double board - FM and EM

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brucecanbeatyou

brucecanbeatyou

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How does the Navy feel about doing two residencies? I know they don't have any combined FM/EM programs, but would they let you either go back and do a second residency or build your own FM/EM program? I'm guessing the Navy probably wouldn't let you do this, as they seem happy to fill billets with non-board certified physicians in the first place, but just curious. And if, hypothetically, one did do a FP residency first, would ACGME accept the internship year for FP for EM?
 
brucecanbeatyou said:
How does the Navy feel about doing two residencies? I know they don't have any combined FM/EM programs, but would they let you either go back and do a second residency or build your own FM/EM program? I'm guessing the Navy probably wouldn't let you do this, as they seem happy to fill billets with non-board certified physicians in the first place, but just curious. And if, hypothetically, one did do a FP residency first, would ACGME accept the internship year for FP for EM?
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The mil doesn't have combo residencies an if you were to defer you would be deferring for one specialty, either FM or em, and you'd only be allowed the 3 years.

You could do a second residency once yoat obligation is up though. I knew an AF FM doc who was finishing his commitment and the AF was going to send him to do an OBGYN residency, but he opted to get out and go civilian. He was going to have to do all 4 years even though he had 3 years of FM and an OB fellowship.
I would think FM to EM you would have to get at least some credit, maybe not a full year, but who knows.
 
brucecanbeatyou said:
So what you're saying is they'll only let you do one?
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Or I think he's maybe saying that most combined residencies just cater to folks who don't want to ultimately decide what they want to do for a living.
 
brucecanbeatyou said:
How does the Navy feel about doing two residencies? I know they don't have any combined FM/EM programs, but would they let you either go back and do a second residency or build your own FM/EM program? I'm guessing the Navy probably wouldn't let you do this, as they seem happy to fill billets with non-board certified physicians in the first place, but just curious. And if, hypothetically, one did do a FP residency first, would ACGME accept the internship year for FP for EM?
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For the most part, dual residencies don't happen in milmed. The exception is the FM/Psych program (http://www.usuhs.mil/psy/nationalhandbook.html 3rd P; though I don't know which services are advertising for the position. AF wasn't this year). That said, yes, the Navy (I would imagine the AF and Army will as well) will let you do a second residency eventually. I can't speak authoritatively as to when they will let you do it, though I would imagine that it would be after your (first) payback time was completed under most circumstances. When I was in residency there was an ENT resident who was a Navy FM doc previously. The Navy "made" a previously RAM-trained FS complete a residency (he was one our OB residents. Bit of a doofus, but I didn't have any reason to disbelieve him when he told me about the Navy strongly suggesting [thus the "made" in quotes] that he complete a clinical residency to be able to progress in his career).
 
brucecanbeatyou said:
Yeah, I thought so. I'm trying to decide on a witty reply, but there are just too many to decide on just one.
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Lets hear your top three witty replies.

Apparently pick a specialty was too subtle so here you go:

The scope of FP is incredibly broad to begin with. I don't believe it would be possible for me to know everything you need to know to not be dangerous about IM, Peds, OB and do all kinds of minor procedures. But, some very good doctors are able to do ok at this. The fact that FP tends to attract lower performing students only compounds the challenge.

Add to that an entire specialty with increasingly complex expectations for the early management of a variety of diseases with its own set of procedural competencies and I think its impossible to do all of this well for any length of time. Even if you can master that much material as a resident, how are you possibly going to stay competent at all of that at the same time?

So, if you want to be that guy who thinks he knows more than he does, who everyone else shakes their heads at and is never viewed as a master of your craft...go for it...add another specialty to FP and try to do both.

These specialties seem more accessible to medical students because the majority of what they do is familiar but, in many ways, being good at primary care is harder than being a specialist.

The net effect is that you will do FP and EM and then practice as an emergency physician. Your fellow ER docs won't view you as something special and you will ultimately decide that you wasted a couple years.

Pick a specialty.
 
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Agree with Gastrapathy. Except on the point where the other ER docs won't view the FP/EM guy as something special: if he advertises the additional FP residency too much, then they'll kick him every annoying primary care-type patient that walks in the doors with a chuckle and a "you like this kind of stuff, right?"

Do a residency. If after pulling a few years of long hours for low pay you find that you still hunger to spend to push your PGY years towards double digits, then look into another field. Or better yet, do a fellowship. There are tons of 'em.

While we're on the subject of combo residencies, no one has ever been able to explain Med-Peds to me. So you can spend four years on Med-Peds, then get boarded in both IM and Peds so that you can take care of either class of patients, or you can spend three years in FP to do the same thing, and also get trained in OB. If somewhere along the line you don't like birthin' babies, there's still plenty of work with the old folks and the kids to do, and you're getting one more year of attending pay vs residency. How is this not a scam by the Med-Peds people? I went to one of the Med-Peds interest groups in med school to feast on the free pizza, and when I heard the pitch I got the same sensation of skeptical amusement I now get when the guy at Best Buy tries to sell me the extended warranty on an iPad.
 
AF M4 said:
Except on the point where the other ER docs won't view the FP/EM guy as something special: if he advertises the additional FP residency too much, then they'll kick him every annoying primary care-type patient that walks in the doors with a chuckle and a "you like this kind of stuff, right?"

.
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Touche
 
Med-Peds is generally geared to people who want to focus on the in-patient care of both populations or those who want to focus on caring for patients with childhood illnesses that would benefit from specialized care during adulthood such as congenital heart defects or cancers.

EM/FP is generally for people who want to work in rural areas and will be called upon to act in both roles. Apart from rural areas, the military sure seems like a place that would benefit from the extra training.

The combined residencies aren't about trying to do multiple specialties at once. They're about a niche that lies in between two (or more) specialties. It may be an academic niche focusing on care of the subset of patients that fall into the grey zone between specialties or it may be a niche where the patient's being seen draw from the skills of multiple specialties. It's not about trying to do multiple specialties well, it's about trying to specialize in a niche that our rigid educational system has failed to address.

You guys complain about how criminal it is to send a GMO out without a full residency and then berate the guy who wants some extra training. It's a bit interesting how that magic point of just the right amount of training is whenever you can jump into an attending salary...
 
Bah. It's not always about the money, although why someone would want to deny themselves a couple hundred thousand extra dollars is beyond me. If anyone's conscience is berating them about their paycheck, feel free to PM me or simply send your ill-gotten gains via PayPal to [email protected].

The combo residencies have the whiff of Peter Pan-ism about them. Some sort of odd desire to stay cloistered in academia for just a bit longer to avoid the world outside. Look, when you finish a residency, you're fully trained to do the job, but that doesn't mean that you're done learning. I've had multiple attendings tell me this, and I got a strong dose of it during my GMO time: when it's just you without anyone looking over your shoulder, you learn more about the PRACTICE of medicine in the first few weeks than you did for all of medical school and all of residency. Suddenly the difference between what you really know and what you thought you knew but really didn't becomes crystal clear, because where you need to improve your physical exam are never more apparent than when you're trying to figure out whether the guy in front of you has a hot appy or not and there's no one above you to tell you if you were right or wrong.

That level of clarity is extremely hard to get in training. Therefore, there comes a point where you've gotten all the knowledge that you're going to get in training, and you need to get out there, practice some, and find out what is REALLY important in that morass of knowledge you got during residency - this is why I'm a big believer in the educational benefit of moonlighting, by the way.
 
DeadCactus said:
. It's not about trying to do multiple specialties well, it's about trying to specialize in a niche that our rigid educational system has failed to address.
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Ennhhh....not instilling a whole lot of confidence with the jack of all trades, master of none designation. If I'm building a house I don't want to hire a guy who can do everything, but it will all be mediocre. I'd rather hire a good carpenter, an electrician and a plumber who know how to work together professionally and who all do their individual jobs well.
 
AF M4 said:
Ennhhh....not instilling a whole lot of confidence with the jack of all trades, master of none designation. If I'm building a house I don't want to hire a guy who can do everything, but it will all be mediocre. I'd rather hire a good carpenter, an electrician and a plumber who know how to work together professionally and who all do their individual jobs well.
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If we're going to use that analogy then why have FP when you have IM, PEDs, and OB/GYN?

I agree that our society overemphasizes certificates and degrees. But medicine is so rigid and regulated that there is no better alternative than a combined residency for certain niches. The ideal would be a more modular educational system.

I completely agree that an FP/EM physician could never maintain proficiency in the entire scope of both specialties to the level of skill that a pure FP or pure EM physician could. But I find it hard to believe that an FP/EM physician could not maintain the specific aspects of both specialties relevant to the kind of rural or remote practice that would call for a physician with that training.

The point is specialization has more to do with your actual practice after training than whatever you trained in. The IM-Peds with a Cardiology fellowship focusing on life-long care of patients with congenital heart disease or the EM-FP physician focusing on medical care in a rural community is just as focused as any of the traditional specialties. They just don't have a special residency purely for their niche.

The combined residencies are not a good choice for everyone, but there are certain people whose career goals and desires are well served by them...
 
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DeadCactus said:
If we're going to use that analogy then why have FP when you have IM, PEDs, and OB/GYN?

I agree that our society overemphasizes certificates and degrees. But medicine is so rigid and regulated that there is no better alternative than a combined residency for certain niches. The ideal would be a more modular educational system.

I completely agree that an FP/EM physician could never maintain proficiency in the entire scope of both specialties to the level of skill that a pure FP or pure EM physician could. But I find it hard to believe that an FP/EM physician could not maintain the specific aspects of both specialties relevant to the kind of rural or remote practice that would call for a physician with that training.

The point is specialization has more to do with your actual practice after training than whatever you trained in. The IM-Peds with a Cardiology fellowship focusing on life-long care of patients with congenital heart disease or the EM-FP physician focusing on medical care in a rural community is just as focused as any of the traditional specialties. They just don't have a special residency purely for their niche.

The combined residencies are not a good choice for everyone, but there are certain people whose career goals and desires are well served by them...
Click to expand...

I keep calling the AAFP and asking them that same question. They keep sending me emails with a JPG of a middle finger attached. Good times.

The combo residencies seem like too much training on the front end. If there's some sort of niche you want to go after, this is what electives during residency or fellowships afterward are for. Let's see folks complete one residency first before going back for seconds.
 
AF M4 said:
I keep calling the AAFP and asking them that same question. They keep sending me emails with a JPG of a middle finger attached. Good times.

The combo residencies seem like too much training on the front end. If there's some sort of niche you want to go after, this is what electives during residency or fellowships afterward are for. Let's see folks complete one residency first before going back for seconds.
Click to expand...

I have to imagine that the funding and educational credit headaches of doing a second residency are a large reason dual residencies even exist. Besides that, if you know from day one that you want a career that falls between two specialties it makes sense to begin that integration in residency...
 
how about like a EM and preventive medicine residency? that's what i was thinking potentially...clinical skills of the EM and more population based research skills through the prev med residency
 
citrusguy2010 said:
how about like a EM and preventive medicine residency? that's what i was thinking potentially...clinical skills of the EM and more population based research skills through the prev med residency
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Maybe it's just me, but this makes no sense. I'm having a hard time thinking of a residency combination that would be even worse - maybe if you were a plastic surgeon/psychiatrist who tried to counsel your patients out of their cosmetic surgery by exploring root causes of their dissatisfaction of self-image. Anybody got a better one?

Seriously though, on one hand, you have a specialty that emphasizes only acute issues regarding the patient right in front of you. On the other, you're dealing with population wide issues designed to keep patients out of emergency rooms. Does not compute, at least to me.
 
citrusguy2010 said:
how about like a EM and preventive medicine residency? that's what i was thinking potentially...clinical skills of the EM and more population based research skills through the prev med residency
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If youre interested in research of the PrevMed flavor, you can get involved in such things as an EM physician. You need not train in a PrevMed residency (which IMO is a BS specialty--where crappy clinicians flock to, to hide out for the rest of their military careers and collect an O-5 paycheck). Prevmed is a part of every specialty--thus any trained physician can do work along prevmed lines, you need not be a prevmed "doctor".
 
colbgw02 said:
Seriously though, on one hand, you have a specialty that emphasizes only acute issues regarding the patient right in front of you. On the other, you're dealing with population wide issues designed to keep patients out of emergency rooms. Does not compute, at least to me.
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so i see your point and i agree that it doesn't make sense to be certified in one profession that fights disease and another that is geared at preventing disease from happening. however, i believe that medicine's goal is not only to be reactive in fighting disease but also proactive in stopping disease before it can begin - which is why i suggested the possibility of FM with preventive medicine.

i think that with all the healthcare issues going on in this country there's definitely a push for preventive medicine and preventing diseases before they happen (sure it's from a costs point of view but go with the metaphor). besides i feel like the tools learned in a preventive med residency (and a public health degree in general) can complement any specialty in not only trying to prevent disease, but in the EM case, help improve outcomes by improving treatment. true one aspect of prev med is to keep people out of the ER, but the other hand is to assist the EM doc in learning ways to improve the quality of care or efficiency in the ER itself to globally help patients improve healing time, or improve the quality of the procedures they're receiving (and i think even with all the prevention you're still going to have patients who probably will still appear in the ER no matter what we do).

so that was my angle for asking about the preventive med/EM dual training.
 
citrusguy2010 said:
so i see your point and i agree that it doesn't make sense to be certified in one profession that fights disease and another that is geared at preventing disease from happening. however, i believe that medicine's goal is not only to be reactive in fighting disease but also proactive in stopping disease before it can begin - which is why i suggested the possibility of FM with preventive medicine.

i think that with all the healthcare issues going on in this country there's definitely a push for preventive medicine and preventing diseases before they happen (sure it's from a costs point of view but go with the metaphor). besides i feel like the tools learned in a preventive med residency (and a public health degree in general) can complement any specialty in not only trying to prevent disease, but in the EM case, help improve outcomes by improving treatment. true one aspect of prev med is to keep people out of the ER, but the other hand is to assist the EM doc in learning ways to improve the quality of care or efficiency in the ER itself to globally help patients improve healing time, or improve the quality of the procedures they're receiving (and i think even with all the prevention you're still going to have patients who probably will still appear in the ER no matter what we do).

so that was my angle for asking about the preventive med/EM dual training.
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FM/Prev makes more sense. That to me says, "I really enjoy preventive medicine, but I still want to hang out my shingle and take care of patients one-on-one in a setting that permits application of my prev med knowledge."

as far as your second paragraph, that's all fine. in fact, they have a specialty for that - preventive medicine. i'm sure prev med docs can teach all of us something, but as discussed earlier, dual residencies are designed to find the niche between specialties. in this case, i don't see a niche. i don't think spending years of your life to develop the skill set of an ER physician will do much toward teaching other ER docs applicable preventive medicine techniques. a prev med doc should be able to do that.
 
Anybody got a better one?[/QUOTE said:
Interventional Radiology/Derm - Access to every squamous cell in/on your body

OB/Rads - you can irradiate people ... just not YOUR patients.
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freezeray said:
Interventional Radiology/Derm - Access to every squamous cell in/on your body

OB/Rads - you can irradiate people ... just not YOUR patients.
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"I got the best board scores ever and I want to be in training until I die" combo: Neurosurgery/Plastics.

"I hate patients" combo: Rads/Path

"I hate work and money and studied for this board exam over the weekend" combo: PrevMed/OccMed
 
Gastrapathy said:
OK, this is a fun game...

how about ENT and colorectal surgery. You'd have to be really careful which end was up for a given case.

obstetrics and palliative care?

nope....I think I'll go with EM and prev-med.
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I'm going to go with ENT/Proctology. You get them at both ends, but don't care about the middle.
 
To my understanding, preventative medicine is basically just a way to get resident pay while pursuing an MPH with clinically oriented research. Considering that EM gets the front row seat to many of the failures and shortfalls of both our medical system and our constant battle of wits with Darwin, it seems like a reasonable combination to me. Even ignoring the many patients using the ED as a PCP, there is plenty of work to be done in preventing acute disease and death...
 
DeadCactus said:
To my understanding, preventative medicine is basically just a way to get resident pay while pursuing an MPH with clinically oriented research. Considering that EM gets the front row seat to many of the failures and shortfalls of both our medical system and our constant battle of wits with Darwin, it seems like a reasonable combination to me. Even ignoring the many patients using the ED as a PCP, there is plenty of work to be done in preventing acute disease and death...
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Damn your constant use of aposiopesis, always leaving me wanting more...

EM and preventative medicine are two completely different mindsets, to the point that I'm not sure that they can co-exist in one person. EM is about moving the meat; hospitals do not advertise about the quality of care in their ERs, they advertise about the 8 minute wait time.

In comparison, my defining experience with a preventative doc was as a captive audience member at one of the many AF CME boondoggles. He was an O-6 colonel who was proudly showing all of us captains and majors his grand new questionnaire for the annual PHA (Periodic Health Assessment) that he was trying to get implemented Air Force wide. The thing was an unwieldy computerized module with more than a dozen screens with at least 10 questions apiece per screen. All told, there were more than 400 questions, ranging from family health history to what kind of learning style the member preferred (audio? visual? osmotic?), all of which he wanted the clinician to go over with each patient during the visit, every year.

I raised my hand and asked if he'd timed how long it took to fill out. He cheerfully replied that when everything worked, about 55 minutes. And that's just madly clicking away, with no positive answers requiring further elucidation. I then asked how a typical flight surgeon could accomplish this, since a light day in the clinic has at least a half dozen PHAs (plus the rest of the regular patient visits). He glared at me, and gave me a short, gruff answer that amounted to that that wasn't his effing problem. In a somewhat suicidal gesture, I then asked what all this data was going to be used for. He replied that it was going to be analyzed and that question time was over.
 
AF M4 said:
Damn your constant use of aposiopesis, always leaving me wanting more...

EM and preventative medicine are two completely different mindsets, to the point that I'm not sure that they can co-exist in one person. EM is about moving the meat; hospitals do not advertise about the quality of care in their ERs, they advertise about the 8 minute wait time.

In comparison, my defining experience with a preventative doc was as a captive audience member at one of the many AF CME boondoggles. He was an O-6 colonel who was proudly showing all of us captains and majors his grand new questionnaire for the annual PHA (Periodic Health Assessment) that he was trying to get implemented Air Force wide. The thing was an unwieldy computerized module with more than a dozen screens with at least 10 questions apiece per screen. All told, there were more than 400 questions, ranging from family health history to what kind of learning style the member preferred (audio? visual? osmotic?), all of which he wanted the clinician to go over with each patient during the visit, every year.

I raised my hand and asked if he'd timed how long it took to fill out. He cheerfully replied that when everything worked, about 55 minutes. And that's just madly clicking away, with no positive answers requiring further elucidation. I then asked how a typical flight surgeon could accomplish this, since a light day in the clinic has at least a half dozen PHAs (plus the rest of the regular patient visits). He glared at me, and gave me a short, gruff answer that amounted to that that wasn't his effing problem. In a somewhat suicidal gesture, I then asked what all this data was going to be used for. He replied that it was going to be analyzed and that question time was over.
Click to expand...

:laugh:

This is how I envisioned the history of the 'Web HA', I just never knew the real story. I hate that piece of crap.
 
AF M4 said:
Damn your constant use of aposiopesis, always leaving me wanting more...

EM and preventative medicine are two completely different mindsets, to the point that I'm not sure that they can co-exist in one person. EM is about moving the meat; hospitals do not advertise about the quality of care in their ERs, they advertise about the 8 minute wait time.

In comparison, my defining experience with a preventative doc was as a captive audience member at one of the many AF CME boondoggles. He was an O-6 colonel who was proudly showing all of us captains and majors his grand new questionnaire for the annual PHA (Periodic Health Assessment) that he was trying to get implemented Air Force wide. The thing was an unwieldy computerized module with more than a dozen screens with at least 10 questions apiece per screen. All told, there were more than 400 questions, ranging from family health history to what kind of learning style the member preferred (audio? visual? osmotic?), all of which he wanted the clinician to go over with each patient during the visit, every year.

I raised my hand and asked if he'd timed how long it took to fill out. He cheerfully replied that when everything worked, about 55 minutes. And that's just madly clicking away, with no positive answers requiring further elucidation. I then asked how a typical flight surgeon could accomplish this, since a light day in the clinic has at least a half dozen PHAs (plus the rest of the regular patient visits). He glared at me, and gave me a short, gruff answer that amounted to that that wasn't his effing problem. In a somewhat suicidal gesture, I then asked what all this data was going to be used for. He replied that it was going to be analyzed and that question time was over.
Click to expand...

You're really going to use hospital marketing and the prototypical incompetent O6 to define the capabilities of a field? Of course they're different mindsets, that doesn't mean the fields don't have an area of overlap. I'm pretty sure most people can switch among different thought processes as the situation dictates.

Also, the use of an ellipsis is not inherently aposiopesis...
 
It's medicine; all specialties are going to have overlap. Accordingly, every physician with multiple residencies can bring additional knowledge and a different perspective that will allow him or her to better handle the job at hand. However, that's not a compelling argument for training in dual residencies. Dual residencies are intended to fill a niche not sufficiently addressed by any single specialty, and I have yet to hear of a niche that a preventive/emergency medicine physician fills.
 
DeadCactus said:
You're really going to use hospital marketing and the prototypical incompetent O6 to define the capabilities of a field? Of course they're different mindsets, that doesn't mean the fields don't have an area of overlap. I'm pretty sure most people can switch among different thought processes as the situation dictates.

Also, the use of an ellipsis is not inherently aposiopesis...
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Well, the guy was a head honcho in the field for a service branch. Do you have a counter-example?
 
brucecanbeatyou said:
How does the Navy feel about doing two residencies? I know they don't have any combined FM/EM programs, but would they let you either go back and do a second residency or build your own FM/EM program? I'm guessing the Navy probably wouldn't let you do this, as they seem happy to fill billets with non-board certified physicians in the first place, but just curious. And if, hypothetically, one did do a FP residency first, would ACGME accept the internship year for FP for EM?
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I haven't heard of second residencies in the Navy (it seems to be a sign of indecision in my opinion), but there are fellowship opportunities that some have done at prestigious institutions, including Johns Hopkins.
 
BravoZulu said:
I haven't heard of second residencies in the Navy (it seems to be a sign of indecision in my opinion), but there are fellowship opportunities that some have done at prestigious institutions, including Johns Hopkins.
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Really? Let me guess, you did a fellowship at Hopkins.

You must be an outservice product.

Anyone who's been around has seen folks do second residencies. Most often Rads, EM, or other desirable fields after a period in a primary care role. I do know one surgeon who got off the train and did a primary care residency.
 
This gets hashed out a lot on the FM forum- FM and EM are both very important, and very seperate, but there's a decent amount of overlap between the two even if neither side wants to admit it.

All ENT/Procto and the such kidding aside, I doubt the Navy would let you do it, but you could make a coherent argument that its reasonable. One of my FP attendings my 4th year of Medical School did a tour at a base where he was often the lone doctor in the ER- and he had some pretty good hair raising stories for stuff he was expected to immediately manage. Additionally, you can talk to plenty of .mil FM docs who are at some lonely FOB with a couple IDMT's and expected to handle anything that splatters infront of them.

EM- Obviously gets more ER rotations, which leads to a much better familiarity with the latest guidelines for acutely managing emergent conditions. Also many have a great emphasis on critical care, and are more comfortable than a lot of Docs on the floor with pressors/vent settings with sick sick patients.

FM - Less familiar with the nuances of super acute pathology, but a deeper differential that can be worked through because you see the patient multiple visits over time. Additionally, more well versed in the chronic disease managment aspect- Heart Failure, Diabetes, HTN - 'what's the next best step' kind of stuff for long term prevention.

The overlap is in the middle - Not emergent care, not routine care, but Urgent Care 😉

~Smiley.
 
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