EM after finishing IM

[wamcp]

Current PGY2 IM resident. Did my 4 weeks of ED and loved it. I am wondering the pros and cons of completing EM after I graduate versus hospitalist career. Was originally interested in PCCM but just didnt jive with it after more exposure.

Anyone able to help me decide?

I appreciate greatly the value of EM residency training, and if combined with my IM background, would it be naive to say that I would be a far better clinician either as a hospitalist or EP?

Does anyone know of IM/EM folks who flip between the two or generally just stick with EM?

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[josephmedman]

It's going to be very difficult. Have a friend who is a 3rd year IM resident right now going through it. He called like 80 programs more than 2/3 of which he got through to and only 3 programs will even consider him. Medicare only reumburses hospitals 50 percent for those starting a new residency after having finished one. You have ever 3 years of funding and every subsequent year you get 50 percent. A hospital would have to fund you out of pocket. Considering it's about 180k now, they'd have to fund 90k out of pocket every year to take you. If it's your home program you may have a shot, otherwise even for the most competitive programs you're looking at an uphill battle.

 

[gutonc]

Medicare only reumburses hospitals 50 percent for those starting a new residency after having finished one. You have ever 3 years of funding and every subsequent year you get 50 percent. A hospital would have to fund you out of pocket. Considering it's about 180k now, they'd have to fund 90k out of pocket every year to take you. If it's your home program you may have a shot, otherwise even for the most competitive programs you're looking at an uphill battle.

This is patently false and has been discussed ad nauseum in this forum and others by people who know what they're talking about. Please stop with the misinformation.

 

[Makati2008]

It's going to be very difficult. Have a friend who is a 3rd year IM resident right now going through it. He called like 80 programs more than 2/3 of which he got through to and only 3 programs will even consider him. Medicare only reumburses hospitals 50 percent for those starting a new residency after having finished one. You have ever 3 years of funding and every subsequent year you get 50 percent. A hospital would have to fund you out of pocket. Considering it's about 180k now, they'd have to fund 90k out of pocket every year to take you. If it's your home program you may have a shot, otherwise even for the most competitive programs you're looking at an uphill battle.

Wonder if I know your friend in real life. Met someone attempting this now.

 

[la gringa]

from what i have seen, ability to do a 2nd residency hinges much more on visa status than add'l PGY years per se.

trained at a large county hospital w/ FMG-heavy IM program and highly regarded EM program. program was 2-4 so we had some later comers but few doing a 2nd residency - iirc all were US citizens. not sure if any EM residents required H1b's, only 1 i could imagine out of 80+ w/ whom i trained at any point. a few IM residents voiced interest in and/or applied to EM, can only think of 1 who was successful.

if your IM institution has an EM program, that is likely your best option, depending again heavily on how competitive the EM program is.

 

[WilcoWorld]

Many EM programs would consider a solid IM applicant who had a well-informed change of heart.

However, interview season for July 2016 has already started, so you'd likely have to apply next year unless you've got an in at your home institution or something like that.

 

[gro2001]

It's going to be very difficult. Have a friend who is a 3rd year IM resident right now going through it. He called like 80 programs more than 2/3 of which he got through to and only 3 programs will even consider him. Medicare only reumburses hospitals 50 percent for those starting a new residency after having finished one. You have ever 3 years of funding and every subsequent year you get 50 percent. A hospital would have to fund you out of pocket. Considering it's about 180k now, they'd have to fund 90k out of pocket every year to take you. If it's your home program you may have a shot, otherwise even for the most competitive programs you're looking at an uphill battle.

The CMS payments for residency training are capped at December 31, 1996 levels so any residency spots that have appeared since then, either due to program expansion or new residency programs, do not receive direct CMS subsidies (actually it's more complicated than that, but that's the basic summary). My residency was one of many that started after 1996, so it would not be a concern for them.

Also, technically it's the hospital's GME department that gets the funding, and at least some of them pool all the sources of GME funding together for all the departments and draw on that for residents' salaries, etc. I imagine that is a LOT easier than trying to fund each department's residency program separately, especially since the salaries/benefits are by PGY level regardless of department. If that's the case, its less likely that a PD would be as affected by the funding question. But I would love to hear a PD's opinion on that.

 

[dotcb]

EM can be a satisfying career with a decent lifestyle if you're up for it. I know a few who have done EM after IM. You'll likely have to repeat your intern year at most programs in order to get anesthesia, EM, and the surgical rotations. Silver lining: you could moonlight as a hospitalist or urgent care doc during residency. I would do a 3 year program. You will be way ahead of your peers in residency, but will have to learn all the surgery, trauma, ortho, peds, gyn, etc.

 

[gro2001]

EM can be a satisfying career with a decent lifestyle if you're up for it. I know a few who have done EM after IM. You'll likely have to repeat your intern year at most programs in order to get anesthesia, EM, and the surgical rotations. Silver lining: you could moonlight as a hospitalist or urgent care doc during residency. I would do a 3 year program. You will be way ahead of your peers in residency, but will have to learn all the surgery, trauma, ortho, peds, gyn, etc.

I know a lot of IM docs do this (moon light in urgent care), but honestly it really puzzles me how. I did residency at a place that has some of the best IM residents in the country, and they are all wicked smart and super hard working, but they are not prepared to be the urgent care attending. There are so many little pitfalls in the seemingly simple urgent care stuff and endless specialty specific knowledge that's just not taught in IM... Like knowing to splint invisible scaphoid fractures (and fracture reduction/immobilization in general), measuring IOP, knowing about contact lenses wearers and corneal abrasions and the rest of eye stuff (heck, even just using the slit lamp!), getting good cosmetic effect on lacerations, differentiating BS vs concerning gyn complaints...

 

[WilcoWorld]

I know a lot of IM docs do this (moon light in urgent care), but honestly it really puzzles me how. I did residency at a place that has some of the best IM residents in the country, and they are all wicked smart and super hard working, but they are not prepared to be the urgent care attending. There are so many little pitfalls in the seemingly simple urgent care stuff and endless specialty specific knowledge that's just not taught in IM... Like knowing to splint invisible scaphoid fractures (and fracture reduction/immobilization in general), measuring IOP, knowing about contact lenses wearers and corneal abrasions and the rest of eye stuff (heck, even just using the slit lamp!), getting good cosmetic effect on lacerations, differentiating BS vs concerning gyn complaints...

Are you telling me the urgent cares in your area actually handle that stuff?

 

[gro2001]

Are you telling me the urgent cares in your area actually handle that stuff?

Well, yeah. At the very least they splint fractures, suture lacerations, do eye exams... Don't yours? People here do like to complain that the big urgent care chain around here "send everything in" to the ER, but I honestly don't think that's the case. And the stuff they send in is what you would expect (minor head injury sent to ER to get a CT head, BS chest pains, BS r/o PEs, BS abdominal pain sent to r/o appe). Funny that the same people that bitch the loudest about the "inappropriate referrals" are also the most likely to do the tests they were sent in for... But that's another story. But yeah, some of the 'bread and butter' stuff they handle I just don't see most IM residency grads being able to do...

 

[WilcoWorld]

Well, yeah. At the very least they splint fractures, suture lacerations, do eye exams... Don't yours? People here do like to complain that the big urgent care chain around here "send everything in" to the ER, but I honestly don't think that's the case. And the stuff they send in is what you would expect (minor head injury sent to ER to get a CT head, BS chest pains, BS r/o PEs, BS abdominal pain sent to r/o appe). Funny that the same people that bitch the loudest about the "inappropriate referrals" are also the most likely to do the tests they were sent in for... But that's another story. But yeah, some of the 'bread and butter' stuff they handle I just don't see most IM residency grads being able to do...

I was mostly joking, guess I should've added an emoji.

But I can recall the local UC sending every type of the patient you described to the ED (except maybe the corneal abrasion). However, I don't really mind seeing those patients.

 

[gro2001]

I was mostly joking, guess I should've added an emoji.

But I can recall the local UC sending every type of the patient you described to the ED (except maybe the corneal abrasion). However, I don't really mind seeing those patients.

I also don't mind seeing them at all. And of course I've seen some of those sent to the ER, but I think it's the same denominator problem that we have when interacting with the admitting IM docs: they see us admitting BS chest pains and don't see all the chest pains we discharge, so they get the impression we admit ALL the chest pains. I bet those UCs are sending us only the tip of the ginormous iceberg of bull****.

 

[WilcoWorld]

I also don't mind seeing them at all. And of course I've seen some of those sent to the ER, but I think it's the same denominator problem that we have when interacting with the admitting IM docs: they see us admitting BS chest pains and don't see all the chest pains we discharge, so they get the impression we admit ALL the chest pains. I bet those UCs are sending us only the tip of the ginormous iceberg of bull****.

Agreed

 

[wamcp]

I appreciate everyone's input. I am a US allopathic grad, PGY2 at a well known academic IM program. I think if I apply, I will hope to match during 2016-2017 cycle. I agree with gro2001, I think there's a ton of stuff that IM training just doesn't expose you to....hence why I see enormous value in EM residency training to become a true generalist and feel comfortable dealing with anything that walks through the door!

 

[gutonc]

I appreciate everyone's input. I am a US allopathic grad, PGY2 at a well known academic IM program. I think if I apply, I will hope to match during 2016-2017 cycle. I agree with gro2001, I think there's a ton of stuff that IM training just doesn't expose you to....hence why I see enormous value in EM residency training to become a true generalist and feel comfortable dealing with anything that walks through the door!

My question (as an IM guy) for you then is, what do you want written on that door? Do you want it to say "Emergency Department", "Internal Medicine Office", "General Medicine Unit" or "ICU"? Because there are pathways to each of those places, and only the first one requires an EM residency.

To be clear, I'm not knocking the training at all. But if you're going to do it just for the experience, that's kind of dumb. If you'd really rather be an EP than an internist, then absolutely go for it.

One thing that I think a lot of med students and residents don't realize (because, you'd have no reason to know this) is that, while you may feel comfortable "dealing with anything", in the outpatient setting, your office staff (and setup) is likely NOT going to feel that way and will just ship them to the ED before you even know that they walked in the door.

 

[cbrons]

in the outpatient setting, your office staff (and setup) is likely NOT going to feel that way and will just ship them to the ED before you even know that they walked in the door.

I just learned this from my EM attending today. Someone said an indicator of how good a PCP is is how often his/her patients wind up in the E.R. My attending told him it was far more an indicator of how good or bad their office staff is, since they will call first with some complaint and get told to go to the ER

 

[gutonc]

I just learned this from my EM attending today. Someone said an indicator of how good a PCP is is how often his/her patients wind up in the E.R. My attending told him it was far more an indicator of how good or bad their office staff is, since they will call first with some complaint and get told to go to the ER

And we just don't have that many tools to either diagnose or manage most acute issues.

I am an oncologist. I have an onsite lab, onsite pharmacy with pharmacist right there, half a dozen nurses and a couple of MAs as well. But when it comes to diagnosing or fixing acute issues, I'm very limited.

I can get a CBC in 3 minutes and a CMP in 20...that's about it. I have a POC INR machine but not a glucometer (WTF?). I can get vitals but not an EKG. We have a Sonosite for putting in PICCs but that's the limit of our imaging options and only 2 of the RNs know how to use it. My "code cart" is a tackle box with solu-medrol, benadryl, insulin, D50 and an epi-pen. I have an AED. I can put up a liter of NS and hang cefepime (or vanco, ceftriaxone, even voriconazole) but that's it.

Oh wait...I've got dilaudid.

And my office is far better stocked than the vast majority of them, especially PCPs.

 

[Hair Police]

I agree with gutonc. There's not much the average PCP can do in their office. And I don't know if I want them doing it there anyways. One of the sicker patients I've had was a guy on a novel anticoagulant with severe anemia and a new arrhythmia from a GI bleed. The internist didn't send him to the ED until after he had given the patient 3L of LR.

But to the OP's point, as a practicing EP, I might "see everything" that comes in the door, but I certainly don't "manage everything". If I tried to remember what constitutes salvage therapy for Non-Hodgkins lymphoma, that knowledge would push out something else important, like airway skills.

 

[Hair Police]

Well, yeah. At the very least they splint fractures, suture lacerations, do eye exams... Don't yours? People here do like to complain that the big urgent care chain around here "send everything in" to the ER, but I honestly don't think that's the case. And the stuff they send in is what you would expect (minor head injury sent to ER to get a CT head, BS chest pains, BS r/o PEs, BS abdominal pain sent to r/o appe). Funny that the same people that bitch the loudest about the "inappropriate referrals" are also the most likely to do the tests they were sent in for... But that's another story. But yeah, some of the 'bread and butter' stuff they handle I just don't see most IM residency grads being able to do...

These are easy patients to manage. You want to do the due diligence to make sure the PCP didn't miss anything, and unless you have something constructive to add, do the test and send them home. Reserve your concentration for the sick patients and you'll avoid decision fatigue.

 

[josephmedman]

Umm..