, but there are some you couldn't.

 

[BADMD]

If you do EM/CCM you are likely to be confined to the ER and the ICU because having trained in EM, you can not admit your own patients, like an internist would.

Who can admit and to where is purely dependent on what privileges a hospital will give. An EM boarded, fellowship trained toxicologist can get pediatric admitting privileges without doing any additional pediatrics training. Someone who is CCM trained and can round in the ICU, can probably make a reasonable argument that they can have "floor" privileges for ICU downgrades (why would anyone want to admit "not quite sick enough" patients to a CC service on a general medical unit).

I think the biggest issues have to do with being cross departmental. You may be employed by 2 different departments. As an EM/CC, you aren't pulm trained, and thus can't see clinic patients. Likely you also couldn't really do much with the bronchoscope beyond bronchial lavage and almost certainly couldn't do bronch clinic. You may have to do more ICU time to make up for it and thus less EM. The financial aspect of these arrangements are quite important and will differ with each group and hospital.