EM fellowship for Primary Care

[Firebird]

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One of the hospitals associated with our university is offering a 1 yr ER fellowship for primary care physicians. I would be very interested in doing something like this, but have heard really mixed comments from some folks. Anyone have any experience with programs that are similar? I know it doesn't allow any extra board certification, but coming from an Internal Medicine residency, to work in an ED I would need peds and trauma training to make me minimally competant, as well as some small amount of obstetrics. I am also not interested in being only minimally competent, as I like to be good at what I'm doing and not only adequate. Our IM program does offer a fair amount of procedural education and ambulatory experience. Additionally, I could potentially have 3-4 months of dedicated ER electives by the end, also.

Thoughts?

 

[SoCuteMD]

nm

 

[AmoryBlaine]

You will probably be minimally competent.

 

[BADMD]

Thoughts?

Emergency Departments are moving towards requiring board certification for EPs, not away from it. Outside of BCEM, this fellowship does not allow "Board Certification" and certainly not ABMS Board Certification.

Large departments will choose ABEM certified physicians over non-ABEM certified. Departments with trouble getting docs will take you until they don't have to anymore.

Can a one year fellowship make you competent, assuming you are already a competent IM doc? Maybe. It would require busting your ass at a hardcore department, using an accelerated curriculum. Frankly, I don't think you can. EM/IM is a 5 year program. Why would IM/EM only take 4?

 

[zinjanthropus]

If you want to do EM, do an EM residency. You will have a great foundation for EM residency with your IM training and you can knock off 6 months of training sometimes. My program welcomes those with previous training and finds the experience an asset. If you are already thinking of doing a 1 year fellowship, this would only be an additional 1.5 - 2 years on top of that - giving you the right foundation for a career and a much much more marketable background for hiring in a market increasingly shifting to only EM residency trained physicians.

 

[Firebird]

You make a good point about EM/IM being 5 and this being a total of 4. I thought EM/IM was total 4, my mistake I guess.

I'm really not worried about board certification. The hospitals in our area are not currently anywhere near 100% EM trained or board certified. It is considered a rural area, but it is the 2nd largest town in the state, so we have 2 level 2 trauma centers that service the entire region which is indeed rural. It's still a relatively small town and so physician recruitment is difficult.

So my interest for this thread is focused much more on the possibility of being a good physician in an ED and being able to know what needs to be known about peds and ob. Trauma won't be a problem. As you know, IM has the know-it-all-and-then-some approach, so in terms of adult medicine, I'm not concerned at all.

Oh, and in terms of moving to an EM residency, I'm far too anchored to our current location to move, and there are no EM residencies here (obviously, since they're starting an fellowship).

Thanks.

 

[BKN]

I'm really not worried about board certification. The hospitals in our area are not currently anywhere near 100% EM trained or board certified. It is considered a rural area, but it is the 2nd largest town in the state, so we have 2 level 2 trauma centers that service the entire region which is indeed rural. It's still a relatively small town and so physician recruitment is difficult.

We've selected and trained a lot of second career Docs in our residency. They have a leg up, of course, over the EM1s straight out of Med School. But they are not minimally competent at the end of year 1. I suggest that you will not ready for independent EM practice. EPs need to be at the PG3 level in every specialty, that takes time. Even a full residency is only a start. Karl Mangold used to run the Fisher-Mangold group in Calfironia in the 80s. He had to hire a lot of untrained EPs. He said it took 30000 visits to make a good EP and 60,000 to make an outstanding one. I agree, working hard seeing 5000 pt visits a year, that's 6 and 12 years respectively.

You say you aren't worried about being pushed out by qualified docs, but I think you should give it some thought. When I started 30 years ago, anybody with any background could work anywhere. With time, a lot of new residencies have opened, others are expanded their number of trainees. It's much easier to hire trained people today and the City EDs are nearly all completely BCed EP staffed. That will happen in the rural areas eventually. You might be forced out ten years down the road just when you are getting it all down. How difficult will going back to IM be at that time?

Take the full training and respect yourself.

 

[Stitch]

Is there or will there be a legal liability issue? Seems like the trial lawyers could have a field day with you in the event of a bad outcome.

While you are likely very smart and competent at what you do, I would worry that one year of ER training would only teach you enough to make you more likely to get yourself in trouble. Especially in regards to peds and/or OB, though your IM training will serve you well. How much airway and drugs training will you really get? How about peds? I take a lot of referrals from docs who've gotten in over their heads and really messed things up because they assumed things about kids (these are mainly non ER or peds trained docs in the area). Remember that residency is about learning how to deal when 'routine' or 'easy' procedures go bad and how to recognize early who's sick. In all much harder than I every would have imagined.

 

[zinjanthropus]

I'm really not worried about board certification. The hospitals in our area are not currently anywhere near 100% EM trained or board certified. It is considered a rural area, but it is the 2nd largest town in the state, so we have 2 level 2 trauma centers that service the entire region which is indeed rural. It's still a relatively small town and so physician recruitment is difficult.

You are at the beginning of your career though and what you are describing above IS a closing door that will shut during your professional life. If you want to do EM, go do an EM residency.

 

[Firebird]

Thanks for the replies, everyone.

 

[Jeff698]

When I first read the title of this thread, I thought it was talking about a fellowship in primary care for EM physicians.

Might actually be useful considering how many of the visits to my ED are primary care and how little of my training was in primary care.

What the hell is that rash? What kind of bump is that?

After awhile "it ain't gonna kill ya in the next 30 days" gets to be a less than satisfactory answer, at least for me.

Of course, after doing a fellowship in primary care, I'd only learn that PCPs don't know what the hell that rash or bump is either.

Take care,
Jeff

 

[xaelia]

After awhile "it ain't gonna kill ya in the next 30 days" gets to be a less than satisfactory answer, at least for me.
Jeff

It's all about resetting the expectations for people who come to the ED for their 2nd or 3rd opinion, or for a rash or a cough that's been going on for two months: "Here in the Emergency Department, we're very good at treating life-threatening medical conditions. It's not always possible for us to give you definite answers, but we can make sure it isn't something dangerous. You'll have to go back to your regular doctor if your symptoms persist for further testing."

 

[Stitch]

It's all about resetting the expectations for people who come to the ED for their 2nd or 3rd opinion, or for a rash or a cough that's been going on for two months: "Here in the Emergency Department, we're very good at treating life-threatening medical conditions. It's not always possible for us to give you definite answers, but we can make sure it isn't something dangerous. You'll have to go back to your regular doctor if your symptoms persist for further testing."

My motto: I don't tell you what you have, just what you don't have.

 

[Arcan57]

My motto: I don't tell you what you have, just what you don't have.

"I'm almost positive it's not Ebola." That's an answer that makes everybody happy, isn't it?

 

[Jeff698]

It's all about resetting the expectations for people who come to the ED for their 2nd or 3rd opinion, or for a rash or a cough that's been going on for two months: "Here in the Emergency Department, we're very good at treating life-threatening medical conditions. It's not always possible for us to give you definite answers, but we can make sure it isn't something dangerous. You'll have to go back to your regular doctor if your symptoms persist for further testing."

Yeah, I tell my patients the same thing. That wasn't my point, though. I was saying it wasn't a very satisfying answer for me. At some point, from an intellectual curiosity standpoint, I'd like to know what it is. I agree it isn't my job to know that, I'd just like to.

Take care,
Jeff